Improving Hospitalized Children's Sleep by Reducing Excessive Overnight Blood Pressure Monitoring.

BACKGROUND: Although required for healing, sleep is often disrupted during hospitalization. Blood pressure (BP) monitoring can be especially disruptive for pediatric inpatients and has few clinical indications. Our aim in this pilot study was to reduce unnecessary overnight BP monitoring and improve sleep for pediatric inpatients. METHODS: The intervention in June 2018 involved clinician education sessions and updated electronic health record (EHR) orders that enabled the forgoing of overnight BP checks. The postintervention period from July 2018 to May 2019 examined patient-caregiver surveys as outcome measures. These surveys measured inpatient sleep and overnight disruptions and were adopted from validated surveys: the Patient Sleep Questionnaire, expanded Brief Infant Sleep Questionnaire, and Potential Hospital Sleep Disruptions and Noises Questionnaire. Uptake of new sleep-friendly EHR orders was a process measure. Reported patient care escalations served as a balancing measure. RESULTS: Interrupted time series analysis of EHR orders (npre = 493; npost = 1472) showed an increase in intercept for the proportion of patients forgoing overnight BP postintervention (+50.7%; 95% confidence interval 41.2% to 60.3%; P < .001) and a subsequent decrease in slope each week (-0.16%; 95% confidence interval -0.32% to -0.01%; P = .037). Statistical process control of surveys (npre = 263; npost = 131) showed a significant increase in sleep duration for patients older than 2, and nighttime disruptions by clinicians decreased by 19% (P < .001). Annual estimated cost savings were $15 842.01. No major adverse events in patients forgoing BP were reported. CONCLUSIONS: A pilot study combining EHR changes and clinician education safely decreased overnight BP checks, increased pediatric inpatient sleep duration, and reduced nighttime disruptions by clinicians.

Pediatric Hypertension and End-Stage Renal Disease.

Pediatric hypertension is not an uncommon diagnosis, affecting about 3.5% of all children. Most childhood hypertension is associated with obesity, but elevated blood pressure can also be the presenting symptom of a secondary disease process. Moreover, no matter the cause of hypertension, early identification can improve long-term health outcomes as childhood hypertension predicts hypertension in adulthood. In 2017, the American Academy of Pediatrics revised their 2004 guidelines regarding blood pressure screening for all children. Here, we discuss an illustrative case of a 16-year-old girl with hypertension and underlying nephrotic syndrome whose diagnosis was delayed due to inadequate blood pressure screening. Given the varying practices regarding the interpretation of blood pressure data in the outpatient setting, it is important for primary care providers to understand the updated guidelines and the indications for referral. [Pediatr Ann. 2020;49(6):e258-e261.].

Strychnine: Old Remedy, Silent Killer.

Toxin ingestion is a significant public health issue for children, accounting for hundreds of visits per day to emergency departments. The most common substances are household cleaning products, personal care products, and medications. This article describes an ingestion of a rare substance called strychnine, which is a plant-based odorless powder that was previously used as a nonspecific stimulant. This toxicity can mimic other ingestions, thus delaying diagnosis, so an increased awareness of the common symptoms and laboratory findings may lead to a more targeted management of strychnine poisoning. [Pediatr Ann. 2019;48(5):e205-e207.].

A Framework for Approaching Refractory Hypocalcemia in Children.

Hypocalcemia is a potentially fatal electrolyte imbalance with complications that include seizures, tetany, prolonged QT interval, cardiomyopathy, and congestive heart failure. In chi dren, persistent hypocalcemia can also be detrimental to bone growth and health. Therefore, it is important to recognize the many ways this electrolyte imbalance may present and determine its etiology. This article provides a framework for assessing hypocalcemia and describes in detail a case with a rare cause of refractory hypocalcemia. [Pediatr Ann. 2019;48(5):e208-e211.].

Hypophosphatemia in a Malnourished Child: When Renal Fanconi Syndrome Does Not Stand for Refeeding Syndrome.

Refeeding syndrome is diagnosed based on the onset of multiple laboratory abnormalities (most commonly hypophosphatemia) and clinical signs in the setting of nutrition rehabilitation of malnourished patients. Because definitions are not uniform, a broad differential diagnosis should always include renal tubular dysfunction. Our report details a 3 year-old child with undiagnosed renal tubular dysfunction who presented with the clinical picture of refeeding syndrome with refractory electrolyte abnormalities. A diagnosis of renal Fanconi syndrome was made after urinalysis that revealed glucosuria and urine electrolyte losses. Thus, urinalysis can aid in making a positive diagnosis of refeeding syndrome.

Lucy Maude Montgomery and Anne of Green Gables: An Early Description of Attention-Deficit/Hyperactivity Disorder.

Attention-deficit/hyperactivity disorder (ADHD) was added to the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised in 1987. Similar disorders had appeared earlier, and many consider the first description of ADHD to be a lecture in 1902 about children with an "abnormal defect in moral control" but normal intelligence. This definition of ADHD is more alarming than the current one. Anne Shirley, the protagonist of the novel Anne of Green Gables (written by Lucy Maude Montgomery and published in 1908), shares the hyperactive and inattentive qualities that fit the current definition of ADHD. She also lacks the menacing characteristics of the 1902 description. This indicates that ADHD, by its modern definition, was probably present in the early 1900s. Furthermore, the character of Anne Shirley shares many biographical similarities with her author, suggesting that Montgomery herself may have had ADHD. Thus, looking at literature from the past not only provides insight into the timeline of ADHD, but also into the thought process of an individual with ADHD. By viewing literary classics through a medical lens, we may gain insight into other diseases as well. [Pediatr Ann. 2017; 46(7):e270-e272.].

Charles Dickens and Barnaby Rudge: The First Description of Williams Syndrome?

Williams syndrome, a disorder caused by a genetic deletion and characterized by moderate intellectual disability with relatively strong language skills and a hypersocial personality, was first described in the medical literature in 1961. However, 120 years earlier, Charles Dickens wrote the novel Barnaby Rudge, which follows an "idiot" through London's Gordon Riots of 1780. We propose that Dickens based this character on a person he knew with Williams syndrome. Common features include an "elfin" face, decreased cognitive ability and dependence on a caretaker, strong language skills with emphatic and perseverative speech, anxiety, and an empathetic, overly trusting personality. In the novel, these traits lead the character Barnaby to be duped into actively participating in the riots, which nearly results in his hanging. This example of fiction providing a description of a disorder more detailed than that of medical journals more than a century later should encourage physicians to look to sources beyond traditional scientific articles for valuable clinical information.

Acute Renal Failure in the Neonate.

Acute renal failure (ARF) in a neonate is a serious condition that impacts 8% to 24% of hospitalized neonates. There is a need for prompt evaluation and treatment to avoid additional complications. In this review, a neonate was found to have renal failure associated with renal vein thrombosis. There are varying etiologies of ARF. Causes of ARF are typically divided into three subsets: pre-renal, renal or intrinsic, and post-renal. Treatment of ARF varies based on the cause. Renal vein thrombosis is an interesting cause of renal or intrinsic ARF and can be serious, often leading to a need for dialysis.