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BMC Pediatrics - Latest articles
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The latest articles from BMC Pediatrics (ISSN 1471-2431) published by
BioMed Central
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The diagnostic work up of growth failure in secondary health care; an evaluation of consensus guidelines
Background:
As abnormal growth might be the first manifestation of undetected diseases, it is important to have accurate referral criteria and a proper diagnostic work-up. In the present paper we assess how many children are correctly referred to secondary health care according to existing consensus guidelines, evaluate the diagnostic work-up in secondary health care and study the frequency of underlying medical disorders.
Methods:
Data on growth and additional diagnostic procedures were collected from medical records of new patients referred for short stature to the outpatient clinics of the general paediatric departments of two hospitals (Erasmus MC - Sophia Children's Hospital, Rotterdam and Spaarne Hospital, Haarlem) between January 1998 and December 2002. As the Dutch Consensus Guideline (DCG) is the only guideline addressing referral criteria as well as diagnostic work-up, the analyses were based on its seven auxological referral criteria to determine whether children were correctly referred or not and on all elements of the diagnostic work up.
Results:
Of children older than 3 years 76% was correctly referred (CR). 74-88% of these children were short corrected for parental height, 40-61% had a height SDS <-2.5 and 21% showed height deflection ([increment] HSDS < -0.25/ yr or [increment] HSDS < -1). In none of the children a complete detailed routine diagnostic work up was performed and in more than 30% no routine laboratory examination was done at all. Pathologic causes of short stature were found in 27 children (5%).
Conclusions:
Although the DCG was poorly put into practice, it detects at least 5 % pathologic causes of growth failure in children referred for short stature. New guidelines for referral are required with a better sensitivity and specificity, wherein distance to target height should get more attention. The general diagnostic work up for short stature should include testing for celiac disease in all children and for Turner syndrome in girls.
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Oxidative stress in children late after Kawasaki disease: relationship with carotid atherosclerosis and stiffness
Background:
Persistent arterial dysfunction in patients with a history of Kawasaki disease (KD) and an integral role of oxidative stress in the development of cardiovascular disease are increasingly recognized. We sought to test the hypothesis that oxidative stress is increased in KD patients and related to carotid atherosclerotic changes and stiffness.
Methods:
We compared the serum levels of oxidative stress biomarkers, carotid intima-media thickness (IMT), and carotid stiffness index among KD patients with coronary aneurysms (n = 32), those without coronary complications (n = 19), and controls (n = 32).
Results:
Compared with controls, patients with coronary aneurysms had significantly higher serum levels of malonaldehyde (2.62 +/- 0.12 uM vs 2.22 +/- 0.07 uM, p = 0.014) and hydroperoxides (26.50 +/- 1.13 uM vs 22.50 +/- 0.62 uM, p = 0.008). A linear trend of the magnitude of oxidative stress in relation to inflammatory damage was observed for malonaldehyde (p = 0.018) and hydroperoxides (p = 0.014) levels. Serum malonaldehyde and hydroperoxide levels correlated positively with carotid IMT (p < 0.001 and p = 0.034, respectively) and stiffness index (p = 0.001 and p = 0.021, respectively). Multivariate analysis identified serum malonaldehyde level as a significant determinant of carotid IMT (beta= 0.31, p = 0.006) and stiffness (beta = 0.27, p = 0.008).
Conclusion:
Our findings suggest oxidative stress is increased in KD patients with coronary aneurysms and is associated with carotid intima-media thickening and stiffening.
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Algorithms for converting estimates of child malnutrition based on the NCHS reference into estimates based on the WHO Child Growth Standards
Background:
The child growth standards released by the World Health Organization (WHO) in 2006 have several technical advantages over the previous 1977 National Center for Health Statistics (NCHS)/WHO reference and are recommended for international comparisons and secular trend analysis of child malnutrition. To obtain comparable data over time, earlier surveys should be reanalyzed using the WHO standards; however, reanalysis is impossible for older surveys since the raw data are not available. This paper provides algorithms for converting estimates of child malnutrition based on the NCHS reference into estimates based on the WHO standards.
Methods:
Sixty-eight surveys from the WHO Global Database on Child Growth and Malnutrition were analyzed using the WHO standards to derive estimates of underweight, stunting, wasting and overweight. The prevalences based on the NCHS reference were taken directly from the database. National/regional estimates with a minimum sample size of 400 children were used to develop the algorithms. For each indicator, a simple linear regression model was fitted, using the logit of WHO and NCHS estimates as, respectively, dependent and independent variables. The resulting algorithms were validated using a different set of surveys, on the basis of which the point estimate and 95% confidence interval (CI) of the predicted WHO prevalence were compared to the observed prevalence.
Results:
In total, 271 data points were used to develop the algorithms. The correlation coefficients (R2) were all greater than 0.90, indicating that most of the variability of the dependent variable is explained by the fitted model. The average difference between the predicted WHO estimate and the observed value was <0.5% for stunting, wasting and overweight. For underweight, the mean difference was 0.8%. The proportion of the 95% CI of the predicted estimate containing the observed prevalence was above 90% for all four indicators. The algorithms performed equally well for surveys without the entire age coverage 0 to 60 months.
Conclusion:
To obtain comparable data concerning child malnutrition, individual survey data should be analyzed using the WHO standards. When the raw data are not available, the algorithms presented here provide a highly accurate tool for converting existing NCHS estimates into WHO estimates.
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Acute-phase reactants after paediatric cardiac arrest. Procalcitonin as marker of immediate outcome
ObjectiveProcalcitonin (PCT) and C reactive protein (CRP) have been used as infection parameters. PCT increase correlates with the infectionas severity, course, and mortality. Post-cardiocirculatory arrest syndrome may be related to an early systemic inflammatory response, and may possibly be associated with an endotoxin tolerance. Our objective was to report the time profile of PCT and CRP levels after paediatric cardiac arrest and to assess if they could be use as markers of immediate survival.
Materials and Methods: A retrospective observational study set in an eight-bed PICU of a university hospital was performed during a period of two years. Eleven children younger than 14 years were admitted in the PICU after a cardiac arrest. PCT and CRP plasma concentrations were measured within the first 12 and 24 hours of admission.
Results:
In survivors, PCT values increased 12 hours after cardiac arrest without further increase between 12 and 24 hours. In non survivors, PCT values increased 12 hours after cardiac arrest with further increase between 12 and 24 hours. Median PCT values (range) at 24 hours after cardiac arrest were 22.7 ng/mL (0.2 - 41.0) in survivors vs. 205.5 ng/mL (116.6 - 600.0) in non survivors (p< 0.05). CRP levels were elevated in all patients, survivors and non-survivors, at 12 and 24 hours without differences between both groups.
Conclusion:
Measurement of PCT during the first 24 hours after paediatric cardiac arrest could serve as marker of mortality.
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The TOBY Study
Whole body hypothermia for the treatment of perinatal asphyxial encephalopathy:a randomised controlled trial.
Background:
A hypoxic-ischaemic insult occurring around the time of birth may result in an encephalopathic state characterised by the need for resuscitation at birth, neurological depression, seizures and electroencephalographic abnormalities. There is an increasing risk of death or neurodevelopmental abnormalities with more severe encephalopathy. Current management consists of maintaining physiological parameters within the normal range and treating seizures with anticonvulsants.
Studies in adult and newborn animals have shown that a reduction of body temperature of 3-4 degrees celsius after cerebral insults is associated with improved histological and behavioral outcome. Pilot studies in infants with encephalopathy of head cooling combined with mild whole body hypothermia and of moderate whole body cooling to 33.5 degrees celsius have been reported. No complications were noted but the group sizes were too small to evaluate benefit.
Methods:
TOBY is a multi-centre, prospective, randomised study of term infants after perinatal asphyxia comparing those allocated to "intensive care plus total body cooling for 72 hours" with those allocated to "intensive care without cooling".
Full-term infants will be randomised within 6 hours of birth to either a control group with the rectal temperature kept at 37 +/- 0.2 degrees celsius or to whole body cooling, with rectal temperature kept at 33-34 degrees celsius for 72 hours. Term infants showing signs of moderate or severe encephalopathy +/- seizures have their eligibility confirmed by cerebral function monitoring. Outcomes will be assessed at 18 months of age using neurological and neurodevelopmental testing methods.
Sample size:
At least 236 infants would be needed to demonstrate a 30% reduction in the relative risk of mortality or serious disability at 18 months.
Recruitment was ahead of target by seven months and approvals were obtained allowing recruitment to continue to the end of the planned recruitment phase. 325 infants were recruited.
Primary outcome:
Combined rate of mortality and severe neurodevelopmental impairment in survivors at 18 months of age. Neurodevelopmental impairment will be defined as any of:
* Bayley mental developmental scale score less than 70
* Gross Motor Function Classification System Levels III - V
* Bilateral cortical visual impairments
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Anthropometric surrogates to identify low birth weight Nepalese newborns: a hospital-based study
Background:
In Nepal, more than 90% of the deliveries take place at home where birth weight is often not recorded. In developing countries, low birth weight (LBW, <2500 grams) accounts for 60-80% of neonatal deaths. Early identification and referral of LBW babies for extra essential newborn care is vital in preventing neonatal deaths. Studies carried out in different populations have suggested that the use of newborn anthropometric surrogates of birth weight may be a simple and reliable method to identify LBW babies in a home setting. However, a reliable anthropometric surrogate to identify LBW babies and its cut-off point is not known for Nepalese newborns.
Methods:
A cross-sectional study was carried out in Western Regional Hospital, Pokhara between April and June, 2006. All consecutive full-term, singleton, live born babies were included. To ensure reliability and avoid inter-observer bias one of the investigators weighed all the newborns and carried out anthropometric measurements within 24 hours after birth. Circumferences of head, chest, mid-upper arm, thigh and calf were measured according to standard techniques. Non-parametric receiver operating characteristic (ROC) curve analyses were carried out using bootstrap to calculate 95% confidence intervals of areas under the curve (AUC). The cut-points with lowest total misclassification rate were chosen to identify LBW babies.
Results:
Out of 400 newborns studied, 204 (51%) were males and 196 (49%) were females. The mean birth weight was 3029+/-438 grams and 34 (8.5%) newborns were LBW. By ROC-AUC analyses, head circumference (AUC = 0.89, 95% CI 0.85 to 0.93) and chest circumference (AUC = 0.86, 95% CI 0.80 to 0.91) were identified as the optimal surrogate indicators of LBW babies. The optimal cut-point for head circumference and chest circumference to identify LBW newborns were [greater than or equal to] 33.5 cm and [greater than or equal to] 30.8 cm respectively.
Conclusions:
Head and chest circumferences were the best anthropometric surrogates of LBW among Nepalese newborns. Further studies are needed in the field to cross-validate our results.
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Do pediatricians manage influenza differently than internists?
Background:
Little is known about how pediatricians or internists manage influenza symptoms. Recent guidelines on antiviral prescribing by the Centers for Disease Control and Prevention (CDC) make almost no distinction between adults and children. Our objective was to describe how pediatricians in two large academic medical institutions manage influenza and compare them to internists.
Methods:
At the end of the 2003?4 influenza season, we conducted a cross sectional on-line survey of physician knowledge, attitudes and practices regarding rapid diagnostic testing and use of antiviral therapy for influenza at two large academic medical centers, one in Massachusetts and the other in Texas. We collected data on self-reported demographics, test use, prescribing practices, and beliefs about influenza and anti-influenza drugs.
Results:
A total of 107 pediatricians and 103 internists completed the survey (response rate of 53%). Compared to internists, pediatricians were more likely to perform rapid testing (74% vs. 47%, p < 0.0001), to use amantadine (88% vs. 48%, p < 0.0001), to restrict their prescribing to high-risk patients (86% vs. 53%, p < 0.0001), and to believe that antiviral therapy could decrease mortality (38% vs. 22%, p = 0.01). Other beliefs about antiviral therapy did not differ statistically between the specialties. Internists were more likely to be unfamiliar with rapid testing or not to have it available.
Conclusion:
Pediatricians and internists manage influenza differently. Evidence-based guidelines addressing the specific concerns of each group would be helpful.
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Effectiveness of physical therapy interventions for children with cerebral palsy: a systematic review
Background:
To assess the effectiveness of physical therapy (PT) interventions on functioning in children with cerebral palsy (CP).
Methods:
A search was made in Medline, Cinahl, PEDro and the Cochrane library for the period 1990 to February 2007. Only randomized controlled trials (RCTs) on PT interventions in children with diagnosed CP were included. Two reviewers independently assessed the methodological quality and extracted the data. The outcomes measured in the trials were classified using the International Classification of Functioning, Disability and Health (ICF).
Results:
Twenty-two trials were identified. Eight intervention categories were distinguished. Four trials were of high methodological quality. Moderate evidence of effectiveness was established for two intervention categories: effectiveness of upper extremity treatments on attained goals and active supination, and of prehensile hand treatment and neurodevelopmental therapy (NDT) or NDT twice a week on developmental status, and of constraint-induced therapy on amount and quality of hand use. Moderate evidence of ineffectiveness was found of strength training on walking speed and stride length. Conflicting evidence was found for strength training on gross motor function. For the other intervention categories the evidence was limited due to low methodological quality and the statistically insignificant results of the studies.
Conclusions:
Due to limitations in methodological quality and variations in population, interventions and outcomes, mostly limited evidence on the effectiveness of most PT interventions is available through RCTs. Moderate evidence was found for some effectiveness of upper extremity training. Well-designed trials are needed especially for focused PT interventions.
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Kangaroo mother care diminishes pain from heel lance in very preterm neonates: A crossover trial
Background:
Skin-to-skin contact, or kangaroo mother care (KMC) has been shown to be efficacious in diminishing pain response to heel lance in full term and moderately preterm neonates. The purpose of this study was to determine if KMC would also be efficacious in very preterm neonates.
Methods:
Preterm neonates (n = 61) between 28 0/7 and 31 6/7 weeks gestational age in three Level III NICU's in Canada comprised the sample. A single-blind randomized crossover design was employed. In the experimental condition, the infant was held in KMC for 15 minutes prior to and throughout heel lance procedure. In the control condition, the infant was in prone position swaddled in a blanket in the incubator. The primary outcome was the Premature Infant Pain Profile (PIPP), which is comprised of three facial actions, maximum heart rate, minimum oxygen saturation levels from baseline in 30-second blocks from heel lance. The secondary outcome was time to recover, defined as heart rate return to baseline. Continuous video, heart rate and oxygen saturation monitoring were recorded with event markers during the procedure and were subsequently analyzed. Repeated measures analysis-of-variance was employed to generate results.
Results:
PIPP scores at 90 seconds post lance were significantly lower in the KMC condition (8.871 (95%CI 7.852?9.889) versus 10.677 (95%CI 9.563?11.792) p < .001) and non-significant mean differences ranging from 1.2 to1.8. favoring KMC condition at 30, 60 and 120 seconds. Time to recovery was significantly shorter, by a minute(123 seconds (95%CI 103?142) versus 193 seconds (95%CI 158?227). Facial actions were highly significantly lower across all points in time reaching a two-fold difference by 120 seconds post-lance and heart rate was significantly lower across the first 90 seconds in the KMC condition.
Conclusion:
Very preterm neonates appear to have endogenous mechanisms elicited through skin-to-skin maternal contact that decrease pain response, but not as powerfully as in older preterm neonates. The shorter recovery time in KMC is clinically important in helping maintain homeostasis.Trial Registration(Current Controlled Trials) ISRCTN63551708
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International survey of diagnostic services for children with Fetal Alcohol Spectrum Disorders
Background:
Early diagnosis and intervention for children with Fetal Alcohol Spectrum Disorder (FASD) reduces the risk of developing a range of secondary social, emotional and behavioural problems and provides an opportunity for prevention of further alcohol exposed pregnancies. The objective of this study was to describe specialist clinical service provision for the diagnosis and assessment of children exposed to alcohol in pregnancy.
Methods:
Fetal Alcohol Spectrum Disorder (FASD) diagnostic clinics were identified through literature and internet searches. Clinics were sent a questionnaire asking for information on the clinic population, clinic staff, assessment process and other services provided.
Results:
Questionnaires were completed for 34 clinics: 29 were in North America, 2 in Africa, 2 in Europe and 1 in South America. No clinics were identified in Asia or Australasia. There was a variety of funding sources, services offered, clinic populations, staff and methods of assessment. Thirty-three clinics had a multi-disciplinary team. In 32 clinics, at least one member of the team had specialist training in assessment of FASD. Neurobehavioural assessment was completed in 32 clinics. Eleven clinics used more than one set of diagnostic criteria or an adaptation of published criteria.
Conclusion:
Diagnostic services are concentrated in North America. Most responding clinics are using a multidisciplinary approach with neurobehavioural assessment as recommended in published guidelines. Agreement on diagnostic criteria would enable comparison of clinical and research data, and enhance FASD research particularly for intervention trials.
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