Recent advances in management of bronchiolitis

Background

Bronchiolitis is one of the major causes for hospital admissions in infants. Managing bronchiolitis, both in the outpatient and inpatient setting remains a challenge to the treating pediatrician. The effectiveness of various interventions used for infants with bronchiolitis remains unclear.

Need and purpose

To evaluate the evidence supporting the use of currently available treatment and preventive strategies for infants with bronchiolitis and to provide practical guidelines to the practitioners managing children with bronchiolitis.

Methods

A search of articles published on bronchiolitis was performed using PubMed. The areas of focus were diagnosis, treatment and prevention of bronchiolitis in children. Relevant information was extracted from English language studies published over the last 20 years. In addition, the Cochrane Database of Systematic Reviews was searched.

Results and Conclusions

Supportive care, comprising of taking care of oxygenation and hydration, remains the corner-stone of therapy in bronchiolitis. Pulse oximetry helps in guiding the need for oxygen administration. Several recent evidence-based reviews have suggested that bronchodilators or corticosteroids lack efficacy in bronchiolitis and should not be routinely used. A number of other novel therapies (such as nebulized hypertonic saline, heliox, CPAP, montelukast, surfactant, and inhaled furosemide) have been evaluated in clinical trials, and although most of them did not show any beneficial results, some like hypertonic saline, surfactant, CPAP have shown promising results.     

Was ist Schmerz?

Background

Pain is a common symptom in children and adolescents. Depending on the pain duration a distinction is made between acute (<?3 months) and chronic (>?3 months) pain. A multidimensional view to understand acute as well as chronic pain includes biological, psychological and social factors. These three dimensions need to be considered for pain diagnostics and therapy; however, diagnostic procedures and therapy greatly differ between acute and chronic pain.

Acute pain

Acute pain is mostly caused by tissue damage that needs to be identified for a causal treatment. The most important module for acute pain therapy are analgesics. Psychological interventions can be used as complementary measures.

Chronic pain

In chronic pain a physiological basis of the symptom is often missing. An exaggerated search for the one underlying cause may lead to further so-called iatrogenic chronification. The relevance of psychological and social interventions increases the longer the pain lasts. Biological components of chronic pain should only be treated by medical interventions if they trigger nociceptive stimuli or a causal therapy can bring fast pain reduction.     

Non-pharmacological management of abdominal pain-related functional gastrointestinal disorders in children

Background

Abdominal pain-related functional gastrointestinal disorder (AP-FGID) comprises of 4 main conditions: functional dyspepsia, irritable bowel syndrome, abdominal migraine and functional abdominal pain. AP-FGIDs are diagnosed clinically based on the Rome IV criteria for FGIDs of childhood. There is limited evidence for pharmacological therapies.

Data sources

This review article discusses nonpharmacological management of AP-FGID based on the current literature including systematic reviews, randomized controlled trials, cohort and case control studies. We aim to provide a comprehensive overview on the available evidence for the pediatricians and pediatric gastroenterologists involved in managing children with AP-FGID.

Results

Managing AP-FGIDs can be challenging. This should follow a stepwise approach with focused history, identification of “red flag” signs and symptoms, physical examination and investigations done following initial consultation. Family needs explaining that there is nothing seriously wrong with the child’s abdomen. This explanation and reassurance can achieve symptom control in large number of cases. Non-pharmacological interventions are delivered through lifestyle and dietary changes and bio-psychosocial therapies. Dietary interventions vary depending on the type of AP-FGID. Bio-psychosocial therapies such as hypnotherapy, cognitive behavioral therapy and yoga aim at stress reduction.

Conclusion

There is increasing evidence for use of non-pharmacological interventions in children with APFGID.

     

Community based newborn care: A systematic review and meta-analysis of evidence: UNICEF-PHFI series on newborn and child health, India

Background

The neonatal mortality rate (NMR) in India has remained virtually unchanged in the last 5 years. To achieve the Millennium Development Goal (MDG) 4 on child mortality (two thirds reduction from 1990 to 2015), it is essential to reduce NMR. A systematic review of the evidence on community-based intervention packages to reduce NMR is essential for advocacy and action to reach MDG-4.

Objective

To assess the effect of community based neonatal care by community health workers (CHWs) on NMR in resource-limited settings.

Design

Systematic review and meta-analysis of controlled trials.

Data sources

Electronic databases and hand search of reviews, and abstracts and proceedings of conferences.

Results

A total of 13 controlled trials involving about 192000 births were included in this systematic review. Community based neonatal care by CHWs was associated with reduced neonatal mortality in resource-limited settings [RR=0.73 (0.65 to 0.83); P<0.0001]. The identified studies were a heterogeneous mix with respect to the extent and quality of community based neonatal care provided and the characteristics of the CHWs delivering the intervention. There was no consistent effect of training duration of the health workers, type of intervention (home visitation versus community participatory action and learning), number of home visits done by CHWs, and provision of only preventive versus both preventive and therapeutic care. Limited data suggests that the ideal time for the first postnatal visit is the first two days of life. The interventions are highly effective when baseline NMR is above 50/1000 live births [RR=0.64(0.54 to 0.77)]. The interventions show a significant decrease in efficacy as the NMR drops below 50/1000 live births [RR=0.85 (0.73 to 0.99)], however is still substantial. NMR gains from home visitation approach are going to materialize only in the presence of high program coverage of 50% or more.

Conclusion

A significant decrease in NMR is possible by providing community based neonatal care in areas with high NMR by community health workers with a modest training duration and ensuring high program coverage with home visitation on the first two days of life.     

Impact of Water,Sanitation and Hygiene Interventions on Growth,Non-diarrheal Morbidity and Mortality in Children Residing in Low- and Middle-income Countries: <Emphasis Type="Italic">A Systematic Review</Emphasis>

Objective

To evaluate the impact of water, sanitation and hygiene (WASH) interventions in children (age <18 y) on growth, non-diarrheal morbidity and mortality in children.

Design

Systematic review of randomized controlled trials, non-randomized controlled trials and controlled before-after studies.

Setting

Low- and middle-income countries.

Participants

41 trials with WASH intervention, incorporating data on 113055 children.

Intervention

Hygiene promotion and education (15 trials), water intervention (10 trials), sanitation improvement (7 trials), all three components of WASH (4 trials), combined water and sanitation (1 trial), and sanitation and hygiene (1 trial).

Outcome Measures

(i) Anthropometry: weight, height, weight-for-height, mid-arm circumference; (ii) Prevalence of malnutrition; (iii) Non-diarrheal morbidity; and (iv) mortality.

Results

There may be little or no effect of hygiene intervention on most anthropometric parameters (low- to very-low quality evidence). Hygiene intervention reduced the risk of developing Acute respiratory infections by 24% (RR 0.76; 95% CI 0.59, 0.98; moderate quality evidence), cough by 10% (RR 0.90; 95% CI 0.83, 0.97; moderate quality evidence), laboratory-confirmed influenza by 50% (RR 0.5; 95% CI 0.41, 0.62; very low quality evidence), fever by 13% (RR 0.87; 95% CI 0.74, 1.02; moderate quality evidence), and conjunctivitis by 51% (RR 0.49; 95% CI 0.45, 0.55; low quality evidence). There was low quality evidence to suggest no impact of hygiene intervention on mortality (RR 0.65; 95% CI 0.25, 1.7). Improvement in water supply and quality was associated with slightly higher weight-for-age Z-score (MD 0.03; 95% CI 0, 0.06; low quality evidence), but no significant impact on other anthropometric parameters or infectious morbidity (low to very low quality evidence). There was very low quality evidence to suggest reduction in mortality (RR 0.45; 95% CI 0.25, 0.81). Improvement in sanitation had a variable effect on the anthropometry and infectious morbidity. Combined water, sanitation and hygiene intervention improved height-for-age Z scores (MD 0.22; 95% CI 0.12, 0.32) and decreased the risk of stunting by 13% (RR 0.87; 95% CI 0.81, 0.94) (very low quality of evidence). There was no evidence of significant effect of combined WASH interventions on non-diarrheal morbidity (fever, respiratory infections, intestinal helminth infection and school absenteeism) (low- to very-low quality of evidence). Any WASH intervention (considered together) resulted in lower risk of underweight (RR 0.81; 95% CI 0.69, 0.96), stunting (RR 0.77; 95% CI 0.68, 0.86) and wasting (RR 0.12, 0.85) (low- to very-low quality of evidence).

Conclusion

Available evidence suggests that there may be little or no effect of WASH interventions on the anthropometric indices in children from low- and middle-income countries. There is low- to very-low quality of evidence to suggest decrease in prevalence of wasting, stunting and underweight. WASH interventions (especially hygiene intervention) were associated with lower risk of non-diarrheal morbidity (very low to moderate quality evidence). There was very low quality evidence to suggest some decrease to no change in mortality. These potential health benefits lend support to the ongoing efforts for provision of safe and adequate water supply, sanitation and hygiene.

     

Non-pharmacological Interventions for Pediatric Cancer Patients: A Comparative Review and Emerging Needs in India

Context

Evidence-based research on psycho-oncology in last three decades lays emphasis upon the critical role of psychological services for better illness adjustment, improved quality of life, reduced distress and cognitive problems among the rapidly increasing pediatric cancer population.

Justification

This review aims to summarize the evidence-based psychological interventions in childhood cancer over the two decades and addresses the wide gap that existed between intervention studies worldwide and India, thus highlighting the need for research and appropriate services.

Evidence acquisition

We searched electronic databases such as MedLine, PubMed, PsycINFO, and Google Scholar. Key search terms were pediatric cancer, psycho-oncology, children with cancer + psychological intervention, or multimodal treatment, psychotherapy, cognitive training, behavioral, social skills+ feasibility study, pilot, randomized controlled trial, case study, systematic reviews.

Results

28 full papers published between 1996 to 2016, including survivors and under-treatment children below 18 years, were reviewed. Various types of key interventions were psychosocial, physical, cognitive behavioral, cognitive, music art therapy and play therapy. Generally, intervention settings were either hospital or home, and were designed to promote psychological well-being. Psychological interventions were more in customised formats in these studies. A generic intervention module was not available for replication.

Conclusion

Development of culture-specific generic intervention module and using the same in randomized control studies with larger effect size are needed in India for larger coverage of patients.

     

Evaluation of Effectiveness of Integrated Intervention in Autistic Children

Objectives

To assess the effectiveness of integrated therapy over the past 3 y on the recipient autistic children and its correlation with the following variables - age at admission, duration of therapy given and initial severity of symptoms.

Methods

The index study was a retrospective study with 18 autistic children as subjects; the maximum duration of intervention was 3 y. The integrated approach consisted of special education using principles of applied behavior analysis, occupational and speech therapy. The progress records, the occupational therapy and the speech therapy progress reports were tabulated as data. The Childhood Autism Rating Scale (Schopler, Reichler and Renner, 1986) was used for evaluation of severity of symptoms at admission and in present day. The data was then compared and analyzed.

Results

The present study showed significant positive results. Only few domains requiring very high integrated cognitive and sensorimotor functioning showed non-significant results. Age at intervention correlated negatively and, duration of therapy given and initial severity of symptoms correlated positively with effectiveness of therapy.

Conclusions

Continuous feedback and modification of the therapy is required to maintain performance and develop target interventions for problematic areas identified. Longitudinal as well as comparative studies are required to better understand the benefits of integrated approach.     

Treatment of children with chronic viral hepatitis: what is available and what is in store

Background

At present, therapy of children with chronic hepatitis B and C is still based on few drugs, all burdened by a series of side-effects, unsatisfactory serum conversion rates, and/or drug-resistance. Moreover, selection of subjects to treat with conventional therapies is not univocal, especially during the pediatric age when the disease course is often mild with significant spontaneous seroconversion rate. Our review deals with pros and cons points when a physician decides to design a drug therapy for a child with chronic viral hepatitis, and different possible therapeutic opportunities.

Methods

A literature search was performed through PubMed. The newest articles, reviews, systematic reviews, and guidelines were included in this review.

Results

The management of children with viral hepatitis is still controversial over whom and when to treat and the use of drug(s). Novel therapeutic strategies have been evaluated only in clinical and preclinical trials involving, for instance, “therapeutic” vaccines. The data on safety and effectiveness of new drugs are also reviewed.

Conclusion

The results of reported studies confirmed that at least some of the new drugs, with greater efficacy and/or minor side-effects, will be used clinically.     

Propranolol therapy for infantile hemangioma

Context

There has been widespread interest surrounding the use of beta-blockers (i.e. propranolol, timolol, nadolol, acebutolol) in the treatment of infantile hemangiomas (IH).

Objective

To review literature evaluating treatment of IH with propranolol.

Evidence Acquisition

We conducted a literature search on PubMed and investigated for case reports, case series, and controlled trials by using search terms including “hemangioma” and “propranolol.”

Results

Data suggest that beta-blockers are efficacious in cutaneous, orbital, subglottic, and hepatic hemangiomas and assist in the resolution of ulcerated hemangiomas. Improvement has also been documented in children with PHACE syndrome. Propranolol produces favorable results in children who do not respond to steroids and with no long-term adverse effects. Propranolol should be administered with caution due to rare but serious side effects including hypoglycemia, wheezing, hypotension, and bradycardia. Additionally, recurrence of lesions following the cessation of treatment has been documented.

Conclusions

Although large-scale randomized controlled trials must be conducted in order to further evaluate the safety and the possible role of propranolol in the treatment of IH, the reviewed literature suggests that propranolol carries promise as a potential replacement for corticosteroids as first-line therapy or as a part of a multimodal approach.     

Does mothers’ perception of social support mediate the relationship between fecal incontinence and quality of life of the child?

Purpose

Fecal incontinence is a common problem in children and adolescents with anorectal malformation (ARM) and may negatively impact psycho-social well-being. Mothers’ perception of social support has been proved to contribute to children’s quality of life (QOL). Considering ARM studies, the role of family and social resources have received little attention. The aim of the present study was to analyze whether mothers’ perception of social support mediates the impact of child fecal incontinence on his/her QOL.

Methods

One hundred and nine mothers with a child born with ARM (aged 6–15 years old; mean age = 11 years) completed questionnaires including the fecal incontinence subscale of the Hirschsprung’s Disease/Anorectal Malformation QOL Questionnaire, the Pediatric QOL Inventory, and a social relationship questionnaire. Structural equation models were used to explore the relations hypothesized.

Results

No differences were found in the QOL scores across gender. The hypothesized model fits the data well; mothers’ perception of social support partially mediated the relationship between fecal incontinence and QOL.

Conclusions

An important direction for pediatric surgeons and their interdisciplinary teams may be to develop strategies to strengthen mothers’ social relationships.     

Rehabilitation behinderter Kinder und deren Eltern mit Stepping Stones Triple P

Background

Besides acquisition of characteristics of outcome quality in ascertaining the effectiveness of treatment, the question arises how the outcome quality is perceived subjectively by affected persons. Until now, studies for parent training or therapies that focus on rehabilitation of children and adolescents with disabilities have been lacking. Within the evaluation of the parent training Stepping Stones Triple P, the study presented here addresses subjective outcome quality, its relation to objective parameters of therapeutic success, as well as predictors of subjectively experienced therapy success.

Participants

Participants were parents (n=71) of children and adolescents (20 female) with disabilities or developmental disorders and comorbid behavioral problems aged between 2 and 20.5 years.

Method

The correlation between subjective and objective parameters of outcome was conducted with stepwise regression analyses.

Results

The results show a high subjectively perceived outcome quality and significant correlations with objective improvements. Important predictors in the regression models are self-esteem of the disabled child (stand.?beta?=?0.472?C0.932) and reduction of depressive parental symptoms (stand.?beta?=?0.369?C0.855).

Conclusions

In particular, positive changes in parental sense of competence and already exiguous alterations in child behavior seem to be important for therapy success from the point of view of parents.     

Strukturierte Erfassung der Therapieangebote für adipöse Kinder und Jugendliche

Background

A structured survey of treatment programs for obese children is still missing in Germany. We performed this survey on behalf of the AGA (association for treatment of obesity in children and adolescents) to identify treatment programs and evaluate their success.

Methods

A structured questionnaire was sent to all members of the AGA, children's hospitals, social pediatric centers, public health offices, rehabilitation clinics, and the federation of health insurance providers in Germany (n=1464). In addition, a request for information was published in medical journals and on the home page of the AGA.

Results

A total of 119 outpatient and 56 inpatient treatment centers for obese children and adolescents were identified in Germany. They will be published on the Internet pages of the AGA. The recommendations of the AGA are not met by 51% of the outpatient and 27% of the inpatient therapy plans. Only 16% of the outpatient and 14% of the inpatient therapy institutions evaluate therapy success at the end of the treatment program.

Discussion

This survey demonstrates considerable heterogeneous quality in the therapy of obese children. The efficacy of treatment plans is still unclear since no long-term follow-up data are available. A controlled long-term follow-up study is necessary to improve the quality of treatment programs and to evaluate their efficacy.     

Mütterlicher Alkoholkonsum in der Schwangerschaft und fetales Alkoholsyndrom

Background

At least 14?% of German women drink alcohol during pregnancy. It is estimated that approximately 4 out of 1000 children show the full picture of fetal alcohol syndrome (FAS).

Aim

This study was carried out to identify possible risk factors for maternal alcohol consumption and for the development of FAS.

Material and methods

A systematic literature search from 2001 until 2013 was carried out for the evaluation of risk factors for maternal alcohol consumption confirmed in European studies. The search was limited to European studies because the social conditions and development described in them were more compatible with those of the German society. A further systematic literature search was carried out for evaluation of the risk factors for FAS as confirmed by international studies. The very low number of European studies would not have led to any conclusive results; therefore, the search was extended to American and Canadian studies in addition to the European studies.

Results

Well-educated and well-paid older women in particular consume alcohol during pregnancy; however, women who use (other) drugs, smoke or have close relatives or friends who drink alcohol or use drugs also drink alcohol more often. Women who suffer from a psychiatric disorder have a higher risk of drinking alcohol during pregnancy. A combination of multiple risk factors for alcohol consumption during pregnancy often exists. Whether a pregnant woman who consumes alcohol actually gives birth to a child with FAS or fetal alcohol spectrum disorder (FASD), seems to depend on multiple factors including the stage of pregnancy, duration, frequency and amount of alcohol consumed, nutrition, maternal age, ethnicity, genetic disposition and other factors.

Conclusion

The knowledge of risk factors can contribute to the primary prevention of FAS, via education and support of affected mothers and their families and to the early diagnosis of FAS in affected children.     

Behandlung der Purpura-Schönlein-Henoch-Nephritis bei Kindern und Jugendlichen

Renal involvement in Henoch-Schönlein purpura

Henoch-Schönlein purpura frequently affects the kidneys and can lead to chronic renal insufficiency or end-stage renal disease in severe cases.

Background

As appropriate controlled studies have not been conducted in either children or adults it has not been defined which cases of Henoch-Schönlein purpura nephritis (HSPN) should be treated, when they should be treated and which medication should be selected. In adults the incidence of HSPN is considerably lower than in children and treatment evidence is unlikely to be gained in adults. Even in children the incidence of severe HSPN is low so that randomized controlled treatment studies would require an international multicenter approach.

Therapy

As there is no consensus regarding the treatment of pediatric HSPN various protocols are used. The different treatment protocols for HSPN as well as the medication recommended in this consensus represent an off label use. The responsibility for the effects and side effects of the medication lies with the prescribing doctor and the treatment should be chosen based on current clinical and scientific knowledge.

Conclusions

The presented consensus evaluates the current literature and derives recommendations for the treatment of HSPN which reflects the expert opinion of the authors. Standardizing the therapy and documentation of the outcome aim at increasing experience with this entity and will allow better evaluation. To this end treatment modalities and long-term outcome of pediatric patients with HSPN are documented in a registry of the Society for Pediatric Nephrology (GPN).     

Duration of exclusive breastfeeding; validity of retrospective assessment at nine months of age

Background

Ethanol is the most widely used drug in the world and a human teratogen whose consumption among women of childbearing age has been steadily increasing. There are no Italian or Spanish statistics on ethanol consumption during pregnancy nor any information regarding prevalence of fetal alcohol syndrome (FAS) and fetal alcohol spectrum disorders (FASD). There is also a reasonable suspicion that these two diseases are underdiagnosed by professionals from the above-reported countries. The objectives of this study were: 1) to evaluate the experience, knowledge and confidence of Italian and Spanish neonatologists and paediatricians with respect to the diagnosis of FAS and FASD, and 2) to evaluate professionals awareness of maternal drinking patterns during pregnancy.

Methods

A multiple-choice anonymous questionnaire was e-mailed to Italian neonatologists registered in the mailing list of the corresponding Society and administered to Italian and Spanish paediatricians during their National Congress.

Results

The response rate was 16% (63/400) for the Italian neonatologists of the National Society while a total of 152 Spanish and 41 Italian paediatricians agreed to complete the questionnaire during National Congress. Over 90% of the surveyed physicians declared that FAS is an identifiable syndrome and over 60% of them identified at least one of the most important features of FAS. Although over 60% Italian responders and around 80% Spanish responders were aware that ethanol use in pregnancy is dangerous, approximately 50% Italian responders and 40% Spanish ones allowed women to drink sometimes a glass of wine or beer during pregnancy. Neonatologists and paediatricians rated confidence in the ability to diagnosis FAS and FASD as low, with over 50% responders feeling they needed more information regarding FAS and FASD identification in newborn and child.

Conclusions

Italian and Spanish neonatologists and paediatricians do not feel confident about diagnosing FAS and FASD. More training is needed in order to accurately diagnose ethanol use during pregnancy and correctly inform pregnant women on the consequences on the newborn.     

Assessing the quality of reports of systematic reviews in pediatric complementary and alternative medicine

Objective

To examine the quality of reports of complementary and alternative medicine (CAM) systematic reviews in the pediatric population. We also examined whether there were differences in the quality of reports of a subset of CAM reviews compared to reviews using conventional interventions.

Methods

We assessed the quality of reports of 47 CAM systematic reviews and 19 reviews evaluating a conventional intervention. The quality of each report was assessed using a validated 10-point scale.

Results

Authors were particularly good at reporting: eligibility criteria for including primary studies, combining the primary studies for quantitative analysis appropriately, and basing their conclusions on the data included in the review. Reviewers were weak in reporting: how they avoided bias in the selection of primary studies, and how they evaluated the validity of the primary studies. Overall the reports achieved 43% (median = 3) of their maximum possible total score. The overall quality of reporting was similar for CAM reviews and conventional therapy ones.

Conclusions

Evidence based health care continues to make important contributions to the well being of children. To ensure the pediatric community can maximize the potential use of these interventions, it is important to ensure that systematic reviews are conducted and reported at the highest possible quality. Such reviews will be of benefit to a broad spectrum of interested stakeholders.     

Pulmonale Hypertonie im Kindes- und Jugendalter

Background

Pediatric pulmonary hypertension (PH) is a significant cause of morbidity and mortality. Recommendations for the diagnosis and therapy of pediatric PH have been derived from guidelines for adults with PH. However, recent publications and international registry data demonstrate specific differences between PH in adulthood and in childhood.

Methods

Based on a selective literature research in PubMed with an emphasis on population-based studies, the most important aspects of pediatric PH are summarized. In addition, our own experiences from a national expert center for children with PH are considered.

Results

Idiopathic PAH (IPAH) and PAH associated with congenital heart disease (PAH-CHD) are the most frequent types of PAH in children. Follow-up studies have highlighted the importance of right ventricular function as a major determinant of the long-term prognosis of PAH-CHD patients and have led to the development of new combined interventional/surgical treatment strategies. The prognosis of children with PH has been improved by focusing on the right ventricular-pulmonary arterial unit and by recent developments of PAH-specific drugs. However, curative treatment of PAH is not within reach yet.

Conclusions

The specific pathophysiology of PAH-CHD, modified diagnostic algorithms, as well as new pathophysiologically orientated therapeutic strategies are different in pediatric PH compared with PH in adults. Nationwide registries and systematic treatment protocols are important in improving the care of these patients in the future.     

Health-related quality of life in children with cerebral palsy and their families

Objective

To determine the health-related quality of life in children with cerebral palsy and their families.

Methods

One hundred children (3–10 years of age) receiving regular rehabilitation therapy for cerebral palsy for last 1 year at a Child Development Centrer were enrolled and the Lifestyle assessment questionnaire — cerebral palsy was administered to the parents.

Results

9% had good, 24% had mildly-affected, 37% had moderately-affected and 30% had severely-affected healthrelated quality of life. The physical independence, mobility and social integration dimensions were much more severely affected than the clinical burden, economic burden and schooling dimensions.

Conclusion

Health-related quality of child is affected in most children with cerebral palsy.     

Intermittierende Spülung peripherer Venenverweilkanülen

Background

Until recently, commercially available preparations of diluted heparin were often used for intermittent flushing of indwelling venous catheters in pediatric patients. Because such dilute heparin preparations have been withdrawn from the German market, the question of whether flushing with physiological saline can serve the same purpose has arisen.

Patients and methods

Randomized studies comparing the effects of intermittent flushing of peripheral venous cannulas with dilute heparin and with physiological saline in newborns and children were evaluated. Studies evaluating the influence of continuous heparin infusions were analyzed separately. Endpoints were the proportion of obstructed catheters or mean catheter lifetime.

Results

The randomized, prospective trials evaluating intermittent flushing showed no benefit of heparin over saline in terms of the mean catheter lifetime. In contrast, 5 studies examining the effect of a small amount of heparin added to every i.v. solution during continuous infusion therapy showed that the duration of catheter patency was significantly longer than without added heparin. Heparin concentrations of 0.25 IU or higher in the infusion fluids were effective. Because the methods used in the studies evaluating intermittent heparin flushing varied widely, further strictly controlled scientific studies of this topic are warranted.