Can parents predict the severity of childhood obstructive sleep apnoea?

OBJECTIVE: To determine whether parents' observations can be used to predict the severity of the obstructive sleep apnoea syndrome (OSAS) in children. STUDY DESIGN: Sixty-five children with OSAS diagnosed by overnight polysomnography were consecutively recruited and classified as having severe or non-severe OSAS according to the obstructive apnoea index (OAI) and the oxygen saturation measured by pulse oximetry (SpO2) nadir. Parents were asked to complete a questionnaire about the child's breathing difficulties at night. RESULTS: Twenty-eight patients were classified as severe OSAS and 37 as non-severe OSAS. There were no differences between the two groups with respect to age, sex or body mass index. Male to female ratio was 5:1. Parents of children with severe OSAS more frequently reported observed cyanosis (35 vs 8%; p=0.02); obstructive apnoea (60 vs 35%; p = 0.04); snoring extremely loudly (52 vs 22%; p = 0.01); shaking the child (64 vs 35%; p = 0.02); watching the child during sleep and being afraid of apnoea (85 vs 60%; p = 0.03). However, neither any single nor combinations of observations showed high values for both sensitivity and specificity. CONCLUSIONS: Although some parents' observations are more frequently reported in children with severe OSAS, neither any single nor combinations of observations accurately predict the severity of OSAS. Polysomnography is still needed to determine the severity of obstruction.     

SARS‐CoV‐2 and human milk: What is the evidence?

The novel coronavirus SARS‐CoV‐2 has emerged as one of the most compelling and concerning public health challenges of our time. To address the myriad issues generated by this pandemic, an interdisciplinary breadth of research, clinical and public health communities has rapidly engaged to collectively find answers and solutions. One area of active inquiry is understanding the mode(s) of SARS‐CoV‐2 transmission. Although respiratory droplets are a known mechanism of transmission, other mechanisms are likely. Of particular importance to global health is the possibility of vertical transmission from infected mothers to infants through breastfeeding or consumption of human milk. However, there is limited published literature related to vertical transmission of any human coronaviruses (including SARS‐CoV‐2) via human milk and/or breastfeeding. Results of the literature search reported here (finalized on 17 April 2020) revealed a single study providing some evidence of vertical transmission of human coronavirus 229E; a single study evaluating presence of SARS‐CoV in human milk (it was negative); and no published data on MERS‐CoV and human milk. We identified 13 studies reporting human milk tested for SARS‐CoV‐2; one study (a non‐peer‐reviewed preprint) detected the virus in one milk sample, and another study detected SARS‐CoV‐2 specific IgG in milk. Importantly, none of the studies on coronaviruses and human milk report validation of their collection and analytical methods for use in human milk. These reports are evaluated here, and their implications related to the possibility of vertical transmission of coronaviruses (in particular, SARS‐CoV‐2) during breastfeeding are discussed.     

Does maternal depression predict young children’s executive function? – a 4‐year longitudinal study

Background: Building on reports that parental maltreatment and neglect adversely affect young children’s executive function (EF), this longitudinal study examined whether exposure to a more common risk factor, mothers’ depressive symptoms, predicted individual differences in EF at school‐age. Methods: We followed up at age 6 a socially diverse sample of 126 children (78 boys, 48 girls) for whom direct observations of mother–child interactions have been shown to predict gains in EF between the ages of 2 and 4. We used an EF latent factor based on scores from three tasks (Beads, Day/Night, Tower of London) that tapped working memory, inhibitory control and planning, as well as a latent growth model of mothers’ Beck Depression Inventory factor scores at four time‐points, and included age 6 verbal ability as a covariate in all analyses. Results: The intercept and slope for mothers’ depressive symptoms each predicted unique variance in EF at age 6; these predictive effects remained significant when we also included: (a) age 2 working memory, (b) maternal education and (c) direct observations of maternal positive control at ages 2 and 6. Conclusion: Our findings suggest that early exposure to mothers’ depressive symptoms adversely affects children’s developing EF, and that the chronicity of this exposure may matter.     

Can severity‐of‐illness indices for neonatal intensive care predict outcome at 4 years of age?

Aim: To test four neonatal severity-of-illness indices (CRIB, NTISS, SNAP, SNAP-PE) for their ability to predict short- and long-term outcome in very low-birthweight infants receiving neonatal intensive care.

Methods: Data on 240 newborns with birthweights below 1500 g from two Swedish neonatal units were collected. The predictive values of the indices for an adverse outcome in the neonatal period and at 4 y of age were compared with those of gestational age and birthweight.

Results: An early adverse outcome (in-hospital death, severe haemorrhagic-ischaemic brain lesion, retinopathy, chronic lung disease) was better predicted with CRIB (area under ROC curve (Az) = 0.87) and SNAP-PE (Az = 0.86), while SNAP-PE was best for predicting late problems (deviations in growth and psychomotor development, neurosensory impairment, difficulties in concentration, and impairment in vision, and hearing,) (Az = 0.63). All indices predicted the early outcome better than the outcome at the 4-y follow-up. Severity-of-illness indices can be used as instruments to follow and improve the level of neonatal intensive care, but unfortunately seem to be of little value in long-term follow-up.

Conclusion: CRIB and SNAP-PE indices are better in predicting hospital mortality than birthweight. None of the systems can predict adverse outcome at 4 y of age.     

Can ‘high‐risk’ human papillomaviruses (HPVs) be detected in human breast milk?

Aim: Human papillomavirus (HPV) transmission via nonsexual modes in childhood has been proposed by several researchers. The aim of our study was to determine the presence of ‘high‐risk’ HPV DNA in human breast milk. Methods: Using polymerase chain reaction techniques, we evaluated the presence of HPV infection in human breast milk collected from 21 HPV‐positive and 11 HPV‐negative mothers. Results: Of the 32 studied human milk specimens, no ‘high‐risk’ HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58 or 58 DNA was detected. Conclusion: This preliminary case–control study indicates the absence of mucosal ‘high‐risk’ HPV types in human breast milk.     

Can MII–pH values predict the duration of treatment for GERD in preterm infants?

BackgroundLittle is known regarding the prognostic role of Multichannel Intraluminal Impedance and pH monitoring (MII/pH) parameters in preterm infants with Gastro-Esophageal Reflux Disease (GERD).AimOur study aimed to evaluate the relationship between MII/pH variables and the duration of pharmacological therapy for GERD, in preterm infants with gestational age (GA) ≤ 34 weeks.Subjects, study design, outcome measuresWe retrospectively reviewed data of all newborns with GA ≤ 34 weeks that underwent MII/pH in our Neonatal Intensive Care Unit (NICU) and pharmacological treatment for GERD. We included them in a 12-month follow-up program. MII/pH parameters were used as independent variables and the duration of pharmacological therapy as dependent variable in linear regression models.Results16 patients (GA 28.4 ± 1.8 weeks, BW 1122 ± 427 g) were enrolled into the study. Regression analysis performed on all reflux events reported a significant correlation between the duration of pharmacological treatment and MII-BEI (r² = 0.36, p = 0.01) and MII-reflux frequency (r² = 0.33, p = 0.02). Moreover, regression analysis performed on all events classified according to the corresponding pH change – acidic (ac.), weakly acidic (w.ac.) or weakly alkaline (w.a.) – showed a significant correlation between the duration of pharmacological treatment and MII-w.ac.BEI (r² = 0.26, p = 0.05), MII-w.ac. reflux frequency (r² = 0.44, p = 0.01), and MII-proximal w.ac. reflux frequency (r² = 0.35, p = 0.02). No statistically significant correlation was found between pH-Reflux Index and the duration of treatment.ConclusionThe study shows how, in our population of preterm infants, MII-parameters could have not only a diagnostic role, but also a prognostic value in terms of the duration of pharmacological treatment.     

Donor‐specific antibodies: Can they predict C4d deposition in pediatric heart recipients?

There is limited evidence regarding the utility of circulating DSA in surveillance for AMR of pediatric heart recipients. Our hypothesis is that quantitation of DSA improves their power for predicting a C4d+, an integral component in the current diagnostic criteria of AMR. All pediatric recipients transplanted between 10/2005 and 1/2011 were retrospectively reviewed for DSA determined within 48 h of EMB. C4d+ was defined as >25% endothelial cell staining by immunohistochemical methods. A total of 183 paired DSA–EMB determinations were identified in 60 patients, a median of three paired studies per patient (range: 1–9). DSA were detected in 60 of these determinations. A receiver‐operating characteristic plot identified a threshold single‐antibody MFI of >6000 that strongly correlated with C4d+ (p < 0.0001) with a high negative predictive value (0.97) and specificity (0.95). The sensitivity and positive predictive values were 0.71 and 0.60, respectively. The predictive power of single‐antigen DSA for C4d deposition was improved in pediatric heart recipients using an institution‐specific MFI threshold value. In post‐transplant care, quantitative DSA should be an essential component in the surveillance for AMR.     

Can methadone concentrations predict the severity of withdrawal in infants at risk of neonatal abstinence syndrome?

AIM: To assess the usefulness of cord and serum methadone concentrations at 2 days of age in predicting the severity of neonatal abstinence syndrome (NAS) in infants whose mothers received methadone during pregnancy. METHODS: After informed consent, infants were enrolled if they were delivered at 35 weeks gestation or greater. Relevant information was collected from maternal notes. A sample of cord blood was taken at delivery, with a follow up sample at 48 hours of age. The samples were analysed in batches, and the results were unavailable to the attending clinical staff. Infants were treated for NAS on clinical grounds according to a standardised scoring system. RESULTS: Twenty five of 36 eligible infants over the 21 month period of the study were enrolled. Of these, 12 required treatment for NAS. Maternal methadone dose did not predict the need for treatment. However, infants who required treatment had significantly lower methadone concentrations in cord blood than the group who did not receive treatment (31 v 88 ng/ml respectively; p = 0.029). Paired blood samples for methadone concentrations were available for 17 infants. All but one of the 12 infants who required treatment had undetectable concentrations of methadone in the postnatal sample, whereas the median postnatal methadone concentration in untreated infants was 23 ng/ml (p = 0.002). CONCLUSIONS: Methadone concentrations taken from cord blood may identify infants at greater risk of neonatal withdrawal and therefore requiring treatment.     

Chickens and eggs—how should we interpret environment‐behavior associations?

As usual, the research published in this issue of the Journal of Child Psychology and Psychiatry contains impressive state‐of‐the‐science studies of child and adolescent psychopathology and related issues. Breeman and colleagues, for example, found that children born before 32 weeks gestation or with a very low birth weight (<1,500 g) were not only more frequently diagnosed with Attention‐Deficit Hyperactivity Disorder (ADHD) during childhood, but continued to have an increased risk for attention problems up through early adulthood.     

Can pediatric steroid‐free renal transplantation improve growth and metabolic complications?

We analyzed the effects of a steroid avoidance protocol in pediatric renal transplant recipients on calculated CrCl (Schwartz), CMV infection, cholesterol, height Z scores, weight Z scores, and BMI Z scores in a case control trial with contemporaneous controls. From 1999 to 2004, 19 pediatric patients (age 1-20 yr) received transplants without steroids using immunosuppression with tacrolimus, mycophenolate mofetil, and daclizumab. Control patients (n = 30) were matched for length of follow-up (minimum one yr), donor type age, type of immunosuppression, sex, date of transplant, and original disease, and CMV status. Graft survival at one year was 100% in both groups. Mean CrCl of steroid-free vs. control patients were not different at 1 year post-transplant. CMV disease was more prevalent in steroid-treated control group (seven of 30 patients) vs. the steroid free control group (zero of 19). Height delta Z scores at one year were NOT different between groups. Weight and BMI delta Z scores were significantly higher in the control group. Cholesterol levels at one year post-transplant were different in the two groups but NOT ABNORMALLY elevated in either group. At one yr post-transplant, steroid-free immunosuppression with tacrolimus, mycophenolate mofetil and daclizumab provides outcomes that are equivalent or superior to those in contemporaneous control patients receiving steroids.     

LC‐PUFA content in human milk: Is it always optimal?

The content of long-chain polyunsaturated fatty acids (LC-PUFAs) in human milk has been connected with infant growth and developmental indices. The LC-PUFA content of human milk usually reflects the dietary habits of mothers, so questions have been raised regarding the possibility of enriching maternal diet with LC-PUFAs during lactation (or even before) in order to improve infant outcome. Nevertheless, environmental and genetic factors have independent roles in affecting both maternal milk composition and infant development.

Conclusion: Diet-related differences in the LC-PUFA composition of human milk are under active investigation for their possible contribution to infant development, but environment- and gene-related differences in both human milk composition and maternal diet should be considered in evaluating the adaptive mechanisms of infants and the effects of specific LC-PUFA dietary supplementations.     

Diagnosis of gastrointestinal graft‐versus‐host disease—Is rectal biopsy enough?

BACKGROUND: Graft-versus-host disease (GVHD) is an important cause of morbidity and mortality after allogeneic bone marrow transplantation (BMT). The clinical diagnosis of gastrointestinal GVHD can be difficult to establish and endoscopic diagnosis entails a procedural risk. The aim of this study was to determine whether rectal biopsy alone might be sufficient to establish or exclude the diagnosis of intestinal GVHD. METHODS: A retrospective chart review of children with histological evidence of gastrointestinal GVHD after allogeneic BMT at the Royal Children's Hospital in Melbourne, Australia, between January 1981 and July 2004. RESULTS: During the study period, 264 patients received allogeneic BMT. Thirty-three had either an upper or lower gastrointestinal endoscopy, or both. Of these, 14 (8 M: 6 F, mean age 9 years 5 months at the time of BMT) had histological features suggestive of GVHD in at least one gastrointestinal biopsy. Overall, 9 of 14 could have been diagnosed with GVHD on the basis of rectal biopsies alone (negative predictive value: 64%). Gastroscopy was needed to establish the diagnosis in a further five patients. Multiple biopsies obtained from each site in the lower gastrointestinal tract showed similar histological findings, but there was frequent non-agreement between biopsies obtained at differing sites within the upper gastrointestinal tract. CONCLUSIONS: Based on these results, we suggest that regardless of symptoms, rectal biopsy should initially be performed to identify gastrointestinal GVHD. Gastroscopy should be added only if the rectal biopsy is unhelpful and there is still good reason to suspect GVHD.