Improving Consistency and Accuracy of Neonatal Amplitude-Integrated Electroencephalography.

OBJECTIVE: This study aimed to improve the utilization of amplitude-integrated electroencephalography (aEEG) in a neonatal unit by improving aEEG documentation, aEEG knowledge, and pattern recognition ability of neonatal staff. METHODS: A quality improvement (QI) program comprising the two Plan-Do-Study-Act (PDSA) cycles was conducted in a level-3 neonatal intensive care unit. The first cycle was focused on improving aEEG documentation with the primary outcome indicator being compliance with aEEG documentation. The second cycle was focused on aEEG interpretation in a health care professional education program with the outcome indicators being accuracy of seizure identification on aEEG and change in conventional EEGs (cEEG) performed. Other outcome indicators included accuracy in identification of background pattern, sleep-wake cycles and artifacts. Process indicators included improvement in aEEG-related knowledge. RESULTS: First PDSA cycle includes lectures on aEEG interpretation, a bedside key, and documentation form. Second PDSA cycle includes online aEEG education pack and detailed aEEG guideline. There was a significant improvement in aEEG documentation after the implementation of both PDSA cycles. Seven of the 46 patients (15.2%) had isolated electrographic seizures which would not have been identified in the pre-aEEG monitoring era. There was an increase in the number of patients with cEEGs done but a steady decrease in number of cEEGs per patient. CONCLUSION: With the successful application of standardized QI methods, improvements in outcome indicators, such as correct aEEG pattern recognition and improved coverage of at risk infants with cEEGs, were observed. Our QI measures were associated with improvement in aEEG pattern recognition. KEY POINTS: · Consistent and accurate use of aEEG is challenging.. · Standardized forms and guidelines improve aEEG interpretation consistency and documentation.. · Interactive self-paced online education packs can improve aEEG knowledge and pattern recognition..

Gestational Age, Birthweight for Gestational Age, and Childhood Hospitalisations for Asthma and Other Wheezing Disorders.

BACKGROUND: Preterm birth, early term birth, and low birthweight are associated with childhood wheezing disorders in developed Western settings, but observed associations could be confounded by socio-economic position. This study aims to clarify such associations in a developed non-Western setting with a different confounding structure. METHODS: Using Cox regression, we examined the adjusted associations of gestational age and birthweight for gestational age with time to first public hospital admission for asthma, bronchitis, and bronchiolitis (International Classification of Diseases, Ninth Version Clinical Modification 466, 490, and 493) from 9 days to 12 years in a population-representative birth cohort of 8327 Chinese children in Hong Kong, a developed setting with less clear social patterning of prematurity or birthweight. Analyses were adjusted for infant and parental characteristics and socio-economic position. RESULTS: Children born late preterm (34 to <37 weeks) had higher risk of hospitalisation for asthma and other wheezing disorders [hazard ratio (HR) 1.99, 95% confidence interval (CI) 1.48, 2.67] than children born full term (39 to <41 weeks). Early term births (37 to <39 weeks) had HR 1.01 (95% CI 0.84, 1.22), late term births (41 to <42 weeks) had HR 0.77 (95% 0.59, 1.01), and post-term births (≥42 weeks) had HR 0.56 (95% CI 0.32, 0.98). Large for gestational age was associated with lower risk of hospitalisation (HR 0.76, 95% CI 0.57, 0.99). CONCLUSION: The association of preterm birth with childhood wheezing could be biologically mediated. We cannot rule out an association for early term births.

Understanding paediatric COVID-19 vaccination during the pandemic: a prospective cohort and a population-based registry study.

Background: Despite the early demonstrated safety and effectiveness of COVID-19 vaccines in children, uptake was slow throughout the pandemic and remains low globally. Understanding vaccine refusal could provide insights to improving vaccine uptake in future pandemics. Methods: In a population-wide registry of all COVID-19 paediatric vaccination appointments, we used interrupted time series analysis to evaluate the impact of public policies. In a population-based cohort of adults, we used population attributable fractions to assess the individual and joint contributions of potential determinants to paediatric COVID-19 vaccination, and used mediation analysis to identify modifiable mediators between political views and paediatric vaccination. Findings: School vaccination requirements were associated with an increase in vaccination appointments by 278.7% (95% CI 85.3-673.9) in adolescents aged 12-17 and 112.8% (27.6-255.0) in children aged 5-11. Government-mandated vaccine pass, required for entry into restaurants, shopping malls and supermarkets, was associated with increased vaccination appointments by 108.7% (26.6-244.0) in adolescents. The following four determinants may explain 82.5% (63.5-100.0) of the reasons why children were unvaccinated: familial political views, vaccine hesitancy for children, mistrust in doctors and academics, and vaccine misconceptions. The influence of political views may be mitigated since 95.9% (76.4-100.0) of its association with vaccine reluctance for adolescents was mediated by modifiable factors such as mistrust in health authorities and low vaccine confidence. Interpretation: School vaccination requirements and vaccine passes were associated with increased vaccine uptake. Clinicians should recognise that factors beyond health, such as political views, can influence paediatric vaccine uptake to a significant extent. Nonetheless, such influences could be mitigated by targeted interventions and public policies. Funding: Hong Kong Jockey Club Charities Trust, Research Grants Council, University Grants Committee, and Health Bureau.

Gut-associated biomarkers L-FABP, I-FABP, and TFF3 and LIT score for diagnosis of surgical necrotizing enterocolitis in preterm infants.

OBJECTIVES: To evaluate the use of gut barrier proteins, liver-fatty acid binding protein (L-FABP), intestinal-fatty acid binding protein (I-FABP), and trefoil factor 3 (TFF3), as biomarkers for differentiating necrotizing enterocolitis (NEC) from septicemic/control infants and to identify the most severely affected surgical NEC from nonsurgical NEC infants. BACKGROUND: Clinical features and routine radiologic investigations have low diagnostic utilities in identifying surgical NEC patients. METHODS: The diagnostic utilities of individual biomarkers and the combination of biomarkers, the LIT score, were assessed among the NEC (n = 20), septicemia (n = 40), and control groups (n = 40) in a case-control study for the identification of proven NEC and surgical NEC infants. RESULTS: Plasma concentrations of all gut barrier biomarkers and the LIT score were significantly higher in the NEC than in the septicemia or control group (P < 0.01). Using median values of biomarkers and the LIT score in the NEC group as cutoff values for identifying NEC from septicemic/control cases, all had specificities of 95% or more and sensitivities of 50%. Significantly higher levels of biomarkers and the LIT score were found in infants with surgical NEC than in nonsurgical NEC cases (P ≤ 0.02). The median LIT score of 4.5 identified surgical NEC cases with sensitivity and specificity of 83% and 100%%, respectively. A high LIT score of 6 identified nonsurvivors of NEC with sensitivity and specificity of 78% and 91%, respectively. CONCLUSIONS: The LIT score can effectively differentiate surgical NEC from nonsurgical NEC infants and nonsurvivors of NEC from survivors at the onset of clinical presentation. Frontline neonatologists and surgeons may, therefore, target NEC infants who are most in need of close monitoring and those who may benefit from early surgical intervention.

Deficits in neural encoding of speech in preterm infants.

Preterm children show developmental cognitive and language deficits that can be subtle and sometimes undetectable until later in life. Studies of brain development in children who are born preterm have largely focused on vascular and gross anatomical characteristics rather than pathophysiological processes that may contribute to these developmental deficits. Neural encoding of speech as reflected in EEG recordings is predictive of future language development and could provide insights into those pathophysiological processes. We recorded EEG from 45 preterm (≤ 34 weeks of gestation) and 45 term (≥ 38 weeks) Chinese-learning infants 0-12 months of (corrected) age during natural sleep. Each child listened to three speech stimuli that differed in lexically meaningful pitch (2 native and 1 non-native speech categories). EEG measures associated with synchronization and gross power of the frequency following response (FFR) were examined. ANCOVAs revealed no main effect of stimulus nativeness but main effects of age, consistent with earlier studies. A main effect of prematurity also emerged, with synchronization measures showing stronger group differences than power. By detailing differences in FFR measures related to synchronization and power, this study brings us closer to identifying the pathophysiological pathway to often subtle language problems experienced by preterm children.

Follow up of aerobic capacity in children affected by severe acute respiratory syndrome.

BACKGROUND AND OBJECTIVE: The aim of this study was to investigate the aerobic capacity of children 3 years after they were diagnosed with severe acute respiratory syndrome (SARS). METHODS: Twenty-seven patients who completed both pulmonary function and maximal aerobic capacity tests at 6 and 15 months after the acute illness were invited to return for reassessment. RESULTS: Twenty-one patients (median age 18.2 years, interquartile range (IQR) 16.5-19.7) completed all investigations at 36 months. Pulmonary function was normal in all patients. Maximal aerobic capacity, peak oxygen pulse (peak VO(2) ) and ventilatory anaerobic threshold showed significant improvements compared with values measured at 6 months in both boys and girls. In girls, ventilatory efficiency (ventilatory equivalents for oxygen and carbon dioxide) and perfusion of the lungs (end-tidal partial carbon dioxide pressure) had not increased further compared with the values measured at 15 months. Although peak VO(2) improved further at 36 months in patients with or without persistent radiological abnormalities, the values were 68% (IQR 50-84) and 74% (IQR 60-99), respectively, of those for normal control subjects. CONCLUSIONS: There were improvements in aerobic capacity at 36 months in children affected by SARS; however, the measured values remained suboptimal.

A prospective longitudinal study to estimate the "adjusted cortisol percentile" in preterm infants.

The normal range of serum cortisol concentrations and the appropriate levels of circulating cortisol in different clinical situations in preterm infants are not well defined. This study aimed to evaluate the impact of perinatal factors on circulating cortisol levels in preterm infants and to create a quantitative model that could estimate the "adjusted cortisol percentile." Serial serum cortisol concentrations were measured in 209 infants ≤ 32 wk gestation on d 1, 4, 7, 14, and 21 of life. Seven perinatal factors or conditions that could affect circulating cortisol level were identified. Serum cortisol levels were higher on d 4 (p = 0.007) and d 7 (p = 0.007) but lower on d 21 (p = 0.001) compared with d 1. Serum cortisol was also higher in infants on nasal continuous positive airway pressure (p = 0.003); requiring a second vasopressor (p < 0.001); with intraventricular hemorrhage (≥ grade 3; p < 0.001); with histologic chorioamnionitis (p = 0.007); with severe lung disease (p = 0.046); and with decreasing GA (p < 0.001). A mathematical equation was proposed based on factors derived in this preliminary study for estimating the adjusted cortisol percentile. Frontline neonatologists could now access the equation on our Web site (http://www.sta.cuhk.edu.hk/pswong/ACortP.html) to calculate the adjusted cortisol percentile, which could potentially improve the interpretation of circulating cortisol in different clinical situations.

Use of prokinetics in the preterm infant.

PURPOSE OF REVIEW: Functional gastrointestinal dysmotility is a common condition that affects premature infants. Delay in achievement of full enteral nutrition results in dependence on prolonged parenteral nutrition, predisposing to adverse outcomes. Studies in recent years show apparently conflicting results regarding the use of prokinetic agents in preterm infants. This review aims to evaluate these studies to determine whether use of these agents in premature infants is beneficial and justified. RECENT FINDINGS: Randomized controlled trials in recent years have been performed to investigate the effectiveness of erythromycin in the treatment of nonobstructive gastrointestinal dysmotility in preterm infants. Overall, neither low-dose regimes nor prophylactic trials have been shown to be useful. High-dose regimes used as rescue therapy of infants with established gastrointestinal dysmotility have consistently shown clinical benefit. Theoretical risks of prolonged antibiotic use, such as emergence of antibiotic resistance and abnormal intestinal microbiota, have not been fully evaluated. SUMMARY: Judicious use of high-dose erythromycin in premature infants as rescue therapy is probably justifiable. Further research in this area is warranted to develop newer prokinetic agents which may improve the safety profile of therapy.

Serum levels of heavy metals in childhood eczema and skin diseases: friends or foes.

The incidence of eczema has been increasing in developed countries. Environmental and hygiene factors have been incriminated. Although air and food pollution with heavy metals have been considered as possible culprits, these factors have never been investigated in Hong Kong. To evaluate if quality of life and eczema severity are associated with abnormal serum levels of six common heavy metals, namely, cadmium, lead, mercury, selenium, copper and zinc. Serum or whole blood was taken for measurement of six heavy metals from patients referred to the pediatric dermatology clinic. Eczema severity (SCORAD and NESS) and quality of life (CDLQI) were recorded. A total of 110 patients with eczema and 41 patients with miscellaneous skin conditions were recruited. Serum levels of the six heavy metals were generally within the upper limits of local reference ranges. Zinc levels were below the lower reference limit of 9.4 mum in 66 patients with eczema (60%) and 22 non-eczema patients (53%). Forty-four patients with eczema (40%) and 24 (58%) in non-eczema group had low copper levels. In eczema patients, lead levels were generally within normal limits but their levels were positively correlated with poor quality of life (CDLQI: r = 0.22 and p < 0.05), disease severity (objective SCORAD: r = 0.33 and p < 0.005; NESS: 0.20, p < 0.05), eosinophil count and log-transformed IgE. Copper/zinc ratio also correlated with NESS and CDLQI and was generally higher than non-eczema skin diseases. Our findings help reassure parents that levels of heavy metals generally do not exceed the local reference ranges for toxicity. However, lead levels have significant correlations with disease severity, quality of life and atopy. Low zinc and copper levels are commonly found in pediatric skin diseases and their significance needs to be determined.

Rapid identification and differentiation of Gram-negative and Gram-positive bacterial bloodstream infections by quantitative polymerase chain reaction in preterm infants.

OBJECTIVE: To evaluate the usefulness of the Gram-specific probe-based quantitative polymerase chain reaction test for rapid detection and differentiation of Gram-negative and Gram-positive bacterial bloodstream infection in preterm infants. DESIGN: Cross-sectional study. SETTING: University-affiliated Level III neonatal intensive care unit. PATIENTS: Preterm infants with clinical features suggestive of late-onset infection. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In addition to the full sepsis screen, 0.5 mL of EDTA blood was collected aseptically for Gram-specific quantitative polymerase chain reaction evaluation. The results were analyzed with respect to outcomes of bacterial culture in blood and other body fluids, including peritoneal and cerebrospinal fluids. The diagnostic utilities of the quantitative polymerase chain reaction were determined. A total of 218 suspected infection episodes were investigated, of which 42 episodes were culture positive and 176 were culture negative. For Gram-negative infection, the quantitative polymerase chain reaction test correctly identified 19 of 22 episodes, and the sensitivity and specificity were 86.4% and 99.0%, respectively. For Gram-positive infection, the test correctly identified 14/19 episodes, and the sensitivity and specificity were 73.7% and 98.5%. The remaining one episode was Candida albicans septicemia. None of the episodes with positive quantitative polymerase chain reaction test were classified into the wrong Gram stain category. More importantly, despite negative blood culture in five infants suffering from intra-abdominal sepsis (peritonitis [n = 4] and hepatosplenic abscess [n = 1]), the quantitative polymerase chain reaction test could detect the Gram-specific category of causative organisms in blood. CONCLUSIONS: The Gram-specific quantitative polymerase chain reaction test is reliable and highly specific for rapid identification and differentiation of Gram-negative and Gram-positive bloodstream and intra-abdominal infections. The result could be made available within 5 hrs after the specimen reaches the laboratory. A positive test is able to "rule in" bacterial bloodstream infection before blood culture results become available, and serves as a guide to predict the virulence of the causative organism according to its Gram-specific category so that critical patients can be targeted for intensive treatment.

Sleep Duration and Adiposity in Children and Adults: Observational and Mendelian Randomization Studies.

OBJECTIVE: This study used two complementary designs, an observational and a Mendelian randomization (MR) study, to assess whether sleep duration causes adiposity in children and adults. METHODS: In Hong Kong's "Children of 1997" birth cohort, the adjusted cross-sectional associations of sleep duration with BMI z score and obesity and overweight were assessed at ~11 years of age. Generalized estimating equations were also used to examine longitudinal associations of sleep duration at ~11 years with annual BMI z score and obesity and overweight at about 11 to 16 years of age. Using MR, this study assessed the association of genetically predicted sleep duration, based on 54 single-nucleotide polymorphisms, applied to genetic studies of adiposity in children (n = 35,668), men (n = 152,893), and women (n = 171,977). RESULTS: Longer sleep was cross-sectionally associated with lower BMI z score at ~11 years of age (-0.13 per category, 95% CI: -0.22 to -0.04) and at about 11 to 16 years of age longitudinally in girls (-0.39, 95% CI: -0.66 to -0.13). Using MR, sleep duration was inversely associated with BMI in children (-0.29 SD per hour, 95% CI: -0.54 to -0.04), but was not clearly associated with BMI in adults, particularly for women. CONCLUSIONS: A small beneficial effect of sleep on BMI in children cannot be ruled out.

Transient increase in intraocular pressure during a dose-tapering regime of systemic dexamethasone in preterm infants.

PURPOSE: To determine the intraocular pressure (IOP) profile during and after systemic dexamethasone treatment in preterm very low birth weight (VLBW; <1500 g) infants. DESIGN: A cohort study at a university-affiliated tertiary neonatal center. PARTICIPANTS: Twenty-seven VLBW infants who received a 3-week dose-tapering course of systemic dexamethasone for treatment of bronchopulmonary dysplasia were consecutively enrolled over a period of 32 months. METHODS: Intraocular pressure was assessed using a handheld tonometer immediately before (week 0), during (weeks 1 and 3), and after (weeks 5, 7, and 9) commencement of the dexamethasone course. The mixed-effects models were used to evaluate the longitudinal IOP measurements at different time points. MAIN OUTCOME MEASURES: To assess the magnitude and duration of increase in IOP during systemic corticosteroid treatment. RESULTS: The IOP at week 1, while the infants were receiving the maximum dose of dexamethasone (0.6 mg/kg/day), was significantly higher than (1) the pretreatment IOP at week 0 (mean [+/- standard deviation]: 19.7 [+/-3.7] vs. 16.4 [+/-3.7] mmHg, respectively) (P<0.0001), (2) the IOP when the infants were receiving the minimum dose of dexamethasone (0.15 mg/kg/day) at week 3 (19.7 [+/-3.7] vs. 15.8 [+/-4.3] mmHg) (P<0.0001), and (3) the IOP after the dexamethasone course had been stopped between week 5 and week 9 (19.7 [+/-3.7] vs. 16.0 [+/-4.0], 15.3 [+/-3.5], and 14.5 [+/-3.3] mmHg for weeks 5, 7, and 9, respectively) (P<0.0001 for all comparisons). In contrast, there was no significant difference between the pretreatment IOP (week 0) and IOP at week 3, 5, 7, or 9 (P = 0.07-0.62) and in the IOP between week 3 and week 5, 7, or 9 (P = 0.27-0.75). CONCLUSIONS: The use of a dose-tapering regime of dexamethasone is associated with transient increase of IOP. As IOP was significantly raised during the high-dose but not the low-dose treatment period, we speculate that the physiologic or stress dose of corticosteroids commonly advocated for treatment of serious neonatal conditions should be safe and unlikely to cause significant ocular hypertension in preterm infants.

Biochemical markers of neonatal sepsis.

The use of biochemical markers in neonatal infection has remained an important area of research in the past decades. Many infection markers are components of the inflammatory cascade and reflect the host's immunological status and response to infection. Cytokines and chemokines such as interleukin (IL)-6 and IL-8 have been demonstrated to have good diagnostic utilities as early phase markers, while acute phase reactants such as C-reactive protein and procalcitonin have superior diagnostic properties during the later phases. Other markers, including inter-alpha-inhibitor proteins, IL-10 and regulated upon activation normal T cells expressed and secreted (RANTES) have been demonstrated to yield important prognostic information and may help the clinician identify infants who will develop fulminant infection from the outset of presentation. The advent of flow cytometry and molecular techniques have made crucial contributions to the field and promise to further improve the diagnostic accuracy and clinical management of infected infants.

Predictors for failed dose reduction of inhaled corticosteroids in childhood asthma.

BACKGROUND AND OBJECTIVE: Studies of Western populations have shown that increased exhaled nitric oxide (FeNO) and/or sputum eosinophils (sp-Eos) are predictive of asthma exacerbations. However, the utility of these measurements in different populations and settings is unknown. This study aimed to determine the predictors for failure of reduction of inhaled corticosteroid (ICS) doses in children with stable asthma. METHODS: Fifty children (median age 11.8 years, interquartile range (IQR) 5.9 years) had their dose of ICS halved every 8 weeks until they reached the study end-point (exacerbation or weaned off ICS). Spirometry, FeNO and induced sputum cells were measured at baseline and at each stage of ICS reduction. RESULTS: Eleven subjects suffered an asthma exacerbation and the remainder was successfully weaned off ICS. Subjects with an exacerbation were older (15.4 years (IQR 5.4) vs 11.4 years (IQR 3.9), P = 0.019) and more likely to be boys (P = 0.035). FeNO (median 156 p.p.b. (IQR 131) vs 76.1 p.p.b. (IQR 79.5), P = 0.013) and sp-Eos (17.3% (IQR 33.8%) vs 7.1% (IQR 9.9%), P = 0.019) were significantly greater in those who had an exacerbation. The areas under the receiver operating characteristic curves for FeNO (0.78, 95% CI: 0.59-0.97, P = 0.013) and sp-Eos (0.76, 95% CI: 0.56-0.96, P = 0.016) were similar (P = 0.88) and both were significantly greater than that for FEV(1)% predicted (0.12, 95% CI: 0.08-0.56, P = 0.0013). CONCLUSIONS: Older boys with raised FeNO and sp-Eos are at higher risk of failure of reduction in their ICS dose. Monitoring airway inflammation in children with asthma using FeNO or sp-Eos is clinically useful in guiding ICS dose reduction in a non-Western outpatient setting.

Inflammatory cytokines and childhood obstructive sleep apnoea.

OBJECTIVE: To evaluate serum cytokine concentrations in children with and without obstructive sleep apnoea (OSA) and to investigate the effects of OSA treatment on cytokines. MATERIALS AND METHODS: Consecutive children with habitual snoring and symptoms suggestive of OSA were recruited. They completed a sleep apnoea symptom questionnaire, underwent physical examination and overnight polysomnography (PSG). OSA was diagnosed if obstructive apnoea index (OAI) >1. A blood sample was collected for analysis of IL-6, IL-8, and TNF-alpha after PSG. RESULTS: One hundred forty-two children (97 males) with a median (IQR) age of 11.1 years (9.0-12.8) were recruited. The commonest presenting symptoms were nocturnal mouth breathing, prone sleeping position and poor attention at school. Forty-seven children were found to have OSA and they had higher serum IL-6 [0.1 (0.1-0.4) vs 0.1 (0.1-0.1) pg/mL, P = 0.001] and IL-8 [1.7 (1.0-2.3) vs 1.3 (0.9-1.7) pg/mL, P = 0.029] concentrations compared to their non-OSA counterparts. Multiple regression analysis indicated that OAI was significantly associated with both IL-6 (r = 0.351, P <0.001) and IL-8 (r = 0.266, P = 0.002). Sixteen children underwent treatment and there was significant reduction in mean (SD) serum IL-8 after intervention [pre vs post levels of 1.9 (1.0) vs 1.1 (0.6) pg/mL, P = 0.001] independent of weight loss. CONCLUSION: Children with OSA had elevated levels of pro-inflammatory cytokines that normalised following treatment suggesting that the inflammatory response is potentially reversible. Early detection and intervention may be beneficial.

Fetal methylmercury exposure as measured by cord blood mercury concentrations in a mother-infant cohort in Hong Kong.

This study was designed to examine newborn infants in Hong Kong prenatally exposed to levels of methylmercury considered to increase risk of neurotoxic effects and to examine subject characteristics that modify the degree of prenatal mercury exposure. Mercury concentrations in 1057 sets of maternal and cord blood samples and 96 randomly selected maternal hair samples were measured. Subject characteristics were measured or collected by questionnaire. Of the 1057 cord blood samples collected only 21.6% had mercury concentrations less than 29 nmol/L (5.8 micro g/L). Median maternal hair mercury concentration was 1.7 ppm. The geometric mean cord to maternal blood mercury ratio was 1.79 to 1. Increasing maternal fish consumption and maternal age were found to be associated with increased cord blood mercury concentrations. Marine fish consumption increased cord blood mercury concentrations more than freshwater fish (5.09%/kg vs 2.86%/kg). Female babies, maternal alcohol consumption and increasing maternal height were associated with decreased cord blood mercury concentrations. Pregnant women in Hong Kong consume large amounts of fish and as a result, most of their offspring have been prenatally exposed to moderately high levels of mercury. In this population, pregnant women should choose freshwater over marine fish and limit fish consumption.

Sputum induction in children with asthma: a tertiary-center experience.

Our aims were 1) to report on our experience with sputum induction (SI), and 2) to determine predictive factors associated with successful SI in asthmatic children. Children with asthma attending the chest clinic of a university teaching hospital between October 2003-December 2004 were recruited. They completed a visual analogue scale for symptom severity, and underwent physical examination, skin-prick test, exhaled nitric oxide (eNO) measurement, spirometry, and SI. Adequate sputum contained <50% squamous epithelial cells. Predictors for successful induction were evaluated using multivariate logistic regression analysis. One hundred and thirty subjects were recruited. The median age was 11.25 years (range 7.0-17.5), and the majority were boys (75%). All except two had normal percent predicted forced expired volume in 1 sec (>80%). The median eNO was 48.95 ppb. Sputum induction was successful in 93 subjects (74.5%). Sore throat and chest discomfort occurred in 20 (15%) and 8 (6%) subjects, respectively, and the procedure was prematurely terminated in three cases. Levels of eNO were found to be a predictor for successful induction (area under the ROC (receiver operator characteristics curves) curve, 0.634). Sputum induction was well-tolerated by all subjects, and was successful in 74.5% of cases. Exhaled nitric oxide may be a useful marker for successful induction.

Insulin and obstructive sleep apnea in obese Chinese children.

OBJECTIVE: In adults, obstructive sleep apnea (OSA) is associated with insulin resistance and dyslipidemia. We aimed to establish correlation between OSA, serum lipid profile, and insulin levels in obese snoring children. METHODS: Consecutive obese children with habitual snoring were recruited. They underwent physical examination, overnight polysomnography (PSG), and metabolic studies. OSA was diagnosed if apnea hypopnea index (AHI) > 1.0, and cases were considered to have moderate to severe OSA if AHI > 10. RESULTS: Ninety-four obese subjects with habitual snoring were studied. Seventy-three subjects were male and the median age of the studied group was 12.0 years (IQR 9.7-13.9). None of the subjects had active cardiopulmonary disease, and the BMI values of our subjects were >95th percentile using local reference charts. Sixty subjects had OSA, 47 being mild, and 13 being moderate to severe OSA. Multiple logistic regression analysis revealed that saturation nadir and insulin levels were significantly associated with OSA. CONCLUSION: OSA is prevalent among obese children with habitual snoring and insulin is independently associated with the condition. Its role in the cardiovascular complications of childhood sleep apnea is worthy of further exploration.

Life-Threatening Hemolytic Anemia after Intrapleural Instillation of OK-432 for Treatment of Congenital Chylothorax.

Recent reports have advocated treatment of congenital chylothorax with chemical pleurodesis via intrapleural administration of OK-432. Severe complications have not been reported, but recently we have encountered a life-threatening case of massive hemolysis after the procedure. The hemoglobin of the infant decreased from 8.7 to 3.1 g/dl within 48 h, with concomitant severe hyperbilirubinemia (472 µmol/l) requiring exchange transfusion. Frontline neonatologists should be aware of this rare but potentially life-threatening adverse reaction. In addition, it is possible that a longer indwelling time (3.5 vs. 0.5 h) for OK-432 pleurodesis may alter the therapeutic response.

The neonatal resuscitation algorithm organized cart is more efficient than the airway-breathing-circulation organized drawer: a crossover randomized control trial.

INTRODUCTION: Although there is consensus on the resuscitation of newborns, there is no standardization on how resuscitation equipment should be organized. This might lead to difficulty and inefficiency in retrieval of the right equipment during resuscitation. The neonatal resuscitation carts organized in accordance with the American Academy of Pediatrics (AAP) Neonatal Resuscitation Program (NRP) algorithm might result in more efficient retrieval of resuscitation equipment. OBJECTIVES: To compare user preference and lengths of time required to retrieve standard resuscitation equipment from an NRP Cart versus a generic storage drawer. STUDY DESIGN: A prospective, randomized, controlled, and crossover trial was conducted during simulation-based NRP provider courses in the Accident & Emergency Training Centre from September to October 2013. The mean time of accurate equipment retrieval and ease of use, which was rated by the participants using a five-point Likert scale (1=most difficult, 5=easiest to use), were compared using the Wilcoxon signed-rank test because of right skew. RESULTS: A total of 55 individuals participated in this study. The mean length of time required for equipment retrieval from the NRP Cart was significantly less than that from the drawer (Z=-3.90, P<0.01, median=36.23 s, interquartile range=97 s). In general, the NRP Cart was 32% faster than the drawer when extensive resuscitation equipment was required. All the participants rated the NRP Cart as easier to use than the drawer, with a median score of 4 for NRP Cart and 3 for the drawer (Z=-4.10, P<0.01, interquartile range=2). CONCLUSION: The NRP Cart was superior to the generic drawer in terms of the speed of equipment retrieval and user acceptability.