[Emergency Care Plans for the Management of Emergencies in Children on Home Mechanical Ventilation]. / Notfallpläne zum Management von Notfällen bei Kindern mit außerklinischer Beatmung.

In pediatrics chronic respiratory insufficiency is increasingly treated on an outpatient basis with home mechanical ventilation. Nursing and medical teams with different structures take care of the often complex ill children in the outpatient setting. Structured treatment processes, especially emergency plans for the management of respiratory emergencies of home mechanical ventilated children are lacking. This article is a proposal for emergency management of respiratory infections, emergencies of non-invasively ventilated and invasively ventilated, tracheotomized children. In addition to resuscitation measures according to ERC/AHA, the focus is primarily on secretion management, as well as on the handling of ventilators and devices.

Tracheostomy decannulation in children: a proposal for a structured approach on behalf of the working group chronic respiratory insufficiency within the German-speaking society of pediatric pulmonology.

The number of children with tracheostomies with and without home mechanical ventilation has grown continuously in recent years. For some of these children, the need for tracheostomy resolves and the child can be weaned from the tracheal cannula. Choosing the optimal time point for decannulation after elaborated prior diagnostic work-up needs careful consideration. The decannulation process requires an interdisciplinary team; however, these specialized structures for the experienced care of these children with tracheostomy are not available in all areas. The Working Group on Chronic Respiratory Insufficiency in the German Speaking Pediatric Pneumology Society (GPP) developed these recommendations to guide through a decannulation process. Initial evaluation of decannulation feasibility starts in the outpatient clinic with a detailed history, examination, and a speaking valve trial and is followed by an inpatient workup including sleep study, airway endoscopy and possibly modifications of the tracheal cannula. Downsizing the tracheal cannula allows a stepwise controlled weaning prior to removal of the tracheal cannula. After shrinking of the tracheostomy, the final surgical closure is performed.  Conclusion: An algorithm with diagnostic and therapeutic procedures for a safe and successful decannulation process is proposed. What is Known: • In children tracheostomy decannulation is a complex process that requires careful preparation and surveillance. What is New: • This statement of the German speaking society of pediatric pulmonology provides an expert practice guidance on the decannulation procedure and the value of one-way speaking valves.

Plötzlicher Kindstod von zwei Säuglingen in Babytragehilfen.

Sudden unexpected death in infancy (SUDI), previously termed sudden infant death syndrome (SIDS), is the second leading cause of death in infants beyond the neonatal period in Germany, and a major cause of infant mortality in economically well developed countries (OECD Health Statistics, 2019). The risk of SUDI peaks at the age of 2-4 months and then decreases continuously till the end of the first year. A complex multifactorial cause, rather than a single characteristic factor, may cause SUDI within a critical period of infant development (Guntheroth WG et al., Pediatrics 2002; 110: e64-e64). Risk factors include prematurity, male gender, bottle-feeding, prone sleeping position, overheating, as well as exposure to smoke amongst others (Carpenter RG et al., Lancet 2004; 363: 185-191). Thus, health professionals consistently advise and educate parents about avoidable risk factors of SUDI at routine well-baby examinations. Since the advent of SUDI prevention strategies in the 1980s, the incidence has decreased 10fold, from 1,55/1.000 live births in 1991 to 0,15/1000 in 2015. This number seems to have reached a steady state (Statistisches Bundesamt Germany, 2015).

Neonatal assessment in the delivery room--Trial to Evaluate a Specified Type of Apgar (TEST-Apgar).

BACKGROUND: Since an objective description is essential to determine infant's postnatal condition and efficacy of interventions, two scores were suggested in the past but weren't tested yet: The Specified-Apgar uses the 5 items of the conventional Apgar score; however describes the condition regardless of gestational age (GA) or resuscitative interventions. The Expanded-Apgar measures interventions needed to achieve this condition. We hypothesized that the combination of both (Combined-Apgar) describes postnatal condition of preterm infants better than either of the scores alone. METHODS: Scores were assessed in preterm infants below 32 completed weeks of gestation. Data were prospectively collected in 20 NICU in 12 countries. Prediction of poor outcome (death, severe/moderate BPD, IVH, CPL and ROP) was used as a surrogate parameter to compare the scores. To compare predictive value the AUC for the ROC was calculated. RESULTS: Of 2150 eligible newborns, data on 1855 infants with a mean GA of 28(6/7) ± 2(3/7) weeks were analyzed. At 1 minute, the Combined-Apgar was significantly better in predicting poor outcome than the Specified- or Expanded-Apgar alone. Of infants with a very low score at 5 or 10 minutes 81% or 100% had a poor outcome, respectively. In these infants the relative risk (RR) for perinatal mortality was 24.93 (13.16-47.20) and 31.34 (15.91-61.71), respectively. CONCLUSION: The Combined-Apgar allows a more appropriate description of infant's condition under conditions of modern neonatal care. It should be used as a tool for better comparison of group of infants and postnatal interventions. TRIAL REGISTRATION: clinicaltrials.gov Protocol Registration System (NCT00623038). Registered 14 February 2008.

Severe infections of Panton-Valentine leukocidin positive Staphylococcus aureus in children.

Infections caused by Panton-Valentine leukocidin-positive Staphylococcus aureus (PVL-SA) mostly present as recurrent skin abscesses and furunculosis. However, life-threatening infections (eg, necrotizing pneumonia, necrotizing fasciitis, and osteomyelitis) caused by PVL-SA have also been reported.We assessed the clinical phenotype, frequency, clinical implications (surgery, length of treatment in hospitals/intensive care units, and antibiotic treatments), and potential preventability of severe PVL-SA infections in children.Total, 75 children treated for PVL-SA infections in our in- and outpatient units from 2012 to 2017 were included in this retrospective study.Ten out of 75 children contracted severe infections (PVL-methicillin resistant S aureus n = 4) including necrotizing pneumonia (n = 4), necrotizing fasciitis (n = 2), pyomyositis (n = 2; including 1 patient who also had pneumonia), mastoiditis with cerebellitis (n = 1), preorbital cellulitis (n = 1), and recurrent deep furunculosis in an immunosuppressed patient (n = 1). Specific complications of PVL-SA infections were venous thrombosis (n = 2), sepsis (n = 5), respiratory failure (n = 5), and acute respiratory distress syndrome (n = 3). The median duration of hospital stay was 14 days (range 5-52 days). In 6 out of 10 patients a history suggestive for PVL-SA colonization in the patient or close family members before hospital admission was identified.PVL-SA causes severe to life-threatening infections requiring lengthy treatments in hospital in a substantial percentage of symptomatic PVL-SA colonized children. More than 50% of severe infections might be prevented by prompt testing for PVL-SA in individuals with a history of abscesses or furunculosis, followed by decolonization measures.

Trefoil factors in human milk.

We measured concentrations of the gastrointestinal protective peptides Trefoil factors in human milk. By the use of in-house ELISA we detected high amounts of TFF3, less TFF1 and virtually no TFF2 in human breast milk obtained from 46 mothers with infants born extremely preterm (24-27 wk gestation), preterm (28-37 wk gestation), and full term (38-42 wk gestation). Samples were collected during the first, second, third to fourth weeks and more than 4 wks postpartum. Median (range) TFF1 [TFF3] concentrations in human milk were 320 (30-34000) [1500 (150-27,000)] pmol/L in wk 1, 120 (30-720) [310 (50-7100)] pmol/L in wk 2, 70 (20-670) [120 (20-650)] pmol/L in wks 3 to 4, and 60 (30-2500) [80 (20-540)] pmol/L in >4 wks after delivery. The lowest concentrations of TFF1 and TFF3 were found later than 2 wks after birth. In conclusion, TFF was present in term and preterm human milk with rapidly declining concentrations during the first weeks post partum. The clinical significance of TFF present in human milk remains to be explored, both regarding development of the fetal gut and protection against necrotizing enterocolitis.

End-of-life opioid administration on neonatal and pediatric intensive care units: nurses' attitudes and practice.

OBJECTIVES: (1) To compare caregivers attitudes on the use of end-of-life opioid analgesia in neonatal (NICU) and pediatric (PICU) intensive care units. (2) To investigate actual opioid administration to DR (delivery room), NICU and PICU patients in various end-of-life situations. METHODS: (1) Administration of an anonymous self-report questionnaire survey to nurses of 2 level III NICUs and 3 PICUs, presenting 5 hypothetical NICU and PICU patients in end-of-life situations. (2) Retrospective chart review of all deaths at the above mentioned DRs (served by NICU staff), NICUs and PICUs during the years 2008-2009. RESULTS: There was no difference between NICU and PICU nurses in self-proclaimed opioid administration in dying NICU or PICU patients with signs of pain (about 80%) or distress (about 65%). 35.0% of NICU and 44.5% of PICU nurses favoured opioid administration with the implicit aim of active intentional ending of life. Shortening of life as an adverse effect of end-of-life opioid analgesia was acceptable for the majority of PICU (94.5%) and NICU (87.0%) nurses. The rate of dying infants who actually had received opioids was similar in NICUs (41/74, 55.4%) and PICUs (40/68, 58.8%). In contrast, none of the neonates (n=24) who died under primary comfort care in the DR received opioids. CONCLUSIONS: End-of-life opioid administration to primary comfort care patients in the DR differs fundamentally from NICU or PICU handling of dying patients. Once patients are admitted to an intensive care unit, practice and attitudes towards end-of-life opioid administration are similar in NICUs and PICUs.