Henrietta Egleston Hospital for Children

BACKGROUND: Inhaled nitric oxide improves gas exchange in neonates, but the efficacy of low-dose inhaled nitric oxide in reducing the need for extracorporeal membrane oxygenation has not been established. METHODS: We conducted a clinical trial to determine whether low-dose inhaled nitric oxide would reduce the use of extracorporeal membrane oxygenation in neonates with pulmonary hypertension who were born after 34 weeks' gestation, were 4 days old or younger, required assisted ventilation, and had hypoxemic respiratory failure as defined by an oxygenation index of 25 or higher. The neonates who received nitric oxide were treated with 20 ppm for a maximum of 24 hours, followed by 5 ppm for no more than 96 hours. The primary end point of the study was the use of extracorporeal membrane oxygenation. RESULTS: Of 248 neonates enrolled, 126 were randomly assigned to the nitric oxide group and 122 to the control group. Extracorporeal membrane oxygenation was used in 78 neonates in the control group (64 percent) and in 48 neonates in the nitric oxide group (38 percent) (P=0.001). The 30-day mortality rate in the two groups was similar (8 percent in the control group and 7 percent in the nitric oxide group). Chronic lung disease developed less often in neonates treated with nitric oxide than in those in the control group (7 percent vs. 20 percent, P=0.02). The efficacy of nitric oxide was independent of the base-line oxygenation index and the primary pulmonary diagnosis. CONCLUSIONS: Inhaled nitric oxide reduces the extent to which extracorporeal membrane oxygenation is needed in neonates with hypoxemic respiratory failure and pulmonary hypertension.

Clinical and laboratory investigations of neonatal pain suggest that preterm neonates have an increased sensitivity to pain and that acute painful stimuli lead to the development of prolonged periods of hyperalgesia. Non-noxious stimuli during these periods of hyperalgesia may expose preterm neonates to established or chronic pain. Acute physiologic changes caused by painful or stressful stimuli can be implicated as important factors in the causation or subsequent extension of early intraventricular hemorrhage (IVH) or the ischemic changes leading to periventricular leukomalacia (PVL). Therapeutic interventions that provide comfort/analgesia in preterm neonates were correlated with a decreased incidence of severe IVH. Long-term follow-up studies of preterm neonates may substantiate the preliminary data associating repetitive painful experiences with some of the neurobehavioral and developmental sequelae resulting from neonatal intensive care.

BACKGROUND: Vitamin and mineral deficiencies, particularly those of iron, vitamin A and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Micronutrient powders (MNP) are single-dose packets containing multiple vitamins and minerals in powder form that can be sprinkled onto any semi-solid food.The use of MNP for home or point-of-use fortification of complementary foods has been proposed as an intervention for improving micronutrient intake in children under two years of age. OBJECTIVES: To assess the effects and safety of home (point-of-use) fortification of foods with multiple micronutrient powders on nutritional, health and developmental outcomes in children under two years of age. SEARCH STRATEGY: We searched the following databases in February 2011: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE (1948 to week 2 February 2011), EMBASE (1980 to Week 6 2011), CINAHL (1937 to current), CPCI-S (1990 to 19 February 2011), Science Citation Index (1970 to 19 February 2011), African Index Medicus (searched 23 February 2011), POPLINE (searched 21 February 2011), ClinicalTrials.gov (searched 23 February 2011), mRCT (searched 23 February 2011), and World Health Organization International Clinical Trials Registry Platform (ICTRP) (searched 23 February 2011). We also contacted relevant organisations (25 January 2011) for the identification of ongoing and unpublished studies. SELECTION CRITERIA: We included randomised and quasi-randomised trials with either individual or cluster randomisation. Participants were children under the age of two years at the time of intervention, with no specific health problems. The intervention was consumption of food fortified at the point of use with multiple micronutrient powders formulated with at least iron, zinc and vitamin A compared with placebo, no intervention or the use of iron containing supplements, which is the standard practice. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies and assessed the risk of bias of the included studies. MAIN RESULTS: We included eight trials (3748 participants) conducted in low income countries in Asia, Africa and the Caribbean, where anaemia is a public health problem. The interventions lasted between two and 12 months and the powder formulations contained between five and 15 nutrients. Six trials compared the use of MNP versus no intervention or a placebo and the other two compared the use of MNP versus daily iron drops. Most of the included trials were assessed as at low risk of bias.Home fortification with MNP reduced anaemia by 31% (six trials, RR 0.69; 95% CI 0.60 to 0.78) and iron deficiency by 51% (four trials, RR 0.49; 95% CI 0.35 to 0.67) in infants and young children when compared with no intervention or placebo, but we did not find an effect on growth.In comparison with daily iron supplementation, the use of MNP produced similar results on anaemia (one trial, RR 0.89; 95% CI 0.58 to 1.39) and haemoglobin concentrations (two trials, MD -2.36 g/L; 95% CI -10.30 to 5.58); however, given the limited amount of data these results should be interpreted cautiously.No deaths were reported in the trials and information on side effects and morbidity, including malaria, was scarce.It seems that the use of MNP is efficacious among infants and young children six to 23 months of age living in settings with different prevalences of anaemia and malaria endemicity, regardless of whether the intervention lasts two, six or 12 months or whether recipients are male or female. AUTHORS' CONCLUSIONS: Home fortification of foods with multiple micronutrient powders is an effective intervention to reduce anaemia and iron deficiency in children six months to 23 months of age. The provision of MNP is better than no intervention or placebo and possibly comparable to commonly used daily iron supplementation. The benefits of this intervention as a child survival strategy or on developmental outcomes are unclear. Data on effects on malaria outcomes are lacking and further investigation of morbidity outcomes is needed. The micronutrient powders containing multiple nutrients are well accepted but adherence is variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups.

Field studies of Streptococcus pneumoniae (pneumococci) nasopharyngeal (NP) colonization are hampered by the need to directly plate specimens in order to ensure isolate viability. A medium containing skim milk, tryptone, glucose, and glycerin (STGG) has been used to transport and store NP material, but its ability to preserve pneumococci has not been evaluated. Our objective was to qualitatively and semiquantitatively evaluate the ability of STGG to preserve pneumococci in NP secretions. Entwined duplicate calcium alginate NP swab samples were obtained from children. One swab was plated directly onto a gentamicin blood agar plate; the other was placed in STGG. Growth from the directly plated specimen was compared with growth from an STGG aliquot immediately cultured or stored at -70 degrees C for 9 weeks, -20 degrees C for 9 weeks, or 4 degrees C for 5 days. Of 186 specimens, 96 (52%) were positive for pneumococci from the direct plating; 94 (98%) of these were positive from the fresh STGG specimen. Pneumococci were recovered from all 38 positive specimens frozen at -70 degrees C, all 18 positive specimens frozen at -20 degrees C, and 18 of 20 positive specimens stored at 4 degrees C. Recovery of pneumococci after storage of NP material in STGG medium at -70 degrees C is at least as good as that from direct plating. Storage at -20 degrees C is also acceptable. Storage at 4 degrees C for 5 days is not ideal.

PURPOSE: To determine whether breath holding can be eliminated in two-dimensional magnetic resonance (MR) imaging of the coronary arteries by using real-time respiratory gating. MATERIALS AND METHODS: Thirty-one subjects (20 healthy volunteers, 11 patients) underwent MR imaging. In 13 subjects, a respiratory monitoring belt was used, and in 18 subjects, a navigator echo was used. MR imaging was performed with breath holding, respiratory gating, and respiratory gating with two signals acquired. Three reviewers conducted a blinded review of the images, and overall image quality was rated on a scale from 1 (poor) to 5 (excellent). RESULTS: Respiratory gating with two signals acquired provided image quality superior to that with breath-hold imaging (3.7 vs 3.0, respectively; P < .05). Measurements of signal-to-noise ratio (14.5 for respiratory gating with two signals acquired and 11.9 for breath holding) supported the results of the image review. Navigator-echo gating provided better image quality than the monitoring belt (3.7 vs 3.1, respectively; P < .05). CONCLUSION: Breath holding may be eliminated by gating image acquisition to a real-time monitor of respiratory position. Respiratory gating enables improved resolution by means of acquisition of multiple signals, provides aligned sections of coronary arteries, and improves patient tolerance.

The use of color Doppler sonography to evaluate the symptomatic testes in children with scrotal pain or swelling was prospectively studied with a fourth-generation color sonographic unit with a 7-MHz linear transducer. The 32 patients were 1 day to 18 years old (mean age, 8.6 years). Results were correlated with scintigraphic findings in 23 patients, with the final diagnosis established by surgery in 12 patients, and with clinical follow-up in all patients. Eight cases of testicular torsion, including two of acute torsion and six of late torsion, were correctly detected by color Doppler sonography and confirmed surgically. In the remaining patients, perfusion of the testis was correctly detected by color Doppler examination. The final diagnoses in these patients included torsion of the appendix testis (15 patients), epididymitis (five patients), epididymo-orchitis (one patient), yolk sac tumor of the testis (one patient), hydrocele (one patient), and local reaction to an insect bite (one patient). The ability to detect blood flow in the normal contralateral testis was also evaluated in 28 patients. Blood flow was demonstrated in normal testes larger than 1 cm3. Detection of flow in the very small normal prepubertal testis was often difficult, and no flow was identified in one testis. Flow was identified in central arteries in only six of 13 testes smaller than 1 cm3. We conclude that color Doppler sonography is helpful in the initial evaluation of pediatric testes, providing accurate evaluation of the involved hemi-scrotum in our patients and also providing the benefit of both structural and flow information. Until our sensitivity to low-velocity flow improves, we would not suggest the exclusive use of color Doppler sonography in the evaluation of testicular perfusion in the prepubertal patient. We advocate the addition of testicular scintigraphy to corroborate the presence of testicular perfusion when flow in intratesticular arteries cannot be established with certainty by color Doppler sonography.

UNLABELLED: Coagulopathies in children after cardiopulmonary bypass (CPB) are complex. There are very limited data correlating coagulation tests with postoperative bleeding. We evaluated coagulation changes after CPB and after the administration of coagulation products to 75 children. Baseline coagulation tests were obtained and repeated after protamine administration, after transfusion of individual coagulation products, and on arrival in the intensive care unit (ICU). Regression analysis demonstrated no baseline coagulation test to predict postoperative chest tube drainage. Weight and duration of CPB were determined to be the only predictors of bleeding. Further analyses demonstrated that children <8 kg had more bleeding and required more coagulation products than children >8 kg. Postprotamine platelet count and fibrinogen level correlated independently with 24-h chest tube drainage in children <8 kg, whereas postprotamine platelet count and thrombelastographic values did so in patients weighing >8 kg. Platelet administration alone was found to restore effective hemostasis in many patients. With ongoing bleeding, cryoprecipitate improved coagulation parameters and limited blood loss. Fresh-frozen plasma administration after platelets worsened coagulation parameters and was associated with greater chest tube drainage and more coagulation product transfusions in the ICU. Objective data to guide post-CPB component therapy transfusion in children are suggested. IMPLICATIONS: Children <8 kg can be expected to have more severe coagulopathies, require more coagulation product transfusions, and bleed more after cardiopulmonary bypass. Correlations between coagulation tests and postoperative chest tube drainage are defined. Platelets and, if necessary, cryoprecipitate optimally restore hemostasis. Fresh-frozen plasma offers no benefits in correcting postcardiopulmonary bypass coagulopathies in children.

OBJECTIVE: To evaluate caregiver (parent or guardian) use of over-the-counter medications (OTCs) as related to the accuracy and correctness of dosing for children seen at a pediatric emergency department with nonemergent concerns. DESIGN: Prospective patient series. SETTING: A tertiary care pediatric emergency center. PARTICIPANTS: A representative sample of children with nonemergent chief complaints. INTERVENTIONS: A questionnaire about general demographic characteristics, recent OTC use, and medical history of the patients was given to each caregiver. A mock scenario was then presented that required the caregivers to determine and measure a correct dose of acetaminophen for their child. A dose of 9 to 16.5 mg/kg was considered correct. Accuracy of measuring was considered within +/-20% of the caregivers' stated intended dose for their child. RESULTS: One hundred caregivers were enrolled in the study. Mean caregivers' age was 29 years, with 82% having at least a high school education. Seventy-seven percent of their children used OTCs within the previous 2 months, and Tylenol (acetaminophen) was the most commonly used. While 66% of the caregivers reported Tylenol use, only 8% reported the use of acetaminophen. During the dosing scenario, only 40% of the caregivers stated an appropriate dose for their child and only 67% accurately measured the amount of acetaminophen they intended. Forty-three percent measured out a correct amount of acetaminophen for their child. However, almost one third of these occurred strictly by accident because they inaccurately measured an improper intended dose. Combining these results, only 30% of the caregivers were able to demonstrate both an accurately measured and correct dose for their child. CONCLUSIONS: Although a large number of caregivers administer OTCs, knowledge of these medications, and accuracy and correctness of dosing remain a marked concern. Improved caregiver education on the accuracy and correctness of dosing OTCs is necessary.

BACKGROUND: Hemochromatosis, which can lead to serious chronic diseases resulting from iron overload, has an estimated prevalence of 50 to 80 cases per 10000 persons. However, little population-based information is available on the impact of hemochromatosis on morbidity and mortality. OBJECTIVE: To evaluate trends over 14 years in deaths and medical conditions associated with hemochromatosis in the United States. DESIGN: We searched Multiple-Cause Mortality Files compiled by the National Center for Health Statistics for the years 1979 to 1992 for all records listing hemochromatosis. We used these data to calculate age-adjusted and age-specific mortality rates, identify medical conditions associated with a known diagnosis of hemochromatosis at death, and calculate proportionate mortality ratios for these medical conditions. RESULTS: The listing of hemochromatosis on death certificates increased 60% from 1979 to 1992. Decedents with hemochromatosis were 23, 13, and 5 times more likely to have liver neoplasms, liver disease, and cardiomyopathy, respectively, than were decedents without hemochromatosis. Conversely, decedents with liver neoplasms, liver disease, and cardiomyopathy were 26, 14, and 5 times more likely, respectively, to have hemochromatosis than were decedents without these conditions. Hemochromatosis was 82 times more likely in persons with the combination of liver neoplasms and diabetes and 43 times more likely in those with the combination of liver disease and diabetes than in those without these conditions. CONCLUSIONS: Comparison of the reported prevalence of hemochromatosis among decedents with estimates of prevalence in the general U.S. population suggests that either the penetrance or the recognition of hemochromatosis, or both, is low. Nevertheless, substantial mortality resulting from liver disease, liver neoplasms, cardiomyopathy, and a combination of liver disease and diabetes in patients with hemochromatosis argues for the improved diagnosis and treatment of hemochromatosis in persons with these conditions.

The histories of 22 infants presenting during the first year of life with obstructive uropathy due to posterior urethral valves were analyzed to determine outcome and prognostic features. Mean patient age at the time of the initial surgical intervention was 39 days, and the mean duration of followup inclusive of renal function data was 5.8 years. One patient died (5 per cent) and one had end stage renal disease. The mean preoperative and postoperative serum creatinine concentrations during the initial hospitalization were 3.1 and 1.4 mg. per dl., respectively. Neither value was significantly predictive of the creatinine concentration at final followup. In contrast, the nadir creatinine value during the first year of life correlated significantly with final renal function. Children with nadir creatinine values less than or equal to 0.8 mg. per dl. by 12 months of age maintained creatinine levels less than or equal to 1.1 mg. per dl. at the time of final evaluation, whereas children with higher values during the first year of life were likely to have progressive renal failure. Of 19 final creatinine determinations 6 were normal and 5 exceeded 1.5 mg. per dl. Proteinuria, hypertension, renal biopsy findings, urinary infection, unilateral nephrectomy and type of surgery did not correlate significantly with functional outcome. Followup studies of longer duration are needed to determine the ultimate outcome of these patients, more than half of whom had some degree of renal insufficiency at final evaluation.

OBJECTIVES: To review the definitions and scientific basis for opioid tolerance and dependence in neonates and older children; to assess objective methods for the clinical evaluation of opioid abstinence syndromes in this age group; and to suggest therapeutic strategies for the treatment of opioid abstinence in critically ill neonates and children. DATA SOURCES: The published literature on opioid tolerance and dependence in pediatric patients was reviewed. Data from current clinical practices, nursing procedures, and ongoing clinical research were evaluated. DATA SYNTHESIS: Currently proposed mechanisms of opioid tolerance and dependence are assessed, with particular relevance to the developing human central nervous system. The validity and clinical role of currently available objective methods for the assessment of opioid abstinence in neonates and older infants are defined. The efficacy of various pharmacologic and nonpharmacologic modalities for the treatment of opioid abstinence is evaluated and compared, and a therapeutic approach based on receptor mechanisms, clinical monitoring data, and pharmacologic efficacy is suggested. CONCLUSIONS: Important parallels for therapeutically-induced opioid tolerance and withdrawal may be drawn from the assessment and management of neonates born from opioid-addicted mothers. Opioid withdrawal can be prevented with appropriate weaning schedules, diagnosed by objective clinical methods, and treated by a variety of pharmacologic and non-pharmacologic means. Pharmacologic therapy includes the use of opioids, with adjuvant drugs such as diazepam, clonidine, or chlorpromazine. The pathophysiology and assessment of therapeutically induced opioid tolerance and withdrawal merit further research in critically ill pediatric patients.

OBJECTIVE: To determine the effectiveness of a tissue adhesive, Histoacryl Blue (HAB), for laceration repair in children. DESIGN: Prospective, randomized clinical trial. SETTING: A tertiary care pediatric emergency center at Egleston Children's Hospital. PARTICIPANTS: Children who presented for laceration repair between October 1994 and February 1995 were prospectively evaluated. Patients less than 1 or greater than 18 years of age, those with lacerations greater than 5 cm, and those with lacerations located on the eyelids, ears, nose, lips, hands, feet, joints, or perineum were excluded. INTERVENTIONS: Following consent and routine wound management, including subcutaneous closure when deemed necessary, patients were randomized to receive skin sutures or HAB for cutaneous closure. METHODS: Length of time required for laceration repair was recorded. Parental perception of the pain experienced by their child was assessed using a visual analogue scale. Photographic documentation of scar appearance at the 2-month follow-up visit was evaluated by plastic surgeons using a visual analogue scale. RESULTS: Sixty-one children were enrolled: HAB group (N = 30), suture group (N = 31). No differences occurred between groups in laceration length, depth, location, or patient demographics. Length of time required for repair was decreased (median, HAB 7 minutes vs suture 17.0 minutes) and parental assessment of their child's pain was significantly less in the HAB group. Parents were more likely to recommend HAB over suturing to other parents or guardians. Cosmetic outcome in the HAB group was assessed to be as good as, or better than, the cosmetic outcome in the suture group as evaluated by two plastic surgeons. CONCLUSION: The use of HAB for laceration repair is an acceptable alternative to conventional suturing with a comparable cosmetic outcome. Advantages include less pain to the child, no need for suture removal, and more efficient use of physician time. Parents were also more likely to recommend HAB over suturing for laceration repair.

BACKGROUND: Headache may be the presenting complaint of serious diagnoses such as meningitis, brain tumor, or shunt malfunction, yet no previous studies have examined the spectrum of diagnoses for the pediatric emergency department (ED) population with a chief complaint of headache. METHODS: In 1993, 53,988 visits were made to the ED of an urban children's hospital. Six hundred ninety-six patients (1.3%) had a chief complaint of headache. Half of these visits, distributed randomly throughout the year, were chosen for review; total sample size was 288. RESULTS: Patient age ranged from two to 18 years (2-5 years, 24.3%; 6-12 years, 57.6%; 13-18 years, 18.1%). The spectrum of ED diagnoses included viral illness (39.2%), sinusitis (16.0%), migraine (15.6%), post-traumatic headache (6.6%), streptococcal pharyngitis (4.9%), and tension headache (4.5%). No cases of brain tumor or bacterial meningitis were identified at the time of ED visit. The only serious neurologic conditions diagnosed were 15 cases of viral meningitis (5.2%), one shunt malfunction, one newly diagnosed hydrocephalus, one Burkitt's lymphoma patient with newly diagnosed CNS infiltration, and one punctate hemorrhage post head trauma. Two thirds of patients had radiologic and/or laboratory tests. Positive findings were as follows: 45.6% of sinus radiographs, 16.3% of rapid streptococcal antigen tests, 60.9% of lumbar punctures, and 19.0% of brain imaging studies. The frequency of serious and nonserious conditions as a cause of headache was compared to data from general EDs. CONCLUSION: Serious conditions presenting with the chief complaint of headache in the pediatric ED were not common in our population. The most frequent diagnoses in our review were viral illness, sinusitis, and migraine, in contrast to adult studies in which tension headache and migraine were most common. Only 6.6% of patients had serious neurologic diagnoses, which is in the range reported for general EDs. Of the serious conditions in our study, 80% were viral meningitis.

OBJECTIVE: Diffusion-weighted imaging (DWI) reveals nonhemorrhagic posttraumatic infarction hours to days before conventional computed tomographic scanning or magnetic resonance imaging (MRI). We evaluated the diagnostic utility of DWI in children with nonaccidental head trauma. METHODS: The medical records and imaging examinations obtained between January 1998 and May 2000 for all children less than 2 years of age with presumed or suspected nonaccidental head injury were reviewed retrospectively. Twenty children who had undergone DWI within 5 days of presentation were included in the study. Computed tomographic scans, conventional MRI sequences, and DWI combined with apparent diffusion coefficient (ADC) maps were evaluated. RESULTS: Eleven girls and nine boys (median age, 5 mo) were studied. Eighteen children had presumed nonaccidental head trauma, and two children had suspected nonaccidental head trauma. Of the 18 children with presumed nonaccidental trauma, 16 (89%) demonstrated abnormalities on DWI/ADC, as compared with neither of the two children with suspected nonaccidental trauma. In 13 (81%) of 16 positive cases, DWI revealed more extensive brain injury than was demonstrated on conventional MRI sequences or showed injuries not observed on conventional MRI. DWI combined with ADC maps allowed better delineation of the extent of white matter injury. DWI/ADC abnormalities in the nonaccidental head-injured children were likely to involve posterior aspects of the cerebral hemispheres, with relative sparing of the frontal and temporal poles. Severity on DWI correlated significantly with poor outcome (P < 0.005). CONCLUSION: DWI has broad applications in the early detection of infarction in children with nonaccidental head injury and enhances the sensitivity of conventional MRI. In the patients in this study, early DWI provided an indicator of severity that was more complete than any other imaging modality. The use of DWI may help to identify children at high risk for poor outcome and to guide management decisions.

A total of 34 children with normal renal function underwent either gastrocystoplasty or continent urinary reservoirs with stomach at our institutions. Severe hypochloremic hypokalemic metabolic alkalosis developed in 2 patients, manifested by intractable seizure disorder in 1 and altered mental status with respiratory depression in 1. Symptoms developed at 4 and 6 months, respectively. Despite severe alkalosis, urinary pH was less than 5.0 and fractional excretion of chloride remained high in both patients. Resuscitation with sodium chloride, arginine hydrochloride and potassium chloride restored electrolyte balance in less than 48 hours in both patients. Serum gastrin was slightly elevated in 1 patient (137 pg./ml., normal 0 to 125) who responded to long-term histamine-blocker therapy. The other patient had significant hypergastrinemia (624 pg./ml.) with secondary hyperaldosteronism. Maximum doses of histamine blockers, oral replacement of sodium chloride and potassium chloride, and the proton pump inhibitor omeprazole failed to control recurrent bouts of severe hypochloremic metabolic alkalosis. This patient ultimately underwent removal of three-quarters of the gastric augmentation and replacement with ileum. Postoperatively, serum gastrin levels and electrolytes reverted to normal. The pathophysiology of this potentially lethal complication is further discussed.

Experience and Reason| April 01 1998 Hemolytic Uremic Syndrome Associated With InvasiveStreptococcus pneumoniae Infection Greg R. Cabrera, MD; Greg R. Cabrera, MD Search for other works by this author on: This Site PubMed Google Scholar James D. Fortenberry, MD; James D. Fortenberry, MD Search for other works by this author on: This Site PubMed Google Scholar Barry L. Warshaw, MD; Barry L. Warshaw, MD Search for other works by this author on: This Site PubMed Google Scholar C. Robert Chambliss, MD; C. Robert Chambliss, MD Search for other works by this author on: This Site PubMed Google Scholar Jay C. Butler, MD; Jay C. Butler, MD Search for other works by this author on: This Site PubMed Google Scholar Brenda G. Cooperstone, MD Brenda G. Cooperstone, MD Search for other works by this author on: This Site PubMed Google Scholar Reprint requests to (G.R.C.) Division of Critical Care, Egleston Children's Hospital, 1405 Clifton Road NE, Atlanta, GA 30322. Pediatrics (1998) 101 (4): 699–703. https://doi.org/10.1542/peds.101.4.699 Article history Received: June 04 1997 Accepted: August 28 1997 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Greg R. Cabrera, James D. Fortenberry, Barry L. Warshaw, C. Robert Chambliss, Jay C. Butler, Brenda G. Cooperstone; Hemolytic Uremic Syndrome Associated With InvasiveStreptococcus pneumoniae Infection. Pediatrics April 1998; 101 (4): 699–703. 10.1542/peds.101.4.699 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP Grand RoundsAAP NewsAll AAP Sites Search Advanced Search Topics: hemolytic-uremic syndrome, invasive pneumococcal disease, pneumococcal infections Hemolytic uremic syndrome (HUS), the most common cause of acute renal failure in childhood, is characterized by acute renal failure, microangiopathic hemolytic anemia, and thrombocytopenia. The majority of HUS cases occur after infectious diarrhea, and most of these cases are associated with Escherichia coli O157:H7 infection.1 2 However, atypical cases of HUS also occur in the absence of infectious diarrhea, although less commonly.3 Among 117 children <18 years of age identified with HUS in the state of Minnesota from 1979 through 1988, 16 patients had no preceding diarrheal illness, and 6 had a respiratory illness prodrome.4 Invasive infection with Streptococcus pneumoniae has rarely been associated with atypical HUS cases.5-14 However, there are no published data on the prevalence of invasive pneumococcal infections among patients with HUS or on the prevalence of HUS cases associated with invasive S pneumoniae infection. We report 7 cases of S pneumoniae... You do not currently have access to this content.

There are quantitative deficiencies in the coagulation system for at least the first 6 mo of life.Clinical experience, however, does not indicate an increased risk of excessive bleeding during surgical procedures. Thrombelastography, a test providing a functional evaluation of coagulation, was used to assess the hemostatic system of pediatric patients under 2 yr of age. Thrombelastographic data were obtained from 237 healthy pediatric patients less than 2 yr of age undergoing elective noncardiac surgery. Five groups were distinguished: under 30 days, 1-3 mo, 3-6 mo, 6-12 mo, and 12-24 mo. Thrombelastography revealed no defects in coagulation when these groups were compared to each other or to adults, indicating a functionally intact hemostatic process even in neonates. Indeed, children less than 12 mo of age were found to initiate and develop clot faster than adults, with the coagulation process slowing to adult rates after 1 yr of age. In addition to defining functional integrity, our data represents a set of pediatric control thrombelastographic values that have not been previously reported and that may become important in understanding coagulation changes that accompany disease states and surgery in pediatric patients. (Anesth Analg 1997;84:745-8)

BACKGROUND: Histoacryl Blue (HAB), a tissue adhesive, has been shown to decrease laceration repair time, cause less pain to the child, eliminate the need for suture removal, and result in a similar short-term cosmetic outcome compared with conventional suturing. Reports suggest that poor correlation can exist between the short-term and long-term cosmetic outcomes for lacerations repaired by conventional suturing. Therefore, this study compares the long-term cosmetic outcome of HAB to conventional suturing for laceration repair in children. DESIGN: Prospective, randomized clinical trial. PARTICIPANTS: Children presenting an urban pediatric emergency department for laceration repair between October 1994 and February 1995 were eligible. Patients less than 1 or more than 18 years old, those with lacerations more than 5 cm in length, or in areas of high tension or mobility were excluded. INTERVENTIONS: After routine wound management, including subcutaneous closure when deemed necessary, patients were randomized to receive skin sutures or HAB for cutaneous closure. Photographs taken at the 2-month and 1-year follow-up visits were evaluated for cosmetic appearance by two plastic surgeons blinded to the method of repair. RESULTS: Sixty-one children were enrolled: HAB (N = 30), suture (N = 31). Thirty HAB and 25 sutured patients were assessed at 2 months, while 17 HAB and 15 sutured patients were reevaluated at 1 year. Patients that followed-up at 2 months and 1 year were comparable to those with no follow-up in: treatment group (HAB vs suture), demographics, wound characteristics, and initial parental satisfaction. The two plastic surgeons graded the cosmetic appearance of the wounds repaired by HAB to be comparable to those repaired by conventional suturing at both the 2-month and 1-year follow-up. CONCLUSIONS: The use of HAB is an ideal alternative to conventional suturing for the cutaneous closure of low tension lacerations in children with a long-term cosmetic outcome comparable to conventional suturing.

aEmory University School of Medicine, Department of Pediatrics, Egleston Children's Hospital at Emory University, 1405 Clifton Road, N.E. Atlanta GA 30322, USA bUniversity of British Columbia, 2136 West Mall, Vancouver B. C., Canada V6I 124 Assistant Professor of Pediatrics, Anesthesia, Psychiatry Professor of Psychology

BACKGROUND: Each year, thousands of children are injured or killed from unintentional gunshot wounds. Discovering a gun while playing in the home places children at risk of being injured by the firearm. OBJECTIVES: To determine parental firearm storage practices and parental perceptions of the behavior of their children around guns. METHODS: Cross-sectional survey of parents of children from 4 to 12 years of age. A sample of 424 parents, bringing their children to one of five pediatric ambulatory care centers, were asked to complete a 20-point self-administered questionnaire at the time of their visit. RESULTS: A total of 400 parents (94%) completed the questionnaire; 113 parents (28%) reported keeping a firearm (most often a handgun) in the home. Firearm owners were predominantly male, 30 years of age or older, white, and married. Of the gun owners, 52% stored their firearms loaded or unlocked, and 13% kept one or more guns loaded and unlocked. Three fourths of gun-owning parents believed that their 4- to 12-year-old child could tell the difference between a toy gun and a real gun, and 23% believed that their child could be trusted with a loaded gun. Although the majority of gun-owning parents (53%) endorsed safe storage as the best firearm injury prevention strategy, 61% of parents who do not own firearms endorse not owning guns as the best way to prevent pediatric firearm injuries. CONCLUSION: A majority of gun-owning parents store their firearms loaded or unlocked, substantially underestimating the risk of injury to their children. Many firearm-owning parents trust their child with a loaded gun and believe that their young child can tell the difference between a toy gun and a real gun.