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Mauritz MD, von Both U, Dohna-Schwake C, Gille C, Hasan C, Huebner J, Hufnagel M, Knuf M, Liese JG, Renk H, Rudolph H, Schulze-Sturm U, Simon A, Stehling F, Tenenbaum T, Zernikow B. Clinical recommendations for the inpatient management of lower respiratory tract infections in children and adolescents with severe neurological impairment in Germany. Eur J Pediatr 2024; 183:987-999. [PMID: 38172444 PMCID: PMC10951000 DOI: 10.1007/s00431-023-05401-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/06/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024]
Abstract
Children and adolescents with severe neurological impairment (SNI) require specialized care due to their complex medical needs. In particular, these patients are often affected by severe and recurrent lower respiratory tract infections (LRTIs). These infections, including viral and bacterial etiology, pose a significant risk to these patients, often resulting in respiratory insufficiency and long-term impairments. Using expert consensus, we developed clinical recommendations on the management of LRTIs in children and adolescents with SNI. These recommendations emphasize comprehensive multidisciplinary care and antibiotic stewardship. Initial treatment should involve symptomatic care, including hydration, antipyretics, oxygen therapy, and respiratory support. In bacterial LRTIs, antibiotic therapy is initiated based on the severity of the infection, with aminopenicillin plus a beta-lactamase inhibitor recommended for community-acquired LRTIs and piperacillin-tazobactam for patients with chronic lung disease or tracheostomy. Ongoing management includes regular evaluations, adjustments to antibiotic therapy based on pathogen identification, and optimization of supportive care. Implementation of these recommendations aims to improve the diagnosis and treatment of LRTIs in children and adolescents with SNI. What is Known: • Children and adolescents with severe neurological impairment are particularly affected by severe and recurrent lower respiratory tract infections (LRTIs). • The indication and choice of antibiotic therapy for bacterial LRTI is often difficult because there are no evidence-based treatment recommendations for this heterogeneous but vulnerable patient population; the frequent overuse of broad-spectrum or reserve antibiotics in this patient population increases selection pressure for multidrug-resistant pathogens. What is New: • The proposed recommendations provide a crucial framework for focused diagnostics and treatment of LRTIs in children and adolescents with severe neurological impairment. • Along with recommendations for comprehensive and multidisciplinary therapy and antibiotic stewardship, ethical and palliative care aspects are taken into account.
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Affiliation(s)
- Maximilian David Mauritz
- Paediatric Palliative Care Centre, Children's and Adolescents' Hospital, 45711, Datteln, Germany.
- Department of Children's, Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine , Herdecke University, 58448, WittenWitten, Germany.
| | - Ulrich von Both
- Department of Infectious Diseases, Dr von Hauner Children's Hospital, LMU University Hospital, 80337, Munich, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, 45147, Essen, Germany
| | - Christian Gille
- Department of Neonatology, Heidelberg University Children's Hospital, 69120, Heidelberg, Germany
| | - Carola Hasan
- Paediatric Palliative Care Centre, Children's and Adolescents' Hospital, 45711, Datteln, Germany
- Department of Children's, Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine , Herdecke University, 58448, WittenWitten, Germany
| | - Johannes Huebner
- Department of Infectious Diseases, Dr von Hauner Children's Hospital, LMU University Hospital, 80337, Munich, Germany
| | - Markus Hufnagel
- Department of Paediatrics and Adolescent Medicine, Medical Faculty, University Medical Centre, University of Freiburg, 79106, Freiburg, Germany
| | - Markus Knuf
- Department for Pediatric and Adolescent Medicine, Worms Clinic, 67550, Worms, Germany
| | - Johannes G Liese
- Department of Paediatrics, Division of Paediatric Infectious Diseases, University Hospital of Wuerzburg, 97080, Würzburg, Germany
| | - Hanna Renk
- University Children's Hospital Tuebingen, 72076, Tuebingen, Germany
| | - Henriette Rudolph
- Department of Pediatrics, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany
| | - Ulf Schulze-Sturm
- University Children's Hospital, University Medical Centre Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Arne Simon
- Pediatric Oncology and Hematology, University Hospital Homburg Saar, 66421, Homburg/Saar, Germany
| | - Florian Stehling
- Department of Pediatric Pulmonology and Sleep Medicine, University Children's Hospital Essen, 45147, Essen, Germany
| | - Tobias Tenenbaum
- Clinic for Child and Adolescent Medicine, Sana Klinikum Lichtenberg, Academic Teaching Hospital, Charité-Universitätsmedizin, 10365, Berlin, Germany
| | - Boris Zernikow
- Paediatric Palliative Care Centre, Children's and Adolescents' Hospital, 45711, Datteln, Germany
- Department of Children's, Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine , Herdecke University, 58448, WittenWitten, Germany
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2
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Lower Respiratory Tract Infections in Pediatric Patients with Severe Neurological Impairments: Clinical Observations and Perspectives in a Palliative Care Unit. CHILDREN 2022; 9:children9060852. [PMID: 35740789 PMCID: PMC9221664 DOI: 10.3390/children9060852] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/02/2022] [Accepted: 06/06/2022] [Indexed: 11/29/2022]
Abstract
Pediatric palliative care (PPC) patients with a severe neurologic impairment (SNI) suffer considerable morbidity and increased mortality from lower respiratory tract infections (LRTIs). The indication and choice of antibiotic therapy for bacterial LRTIs are often challenging given the lack of evidence-based treatment recommendations for this vulnerable patient population. We conducted an observational study before the SARS-CoV-2 pandemic in an eight-bed pediatric palliative care inpatient unit. During two years of surveillance, we diagnosed and treated 33 cases of a bacterial LRTI in patients with an SNI; 5 patients were hospitalized with an LRTI more than once. Two patients died from complications due to LRTIs during hospitalization. Three patients (15%) were colonized with multidrug-resistant organisms. An initial antibiotic treatment failed in one-third of the cases; a successful therapy of the LRTI was achieved with broad-spectrum and extended-spectrum penicillins (n = 13; in combination with β-lactamase inhibitors for n = 5 cases), cephalosporins (n = 13: n = 4 second-generation and n = 9 third-generation cephalosporins; in combination with other substances for n = 5 cases), ciprofloxacin (n = 3), and meropenem plus vancomycin (n = 2) or meropenem (n = 1). A respiratory specimen was obtained in 66.7% of cases with P. aeruginosa, E. coli, and K. pneumoniae accounting for the majority of the detected species. In most cases, there was no definite confirmation that the LRTI was caused by the species detected. The diagnostics and treatment of bacterial LRTIs in PPC patients with an SNI are challenging. The lack of controlled studies and the heterogeneity of this population often necessitate an individual approach. This lack of controlled studies may partly be compensated by a set of diagnostic and antibiotic stewardship criteria.
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Keller SR, Mallack EJ, Rubin JP, Accardo JA, Brault JA, Corre CS, Elizondo C, Garafola J, Jackson-Garcia AC, Rhee J, Seeger E, Shullanberger KC, Tourjee A, Trovato MK, Waldman AT, Wallace JL, Wallace MR, Werner K, White A, Ess KC, Becker C, Eichler FS. Practical Approaches and Knowledge Gaps in the Care for Children With Leukodystrophies. J Child Neurol 2021; 36:65-78. [PMID: 32875938 PMCID: PMC7736398 DOI: 10.1177/0883073820946154] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Leukodystrophies are a group of neurodegenerative genetic disorders that affect approximately 1 in 7500 individuals. Despite therapeutic progress in individual leukodystrophies, guidelines in neurologic care are sparse and consensus among physicians and caregivers remains a challenge. At patient advocacy meetings hosted by Hunter's Hope from 2016-2018, multidisciplinary experts and caregivers met to conduct a literature review, identify knowledge gaps and summarize best practices regarding neurologic care. Stages of severity in leukodystrophies guided recommendations to address different levels of need based on a newly defined system of disease severity. Four core neurologic domains prioritized by families were identified and became the focus of this guideline: sleep, pain, seizures/epilepsy, and language/cognition. Based on clinical severity, the following categories were used: presymptomatic, early symptomatic, intermediate symptomatic, and advanced symptomatic. Across the leukodystrophies, neurologic care should be tailored to stages of severity while accounting for unique aspects of every disease and multiple knowledge gaps present. Standardized tools and surveys can help guide treatment but should not overburden families.
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Affiliation(s)
- Stephanie R. Keller
- Department of Pediatrics, Division of Pediatric Neurology, Emory University/Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Eric J. Mallack
- Department of Pediatrics, Division of Child Neurology, Weill Cornell
Medical College/New York-Presbyterian Hospital, New York, NY, USA
| | - Jennifer P. Rubin
- Department of Pediatric Neurology, Northwestern Feinberg School of
Medicine, Chicago, IL, USA
| | - Jennifer A. Accardo
- Department of Neurology, Children’s Hospital of Richmond at VCU,
Richmond, VA, USA
| | - Jennifer A. Brault
- Department of Pediatrics, Division of Pediatric Neurology Vanderbilt University Medical Center, Nashville, TN, USA
| | - Camille S. Corre
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Camila Elizondo
- East Boston Neighborhood Health Canter, East Boston, MA, USA
| | - Jennifer Garafola
- Department of Pediatrics, Division of Pediatric Neurology Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Jullie Rhee
- Children’s National Health Systems, Washington, DC, USA
| | | | | | - Amanda Tourjee
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Melissa K. Trovato
- Department of Physical Medicine and Rehabilitation, Kennedy Krieger Institute and Johns Hopkins University, Baltimore, MD, USA
| | - Amy T. Waldman
- Division of Neurology, The Children’s Hospital of Philadelphia,
University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Klaus Werner
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - Angela White
- Department of Pediatrics, Division of Pediatric Neurology Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kevin C. Ess
- Department of Pediatrics, Division of Pediatric Neurology Vanderbilt University Medical Center, Nashville, TN, USA
| | - Catherine Becker
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Florian S. Eichler
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA,Florian S. Eichler, MD, Department of
Neurology, Massachusetts General Hospital, 175 Cambridge Street, Suite 340,
Boston, MA 02114, USA.
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Mauritz MD, Hasan C, Dreier LA, Schmidt P, Zernikow B. Opioid-Induced Respiratory Depression in Pediatric Palliative Care Patients with Severe Neurological Impairment-A Scoping Literature Review and Case Reports. CHILDREN-BASEL 2020; 7:children7120312. [PMID: 33371493 PMCID: PMC7767476 DOI: 10.3390/children7120312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/18/2020] [Accepted: 12/18/2020] [Indexed: 11/16/2022]
Abstract
Pediatric Palliative Care (PPC) addresses children, adolescents, and young adults with a broad spectrum of underlying diseases. A substantial proportion of these patients have irreversible conditions accompanied by Severe Neurological Impairment (SNI). For the treatment of pain and dyspnea, strong opioids are widely used in PPC. Nonetheless, there is considerable uncertainty regarding the opioid-related side effects in pediatric patients with SNI, particularly concerning Opioid-Induced Respiratory Depression (OIRD). Research on pain and OIRD in pediatric patients with SNI is limited. Using scoping review methodology, we performed a systematic literature search for OIRD in pediatric patients with SNI. Out of n = 521 identified articles, n = 6 studies were included in the review. Most studies examined the effects of short-term intravenous opioid therapy. The incidence of OIRD varied between 0.13% and 4.6%; besides SNI, comorbidities, and polypharmacy were the most relevant risk factors. Additionally, three clinical cases of OIRD in PPC patients receiving oral or transdermal opioids are presented and discussed. The case reports indicate that the risk factors identified in the scoping review also apply to adolescents and young adults with SNI receiving low-dose oral or transdermal opioid therapy. However, the risk of OIRD should never be a barrier to adequate symptom relief. We recommend careful consideration and systematic observation of opioid therapy in this population of patients.
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Affiliation(s)
- Maximilian David Mauritz
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany; (C.H.); (P.S.); (B.Z.)
- Correspondence: ; Tel.: +49-2363-9750
| | - Carola Hasan
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany; (C.H.); (P.S.); (B.Z.)
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
| | | | - Pia Schmidt
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany; (C.H.); (P.S.); (B.Z.)
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
| | - Boris Zernikow
- Paediatric Palliative Care Centre, Children’s and Adolescents’ Hospital, 45711 Datteln, Germany; (C.H.); (P.S.); (B.Z.)
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, 58448 Witten, Germany
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5
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Allen J, Molloy E, McDonald D. Severe neurological impairment: a review of the definition. Dev Med Child Neurol 2020; 62:277-282. [PMID: 31237356 DOI: 10.1111/dmcn.14294] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2019] [Indexed: 12/30/2022]
Abstract
Severe neurological impairment (SNI) is a term commonly used in the medical literature, though there is no agreed definition. This limits opportunities for research into healthcare needs, treatment opportunities, resource planning, and outcome. We reviewed the literature to establish consistency of use of the term and to place it in the context of other commonly employed terms used to describe children with severe, complex medical needs. Forty-two articles were included for full-text analysis, with 23 including a definition of SNI. Motor impairment, intellectual disability, communication difficulties, and increased care needs were included in the definition in 80%, 70%, 30%, and 13% of papers respectively. Dependence on others for decision-making, chronicity, and distinction between disorders of the central nervous system and peripheral nervous system were less frequently included. There is wide variation in the use of the term SNI. A consensus-based definition of this term would be useful to facilitate future research. WHAT THIS PAPER ADDS: There is inconsistency in use of the term severe neurological impairment (SNI), limiting research efforts. In defining SNI, considerations are mobility, intellectual disability, communication difficulties, and increased care needs. Distinction between acute and chronic, central and peripheral nervous system disorders, and dependence on others for decision-making were less significant.
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Affiliation(s)
- John Allen
- Department of Paediatrics, Tallaght University Hospital, Tallaght, Dublin, Ireland.,Discipline of Paediatrics and Child Health, Trinity College, University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College, University of Dublin, Dublin, Ireland
| | - Eleanor Molloy
- Department of Paediatrics, Tallaght University Hospital, Tallaght, Dublin, Ireland.,Discipline of Paediatrics and Child Health, Trinity College, University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College, University of Dublin, Dublin, Ireland.,Trinity Translational Medicine Institute, St. James' Hospital, Dublin, Ireland.,Neonatology, Coombe Women and Infants' University Hospital, Dublin, Ireland.,Neonatology, Our Lady's Children's Hospital, Dublin, Ireland
| | - Denise McDonald
- Department of Paediatrics, Tallaght University Hospital, Tallaght, Dublin, Ireland.,Discipline of Paediatrics and Child Health, Trinity College, University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College, University of Dublin, Dublin, Ireland
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6
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Pieper L, Zernikow B, Drake R, Frosch M, Printz M, Wager J. Dyspnea in Children with Life-Threatening and Life-Limiting Complex Chronic Conditions. J Palliat Med 2018; 21:552-564. [DOI: 10.1089/jpm.2017.0240] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lucas Pieper
- Paediatric Palliative Care Centre, Children's and Adolescents' Hospital, Datteln, and Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health–School of Medicine, Witten/Herdecke University, Datteln, Germany
| | - Boris Zernikow
- Paediatric Palliative Care Centre, Children's and Adolescents' Hospital, Datteln, and Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health–School of Medicine, Witten/Herdecke University, Datteln, Germany
| | - Ross Drake
- Clinical Lead Paediatric Palliative Care Service, Starship children's Health, Auckland, New Zealand
| | - Michael Frosch
- Paediatric Palliative Care Centre, Children's and Adolescents' Hospital, Datteln, and Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health–School of Medicine, Witten/Herdecke University, Datteln, Germany
| | - Michael Printz
- Paediatric Palliative Care Centre, Children's and Adolescents' Hospital, Datteln, and Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health–School of Medicine, Witten/Herdecke University, Datteln, Germany
| | - Julia Wager
- Paediatric Palliative Care Centre, Children's and Adolescents' Hospital, Datteln, and Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health–School of Medicine, Witten/Herdecke University, Datteln, Germany
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7
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Hauer J, Houtrow AJ, Feudtner C, Klein S, Klick J, Linebarger J, Norwood KW, Adams RC, Brei TJ, Davidson LF, Davis BE, Friedman SL, Hyman SL, Kuo DZ, Noritz GH, Yin L, Murphy NA. Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System. Pediatrics 2017; 139:peds.2017-1002. [PMID: 28562301 DOI: 10.1542/peds.2017-1002] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pain is a frequent and significant problem for children with impairment of the central nervous system, with the highest frequency and severity occurring in children with the greatest impairment. Despite the significance of the problem, this population remains vulnerable to underrecognition and undertreatment of pain. Barriers to treatment may include uncertainty in identifying pain along with limited experience and fear with the use of medications for pain treatment. Behavioral pain-assessment tools are reviewed in this clinical report, along with other strategies for monitoring pain after an intervention. Sources of pain in this population include acute-onset pain attributable to tissue injury or inflammation resulting in nociceptive pain, with pain then expected to resolve after treatment directed at the source. Other sources can result in chronic intermittent pain that, for many, occurs on a weekly to daily basis, commonly attributed to gastroesophageal reflux, spasticity, and hip subluxation. Most challenging are pain sources attributable to the impaired central nervous system, requiring empirical medication trials directed at causes that cannot be identified by diagnostic tests, such as central neuropathic pain. Interventions reviewed include integrative therapies and medications, such as gabapentinoids, tricyclic antidepressants, α-agonists, and opioids. This clinical report aims to address, with evidence-based guidance, the inherent challenges with the goal to improve comfort throughout life in this vulnerable group of children.
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Affiliation(s)
- Julie Hauer
- Complex Care Service, Division of General Pediatrics, Boston Children’s Hospital, Assistant Professor, Harvard Medical School, Boston Massachusetts
- Seven Hills Pediatric Center, Groton, Massachusetts; and
| | - Amy J. Houtrow
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pediatric Rehabilitation Medicine, Rehabilitation Institute, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
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8
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Abstract
Pain management in the neonatal ICU remains challenging for many clinicians and in many complex care circumstances. The authors review general pain management principles and address the use of pain scales, non-pharmacologic management, and various agents that may be useful in general neonatal practice, procedurally, or at the end of life. Chronic pain and neonatal abstinence are also noted.
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Affiliation(s)
- Brian S Carter
- Department of Pediatrics, Division of Neonatology, University of Missouri at Kansas City School of Medicine, 2401 Gillham Rd, Kansas City, MO 64108; Children׳s Mercy Bioethics Center, Kansas City, MO.
| | - Jessica Brunkhorst
- Department of Pediatrics, Division of Neonatology, University of Missouri at Kansas City School of Medicine, 2401 Gillham Rd, Kansas City, MO 64108
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