Preliminary experience with nesiritide in the pediatric population

Nesiritide is a recombinant formulation of brain-type natriuretic factor. Preliminary experience in the adult population suggests that nesiritide may be an effective agent in the treatment of decompensated congestive heart failure. Given its physiologic effects, it may be an effective agent in the pediatric population; however, to date, there are no reports regarding its use in infants and children. The authors retrospectively review their experience with nesiritide in 5 pediatric patients. The cohort of 5 patients included a diverse population with 2 patients who were status postcardiothoracic surgery, 2 with adult respiratory distress syndrome, and 1 in the recovery phase from septic shock. Although no direct measurement of cardiac output was feasible as none of the patients had a pulmonary artery catheter, other indicators of increased cardiac output were noted. These included improved peripheral perfusion with warming of the extremities and improvement of peripheral pulses in all of the patients, increased venous saturation in 2 of the patients, and maintenance of or increased urine output despite weaning or discontinuation of diuretics. In 3 of the patients, nesiritide was started as the primary agent to provide a decrease in systemic vascular resistance and augment cardiac output, while in the other 2 patients, nesiritide was used when other vasoactive agents failed to provide the desired effect or resulted in adverse effects.     

Limb fractures and nonaccidental injury in children less than 24 months of age.

AIM: The pattern of limb fractures in children aged 24 months or younger is poorly understood. This age group is particularly vulnerable to nonaccidental injury, which can be difficult for inexperienced clinicians to detect. The aim of this study is to identify fracture patterns in children below the age of 24 months. METHODS: Data was collected prospectively. For all fractures, the mechanism of injury including height of fall (cm), severity of injury, outcome and deprivation scores were collected. Information on children referred for child-protection review was also noted. RESULTS: During the 12 months of the year 2003, 122 new patients aged less than 24 months presented with limb fractures directly to the Emergency Department of the Royal Hospital for Sick Children, giving an incidence of 4.55 per 1000 in the 0-12-month group and 17 per 1000 in the 13-24-month group. Sixty-three (52%) children sustained the injury during a fall and only 7% of children were admitted, the rest being followed up as outpatients. Thirty-eight (31%) had simple distal radius/ulna fractures. Five children with unclear histories or mechanisms of injury underwent formal child-protection procedures. All were less than 14 months of age. CONCLUSIONS: Fractures are relatively rare in the first 2 years of life. Child protection needs to be considered in all children, but specifically in those patients with atypical fractures presenting with an unclear mechanism of injury.     

社区36个月内婴幼儿营养不良发病状况分析

[目的]了解我院社区卫生服务中心儿童保健门诊婴幼儿营养不良发病情况及其影响因素.[方法]对1 387例36个月内婴幼儿进行系统的监测,并对婴幼儿营养不良发病情况进行回顾性分析.[结果]营养不良总发病率为13.77%,以低体重类型为主,占营养不良的73.30%(140/191).轻度营养不良的发生率最高,为8.94%(124/1 387),中度营养不良的发生率为4.69%(65/1 387);7个月～12个月婴幼儿营养不良的发病率明显高于其他月龄段,而13个月～24个月婴幼儿营养不良患病率最高;营养不良发生的主要影响因素有喂养方式、添加辅食时间、家庭经济状况和父母文化程度等.[结论]24个月以内婴幼儿是防治营养不良的重点对象,早期普及教育,提倡母乳喂养,加强对婴幼儿家长喂养知识的指导,及时合理增加各种营养食物是降低婴幼儿营养不良的重要措施.     

卡泊芬净在新生儿及不足3月龄婴儿中的药动学和安全性研究

念珠菌感染在新生儿监护室,特别是对于极低体重（〈1500g）新生儿是一个主要威胁。迟发性脓毒血症在重症患儿及低体重新生儿的患病率约为20％,其中至少10％的感染由念珠菌引起。     

Preliminary experience with amlodipine in the pediatric population

The authors retrospectively examined their experience with amlodipine in the treatment of hypertension in 32 pediatric-aged patients, ranging in age from 4 to 26 years, with blood pressure (BP) readings greater than the 90th percentile for age. Amlodipine was used as the sole therapy in 9 patients and with other antihypertensive therapy in 23 patients. Additional antihypertensive drugs used in combination with amlodipine included beta-adrenergic antagonists, ACE inhibitors, and diuretics. The starting dose of amlodipine was 0.13+/-0.09 mg/kg/d. The dose was increased in 20 of 32 patients to 0.23+/-0.13 mg/kg/d. Amlodipine was administered once daily to 26 patients and twice daily to 6 patients. After therapy with amlodipine was initiated, the systolic BP decreased from 141+/-15 to 132+/-9 mm Hg (P=0.01) and the diastolic BP decreased from 84+/-16 to 77+/-8 mmHg (P=0,03). There were a total of 2145 follow-up BP readings. The follow-up systolic BP was lower than the initial BP prior to starting amlodipine 59% of the time and the diastolic BP was lower than the initial BP 61% of the time. The follow-up systolic BP was lower than the 90th percentile predicted for age 33% of the time after starting amlodipine and the diastolic BF was lower than the 90th percentile for age 52% of the time. Adverse effects were noted in 4 of the 32 patients (12.5%). These included fatigue (n=2), dizziness (n=1), and ankle edema (n=1). Amlodipine therapy was discontinued in only 1 patient (the patient with ankle edema). Given its efficacy, the low incidence of adverse effects, and availability as a suspension, amlodipine is an effective agent for the treatment of hypertension in the pediatric-aged patient.     

Carcinoma of the colon and rectum in patients less than 20 years of age

We report the cases of eight children and adolescents with adenocarcinoma of the colon treated at three large referral hospitals over a 25-year period. We recorded demographic factors, initial symptoms, stage at operation, type of operation, pathologic grade, and survival, and compared our results to those in the English literature. There were seven male patients and one female patient, with an average age of 15.1 years and an average duration of symptoms of 7 1/2 months. The most common initial complaint was rectal bleeding (6/8 patients, 75%). Pain, anemia, and abdominal distention were present in five of the eight patients (63%). Six of our eight patients (75%) had stage C or D disease at diagnosis, and six of the eight tumors (75%) were poorly differentiated. Only three of the eight patients lived for more than six months. Unexplained gastrointestinal bleeding or abdominal complaints in children should prompt a thorough investigation of the gastrointestinal tract.     

6个月内婴儿正常髋关节的超声表现

目的探讨6个月内婴儿不同月龄正常髋关节的超声特点及变化情况,为诊断6个月内婴儿髋关节发育不良提供参考。方法对290个正常髋关节进行超声检查,根据月龄分为0~2月组(n=56)、2~4月组(n=130)、4~6月组(n=104)三组,运用Graf法对图像进行测量,对不同月龄组间测量结果进行统计分析。结果超声可清晰显示髋关节形态结构、股骨头及髋臼位置关系。290个髋关节中,97.9%为Ⅰ型,2.1%为Ⅱa型。左右两侧髋关节的α角、β角的差异无统计学意义(F=1.56,P0.05);各月龄段左右两侧髋关节的α角、β角的差异均无统计学意义(F=1.23~2.75,P0.05);而各月龄组正常髋关节α角、β角不年龄组间差异有统计学意义(F=18.72,25.72,P0.05)。结论超声能够良好显示髋关节的形态特点,为婴儿发育性髋关节异常早期确诊及筛查提供参考依据。     

Safety of procedural sedation and analgesia in children less than 2 years of age in a pediatric emergency department

Background

Although young age is considered a risk factor for adverse events related to procedural sedation and analgesia (PSA), data in very young children (<2 years of age) are lacking.

Aims

The main objective of our study is to describe PSA in children <2 years of age in an inner city tertiary care pediatric emergency department (PED).

Methods

We conducted a retrospective chart review from January 2005 to June 2007 of children <2 years of age who received PSA in our PED. We collected demographic variables, indication for and medications used for PSA, adverse events (AE) related to PSA, and interventions performed to treat them.

Results

Of the children who received PSA, 14.5% (180/1,235) were <2 years of age of whom 173 were included for the analysis; 73% (126/173) of the study subjects were between 1 and 2 years of age, 54.3% (94/173) were male, and 96.5% (167/173) belonged to American Society of Anesthesiologists class 1. Incision and drainage (45.0%, 78/173) and laceration repair (32.4%, 56/173) were the two most common indications for PSA. Ketamine and midazolam was the most common combination medication used for PSA (62.4%, 108/173). Sedation was deemed ineffective in 5.8% (10/173) of the children. There were only two failed sedations; 5.8% (10/173) of the children experienced AE with most being minor [oxygen desaturations 1.7% (3/173), emesis 2.3% (4/173), and others 1.2% (2/173)]. One child experienced serious AE in the form of apnea and bradycardia requiring intubation.

Conclusions

Our data suggest that children under 2 years of age can be sedated effectively without increased risk of AE in a PED.     

Additional experience with dexmedetomidine in pediatric patients

PURPOSE: This study evaluates the efficacy of dexmedetomidine in clinical scenarios other than sedation during mechanical ventilation. METHODS: We conducted a retrospective chart review and presentation of case series of children in the pediatric intensive care unit and the postanesthesia care unit who received dexmedetomidine. RESULTS: Dexmedetomidine was administered by continuous infusion to three patients and as a single bolus dose (0.5 microg/kg) to two patients. In the five clinical scenarios, dexmedetomidine provided effective sedation during spontaneous ventilation in two patients, reversed the clinical signs and symptoms of withdrawal from illicit substances in one patient, and was effective in the treatment of postanesthesia emergence delirium and shivering in two additional patients. CONCLUSION: These preliminary data suggest that dexmedetomidine may be an effective agent for sedation in spontaneously breathing patients, in the treatment of drug withdrawal, and in the treatment of two common postanesthesia problems.     

Management of new onset atrial fibrillation in previously well patients less than 60 years of age

Objective: This study reviewed the ED management of new onset atrial fibrillation (AF) in previously well patients aged less than 60 years. Methods: We undertook a retrospective review of ED patients from 1998 to 2002 inclusive. The main outcome measures were approaches to rate or rhythm control and anticoagulation, the use of echocardiography, the value of diagnostic testing and the frequency of hospital admission. Results: Fifty‐two patients were identified. In general, all patients were haemodynamically stable. One patient had mild cardiac failure and one was clinically thyrotoxic. Serum potassium was measured in 51 (98%) patients, magnesium in 23 (44%) and cardiac enzymes in 30 (58%); results were generally unhelpful. Thyroid function tests were carried out in 40 (77%) patients; results were unremarkable except for the clinically thyrotoxic patient. No patient had echocardiography in the ED; however, 6 patients (12%) were later found to have major cardiac abnormalities. Forty‐four (85%) patients received a variety of medications; 37 (71%) received an anti‐arrhythmic and 24 (46%) an antithrombotic. Overall, 17 (33%) patients received theoretically effective therapy for conversion to sinus rhythm. Twenty‐two (42%) patients were admitted to hospital. Conclusions: This study reveals variation in the management of acute AF in previously well, haemodynamically stable, young patients. Pathology testing was frequently carried out with a low yield. There were high rates of attempts to cardiovert, use of antithrombotics and of admission to hospital. Although cardioversion attempts appeared to be contrary to existing guidelines, decisions may have been based primarily on patient symptoms. Echocardiography should be considered prior to anti‐arrhythmic therapy.     

Preliminary experience with the use of recombinant factor VIIa to treat coagulation disturbances in pediatric patients

OBJECTIVE: This study evaluates the efficacy of recombinant factor VII (rVIIa) in the treatment of coagulation dysfunction in pediatric patients. METHODS: We retrospectively reviewed the records of pediatric patients who received rVIIa in the intensive care unit or operating room for treatment of coagulopathy. Case series in the literature were also reviewed. RESULTS: Ten patients, ranging in age from 3 months to 19 years, received 22 doses of rVIIa. Seven of the 10 patients had received fresh frozen plasma and cryoprecipitate before the administration of rVIIa without effect. All 10 patients had a fibrinogen level above 100 mg/dl and platelet count above 100,000/mm3 at the time of rVIla administration. After rVIIa administration, there were significant decreases in prothrombin time, international normalized ratio, and partial thromboplastin time. No adverse effects were noted. CONCLUSION: Recombinant factor VIIa can be used to effectively reverse coagulation disturbances in the pediatric patient even when treatment with fresh frozen plasma has failed. Given its therapeutic potential, prospective, randomized trials are warranted.     

Pharmacokinetics of penicillin G in infants with a gestational age of less than 32 weeks

The pharmacokinetics of penicillin G were studied in 20 preterm neonates with a gestational age of less than 32 weeks on day 3 of life by using a population approach performed with the nonlinear mixed effects modeling program NONMEM. The derived population estimates and the correlation matrix of these estimates were used to perform Monte Carlo simulations and obtain the probability of target attainment (PTA). The pharmacokinetics of penicillin G were best described by a two-compartment pharmacokinetic model. The population estimates of the central volume of distribution, the peripheral volume of distribution, the intercompartmental clearance, and the total body clearance were 0.359 +/- 0.06 liter, 0.152 +/- 0.03 liter, 0.774 +/- 0.28 liter/h, and 0.103 +/- 0.01 liter/h (mean +/- standard error), respectively. The terminal half-life was 3.9 h. Clearance increased significantly with increasing birth weight. Assuming the percentage of time that the concentration of unbound drug remained above the MIC of 50% for preterm neonates, the susceptibility breakpoint based on a 100% PTA was < or =4 mg/liter, simulating the current dosing regimen of 50,000 U/kg every 12 h. This regimen is therefore adequate for the treatment of common infections in neonates on the third day of life.     

Subjective burden over 12 months in parents of patients with schizophrenia

This is a follow-up study aimed at investigating subjective burden in parents of patients with schizophrenia during a 12-month period. Using a narrative interview technique, parents were questioned regarding the subject of illness-related burden; follow-up interviews were conducted after 6 and 12 months, respectively. Forty-seven interview sets were examined with the aim of determining different types of burden development. The analysis yielded the following six developmental types: (1). constantly high level of burden; (2). increased burden; (3). reduced burden; (4). shifting burden; (5). preeminence of other burdens; and (6). constantly low level of burden. In general, changes in the parents' burden level are closely interconnected with the illness curve of the patients, with 40% of the study participants experiencing a constantly high level of burden during the course of the study. The results suggest that parents of continuously and severely affected patients are overloaded with their long-term caring tasks. Particularly for these extremely strained parents, practical and psychologic assistance should be provided.     

Fever in children less than 36 months of age--questions and strategies for management in the emergency department

Fever is a common pediatric complaint in the Emergency Department. Emergency Physicians often must be conservative in their management of febrile children, as patient follow-up is not always available. A unified approach for the management of febrile infants will be discussed in this article.     

Initiation of breast-feeding practice and associated factors among mothers who have infants less than 12 months of age in Debre Tabor Town,North West Ethiopia, 2021: A multicenter community-based cross-sectional study

Introductioninitiation of breastfeeding is crucial in preventing newborn deaths and influences childhood nutrition. There was limited updated evidence regarding early initiation of breast-feeding practice and associated factors among the target population in the study area.ObjectiveTo assess initiation of breastfeeding practice and its associated factors among mothers who have infants less than six months of age in, North West Ethiopia, 2020.MethodsThe Community based quantitative cross-sectional study was conducted among 405 respondents in the stud area, then data would be entered and analyzed by using SPSS version 20 statistical packages. Bivariate and multivariable logistic regression model analysis would be done. Odds ratio with 95% confidence was computed to determine the level of significance-value less than 0.05 considered as significant.ResultThis study showed that 94.7% of mothers in Debre Tabor Town practiced initiation of breastfeeding for their infants within the Less Than 12 Months of age. In multivariable analysis I n f a n t S e x, Female [AOR (95% CI) = 0.068 (0.002, 1.659), and Age of Mother 20–24 years [AOR (95% CI) = 2.33 (0.030, 17.12)], 25–29 years ((AOR = 8.20 [(95% CI: 12.212, 22.189]), and 30–34 years (AOR = 4.48 [95% CI: 0.463, 15.478], Assists (Attend) during delivery, Doctor (AOR = 0.644 [95% CI: 0.041, 10.138]) and Encourage BF by religious father (AOR = 6.669 [(95% CI: 4.27, 8.895]) were remained significantly associated with the outcome variable with at 95% CI and P- value of <0.05.Conclusionand Recommendation: The prevalence of EIBF among mother-infant pairs of less than 12 months in debre tabor town, Northwest, Ethiopia, was found to be high as compared to national and global infant and young child feeding guidelines. However; it shows improvement as compared with some previous studies in Ethiopia. I n f a n t s e x, age of mother, assists during delivery, and encourage BF by religious father were factors associated with outcome in the stud area.     

Preliminary experience with plasma exchange in patients with ulcerative colitis

We decided to test the effect of plasma exchange (PE) in selected patients with inflammatory bowel disease in which conventional medical treatment proved insufficient. Twenty-six patients with ulcerative colitis (UC) were treated with PE, six patients with fulminant colitis and 20 with long lasting severe colitis. After very promising results initially, 17 patients with long lasting severe colitis were selected in a careful prospective study. Twelve patients completed the treatment protocol. Two litres of plasma were exchanged every second or third day, 5-6 times in two weeks. The replacement fluid was fresh frozen plasma. The activity indices and histological evaluation were used as criteriae for treatment response. A reduction of 35% in the activity index is considered a significant improvement. In all but three patients (out of 12), the activity indices were reduced two weeks after end of treatment. Six patients had a reduction of more than 35%, three patients had a reduction between 22-28% and three had a reduction less than 10%. None became worse. In this carefully studied group, the immediate beneficial effects of PE was only demonstrable by the activity indices and not evident by blind evaluation of biopsies from the mucosa. In two of the six patients with fulminant colitis, PE was followed by an immediate dramatic clinical improvement. In the follow up period (2-14 years) 14 of the 26 patients reported marked and long lasting improvement of inflammatory bowel disease. We conclude that PE might be beneficial in subsets of patients with UC.     

Cancer pain management at home (I): do older patients experience less effective management than younger patients?

Goals of work  We wanted to examine whether older cancer patients living at home experienced poorer pain management than younger patients, and if so, what were the potential explanations for this. Materials and methods  We interviewed 90 new referrals to community palliative care services who were aged 75 years and above or aged 60 years and below. We asked about pain intensity, pain relief and pain quality, access to and type of analgesic medication and, finally, sources of support and self-management strategies. Main results  Older and younger cancer patients who were living at home had very similar experiences of pain, pain relief, access to and use of analgesia, contact with health care professionals and use of additional pain management strategies. As a whole, participants had more frequent contact with family members, community nurses and pharmacists than with general practitioners. Conclusions  In this sample, the experience and management of pain in older cancer patients was no different from that in younger patients. This suggests that delivering improvements in cancer pain management in the community is appropriate for all age groups. In addition, focussing efforts on patients, carers and non-medical health care professionals may prove to be the most successful strategy.     

水胶体敷料对先天性心脏病术后患儿气管插管处皮肤的效果观察

目的探讨水胶体敷料对6个月以下先天性心脏病术后患儿气管插管处皮肤的效果。方法选择6个月以下先天性心脏病术后带气管插管的患儿80例,分为对照组和实验组各40例,对照组使用3 M弹力胶布固定气管插管,实验组使用水胶体敷料保护脸颊后再使用3M弹力胶布固定气管插管。比较2组患儿气管插管拔管后面部皮肤情况。结果实验组患儿在拔除气管插管后面部皮肤完好情况优于对照组(P0.05)。结论使用水胶体敷料做前瞻性保护脸颊,可以降低气管插管后面部皮肤撕脱伤发生率及压疮发生率。     

A 13-year review of lisinopril ingestions in children less than 6 years of age

Abstract

Background. Lisinopril is an angiotensin converting enzyme inhibitor used for treatment of hypertension, congestive heart failure, and acute myocardial infarction. Reports of clinical experience with pediatric ingestions are minimal. Method. A 13-year retrospective study of lisinopril ingestions in children reported to the California Poison Control System was analyzed and case notes were reviewed. Institutional Review Board approval was obtained and cases were blinded. Inclusion criteria were lisinopril as a single ingestant, age less than 6 years, treatment in a health care facility, case followed to a known outcome. Results. Inclusion criteria were met in 296 cases. Demographics include 51% of male patients and the mean age was 1.97 years (range: 9 months–5 years). Of the 296 patients, 8 patients (2.7%) developed hypotension (ranges: 55–74 mm Hg systolic and 22–48 mm Hg diastolic). The lowest blood pressure of 55/22 mm Hg was recorded in a 22-month old male who ingested an estimated 120-mg lisinopril (13.3 mg/kg). The lowest dose of lisinopril causing hypotension was with an estimated dose of approximately 50 mg or 3.9 mg/kg in a 2-year old. Two hundred and eighty-two patients (95.3%) were treated and released from the emergency department and 14 patients (4.7%) were admitted. The dose ingested was reported in 189 cases and an exact-dose of lisinopril was reported in 61 patients (20.6%); mean amount ingested was 3.0 mg/kg, median amount ingested was 2.1 mg/kg (range: 0.1–10.9 mg/kg, N = 38); and mean total dose was 33.4 mg, median total dose was 20 mg (range: 2.5–160 mg, N = 61). None of the patients with exact-dose lisinopril ingestions developed hypotension, received intravenous fluids, or were admitted. Conclusion. The lowest estimated dose of lisinopril to cause hypotension was 50 mg or 3.9 mg/kg. Although continued evaluation of pediatric lisinopril ingestions is essential to determine more specific thresholds of toxicity, the lack of effect on blood pressure in children with exact-dose ingestions indicate that pediatric lisinopril ingestions (for ages > 9 months) ≤ 4 mg/kg up to 40 mg total may be safely managed at home.     

An 11-year review of levetiracetam ingestions in children less than 6 years of age

Background. Levetiracetam is a new anticonvulsant, which works to block high-voltage-activated Ca⁺⁺ channels in children, for partial-onset seizures. Reports of clinical experience with pediatric ingestions are minimal. The purpose of this study was to characterize the toxicity of accidental levetiracetam exposures in children less than 6 years of age. Methods. This was an 11-year retrospective observational case series of pediatric (< 6 years old) levetiracetam ingestions reported to a Poison Control System from 2002 to 2013. Case narratives were individually reviewed to collect desired information on exposure and clinical course. Inclusion criteria were levetiracetam as a single ingested medication, age less than 6 years, treatment in a health care facility, and followed to a known outcome. Results. Eighty-two cases met inclusion criteria with 55% female patients and overall median age of 2.0 years (range: 1–60 months). The levetiracetam dose ingested was reported in 69 (84.1%) cases, with exact dose (median dose, 45.0 mg/kg; range, 10.5–1429 mg/kg) reported in 33 cases (40.2%). Of these, twenty-nine cases (88%) involved the oral solution formulation and 28 cases (85%) had unintentional therapeutic error as the cause of the exposure. No dose–response relationship was demonstrated; however, the odds of a levetiracetam-naive patient, (median dose, 26.9 mg/kg; N = 15) with an unintentional exposure, developing drowsiness or ataxia was 6 times that of a patient who was not naïve to levetiracetam (median dose, 70.1 mg/kg; N = 20) (Odds ratio [OR], 6.0; 95% confidence interval [CI], 1.03–35.91).Of the 82 cases, 17 (20.7%) developed untoward clinical effects of drowsiness and/or ataxia. Eighty patients (97.6%) were treated and discharged from the emergency department, and two patients (2.4%) were admitted. The two patients admitted included a two-month old who was accidentally given a dose 10 times that of her usual dose and a 3-year old who was lethargic on arrival to the hospital after ingestion of an unknown dose. Of all patients, 66 patients (80.5%) had no effect from the drug exposure. The medical outcome was considered to be minor in 15 cases (18.3%), and moderate in 1 case (1.2%). There were no cases with major outcomes and no deaths. Conclusions. Pediatric levetiracetam exposures were associated with few transient clinical effects. Poison Control Centers may wish to consider acuity of ingestion when developing send-in protocols.