Radiographic predictors determined with an objective assessment tool for neonatal patients with necrotizing enterocolitis

Jornal de Pediatria, Volume 95, Issue 6, November–December 2019, Pages 674-681

Abstract

Objective

The objective of this study was to develop and validate a computational tool to assist radiological decisions on necrotizing enterocolitis.

Methodology

Patients that exhibited clinical signs and radiographic evidence of Bell’s stage 2 or higher were included in the study, resulting in 64 exams. The tool was used to classify localized bowel wall thickening and intestinal pneumatosis using full-width at half-maximum measurements and texture analyses based on wavelet energy decomposition. Radiological findings of suspicious bowel wall thickening and intestinal pneumatosis loops were confirmed by both patient surgery and histopathological analysis. Two experienced radiologists selected an involved bowel and a normal bowel in the same radiography. The full-width at half-maximum and wavelet-based texture feature were then calculated and compared using the Mann–Whitney U test. Specificity, sensibility, positive and negative predictive values were calculated.

Results

The full-width at half-maximum results were significantly different between normal and distended loops (median of 10.30 and 15.13, respectively). Horizontal, vertical, and diagonal wavelet energy measurements were evaluated at eight levels of decomposition. Levels 7 and 8 in the horizontal direction presented significant differences. For level 7, median was 0.034 and 0.088 for normal and intestinal pneumatosis groups, respectively, and for level 8 median was 0.19 and 0.34, respectively.

Conclusions

The developed tool could detect differences in radiographic findings of bowel wall thickening and IP that are difficult to diagnose, demonstrating the its potential in clinical routine. The tool that was developed in the present study may help physicians to investigate suspicious bowel loops, thereby considerably improving diagnosis and clinical decisions.

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Low FODMAPs diet for functional abdominal pain disorders in children: critical review of current knowledge

Jornal de Pediatria (Versão em Português), Volume 95, Issue 6, November–December 2019, Pages 642-656

Abstract

Objective

This narrative review aimed to provide practitioners a synthesis of the current knowledge on the role of a low Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols diet in reducing symptoms associated with functional abdominal pain disorders in children. This review is focused on the pathophysiology, efficacy and criticism of low Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols diet in children.

Sources

Cochrane Database, Pubmed and Embase were searched using specific terms for Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols diet interventions and functional abdominal pain disorders.

Summary of the findings

In children, only one Randomized Control Trial and one open-label study reported positive results of low Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols diet; one Randomized Control Trial showed exacerbation of symptoms with fructans in children with Irritable Bowel Syndrome; no effect was found for the lactose-free diet whilst fructose-restricted diets were effective in 5/6 studies.

Conclusions

In children there are few trials evaluating low Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols in functional abdominal pain disorders, with encouraging data on the therapeutic efficacy particularly of fructose-restricted diet. Additional efforts are still needed to fill this research gap and clarify the most efficient way for tailoring dietary restrictions based on the patient’s tolerance and/or identification of potential biomarkers of low Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols efficacy, to maintain nutritional adequacy and to simplify the adherence to diet by labeling Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols content in commercial products.

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Autism spectrum disorder is associated with gut microbiota disorder in children

BMC Pediatrics volume 19, Article number: 516 (2019)

Abstract

Background

The aim of this study was to evaluate the occurrence and clinical characteristics of autism spectrum disorder (ASD) associated to the stable state of the gut microbiota.

Methods

A total of 9 children with ASD and 6 healthy children used as control were selected and feces samples were collected from all of them. The 16S gene ribosomal RNA sequencing was used to analyze the difference in gut microbiota between healthy control children and ASD patients.

Results

The results of 16S sequencing based on operational taxonomic units (OTUs) analysis showed that the ASD group and the healthy control (HC) group had a large difference in the abundance of microbiota at the level of family, genus and species. The abundance of Bacteroidales and Selenomonadales was significantly lower in the ASD group than in the HC group (p = 0.0110 and p = 0.0076, respectively). The abundance of Ruminococcaceae in the ASD group was higher than that in the HC group (p = 0.0285), while the amount of Prevotellaceae was significantly lower in the ASD group than in the HC group (p = 0.0111). The Tax4Fun analysis based on Kyoto Encyclopaedia of Genes and Genomes (KEGG) data indicated differentially expressed functional pathway between the ASD group and healthy control group associated to the nervous system, environmental information processing and cellular processing.

Conclusions

The abundance of gut microbiota in the ASD group is different from that in the healthy control children. These differences affect the biological function of the host. These results suggest that a disorder in the gut microbiota may be associated, at least in part, with ASD in children.

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Predicting the serum digoxin concentrations of infants in the neonatal intensive care unit through an artificial neural network

Image: PXhere.com

BMC Pediatrics volume 19, Article number: 517 (2019)

Abstract

Background

Given its narrow therapeutic range, digoxin’s pharmacokinetic parameters in infants are difficult to predict due to variation in birth weight and gestational age, especially for critically ill newborns. There is limited evidence to support the safety and dosage requirements of digoxin, let alone to predict its concentrations in infants. This study aimed to compare the concentrations of digoxin predicted by traditional regression modeling and artificial neural network (ANN) modeling for newborn infants given digoxin for clinically significant patent ductus arteriosus (PDA).

Methods

A retrospective chart review was conducted to obtain data on digoxin use for clinically significant PDA in a neonatal intensive care unit. Newborn infants who were given digoxin and had digoxin concentration(s) within the acceptable range were identified as subjects in the training model and validation datasets, accordingly. Their demographics, disease, and medication information, which were potentially associated with heart failure, were used for model training and analysis of digoxin concentration prediction. The models were generated using backward standard multivariable linear regressions (MLRs) and a standard backpropagation algorithm of ANN, respectively. The common goodness-of-fit estimates, receiver operating characteristic curves, and classification of sensitivity and specificity of the toxic concentrations in the validation dataset obtained from MLR or ANN models were compared to identify the final better predictive model.

Results

Given the weakness of correlations between actual observed digoxin concentrations and pre-specified variables in newborn infants, the performance of all ANN models was better than that of MLR models for digoxin concentration prediction. In particular, the nine-parameter ANN model has better forecasting accuracy and differentiation ability for toxic concentrations.

Conclusion

The nine-parameter ANN model is the best alternative than the other models to predict serum digoxin concentrations whenever therapeutic drug monitoring is not available. Further cross-validations using diverse samples from different hospitals for newborn infants are needed.

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Higher oxygen saturation with hydroxyurea in paediatric sickle cell disease

Archives of Disease in Childhood, Published Online First: 23 December 2019

Abstract

Introduction Sickle cell disease (SCD) is one of the most common inherited diseases worldwide. It is associated with lifelong morbidity and reduced life expectancy. Hydroxyurea (HU) has been shown to reduce the frequency and severity of vaso-occlusive episodes in SCD. Hypoxaemia and intermittent nocturnal oxygen desaturations occur frequently in children with SCD and contribute to the associated morbidity, including risk of cerebrovascular disease.

Objective To evaluate the effect of HU on oxygen saturation (SpO₂) overnight and on daytime SpO₂ spot checks in children with SCD.

Methods A retrospective review of children with SCD and respiratory problems who attended two UK tertiary sickle respiratory clinics and were treated with HU. Longitudinal data were collected from 2 years prior and up to 3 years after the commencement of HU.

Results Forty-three children, 23 males (53%) with a median age of 9 (range 1.8–18) years were included. In the 21 children who had comparable sleep studies before and after starting HU, mean SpO₂ was higher (95.2% from 93.5%, p=0.01) and nadir SpO₂ was higher (87.2% from 84.3%, p=0.009) when taking HU. In 32 of the children, spot daytime oxygen saturations were also higher (96.3% from 93.5%, p=0.001).

Conclusion Children with SCD had higher oxygen saturation overnight and on daytime spot checks after starting HU. These data suggest HU may be helpful for treating persistent hypoxaemia in children with SCD pending more evidence from a randomised clinical trial.

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Contact burns: the influence of agents and mechanisms of injury on anatomical burn locations in children <5 years old and associations with child protection referrals

Archives of Disease in Childhood, Published Online First: 23 December 2019

Abstract

Objective To identify how causative agents and mechanisms of injury influence the location of an accidental contact burn in children and whether these factors differ in cases referred for child protection (CP) assessment.

Design Prospective multicentre cross-sectional study.

Setting 20 hospital sites across England and Wales, including: emergency departments, minor injury units and regional burn units.

Patients Children less than 5 years old who attended hospital for a contact burn (August 2015 to September 2018).

Main outcome measures Location of burns with respect to agent and mechanism for accidental contact burns. Secondary outcome: mechanism, agent and location of burns referred for CP assessment.

Results 816 accidental burns and 92 referrals for CP assessment. The most common for accidental burns: mechanism was reaching while stationary (68%, 553/816), agent was oven (24.5%, 200/816) and site was the hand (69.2%, 565/816). Burns to head and trunk were rare at 3.7% (30/816). The data enabled a tabulation of the locations of burns as predicted by agent and mechanism of injury. The location of the burn was most strongly influenced by mechanism.

Burns from irons (p<0.01), caused by mechanisms independent of the child (p=0.01), unwitnessed burns (p<0.001) and burns to the head and trunk (p<0.001) were significantly more common among the children referred for CP assessment.

Conclusions By overlaying agent, mechanism and site it was possible to tabulate and quantify simple narratives of accidental contact burns in population of young children. These findings have the potential to aid clinicians in recognising accidental contact burns.

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NICE Bites – Fever in under 5s

This guideline covers the assessment and early management of
fever (elevation of body temperature above the normal daily
variation) with no obvious cause in children aged under 5 years. It
aims to improve clinical assessment and diagnosis of serious
illness among young children who present with fever in primary
and secondary care.

Link to article here

National Neonatal Audit Programme 2019 Annual report on 2018 data

 

Executive summary

Approximately one in seven babies born in England,
Scotland and Wales need specialist neonatal care in
a hospital because they are born too early, have too
low a birth weight or have a medical condition that
requires specialist treatment. The National Neonatal
Audit Programme (NNAP) reports on key measures
of the care provided to those babies in the 181
neonatal services in England, Wales, Scotland and
the Isle of Man that take part in this audit.
Established in 2006, the NNAP is delivered by the Royal College of Paediatrics and Child Health (RCPCH), commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England, the Scottish Government and the Welsh Government.
The NNAP uses routine data collection to report on a range of care processes and outcomes throughout the pathway of neonatal care, from antenatal interventions to follow-up of developmental outcomes after discharge from neonatal care. For most audit measures, this 2019 report looks at care provided to babies with a final discharge from neonatal care between 1 January 2018 and 31 December 2018.

Conclusion and future developments in the NNAP

UK neonatal professionals, together with the NNAP team, have demonstrated that aspects of neonatal care continue to improve. Working with parents and other stakeholders, neonatal professionals need to use their demonstrated ability to deliver improvement to address the marked variations in care that this report make obvious. The recommendations this report makes are designed to support networks and hospitals in planning and delivering improvements to their care. Some recommendations
may not be applicable or helpful to every service, but all networks and units should consider each recommendation against their own priorities and their audit results.
This report includes network level reporting of mortality until discharge from the neonatal unit, and adherence to neonatal nurse staffing standards, for the first time. The NNAP continues to develop and adapt in response to quality improvement priorities. For the forthcoming year, the NNAP is introducing a new measure of breastmilk feeding at 14 days of life. Looking forward to 2020, we intend to introduce a measure of deferred cord clamping in very preterm infants.

Full report here

 

Comprehensive Migraine Initiative in the Pediatric Emergency Department Improves Treatment Outcomes.

 

Journal of Child Neurology, Dec 5

Abstract

OBJECTIVE:

To compare pediatric migraine treatment efficacy in the emergency department before and after the implementation of a comprehensive migraine initiative, consisting of a standardized treatment protocol, provider educational series and standardized physician documentation template.

BACKGROUND:

Pediatric migraine is common, accounting for 1% of pediatric emergency department visits. Yet there is large variability in treatment practices, with few studies looking into measures of both clinical effectiveness and timeliness of treatment following implementation of standardized protocols.

METHODS:

A single-center retrospective chart review of pediatric patients presenting to the emergency department with migraine before and after implementation of an institutional headache initiative designed to more effectively and efficiently deliver care to pediatric migraine patients.

RESULTS:

The study yielded 110 patients each in the intervention and preintervention groups. There were no significant differences in patient characteristics with respect to age, gender, or initial pain score. Compared with the preintervention group, the intervention group demonstrated a significant reduction in headache pain score prior to discharge (decrease of 5.9 vs 4.8 in preintervention group, P value .006) with a greater percentage of patients achieving ≥50% reduction in pain (82% vs 67% in preintervention group, P value .039). Additionally, we found a significantly decreased time to treatment in the intervention group compared with the preintervention group (1.8 vs 2.1 hours, P value .046).

CONCLUSION:

Through the use of a standardized treatment protocol, improved provider education, and ease of documentation, this comprehensive migraine initiative improved efficacy and efficiency of migraine treatment in the pediatric emergency department.

Article page here

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Does general anesthesia affect neurodevelopment in infants and children?

Image: Flickr.com

BMJ. 2019 Dec 9;367:l6459

Abstract

General anesthesia has been unequivocally linked to abnormal development of the central nervous system, leading to neurocognitive impairments in laboratory models. In vitro and in vivo studies have consistently shown that exposure to GABA agonists (eg, volatile anesthetics, midazolam, and propofol) or NMDA antagonists (eg, ketamine, isoflurane, and nitrous oxide) produces dose dependent and developmental age dependent effects on various neuronal transmission systems. Exposure to these drugs increases neuronal cell death in juvenile animals including rats, mice, and non-human primates. The possibility of anesthetic induced neurotoxicity occurring in children has led to concerns about the safety of pediatric anesthesia. A spectrum of behavioral changes has been documented after general anesthetic exposure in young children, including emergence delirium, which may be evidence of toxicity. Most clinical studies are retrospective; specifics about medications or monitoring are unavailable and many of the outcomes may not be sensitive to detect small neurocognitive deficits. Some of these retrospective studies have shown an association between anesthesia exposure at a young age and neurocognitive deficits, but others have not. Practitioners and families should be reassured that although general anesthetics have the potential to induce neurotoxicity, very little clinical evidence exists to support this.

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