Abnormal blood pressure in prepubertal children with sleep-disordered breathing

The purpose of this study was to investigate the association between low blood pressure (BP) with mild symptoms of orthostatism, sleep-disordered breathing (SDB) and tilt test results in 7- to 12-y-old children. A retrospective chart review of 301 children, ages 7 to 12 y, was initially performed to evaluate the frequency of abnormal BP measurements. Then a prospective study was performed on 7- to 12-y-old prepubertal children with SDB, looking for both abnormal BP and mild orthostatism. All children had polysomnography. Those identified with abnormal (high or low) BP measurements (called "BP outliers") were studied with a new polysomnogram followed by a head-up tilt test as an indicator of autonomic activity. Four of the children with low BP were treated with nasal continuous positive airway pressure and received a second head-up tilt test 3.5 to 7 mo after starting treatment. The prospective study included 78 children, eight of whom were BP outliers. Seven of these outliers had low BP. Compared with all of the SDB subjects, SDB subjects with low BP and indicators of mild orthostatic hypotension had a significantly higher incidence of craniofacial dysmorphism, symptoms of SDB early in life, chronically cold extremities, and dizziness on standing up (chi2, p = 0.01 to 0.0001). They had a significantly greater drop in BP without evidence of autonomic neuropathy than all other children on head-up tilt testing (Kruskal-Wallis ANOVA with Bonferroni adjustment, p = 0.001 to 0.0001). However, the normotensive SDB controls also had significantly different BP drops than the normal controls (p = 0.0001). The four children placed on nasal continuous positive airway pressure had a nonsignificant trend toward normalization of tilt test response. SDB in prepubertal children can lead to different abnormal stimulation of the autonomic nervous system, with different impacts on BP. The severity and frequency of oxygen saturation drops during sleep, nonhypoxic increases in respiratory effort, and the duration of abnormal breathing are suspected of playing a role in the difference in autonomic nervous system stimulation.     

Breathing patterns in prepubertal children with sleep-related breathing disorders

OBJECTIVE: To investigate abnormal breathing patterns during sleep in prepubertal children using nonstandard polysomnographic patterns in association with an apnea-hypopnea scoring technique. PATIENTS AND METHODS: Study participants included 400 children with suspected sleep-related breathing disorders and 60 control children. We analyzed clinical signs and symptoms at entry into the study and 3 months after otolaryngological treatment. We determined the frequency of predefined breathing patterns during sleep through blind analysis of polysomnograms obtained once in control subjects and twice in children referred to our clinic (before and after adenotonsillectomy), using the nasal cannula-pressure transducer system, mouth thermistor, esophageal manometry, microphone, and pulse oximetry. We also determined the relationship between breathing patterns during sleep and residual postsurgery symptoms. Further analysis was performed of symptoms and polysomnographic patterns in those children who underwent new treatment interventions due to persistence of symptoms and abnormal polysomnogram findings. RESULTS: Tachypnea, persistently elevated breathing effort, progressively increased breath effort, and discrete flattening of nasal airflow monitored with the nasal cannula-pressure transducer system without oxygen saturation decreases help determine disorder as much as apneas and hypopneas. Abnormal, nonstandard breathing patterns were associated with the same symptoms as those in children with apnea and hypopnea and were more commonly present when there was incomplete resolution of initial symptoms that led treating practitioners to request further treatment. CONCLUSION: Currently published polysomnographic scoring recommendations overlook common breathing abnormalities during sleep that are associated with clinical complaints.     

Spontaneous breathing during partial liquid ventilation in animals with meconium aspiration

Partial liquid ventilation (PLV) has been shown to improve gas exchange in paralyzed animals and humans with lung disease. The present study tests the hypothesis that PLV improves gas exchange in spontaneously breathing animals with meconium aspiration supported by proportional assist ventilation. Twenty-five adult anesthetized intubated rabbits with experimental meconium aspiration were randomized to gas ventilation (GV) or PLV while being supported by proportional assist ventilation. Minute ventilation, tidal volume, respiratory rate, mean airway pressure, heart rate, and mean arterial and pulmonary arterial pressure were recorded continuously. Every 30 min, arterial blood gases were obtained, and lung compliance, airway resistance, work of breathing, and cardiac output were measured. Animals were sacrificed after 5 h to obtain lung histology. More PLV animals survived until the end of the study period. PaO(2) (14.5 +/- 4.5 versus 25.6 +/- 6.7 kPa; p < 0.01; GV versus PLV) and lung compliance (4.3 +/- 0.4 versus 6.1 +/- 1.2 mL.kPa(-1).kg(-1); p < 0.001) were improved during PLV, resulting in a lower work of breathing (5.3 +/- 2.8 versus 3.5 +/- 1.5 mL.kPa.kg(-1); p < 0.05) and less need for ventilatory support. Minute ventilation and respiratory rate were higher during GV versus PLV, resulting in a slightly lower PaCO(2) (3.9 +/- 0.5 versus 4.5 +/- 0.7 kPa; p < 0.05). Histologic evaluation showed more atelectasis, inflammatory changes, and hemorrhage in GV animals. Other parameters measured were similar. We conclude that PLV improves oxygenation, lung compliance, and survival and results in less lung injury in spontaneously breathing animals with meconium aspiration when supported by proportional assist ventilation.     

Obstructed breathing in children during sleep monitored by echocardiography

Six 3 to 14-year-old boys with snoring and obstructive sleep apnea syndrome were monitored polygraphically during sleep with and without nasal continuous positive airway pressure with simultaneous recording of esophageal pressure (P_es) and M-mode and two-dimensional echocardio-grams. Continuous non-invasive blood pressure monitoring was performed in two older children. Three of the six children demonstrated a diastolic leftward shift of the interventricular septum related to the negativity of P_es. Progressively more negative P_es correlated significantly with an increase in right ventricular internal end-diastolic dimension and a decrease in left ventricular internal end-diastolic dimension, with at times left ventricular "collapse". One of the subjects with blood pressure monitoring demonstrated pulsus paradoxus with leftward shift of the interventricular septum. Nasal continuous positive airway pressure normalized all changes. Pulsus paradoxus and leftward shift of the interventricular septum are related to the mechanical changes associated with heavy snoring during sleep, regardless of the amount of oxygen desaturation.     

Obstructed breathing in children during sleep monitored by echocardiography

Six 3 to 14-year-old boys with snoring and obstructive sleep apnea syndrome were monitored polygraphically during sleep with and without nasal continuous positive airway pressure with simultaneous recording of esophageal pressure (P_es) and M-mode and two-dimensional echocardio-grams. Continuous non-invasive blood pressure monitoring was performed in two older children. Three of the six children demonstrated a diastolic leftward shift of the interventricular septum related to the negativity of P_es. Progressively more negative P_es correlated significantly with an increase in right ventricular internal end-diastolic dimension and a decrease in left ventricular internal end-diastolic dimension, with at times left ventricular "collapse". One of the subjects with blood pressure monitoring demonstrated pulsus paradoxus with leftward shift of the interventricular septum. Nasal continuous positive airway pressure normalized all changes. Pulsus paradoxus and leftward shift of the interventricular septum are related to the mechanical changes associated with heavy snoring during sleep, regardless of the amount of oxygen desaturation.     

Dynamics of breathing during partial liquid ventilation in spontaneously breathing rabbits supported by elastic and resistive unloading

Partial liquid ventilation (PLV) has been shown to improve gas exchange in paralyzed animals and in humans with lung disease. This study tests the hypothesis that PLV combined with respiratory mechanical unloading results in stable ventilation and gas exchange in spontaneously breathing animals. Ten adult anesthetized, intubated, and spontaneously breathing rabbits received ventilatory support by respiratory mechanical unloading (Fi(O2) 1.0). Minute ventilation, respiratory rate, esophageal pressure, heart rate, and arterial blood pressure were recorded continuously during gas ventilation for 1 h. Next, 30 mL/kg of perfluorocarbon was instilled into the endotracheal tube. Thereafter, data were recorded again for 1 h (PLV). Arterial blood gases were obtained at the end of each period. Variability of recorded data was assessed by calculating coefficients of variation using data obtained each minute. Compared with gas ventilation, minute ventilation was larger during PLV (275 +/- 93 versus 368 +/- 89 mL/kg/min.; p < 0.01). This was because of a higher respiratory rate during PLV (58 +/- 23 versus 74 +/- 18 breaths/min; p < 0.05), while tidal volume was similar. Compared with gas ventilation, Pa(O2) was lower during PLV (61.31 +/- 5.32 versus 47.35 +/- 8.38 kPa; p < 0.05). Pa(CO2), peak esophageal pressure deflections, heart rate, mean arterial blood pressure, and coefficients of variation for minute ventilation, tidal volume, respiratory rate, and peak esophageal pressure were not significantly different between modes. Compliance was decreased and resistance and work of breathing were increased during PLV. We conclude that stable ventilation and gas exchange may be achieved during PLV combined with mechanical unloading in spontaneously breathing animals without lung disease.     

Sleep-related breathing disorder in Duchenne muscular dystrophy: disease spectrum in the paediatric population

Duchenne muscular dystrophy (DMD) is a progressive neuromuscular disease with death usually occurring because of respiratory failure. Signs of early respiratory insufficiency are usually first detectable in sleep. OBJECTIVE: To study the presentation of sleep-related breathing disorder (SRBD) in patients with DMD. METHOD: A retrospective review of patients with DMD attending a tertiary paediatric sleep disorder clinic over a 5-year period. Symptoms, lung function and polysomnographic indices were reviewed. RESULTS: A total of 34 patients with DMD were referred for respiratory assessment (1-15 years). Twenty-two (64%) reported sleep-related symptomatology. Forced vital capacity (FVC) was between 12 and 107% predicted (n = 29). Thirty-two progressed to have polysomnography of which 15 were normal studies (median age: 10 years) and 10 (31%) were diagnostic of obstructive sleep apnoea (OSA) (median age: 8 years). A total of 11 patients (32%) showed hypoventilation (median age: 13 years) during the 5-year period and non-invasive ventilation (NIV) was offered to them. The median FVC of this group was 27% predicted. There was a significant improvement in the apnoea/hypopnoea index (AHI) (mean difference = 11.31, 95% CI = 5.91-16.70, P = 0.001) following the institution of NIV. CONCLUSIONS: The prevalence of SRBD in DMD is significant. There is a bimodal presentation of SRBD, with OSA found in the first decade and hypoventilation more commonly seen at the beginning of the second decade. Polysomnography is recommended in children with symptoms of OSA, or at the stage of becoming wheelchair-bound. In patients with the early stages of respiratory failure, assessment with polysomnography-identified sleep hypoventilation and assisted in initiating NIV.     

Steroid rosacea in prepubertal children

OBJECTIVE: To examine clinical associations, family history of rosacea, and response to treatment in prepubertal children with steroid rosacea. DESIGN: Retrospective case-series evaluation of children younger than 13 years with steroid rosacea seen over an 8-year period (1991-1998). SETTING: Ambulatory care university hospital. PATIENTS: Referral patients from pediatricians serving a population of 3.4 million. INTERVENTIONS: Abrupt cessation of topical corticosteroid use and initiation of treatment with oral erythromycin stearate for 4 weeks. MAIN OUTCOME MEASURES: Age at onset, class of topical corticosteroid used, family history of rosacea, location of lesions, treatment, and weeks to clearing. RESULTS: We evaluated 106 (46 boys and 60 girls) who developed steroid rosacea. Preceding steroids used were predominantly (54% of children) class 7 agents including 1% hydrocortisone and over-the-counter hydrocortisone preparations. Only 3% of children had used superpotent (class 1) topical corticosteroids. The mean age at onset was 7.04 years (range, 6 months to 13 years). Twenty-nine children were younger than 3 years. A family history of rosacea was found for 20% of the children. After abruptly stopping topical steroid use and starting treatment with oral erythromycin, 86% of children had complete clearing within 4 weeks and 100% by 8 weeks. Clearing within 3 weeks was observed in 22% of children. CONCLUSIONS: Abrupt discontinuation of topical corticosteroids and institution of oral antibiotics resulted in clearing within 4 weeks. This finding does not support the concept that prepubertal children with steroid rosacea need to continue low-strength steroids in a gradual withdrawal strategy. This conclusion is supported by the finding that 54% developed the steroid rosacea while being treated with the lowest-strength (class 7) topical corticosteroids. Even over-the-counter hydrocortisone preparations induced steroid rosacea in susceptible children. Susceptibility may be genetic as 20% of children had a first-degree relative with rosacea.     

Gonococcal conjunctivitis in prepubertal children

Four prepubertal children had confirmed gonococcal conjunctivitis. All were febrile and had hyperpurulent conjunctival discharge with periorbital inflammation. Cultures of pharyngeal, rectal, and genital specimens on selective media excluded infection at other sites. Detailed social evaluation revealed no evidence or suspicion of sexual abuse. Isolated gonococcal conjunctivitis occurs in prepubertal children. Unlike gonococcal infections at other locations, a nonsexual mode of transmission may exist. However, a careful physical examination and detailed social evaluation, looking for signs of sexual abuse, must be obtained in any prepubertal child with a gonococcal infection.     

'Athlete's heart' in prepubertal children

Bradycardia, cardiomegaly, heart murmurs, and ECG changes are typically observed in adult endurance athletes, but frequency of such changes among children involved in sports training is unclear. Pediatricians need to be aware of whether these features of the "athlete's heart" occur in their patients, because such features may mimic those of cardiac disease. Fourteen prepubertal competitive male swimmers were evaluated by physical examination, ECG and echocardiogram, and findings were compared to those of a group of active but nontrained control boys. Lower resting heart rates and echocardiographic manifestations of chronic left ventricular volume overload were observed among the swimmers. These changes were not manifest on physical examination, however, and no significant ECG alterations were identified among the athletes. These findings indicate that, although features of the athlete's heart are present in children involved in endurance training, seldom will these findings simulate heart disease or be apparent on routine clinical examination.     

Ureteroscopic stone management in prepubertal children

Ureteroscopy for treating ureteric stones in prepubertal children has become more common with the advent of smaller endoscopes. We retrospectively reviewed our experience with ureteroscopy for ureteric stone in this cohort of patients. During the period Jan 2001 and June 2005, we performed 22 ureteroscopic procedures in 20 children. Ureteroscopy was done in a manner similar to that in adults. Ureteral dilatation was done in all cases. A stent was placed postoperatively if there was significant stone burden, ureteral trauma, impaction and edema of ureteric orifice. Of the 20 children, 18 were male and 2 were females. Average age was 5.2 years (range 3–9). Stones were 4–14 mm in size (average 6 mm). Overall 90% of the children were rendered stone free after one procedure and 100% after two procedures. Ureteroscopy for ureteric stones in prepubertal children is safe and effective first line treatment in whom conservative therapy fails. Routine ureteral stent placement postoperatively is not always necessary.     

Sleep-disordered breathing in children

Sleep-disordered breathing, particularly the obstructive sleep apnea syndrome, is common during childhood. Complications include neurocognitive deficits, growth failure, and pulmonary hypertension. Nevertheless, sleep-disordered breathing is often unrecognized in children. New syndromes, such as the upper airway resistance syndrome, have recently been described. Polysomnography is invaluable for the evaluation of sleep-disordered breathing. Advances in diagnosis and management can alleviate much of the morbidity previously associated with sleep-related respiratory disorders.     

Body fat, abdominal fat and body fat distribution related to cardiovascular risk factors in prepubertal children

Aim: We analysed whether total body fat (TBF), abdominal fat and body fat distribution are associated with higher composite risk factor scores for cardiovascular disease (CVD) in young children. Methods: Cross‐sectional study of 238 children aged 8–11 years. TBF and abdominal fat mass (AFM) were measured by Dual‐Energy X‐Ray Absorptiometry. TBF was expressed as a percentage of body weight (BF%). Body fat distribution was calculated as AFM/TBF. Maximal oxygen uptake (VO_2PEAK), systolic and diastolic blood pressure (SBP, DBP), and resting heart rate (RHR) were measured. Mean arterial pressure (MAP) and pulse pressure (PP) were calculated. Left atrial diameter (LA) was measured, and left ventricular mass (LVM) and relative wall thickness (RWT) were calculated. Z‐scores were calculated. Sum of z‐scores for SBP, DBP, MAP, PP, RHR, LVM, LA, RWT and ?VO_2PEAK was calculated in boys and girls, separately, and used as composite risk factor score. Results: Pearson correlations between ln BF%, ln AFM and AFM/TBF versus composite risk factor score for boys were r = 0.56, r = 0.59 and r = 0.48, all p < 0.001, and for girls r = 0.45, r = 0.50 and r = 0.48, all p < 0.001. Conclusion: Total body fat, abdominal fat and body fat distribution were all associated with higher composite risk factor scores for CVD in young children.     

Spectinomycin therapy for gonorrhea in prepubertal children

Twenty-six episodes of gonococcal urethritis or vulvovaginitis in 24 prepubertal patients were each treated with a single intramuscular (IM) dose of spectinomycin hydrochloride. Twenty-five episodes were treated successfully, and there were no side effects from this therapy. All tested isolates of Neisseria gonorrhoeae were susceptible in vitro to spectinomycin, and all serum levels one hour after therapy were in at least two-fold excess of the observed minimum inhibitory concentrations. Two patients had symptomatic and two had asymptomatic postgonococcal anogenital infections with Chlamydia trachomatis. A single dose of IM spectinomycin is a safe and efficacious regimen for uncomplicated gonococcal infection in prepubertal children who are penicillin-allergic or who have infections unresponsive or resistant to other antimicrobials, but it is not effective against incubating syphilis or chalmydial infection.     

Testicular germ cell tumors in prepubertal children

Pediatric testicular germ cell tumors are rare. Fifteen children, all less than 5 years of age, were evaluated and treated during February 1987 to July 1996. The median age was 18 months (range, 4-60 months). All were staged according to the Pediatric Oncology Group/Children's Cancer Study Group staging system. Seven patients had stage III disease. Histologically, 9 patients had pure endodermal sinus tumor, 1 had endodermal sinus tumor with embryonal carcinoma, 1 had embryonal carcinoma alone, 2 had immature teratoma, and 2 had mature teratoma. Six children were kept on surveillance. All others received chemotherapy with cisplatin, bleomycin, and vinblastine. The 10-year actuarial overall survival rate was 86.7%.