Sudden unexpected death in children: myth or reality?

PURPOSE OF REVIEW: Despite many years of study, sudden unexplained death remains a tenuous diagnosis of exclusion. Here, we discuss the current science behind the uncertainties of sudden death, as well as the questions that still remain. RECENT FINDINGS: Failure in any part of the complex interplay between peripheral sensors and central cardiorespiratory regulation can result in sudden death. Diagnostic testing with electrocardiograms, electroencephalogram, sleep studies, or even genetic studies have increased our ability to identify patients at the highest risk. SUMMARY: Advances in the understanding of sudden unexplained death in children may show common pathways leading to sudden death from multiple different diseases. Although rare, the devastating implication prioritizes the importance in educating patients about how to live with the risk of sudden death.

Project CARPE Diem: Curriculum and Assessment for Residents on Pediatric Epilepsy.

BACKGROUND: Pediatric residencies are not preparing trainees well to manage patients with seizures and epilepsy. To address this, we implemented a six-session curriculum using active learning techniques with the goals of improving the knowledge and attitudes needed to effectively identify and treat seizures and epilepsy, and increase residents' comfort with counseling families about these topics. METHODS: A structured curriculum was implemented over the course of one month for the pediatric resident learner using andragogical methods such as didactic presentation, small-group sessions, role play, and simulation. A 15 multiple-choice question (MCQ) assessment and 13-statement attitudes inventory (AI) using Likert scales were given before the start of the curriculum and after its completion. Pretest and post-test scores were compared for the residents who attended at least three of the six sessions. RESULTS: Fifty residents completed the pretest, 34 residents completed the post-test, and 24 residents completed both. Of the 24, only 19 residents attended at least half the sessions. There was a significant improvement in scores for the MCQ assessment, for each grouped AI domain, and in the proportion of residents who reported comfort with 11 of 13 AI statements. CONCLUSION: The findings of this study demonstrate that given quality high-impact educational content, pediatric residents' knowledge about seizures and epilepsy improves significantly. It is feasible to implement active learning techniques during structured didactic time. The importance of closing the knowledge gap and improving pediatric comfort with seizures and epilepsy is essential and may translate to the much needed improvement in access to care for the patients with these disorders.

Migraine and Sleep in Children: A Bidirectional Relationship.

Migraine and sleep disorders in children exhibit a bidirectional relationship. This relationship is based on shared pathophysiology. Migraine involves activation of the trigeminal vascular system. Nociceptive neurons that innervate the dura release various vasoactive peptides. Calcitonin gene-related peptide is the most active of these peptides. Neural pathways that are involved in sleep generation are divided into those responsible for circadian rhythm, wake promotion, non-rapid eye movement, and rapid eye movement sleep activation. Sleep state switches are a critical component of these systems. The cerebral structures, networks, and neurochemical systems that are involved in migraine align closely with those responsible for the regulation of sleep. Neurochemical systems that are involved with both the pathogenesis of migraine and regulation of sleep include adenosine, melatonin, orexin, and calcitonin gene-related peptide. Sleep disorders represent the most common comorbidity with migraine in childhood. The prevalence of parasomnias, obstructive sleep apnea, and sleep-related movement disorders is significantly greater in children migraineurs. Infantile colic is a precursor of childhood migraine. Treatment of comorbid sleep disorders is important for the appropriate management of children with migraine. Sleep-based behavioral interventions can be of substantial benefit. These interventions are particularly important in children due to limited evidence for effective migraine pharmacotherapy.

Doxepin in children and adolescents with symptoms of insomnia: a single-center experience.

STUDY OBJECTIVES: Pediatric insomnia is a widespread problem and especially difficult to manage in children with neurodevelopmental disorders. There are currently no US Food and Drug Administration-approved medications to use once first-line therapy fails. The objective of this study was to evaluate the efficacy and tolerability of doxepin in pediatric patients. METHODS: This is a retrospective single-center chart review of children and adolescents (2-17 years of age) whose sleep failed to improve with behavioral intervention and melatonin who were then trialed on doxepin. Treatment was initiated at a median starting dose of 2 mg and slowly escalated to a median maintenance dose of 10 mg. Improvement in sleep was recorded using a 4-point Likert scale reported by parents on follow-up visits. RESULTS: A total of 29 patients were included in the analysis. Mean follow-up duration was 6.5 ± 3.5 months. Of 29 patients, 4 (13.8%) patients discontinued doxepin because of lack of efficacy or side effects. Eight (27.6%) patients showed significant improvement of their insomnia, 8 (27.6%) showed moderate improvement, 10 (34.5%) showed mild improvement, and 3 (10.3%) showed minimal to no improvement on treatment with doxepin (P < .05) Only 2 patients (6.9%) experienced adverse effects in the form of behavioral side effects (aggression) and enuresis. CONCLUSIONS: Results of our studies suggest that low-dose doxepin is both effective and well tolerated in pediatric patients with insomnia.

Comparison of artifacts between paste and collodion method of electrode application in pediatric EEG.

OBJECTIVES: Children pose challenges to obtain quality EEG data due to excessive artifact. Collodion is used in EEG electrodes due to its water resistance and strong adhesive qualities. This study was done to evaluate differences in artifacts between the collodion and paste method. METHODS: 115 subjects (children age >3 years) were randomized into paste and collodion groups and artifacts evaluated at baseline and every hour over 30 s increments. Age, sleep state, and number of electrodes with artifact were also documented. T-test was performed to determine differences in the various parameters between the two groups. RESULTS: 61 subjects were in the paste group and 54 in the collodion group. Mean of total seconds of artifact from 0 to 24 h were 41.8 s in paste group versus 30.3 s in collodion group (P = 0.02). Children >11 years old had less artifact than younger children from 0 to 24 h (24.3 versus 41.2 s, P = 0.03), and from 24 to 48 h (33.1 versus 43.1 s, P = 0.03). There was a significant effect of sleep vs. awake state recordings on artifact from 0 to 24 h (30.3 versus 50.2 s, P = 0.01). CONCLUSION: Electrode problems are common with both collodion and paste in prolonged AEEG monitoring. However, for studies less than 24 h, collodion may be a better alternative. SIGNIFICANCE: Our study provides evidence that in some cases collodion may be a better alternative to paste in terms of decreased artifacts.

Evaluating a multiple-family group access intervention for refugees with PTSD.

The purpose of this study was to analyze the effects of a multiple-family group in increasing access to mental health services for refugees with posttraumatic stress disorder (PTSD). This study investigated a nine-session multiple-family group called Coffee and Families Education and Support with refugee families from Bosnia-Herzegovina in Chicago. Adults with PTSD (n = 197) and their families were randomly assigned to receive either the intervention or a control condition. The results indicated that a multiple-family group was effective in increasing access to mental health services and that depression and family comfort with discussing trauma mediated the intervention effect. Further well-designed studies of family interventions are needed for developing evidence-based interventions for refugee families.

A family beliefs framework for socially and culturally specific preventive interventions with refugee youths and families.

To assist in designing socially and culturally specific preventive interventions for refugee youths and families, this study identified the processes by which refugee families adapt and apply family beliefs concerning youths. A grounded-theory model constructed with ATLAS/ti for Windows and named the family beliefs framework describes (a) family beliefs concerning refugee youths, (b) contextual factors interacting with these family beliefs, (c) adaptation of family beliefs concerning refugee youths, and (d) the interplay of adapting family beliefs and behaviors concerning refugee youths. Preventive interventions for refugee youths and families would be more socially and culturally specific if they addressed the specific processes of adapting family beliefs experienced by refugee youths and their families amid transitions and traumas.

A family approach to severe mental illness in post-war Kosovo.

This study describes the effects of a psychoeducational multiple-family group program for families of people with severe mental illness in post-war Kosovo that was developed by a Kosovar-American professional collaborative. The subjects were 30 families of people with severe mental illnesses living in two cities in Kosovo. All subjects participated in multiple-family groups and received family home visits. The program documented medication compliance, number of psychiatric hospitalizations, family mental health services use, and several other characteristics, for the year prior to the groups and the first year of the groups. The families attended an average of 5.5 (out of 7) groups, and 93% of these families attended four or more meetings. The uncontrolled pre- to post-intervention comparison demonstrated decreases in medication non-compliance and hospitalizations, and increases in family mental health service use. The program provided training for mental health professionals, led to policy change in the Ministry of Health, and resulted in dissemination to other community mental health centers. This study provides preliminary evidence that a collaboratively designed and implemented psychoeducational, multiple-family program is a feasible and beneficial intervention for families of people with severe mental illness in impoverished post-war settings.

The TAFES multi-family group intervention for Kosovar refugees: a feasibility study.

The object of this study was to describe a feasibility study of the Tea and Families Education and Support (TAFES) intervention used in a group of newly resettled adult refugees from Kosova. The subjects were 86 newly resettled Kosovar refugees in Chicago who gave informed consent to participate in an investigation of the TAFES intervention. All subjects received family home visits, and most participated in the TAFES multi-family groups. The instruments were administered to adult participants before and 3 months after the intervention. The TAFES program had contact with 61 Kosovar refugee families, of which 42 families (69%) engaged in TAFES groups, including families with educated and working members. Several characteristics were associated with engaging in TAFES groups and included lower monthly family income and higher age of the first child. The uncontrolled postintervention assessments demonstrated increases in social support and psychiatric service use associated with engagement in the TAFES group. Participants also showed time changes in scale scores assessing trauma mental health knowledge, trauma mental health attitudes, and family hardiness. This study provides preliminary evidence that multi-family support and education groups are a feasible and possibly beneficial intervention for newly resettled refugees and indicates the need for further studies.

Family consequences of refugee trauma.

OBJECTIVE: To construct a model on the consequences of political violence for refugee families based upon a qualitative investigation. METHODS: This study used a grounded-theory approach to analyze qualitative evidence from the CAFES multi-family support and education groups with Bosnian refugee families in Chicago. Textual coding and analysis was conducted using ATLAS/ti for Windows. RESULTS: A grounded-theory model of Family Consequences of Refugee Trauma (FAMCORT) was constructed that describes Displaced Families of War across four realms of family life: (1) changes in family roles and obligations, (2) changes in family memories and communications, (3) changes in family relationships with other family members; and (4) changes in family connections with the ethnic community and nation state. In each realm, the model also specifies family strategies, called Families Rebuilding Lives, for managing those consequences. CONCLUSIONS: Political violence leads to changes in multiple dimensions of family life and also to strategies for managing those changes. Qualitative family research is useful in better understanding refugee families and in helping them through family-oriented mental health services.