Current Pediatric Reviews - Volume 1, Issue 2, 2005

Bronchopulmonary dysplasia (BPD) is a common outcome of very premature birth. Affected infants are chronically oxygen dependent, require frequent hospital readmission and have troublesome respiratory symptoms and lung function abnormalities even at school age. BPD has a multifactorial aetiology and many preventative strategies have been assessed. Unfortunately, results of randomised trials have demonstrated that neither antenatal administration of corticosteroids or TRH nor postnatal surfactant administration prevents BPD. Similarly randomised comparisons of various respiratory modes have failed to identify one with a lower incidence of BPD. Fluid overload increases the likelihood of a patent ductus arteriosus and hence BPD, but neither fluid restriction nor diuresis promoting agents prevent BPD. Preliminary evidence suggests that inhaled nitric oxide given prophylactically might be efficacious. The only effective preventative strategy identified by large randomised trials is systemic administration of corticosteroids in the first two weeks after birth, unfortunately this treatment may also increase adverse neurodevelopmental outcome. It is, therefore, crucial to find a corticosteroid regime with a positive risk benefit ratio or preferably a safer and more effective treatment. In addition, it is important to develop a tool to accurately identify infants predestined to develop BPD, enabling them to be targeted for preventative strategies.

Bronchiolitis is an inflammatory or fibrosing process that primarily affects the small airways, often sparing a considerable portion of the interstitium. Although acute bronchiolitis, mainly caused by viruses, is the most frequently recognized affliction of the bronchioles in the pediatric age group, diseases primarily located in the small, peripheral airways of the lung are reported in various clinical settings. Bronchiolar injury includes infection, collagen-vascular diseases, reaction to drugs, exposure to toxic fumes, and may follow organ or bone marrow transplantation. In addition, bronchiolar involvement may be seen in conditions that are more suggestive of an interstitial lung disease and it frequently accompanies diseases of the large airways. The purpose of this review is to provide a description of the spectrum of childhood bronchiolar disorders and the different clinical settings in which they occur. A summary of both the anatomic and histologic characteristics of small airways is given. A comprehensive description of the clinical presentation of bronchiolitis, functional impairment, and radiologic features is reported, with special emphasis on the role of high resolution computed tomography in the diagnosis of pediatric diffuse lung diseases and to the therapeutic options.

Conventional time cycled, pressure-limited ventilation has been used in neonatal intensive care units for many years. Meta-analysis of randomised trials demonstrated that conventional ventilation at rates of at least 60 breaths per minute rather than at slower rates significantly reduced the risk of airleak. Patient triggered ventilation more successfully than conventional ventilation promotes synchronous ventilation; nevertheless, randomised trials demonstrated the only advantage of patient triggered ventilation was that it was associated with a shorter duration of ventilation. More sophisticated triggered modes, pressure support, volume guarantee and proportional assist ventilation, have been developed. Results from physiological studies suggest these modes may be advantageous, but they have not been tested in large randomised controlled trials with long-term outcomes. Many anecdotal studies report avoidance of intubation and mechanical ventilation by use of continuous positive airways pressure reduces bronchopulmonary dysplasia, but the randomized trials which have been undertaken have been too small to appropriately address that outcome. Prophylactic high frequency oscillatory ventilation has been examined in many trials, but overall no benefit or disadvantage has been demonstrated. In conclusion, studies to date have not identified a clear advantage of any of the newer ventilation modes.

In recent years there has been a growing body of evidence from laboratory and clinical studies that at least 2% of newborns have been exposed to an asphyxial insult during labor and delivery, which may affect their outcome. Despite all the progress achieved in obstetric and neonatal care, intrapartum fetal asphyxia is still a major cause of hypoxicischaemic brain injury in term newborns such the one caused by pre-eclampsia, a complication of pregnancy that can cause birth asphyxia at or near term, due to influence on uteroplacental circulation, resulting in brain damage. Up to now it has not been possible to assess fetal brain function directly while the membranes are intact. Several indirect methods are in clinical use such as cardiotocography, biophysical profile, amniotic fluid examination, Doppler sonography, hormone analysis, and ultrasound investigations of fetal growth and movements. During the last decade fetal magnetoencephalography (MEG) has been developed as a useful screening tool for detection of severely neurologically damaged fetuses due to its ability to record brain activity without direct contact with the head as well as to the transparency of magnetic signals in passing through extracerebral fetal layers and through the mother's abdomen. Few studies in the literature refer to neonatal MEG. This article provides an overview of the uses and limitations of fetal and neonatal MEG, especially in the detection of brain damage due to perinatal hypoxia.

Cerebral palsy (CP) is a static encephalopathy affecting the immature brain and leading into a permanent motor disability. There is a spectrum of causative factors, which may be congenital in origin, or can be related to incidences occurring in the perinatal or postnatal period. The development of spine deformity constitutes a common orthopaedic problem with an increased incidence in children with spasticity. The prevalence of spine deformity is directly proportionate to the degree of neurological impairment, and inversely proportionate to the ambulatory capacity. Scoliosis in this group of severely disabled children decreases their sitting tolerance, causes pain from impingement of their pelvis against the rib cage on the concavity of scoliosis, and creates cardiopulmonary complications. Patients with walking function gradually lose their ability to ambulate and become wheelchair-dependent. Spinal arthrodesis is indicated in children with progressive curve size and rigidity, which interferes with their level of function. Spine surgery in patients with severe neurological compromise and complex medical problems is associated with technical difficulties and an increased risk of life-threatening complications. However, there is a documented positive impact on these children by correcting the deformity and maintaining a good coronal and sagittal spinal balance. Spinal fusion is the only surgical procedure that has such a high satisfaction rate among parents and caregivers, especially for quadriplegics. With improved medical management, life expectancy for this group is higher than previously reported and operative procedures to correct the spine have a definitive effect in improving the patients` quality of life. The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

Developmentally regulated changes in the immature brain may contribute to an age-related period of susceptibility to seizures and brain injury resulting from impaired brain perfusion. It is therefore crucial that immature animal models be developed that are relevant to ischemic injury in the immature brain as an important cause of neurologic morbidity. We review here the animal models for ischemic injury in the immature brain with a focus on rodent models. These models have begun to be used for neuroprotective studies. Of the findings from these pre-clinical studies, a few interventions, including hypothermia and magnesium, have been studied in clinical trials. The published results so far from these clinical studies are reviewed here as well. More pre-clinical and clinical studies are needed to assess approaches to preventing ischemic brain injury in term neonates, infants, and children.

The term hemolytic uremic syndrome (HUS) describes a heterogenous group of diseases characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and renal failure. Diarrhea-associated HUS (D+ HUS) accounts for 90 % of cases in childhood, and it is one of the most frequent causes of acute renal failure in children less than five years of age leading to a significant degree of morbidity and mortality. The first step in the pathogenesis of D+HUS is the local inflammation of the intestinal epithelium and endothelium due to Shigatoxin (Stx) producing E. coli infection. This leads to intestinal hemorrhagie, loss of barrier functions, and generation of inflammatory cytokines. Together with TNFα and E.coli derived lipopolysaccharide Stx may act synergistically to damage vascular endothelium. Vascular endothelial injury and its consequences may lead to permanent damage of the kidney, brain, heart, pancreas, and necrosis of intestine. In contrast to D+HUS, the atypical HUS is not associated with diarrhea. Familial and recurrent form of HUS may be associated with low C3 complement levels and/or genetic mutations in factor H. The main purpose of this article is to review the epidemiological, pathogenetic, and clinical features, current treatment strategies, and outcome of D+ HUS with a brief focus on atypical HUS.

Henoch Schonlein purpura (HSP) is one of the most common vasculitis in childhood characterized by nonthrombocytopenic purpura, abdominal pain, arthritis, and glomerulonephritis. Depending on the anatomical sites of involvement many other manifestations including every other organ of the body can be seen. However the most important involvement determining the longterm prognosis is the severity of renal disease. The pathogenesis of HSP is not clear, but it is believed to be an immunoglobulin-mediated inflammatory process resulting from immune complex reaction to various antigenic stimuli. Although none of them has been confirmed to be the exact cause, many bacterial, viral and parasitic infections, insect bites, vaccinations, and exposure to drug and dietary allergens have been described as triggering factors for HSP. Immune complexes are deposited in the vascular walls and mesangium triggering the mediators of inflammation. Treatment of HSP is supportive, and a clear advantage of glucocorticoids over supportive therapy has not been shown in the management of the disease except rapidly progressive type of glomerulonephritis. In this article the epidemiological, clinical and pathogenetic features, current treatment strategies, and outcome of the disease will be reviewed.

Objective: Identify approaches for improving clinician provision of sexually transmitted diseases (STDs) prevention services among outpatient adolescents. Methods: Reviewed all peer-reviewed, published clinical trials identified through computerized searches (MEDLINE, PsychINFO) evaluating STD prevention services to outpatient adolescents by clinicians. Results: Five trials were identified examining changes in clinician provision of STD prevention services. Two of these trials resulted in adolescent self-reported risk reduction, but neither of these trials effectively demonstrated reductions in objectively measured STD incidence. Nine clinical trials were identified that compared clinician with non-clinician provision of STD prevention services. Four of these trials resulted in adolescent self-reported risk reduction, and one of these trials demonstrated a reduction in objectively measured STD incidence. Conclusion: Trials indicate that improvement in outpatient adolescent STD incidence is possible with non-clinicians as interventionists and perhaps clinicians as interventionists, if clinicians are supported by other educational resources. Opportunities for personalized, interactive adolescent education appears key to intervention success. The clinician role that is tested in most trials is confined to a single brief encounter with little attention to: development of clinician skills, quality of psychosexual risk assessment and tailoring to meet individual adolescent need, systems-level resources and supports, the parental role, or the impact of incorporating prevention into an ongoing adolescent-clinician relationship.

Sleepwalking is a disorder that manifests in the pediatric population and is seen out of stages 3-4 NREM sleep during the first third of the night. This paroxysmal disorder of arousal is reproducible and associated with automatic actions and retrograde amnesia. Clinicians need to consider sleep terrors, confusional arousals, nocturnal seizures, and migraines in the differential. Overnight polysomnograms of patients with sleepwalking show an instability of NREM sleep, which may be due to the presence of other sleep-related disorders. One of the most common of these disorders is related to abnormal breathing during sleep. This abnormal breathing may be the well known obstructive sleep apnea syndrome, but often it is a more subtle form called Upper Airway Resistance Syndrome. This last presentation may be associated with chronic allergy, orthodontic problems or moderately enlarged adenotonsils. Restless Leg or Periodic Limb Movement syndromes may also lead to chronic instability of NREM sleep, on which sleepwalking will occur. Treatment of these underlying disorders eliminates the sleepwalking. Use of special recording techniques in polysomnography enables appropriate recognition of the associated and subtle sleep disorders, particularly in cases of chronic sleepwalking. Patients with sleepwalking as well as their family members should be informed of the many ways to safeguard their environment at night.