Risk of Respiratory Syncytial Virus Infection in Cyanotic Congenital Heart Disease in a Subtropical Area.

OBJECTIVE: To compare the risk of respiratory syncytial virus (RSV)-associated hospitalization and analyze the epidemiology of RSV infection in patients with cyanotic and acyanotic congenital heart disease (CHD), we analyzed the nationwide health insurance database from 2005-2010. STUDY DESIGN: This study included 1050 patients with cyanotic CHD and 7077 patients with acyanotic CHD. Patients with acyanotic CHD were further classified into hemodynamically significant (hs)-acyanotic and non-hs-acyanotic groups according to whether they underwent surgery or took at least 2 anticongestive medications. RESULTS: RSV-associated hospitalization was higher in the cyanotic group than in hs-acyanotic and non-hs-acyanotic groups both before 1 year of age (4.8% vs 2.1% vs 1.5%, P < .001) and between 1 and 2 years of age (0.9% vs 0.56% vs 0.14%, P = .003). The hospitalization duration, intensive care, ventilator support prevalence, hospitalization cost, and mortality rate were significantly higher in the cyanotic group than in the other 2 groups. Logistic regression revealed that cyanotic CHD was the most significant risk factor for the ventilator support and RSV-associated mortality. In both patients with cyanotic and acyanotic CHD, RSV-associated hospitalization rate was higher in patients aged younger than 1 year and in spring and autumn in Taiwan, a subtropical country. CONCLUSIONS: The results show that patients with cyanotic CHD have a higher risk of severe RSV infection than do those with acyanotic CHD. RSV prophylaxis is more important and may reduce costs more for patients with cyanotic CHD.

[Hospital Admissions due to cyanosis episodes in newborns with gestational age of 34 weeks or more]. / Hospitalización por episodios de cianosis en recién nacidos de edad gestacional igual o mayor a 34 semanas.

OBJECTIVES: A retrospective study was performed between January 2007 and December 2012 to assess the admission rates of newborns due to episodes of cyanosis PATIENTS AND METHOD: Retrospective study that included all the newborns hospitalized with episodes of cyanosis between January 2007 and December 2012. In them were employed two study protocols that considered first and second line tests, the latter in view of recurrence of events. The first line protocol considered general biochemical tests, chest x-ray and echocardiography in selected cases, while the second line protocol included electroencephalogram, electrocardiogram, nuclear magnetic resonance of the brain, expanded metabolic screening, pyruvic acid, lactic acid, and in case of seizures, cytochemical, and culture of cerebrospinal fluid (CSF) and PCR (polymerase chain reaction) for herpes. RESULTS: A total of 98 (2.8%) out of 3,454 newborns were admitted due to episodes of cyanosis. Gestational age: 37.8+1.4 weeks, birth weight: 3,145+477 g. Maternal age: 32+4.8 years. Disease was present in 19.4% of mothers; gestational diabetes (8.1%), pregnancy induced hypertension (5.1%), intrahepatic cholestasis (3.1%), and intrauterine growth retardation (3.1%). Gender: 48.8% male, 51.2% female (NS). Birth: caesarean section, 68.4%, and vaginal delivery, 31.6%. Age on admission 1.9+1.4 days. Hospital stay: 4.2+4.2 days. First line tests were performed in 100% of patients with 39.8% fulfilling the criteria for second line study. A condition was detected in 21.4%, with convulsive syndrome was the most frequent (33%). Newborns with an identified condition had 3.8+2.7 episodes versus 1.5+2,4 in those without diagnosis (NS). A home oxygen monitor was given to 15.4%. There were no re-admissions. CONCLUSIONS: Most newborns admitted due to cyanosis are discharged with a condition of unknown origin. In this study, convulsive syndrome was the most frequent cause.

Gastroesophageal reflux causing sleep interruptions in infants.

BACKGROUND AND AIM: Little is known about the relation between gastroesophageal reflux (GER) episodes and sleep interruptions in infants. The aim of the study was to evaluate the relationship between GER and the incidence of sleep interruptions in infants. METHODS: Study patients included 24 infants (younger than 1 year) referred for multichannel intraluminal impedance and esophageal pH monitoring with simultaneous polysomnography. Exclusion criteria were a previous fundoplication and studies lasting <20 hours. Tests were clinically indicated to investigate suspicion of GER-related apnea (17, 70.8%), stridor (6, 25%), noisy breathing (2, 8.3%), and cyanotic spells (1, 4.2%). Most patients presented with significant comorbidities (19, 79.2%). RESULTS: The number of nonacid GER (NAGER) per hour was greater during sleep time than during daytime and awakening following sleep onset (median 0.27 vs 1.85 and 1.45, P<0.01). A total of 1204 (range 7-86 per infant) arousals in 24 infants was detected, 165 (13.7%) that followed GER episodes, and 43 (3.6%) that preceded GER episodes. Seven patients presented with a positive symptom association probability for arousals; 5 were exclusively because of NAGER. A positive symptom association probability for awakenings was detected in 9 patients; 4 were because of NAGER, 4 were because of AGER, and 1 was because of both NAGER and GER. Patients with awakenings related to GER presented longer mean clearance time of AGER during sleep (165.5 vs 92.8 seconds, P=0.03). CONCLUSIONS: GER was a frequent cause of interrupting sleep among our infant patients, and NAGER proved to be equally important as AGER for causing arousals and awakenings in infants.

Risk factors for extreme events in infants hospitalized for apparent life-threatening events.

OBJECTIVE: To determine whether known risk factors for cardiorespiratory illnesses will help identify infants who could experience extreme events during an admission for an apparent life-threatening event (ALTE) or later at home. STUDY DESIGN: Retrospective cohort study of all patients admitted for ALTE between 1996 and 2006. Extreme events included central apnea >30 seconds, bradycardia >10 seconds, and desaturation >10 seconds at hemoglobin-oxygen saturation value with pulse oximetry <80%. RESULTS: Of the 625 patients included in the study, 46 (7.4%) had extreme cardiorespiratory events recorded, usually within 24 hours of hospital admission. The most frequent diagnosis was upper respiratory tract infection (URTI, 30 infants). These factors increased the likelihood of having extreme events (P < .0001): post-conceptional age <43 weeks (5.2-fold increase), premature birth (6.3-fold), and URTI symptoms (11.2-fold). The most frequent events were extreme desaturations (43/46 infants), preceded by a central apnea. Seven infants had extreme events recorded later during home monitoring (4 with URTI); all 7 infants had sustained extreme events in the hospital. CONCLUSION: Extreme events were identified mostly in association with symptoms of URTIs, in infants born prematurely, and in infants <43 weeks post-conceptional age. Monitoring with a pulse oximeter should identify infants who sustain these events.

Causas atribuidas a eventos de aparente amenaza a la vida del lactante / Causes attributed to apparent life-threatening event: 3 years of experience

Background: An Apparent Life-Threatening Event (ALTE) is an important challenge for the pediatrician, which requires guidelines for finding the etiology and making appropriate clinical decisions. Objective: To describe etiologies and clinical features of ALTE in infants, as determined by a standarized protocol. Methods: A prospective study including infants admitted to the Emergency Room and hospitalized due to an ALTE between May 2002 and May 2005. They were evaluated with an established protocol that considers the episode description, clinical history, and complementary laboratory studies. Results: 109 patients with ALTE and a mean age of 11 weeks had the following symptoms: apnea (100 percent), skin color changes (97 percent), and muscle tone changes (83 percent). 96 percent received CPR maneuvers or strong stimulation maneuvers for ending the episode. Fourteen percent of the cases were idiopathic, while other etiologies included respiratory infections (46 percent), gastroesophageal reflux (16 percent), seizures (6 percent), and urinary tract infections (6 percent). 3 patients expired. Conclusions: With this protocol, based on tools available in most public tertiary hospitals in Chile, we can identify the causes of ALTE similar to those reported in other studies, howeber with a lesser percentage of idiopathic episodes.

Introducción: Un Evento de Aparente Amenaza a la Vida (ALTE) plantea un importante desafío al pediatra, quién debe investigar la etiología para orientar su conducta. Esta labor se facilita con la aplicación de una guía. Objetivo: Describir la presentación clínica y determinar posibles causas de ALTE mediante un protocolo especifico. Pacientes y Método: Estudio prospectivo en lactantes que consultaron en un Servicio de Urgencia y se hospitalizaron por ALTE entre Mayo 2002 a Mayo 2005. Se evaluaron con un protocolo preestablecido considerando la descripción del episodio, antecedentes y estudios complementarios por pasos. Resultados: En 109 pacientes con ALTE, edad promedio 11 semanas, se observó apnea en 100 por ciento y cambio de color en 97 por ciento. El 83 por ciento presentó cambio de tono y en el 96 por ciento se utilizaron maniobras para abortar el episodio. Se consideró idiopático el 14 por ciento de los casos. Las principales causas atribuidas fueron: infecciones respiratorias (46 por ciento), reflujo gastroesofágico (16 por ciento), convulsiones (6 por ciento) e infecciones urinarias (6 por ciento). Fallecieron 3 pacientes. Conclusiones: Mediante este protocolo, que utiliza herramientas disponibles en la mayoría de los hospitales públicos terciarios de nuestro país, se atribuyeron causas similares a las reportadas en otros estudios prospectivos, donde destaca un menor porcentaje de episodios idiopáticos.

Congenital heart diseases in the newborn: from the pediatrician's request to the cardiologist's evaluation.

OBJECTIVE: To analyze the importance of symptoms as a reason for referral to pediatric cardiologists in the diagnosis of congenital heart diseases (CHD) in the newborn (NB). METHODS: Prospective study on live NB referred for cardiac evaluation, with performance of electrocardiogram, chest radiography and echocardiography. Cardiology consultation was requested by means of a multiple-choice form including signs and symptoms suggestive of CHD. Patent ductus arteriosus (PDA) without clinical and/or hemodynamic consequences was not considered a heart disease. RESULTS: From 1999 to 2002, 358 out of 3716 NB were studied, and 49 cases of CHD and 128 of PDA were found. The prevalence of CHD was 13.2:1000 NB. The main reason for referral to the cardiologist was heart murmur in 256 (72%) NB, of which 39 (15%) had CHD, and in 91% of the 128 cases of PDA. In 14 (4%) NB, the reason for referral was cyanosis, and eight of these patients (57%) had a CHD. Heart failure was the reason for referral in 37 (10%) NB, of whom 17 (46%) had CHD. Arrhythmia, associated congenital malformations, or chromosome disorders were the reasons for referral in 14% of the cases. CONCLUSION: The main reason for referral was detection of a heart murmur on cardiac auscultation. Although cyanosis and heart failure were uncommon reasons for referral, their presence indicated a high probability of the diagnosis of heart disease. Pediatric screening plays a key role in this diagnosis.

Cardiopatia congênita no recém-nascido: da solicitação do pediatra à avaliação do cardiologista / Congenital heart diseases in the newborn: from the pediatrician's request to the cardiologist's evaluation

OBJETIVO: Analisar a importância dos sintomas, como motivo de interconsulta com o cardiologista pediátrico, no diagnóstico de cardiopatias congênitas (CC) em recém-nascidos (RN). MÉTODOS: Estudo prospectivo de RN vivos encaminhados para avaliação cardiológica, com realização de eletrocardiografia, radiografia de tórax e ecocardiografia. Solicitação de interconsulta mediante preenchimento de ficha de múltipla escolha, constando os sintomas e sinais sugestivos de CC. Persistência do canal arterial (PCA) sem repercussão clínica e/ou hemodinâmica não foi considerada cardiopatia. RESULTADOS: Entre 1999 e 2002, foram estudados 358 dentre 3.716 RN, demonstrando 49 casos de CC e 128 de PCA. A prevalência de CC foi de 13,2:1.000 RN. O principal motivo para interconsulta com o cardiologista foi sopro em 256 (72 por cento) dos RN, dentre os quais 39 (15 por cento) eram portadores de CC e 91 por cento dos 128 casos, de PCA. Em 14 (4 por cento) dos RN, o motivo de interconsulta foi cianose, dentre os quais 8 (57 por cento) eram portadores de CC. Insuficiência cardíaca foi o motivo de interconsulta em 37 (10 por cento) dos RN, dentre os quais 17 (46 por cento) eram portadores de CC. Arritmia, malformações congênitas associadas ou cromossomopatias foram os motivos de interconsulta em 14 por cento dos casos. CONCLUSÃO: O principal motivo da interconsulta foi ausculta de sopro. Apesar de cianose e insuficiência cardíaca serem pouco freqüentes como motivo de interconsulta, sua presença indicou alta probabilidade de diagnóstico de cardiopatia. A triagem pediátrica tem papel importante para o diagnóstico.

OBJECTIVE: To analyze the importance of symptoms as a reason for referral to pediatric cardiologists in the diagnosis of congenital heart diseases (CHD) in the newborn (NB). METHODS: Prospective study on live NB referred for cardiac evaluation, with performance of electrocardiogram, chest radiography and echocardiography. Cardiology consultation was requested by means of a multiple-choice form including signs and symptoms suggestive of CHD. Patent ductus arteriosus (PDA) without clinical and/or hemodynamic consequences was not considered a heart disease. RESULTS: From 1999 to 2002, 358 out of 3716 NB were studied, and 49 cases of CHD and 128 of PDA were found. The prevalence of CHD was 13.2:1000 NB. The main reason for referral to the cardiologist was heart murmur in 256 (72 percent) NB, of which 39 (15 percent) had CHD, and in 91 percent of the 128 cases of PDA. In 14 (4 percent) NB, the reason for referral was cyanosis, and eight of these patients (57 percent) had a CHD. Heart failure was the reason for referral in 37 (10 percent) NB, of whom 17 (46 percent) had CHD. Arrhythmia, associated congenital malformations, or chromosome disorders were the reasons for referral in 14 percent of the cases. CONCLUSION: The main reason for referral was detection of a heart murmur on cardiac auscultation. Although cyanosis and heart failure were uncommon reasons for referral, their presence indicated a high probability of the diagnosis of heart disease. Pediatric screening plays a key role in this diagnosis.

Polysomnographic findings in 320 infants evaluated for apneic events.

Apnea is a common problem that causes significant parental anxiety. The aim of this study was to describe polysomnographic findings in infants who were referred over a 4-year period for an apnea and/or cyanotic event. Our hypothesis was that most infants with apnea or cyanosis events will have normal polysomnography (PSG). In total, 320 patients younger than 2 years old were recruited sequentially and prospectively. Patients underwent a day or overnight PSG by computerized polysomnograph; 78% of studies were performed with pH probe in situ. Subjects' ages ranged from 10 days to 21 months (55% male and 84% full-term babies); 55% and 74% were younger than 3 and 6 months, respectively. The average total sleep time was 473.4 min (SD, 52.3), with mean sleep efficiency of 83.5%. The distribution of sleep stages was 56.5% active, 38.5%, quiet and 5.1% indeterminate sleep. Sixty-nine percent (n = 220) of PSG studies were done overnight. There were significant differences in average sleep efficiency (78.1% vs. 83.3%) and REM sleep time (63.6% vs. 59.1%) between PSGs done during the day and overnight (P < 0.05). In total, 34 patients with apneas were studied. The median apnea index for the whole study population was 1.01 (range, 0.1-9.1). In conclusion, our study showed a high prevalence of normal polysomnographic findings in infants referred because of apnea and/or cyanotic events. New clinical prospective studies should be conducted to evaluate whether there is a correlation between PSG findings and outcome at follow-up of infants with a history of apnea and cyanosis.

Sistema de hipertexto em cardiologia pediátrica / Hipertext system in pediatric cardiology

O sistema de hipertexto em cardiologia pediátrica destina-se a apoiar o profissional médico que trata de crianças com suspeita de cardiopatia. O sistema deverá auxiliar o médico que faz o primeiro atendimento no diagnóstico e manejo do paciente. A metodologia usada para criação do hipertexto é baseada na linguagem orientada a objetos, utilizando o software Toolbook 4.0. O sistema multimídia poderá ser rodado em computadores PC 386 ou superior, com 8 MB de memória RAM.

Cianosis como emergencia: informe de 138 casos / Cyanosis as emergency: report of 134 cases

Durante el período 1985-1987 se seleccionaron 138 casos con ingreso por cianosis dominante a la sala de emergencia; todos los pacientes menores de 2 años. Relación varones/ hembras de 2,6/1. Un 18,84% de los ingresos fallecieron en las primeras horas de su estancia; representando el 3,04% de la mortaliad general acumulada durante el período. Todos los ingresos provenientes del Dto. Federal y Miranda. Predominaron con cianosis dominante al ingreso los individuos entre 15 días y 6 meses con un 6,159%, siendo ésta generalizada. Cianosis como dato clínico significativo predominó en el 92,8% de los pacientes menores de 12 años. Entre los antecedentes: (a) peso al nacer: 86,96% entre 2.500 - 2.999 gr; (b) talla al nacer: 78,26% entre 46-47 cm; (c) 94,2% producto de embarazos controlados: 21,01% (e) embarazos multiples 63,04%; (f) asfixia perinatal; (g) cianosis persistente desde el nacimiento; 4,34%; (h) retraso psicomotor variable (Denver); 18,84%. ninguno de los casos con antecedentes cardiovasculares patológicos. Las diversas cardiopatías fueron responsables de 82,60% de las cianosis ingresadas al servicio, particularmente el Fallot con un 54,39%; otras cardiopatías complejas congénitas, de un 33,33%. se sospecho de posible cardiopatía al momento del ingreso a Emergencia en un 25,36% de los sujetos. un 74,63% de los ingresos se atribuyeron a problemas respiratorios