Children, Volume 4, Issue 11 (November 2017) – 10 articles

The ability of body mass index (BMI) to predict excess fat in South Asian children is unknown. This cross-sectional study examines the influence of ethnicity on body fatness in children. Weight status and body fat were determined using BMI, waist circumference (WC), two skinfold sites (SF; triceps and subscapula) and leg-to-leg bioelectrical impedance analysis (BIA; Tanita BF350, Tanita, Tokyo, Japan) in 194 children aged 8.47 ± 0.50 years from Coventry, United Kingdom. Biological maturity was also determined. Analysis of covariance (ANCOVA) identified significant differences between ethnic (p < 0.001) and gender groups’ BMI (p = 0.026), with a significant covariate for skinfold (p < 0.001) and bioelectrical impedance (p < 0.001). For a given body fat value, South Asian children and females had a lower BMI value (−1.12 kg/m², p < 0.001 and −0.50 kg/m², p = 0.026, respectively, when adjusted for SF; −1.56 kg/m², p < 0.001 and −0.31 kg/m², p = 0.16, respectively, when adjusted for BIA) compared with white children and boys. The prediction model including ethnicity, gender and BIA explained 80.4% of the variance in BMI. Maturation was not found to be a significant covariate (p > 0.05). To conclude, the findings suggest that BMI cut-points may need to be lowered in South Asian children, and thus age-by-sex-by-ethnicity specific BMI cut-points are needed in children. Further research examining body composition with health parameters in this population is needed. Full article

Introduction: This study aimed to determine factors associated with the need for extracorporeal membrane oxygenation (ECMO) in children with congenital heart disease (CHD) during admission for cardiac surgery (CS). A secondary aim was to determine how ECMO impacted length, cost, and mortality of the admission. Methods: Data from the Kids’ Inpatient Database (KIDS) were utilized. Admissions with CHD under 18 years of age with cardiac surgery were included. Need for ECMO in these admissions was then identified. Univariate analysis was conducted to compare characteristics between admissions with and without ECMO. Regression analyses were conducted to determine what factors were independently associated with ECMO and whether ECMO independently impacted admission characteristics. Results: A total of 46,176 admissions with CHD and CS were included in the final analysis. Of these, 798 (1.7%) required ECMO. Median age of ECMO admissions was 0.5 years. The following were associated with ECMO: decreased age, heart failure, acute kidney injury, arrhythmia, double outlet right ventricle, atrioventricular septal defect, transposition, Ebstein anomaly, hypoplastic left heart syndrome, common arterial trunk, tetralogy of Fallot, coronary anomaly, valvuloplasty, repair of total anomalous pulmonary venous connection, arterial switch, RV to PA conduit placement, and heart transplant (p < 0.01). ECMO independently increased length of stay by 17.8 days, cost of stay by approximately $415,917, and inpatient mortality 22-fold. Conclusion: Only a small proportion of CHD patients undergoing CS require ECMO, although these patients require increased resource utilization and have high mortality. Specific cardiac lesions, cardiac surgeries, and comorbidities are associated with increased need for ECMO. Full article

Parents’ ability to regulate their emotions is essential to providing supportive caregiving behaviours when their child is in pain. Extant research focuses on parent self-reported experience or observable behavioural responses. Physiological responding, such as heart rate (HR) and heart rate variability (HRV), is critical to the experience and regulation of emotions and provides a complementary perspective on parent experience; yet, it is scarcely assessed. This pilot study examined parent (n = 25) cardiac response (HR, HRV) at rest (neutral film clip), immediately before the cold pressor task (pre-CPT), and following the CPT (post-CPT). Further, variables that may influence changes in HR and HRV in the context of pediatric pain were investigated, including (1) initial HRV, and (2) parent perception of their child’s typical response to needle procedures. Time-domain (root mean square of successive differences; RMSSD) and frequency-domain (high-frequency heart rate variability; HF-HRV) parameters of HRV were computed. HR and HF-HRV varied as a function of time block. Typical negative responses to needle pain related to higher parental HR and lower HRV at rest. Parents with higher HRV at baseline experienced the greatest decreases in HRV after the CPT. Consequently, considering previous experience with pain and resting HRV levels are relevant to understanding parent physiological responses before and after child pain. Full article

Background: Placement of endotracheal tubes (ETTs) and umbilical catheters (UCs) is essential in very preterm infant care. The aim of this study was to assess the effect of an educational initiative to optimize correct placement of ETTs and UCs in very preterm infants. Methods: A pre–post study design, evaluating optimal radiological position of ETTs and UCs in the first 72 h of life in infants <32 weeks gestational age (GA) was performed. Baseline data was obtained from a preceding 34-month period. The study intervention consisted of information from the pre-intervention audit, surface anatomy images of the newborn for optimal UC positioning, and weight-based calculations to estimate insertion depths for endotracheal intubation. A prospective evaluation of radiological placement of ETTs and UCs was then conducted over a 12-month period. Results: During the study period, 211 infants had at least one of the three procedures performed. One hundred and fifty-seven infants were included in the pre-education group, and 54 in the post-education group. All three procedures were performed in 50.3% (79/157) in the pre-education group, and 55.6% (30/54) in the post-education group. There was no significant difference in accurate placement following the introduction of the educational sessions; depth of ETTs (50% vs. 47%), umbilical arterial catheter (UAC) (40% vs. 43%,), and umbilical venous catheter (UVC)(14% vs. 23%). Conclusion: Despite education of staff on methods for appropriate ETT, UVC and UAC insertion length, the rate of accurate initial insertion depth remained suboptimal. Newer methods of determining optimal position need to be evaluated. Full article

Background: We report the prevalence of children with multiple medical symptoms in a pediatric neurology clinic, describe their symptom profiles, and explore their association with adverse childhood experiences (ACEs). Methods: We retrospectively reviewed 100 consecutive patients from an outpatient pediatric neurology clinic. Patients were included if they were ≥5 years old and reported ≥4 symptoms that were unexplained for ≥3-months. Symptom profiles across six functional domains were recorded: (1) executive dysfunction, (2) sleep disturbances, (3) autonomic dysregulation, (4) somatization, (5) digestive symptoms, and (6) emotional dysregulation. ACEs were scored for all patients. Results: Seventeen patients reported ≥4 medical symptoms. Somatization, sleep disturbances, and emotional dysregulation occurred in 100% patients, with executive dysfunction (94%), autonomic dysregulation (76%), and digestive problems (71%) in the majority. Forty-two children reported ≥1 ACE, but children with ≥4 symptoms were more likely to report ACEs compared to other children (88% vs. 33%; p < 0.0001) and had a higher median total ACE score (3 vs. 1; p < 0.001). Conclusions: Children with multiple medical symptoms should be screened for potential exposure to ACEs. A clinical profile of symptoms across multiple functional domains suggests putative neurobiological mechanisms involving stress and nervous system dysregulation that require further study. Full article

The relationship between asthma and sleep-disordered breathing is bidirectional due to common risk factors that promote airway inflammation. Obstructive sleep-disordered breathing and recurrent wheeze/asthma are conditions that involve the upper and the lower respiratory system, respectively. The aim of the present study was to investigate the sleep disordered breathing in children with recurrent wheeze/asthma. This was a retrospective study concerning children older than 2 years who underwent—between January 2014 and November 2016—an in-laboratory overnight polygraphic study. We match the children between those who do or do not have recurrent wheeze/asthma disease. We examined the clinical records of 137 children. We excluded eight patients because of neurological and genetic conditions. Children with recurrent wheeze/asthma (N = 28) were younger (p = 0.002) and leaner (p = 0.013) compared to non-affected children (N = 98). Children with wheeze/asthma and unaffected ones had a similar obstructive apnea-hypopnea index (p = 0.733) and oxygen desaturation index (p = 0.535). The logistic regression analysis, in which the condition of wheeze/asthma (yes/no) was a dependent variable, while demographic (age, sex, body mass index (BMI) Z-score) and polygraphic results during sleep (obstructive apnea-hypopnea index, central apnea index, peripheral oxygen saturation (SpO₂), and snoring) were covariates, showed that children with wheeze/asthma had higher central apnea index (Exp(B) = 2.212; Wald 6.845; p = 0.009). In conclusion, children with recurrent wheeze/asthma showed an increased number of central sleep apneas than unaffected children. This finding may suggest a dysfunction of the breathing control in the central nervous system during sleep. Systemic or central inflammation could be the cause. Full article

This paper reviews the theoretical and empirical literature on risk and resilience factors impacting on parental bereavement outcomes following the death of a child with a life-limiting condition. Over the past few decades, bereavement research has focussed primarily on a risk-based approach. In light of advances in the literature on resilience, the authors propose a Risk and Resilience Model of Parental Bereavement, thus endeavouring to give more holistic consideration to a range of potential influences on parental bereavement outcomes. The literature will be reviewed with regard to the role of: (i) loss-oriented stressors (e.g., circumstances surrounding the death and multiple losses); (ii) inter-personal factors (e.g., marital factors, social support, and religious practices); (iii) intra-personal factors (e.g., neuroticism, trait optimism, psychological flexibility, attachment style, and gender); and (iv) coping and appraisal, on parental bereavement outcomes. Challenges facing this area of research are discussed, and research and clinical implications considered. Full article

The aim of this study was to review the aetiology, presentation and management of these patients with upper gastrointestinal bleeding (UGIB) at a tertiary children’s unit in the United Kingdom. This was a retrospective single-institution study on children (<16 years) who presented with acute UGIB over a period of 5 years using known International Classification of Diseases (ICD) codes. A total of 32 children (17 males, 15 females) were identified with a total median age at presentation of 5.5 years. The majority (24/32) of patients presented as an emergency. A total of 19/32 presented with isolated haematemesis, 8/32 with isolated melaena and 5/32 with a combination of melaena and haematemesis. On admission, the mean haemoglobin of patients who presented with isolated haematemesis was 11 g/dL, those with isolated melaena 9.3 g/dL and those with a combination 7.8 g/dL. Blood transfusion was required in 3/19 with haematemesis and 3/5 with haematemesis and melaena. A total of 19/32 underwent upper gastrointestinal endoscopy. Endoscopic findings were oesophageal varices (5/19) of which 4 required banding; bleeding gastric ulcer (1/19) requiring clips, haemospray and adrenaline; gastric vascular malformation (1/19) treated with Argon plasma coagulation therapy; duodenal ulcer (3/19) which required surgery in two cases; oesophagitis (5/19); and gastritis +/− duodenitis (3/19). A total of 13/32 patients did not undergo endoscopy and the presumed aetiology was a Mallory–Weiss tear (4/13); ingestion of foreign body (2/13); gastritis (3/13); viral illness (1/13); unknown (2/13). While UGIB is uncommon in children, the morbidity associated with it is very significant. Melaena, dropping haemoglobin, and requirement for a blood transfusion appear to be significant markers of an underlying cause of UGIB that requires therapeutic intervention. A multi-disciplinary team comprising gastroenterologists and surgeons is essential. Full article

Autoimmune hemolytic anemia is a rare hematologic entity in children. Etiologies are mainly viruses or bacteria. We describe here a case of severe warm autoimmune hemolytic anemia (IgG- and C3d-positive direct antiglobulin test) in an immunocompetent 6-month-old infant with acute Cytomegalovirus infection that responded well to corticotherapy and intraveneous immunoglobulins without using blood component transfusion. This case demonstrates the importance of recognizing CMV in infantile Autoimmune Hemolytic Anemia, especially because hemolysis can be severe and lethal. Full article

There is a need to examine the issue of childhood obesity from a systems perspective. This study aimed to describe the baseline characteristics of children attending pediatric multidisciplinary weight management services and understand how this information will inform future service delivery. A total of 51 children and adolescents who were overweight and obese (27 male) and aged between two and 16 years participated. Body size measures such as body mass index (BMI) and body fat percentage were collected. Participants and their parents/guardians also completed questionnaires on dietary intake, behaviors and habits, physical activity and health-related quality of life. A total of 72% of participants were classified as morbidly obese. Adolescents had significantly lower scores for overall diet, physical activity and particular health-related quality of life scores. No significant correlations were found between BMI z-scores and diet, physical activity and health-related quality of life. In adolescents, correlations were detected between dietary scores and health-related quality of life. Results confirm the need to critically examine the current context to adapt and tailor interventions to individual circumstances, and when combined with focused referral, triaging and screening processes, should assist in delivering the right care at the right time. Full article