Airwave oscillometry to measure lung function in children with Down syndrome.

BACKGROUND: Children with Down syndrome are at risk for significant pulmonary co-morbidities, including recurrent respiratory infections, dysphagia, obstructive sleep apnea, and pulmonary vascular disease. Because the gold standard metric of lung function, spirometry, may not be feasible in children with intellectual disabilities, we sought to assess the feasibility of both airwave oscillometry and spirometry in children with Down syndrome. METHODS: Thirty-four children with Down syndrome aged 5-17 years were recruited. Participants performed airwave oscillometry and spirometry before and 10 min after albuterol. Outcomes include success rates, airway resistance and reactance pre- and post-bronchodilator, and bronchodilator response. RESULTS: Participants were median age 9.2 years (interquartile range 7.2, 12.0) and 47% male. Airwave oscillometry was successful in 26 participants (76.5%) and 4 (11.8%) were successful with spirometry. No abnormalities in airway resistance were detected, and 16/26 (61.5%) had decreased reactance. A positive bronchodilator response by oscillometry was observed in 5/23 (21.7%) of those with successful pre- and post-bronchodilator testing. CONCLUSIONS: Measures of pulmonary function were successfully obtained using airwave oscillometry in children with Down syndrome, which supports its use in this high-risk population. IMPACT: Children with Down syndrome are at risk for significant pulmonary co-morbidities, but the gold standard metric of lung function, spirometry, may not be feasible in children with intellectual disabilities. This may limit the population's enrollment in clinical trials and in standardized clinical care. In this prospective study of lung function in children with Down syndrome, airwave oscillometry was successful in 76% of participants but spirometry was successful in only 12%. This study reinforces that measures of pulmonary function can be obtained successfully using airwave oscillometry in children with Down syndrome, which supports its use in this high-risk population.

Pediatric Primary Tympanoplasty Outcomes With Autologous and Non-autologous Grafts.

OBJECTIVE: To compare rates of successful tympanic membrane (TM) closure in primary pediatric tympanoplasty between various autologous and non-autologous tissues. METHODS: A retrospective chart review was performed examining all primary pediatric tympanoplasties over a 20-year period at a single institution. RESULTS: In 564 pediatric tympanoplasties, no statistically significant difference existed between success rates of autologous and non-autologous grafts (p = 0.083). Compared with fascia, the hazard ratios (and 95% confidence intervals [CI]) for failure for each graft were as follows: human pericardial collagen (HR 0.90, CI 0.54-1.50, p = 0.680), porcine submucosal collagen (HR 1.07, CI 0.56-2.05, p = 0.830), human acellular dermal collagen (HR 1.66, CI 0.95-2.87, p = 0.073), and "multiple grafts" (HR 0.72, CI 0.26-1.98, p = 0.520). Survival curves demonstrated that 75% of graft failures occurred by 6 months after surgery, the rest occurring between 6 and 12 months postoperatively. Larger perforations encompassing more than or equal to 50% of the TM had lower success rates (HR 1.50, CI 1.02-2.21, p = 0.041) than smaller perforations encompassing less than 50% of the TM. Age was not correlated with success (HR 0.98, CI 0.93-1.03, p = 0.390). CONCLUSION: This study found that non-autologous collagen grafts provide equivalent rates of healing when compared with autologous tissue in primary pediatric tympanoplasty. In addition to the potential for reduced operative time and donor site morbidity, these materials provide a viable graft alternative in fascia-depleted ears.Level of Evidence: Level 4.

Why Delay? Early Enteral Nutrition in Pediatric Burn Patients Improves Outcomes.

Children who sustain moderate to large surface area burns present in a hypermetabolic state with increased caloric and protein requirements. A policy was implemented at our institution in 2017 to initiate enteral nutrition (EN) in pediatric burn patients within 4 hours of admission. The authors hypothesize that early EN (initiated within 4 hours of admission) is more beneficial than late EN (initiated ≥ 4 hours from admission) for pediatric burn patients and is associated with decreased rates of pneumonia, increased calorie and protein intake, fewer feeding complications, a shorter Intensive Care Unit (ICU) length of stay (LOS), and a reduced hospital LOS. Children who sustained a total body surface area (TBSA) burn injury ≥ 10% between 2011 and 2018 were identified in a prospectively maintained burn registry at Children's Hospital Colorado. Patients were stratified into two groups for comparison: early EN and late EN. The authors identified 132 pediatric burn patients who met inclusion criteria, and most (60%) were male. Approximately half (48%) of the study patients were in the early EN group. The early EN group had lower rates of underfeeding during the first week (P = .014) and shorter ICU LOS (P = .025). Achieving and sustaining adequate nutrition in pediatric burn patients with moderate to large surface area burn injuries are critical to recovery. Early EN in pediatric burn patients is associated with decreased underfeeding and reduced ICU LOS. The authors recommend protocols to institute feeding for patients with burns ≥ 10% TBSA within 4 hours of admission at all pediatric burn centers.

Retrospective Comparison of the Supported and Unsupported Bovine Jugular Vein Conduit in Children.

BACKGROUND: Bovine jugular vein (BJV) conduits are commonly used for pulmonary valve replacement in pediatric patients. They are available in supported (sBJV) and unsupported (uBJV) versions. The purpose of this study was to compare outcomes of sBJV and uBJV conduits. METHODS: In this single-center retrospective review of patients younger than 18 years undergoing BJV placement (2009 to 2017), blinded cardiologists reviewed postoperative 6-, 12-, 24-, 36-month, and the most recent echocardiogram before any valve-related event or death. Outcomes assessed included conduit stenosis (m/s), regurgitation (none to mild vs moderate to severe) and right ventricular function (normal vs abnormal). Cox proportional models and Kaplan-Meier analyses were performed. RESULTS: BJV conduits (N = 109) were placed (39 supported, 70 unsupported) in 101 patients. Patient characteristics and conduit size were not different between cohorts. sBJV had more stenosis at 6 and 12 months (p = 0.02 and p = 0.03), but Vmax in both groups was mild (≤2 m/s). A greater proportion of uBJV had moderate to severe regurgitation at 12 months compared with sBJV (p = 0.03). Right ventricular function did not differ at any time point. On last follow-up echocardiogram, sBJV conduits had higher gradients (p = 0.01). This was not associated with increased intervention or replacement. Freedom from replacement or intervention did not differ between valve types (median follow-up, 3.6 years). There was a 9% incidence of endocarditis at median follow-up 2.4 years. Seventy percent of cases with endocarditis were managed medically. CONCLUSIONS: There were no clinically significant echocardiographic or outcome differences between sBJV and uBJV conduits. We identified a relatively high incidence of endocarditis, which is consistent with prior reports.

High Altitude Pulmonary Edema in Children: A Single Referral Center Evaluation.

OBJECTIVE: To describe the clinical features of children who presented to Children's Hospital Colorado (CHCO) with high-altitude pulmonary edema (HAPE). STUDY DESIGN: We performed a retrospective chart review in children discharged from CHCO (an elevation of 1668 m) with a clinical diagnosis of HAPE and a chest radiograph consistent with noncardiogenic pulmonary edema. Descriptive statistics were used to describe the demographics, presentations, and treatment strategies. RESULTS: From 2004 to 2014, 50 children presented to CHCO who were found to have a clinical diagnosis of HAPE and a chest radiograph consistent with noncardiogenic pulmonary edema. Most (72%) patients were male, and most (60%) of the children in the study were diagnosed with classic HAPE, 38% with re-entry HAPE, and 2% with high altitude resident pulmonary edema. Elevation at symptom presentation ranged from 1840 to 3536 m. Patients were treated with a variety of medications, including diuretics, steroids, and antibiotics. Four patients were newly diagnosed with structural heart findings: 2 patients with patent foramen ovale and 2 with atrial septal defects. Eleven patients had findings consistent with pulmonary hypertension at the time of echocardiography. CONCLUSIONS: HAPE symptoms may develop below 2500 m, so providers should not rule out HAPE based on elevation alone. Structural heart findings and pulmonary hypertension are associated with HAPE susceptibility and their presence may inform treatment. Inappropriate use of antibiotics and diuretics in children with HAPE suggest that further education of providers is warranted.

The impact of parental primary language on communication in the neonatal intensive care unit.

OBJECTIVE: Language barriers contribute to suboptimal healthcare delivery. We sought to explore disparities in communication between English and Spanish-speaking parents and their neonatal intensive care unit (NICU) providers. STUDY DESIGN: We compared English-speaking versus Spanish-speaking parents' understanding of their infant's diagnosis through a structured interview. RESULTS: Spanish-speaking parents were four times (RR 4.0, 95% CI: 1.5, 11.0; p = 0.004) more likely to incorrectly identify their child's diagnosis than English-speaking parents. Spanish speakers also self-reported lower understanding of NICU interventions. Physicians provided updates to Spanish-speaking parents in their native language only 39% of the time. CONCLUSIONS: Spanish-speaking NICU parents more commonly misunderstood aspects of their child's care than did English-speaking parents. Providers' failed to communicate with Spanish-speaking families in their native language the majority of the time. Additional research is needed to assess the barriers to effective communication between NICU providers and Spanish-speaking parents.