A Pediatric Upper Airway Library to Evaluate Interpatient Variability of In Silico Aerosol Deposition.

The airway of pediatric patients' changes through development, presenting a challenge in developing pediatric-specific aerosol therapeutics. Our work aims to quantify geometric variations and aerosol deposition patterns during upper airway development in subjects between 3.5 months-6.9 years old using a library of 24 pediatric models and 4 adult models. Computational fluid-particle dynamics was performed with varying particle size (0.1-10 µm) and flow rate (10-120 Lpm), which was rigorously analyzed to compare anatomical metrics (epiglottis angle (θE), glottis to cricoid ring ratio (GC-ratio), and pediatric to adult trachea ratio (H-ratio)), inhaler metrics (particle diameter, [Formula: see text], and flow rate, Q), and clinical metrics (age, sex, height, and weight) against aerosol deposition. Multivariate non-linear regression indicated that all metrics were all significantly influential on resultant deposition, with varying influence of individual parameters. Additionally, principal component analysis was employed, indicating that [Formula: see text], Q, GC-ratio, θE, and sex accounted for 90% of variability between subject-specific deposition. Notably, age was not statistically significant among pediatric subjects but was influential in comparing adult subjects. Inhaler design metrics were hugely influential, thus supporting the critical need for pediatric-specific inhalable approaches. This work not only improves accuracy in prescribing inhalable therapeutics and informing pediatric aerosol optimization, but also provides a framework for future aerosol studies to continue to strive toward optimized and personalized pediatric medicine.

Tracheostomy in the extremely premature neonate - Long term outcomes in a multi-institutional study.

OBJECTIVES: To describe the long-term outcomes related to breathing, feeding, and neurocognitive development in extremely premature infants requiring tracheostomy. STUDY DESIGN: Pooled cross-sectional survey. SETTING: Multi-institutional academic children's hospitals. METHODS: Extremely premature infants who underwent tracheostomy between January 1, 2012, and December 31, 2019, at four academic hospitals were identified from an existing database. Information was gathered from responses to a questionnaire by caregivers regarding airway status, feeding, and neurodevelopment 2-9 years after tracheostomy. RESULTS: Data was available for 89/91 children (96.8%). The mean gestational age was 25.5 weeks (95% CI 25.2-25.7) and mean birth weight was 0.71 kg (95% CI 0.67-0.75). Mean post gestational age at tracheostomy was 22.8 weeks (95% CI 19.0-26.6). At time of the survey, 18 (20.2%) were deceased. 29 (40.8%) maintained a tracheostomy, 18 (25.4%) were on ventilatory support, and 5 (7%) required 24-h supplemental oxygen. Forty-six (64.8%) maintained a gastrostomy tube, 25 (35.2%) had oral dysphagia, and 24 (33.8%) required a modified diet. 51 (71.8%) had developmental delay, 45 (63.4%) were enrolled in school of whom 33 (73.3%) required special education services. CONCLUSIONS: Tracheostomy in extremely premature neonates is associated with long term morbidity in the pulmonary, feeding, and neurocognitive domains. At time of the survey, about half are decannulated, with a majority weaned off ventilatory support indicating improvement in lung function with age. Feeding dysfunction is persistent, and a significant number will have some degree of neurocognitive dysfunction at school age. This information may help caregivers regarding expectations and plans for resource management.

Spatial aerosol deposition correlated to anatomic feature development in 6-year-old upper airway computational models.

The upper airways of children undergo developmental changes around age 6, yielding differences between adult and pediatric anatomies. These differences include the cricoid ring area shape, the location of narrowest constriction, and the angle of the epiglottis, all of which are expected to alter local fluid dynamic profiles and subsequent upper airway deposition and downstream aerosol delivery of inhaled therapeutics. In this work, we quantify "pediatric"-like and "adult"-like geometric and fluid dynamic features of two computed tomography (CT)-scan derived models of 6-year-old upper airways in healthy subjects and compare to an idealized model. The two CT-scan models had a mixture of "adult"- and "pediatric"-like anatomic features, with Subject B exhibiting more "pediatric"-like features than Subject A, while the idealized model exhibited entirely "adult"-like features. By computational fluid-particle dynamics, these differences in anatomical features yielded distinct local fluid profiles with altered aerosol deposition between models. Notably, the idealized model better predicted deposition characteristics of Subject A, the more "adult"-like model, including the relationship between the impaction parameter, dp2Q and the fraction of deposition across a range of flow rates and particle diameters, as well as deposition of an approximate pharmaceutical particle size distribution model. Our results with even this limited dataset suggest that there are key personalized metrics that are influenced by anatomical development, which should be considered when developing pediatric inhalable therapeutics. Quantifying anatomical development and correlating to aerosol deposition has the potential for high-throughput developmental characterization and informing desired aerosol characteristics for pediatric applications.

Tracheostomy on infants born in the periviable period: Outcomes at discharge from the neonatal intensive care unit (NICU).

OBJECTIVES: Advances in neonatal intensive care have allowed successful resuscitation of children born at the border of viability. However, there has been little change in the incidence of bronchopulmonary dysplasia (BPD) and anatomical upper airway obstruction which may require a tracheostomy in that group. The benefits of the procedure are accompanied by sequelae that impact outcomes. Information about these issues can assist caregivers in making decisions and planning care after discharge from the neonatal intensive care unit (NICU). The objectives of this study were to describe the clinical characteristics of neonates born in the periviable period (≤25 weeks gestation) requiring tracheotomy and to highlight their hospital course, complications and status upon NICU discharge. METHODS: Retrospective analysis at four tertiary care academic children's hospitals. Medical records of neonates born ≤25 weeks gestation who required tracheotomy between January 1, 2012 and December 31, 2018 were reviewed. Demographics, medical comorbidities, and tracheostomy related complications were studied. Feeding, ventilation, and neurodevelopmental outcomes at time of transfer from NICU were evaluated. RESULTS: Fifty-two patients were included. The mean gestational age was 24.3 (95% confidence interval, 24.1 to 24.5) weeks. The mean birth weight was 635 (95% CI: 603 to 667) grams and 50 (96.2%) children had BPD. At time of discharge from the NICU, 47 (90.4%) required mechanical ventilation, four (7.7%) required supplemental oxygen and one (1.9%) was weaned to room air. Forty-two (80.8%) were discharged with a gastrostomy tube, seven (28%) with a nasogastric tube, and three (5.8%) were on oral feeds. Two (3.8%) suffered hypoxic ischemic encephalopathy, 27 (51.9%) had neurodevelopmental delay, seven (13.5%) were diagnosed with another anomaly, and 16 (30.8%) were considered normal. Complications related to the procedure were observed in 28 (53.8%) neonates. Granulation tissue was seen in 17 (32.7%), wound break down or cellulitis in three (5.8%), one (1.9%) with tracheostomy plugging, three (5.8%) with dislodgement of the tracheostomy tube and four (7.7%) developed tracheitis. CONCLUSIONS: Tracheostomy in infants born in the periviable period is primarily performed for BPD and portends extended ventilatory dependence. It is associated with non-oral alimentation at the time of discharge from the NICU and developmental delay. Mortality directly related to the procedure is rare. Minor complications are common but do not require surgical intervention. These data may aid in counseling caregivers about the procedure in this vulnerable population.

Comparing decannulation failures and successes in pediatric tracheostomy: An 18-year experience.

OBJECTIVES: There is a paucity of published literature identifying patients at higher risk of decannulation failure. The purpose of this study is to evaluate patient factors that may predict successful decannulation of pediatric tracheostomy patients and analyze factors contributing to tracheostomy decannulation failures. METHODS: A retrospective chart review of tracheostomy outcomes was conducted at a pediatric referral hospital. Successful and failed decannulations were compared using the following patient variables: age at tracheostomy, sex, ethnicity, gestational age and weight, the primary indication for tracheostomy, comorbidities, age at decannulation attempt, polysomnography data, and status of airway before decannulation as assessed endoscopically by airway team. RESULTS: Four hundred thirty-nine tracheostomies were performed over the 18-year period with 173 decannulation attempts. The overall rate of successful decannulation on the first attempt was 91.9% (159 of 173), with an eventual decannulation success rate of 97.1% (168 of 173). Compared with failed decannulations, the patients with successful decannulations had a shorter duration of tracheostomy and no medical comorbidities. Gestational age and weight approached, but did not achieve, statistical significance. After 25 months with a tracheostomy, approximately 50% of patients are decannulated with very few decannulations occurring after 75 months. The overall mortality rate in this cohort was 18.6% (78 of 420) with a tracheostomy-related mortality rate of 0.95% (4 of 420). CONCLUSIONS: The decannulation protocol at this institution is successful nearly 92% of the time. Fewer medical comorbidities, shorter duration of tracheostomy placement, and older gestational age may improve the likelihood of successful decannulation. Future studies are needed to determine the optimal timing and workup to evaluate patients for decannulation.

Geometric model to predict improvement after lingual frenulectomy for ankyloglossia.

OBJECTIVES: Frenulectomy for ankyloglossia is an intervention that often improves breastfeeding quality for both the mother and infant. Current classification systems assess and identify patients with ankyloglossia, but they do not predict the degree of improvement after lingual frenulectomy. We propose an idealized geometric model to quantify the potential effect of frenulectomy for ankyloglossia. METHODS: Our geometric model depicts the intact lingual frenulum as a triangular pyramid of mucosa on the floor of mouth. After incising one edge of the pyramid, as is performed during a frenulectomy, the structure unfolds to a two-dimensional diamond whose dimensions can be calculated. Utilizing this calculation, we can predict percent improvement in tongue extension after frenulectomy based off the original dimensions of the pyramid. RESULTS: Our multivariable equation that allows for the calculation of the percent increase in tongue extension is based on the frenulum thickness, frenulum length, tongue length, and insertion point of the frenulum on the tongue. The initial height of the frenulum and the proximity of the frenulum insertion to the tip of the tongue had the largest impact on tongue extension, whereas frenulum width had the smallest impact. CONCLUSION: Lingual frenulectomy has subjectively been reported to improve lingual tongue movement. Our mathematical model identifies multiple anatomic variables that lead to an increase in tongue extension after frenulectomy. Our model is the first step in supporting this subjective improvement with quantifiable measurements, and can allow for future validation studies.

Tracheostomy in the Extremely Premature Neonate: A Multi-Institutional Study.

OBJECTIVE: (1) To describe characteristics associated with tracheostomy placement and (2) to describe associated in-hospital morbidity in extremely premature infants. STUDY DESIGN: Pooled retrospective analysis of charts. SETTING: Academic children's hospitals. SUBJECTS AND METHODS: The patient records of premature infants (23-28 weeks gestational age) who underwent tracheostomy between January 1, 2012, and December 31, 2017, were reviewed from 4 academic children's hospitals. Demographics, procedural morbidity, feeding, respiratory, and neurodevelopmental outcomes at the time of transfer from the neonatal intensive care unit (NICU) were obtained. The contribution of baseline characteristics to mortality, neurodevelopmental, and feeding outcomes was also assessed. RESULTS: The charts of 119 infants were included. The mean gestational age was 25.5 (95% confidence interval, 25.2-25.7) weeks. The mean birth weight was 712 (671-752) g. Approximately 50% was African American. The principal comorbidity was chronic lung disease (92.4%). Overall, 60.5% of the infants had at least 1 complication. At the time of transfer, most remained mechanically ventilated (94%) and dependent on a feeding tube (90%). Necrotizing enterocolitis increased the risk of feeding impairment (P = .002) and death (P = .03). CONCLUSIONS: Tracheostomy in the extremely premature neonate is primarily performed for chronic lung disease. Complications occur frequently, with skin breakdown being the most common. Placement of a tracheostomy does not seem to mitigate the systemic morbidity associated with extreme prematurity.

Evaluating pediatric intensive care unit utilization after tonsillectomy.

OBJECTIVES: To identify patients at risk for a pediatric intensive care unit (PICU) level intervention after adenotonsillectomy. STUDY DESIGN: Retrospective cross-sectional study. SETTING: Tertiary Children's Hospital. SUBJECTS AND METHODS: Ninety-four patients who were admitted to the PICU after adenotonsillectomy were included. The need for PICU level intervention, defined as high flow oxygen by nasal cannula, positive airway pressure (PAP), heliox, and intubation, was documented. The age, gender, BMI percentile, polysomnography (PSG) data, home PAP use, and accompanying comorbidities of patients who required a PICU level intervention were compared to those who did not. RESULTS: Of the 94 patients admitted post-adenotonsillectomy to the PICU, most had at least one comorbidity, with obesity being the most common. PICU admission was unplanned in 29 (30.9%) patients. Postoperatively, 25 (26.5%) patients required a PICU level intervention, with PAP being the most common intervention. On chi-square analysis, there was no significant difference in the age, BMI percentile, or PSG parameters of children who required PICU intervention. Significantly more children who used preoperative PAP were started on PAP in PICU (p = 0.018). Only the comorbidity of neuromuscular disorder was associated with PICU intervention (p = 0.04). Using binary logistic regression, the use of home PAP and an oxygen nadir <80% on preoperative PSG were found to be independent predictors of PICU intervention (p = 0.04 and 0.025, respectively). CONCLUSION: Home PAP use, the presence of a neuromuscular disorder, and an oxygen nadir <80% on preoperative PSG is related to a PICU level intervention.

Dyskeratosis Congenita and Oral Cavity Squamous Cell Carcinoma: Report of a Case and Literature Review.

Dyskeratosis congenita is a rare genetic condition of telomerase dysfunction in which patients are at an increased risk of squamous cell carcinoma (SCCa) of the oral cavity. We present here the youngest patient in the literature with a diagnosis of SCCa. We discuss the literature and management of this advanced presentation of SCCa in a child, stressing the importance of palliative care involvement in facilitating medical decision making.

Computerized Tomography Analysis of Young Children for Prevention of Aspiration Injuries.

OBJECTIVE: The Small Parts Test Fixture (SPTF) (16 CFR 1501) was developed from cadavers of young children and foreign body (FB) data. Recent FB studies reveal that the SPTF misses outliers. Computerized tomography (CT) provides detailed dimensional data for young children. Our null hypothesis is that the SPTF (31.75 mm) is smaller than relevant portions of the aerodigestive tract. METHODS: A 3-year retrospective review (2011-2014) of head/neck CT data for infants and children (N = 106) aged 6 months to 6 years was completed. Six measurements (mm) were recorded: 1) maxillary incisors to posterior edge of hard palate (MI/HP); 2) posterior edge of hard palate to first cervical (C1) vertebra (HP/C1); 3) soft palate to posterior pharyngeal wall; and 4) interpalatine tonsillar distance; 5, 6) larynx diameter, and width. Two ratios were calculated: 1) ratio of lengths (hard palate to soft palate), and 2) laryngeal dimensional ratio. RESULTS: A linear trend of increasing dimensions with increased age was noted. The length measured MI/HP best correlates with known data of potential FBs causing injury or death. This MI/HP length can range from 33.8 to 45.8 mm for all children younger than 3 years of age and exceeds the SPTF diameter (31.75 mm). There were no statistical anatomical differences by gender in any of the age groups. CONCLUSION: Computed tomography measurements appear larger than SPTF values developed from cadavers. These CT data support enlargement of the SPTF to enhance safety for choking hazards in children. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1468-1476, 2019.

Comparison of Artificial Saliva vs Saline Solution on Rate of Suture Degradation in Oropharyngeal Surgery.

Importance: Absorbable sutures are designed to degrade and lose strength over time. Manufacturers warn that exposure to various body fluids can change the estimated degradation rate of these sutures, but few studies have been conducted to quantify the degree of change associated with saliva. Objective: To quantify the association of increased loss of strength of sutures over time after exposure to artificial saliva (hereinafter referred to as "saliva"). Design, Setting, and Participants: This experimental in vitro study was conducted at Bucknell University (Lewisburg, Pennsylvania) from June 19, 2015, to July 4, 2015. No participants were involved. The loss of strength over time of sutures submerged in physiological saline and artificial saliva solutions was compared. Three types of absorbable sutures commonly used in oral surgery were tested: chromic, poliglecaprone 25, and polyglactin 910. Data analysis was conducted from July 15, 2016, to August 16, 2016. Main Outcomes and Measures: The primary outcome measure was 50% strength reduction. To measure breaking strength, 6 knotted sutures of each type were pulled to failure at regular time intervals after immersion in either saline or synthetic saliva at 37°C. Regression analysis was used to interpret strength degradation profiles and to estimate the time to reach 50% of the original breaking strength. Results: Of the 3 suture types submerged in the 2 solutions, all 3 degraded to 50% strength faster (by 2 to 13 days) in saliva than in saline. The differences in the degradation profiles varied by suture type. Poliglecaprone 25 sutures demonstrated a sudden decrease in failure strength between day 5 and day 8 in both solutions, but the decrease was greater in saliva (-10.2 N; 95% CI, -15.5 to -4.9 N) than in saline (-6.1 N; 95% CI, -11.2 to -0.9 N). The polyglactin 910 and chromic sutures share a similar degradation profile when implanted in tissue, but saliva was associated with more degradation of chromic sutures. Differences in degradation rate were seen in polyglactin 910 sutures after day 6 (saline: -0.9 N/d; 95% CI, -1.0 to -0.7 vs saliva: -1.2 N/d; 95% CI, -1.4 to -1.1). After day 2, chromic sutures had a degradation rate of -0.3 N/d (95% CI, -0.5 to -0.2) in saline and -0.5 N/d (95% CI, -0.6 to -0.3) in saliva. Conclusions and Relevance: Knowing the association of saliva with suture degradation rates of various suture types may enable oropharyngeal surgeons to select sutures that retain their strength and degrade at an appropriate rate to allow for the effective healing of the wound.

Risk factor analysis for mortality among infants requiring tracheostomy.

INTRODUCTION: An increasing number of tracheostomies are performed in infants with complex comorbidities including bronchopulmonary dysplasia (BPD) and congenital heart disease (CHD). With this shift in indications, there is an urgent need to characterize outcomes in this population. METHODS: This 5-year retrospective chart review assessed rates of 12-month mortality in infants who were ≤12 months of age at the time of tracheostomy at a tertiary care pediatric hospital and risk factors associated with death. Patient characteristics evaluated included chronologic age and post-menstrual age at tracheostomy placement, gestational age and weight, sex, ethnicity, indication for tracheostomy, and comorbidities including BPD, CHD, subglottic stenosis (SGS), craniofacial syndromes, and chromosomal trisomy syndromes. Subgroup analysis was performed in infants with CHD. RESULTS: One hundred thirty-two tracheostomies were performed during the study period with an overall 12-month mortality of 14.4% (19/132). Mortality was increased in patients with CHD (35%) and decreased in patients with SGS (3.7%). No other patient characteristics were associated with differences in mortality. There was a trend towards improved mortality outcomes among patients born at earlier gestational ages. CONCLUSIONS: Among infants with tracheostomy in this cohort, overall mortality rates were relatively low but not insignificant. CHD was associated with increased mortality; however, children with SGS showed more favorable outcomes. Other patient characteristics were not associated with differences in mortality. These data clarify outcomes in a group of infants with tracheostomy.