Prolongation of the prothrombin time and activated partial thromboplastin time in children with sickle cell disease

BACKGROUND: Patients with sickle cell disease (SCD) have high rates of perioperative complications, including bleeding 1,2. PROCEDURES: We conducted a retrospective review of pre-operative coagulation studies in pediatric patients with SCD followed by a prospective study of 100 well children with SCD to determine the prevalence of abnormal coagulation screening tests, and to evaluate potential etiologies. RESULTS: In the retrospective study, 32/84 (38.1%) had a prolonged prothrombin time (PT), compared to 8/100 in the prospective study. Prolongations of the activated partial thromboplastin time (aPTT) were less common. Children in the prospective study with prolonged PTs had significantly lower levels of Factor V and VII compared to those with normal PTs. Factor VII levels were <50% in 4/8 with long PTs, compared to 3/92 with normal PTs, P=0.001. Though retrospectively, several patients had normalization of their PT with vitamin K, there was no laboratory evidence of vitamin K deficiency in the prospective study. In the retrospective analysis, six of seven children who had pre-operative coagulation studies and significant intraoperative blood loss had prolonged PTs (P=0.04). CONCLUSIONS: Children with SCD admitted for surgical procedures were more likely to have prolonged PTs than those tested at a well visit. There was intra-patient variability in coagulation studies that may be related to clinical status, hepatocellular dysfunction, and/or increased clotting factor consumption. Future well-designed prospective studies to determine whether abnormal coagulation studies are associated with an increased risk of perioperative bleeding in children with SCD are necessary.     

Controlled fall in natremia in hypertonic dehydration: Possible avoidance of rehydration seizures

This prospective study comprises 40 infants with severe hypernatremic dehydration due to gastroenteritis. During the first 24 h, natremia was closely monitored and infusion rates were adjusted so as to keep the rate of fall in natremia below 0.5 mEq/l/h. This could be achieved by giving a 70 mEq/l Na solution at the rate of 120 ml/kg/24 h. Rehydration was uneventful in all cases, and no convulsions were observed.     

Random practice patterns of surgical antimicrobial prophylaxis in neonates

Antimicrobial prophylaxis accounts for 75% of antibiotic use on pediatric surgical services, but controlled, prospective studies evaluating surgical prophylaxis in neonates are lacking. We surveyed pediatric surgeons at 21 centers to: (1) determine practice patterns in neonatal surgical prophylaxis and treatment of necrotizing enterocolitis (NEC), and (2) assess whether a prospective study evaluating the efficacy of a single agent in place of a multiple drug regimen would be indicated, practical, and have the potential to effect a positive change in practice patterns. Surgeons responded concerning prophylactic regimens for common congenital anomalies and treatment of NEC. The most common regimen was an ampicillin/gentamicin combination (55% to 82%), while 23% added clindamycin for contaminated alimentary tract cases and 41% added clindamycin for NEC. There was wide variation in dosage and duration of coverage. A prospective study would determine whether antimicrobial monotherapy provides equal or better clinical results than an ampicillin/gentamicin regimen; whether there are cost savings associated with monotherapy; and whether a shorter treatment scheme would be effective, safe, and feasible. Correspondence to: M. E. Fallat     

Comparison of two methods for assessing injuries among preschool children

BACKGROUND: Most studies of injuries use health services records or recall rather than prospective methods, and there is no information on how these different methods compare. This study was aimed at comparing a report (retrospective) with a diary (prospective) for recording childhood injuries. METHODS: The study included 1,273 and 620 children, the retrospective and prospective subsamples, respectively, from a population based birth cohort in Pelotas, southern Brazil. The reported incidence of injuries in the preceding month were compared with those reported over month by diary (prospective study). RESULTS: Both methods were well accepted and 92.7% of the diaries were returned. One or more injuries per child month were reported for 20.8% (retrospective) and 48.4% (prospective) of the children. The total number of reported injuries for the 620 children were 145 (retrospective) and 715 (prospective). Using the prospective method as the gold standard, the retrospective method detected only 20.2% of all injuries. Under-reporting did not vary significantly with maternal education, but was greater (51.8%) for injuries requiring medical care than for those managed at home (18.3%; p=0.003). CONCLUSIONS: The diary was well accepted and resulted in higher incidences of reported injuries than the recall method, particularly for injuries that did not require medical care. Use of this method should be promoted to provide more complete epidemiological information to guide preventive strategies.     

Requirements and performance profile of the Paediatric Radiation Oncology Working Group (APRO): evaluation of the present situation and description of future developments

BACKGROUND: Radiation therapy is an integral component in the management of childhood malignancies and undergoes a continuous process of optimization within the prospective trials of the GPOH. At present there are approximately 20 active protocols, some specifying radio-oncological study questions, in which about 500 to 600 children annually are given radiotherapy. MATERIALS/METHODS: The Pediatric Radiation Oncology Working Group (APRO) of the German Society for Radiation Oncology (DEGRO) represents the organizational link between GPOH and DEGRO. Their activities range from phrasing guidelines of radio-oncological therapy, through writing a protocol for a prospective study on radiation-induced late effects (RISK--in co-operation with GPOH, 695 patients registered so far) and organizing meetings for information transfer, to implementing radio-oncology within the prospective studies of the GPOH by establishing study chairs for radio-oncology when radio-oncological questions are a primary focus and/or to function as a reference institution for quality assurance. These activities also include individual case consultations outside the study proper. Twice annually the members of the APRO meet for an update on current knowledge and future directions where a representative of the GPOH is invited to contribute special aspects of pediatric oncology. CONCLUSIONS: In the future, modern technology (intensity modulated radiotherapy, proton therapy, inclusion of imaging in treatment planning) will be part of disease management in pediatric oncology. A working group for modern radiotherapy technology was established to enhance this development. Prospective studies of the GPOH with primary or secondary radio-oncological questions require the implementation of corresponding tasks (documentation, monitoring, etc.) in order to meet future demands on clinical trials and to achieve the aims of the protocol. Consequently adequate financial support is indispensable.     

Surveillance of nosocomial infections: prospective study in a pediatric intensive care unit. Background, patients and methods

BACKGROUND, PATIENTS AND METHODS: From November 1997 through May 1998, the incidence of nosocomial infections was studied prospectively in a 10-bed multidisciplinary pediatric intensive care unit in Germany. A standardized surveillance [SEKI] system based on the National Nosocomial Infection Surveillance [NNIS] System of the Centers for Disease Control and Prevention [CDC] was used. The CDC definitions for nosocomial infections were adapted to the current practice of pediatric intensive care in Germany. Infection rates were calculated as infections per 100 patients, per 1000 patient-days, and per 1000 device-days (central venous catheters, urinary-catheters, and mechanical ventilation). RESULTS: Fifteen nosocomial infections were recorded in 201 patients during 1035 patient-days. The overall nosocomial infection rates were 7.5/100 patients and 14.5/1000 patient-days. Device-associated nosocomial infection rates for urinary-catheters and mechanical ventilation were 7.2/1000 utilization-days and thus below the 75th percentile of the last NNIS report. Central line infection rates were 10.7/1000 utilization days and therefore above the 75th percentile of the NNIS data (10.2/1000). The median length-of-stay was 5.1 days. CONCLUSIONS: Surveillance data are indispensable for internal and external quality control, and prospective surveillance of nosocomial infections should become an essential component of hospital infection control programs in pediatric intensive care in Germany. The standardized calculation of (device utilization ratios and) device-specific infection rates yields results which can be compared with national and international surveillance data. SEKI meets the criteria of a practice oriented, prospective and standardized surveillance system. Considerable efforts for collecting and interpreting the required data should be balanced against the benefit of prevention of nosocomial infections in this population of critically ill persons.     

A prospective randomized clinical trial of total parenteral nutrition in children with cancer

A prospective randomized clinical trial was undertaken to test the efficacy of total parenteral nutrition (TPN) among previously untreated children receiving abdominal/pelvic irradiation with or without adjuvant chemotherapy who were at risk for weight loss, malnutrition, and complications from treatment. Children were evaluated by weight/height determinations, anthropomorphic measurements, and laboratory studies. TPN was associated with an improved nutritional status during therapy as compared with control patients on ad libitum intake. However, when TPN was discontinued, weight declined and there were no differences among treated and control patients detected at three-month follow-up. Likewise there was no obvious effect from TPN on tolerance to therapy in the adequately nourished child. TPN as initial supportive therapy should be reserved for those children who are malnourished or marginally malnourished at the time of presentation. Close nutritional assessment during treatment is essential since approximately 25% of children undergoing abdominal/pelvic radiotherapy with chemotherapy can be expected to become malnourished during an initial course of therapy.     

Steroid treatment of idiopathic thrombocytopenic purpura in children. Preliminary results of a randomized cooperative study

Preliminary data from a prospective randomized study of the use of a short course of adrenocorticosteroids in 73 children with ITP demonstrates a significant advantage of moderate dose (60 mg/m2/day p.o. X 21 days) prednisolone therapy in decreasing the duration of severe thrombocytopenia in most patients. The period of risk for serious bleeding, as reflected in the Rumpel-Leede test, was also significantly reduced. The number of children who developed chronic thrombocytopenia, although small in both groups, appeared to be uninfluenced by steroid therapy. No side effects or serious complications were noted in this trial.     

Prenatal diagnosis

With the leaping advances in knowledge of genetics, its applications in patient management are also increasing. Prenatal diagnosis is the most useful application as it offers prospective parents the assurance of having an unaffected child in situations of high recurrence risks. Pretest and post test counseling is an integral part of prenatal diagnosis. All Pediatricians and Obstetricians should be familiar with the basic prerequisites of prenatal screening/testing. Timely referral, preferably prepregnancy is important. There is more or less a consensus regarding offering prenatal diagnosis for lethal/chronic disabling or difficult/expensive to treat conditions. Ethical issues are already around regarding prenatal testing for disabilities like deafness and late onset disorders. The present communication is an effort to present the clinician’s perspective of prenatal diagnosis     

The National Children's Study: a 21-year prospective study of 100,000 American children

Prospective, multiyear epidemiologic studies have proven to be highly effective in discovering preventable risk factors for chronic disease. Investigations such as the Framingham Heart Study have produced blueprints for disease prevention and saved millions of lives and billions of dollars. To discover preventable environmental risk factors for disease in children, the US Congress directed the National Institute of Child Health and Human Development, through the Children's Health Act of 2000, to conduct the National Children's Study. The National Children's Study is hypothesis-driven and will seek information on environmental risks and individual susceptibility factors for asthma, birth defects, dyslexia, attention-deficit/hyperactivity disorder, autism, schizophrenia, and obesity, as well as for adverse birth outcomes. It will be conducted in a nationally representative, prospective cohort of 100,000 US-born children. Children will be followed from conception to 21 years of age. Environmental exposures (chemical, physical, biological, and psychosocial) will be assessed repeatedly during pregnancy and throughout childhood in children's homes, schools, and communities. Chemical assays will be performed by the Centers for Disease Control and Prevention, and banks of biological and environmental samples will be established for future analyses. Genetic material will be collected on each mother and child and banked to permit study of gene-environment interactions. Recruitment is scheduled to begin in 2007 at 7 Vanguard Sites and will extend to 105 sites across the United States. The National Children's Study will generate multiple satellite studies that explore methodologic issues, etiologic questions, and potential interventions. It will provide training for the next generation of researchers and practitioners in environmental pediatrics and will link to planned and ongoing prospective birth cohort studies in other nations. Data from the National Children's Study will guide development of a comprehensive blueprint for disease prevention in children.     

Prenatal and postnatal maternal smoking as risk factors for preschool children's mental health

Aim: To identify maternal prenatal and postnatal smoking as risk factors for psychosocial behaviour problems in Swedish preschool children. Methods: This prospective, longitudinal population study compared mothers' self-reported smoking during pregnancy and when the child was 3 mo old with behaviour problems according to Achenbach's Child Behavior Checklist at 3 y (1428 children) and 5.5 y of age (677 of the children). Results: 16% of the mothers smoked during pregnancy and the same number after the birth of the child. Controlling for possible confounding variables, maternal smoking was significantly related to externalizing problems, aggressive behaviour, and destructive/delinquent behaviour both at 3 y and 5.5 y. The effect was as strong for girls as for boys. Length and weight were lower for children of smoking mothers than for children of non-smoking mothers.

Conclusion: Our study supports the importance of preventing maternal smoking during pregnancy and the infant years. Even a few cigarettes per day have negative consequences for the child. The goal must be total abstinence from smoking both pre- and postnatally.     

Relationship of food frequencies as reported by parents to overweight and obesity at 5 years

Aim: To investigate if food frequencies are related to overweight/obesity in 5-year-old children.
Methods: During 1997–1999, 21 700 infants were invited to participate in ABIS (All Babies in Southeast Sweden), a prospective, cohort study. Participants were followed from birth (n = 16 058) to 5 years (n = 7356). Food frequencies reported by parents at 2.5 and 5 years were studied in the relation to overweight/obesity at 5 years using multiple logistic regressions. A p-value < 0.01 was considered statistically significant.
Results: At 2.5 years frequencies of intake of cheese were positively associated with overweight/obesity at 5 years while porridge, fried potatoes/french fries and cream/crème fraiche showed a negative association. When adjusting for known risk factors, porridge and fried potatoes/french fries remained negatively associated with overweight/obesity. At 5 years, chocolate and lemonade were positively associated with overweight/obesity whereas cream/crème fraiche, pastries and candy were negatively associated. Candy remained negatively associated to overweight/obesity after adjustment for potential confounders.
Conclusion: Food frequencies do not offer any simple explanation for overweight/obesity. Porridge at 2.5 years may protect against overweight/obesity at 5 years, while lemonade may contribute to overweight. Our finding that fried potatoes/french fries may protect against overweight/obesity is unexpected and must be interpreted with caution. These findings should be confirmed by prospective studies using objective recordings.     

A review and analysis of the effectiveness of early intervention programs

A review was made of 27 studies describing early intervention for biologically impaired infants and young children. Although every study provided some type of documentation of outcome, most studies failed to meet common criteria for scientific research, such as specification of inclusion criteria, documentation of reliability, random assignment, and/or the use of control/contrast groups. Studies were grouped into four classifications on the basis of experimental design as follows: retrospective, prospective-no control group, prospective-control/contrast group, and prospective-random group assignment. A comparative analysis was made of the effectiveness of findings on the basis of statistical evidence and clinical support. Statistical procedures were used in 59% of the studies and statistical support for the effectiveness of early intervention was reported in 48% of the studies. Effectiveness on the basis of subjective, clinical conclusions was reported in 93% of the studies. Implications of the discrepancy between effectiveness based on statistical evidence and clinical conclusions are discussed.     

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??Fluid resuscitation continues to be recommended as the first-line resuscitative therapy for patients with septic shock. The current acceptance of the therapy is based in part on long history and familiarity with its use in the resuscitation of other forms of shock??as well as on an incomplete and incorrect understanding of the pathophysiology of septic shock. Recently??the safety of intravenous fluids resuscitation in patients with septic shock has been called into question with both prospective and observational data suggesting improved outcomes with less fluid. The current evidence for the continued use of fluid resuscitation for septic shock remains contentious with no prospective evidence demonstrating benefit to fluid resuscitation as a therapy in isolation. The article reviews the pathophysiological rationale for the introduction of fluid resuscitation as treatment for septic shock and highlights a number of significant concerns based on current clinical evidence.     

Treatment of hypertensive attacks in children with nicardipine

A prospective study of the hypotensive effects of nicardipine has been performed during 65 administrations of the drug in 6 children with malignant hypertension. We conclude that this calcium channel blocker is useful to treat hypertensive emergency in children owing to its tolerance and its efficacy (mean arterial blood pressure was lowered by 28 to 38% after 90 min). In addition, it ensures the maintenance of cerebral, renal and myocardial blood flow. A posology of 1 mg/kg/dose, 3 or 4 times/day (oral route) seems to be sufficient, as its effects last 6 to 10 h. Nevertheless the control of acute arterial hypertension must always be associated with the introduction or adjustment of long-term antihypertensive therapy.     

Systematic review of the occurrence of infantile colic in the community

AIMS—To assess the occurrence of infantile colic in the community and the need for professional help; and to study the influences of potential determinants of infantile colic.
METHODS—Surveys were identified by a systematic search in Medline (1966-98) and Embase (1988-98). Retrieved publications were checked for references. Studies selected were community based, prospective, and retrospective surveys on the occurrence of infantile colic published in English, German, French, or Dutch. Occurrence rates were calculated as percentages. Methodological quality of the surveys was assessed by two assessors independently with a standardised criteria list containing items on method of data gathering, definition of colic, and drop out rate.
RESULTS—Fifteen community based surveys were identified. The methodological quality varied considerably and was generally low. Even the two most methodologically sound prospective studies yielded widely varying cumulative incidence rates of 5-19%. Referral rates or the need to seek help because of crying were consistently lower than occurrence rates for prolonged crying as such. Gender, socioeconomic class, type of feeding, family history of atopy, and parental smoking were not shown to be associated with colic.
CONCLUSION—Occurrence rates of infantile colic vary greatly according to methodological quality. A considerable number of parents reporting prolonged crying do not seek or need professional help.

     

The progressive development of pyloric stenosis: a role for repeat ultrasound.

INTRODUCTION: Patients presenting in the first 3 months of life with nonbilious emesis are commonly studied by ultrasound. A negative study effectively rules out pyloric stenosis. However, the development of pyloric stenosis is a progressive and dynamic process. The rate of hypertrophy to the point of meeting diagnostic criteria is unknown and there is no data published in the literature regarding the role of repeat ultrasound in patients with persistent symptoms. During a prospective, randomized trial we identified 3 patients with negative ultrasounds who subsequently were diagnosed and treated for pyloric stenosis. We present this series as an illuminating depiction of the development of muscle hypertrophy in patients with pyloric stenosis. METHODS: Patients with pyloric stenosis and repeat ultrasound were identified from our prospective, randomized trial. All patients had sonographic pyloric measurements obtained at our institution. Data included patient age upon presentation, ultrasound-defined pyloric parameters, operation, and outcome. RESULTS: Three patients were identified with a negative ultrasound with a pyloric thickness ranging from 0.8 mm to 2.5 mm. Subsequent thickness on repeat ultrasound ranged from 3.5 to 6.2 mm. The rate of hypertrophy ranged from 0.17 mm/day to 0.5 mm/day. CONCLUSIONS: A negative pyloric sonogram may be due to the fact that the patient is in the very initial stages of development of pyloric stenosis. Caregivers should counsel parents to return if symptoms persist and there should be a low threshold for repeat ultrasound in these patients.     

Nebulized budesonide versus oral steroid in severe exacerbations of childhood asthma

The aim of this study was to assess whether nebulized budesonide may substitute for oral prednisolone in the management of children whose asthma is severe enough to warrant hospital admission, but who have no life threatening features. In a prospective, double-blind, randomized study nebulized budesonide (2 mg 8 hourly) was compared with oral prednisolone (2 mg/kg at entry and again at 24 h) in 46 children admitted to hospital with severe asthma exacerbations. Efficacy variables (including lung function measurements such as the primary outcome variable, Forced Expiratory Volume in 1 second (FEV₁) and symptoms) were measured 24 h after treatment initiation. FEV₁ improved significantly compared to baseline in patients who received nebulized budesonide compared to the prednislone group. The data show nebulized budesonide to be at least as effective as oral steroid in improving lung function and symptom severity in severe exacerbations of childhood asthma.     

Status of Newborn Screening and Inborn Errors of Metabolism in India

Inborn errors of metabolism (IEM) are a heterogeneous group of genetic disorders that cause significant neonatal and infant mortality. Expanded newborn screening which detects these disorders at birth is the standard preventive strategy in most countries. Prospective studies to evaluate the impact of these in the Indian population are lacking. The imminent need to address this lacuna warrants a review of available pan India data, as well as efforts for a carefully conducted prospective assessment of the burden of IEM. Published data on IEM in the Indian population comprising universal prospective screening and screening in selected subgroups (patients admitted to pediatric/neonatal ICUs, patients with developmental delay/mental retardation) was collected through a systematic search. The primary focus was to get an estimate of the disease burden in the Indian population. A true prevalence of IEM in India is not available. The systematic review identifies and stratifies the various situations where IEM are found. Data collected by universal screening of the low risk population is essential to identify the true prevalence of IEM in India.     

Relationship between pressure passivity and subependymal/intraventricular hemorrhage as assessed by pulsed Doppler ultrasound

A prospective study was undertaken using a range-gated, pulsed Doppler velocimeter to study flowpressure relationships in the anterior cerebral artery. Serial velocity and pressure studies were performed with each infant serving as his or her own control. The hypothesis tested was that ill preterm infants sustaining subependymal/intraventricular hemorrhage would have absent autoregulation. The hypothesis has been tested in 88 studies on 32 infants. Of 32 infants studied, 15 were judged to be pressure passive; nine of these children bled. The other 17 infants were not pressure passive; eight of these children bled (P greater than .05). From these studies, it may be concluded that the pressure passive state is not the final common link in the genesis of subependymal/intravertricular hemorrhage. Pulsed Doppler ultrasound may provide an extremely useful noninvasive technique for studying both the arterial and venous sides of the cerebral circulation.