Apparent life-threatening events and brief resolved unexplained events: management of children at a Swiss tertiary care center.

AIMS OF THE STUDY: Apparent life threatening events (ALTEs) are highly stressful situations for the caregiver and commonly result in presentation of the child to an emergency department. As the events are usually brief and resolve in a short period of time, the entity is now called a brief resolved unexplained event (BRUE). Updated recommendations have been published in recent years on the management of BRUE, including a risk stratification to identify those at lower risk for subsequent events or severe underlying disorders. The aim of this study was to describe the epidemiology of ALTE and BRUE at our hospital and detail clinical practice of management in this population in a tertiary care children's hospital in Switzerland. METHODS: We retrospectively analysed all cases of children with an ALTE or BRUE admitted to the University Children's Hospital Basel between September 2009 and April 2018, identified using ICD-10GM coding. Electronic health records were used to extract data on diagnostic procedures, duration of admission and outcome. Infants with a lower-risk BRUE (defined as age >60 days and <1year, born at ≥32 weeks gestational age and postconceptional age ≥45 weeks, first BRUE episode with a duration of <1 minute and no cardiopulmonary resuscitation by trained medical provider required) were compared with those with a higher-risk BRUE/ALTE (not fulfilling all the criteria for lower-risk BRUE). RESULTS: A total of 65 patients with a median age of 42 days (interquartile range 20-67) were identified, of whom 15% were classified as having a lower-risk BRUE. A blood sample was analysed in 97% of patients, cranial ultrasound was performed in 63%, an electrocardiogram in 78% and polysomnography in 26%. The results remained normal in almost all patients and none had a further event recorded during admission. In one patient only QTc prolongation was detected as a potential serious underlying disease. CONCLUSIONS: Our data show that admission for more than 24 hours and extensive investigations for infants admitted for an ALTE/BRUE rarely led to identification of specific underlying causes. According to current recommendations, 15% of the admitted patients could be categorised as having a lower-risk BRUE and therefore hospital admissions and investigations can safely be reduced. We propose an adaptation of the current Swiss recommendations for ALTE/BRUE to optimise clinical management of children presenting with a BRUE.

Diagnostic accuracy of an interdisciplinary tertiary center evaluation in children referred for suspected congenital anomalies of the kidney and urinary tract on fetal ultrasound - a retrospective outcome analysis.

BACKGROUND: Fetal ultrasound organ screening has become a standard of care in most high-income countries. This has resulted in increased detection of congenital abnormalities, which may lead to major uncertainty and anxiety in expectant parents, even though many of them are of minor relevance. In order to optimize prenatal counselling, we introduced an interdisciplinary approach for all pregnant women referred to our center by private obstetricians for a co-assessment of suspected relevant fetal abnormalities of the kidney or urinary tract, involving both experienced prenatal ultrasound specialists and a pediatric nephrologist or urologist. METHODS: In a retrospective analysis, we evaluated reports of intrauterine evaluation and postnatal follow-up in order to assess accuracy of explicit intrauterine diagnoses and outcome of hydronephroses according to their severity in this setting. RESULTS: A total of 175 fetuses were examined between 2012 and 2019 and followed postnatally at our Pediatric Nephrology or Urology Department. There was a high concordance (85.9%) between explicit intrauterine and final diagnoses. Resolution rate of hydronephrosis was higher in patients with intrauterine low-grade than high-grade hydronephrosis (61.8% versus 11.9%). An etiological diagnosis was found in 62.5%, 52.0%, and 11.1% of patients with intrauterine bilateral high-grade, unilateral high-grade, and unilateral high-grade with contralateral low-grade hydronephrosis, respectively, but in none of the patients with intrauterine low-grade hydronephrosis. CONCLUSIONS: The results of our study demonstrate that, through interdisciplinary teamwork, intrauterine assessment of the fetal kidneys and urinary tract is highly accurate and allows a good discrimination between relevant and transient/physiological hydronephroses. A higher resolution version of the Graphical abstract is available as Supplementary information.

Serum Neurofilament Levels in Children With Febrile Seizures and in Controls.

OBJECTIVE: Neuroaxonal damage is reflected by serum neurofilament light chain (sNfL) values in a variety of acute and degenerative diseases of the brain. The aim of this study was to investigate the impact of febrile and epileptic seizures on sNfL, serum copeptin, and prolactin levels in children compared with children with febrile infections without convulsions. METHODS: A prospective cross-sectional study was performed in children aging 6 months to 5 years presenting with fever (controls, n = 61), febrile seizures (FS, n = 78), or epileptic seizures (ES, n = 16) at our emergency department. sNfL, copeptin, and prolactin were measured within a few hours after the event in addition to standard clinical, neurophysiological, and laboratory assessment. All children were followed up for at least 1 year after presentation concerning recurrent seizures. RESULTS: Serum copeptin values were on average 4.1-fold higher in FS and 3.2-fold higher in ES compared with controls (both p < 0.01). Serum prolactin values were on average 1.3-fold higher in FS compared with controls ( p < 0.01) and without difference between ES and controls. There was no significant difference of mean sNfL values (95% CI) between all three groups, FS 21.7 pg/ml (19.6-23.9), ES 17.7 pg/ml (13.8-21.6), and controls 23.4 pg/ml (19.2-27.4). In multivariable analysis, age was the most important predictor of sNfL, followed by sex and C reactive protein. Neither the duration of seizures nor the time elapsed from seizure onset to blood sampling had an impact on sNfL. None of the three biomarkers were related to recurrent seizures. SIGNIFICANCE: Serum neurofilament light is not elevated during short recovery time after FS when compared with children presenting febrile infections without seizures. We demonstrate an age-dependent decrease of sNfL from early childhood until school age. In contrast to sNfL levels, copeptin and prolactin serum levels are elevated after FS.

Comparison of Blood Pressure and Kidney Markers between Adolescent Former Preterm Infants and Term Controls.

BACKGROUND: Preterm infants are at an increased risk of developing hypertension and chronic kidney disease later in life. No recommendations exist for blood pressure (BP) and renal follow up for these patients. AIM: To compare BP and serum and urinary kidney markers between preterm-born adolescents and term-born controls. METHODS: BP measurements in 51 preterm-born (≤32 weeks gestational age) and 82 term-born adolescents at the age of 10-15 years were conducted. Stepwise regression analysis explored the association between BP and participant characteristics. Kidney markers measured in the serum and urine were creatinine, neutrophil gelatinase-associated lipocalin (NGAL), and uromodulin. Kidney markers measured in the serum were cystatin C, beta-2 microglobulin, and beta trace protein. RESULTS: Systolic BP was significantly higher in preterm boys compared with term boys, but not in girls, and low birth weight was associated with higher BP in boys. In the preterm group, maternal hypertension/preeclampsia and adolescent height were associated with higher systolic BP. Serum creatinine and NGAL were significantly higher in the preterm group. CONCLUSIONS: Our study confirms an inverse sex-dependant relationship between birth weight and BP at adolescent age. The higher serum creatinine and NGAL in the preterm group may indicate that premature birth affects kidney function in the long term.

"Chaotic Arrhythmia" During Successful Resuscitation After Ingestion of Yew (Taxus baccata) Needles.

OBJECTIVE: The study aims to describe the management of a case of life-threatening yew (Taxus baccata) intoxication. BACKGROUND: The needles of the yew tree contain highly cardiotoxic taxines. Intoxication with taxines, typically as part of suicide attempts, may lead to potentially lethal arrhythmias which often require prolonged cardiopulmonary resuscitation and other supportive measures. No specific therapy has been described. In some cases, extracorporeal life support has been used. CASE: After an attempted suicide with yew needles and out-of-hospital cardiac arrest, a female adolescent was resuscitated for 6 hours according to Advanced Cardiovascular Life Support guidelines. Complex ventricular tachycardias were treated by repeated direct current shocks and broad complex bradycardia managed with transvenous cardiac pacing. Antiarrhythmic drugs (amiodarone, lidocaine), magnesium sulfate, and supportive measures (intravenous lipids, sodium bicarbonate) were provided. The arrhythmias finally resolved, and the patient did not show any significant neurological or cardiac short-term sequelae after 24 hours. RESULTS: The authors describe the successful management of a case of severe taxine intoxication by prolonged conventional advanced cardiac life support lasting for more than 6 hours. CONCLUSIONS: In life-threatening yew intoxication, prolonged cardiopulmonary resuscitation is absolutely essential owing to the long duration of the cardiotoxic action of taxines and can lead to an outcome without cardiac or neurological sequelae.