Abusive head injury in the very young: outcomes from a Singapore children's hospital.

PURPOSE: Abusive head trauma (AHT) is a serious problem in children. The aims of this study are to identify risk factors that correlate with outcomes for those requiring neurosurgical intervention for very young children with AHT, assessment of variables associated with outcomes, and corroboration of our results with literature. METHODS: This is an ethics-approved, retrospective study. Inclusion criteria consisted of patients aged 2 years old or less with a diagnosis of AHT managed by the Neurosurgical Service, KK Women's and Children's Hospital. Demographical and clinical variables are incorporated in the statistical analyses. Logistic regression was applied to statistically significant variables for the risk prediction model. RESULTS: From 2000 to 2020, 24 patients required surgery for AHT. Timepoint was set at 12 months post-diagnosis. Univariate analyses demonstrated that patients with mild TBI were likely to have a favourable GOS-E Peds (p = 0.01), whereas radiological presence of cerebral oedema (p < .001), development of scar epilepsy (p = 0.021), and progression to cerebral palsy (p = 0.001) were associated with unfavourable GOS-E Peds. CONCLUSION: This is the first study focused on neurosurgical outcomes for very young children with AHT in Singapore. We advocate multidisciplinary efforts to improve outcomes for this devastating condition.

Pediatric Palliative Transport in Critically Ill Children: A Single Center's Experience and Parents' Perspectives.

The transfer of critically ill children from intensive care units (ICUs) to their homes for palliation is seldom described. We report our 10-year pediatric palliative transport experience and conducted a survey to gain parents' perspectives of their child's transport experience. Over the study period, eight patients were transported from our pediatric ICU to their homes or hospice facilities. There were no intratransport adverse events. Parents who participated in the survey responded positively to the transport experience. The availability of a dedicated critical care transport service allowed for palliative transfers to be performed safely. Facilitating transport to allow withdrawal of life support at home is an acceptable option to families as part of holistic end-of-life care.

Use of an Offsite Intraoperative MRI Operating Theater for Pediatric Brain Tumor Surgery: Experience from a Singapore Children's Hospital.

BACKGROUND: Intraoperative magnetic resonance imaging (iMRI) has been recognized as a useful adjunct for brain tumor surgery in pediatric patients. There is minimal data on the use of an offsite intraoperative magnetic resonance imaging operating theater (iMRI OT), whereby vehicle transfer of patients is involved. The primary aim of this study is to validate the feasibility of perioperative patient transfer to use an offsite iMRI OT for patients with pediatric brain tumor. Secondary objectives include the assessment of tumor resection efficacy and perioperative outcomes in our patient cohort. METHODS: This is a retrospective, single-institution clinical study of prospectively collected data from Singapore's largest children hospital. Variables of interest include issues encountered during interhospital transfer, achievement of surgical aims, length of stay in hospital, and postoperative complications. Our findings were compared with results of related studies published in the literature. RESULTS: From January 1, 2009 to December 31, 2018, a total of 35 pediatric operative cases were performed in our offsite iMRI OT. Within this cohort, 24 of these were brain tumor surgery cases. For all the patients in this study, use of the iMRI OT influenced intraoperative decisions. Average ambulance transport time from parent hospital to the iMRI OT was 30.5 minutes, and from iMRI OT back to the parent hospital after surgery was 27.7 minutes. The average length of hospitalization stay was 7.9 days per patient. There were no ferromagnetic accidents during perioperative iMRI scanning and no airway/hemodynamic incidents in patients encountered during interhospital transfer. CONCLUSIONS: In our local context, the use of interhospital transfers for access to iMRI OT is a safe and feasible option in ensuring good patient outcomes for a select group of patients with pediatric brain tumors.

Noninvasive ventilation in children: a review.

OBJECTIVE: To assess the use of noninvasive ventilation (NIV) in children and its application in the acute and chronic setting of pediatric respiratory failure. SOURCES: Search of pertinent articles within PubMed, Cochrane and Ovid MEDLINE databases from 1950 to 2007, using the keywords pediatrics, noninvasive ventilation and positive airway pressure. SUMMARY OF THE FINDINGS: There is a paucity of published data on pediatric NIV. The majority of the data available are case reports or small case series, with a number of small, randomized studies reported. CONCLUSION: Although the use of NIV is increasingly recognized in pediatrics, there are currently still no generally accepted guidelines for its use. In the chronic setting, its use has mainly been proven in obstructive sleep apnea and respiratory failure secondary to neuromuscular disorders. It would appear that the major challenge is ensuring compliance, and this can be enforced by patient/caregiver education, use of a suitable interface, heated humidifiers and by minimizing the side effects of NIV. In the setting of acute respiratory failure, it would appear from available data that success is usually predicted by the rapidity of response. Patients placed on NIV should be monitored closely and this mode of ventilation should be reviewed if there is a lack of response within a few hours after commencement of therapy.

Severely obstructed totally anomalous pulmonary venous return with residual connection to the left atrium.

Totally anomalous pulmonary venous return may present diagnostic difficulty to clinicians, as it often appears similar to severe neonatal pulmonary disease. We describe a neonate who presented with severely obstructed pulmonary venous return, but with a residual venous connection to the left atrium. The unusual anatomy confounded the diagnosis. To our knowledge, this particular permutation has not previously been described. Our experience indicates that echocardiographic interrogation should be repeated in cases where there is no response to conventional therapy, and all individual pulmonary veins should be observed carefully.

Severe acute respiratory syndrome (SARS) in a paediatric cluster in Singapore.

BACKGROUND: Severe acute respiratory syndrome (SARS) is a major infectious disease pandemic that occurred in early 2003, and one of the diagnostic criteria is the presence of chest radiographic findings. OBJECTIVE: To describe the radiographic features of SARS in a cluster of affected children. MATERIALS AND METHODS: The chest radiographs of four related children ranging in age from 18 months to 9 years diagnosed as having SARS were reviewed for the presence of air-space shadowing, air bronchograms, peribronchial thickening, interstitial disease, pleural effusion, pneumothorax, hilar lymphadenopathy and mediastinal widening. RESULTS: Ill-defined air-space shadowing was the common finding in all the children. The distribution was unifocal or multifocal. No other findings were seen on the radiographs. None of the children developed radiographic findings consistent with acute respiratory distress syndrome. All four children showed significant resolution of the radiographic findings 4-6 days after the initial radiograph. CONCLUSIONS: Early recognition of these features is important in implementing isolation and containment measures to prevent the spread of infection. SARS in children appears to manifest as a milder form of the disease as compared to adults.

Ventilação não-invasiva em crianças: uma revisão / Noninvasive ventilation in children: a review

OBJETIVO: Avaliar o uso de ventilação não-invasiva (VNI) em crianças e sua aplicação na insuficiência respiratória aguda e crônica. FONTES DOS DADOS: Busca de artigos pertinentes no Pubmed, base de dados Cochrane e Ovid MEDLINE entre 1950 e 2007, através do emprego dos termos pediatria, ventilação não-invasiva e pressão positiva nas vias aéreas. SíNTESE DOS DADOS: Há uma escassez de publicações acerca da VNI em pediatria. A maioria dos dados disponíveis diz respeito a relatos de caso ou pequenas séries de casos, com apenas alguns estudos randomizados pequenos. CONCLUSÃO: Embora o uso de VNI seja cada vez mais reconhecido em pediatria, atualmente não existem ainda orientações gerais para o seu uso. Nos casos crônicos, seu uso foi eficaz no tratamento de apnéia obstrutiva do sono e na insuficiência respiratória secundária a afecções neuromusculares. Parece que o maior desafio é garantir a adesão ao tratamento e isso pode ser obtido através da instrução do paciente/cuidador, utilização de uma interface adequada, umidificadores aquecidos e minimização dos efeitos colaterais da VNI. Nos casos de insuficiência respiratória aguda, os dados disponíveis parecem indicar que se pode inferir o sucesso do tratamento pela rapidez na resposta terapêutica. Os pacientes submetidos à VNI devem ser monitorados cuidadosamente e essa modalidade de ventilação deve ser reconsiderada caso não haja resposta após algumas horas do início do tratamento.

OBJECTIVE: To assess the use of noninvasive ventilation (NIV) in children and its application in the acute and chronic setting of pediatric respiratory failure. SOURCES: Search of pertinent articles within Pubmed, Cochrane and Ovid MEDLINE databases from 1950 to 2007, using the keywords "pediatrics", "noninvasive ventilation" and "positive airway pressure". SUMMARY OF THE FINDINGS: There is a paucity of published data on pediatric NIV. The majority of the data available are case reports or small case series, with a number of small, randomized studies reported. CONCLUSION: Although the use of NIV is increasingly recognized in pediatrics, there are currently still no generally accepted guidelines for its use. In the chronic setting, its use has mainly been proven in obstructive sleep apnea and respiratory failure secondary to neuromuscular disorders. It would appear that the major challenge is ensuring compliance, and this can be enforced by patient/caregiver education, use of a suitable interface, heated humidifiers and by minimizing the side effects of NIV. In the setting of acute respiratory failure, it would appear from available data that success is usually predicted by the rapidity of response. Patients placed on NIV should be monitored closely and this mode of ventilation should be reviewed if there is a lack of response within a few hours after commencement of therapy.