The association of birth weight and infant growth with childhood autonomic nervous system activity and its mediating effects on energy-balance-related behaviours-the ABCD study

BACKGROUND

The purpose of this study was to examine the association of birth weight and infant growth with childhood autonomic nervous system (ANS) activity and to assess whether ANS activity mediates the associations of birth weight and infant growth with energy-balance-related behaviours, including energy intake, satiety response, physical activity and screen time.

METHODS

In 2089 children, we prospectively collected birth weight, infant growth defined as conditional weight and height gain between birth and 12 months and-at 5 years-indices of cardiac ANS activity and parent-reported energy-balance-related behaviours. A mediation analysis was conducted, based on MacKinnon's multivariate extension of the product-of-coefficients strategy.

RESULTS

Birth weight and infant height gain were inversely associated with sympathetic, but not parasympathetic, activity at age 5. Infant weight gain was not associated with childhood ANS activity. Infant weight gain was predictive of increased childhood screen time and infant height gain of diminished childhood energy intake, but sympathetic activity did not mediate these associations.

CONCLUSIONS

Low-birth-weight children have higher sympathetic activity, which is considered a risk factor for cardiovascular disease. Height gain in infancy seems to be beneficial for childhood sympathetic activity. However, sympathetic activity was no mediator of the associations of infant growth with childhood energy-balance-related behaviours. As individual differences in ANS activity predict increased risk of cardiovascular disease, these differences may offer insight into the early-life origins of chronic diseases and provide further basis for public health strategies to optimize birth weight and infant growth.

Hypothalamic-pituitary-adrenal (HPA) axis suppression after treatment with glucocorticoid therapy for childhood acute lymphoblastic leukaemia

BACKGROUND

Glucocorticoids play a major role in the treatment of acute lymphoblastic leukaemia (ALL). However, supraphysiological doses may cause suppression of the hypothalamic-pituitary-adrenal (HPA) axis. HPA axis suppression resulting in reduced cortisol response may cause an impaired stress response and an inadequate host defence against infections, which remains a cause of morbidity and death. The exact occurrence and duration of HPA axis suppression after glucocorticoid therapy for childhood ALL are unclear.

OBJECTIVES

To examine the occurrence and duration of HPA axis suppression after (each cycle of) glucocorticoid therapy for childhood ALL.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (in The Cochrane Library, issue 3, 2010), MEDLINE/PubMed (from 1945 to July 2010) and EMBASE/Ovid (from 1980 to July 2010). In addition, we searched reference lists of relevant articles, conference proceedings and ongoing trial databases.

SELECTION CRITERIA

All study designs, except case reports and patient series with fewer than 10 patients, examining the effect of glucocorticoid therapy for childhood ALL on the HPA axis function.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection. One review author performed the data extraction and 'Risk of bias' assessment, which was checked by another review author.

MAIN RESULTS

We identified seven studies (total number of participants = 189), including one randomised controlled trial (RCT), which assessed the adrenal function. None of the studies assessed the HPA axis at the level of the hypothalamus, pituitary, or both. Due to substantial differences between studies, results could not be pooled. All studies had some methodological limitations. The included studies demonstrated that adrenal insufficiency occurs in nearly all patients in the first days after cessation of glucocorticoid treatment for childhood ALL. The majority of patients recovered within a few weeks, but a small amount of patients had ongoing adrenal insufficiency lasting up to 34 weeks. In the RCT, the occurrence and duration of adrenal insufficiency did not differ between the prednisolone and dexamethasone arms. In one study included in the review it appeared that treatment with fluconazole prolonged the duration of adrenal insufficiency.

AUTHORS' CONCLUSIONS

Based on the available evidence, we conclude that adrenal insufficiency commonly occurs in the first days after cessation of glucocorticoid therapy for childhood ALL, but the exact duration is unclear. Since no data on the level of the hypothalamus and the pituitary were available we cannot make any conclusions regarding those outcomes. Clinicians should consider prescribing glucocorticoid replacement therapy during periods of serious stress in the first weeks after cessation of glucocorticoid therapy for childhood ALL, to reduce the risk of life-threatening complications. However, more high-quality research is needed for evidence-based guidelines for glucocorticoid replacement therapy.Special attention should be paid to patients receiving fluconazole therapy, and perhaps similar antifungal drugs, as this may prolong the duration of adrenal insufficiency.

Psychological outcome and quality of life in children born with congenital diaphragmatic hernia

OBJECTIVE

To assess psychological and social functioning and health related quality of life and its early determinants in children born with congenital diaphragmatic hernia (CDH).

DESIGN

Cross-sectional follow-up study.

SETTING

Outpatient clinic of a tertiary care hospital.

PARTICIPANTS

33 CDH survivors aged 6-16 years.

MAIN EXPOSURE

Patients who developed CDH associated respiratory distress within 24 h after birth.

MAIN OUTCOME MEASURE

Psychological and social functioning assessed with the Wechsler Intelligence Scale for Children (WISC-R), Bourdon-Vos test, Beery Developmental Test of Visual Motor Integration, Child Behavior Checklist (CBCL) and Teacher Report Form (TRF), and health related quality of life assessed with the Child Health Questionnaire (CHQ) and Health Utilities Index (HUI).

RESULTS

Normal mean (SD) total IQ (100.0 (13.2)) and normal visual-motor integration, but significantly lower results for sustained attention (Bourdon-Vos test, 38.8 (11.2) points) were found. Learning difficulties were reported by 30% of parents. Eight children had scores in the clinical range on the CBCL and/or TRF, indicating clinically significant behavioural problems. Except for the CHQ scale General Health, health status was not different from the reference population. No significant correlations between test results and severity of CDH were found, except for an association of general health and physical functioning with length of hospital stay.

CONCLUSION

CDH patients are at risk for subtle cognitive and behavioural problems, probably not related to CDH severity. Perception of general health is reduced compared to the reference population, indicating that CDH survivors and their parents believe their health is poor and likely to get worse.

Maternal pre-pregnancy body mass index explains infant's weight and BMI at 14 months: results from a multi-ethnic birth cohort study

OBJECTIVE

To investigate the association between (self-reported) maternal pre-pregnancy body mass index (pBMI), and child's weight, height and BMI at age 14 months.

DESIGN

Prospective multi-ethnic community-based cohort study.

SETTING

Amsterdam, The Netherlands.

PARTICIPANTS

8266 pregnant women from the Amsterdam Born Children and their Development study, filled out a questionnaire covering socio-demographic data, obstetric history, lifestyle, dietary habits and psychosocial factors, 2 weeks after their first antenatal visit. 7730 gave birth to a viable term singleton infant with information on birth weight, gender and pregnancy duration. Growth data were available for 3171 of these children.

MAIN OUTCOME MEASURES

Weight (g), height (cm) and BMI (kg/m(2)) of the child at age 14 months.

RESULTS

pBMI was linearly associated with weight and BMI of the child at age 14 months. One unit increase in pBMI resulted in an increment of 29 g (95% CI 19 to 39) in weight and 0.041 kg/m(2) (95% CI 0.030 to 0.053) in BMI. The effect size decreased after adjustment for birth weight (weight: beta coefficient 19 g, 95% CI 10 to 28; BMI: beta coefficient 0.034 kg/m(2), 95% CI 0.023 to 0.046) and hardly changed after adjustment for all other variables (weight: beta coefficient 21 g, 95% CI 11 to 30; BMI: beta coefficient 0.031 kg/m(2), 95% CI 0.019 to 0.043). pBMI was not related to height.

CONCLUSIONS

pBMI is an independent determinant of weight and BMI of the child at age 14 months. At least one third of this effect is mediated through birth weight.

[Corticosteroid administration for critically ill patients]

In critically ill patients, the hypothalamic-pituitary-adrenal axis is usually activated, resulting in elevated plasma cortisol levels. This enables the human organism to cope with sepsis, trauma and other forms of stress. During critical illness, total adrenal insufficiency rarely occurs. On the other hand, septic shock can be accompanied by a relative deficit of cortisol. Causes of this relative adrenal insufficiency are a dysfunction of the hypothalamic-pituitary-adrenal axis and/or cortisol resistance. There are no strict biochemical criteria available to diagnose relative adrenal insufficiency; clinical observation is the decisive factor. In randomised trials with patients in septic shock, a more rapid haemodynamic recovery was obtained with physiological doses of hydrocortisone than with a placebo. The observed haemodynamic response following hydrocortisone administration supports the concept of relative adrenal insufficiency.

Measuring health status using the Health Utilities Index: agreement between raters and between modalities of administration

The aim of this study was to evaluate interrater and intermodality agreement in assessing health status using the Health Utilities Index. A random sample from a Dutch cohort of 14-year-old Very Low Birth Weight children and their parents were invited to participate in a face-to-face (n = 150) or telephone (n = 150) interview. All 300 participants were also sent a questionnaire by mail. Response rate was 68%. Interrater and intermodality agreement were high for the physical HUI3 attributes and poor for the psychological attributes. Children and parents reported more dysfunction in the psychological attributes when interviewed than when completing the mailed questionnaire. High agreement on the physical attributes may have resulted from the fact that hardly any dysfunction was reported in these attributes, and poor agreement in the psychological attributes may have been a result of the fact that in these attributes much more dysfunction was reported. In measuring children's health status using the HUI3, the results and their interpretation vary with the source of information and the modality of administration. For maximum comparability between studies, written self-report questionnaires seem the preferred option.

[Intracranial hemorrhages in infants: child abuse or a congenital coagulation disorder?]

In children with head injuries the severity of the neurological symptoms should concord with the patient's history and signs of neurotrauma on examination. Discrepancies between the (hetero)anamnesis and physical examination on the one hand and neurological findings on the other may indicate child abuse. The presence of both old and new intracranial haemorrhages in the absence of proportional trauma is generally considered as evidence for child abuse. However, these symptoms may also be the first manifestation of a congenital coagulation disorder. Three children, two girls aged 8 and 5 months and a boy aged 6 months were presented with alarming neurological symptoms due to intracranial haemorrhages without external signs of head trauma. The first girl had 'shaken baby' syndrome while the other 2 had congenital coagulation disorders (haemophilia B and factor V deficiency, respectively). All three recovered, the last two with remaining one-sided neurological deficits. Child abuse and congenital coagulation disorders may present with similar neurological symptoms and radiological findings. In these patients coagulation tests are mandatory and--if abnormal--enable early substitution of deficits and prevent inappropriate suspicion or accusation of caretakers.

Carnitine-acylcarnitine translocase deficiency: phenotype, residual enzyme activity and outcome

Carnitine-acylcarnitine translocase deficiency is a rare and life-threatening mitochondrial fatty acid beta-oxidation disorder. We describe a patient who, despite a severe clinical course and an extremely low carnitine-acylcarnitine translocase activity, is currently alive and in good health. We performed an extensive analysis of all previously published cases in order to evaluate the clinical features and prognostic factors. Reports on 21 patients with carnitine-acylcarnitine translocase deficiency were obtained. Only 5 out of the 21 patients survived early childhood. At least 20 siblings are reported to have died of sudden unexplained death in the neonatal period. Although phenotype and residual enzyme activity have been suggested to be related to outcome, we were not able to establish such a relationship.

CONCLUSION

Phenotype and residual enzyme activity do not appear to be major prognostic factors. Vigorous work-up in order to reach an expedite diagnosis and prompt medical intervention during acute episodes, especially in the neonatal period, may prevent fatal complications.

High-frequency oscillatory ventilation in pediatric patients

BACKGROUND

High-frequency oscillatory ventilation (HFOV) is a ventilatory mode using small tidal volumes with low phasic pressures at supraphysiological frequencies. Beyond the neonatal period there are distinct lung diseases for which HFOV is used. Data of 35 children who deteriorated on conventional ventilation were retrospectively analysed in two tertiary pediatric intensive care units.

METHODS

Depending on the underlying pulmonary pathophysiology, three strategies were employed. First, the 'open-lung' strategy designed to rapidly recruit and maintain optimal lung volume in DAD (n=27) and pulmonary hemorrhage (n=5). Second, the 'low-volume' strategy in persistent air leak (n=1) where, after an initial identical approach, mean airway pressure (MAP) is reduced until the air leak ceases. Third, the 'open-airway' strategy in obstructive airway disease (n=5) where MAP is used to recruit and stent the airways.

RESULTS

Seven patients died, two due to respiratory failure. Three patients developed an air leak. Nine patients developed chronic lung disease. There was a significant decrease of the oxygenation index (OI) in the survivors. In the two patients who died of respiratory failure, the OI increased.

CONCLUSION

If certain conditions are met, HFOV appears a safe and effective mode of ventilation in pediatric respiratory failure.

Pediatric risk of mortality (PRISM) score in meningococcal disease

To assess the pediatric risk of mortality (PRISM) score as a prognostic scoring system in severe meningococcal disease, the files of 53 consecutive patients admitted to a tertiary pediatric intensive care with a clinical diagnosis of meningococcal disease and positive cultures from blood and/or cerebrospinal fluid were analysed. PRISM-score-based expected mortality was compared with observed mortality. Expected mortality in the whole study population was 29% while observed mortality was 19% (P<0.05). The highest expected and observed mortality was found in septicaemic patients without (documented) meningitis, while meningitis patients without septicaemia had the lowest mortality. All patients with a mortality risk below 18.3% (n = 29) survived whereas all those with a mortality risk of 65% or higher (n = 7) died. Of the 17 patients with a mortality risk between 18.3% and 63.9%, 14 survived and 3 died. The area under the receiver-operating characteristic (ROC) curve was 0.94, which is at least comparable with the best-performing meningococcal-disease-specific scoring systems.

CONCLUSION

The PRISM score is a useful generic measure of severity of illness in meningococcal disease and can be used to determine the effectiveness of different treatment strategies.

Lethal encephalopathy complicating childhood shigellosis

A 6-year-old girl is described who died following rapid neurological deterioration, ending in lethal cerebral oedema. Despite the absence of severe intestinal and metabolic derangement, Shigella was cultured from the stool. Toxic encephalopathy is responsible for death following this rare complication of childhood shigellosis in developed countries. The pathophysiology is unknown.

CONCLUSION

Lethal toxic encephalopathy can be caused by Shigella despite the absence of severe intestinal and metabolic derangement. If shigelllosis is suspected, headache may be a first significant sign for the development of toxic encephalopathy. Early recognition and rapid measures to prevent brain oedema may improve outcome.

Circumstances of dying in hospitalized children

Conditions of dying in a tertiary children's hospital were assessed in a retrospective cohort study. Non-survivors, excluding newborns and emergency room patients, were allocated to four groups: brain death (BD), failed cardiopulmonary resuscitation (failed CPR), death following a do-not-resuscitate (DNR) order and death following withholding or withdrawal of therapy (W/W). In a 4-year period 190 (1.3%) of 14,903 admitted patients died. Of these 134 (71%) died on the paediatric intensive care unit, 42 (22%) on the ward and 14 (7%) in the operating room. W/W was found in 75 (39%), failed CPR in 57 (30%), BD in 32 (17%), and death following a DNR order in 26 (14%). Justifications for restrictions of treatment (W/W or DNR) were imminent death in 41 (41%), lack of future relational potential in 13 (13%) and excessive burden of disease in 47 (47%). In non-survivors analgesics and sedatives were frequently used to relieve suffering in the terminal phase. General principles for the approach of terminally ill children in whom death may become an option instead of a fate are discussed.

CONCLUSION

In the majority of children dying in hospital, death occurred following restrictions of life-sustaining treatment, comprising do-not-resuscitate or other forms of withholding or withdrawal of therapy.

The relation between TISS and real paediatric ICU costs: a case study with generalizable methodology

OBJECTIVE

To determine the quantitative relation between the Therapeutic Intervention Scoring System (TISS) in combination with other relevant clinical variables and the real costs of (paediatric) intensive care.

DESIGN

A prospective, observational study.

SETTING

A Ten-bed paediatric intensive care unit in a university children's hospital.

PATIENTS AND PARTICIPANTS

In a 17-months registration period we collected patient- and treatment-related data for all 611 consecutive admissions. A 21-day calibration period was used to collect detailed data to calculate the real costs of 33 consecutive admissions, in addition to the same data as in the registration period.

MEASUREMENTS AND RESULTS

We used the Multi Moment Measurement method to measure time spent by nurses and physicians and medication used in the 21-day calibration period. The calibration period data set with explanatory variables including TISS was used to build a regression model to estimate nurse and physician time, which were converted to personnel costs, and to estimate medication costs. The regression models built from the calibration period were subsequently used to estimate the total costs per day and per admission in different patient groups in the registration period.

CONCLUSION

It was feasible to calculate total direct medical costs based on a limited number of readily available clinical variables related to patient characteristics and treatment, of which TISS was the most important determinant. The proposed methods provide further tools for assessment of (paediatric) intensive care unit performance.

[Excess mortality in critically ill patients after treatment with human albumin]

According to the results of a systematic review of randomized clinical studies administration of human albumin to critically ill patients is associated with excess mortality, compared with withholding albumin or administration of crystalloid fluids. The study appears to be well done. Also, there are various explanatory pathophysiological mechanisms supporting the association. However, a favourable effect of albumin in certain patient groups cannot be excluded. Alternatives to albumin are available in most clinical situations, but unfortunately, they are not completely without drawbacks. The use of albumin has to be limited; it might only be abolished when a better effect of other fluids, such as synthetic solutions, is demonstrated.

[The necessity for centralization of pediatric intensive care]

Substantial evidence indicates that outcome of critically ill children, treated in tertiary paediatric intensive care units (PICUs) is superior to that of those treated in other settings. However, a significant number of children who require this level of care are not admitted to such a unit e.g. due to capacity constraints, reluctance of physicians of general hospitals to refer children to a tertiary centre, and transportation problems. Centralization of care, as recently proposed in the UK, is necessary in the Netherlands, as well, to improve the quality of care. This will require a controlled number of PICU beds in a restricted number of centres, adequate transport facilities and step-down or high dependency units in large general hospitals.

Health status prediction in critically ill children: a pilot study introducing Standardized Health Ratios

Performance of intensive care is usually quantified by means of standardized mortality rates, where standardization is directed towards the severity of illness on admission. However, as more critically ill patients survive, functional outcome and quality of life of these patients becomes more important. In a prospective study in a 10-bed tertiary paediatric intensive care unit (ICU), admission and follow-up health status were collected for 209 surviving patients. For this cohort of patients, health status 1 year after admission was also predicted, using the quantified health-utility-index (HUI), as a value between 0 and 1. For this purpose, two alternative multiple regression models were constructed. The most important predictors of 1-year health status were the level of sensation, mobility and cognition on admission to which self-care, systolic blood pressure, oxygen, Glascow Coma Scale, glucose and age may be added. The two alternative predictive models performed equally well (R2 = 0.83 and 0.84 respectively), indicating that health status could be predicted to a significant degree. The concept of relating expected future health status (based on base-line health status), with actual (observed) health status is denoted with the Standardized Health Ratio (SHR). In combination with the Standardized Mortality Ratios (SMR), such a ratio may become a new comprehensive indicator of performance in intensive care medicine.

Reliability and validity of a comprehensive health status measure in a heterogeneous population of children admitted to intensive care

This study assesses psychometric and empirical characteristics of the Multi-Attribute Health Status Classification (MAHSC) in a heterogeneous population of children admitted to intensive care. The MAHSC encompasses six health domains (sensation, mobility, emotion, cognition, self-care, and pain), each with four or five hierarchic levels of dysfunction. The health status of 254 consecutively admitted children was determined independently by 3 different observers (parents, attending clinicians, and investigators). The proportion of children with health impairment varied between 13% (in sensation) and 58.7% (in mobility). Interrater reliability of domain scores, as analyzed by Spearman's rank, Pearson product moment, and intraclass correlations, was high, generally exceeding 0.80 for all pairs of observers. Intraclass correlation appeared to be highest in nonsurgical patients (range, 0.89-0.98) and lowest in cardiovascular surgery patients (range, 0.50-0.84). The validity of the classification was supported by (1) the presence of expected specific health status impairment in patient suffering from diseases with an acknowledged impact on specific domains and (2) the presence of a relation between health impairment and medical consumption. The absence of a relation between the average (chronic) health status preceding admission and the acute risk of mortality precipitating the admission confirmed their independent prominence in outcome assessment. We conclude that the MAHSC is a feasible, reliable, and valid measure for outcome assessment in a heterogeneous population of children within a demanding clinical situation. Excellent interrater reliability allows the use of various raters, adjusted to practical requirements.

Long-term survival and state of health after paediatric intensive care

Survival and state of health were assessed one year after discharge in 468 children admitted to an intensive care unit (ICU). ICU mortality was 7.5%, cumulative hospital mortality 8.3%, and one year mortality 10.5%. An established six domain health status classification was used, comprising sensation, mobility, emotion, cognition, self care, and pain to determine the presence, type, and severity of chronic health impairment. This classification has not been validated for infants, who were therefore excluded. After one year, of the 254 patients eligible for analysis, 80 (31.5%) had no overall health impairment (no affected domains) preceding admission; of these, 11 had died in ICU and 69 were long-term survivors, among whom 45 recovered to perfect health. There was overall health impairment (> or = 1 affected domain) preceding admission in 174 of 254 patients (68.5%). However, after one year, overall state of health was improved or equal to the preadmission state in 164 of 226 survivors (72.6%). In domain-specific health, the proportion improving or remaining unchanged varied from 77.9% (emotional functions) to 89.4% (mobility and pain). Consequently, despite the large number with health impairment before admission, cumulative one year survival was favourable and health status in three quarters of the population was preserved.

Comparative assessment of pediatric intensive care: a national multicenter study. Pediatric Intensive Care Assessment of Outcome (PICASSO) Study Group

OBJECTIVE

Comparative assessment of performance of pediatric intensive care.

DESIGN

Open, prospective multicenter study.

SETTING

All pediatric intensive care units (n = 10; six tertiary and four nontertiary) in the Netherlands.

PATIENTS

1063 consecutive unselected admissions, < or = 18 yrs old, during a 4-month period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Effectiveness was defined as the ratio of observed to expected (Pediatric Risk of Mortality-score-derived) mortality. Efficiency was determined by two objective criteria: mortality risk of > 1%, or administration of at least one intensive care unit (ICU)-dependent therapy. In the total population, observed and expected mortality rates were similar. Between hospitals, crude mortality showed wide variations (mean 7.1%, range 1% to 10%). However, in each center, observed and expected mortality rates were similar (mean ratio of observed/expected mortality 0.99, range 0.8 to 1.5). In tertiary care centers, severity of illness-corrected mortality rates in high-risk patients were less than in a United States reference population. Paradoxically, in low-risk tertiary care patients, the observed mortality rate was higher than expected. The relatively high mortality rate in this group is probably the result of the large number of low-risk tertiary care patients suffering from severe, incurable chronic disease. The average number of efficient ICU days was 72%, although large fluctuations between units were found (range 22% to 95%), suggesting that in several centers efficiency rates might be improved by a better selection of high-risk patients requiring ICU-dependent therapies.

CONCLUSIONS

Differences in mortality rates among pediatric ICUs were largely explained by differences in severity of illness. High efficiency rates combined with adequate effectiveness were found in several centers, indicating that admission and discharge decisions might be improved in less efficient centers.

Patient characteristics and resource utilisation in paediatric intensive care

To determine the relation between basic clinical characteristics and resource utilisation in paediatric intensive care, an open prospective study was performed. Resource utilisation was expressed using the therapeutic intervention score system (TISS) and length of stay (LOS), from which total resource utilisation per admission (TISSTOT) and average daily resource utilisation (TISSMEAN = TISSTOT/LOS) were obtained. Overall 593 admissions, totalling 3130 days, were included. Mortality was 8.4% and non-survivors accounted for 14.1% of overall resource utilisation. In non-survivors, TISSTOT and TISSMEAN were higher, whereas LOS was not different from survivors'. Severity of illness, surgical status, significant chronic comorbidity, emergency admission, and transfer status constituted the major predictive determinants of TISSTOT (r2 = 0.19) and TISSMEAN (r2 = 0.45) in multiple regression analysis. High resource utilisation in high risk patients was probably warranted, as effectiveness of prolonged intensive treatment was demonstrated. It is concluded that TISSTOT and TISSMEAN are appropriate, non-monetary measures of resource utilisation, a considerable proportion of which are determined by a concise set of basic clinical characteristics.

Effectiveness and efficiency of a Dutch pediatric intensive care unit: validity and application of the Pediatric Risk of Mortality score

OBJECTIVE

To assess the performance of pediatric intensive care by an international standard.

DESIGN

Prospective, cohort study.

SETTING

Nine-bed multidisciplinary pediatric intensive care unit (ICU) within a 174-bed, tertiary care children's hospital.

PATIENTS

Consecutive, unselected patients (n = 612) during a 16-month period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Collected data included age, major diagnostic category, primary clinical specialty, severity of illness (daily Pediatric Risk of Mortality [PRISM] score), administration of ICU-dependent therapy (daily), and vital status at discharge. The PRISM score allowed the calculation of overall and daily mortality risk. After testing the applicability of the predictive model, effectiveness was determined by comparing severity of illness-based predicted mortality rate with vital status at discharge. Efficiency was defined by two criteria: a) the administration of at least one ICU-dependent therapy; or b) a mortality risk of > 1%. Five-hundred ninety-three patients were included (19 survivors were excluded because of incomplete data). Mean age was 55.0 months (median 24). Mean length of stay was 4.4 days (median 2). Overall ICU mortality rate was 8.4%. The overall performance of the PRISM score-based predictive model was found to be good (goodness-of-fit test chi 2[5] = 5.49; p = .35; area under receiver operating characteristic curve 0.92). Subgroup analysis showed that the best model performance was in nonoperative patients. Decreased performance was found in operative patients. In cardiovascular patients, the mortality rate was higher. In other surgical patients, the mortality rate was lower than expected. Of 593 patients, 489 (82.5%) admissions were efficient, as were 2,393 (76.5%) of 3,130 patient days in the ICU. The ranking of daily efficiency according to clinical specialty was as follows: postoperative cardiovascular surgical patients (86.3%); nonsurgical patients (76.6%); and other postoperative patients (49.6%).

CONCLUSIONS

In our setting, effectiveness and efficiency of pediatric intensive care appeared to be validly determined using explicit criteria (mortality risk, administration of ICU-dependent therapy). Overall effectiveness met the standard set forth in an American study; validity in stratified analysis of diagnostic subgroups remains to be further established. Efficiency showed marked, specialty-related differences. The low efficiency in other (noncardiovascular) surgical patients was probably caused by the recovery function of the ICU. A more general application of these criteria might be considered in modifying admission and discharge policy, as well as in quality control.

[Submersion in children; the role of hypothermia and development of adult respiratory distress syndrome]

OBJECTIVE

To evaluate the occurrence of the adult respiratory distress syndrome (ARDS), and of hypothermia as a predictor of outcome in cases of submersion injury in children.

DESIGN

Retrospective analysis.

PATIENTS

All drowning cases admitted to the Intensive Care Unit of the Wilhelmina Children's Hospital in Utrecht between January 1986 and January 1993.

RESULTS

There were 45 patients, 29 boys and 16 girls, aged 0-13 years. Hypothermia was related to the duration of submersion and did not correlate with a good outcome. Asystole on arrival at the hospital was associated with demise in all but one patient, who was left with severe neurological impairment. ARDS occurred in 27/45 patients (60%), all within 6 h following admission. Of the 45 patients treated, 11 died. Of the 34 survivors, 7 were discharged from the Intensive Care Unit with neurological sequelae (2 with mild, 5 with serious sequelae).

CONCLUSION

In our patients with drowning accidents, hypothermia did not appear to provide any protective effect. ARDS, if it occurred, became evident within 6 h after admission.

[Shock in children; no child's play]

Shock comprises of circulatory insufficiency accompanied by a discrepancy between oxygen demand and supply at tissue level. This results in tissue hypoxia, which when persisting, can lead to (severe) organ failure. In this article we will discuss pathophysiologic backgrounds of shock following the mechanisms that cause hemodynamic deterioration and tissue hypoxia. Subsequently the role of various cytokines in the pathogenesis of septic shock, which occurs relatively frequent in childhood, are discussed. As far as fluid substitution and vasoactive medication is concerned, therapeutic strategies can be chosen more rationally these days. This is mainly due to the availability of smaller i.v. cannula, central venous catheters and advances in (non) invasive hemodynamic measurements in childhood e.g. central venous pressure, cardiac output, peripheral vascular resistance and left ventricular shortening fraction. Despite these developments, shock (in particular septic shock) remains to have a high mortality, also in childhood.

[Congenital laryngeal stenosis; a rare cause of dyspnea in the newborn infant]

Congenital laryngeal obstruction is a rare but serious cause of severe, often fatal, post partum asphyxia. The condition should be recognized and in most cases an artificial airway has to be established immediately because hypoxia allows little time for extensive evaluation. Thereafter a further diagnostic procedure by means of laryngobronchoscopy and contrast laryngography should be performed. The clinical picture of two cases with a congenital laryngeal stenosis is described and the initial therapeutic approach is discussed.

Early onset agammaglobulinaemia with monoclonal IgG production

Two patients are described with X-linked agammaglobulinaemia (XLA). After a period of gammaglobulin infusions endogenous IgG production appeared to resume and gammaglobulin therapy was gradually stopped. However, bacterial respiratory tract infections recurred. Immunological evaluation showed normal levels of serum IgG with mono/oligoclonal IgG m-bands, while B lymphocytes and plasma cells were absent from the peripheral blood and bone marrow. Endogenous IgG was synthesized in plasma cells in the submucosa of the gastrointestinal tract. Renewed high doses of exogenous gammaglobulin led to the reduction of infections and the disappearance of mono/oligoclonal m-bands in the serum. We suggest that as a rare complication of XLA some pre-B-cells may escape the blockade to B-cell maturation and produce mono/oligoclonal IgG, possibly due to chronic infectious stimulation.

[Prenatal fetal blood group determination using chorionic villi biopsy]

The presence or absence of Rhesus D, c and Kell antigens on foetal red blood cells was determined in the first trimester of pregnancy on erythrocytes obtained by chorionic villi sampling. Pregnancies in 15 severely sensitized women (9 Rh D, 5 Kell and I Rh c) with a poor obstetric history and a partner heterozygous for the offending antigen were examined. A conclusive diagnosis could be made in 13 of the 15 cases studied.

Sensitive methods for determining subclasses of IgG anti-A and anti-B in sera of blood-group-O women with a blood-group-A or -B child

The determination of the subclasses of IgG antibodies against blood groups A and B is important in order to improve our understanding and predict haemolytic disease of the newborn due to IgG anti-A or -B. We describe two techniques that circumvent the problem of the agglutination of A and B red cells by the corresponding IgG antibodies in saline: an antiglobulin consumption test and a modified solid-phase micro-immunofluorescence test. The results of the two techniques are compared with the results obtained in the indirect antiglobulin test beyond the saline agglutination titre in a microplate technique. The solid-phase micro-immunofluorescence test was the most sensitive for the determination of the subclasses of IgG anti-A and -B. Usually sera contained IgG2 anti-A, B in a higher titre than antibodies of other subclasses.

Fetal blood group determination in first-trimester pregnancy for the management of severe immunization

The presence or absence of Rho (D) and Kell antigens on fetal red blood cells was determined in the first trimester of pregnancy on erythrocytes obtained by chorionic villi sampling with the use of mixed agglutination and solid phase microimmunofluorescence techniques. Pregnancies in one Kell-sensitized woman and seven severely RH-sensitized women with a poor obstetric history and a partner heterozygous for the offending antigen were examined. A conclusive diagnosis could be made in seven of the eight cases studied.

ABO and Rhesus phenotyping of fetal erythrocytes in the first trimester of pregnancy

Determination of fetal red blood cell antigens in early pregnancy can be important in cases with a history of severe haemolytic disease of the newborn. From chorionic villus biopsies (CVB) between the 8th and 12th week of gestation a small number of fetal red blood cells was obtained, inevitably highly contaminated with maternal blood cells. Two techniques were used to demonstrate the minor (fetal) cell population with a blood group antigen differing from the major (maternal) cell population: a solid-phase microfluorescence technique (introduced in this paper) which was compared with the mixed agglutination technique. In series of artificial mixtures of erythrocytes it was shown that with the microfluorescence technique the ABO and Rhesus phenotypes of minor cell populations could be determined at a ratio of 1 in 4000 erythrocytes of the major population, making this technique 4 times as sensitive as the mixed agglutination technique. We further investigated the reliability of the microfluorescence technique to demonstrate antagonistic fetal blood groups in the first trimester of pregnancy. Of 18 women undergoing CVB prior to therapeutic abortion, blood group antagonism (ABO and Rhesus systems) was demonstrate in all 11 cases in which it was present. Therefore, it seems that CVB can be reliably used for the prenatal diagnosis of (recurrent) blood group antagonism.