Search

Appeals for health equity call for departments of pediatrics to improve the health of all children including those from underserved communities in North America and around the world. Consequently, North American (NA) departments of pediatrics have a role in global child health (GCH) which focuses on providing health care to underserved children worldwide. In this review, we describe how NA departments of pediatrics can collaboratively engage in GCH education, clinical practice, research, and advocacy and summarize best practices, challenges, and next steps for engaging in GCH in each of these areas. For GCH in low- and middle-income countries (LMICs), best practices start with the establishment of ethical, equitable, and collaborative partnerships with LMIC communities, organizations, and institutions engaged in GCH who are responsible for the vast majority of work done in GCH. Other best practices include adequate preparation of trainees and clinicians for GCH experiences; alignment with local clinical and research priorities; contributions to local professional development and ongoing monitoring and evaluation. Challenges for departments include generating funding for GCH activities; recruitment and retention of GCH-focused faculty members; and challenges meeting best practices, particularly adequate preparation of trainees and clinicians and ensuring mutual benefit and reciprocity in NA–LMIC collaborations. We provide examples of how departments have overcome these challenges and suggest next steps for development of the role of NA departments of pediatrics in GCH. Collaborative implementation of best practices in GCH by LMIC–NA partnerships can contribute to reductions of child mortality and morbidity globally.

Objective Thiamine deficiency has been documented in adults with diabetes and in a single report of reversible encephalopathy in a child with diabetic ketoacidosis. In children who present with severe diabetic ketoacidosis, one of the most serious complications is cerebral edema of which the primary symptom may be encephalopathy. Thiamine deficiency in other disease states has been clearly linked with acute encephalopathy, but there are no data on thiamine status in children with diabetic ketoacidosis. This study describes the prevalence of thiamine deficiency in children with type 1 diabetes mellitus who present with diabetic ketoacidosis and are admitted to the ICU. Design A prospective observational pilot study. Setting PICU in a tertiary care children's hospital. Patients Children 2-18 years admitted to the ICU for treatment of diabetic ketoacidosis. Interventions Treatment of diabetic ketoacidosis. Measurements and main results Twenty-two patients were enrolled. The mean age was 13.7 ± 3.6 years. Five of 21 patients (23.8%) had thiamine deficiency prior to insulin administration. After 8 hours of insulin therapy, seven of 20 patients (35%) had thiamine deficiency, and four of these seven patients also had thiamine deficiency at presentation. Sixty-eight percent of patients had a decrease in thiamine levels after 8 hours of insulin therapy, with a mean fall of 20 ± 31.4 nmol/L. Conclusions Thiamine deficiency is common in children with diabetic ketoacidosis, and this deficiency may be worsened by treatment. When metabolic acidosis persists despite appropriate treatment of diabetic ketoacidosis, other factors such as thiamine deficiency should be considered.

Quality improvement (QI) skills are relevant to efforts to improve the health care system. The Accreditation Council for Graduate Medical Education (ACGME) program requirements call for resident participation in local and institutional QI efforts, and the move to outcomes-based accreditation is resulting in greater focus on the resulting learning and clinical outcomes. Many programs have enhanced practice-based learning and improvement (PBLI) and systems based practice (SBP) curricula, although efforts to actively involve residents in QI activities appear to be lagging. Using information from the extensive experience of Cincinnati Children's Hospital Medical Center, we offer recommendations for how to create meaningful QI experiences for residents meet ACGME requirements and the expectations of the Clinical Learning Environment Review (CLER) process. Resident involvement in QI requires a multipronged approach that overcomes barriers and limitations that have frustrated earlier efforts to move this education from lectures to immersion experiences at the bedside and in the clinic. We present 5 dimensions of effective programs that facilitate active resident participation in improvement work and enhance their QI skills: 1) providing curricula and education models that ground residents in QI principles; 2) ensuring faculty development to prepare physicians for their role in teaching QI and demonstrating it in day-to-day practice; 3) ensuring all residents receive meaningful QI education and practical exposure to improvement projects; 4) overcoming time and other constraints to allow residents to apply their newly developed QI skills; and 5) assessing the effect of exposure to QI on resident competence and project outcomes.

In spite of modern technological advances, ARDS continues to be an important cause of morbidity and mortality from a diverse group of disorders such as sepsis, trauma, and aspiration. ARDS represents a target organ injury resulting from activation of the host's inflammatory cells and uncontrolled liberation of inflammatory mediators. In most instances, therefore, ARDS is a localized manifestation of a widespread onslaught characteristic of SIRS. At this time, there are no proven interventions to prevent ARDS, and the management is mainly supportive. Modulation of the host's inflammatory response seems to hold the most promise for prevention and treatment of ARDS. Such strategies need to be explored with well-controlled clinical trials.

Extracorporeal membrane oxygenation (ECMO) for the support of children outside the newborn period who have pulmonary failure is only recently becoming accepted. It is again being applied, after earlier failures, because well-trained teams and improved equipment and techniques are available following the success of neonatal ECMO. In addition, in Europe extracorporeal CO2 removal (ECCO2R) in adults has been more successful. The use of ECMO for pulmonary failure in children does not have fixed indications and has had considerably less success than neonatal ECMO. Patients who require inspired oxygen fractions of over 0.5 and positive end-expiratory pressures of over 6 cm H2O for more than 12 h after being treated for more than 48 h should be considered candidates, given the high mortality of children with ARDS (70%). Survival averages 50% to 60%. Circuits and patient management techniques are very similar to those for newborn ECMO, but patients usually require longer times on ECMO. There are many more options for cannulation for both venoarterial and venovenous techniques than in neonatal and cardiac ECMO. The improving results indicate that ECMO will play a part in treating children with pulmonary failure. Further studies will be required to determine which patients can benefit from ECMO as well as the exact application in each case.

Disulfiram is used worldwide to treat alcoholism. The presence of this drug in the home makes it a potential agent encountered in accidental poisoning. We report a child who ingested disulfiram and subsequently had unusual and prolonged neurologic manifestations of dystonia, complete loss of developmental milestones, and spastic tetraparesis. A 5-year-old girl was seen at the referring hospital for upper respiratory tract infection for 7 days and vomiting for 2 days. She was incoherent and unresponsive, with significant dehydration and cold clammy extremities on the day of admission. A bedside glucose test indicated low blood sugar. Two doses of 25% dextrose (2 mL/kg) and 0.1 mg/kg naloxone were administered. Laboratory data obtained before the above intervention included serum sodium, 141 mEq/L; potassium, 6.0 mEq/L; chlorides, 106 mEq/L; carbon dioxide content, 5 mEq/L; blood urea nitrogen, 90 mg/dL; creatinine, 1.4 mg/dL; glucose, 359 mg/dL; lactic acid, 1.3 mmol/L; and osmolality, 340 mOsm/kg. Capillary blood gas measurement showed a pH of 7.12, Pco2 of 18 mm Hg, Po2 of 98 mm Hg, and serum bicarbonate of 5.5 mEq/L. A complete blood count and spinal fluid showed no abnormalities. Subsequently, a diagnosis of diabetic ketoacidosis was made. Intravascular volume expansion was carried out using 300 mL of lactated Ringer's solution. She was transferred to the Children's Hospital of Michigan. At arrival to the intensive care unit, the physical examination revealed the following: temperature, 36.6°C (rectal); heart rate, 132 beats/min; Kussmaul breathing at a rate of 36 breaths/min; and blood pressure, 122/76 mm Hg. She had cold, clammy extremities. She remained comatose, with occasional spontaneous, nonpurposeful movements. No focal neurologic deficits were noted. Serum glucose was 551 mg/dL. A comprehensive toxicologic screen including an alcohol panel did not reveal the presence of any drugs or toxins in the urine or serum. Continuous infusions …

NSAIDs are commonly avoided by patients with aspirin-induced asthma based on the premise that there is a significant cross-reactivity between aspirin and other NSAIDs. However, ibuprofen, a NSAID sold over the counter in most countries, is commonly given to children for relief of fever and mild-to-moderate pain. Consequently, increased risk of acute bronchospasm induced by ibuprofen in children with asthma remains a persistent concern. More recently, the assumption that children with asthma are at a greater risk for exacerbations of their disease if they take ibuprofen has been questioned. There is little evidence to measurably increases morbidity in the great majority of children with asthma. In addition, recent evidence suggest that ibuprofen measurably increases morbidity in the great majority of [corrected] children with asthma. Given the infrequent occurrence of aspirin/NSAID sensitivity in children with asthma, it seems reasonable to allow the use of ibuprofen in this population unless there is a personal or family history of aspirin-induced asthma. In addition, the inflammatory pathogenesis of asthma, anti-inflammatory effect of ibuprofen, and evidence suggesting ibuprofen may reduce morbidity in children with asthma raises the intriguing possibility that ibuprofen might actually have therapeutic benefit for at least some children with asthma.

The optimum strategy for mechanical ventilation in a child with status asthmaticus is not established. Volume-controlled ventilation continues to be the traditional approach in such children. Pressure-controlled ventilation may be theoretically more advantageous in allowing for more uniform ventilation. We describe our experience with pressure-controlled ventilation in children with severe respiratory failure from status asthmaticus.Retrospective review.Pediatric intensive care unit in a university-affiliated children's hospital.All patients who received mechanical ventilation for status asthmaticus.Pressure-controlled ventilation was used as the initial ventilatory strategy. The optimum pressure control, rate, and inspiratory and expiratory time were determined based on blood gas values, flow waveform, and exhaled tidal volume.Forty patients were admitted for 51 episodes of severe status asthmaticus requiring mechanical ventilation. Before the institution of pressure-controlled ventilation, median pH and Pco(2) were 7.21 (range, 6.65-7.39) and 65 torr (29-264 torr), respectively. Four hours after pressure-controlled ventilation, median pH increased to 7.31 (6.98-7.45, p.005), and Pco(2) decreased to 41 torr (21-118 torr, p.005). For patients with respiratory acidosis (Pco(2)45 torr) within 1 hr of starting pressure-controlled ventilation, the median length of time until Pco(2) decreased to45 torr was 5 hrs (1-51 hrs). Oxygen saturation was maintained95% in all patients. Two patients had pneumomediastinum before pressure-controlled ventilation. One patient each developed pneumothorax and subcutaneous emphysema after initiation of pressure-controlled ventilation. All patients survived without any neurologic morbidity. Median duration of mechanical ventilation was 29 hrs (4-107 hrs), intensive care stay was 56 hrs (17-183 hrs), and hospitalization was 5 days (2-20 days).Based on this retrospective study, we suggest that pressure-controlled ventilation is an effective ventilatory strategy in severe status asthmaticus in children. Pressure-controlled ventilation represents a therapeutic option in the management of such children.

Background In the evaluation of patients with acute asthma, pulsus paradoxus (PP) is an objective and noninvasive indicator of the severity of airway obstruction. However, in children PP may be difficult or impossible to measure. Indwelling arterial catheters facilitate the measurement of PP, but they are invasive and generally reserved for critically ill patients. Objective To determine the utility of the plethysmographic waveform (PP pleth ) of the pulse oximeter in measuring PP. Methods Patients from the pediatric intensive care unit, emergency department, and inpatient wards of a tertiary care pediatric hospital were eligible for the study. A total of 36 patients (mean age [SD], 11.2 [4.7] years) were enrolled in the study. Pulsus paradoxus was measured using the traditional auscultatory (PP ausc ) method with a sphygmomanometer. Pulsus paradoxus was then measured using a blood pressure cuff observing for the disappearance and reappearance of the (PP pleth ) on the pulse oximeter. Mean difference and 95% confidence intervals were calculated for each method. The 2 methods were also analyzed for correlation and agreement using the Pearson product moment correlation and a Bland and Altman plot. Results Patients with status asthmaticus had higher PP ausc and PP pleth readings compared with nonasthmatic patients. Pulsus paradoxus measured by plethysmography in patients with and without asthma was similar to PP ausc readings (mean difference, 0.6 mm Hg; 95% confidence interval, −0.6 to 2.1 mm Hg). Individual PP pleth readings showed significant correlation and agreement with PP ausc readings in patients both with and without asthma. Conclusion Measurement of PP using the pulse oximeter–pulse plethysmographic waveform offers a simple and noninvasive method for evaluating patients with airway obstruction.

Objective To assess emergency department (ED) utilization and physician preparedness for infants with single ventricle (SV) physiology between stage 1 and stage 2 surgical palliation. Study design Records of infants with SV physiology discharged after stage I palliation between July 2006 and June 2009 were retrospectively reviewed. Next, a cross-sectional survey of registered ED physicians in Michigan was performed. Results Thirty-three of 42 patients (79%) required 65 ED visits, most commonly presenting with respiratory distress (35%). Six patients died in the ED; 35 other visits resulted in hospital admission, 4 requiring urgent surgery or catheterization. Median initial hospital stay in those with ED visits was significantly longer (21 days; IQR, 17-45 days) than those without (12 days; IQR, 5.5-24 days) (P = .032). Three hundred seventy-six of 915 surveyed ED physicians responded. Most (72%) were unsure of the acceptable range of arterial oxygen saturation for these infants, and 58% felt “uncomfortable” or “worried” about their treatment. Despite these concerns, 59% deemed education in SV physiology as low priority. Conclusions Between stages I and II, infants with SV physiology utilized the ED frequently, often with high disease acuity. Most ED physicians surveyed appeared underprepared for these infants. These findings underscore the need for educational efforts aimed at increasing ED preparedness.

The initial evaluation, stabilization, and subsequent transport of the neurologically compromised child should take into account the pathophysiologic response of the CNS to a variety of injurious factors. Little can be done to avoid neuronal damage from the primary event. Secondary insults resulting from hypoxemia, ischemia, intracranial hypertension, and fluid shifts can and must be prevented to ensure maximum neuronal salvage, however. Maintenance of an adequate airway, breathing, and circulation assume an immediate and ongoing priority. Neuroresuscitation should be directed toward reversing alterations in cerebral metabolism, autoregulation, brain water, and ICP associated with individual pathologic states.

Objective: To study the hypothesis that, in the absence of an ischemic-hypoxic state, children with severe traumatic brain injury and with unfavorable Glasgow Coma Scale scores may have good recovery. Design: Retrospective, observational, cross-sectional study with factorial design. Setting: Inpatient population in a university hospital. Patients: Seventy-nine children with traumatic brain injury admitted to the intensive care unit. Interventions: All patients received close monitoring and strict control of intracranial pressure ( 60 mm Hg). Measurements and results: Admission Glasgow Coma Scale score, survival, need for cardiopulmonary resuscitition, presence of shock, peak intracranial pressure, duration of coma, Glasgow outcome Scale score, and the results of neuropsychologic tests were analyzed. Of 79 children, 70 (89%) survived. Although the mortality rate was higher among patients with Glasgow Coma Scale scores of 3 to 5, 14 (64%) of 22 of these children survived. Nonsurvivors had a significantly higher incidence of shock and need for cardiopulmonary resuscitation. Except for two patients who had prolonged hypoxemia, all children, including those with Glasgow Coma Scale scores of 3 to 5, had a satisfactory outcome (Glasgow Outcome Scale scores of 4 or 5). Neuropsychologic outcome was not significantly different in the survivors with Glasgow Coma Scale scores of 3 to 5 and those with Glasgow Coma Scale scores of 6 or more. Conclusions: A low Glasgow Coma Scale score does not always accurately predict the outcome of severe traumatic brain injury; in the absence of hypoxic-ischemic injury, children with traumatic brain injury and Glasgow Coma Scale scores of 3 to 5 can recover independent function.

Ketorolac (KT) is a parenteral nonsteroidal anti-inflammatory analgesic used for the treatment of moderate to severe pain. We studied the efficacy and safety of intravenous (IV) KT, compared to IV morphine (MS) in critically-ill children.

Ketorolac (KT) is administered as a racemic mixture although cyclooxygenase inhibitory activity resides with the (-S) stereoisomer. Little is known about KT stereo-specific pharmacokinetics. We studied plasma pharmacokinetics of(+R) and (-S) KT in 8 children (median age 11.8 yrs) following a 0.6 mg/kg IV dose of racemic KT. Twelve timed plasma samples were collected over 720 minutes after the dose. (+R)-KT and (-S)-KT were measured by HPLC using a CHIRACEL OJ-R column. Kinetic values were estimated from non-linear iterative fit of the the plasma concentrations to a bi-exponential or tri-exponential equation with 10 minutes infusion function. Significant differences were observed between the two enantiomers: Cmax was higher, AUC greater, t1/2elim longer, and Cl less for (+R)-KT. There was no difference between the enatiomers in Vd or t1/2dist. Table

In an effort to delineate the clinical characteristics of respiratory syncytial virus (RSV) infection in the compromised host, we compared children with bronchopulmonary dysplasia (BPD), congenital heart disease (CHD), premature birth, failure to thrive, and gastroesophageal reflux to previously healthy children. During a four-year period, 262 patients were admitted to the hospital with RSV infection diagnosed by a rapid RSV antigen detection test. Children with BPD or CHD had more hospital days and supplemental oxygen days than the previously healthy group (P less than 0.05). Patients with BPD also had more ICU days, ventilator days, and NPO days, as well as a higher physiologic stability index and therapeutic intervention score than the previously healthy group (P less than 0.05). Premature infants were more likely to present with apnea from RSV (P less than 0.001). Patients with underlying illness tended to be older, although significant difference was demonstrated only for the BPD group (7.0 +/- 5.3 vs. 3.5 +/- 3.3, P less than 0.05). Patients with BPD and CHD had more nosocomial infections than the previously healthy group (P less than 0.0001) and death occurred only in patients with underlying illness. We conclude that previously compromised patients are at risk for more severe and prolonged RSV disease. Earlier diagnosis and therapeutic intervention may be necessary in such patients to improve outcome.