Treatment of burns in childhood

Management of burns in children depends above all on infusion therapy, i.e. replacement of the plasma, water and electrolytes of which the circulation and tissue have been deprived as a result of exudation into the wound area, increased evaporation of water, and edema. The inexperienced therapist tends to underestimate these losses in the case of children. In infants and older children with burns covering upwards of 5% and 10% respectively of body surface there is a danger of shock developing, with peripheral vasoconstriction, acidosis, cerebral edema and renal failure. Infusion therapy should therefore be instituted as early as possible. Fusidic acid has proved very valuable in topical treatment of burns in children. Concomitant antimicrobial treatment can be dispensed with in the majority of patients. Keloid overgrowths are now more effectively prevented by means of Lycra pressure dressings.     

Aminophylline therapy and cerebral blood flow velocity in preterm infants

Pulsed Doppler ultrasound was used to evaluate the cerebral blood flow velocity (CBFV), in the middle and anterior cerebral arteries in 10 infants before and after the administration of aminophylline (7.5 mg/kg). Mean CBFV, heart rate, blood pressure, oxygen and carbon dioxide tensions were recorded before the loading dose, and then at 1, 2, 6 and 24 h after completion of the infusion. Mean CBFV in the middle and anterior cerebral arteries were 16.8 cm/s and 10.8 cm/s respectively prior to the infusion. There was a significant decrease ( P <0.05) in velocities in both arteries at 1 and 2 h post drug therapy, which returned to base values by 6h, and remained as such at 24h. The heart rate increased ( P <0.05) after the infusion, while no consistent changes were observed in blood pressure or oxygen tension. Carbon dioxide levels were significantly reduced ( P <0.05) at 2h. The reduction in CBFV, however, was more than would be expected on the basis of the change in carbon dioxide levels alone, suggesting that other factors may be exerting an influence. While no adverse effects were noted in the infants studied, it is suggested that aminophyiline should be used judiciously in sick preterm infants at highest risk from ischaemic brain injury.     

Effect of pentoxifylline on cytokine- and eicosanoid-induced acute pulmonary hypertension in piglets.

The methylxanthine derivative pentoxifylline (PTF) demonstrates vasodilatory properties in vivo. We tested the hypothesis that PTF infusion would blunt or inhibit tumor necrosis factor-alpha (TNF alpha)-induced and U46,619-induced increases in mean pulmonary artery pressure and pulmonary vascular resistance (PVR) in the neonatal piglet and would do so by altering production of eicosanoid vasoactive mediators. Anesthetized, paralyzed piglets (age 10-29 d) were randomized and treated with a 30-min infusion of TNF alpha alone (n = 13 animals), with a combination of TNF alpha plus pretreatment and continuous infusion with PTF (n = 6), or with a combination of U46,619 for 30 min plus pretreatment and continuous infusion of PTF (n = 5). There was no difference in pulmonary or systemic hemodynamic indices between the three groups at baseline. PVR was significantly elevated at 15 min and at 2 h in the TNF alpha-only group. The TNF alpha-induced rise in mean pulmonary artery pressure and PVR was inhibited by the PTF until 2 h, by which time PVR was elevated above baseline and was comparable to the value found in animals treated with only TNF alpha. PTF produced no inhibition in the U46,619-induced elevation of PVR during the 30-min simultaneous treatment. In the PTF + TNF alpha group, mean systemic blood pressure declined to 50% of baseline value (p less than 0.02) by 2 h of age. No significant decline was noted in mean systemic arterial pressure of the TNF alpha-only or the U46,619-treated group.(ABSTRACT TRUNCATED AT 250 WORDS)     

Brain haemodynamic effects of nasal continuous airway pressure in preterm infants of less than 30 weeks' gestation

AIM: To evaluate the hypothesis that increasing levels of nasal continuous positive airway pressure (NCPAP) may decrease cerebral blood volume (CBV) and cerebral oxygenation in infants with gestational age (GA) less than 30 weeks. METHODS: We prospectively studied a cohort of preterm infants treated with NCPAP using near-infrared spectroscopy (NIRS). The pressure limit of NCPAP was set at 2, 4, 6 and again 2 cm H(2)O for 30 min. RESULTS: Changes of pressure levels were not followed by significant changes of oxygenated haemoglobin (O(2)Hb), deoxygenated haemoglobin (HHb), cerebral intravascular oxygenation (HbD), oxidized-reduced cytochrome aa3 (CtOx), tissue oxygenation index (TOI), tissue haemoglobin index (THI) and cerebral blood volume (DeltaCBV). CONCLUSION: NCPAP at 2-6 cm H(2)O pressure levels did not affect cerebral oxygenation and CBV. These findings are reassuring and confirm the safety of NCPAP in preterm infants with GA less than 30 weeks.     

Continuous subcutaneous insulin infusion: Special needs for children

Continuous subcutaneous insulin infusion (CSII) is a very common therapy for children with type 1 diabetes. Due to physiological differences they have other requirements for their insulin pump than adults. The main difference is the need for very low basal rates. Even though most available insulin pumps reach a high accuracy at usual basal rates, accuracy decreases for lower rates. In addition, the lowest delivered amount at 1 time is limiting the fine tuning of the basal rate as well as the option for temporary basal rates. Alarms in case of occlusions depend on accumulation of a certain amount of insulin in the catheter, and therefore the time until such an alarm is triggered is much longer with lower basal rates. Accordingly, the risk for hyperglycemia developing into diabetic ketoacidosis increases. The availability of bolus advisors facilitates the calculation of meal and correction boluses for children and their parents. However, there are some differences between the calculators, and the settings that the calculation is based on are very important. Better connectivity, for example with a system for continuous glucose monitoring, might help to further increase safety in the use of CSII in children. When selecting an insulin pump for a child, the features and characteristics of available pumps should be properly compared to ensure an effective and safe therapy.     

Pulmonary deposition sites of an inhaled radiolabeled submicronic aerosol

The clearance rate of aerosolized and deposited 99mtechnetium diethylenetriamine pentacetate provides an index of lung epithelial permeability. However, the location of the epithelium being assessed is uncertain. We determined the percentage of submicronic aerosol deposited on ciliated and nonciliated airways in healthy and damaged lungs using 99mTc-sulphur (99mTc-S) colloid. Colloidal particles can be cleared by mucociliary transport but not through the epithelium. Piglets aged 12-72 h, weighing 0.7-3.3 kg (average 1.6 kg) were anesthetized and underwent endotracheal intubation. 99mTc-S labeled submicronic aerosol (Syntevent II) was collected in anesthetic bags and either inhaled spontaneously (n = 4), or insufflated by hand (n = 5) at 30 breaths per min and a peak airway pressure of 15 cm H2O. Piglets were immediately extubated and scanned on a gamma camera. Twenty-four h later a repeat scan was performed. The residual radioactivity represents the amount of aerosol deposited on nonciliated airways. In six other piglets pulmonary damage was produced by an intravenous infusion of air microemboli for 2 to 3 h (0.14 to 0.38 ml/min). The maximal decrease in PaO2 while breathing room air ranged from 24-59 mm Hg. During the last 15 min of infusion they were intubated, insufflated by hand with the 99mTc-S aerosol, and scanned as above. The results demonstrate that approximately three-fourths of the submicronic aerosol is deposited distally to ciliated airways in both healthy and damaged newborn piglet lungs. This suggests that the clearance rate of 99mtechnetium diethylenetriamine pentacetate predominantly reflects epithelial permeability of terminal lung units when a submicronic aerosol is used for delivery to the lung.     

Television viewing in early childhood predicts adult body mass index

OBJECTIVES: To examine the effects of duration, timing and type of television (TV) viewing at age 5 years on body mass index (BMI) in adult life. STUDY DESIGN AND METHODS: 1970 British Birth Cohort, followed up at 5 (N=13,135), 10 (N=14,875), and 30 years (N=11,261). OUTCOME MEASURES: Weekday and weekend TV viewing at 5 years, type of programs, and maternal attitudes toward TV at age 5 years. BMI z-score at 10 and 30 years. RESULTS: Mean daily hours of TV viewed at weekends predicted higher BMI z-score at 30 years (coefficient=0.03, 95% CI: 0.01, 0.05, P=.01) when adjusted for TV viewing and activity level at 10 years, sex, socioeconomic status, parental BMIs, and birth weight. Each additional hour of TV watched on weekends at 5 years increased risk of adult obesity (BMI > or =30 kg/m2) by 7% (OR=1.07, 95% CI 1.01, 1.13, P=.02). Weekday viewing, type of program and maternal attitudes to TV at 5 years were not independently associated with adult BMI z-score. CONCLUSIONS: Weekend TV viewing in early childhood continues to influence BMI in adulthood. Interventions to influence obesity by reducing sedentary behaviors must begin in early childhood. Interventions focusing on weekend TV viewing may be particularly effective.     

Measurement of cardiopulmonary function by rebreathing methodology in piglets

The use of a multiple gas rebreathing method for the measurement of cardiopulmonary function in mechanically ventilated neonates was evaluated. The following indices of cardiopulmonary function were assessed in 20 piglets (mean weight, 2.3 kg): 1) pulmonary capillary blood flow (Qc), 2) diffusing capacity for carbon monoxide (DLCO), 3) lung gas volume (FRC), 4) oxygen consumption (VO2), and 5) volume of the pulmonary tissues and capillaries (VTPC), the latter an estimate of total lung water. During mechanical ventilation at zero end expiratory pressure, all rebreathing parameters correlated well with body weight. Additionally, a good correlation (r = 0.81, slope = 0.99) between VTPC and postmortem estimate of total lung water was observed. The effect of ventilation with positive end expiratory pressure (PEEP) was then studied in 10 piglets. On increasing PEEP from zero to 15 cm H2O, FRC significantly increased by 208%, Qc significantly decreased by 60%, and no changes in VTPC occurred. Seven piglets were then studied after induction of lung injury by oleic acid infusion. Compared with the pre-oleic acid infusion values, all the rebreathing variables decreased during ventilation without PEEP. Unlike the situation with the normal piglets, when PEEP was increased from zero to 10 cm H2O in the oleic acid-infused piglets, the values for FRC and VTPC significantly increased. Mean VTPC at 10 cm H2O was 20 +/- 2 ml/kg which correlated well (r = 0.93) with the postmortem total lung water value of 19 +/- 1 g/kg. Thus, multiple gas rebreathing methodology is applicable to studies using small animals.(ABSTRACT TRUNCATED AT 250 WORDS)     

Continuous monitoring of blood pressure in children and adolescents,a review of the literature

Continuous or ambulatory blood pressure monitoring (CBPM or ABPM) is becoming a useful tool in the early detection of hypertension in children and adolescents. With increased obesity in pediatrics, chronic diseases such as hypertension, diabetes, dyslipidemia and metabolic syndrome which was more commonly seen in adults in the early years, can now be seen in this population. This review provides the clinical reports of the use of CBPM for diagnosis and management of hypertension in the pediatric population.     

Hyperoxia effects on pulmonary pressure: volume characteristics and lavage surfactant phospholipid in the newborn rabbit

The effect of hyperoxia (greater than 95%) on surfactant phospholipid recovered by lavage and pulmonary pressure:volume characteristics was studied in rabbits exposed from birth through 4 days of life. Decreased surfactant phospholipid (microgram/mg dry lung weight) in the airways was observed as early as 6 h and persisted through 96 h of life in hyperoxia-exposed animals. The composition of lavage phospholipids and fatty acid profile of phosphatidylcholine was not altered by hyperoxia. Pressure:volume analysis revealed a decrease in maximum lung distensibility (V30, volume at 30 cm pressure) at 48 and 96 h and a decrease in inflation compliance (P30i, pressure on inflation to 30% V30) at 48 h of life in newborn pups exposed to hyperoxia. Pressure:volume changes in both male and female newborns were observed with hyperoxia exposure. However, only female pups exhibited a decrease in lavage phospholipid content as measured at 48 h. These data suggest that the newborn rabbit surfactant system is susceptible to oxygen toxicity. In addition to age-related differences, sex differences may exist with regard to susceptibility to hyperoxia. Subtle alterations in the surfactant system at this critical time of rapid lung development could have long lasting effects on lung function.     

Studies of short-term pulmonary and peripheral vascular responses induced in oophorectomized sheep by the infusion of a group B streptococcal extract

Short-term (0-30 min) pulmonary and systemic vascular responses of oophorectomized ewes infused intravenously with a trichloroacetic acid (TCA) extract of a type III (strain 878) group B streptococcus (GBS) were studied. TCA-878 extract induced significant pulmonary hypertension, reduction in femoral artery pressure and reduced femoral artery PO2. These responses were similar to those observed after the infusion of sublethal doses of E. coli endotoxin and could be prevented by priming the animal with ibuprofen or indomethacin. Ewes rechallenged 48 h after their initial dose of TCA-878 extract experienced pulmonary arterial pressure significantly higher than those induced by the first infusion. Similar augmented responses were not seen after rechallenge with endotoxin. Larger doses of TCA-878 extract resulted in increasingly higher pulmonary arterial pressure. We conclude that the venous infusion of TCA extracts of GBS-878 induces significant pulmonary hypertension in sheep and that this response may be mediated by prostaglandins. The vasoactive substance extracted from these streptococci could play a role in promoting the vascular instability experienced by the human neonate with early onset GBS disease.     

Early identification of anthracycline cardiomyopathy: possibilities and implications.

The number of survivors of childhood cancer affected by anthracycline cardiomyopathy is steadily increasing, despite efforts to limit cardiotoxicity by dose restriction. Cardiac function was evaluated prospectively in 125 children during treatment to attempt to identify individual susceptibilities to cardiotoxicity and hence any potential for treatment modification. Left ventricular shortening fraction was used as an index of cardiotoxicity. Shortening fraction declined as cumulative anthracycline dose increased, at an average rate of 1% per 100 mg/m2. Six patients (5%) developed heart failure. Twenty four patients (19%) had abnormal shortening fraction (< 30%) by the end of treatment, and their rate of fall of shortening fraction was significantly steeper throughout treatment than in patients finishing with normal function (shortening fraction > or = 30%). This differential susceptibility to cardiotoxicity was apparent from very early in treatment, interquartile ranges of the two shortening fraction groups separating at doses > 200 mg/m2. Patients at high risk of risk of important anthracycline cardiotoxicity may be identifiable early in treatment by regular and careful monitoring of shortening fraction. However, frequent assessment is required and this has significant resource implications.     

A swine model for studying intestinal circulation of the newborn

We describe a newborn swine model to study intestinal hemodynamics of developing mammals. The preparation is designed to allow measurement of perfusion pressure and blood flow in an isolated segment of ileum under controlled conditions. Piglets in this study had a mean blood pressure of 65 +/- 14 (SD) mm Hg and mean intestinal blood flow of 80 +/- 20 (SD) ml/100 g/min at an average age and weight of 6.1 +/- 3 (SD) days and 1,718 +/- 427 (SD) g (n = 21). Experiments were performed to evaluate the effects of common physiologic perturbations: (a) Increased venous pressure caused a decrease in blood flow proportional to the lower perfusion pressure, but the relative change in vascular resistance was greater than the blood flow change. This effect, suggestive of a myogenic response, was significantly greater at a venous pressure increase of 20 cm of water over baseline compared with an increase of 10 cm water. (b) Gradual decrease in mesenteric artery blood pressure by clamping resulted in proportional decreases in blood flow. The calculated peripheral vascular resistance remained constant at blood pressure greater than 50 mm Hg and then increased as blood pressure decreased. (c) Stimulation of periarterial, postganglionic nerves surrounding the mesenteric artery produced a characteristic initial vasoconstriction followed by "autoregulatory escape." Frequency response tests using trains of stimulation of 6 ms and 12 V demonstrated responses starting at 2 Hz and maximal at 16 Hz. We suggest that this model should be applicable to a number of physiologic studies including assessment of water and nutrient flux in the intestine concomitant to changes in the circulation.     

Glycemic variability in preterm infants receiving intermittent gastric tube feeding: Report of three cases

Late‐onset hypoglycemia (day 12–16, blood glucose <50 mg/dL) was detected in three preterm infants (birthweight 998–1780 g; gestational age 27–30 weeks) by routine screening. All infants showed high serum insulin levels and extremely low ketone levels at the time of hypoglycemia. Continuous glucose monitoring was conducted at 31–34 weeks' postconceptual age when the infants were receiving intermittent gastric tube feeding with no intravenous glucose infusion. The continuous glucose monitoring results showed characteristic postprandial glucose increases and subsequent sharp deceases along with many hyper‐ and hypoglycemic events. This fluctuating pattern disappeared at 38–40 weeks' postconceptual age. These observations suggest that prolonged insulin oversecretion may be associated with early aggressive intravenous nutrition, and that large glycemic variability is a common feature of tube‐fed preterm infants that can be explained by immature glucose homeostasis.     

无创血流动力学监测在急危重症患儿中的临床应用

血流动力学监测是急危重症患儿病情评估及抢救治疗中重要的监测手段,对掌握病情、早期发现循环功能异常、指导针对性用药有重要意义.目前监测血流动力学的方法很多,但各自的缺陷限制了其在儿科中的广泛应用.近年来彩色多普勒技术的广泛应用得以推出新型无创血流动力学监测仪,其具有无创性、可连续动态监测性、适合床边使用等优点,为危重症小...     

Nitroglycerine in scorpion sting with decompensated shock

This study was designed to examine the effect of nitroglycerine infusion in children hospitalized for scorpion sting with severe myocardial dysfunction and decompensated shock. Children satisfying the inclusion criteria were started on nitroglycerine infusion under hemodynamic monitoring and other supportive measures. The effects of nitroglycerine, including improvement in oxygenation and decrease in pulmonary congestion and liver size were recorded. Seven out of 11 children responded well to nitroglycerine therapy and the clinical response was evident within 30 to 60 minutes. The first parameter to improve was oxygen saturation, followed by an improvement in the blood pressure and respiratory rate. Heart rate was the last parameter to improve after nitroglycerine infusion. The average duration of nitroglycerine infusion was 25 hours (12 - 36 hours). It was seen that the non-survivors had significant tachycardia at admission, and a greater need for assisted ventilation compared to the survivors. We conclude that nitroglycerine therapy could bring about significant improvement in myocardial function and hemodynamic parameters with a potential for improved survival.     

Links between parents' and girls' television viewing behaviors: a longitudinal examination

OBJECTIVE: This longitudinal study examines links between parents' television (TV)-related parenting practices and their daughter's daily TV viewing hours. STUDY DESIGN: Participants included 173 non-Hispanic white girls and their parents who were examined when girls were age 9 and 11 years. Girls' daily TV viewing hours, mothers' and fathers' daily TV viewing hours, parents' use of TV as a recreational activity, family TV co-viewing, and parents' restriction of girls' access to TV were assessed. RESULTS: Approximately 40% of girls exceeded the TV-viewing recommendations (ie, < or =2 hours/day). Girls watched significantly more TV when their parents were high-volume TV viewers, relied heavily on TV as a recreational activity, watched TV with them, and failed to limit their access to TV. A parenting risk score was calculated by collapsing information across all parenting variables. In comparison with girls exposed to 1 or fewer parenting risk factors at age 9, girls exposed to 2 or more parenting risk factors were 5 to 10 times more likely to exceed TV viewing recommendations at age 9 and 11. CONCLUSIONS: Efforts to reduce TV viewing among children should encourage parents to limit their own TV viewing, reduce family TV viewing time, and limit their children's access to TV.     

Functional vessel density in the first month of life in preterm neonates

Changes in microcirculation have been recognized as central to many disease processes. The aim of this study was to evaluate factors, which influence the microcirculation of the skin during the first month of life in premature infants. Red blood cell (RBC) velocity, vessel diameter, and functional small vessel density (FSVD) were measured daily for the first 30 d on the upper arm in preterm infants with gestational age <30 wk. Orthogonal polarization spectral (OPS) images were analyzed off-line with the Capi- Scope-Image program. In 25 infants, FSVD decreased significantly from week 1 (mean +/- SD 236 +/- 33 cm/cm2) to week 4 (207 +/- 30 cm/cm2) and correlated directly with Hb levels and incubator temperature. Vessel diameters and RBC velocity did not change significantly, nor did clinical parameters such as blood pressure, heart rate or body temperature. Microvascular parameters were not dependent on gestational or postnatal age. The microcirculation of the skin might be an easily accessible window to obtain better understanding of circulatory changes in the postnatal period. Our data are essential as basis for further studies in this field. Hb levels and possible incubator temperatures have a substantial influence on functional small vessel density and therefore need to be taken in account.     

Thrombotic complications of umbilical artery catheters: A clinical and radiographic study.

Catheterization of the aorta via the umbilical artery provides a convenient route for monitoring arterial blood pressure, for obtaining blood specimens for measurement of blood gas tensions and chemistries, and for the infusion of fluids and pharmacologic preparations in sick newborn infants. Use of this technique may be accompanied by a number of complications of which thrombotic phenomena are the most common. Twenty-three of 98 (24%) newborn infants undergoing umbilical artery catheterization were found to have thrombotic complication determined by aortography. No correlation was present between the duration of time that the umbilical artery catheters were in place and the occurrence of thrombotic complications. From paired aortographic or aortographic and autopsy studies in 24 patients, it was concluded that if a thrombotic complication did not occur early, none was likely to occur subsequently. One patient was considered to have died as a direct result of a thrombotic complication. Aortography is a safe, simple, and reliable technique for the early detection of thrombotic complications of umbilical artery catheters. Umbilical artery catheterization is not without risk and careful selection of patients for this procedure is indicated.