Schnarchen bei Kindern

Background

Snoring in children is a prevalent symptom and may be an indicator of obstructive sleep apnoea. Despite its importance, there is no national guideline on its appropriate management.

Objective

To provide recommendations for the management of snoring in children and adolescents treated in a primary care setting.

Methods

A total of 16 national paediatric sleep experts were included in a Delphi process and formulated recommendations in the form of a step-wise work-up procedure.

Results

The following 8 steps were developed: (1) Identification of true cases of habitual snoring. (2) Identification of high-risk patients who should undergo polysomnography in a sleep laboratory. (3) Identification of mild cases that may be treated with anti-inflammatory medication. (4) Identification of cases that should be referred to an otorhinolaryngologist for potential surgery. (5) Performance of polysomnography in cases that remain unclear despite steps 3 and 4 to rule out obstructive sleep apnoea. (6) Reconsideration of surgery in cases with moderate to severe obstructive sleep apnoea. (7) Identification of severe sleep apnoea cases requiring continuous positive airway pressure therapy. (8) Identification of cases suitable for orthodontic treatment, craniofacial surgery or speech therapy.

Conclusion

This guideline should help to improve the management of snoring children and adolescents in Germany.     

Akute Alkoholintoxikationen bei Kindern und Jugendlichen

Background.

According to a WHO-cross-national-survey the alcohol consumption among children and adolescents in Switzerland has risen during the last three decades.

Methods.

The present study is a retrospective analysis of 103 patients admitted to the university childrens hospital of Zurich due to alcohol intoxication during the period 1971–1997. Investigated parameters include: clinical presentation and management, quantity and type of alcohol ingested as well as sociodemographic and psychosocial factors.

Results.

The average age of the patients, 46 female and 57 males, was 11.3 years. In 39% a blood alcohol concentration (BAC) was measured: mean 1.6‰ (g/l). 30% of cases had a background of psychosocial problems. Overall we found that during the last three decades the rate of non-dependent alcohol intoxication rose, especially among females, and that the amount of alcohol consumed increases.

Conclusion.

Despite a high proportion of severe intoxications all patients survived without complications. Notwithstandig the fact that the principle aim of care is the treatment of hypoglycemias, acidosis and hypothermias a psychosocial evaluation must take place as well. Alcoholintoxication in children and adolescents is increasing and intensive prevention strategies are required.     

Ventilator-associated pneumonia in an Italian pediatric intensive care unit: a prospective study

Background

This study was undertaken to determine the prevalence, risk factors and outcomes associated with ventilator-associated pneumonia (VAP) in a European pediatric intensive care unit (PICU).

Methods

A total of 451 children who had been mechanically ventilated in the PICU for ≥48 hours during a 3-year period were enrolled in this prospective study.

Results

In comparison with children without VAP, 30 children (6.6%) who developed VAP had a longer PICU stay (P=0.0001) and hospital stay (P=0.0001), and a higher mortality rate (P=0.04). Logistic regression analysis showed that the need for re-intubation (P=0.0001), the presence of tracheostomy (P=0.04), and enteral feeding (P=0.02) were independent risk factors for VAP.

Conclusions

A relevant proportion of intubated children develop VAP, which is closely related to invasive procedures. As VAP is associated with increased medical costs and death, multicenter studies are urgently needed to improve the therapeutic approach to VAP and VAP prevention.     

A micro-costing model of neonatal intensive care from a tertiary Indian unit: Feasibility and implications for insurance

Objective

To calculate and compare costs of neonatal intensive care by micro-costing and gross-costing methods.

Methods

The costs of resources of a tertiary care neonatal intensive care unit were estimated by the two methods to arrive at specific costs per diagnosis related categories for 33 neonates followed-up prospectively.

Results

Grosscosting as compared to micro-costing resulted in higher cost per bed (Rs 6315 vs. Rs 4969) and wide variations of costs (?34.8% to +13.4%). Intensity of interventions, relative stay in neonatal intensive care unit compared to the step-down nursery, and total length of hospital admission accounted for these variations.

Conclusions

Estimates based on micro-costing arrived in this study may be used as a starting point in developing assumptions for insurance models covering neonatal intensive care.     

Behandeling van hypothermie bij kinderen na submersie

Objective. To answer to the question, whether in the process of rewarming of hypothermic children after submersion, invasive methods have additional value compared to external methods and where cardiopulmonary bypass (cpb) should stand in the treatment. Design. Retrospective chart reviewnd>/nd> Literature search. Comparison of the approach to treatment in pediatric intensive care units (picus) in the Netherlands. Method. Temperature course and neurological outcome were studied of all near-drowned children admitted to the intensive care unit of the Wilhelmina Children's Hospital in a four year period. We searched for English written articles from 1998 about this subject. Inquiries were made about rewarming methods in other Dutch picus. Results. Hypothermic near-drowned children rewarmed spontaneously or could easily be rewarmed by external or minimally invasive methods. Randomised clinical trials or case-control studies were not found. Only review articles and case-reports were published on this subject. Seven of the eight picus start to warm up externally. Six picus use a combination of external and invasive methods. Six centres consider cpb in hypothermic children with insufficient cardiac output. Conclusion. External rewarming is the method of choice in near-drowned children and is in virtually all cases adequate. More invasive rewarming methods have not been shown to be advantageous. Despite lack of evidence for a better prognosis, cpb should be considered in hypothermic children (T<32 °C) with circulatory arrest, because under these circumstances it is the only method to rewarm effectively and restore circulation simultaneously.     

Extended-spectrum beta-lactamase-producing Klebsiella pneumoniae infection in a neonatal intensive care unit

Background

A molecular epidemiological survey was conducted on an extended-spectrum beta-lactamase-producing Klebsiella pneumoniae (ESBLKp) infection in our neonatal intensive care unit (NICU) from February to June 2008.

Methods

Cultures of clinical samples from neonates in the NICU, the hands of healthcare workers and the environment of the NICU were subjected to ESBLKp isolation. Pulsed-field gel electrophoresis was performed to determine Klebsiella pneumoniae strains (type A-D).

Results

In 1439 neonates, 38 (2.6%) had infections and 65 (4.5%) had colonizations with ESBLKp. Microbiological sampling of the NICU environment yielded 33 (14.9%) ESBLKp isolates from 222 samples. Clone A was found in 88.2% of the infected neonates, 66.7% of the colonized neonates, 69.7% of the environmental samples, and the hands of a healthcare worker.

Conclusions

The detection rate of ESBLKp is high in environmental samples, especially those from frequently touched surfaces. Since ESBLKp was identified on the hands of a healthcare worker in the present study, hand and environmental hygiene is mandatory for infection control in neonatal intensive care units.     

Effect of kangaroo mother care Vs expressed breast milk administration on pain associated with removal of adhesive tape in very low birth weight neonates: A randomized controlled trial

Objective

To compare the pain relief effect of Kangaroo Mother Care (KMC) and Expressed Breast Milk (EBM) on the pain associated with adhesive tape removal in very low birth weight (VLBW) neonates.

Design

Randomized Controlled Trial.

Setting

Neonatal intensive care unit of a tertiary care teaching hospital.

Participants

15 VLBW neonates who needed adhesive tape removal for the first part and 50 VLBW neonates needing adhesive tape removal for the second part.

Methods

In first stage of the study, we studied whether adhesive tape removal in VLBW neonates was painful. In the second stage, eligible VLBW neonates were randomised to compare the efficacy of KMC and EBM in reducing the pain during the procedure of adhesive tape removal.

Outcome Variables

Premature Infant Pain Profile (PIPP) Score, heart rate, oxygen saturation.

Results

There was significant increase in pain associated with the removal of adhesive tape (Mean pre-procedure PIPP score 3.47 ± 0.74; post-procedure mean PIPP score 12.13 ± 2.59; P<0.0001). The post intervention mean PIPP pain score was not significantly different between the KMC and EBM groups (P= 0.62).

Conclusions

Removal of adhesive tape is a painful procedure for VLBW neonates. There was no difference between KMC and EBM in relieving pain associated with adhesive tape removal.     

Nosokomiale Infektionen bei Neugeborenen

Background

Outbreaks of nosocomial infections in neonates have recently received broad media interest.

Objectives

Data on nosocomial infections in German neonatal intensive care units are presented.

Material and methods

The available epidemiological data, mostly based on the NEO-KISS (hospital infection surveillance system) surveillance system were analyzed.

Results

Nosocomial infections (e.g. sepsis, pneumonia and necrotizing enterocolitis) affect approximately 44?% of preterm infants <?500 g birth weight, 34?% of infants with birth weights 500–999 g and 12?% of infants with birth weights 1,000–1,499 g, with sepsis (78?%) dominating over pneumonia (13?%) and necrotizing enterocolitis (9?%). Device use and understaffing have emerged as important risk factors in addition to low birth weight and gestational age. The gap in hazard ratios between central and peripheral catheters has almost disappeared (6.18 and 5.97, respectively). Understaffing (>?5?% below target) is linked with an almost 50?% increase in the risk of catheter-associated sepsis (odds ratio 1.47). Coagulase-negative staphylococci are cultured in more than 50?% of bloodstream positive sepsis cases while bacteria with multiple antibiotic resistance are recovered in only 3.4?% of cases. To date, no cases of carbapenem-resistant gram-negative sepsis have been observed in the German neonatal intensive care units under surveillance. Depending on the time interval (14–90 days) used for defining an outbreak, the number of outbreaks in neonatal intensive care units per year varies from 26 to 61.

Conclusion

More detailed information on neonatal nosocomial infections will be available following incorporation of the NEO-KISS module into the EuroNeoNet quality improvement initiative (2012). Furthermore, data concerning the use of antibiotics and microbial resistance patterns have been collected since 2013.     

Clinical profile and outcome of chronic pancreatitis in children

Objective

To evaluate the etiology, presentation, complications and management of chronic pancreatitis in children.

Design

Retrospective chart review.

Setting

Gastroenterology department at Christian Medical College and Hospital, Vellore, India between January 2005 and December 2010.

Participants

99 Children (<18 yrs) diagnosed with chronic pancreatitis based on clinical and imaging features.

Main outcome measures

Etiology, clinical presentation, complications and management of chronic pancreatitis in children.

Results

Of 3887 children who attended the Gastroenterology department, 99(2.5%) had chronic pancreatitis, of which 60 (60.6%) were males. In 95(95.9%) patients no definite cause was detected and they were labeled as Idiopathic chronic pancreatitis. All patients had abdominal pain, while 9(9.1%) had diabetes mellitus. Of the 22 children tested for stool fat, 10(45.5%) had steatorrhea. Pancreatic calcification was seen in 69 (69.7%). 68 (71.6%) patients with idiopathic chronic pancreatitis had calcification. Calcific idiopathic chronic pancreatitis was more frequent in males (67.6% vs. 48.1%, P=0.07), and was more commonly associated with diabetes mellitus (13.2% vs. none, P=0.047) and steatorrhea (61.5% vs. 16.7%, P=0.069). Pseudocyst (17.1%) and ascites (9.1%) were the most common complications. All children were treated with pancreatic enzyme supplements for pain relief. 57 patients were followed up. With enzyme supplementation, pain relief was present in 32 (56.1%) patients. Of those who did not improve, 10 underwent endotherapy and 15 underwent surgery. Follow up of 8 patients who underwent endotherapy, showed that 5 (62.5%) had relief. Follow up of 11 patients who underwent surgery showed that only 3 (27 %) had pain relief. There was no death.

Conclusions

Idiopathic chronic pancreatitis is the predominant form of chronic pancreatitis in children and adolescents. It can present with or without calcification. The calcific variety is an aggressive disease characterized by early morphological and functional damage to the pancreas.     

INCLEN diagnostic tool for epilepsy (INDT-EPI) for primary care physicians: Development and validation

Objective

To evaluate the diagnostic accuracy of a new diagnostic instrument for epilepsy — INCLEN Diagnostic Tool for Epilepsy (INDT-EPI) — with evaluation by expert pediatric neurologists.

Study design

Evaluation of diagnostic test.

Setting

Tertiary care pediatric referral centers in India.

Methods

Children aged 2–9 years, enrolled by systematic random sampling at pediatric neurology out-patient clinics of three tertiary care centers were independently evaluated in a blinded manner by primary care physicians trained to administer the test, and by teams of two pediatric neurologists.

Outcomes

A 13-item questionnaire administered by trained primary care physicians (candidate test) and comprehensive subject evaluation by pediatric neurologists (gold standard).

Results

There were 240 children with epilepsy and 274 without epilepsy. The candidate test for epilepsy had sensitivity and specificity of 85.8% and 95.3%; positive and negative predictive values of 94.0% and 88.5%; and positive and negative likelihood ratios of 18.25 and 0.15, respectively.

Conclusion

The INDT-EPI has high validity to identify children with epilepsy when used by primary care physicians.     

Clinical-radiologic features and treatment of hepatic lesions caused by inadvertent infusion of parenteral nutrition in liver parenchyma due to malposition of umbilical vein catheters

Background

Umbilical venous catheterization is a common procedure performed in neonatal intensive care units. Hepatic collections due to inadvertent extravasation of parenteral nutrition into the liver have been described previously in literature.

Objective

To recognize the clinicoradiologic features and treatment options of hepatic collections due to inadvertent extravasation of parenteral nutrition fluids caused by malpositioning of umbilical venous catheter (UVC) in the portal venous system.

Materials and methods

This is a case series describing five neonates during a 6-year period at a single tertiary care referral center, with extravasation of parenteral nutrition into the liver parenchyma causing hepatic collections.

Results

All five neonates receiving parenteral nutrition presented with abdominal distension in the second week of life. Two out of five (40%) had anemia requiring blood transfusion and 3/5 (60%) had hemodynamic instability at presentation. Ultrasound of the liver confirmed the diagnosis in all the cases. Three of the five (60%) cases underwent US-guided aspiration of the collections, one case underwent conservative management and one case required emergent laparotomy due to abdominal compartment syndrome. US used in follow-up of these cases revealed decrease in size of the lesions and/or development of calcifications.

Conclusion

Early recognition of this complication, prompt diagnosis with US of liver and timely treatment can lead to better outcome in newborns with hepatic collections secondary to inadvertent parenteral nutrition infusion via malposition of UVC.     

Management of children with severe acute malnutrition: Experience of Nutrition Rehabilitation Centers in Uttar Pradesh,India

Objective

To assess the effectiveness of facility-based care for children with severe acute malnutrition (SAM) in Nutrition Rehabilitation Centers (NRC).

Design

Review of data.

Setting

12 NRCs in Uttar Pradesh, India.

Participants

Children admitted to NRCs (Jan 1, 2010 — Dec 31, 2011).

Intervention

Detection and treatment of SAM with locally-adapted protocols.

Outcomes

Survival, default, discharge, and recovery rates.

Results

54.6% of the total 1,229 children admitted were boys, 81.6% were in the age group 6–23 months old, 86% belonged to scheduled tribes, scheduled castes, or other backward castes, and 42% had edema or medical complications. Of the 1,181 program exits, 14 (1.2%) children died, 657 (47.2%) children defaulted, and 610 (51.7%) children were discharged The average (SD) weight gain was 12.1 (7.3) g/kg body weight/day and the average (SD) length of stay was 13.2 (5.6) days. 206 (46.8%) children were discharged after recovery (weight gain ≥15%) while 324 (53.2%) were discharged, non-recovered (weight gain <15%)

Conclusions

NRCs provide life-saving care for children with SAM; however, the protocols and therapeutic foods currently used need to be improved to ensure the full recovery of all children admitted.     

Intranasal fentanyl versus placebo for pain in children during catheterization for voiding cystourethrography

Background

Voiding cystourethrogram (VCUG) is a common procedure at pediatric tertiary care centres that can be painful as it involves a urinary catheter. Currently there are no widely utilized protocols for non-topical medications to decrease pain that children feel during catheterization.

Objective

To determine if intranasal (IN) fentanyl is effective at decreasing pain that children feel during catheterization of VCUG when compared with sterile water.

Materials and methods

We performed a double-blind randomized controlled trial, using IN fentanyl (2 μg/kg) compared to placebo (sterile water,) in children 4–8 years of age scheduled for elective VCUG in one urban pediatric tertiary center.

Results

Using the Face Pain Score-Revised, children receiving IN fentanyl scored 2.58 (1.93–3.25 95% CI) while those receiving sterile water scored 2.86 (2.20–3.51 95% CI) showing no statistically significant difference. There were no adverse events.

Conclusions

Although we were unable to show a statistically significant difference between our study and control groups, we believe that this may be due to technique (positioning, delivery device) and timing of administration of IN fentanyl as well as multi-factorial causes of distress during VCUG. Future studies investigating alternative delivery techniques of IN fentanyl for analgesia during VCUG may yield more 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.     

Children with high and intermediate imperforate anus: their experiences of hospital care

Purpose

The purpose of this study was to examine the experiences of children with high and intermediate imperforate anus (IA), and specifically their experiences of hospital care.

Methods

Twenty-five children born with high and intermediate IA participated; 9 boys and 16 girls. The mean age was 10.5?years (range 8.0?C13.6). Two control groups were involved in the study. A self-report questionnaire was used to gather the data concerning children??s experiences of hospital care. Items were scored on a 5-point Likert scale.

Results

The children??s responses on hospital care items scored high. The children with IA reported being less satisfied with the information given, and understood less why they needed to visit the hospital than did the children in the two control groups.

Conclusion

The children??s experiences of care seemed to be positive even though the children born with IA are subjected to invasive treatment. More research is called for in the unexplored area of information to the children, and particularly to the children born with a defect. Children??s views are important and should always be considered, as their answers most certainly reflect a genuine experience, contributing to the further development of their specific care.     

Healthcare-associated infections in a neonatal intensive care unit in Turkey

Objective

To determine the incidence, risk factors, mortality rate, antibiotic susceptibility and causative agents of healthcare-associated infections (HAIs) in the Neonatal Intensive Care Unit.

Design

Prospective, cohort.

Setting

A 38-bed, teaching, referral, neonatal intensive-care unit.

Participants

All patients in the neonatal intensive care unit who did not have any sign of infection at admission and remained hospitalized for at least 48 hours.

Methods

The study was conducted between January 2009 and January 2011. Healthcare-associated infection was diagnosed according to the criteria of CDC. Risk factors for HAI were analyzed with univariate and multivariate regression analysis.

Results

The incidence of HAI was found to be 16.2%. Blood stream infection was observed as the most common form of HAI (73.2%). The mortality rate was 17.3%. Antenatal steroid use, cesarean section, male gender, low birth weight, parenteral nutrition, percutaneous and umbilical catheter insertion, mechanical ventilation and low Apgar scores were found to be related with HAI (P<0.05). A 10% reduction in infection rate as a consequence of the application of a new total parenteral nutrition guideline was observed. Coagulase negative staphylococci (44. 4%) and Klebsiella pneumoniae (25.9%) were the most common etiologic agents isolated from cultures. Methicillin resistance of coagulase-negative staphylococci and ESBL resistance of Klebsiella pneumoniae were 72% and 44%, respectively.

Conclusions

Antenatal steroid was found to be associated with HAI. Newly applied total parenteral nutrition guidelines reduced the attack rate of infection. Efforts should be focused on developing more effective prevention strategies to achieve better outcomes.     

Intellectual disability in Indian children: experience with a stratified approach for etiological diagnosis

Objective

To study the clinico-etiological profile of children with intellectual disability using an algorithmic approach.

Design

Cross-sectional study.

Setting

Tertiary care centre in Northern India.

Participants

Consecutive children aged 3 months to 12 years, presenting with intellectual disability, confirmed by Developmental Assessment Scale for Indian Infants, Binet Kulshreshtha Test and Vineland Social Maturity Scale.

Method

All children were assessed on an internally validated structured proforma. A targeted approach included thyroid function tests, Brainstem evoked response audiometry, electroencephalogram, neuroimaging and metabolic screen done as a pre-decided schema. Genetic tests included karyotyping, molecular studies for Fragile X, Multiplex Ligation Dependent Probe Amplification and Array Comparative Genomic Hybridisation.

Results

Data of 101 children (median age 22 months) was analyzed. The etiological yield was 82.1% with genetic causes being the most common (61.4%) followed by perinatal acquired (20.4%), CNS malformations (12%), external prenatal (3.6%), and postnatal acquired (2.4%). Mild delay was seen in 11.7%, moderate in 21.7%, severe in 30.6% and profound in 35.6%.

Conclusion

It is possible to ascertain the diagnosis in most of the cases of intellectual disability using a judicious and sequential battery of tests.     

Risk factors for scholastic backwardness in children

Aim

To identify the risk factors for scholastic backwardness in children.

Participants

Children in the 6–12 year age group attending regular schools and referred to the child guidance clinic for scholastic backwardness.

Setting

Tertiary care hospital in South India.

Methods

Participants were compared with an age-and sexmatched group of children with good academic performance, to ascertain risk factors for scholastic backwardness.

Results

There were 75 boys and 35 girls in the study group. Among them 30 (27%) children had mental retardation, 39 (36%) had borderline intelligence and 12 (11%) had microcephaly. Undernutrition was noted in 36 (33%) children and 31 (28%) had stunted growth. 28 (26%) children had a history of chronic medical problems like epilepsy, bronchial asthma and congenital heart diseases. Visual, hearing and speech defects were present in 6 (6%), 5 (5%) and 12 (11%) children, respectively. Statistically significant differences were noted in the educational level and employment status of parents of children with scholastic backwardness and those with good academic performance.

Conclusion

Social and family factors have a significant influence on the academic functioning of children.