ABSTRACT
OBJECTIVE: To derive prognostic data for survival and clinical improvement in children with severe developmental disabilities. STUDY DESIGN: A 13-year follow-up study of several cohorts of children initially evaluated before their first birthday. The outcomes studied were survival and improvement in condition. Methods were used to overcome limitations in previously published work on the same California data base. Of the 11,912 children who received services from the California Department of Developmental Services between January 1980 and December 1993, we focused on three cohorts defined according to mobility and need for tube feeding. RESULTS: Children who were tube fed and unable to lift their heads by ages 3 to 12 months were at high risk for early death, with a median remaining life expectancy of 3.2 years. Of those who survived an additional 2 years, the condition of about one third improved. A substantial majority of those who either showed improvement or died had done so by that age. CONCLUSION: By age 5 years, the prognoses for survival and improvement have to a large extent been clarified. For children who survive to age 5 years, even those in the lowest functioning cohort have a 60% chance of surviving an additional 5 years. Detailing the probabilities of various outcomes at various ages should be useful to parents, pediatricians, and others concerned with children with developmental disabilities.
Subject(s)
Developmental Disabilities/mortality , Age Distribution , California/epidemiology , Child , Child, Preschool , Cohort Studies , Follow-Up Studies , Humans , Infant , Infant, Newborn , Prognosis , Severity of Illness Index , Survival RateABSTRACT
We examined total and regional cerebral blood flow (CBF) by stable xenon computed tomography in 20 seriously ill children with acute bacterial meningitis to determine whether CBF was reduced and to examine the changes in CBF during hyperventilation. In 13 children, total CBF was normal (62 +/- 20 ml/min/100 gm) but marked local variability of flow was seen. In five other children, total CBF was significantly reduced (26 +/- 10 ml/min/100 gm; p less than 0.05), with flow reduced more in white matter (8 +/- 5 ml/min/100 gm) than in gray matter (30 +/- 15 ml/min/100 gm). Autoregulation of CBF appeared to be present in these 18 children within a range of mean arterial blood pressure from 56 to 102 mm Hg. In the remaining two infants, brain dead within the first 24 hours, total flow was uniformly absent, averaging 3 +/- 3 ml/min/100 gm. In seven children, CBF was determined at two carbon dioxide tension (PCO2) levels: 40 (+/- 3) mm Hg and 29 (+/- 3) mm Hg. In six children, total CBF decreased 33%, from 52 (+/- 25) to 35 (+/- 15) ml/min/100 gm; the mean percentage of change in CBF per millimeter of mercury of PCO2 was 3.0%. Regional variability of perfusion to changes in PCO2 was marked in all six children. The percentage of change in CBF per millimeter of mercury of PCO2 was similar in frontal gray matter (3.1%) but higher in white matter (4.5%). In the seventh patient a paradoxical response was observed; total and regional CBF increased 25% after hyperventilation. Our findings demonstrate that (1) CBF in children with bacterial meningitis may be substantially decreased globally, with even more variability noted regionally, (2) autoregulation of CBF is preserved, (3) CBF/CO2 responsitivity varies among patients and in different regions of the brain in the same patient, and (4) hyperventilation can reduce CBF below ischemic thresholds.
Subject(s)
Brain/blood supply , Carbon Dioxide/blood , Cerebrovascular Circulation , Meningitis/physiopathology , Bacterial Infections/physiopathology , Brain Death/physiopathology , Child , Child, Preschool , Homeostasis , Humans , Hyperventilation/physiopathology , Infant , Infant, Newborn , Meningitis/blood , Meningitis/etiology , Partial Pressure , Regional Blood Flow , Tomography, Emission-Computed , Xenon RadioisotopesABSTRACT
Fifteen infants and children, 11 of whom had clinical brain death and four of whom were comatose, were evaluated with the radionuclide bolus study and electroencephalography. Clinical criteria for brain death included: (1) absence of spontaneous respirations, (2) absence of cephalic reflexes, and (3) unresponsiveness. Results demonstrated complete correlation among clinical examination, EEG, and radionuclide study in 79% of cases. An approach to the evaluation of the infant or child with possible brain death is outlined utilizing serial examinations, radionuclide bolus study, and electroencephalography. The radionuclide bolus study appears to be a safe, rapid, portable technique which can be used for this purpose in infants and children.