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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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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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Lin JL, Rigdon J, Van Haren K, Buu M, Saynina O, Bhattacharya J, Owens DK, Sanders LM. Gastrostomy Tubes Placed in Children With Neurologic Impairment: Associated Morbidity and Mortality. J Child Neurol 2021; 36:727-734. [PMID: 33750232 DOI: 10.1177/08830738211000179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Gastrostomy tube (G-tube) placement for children with neurologic impairment with dysphagia has been suggested for pneumonia prevention. However, prior studies demonstrated an association between G-tube placement and increased risk of pneumonia. We evaluate the association between timing of G-tube placement and death or severe pneumonia in children with neurologic impairment. METHODS We included all children enrolled in California Children's Services between July 1, 2009, and June 30, 2014, with neurologic impairment and 1 pneumonia hospitalization. Prior to analysis, children with new G-tubes and those without were 1:2 propensity score matched on sociodemographics, medical complexity, and severity of index hospitalization. We used a time-varying Cox proportional hazard model for subsequent death or composite outcome of death or severe pneumonia to compare those with new G-tubes vs those without, adjusting for covariates described above. RESULTS A total of 2490 children met eligibility criteria, of whom 219 (9%) died and 789 (32%) had severe pneumonia. Compared to children without G-tubes, children with new G-tubes had decreased risk of death (hazard ratio [HR] 0.47, 95% confidence interval [CI] 0.39-0.55) but increased risk of the composite outcome (HR 1.21, CI 1.14-1.27). Sensitivity analyses using varied time criteria for definitions of G-tube and outcome found that more recent G-tube placement had greater associated risk reduction for death but increased risk of severe pneumonia. CONCLUSION Recent G-tube placement is associated with reduced risk of death but increased risk of severe pneumonia. Decisions to place G-tubes for pulmonary indications in children with neurologic impairment should weigh the impact of severe pneumonia on quality of life.
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Affiliation(s)
- Jody L Lin
- Division of Pediatric Hospital Medicine, Department of Pediatrics, 14434University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Joseph Rigdon
- Department of Biostatistics and Data Science, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Keith Van Haren
- Division of Child Neurology, Department of Neurology and Neurological Science, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - MyMy Buu
- Division of Pediatric Pulmonary Medicine, Department of Pediatrics, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Olga Saynina
- Division of General Pediatrics, Department of Pediatrics, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Jay Bhattacharya
- Stanford Health Policy, 166495Stanford University, Stanford, CA, USA
| | - Douglas K Owens
- Stanford Health Policy, 166495Stanford University, Stanford, CA, USA.,VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Lee M Sanders
- Division of General Pediatrics, Department of Pediatrics, 10624Stanford University School of Medicine, Stanford, CA, USA
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Lin JL, Tawfik DS, Gupta R, Imrie M, Bendavid E, Owens DK. Health and Economic Outcomes of Posterior Spinal Fusion for Children With Neuromuscular Scoliosis. Hosp Pediatr 2021; 10:257-265. [PMID: 32079619 DOI: 10.1542/hpeds.2019-0153] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Neuromuscular scoliosis (NMS) can result in severe disability. Nonoperative management minimally slows scoliosis progression, but operative management with posterior spinal fusion (PSF) carries high risks of morbidity and mortality. In this study, we compare health and economic outcomes of PSF to nonoperative management for children with NMS to identify opportunities to improve care. METHODS We performed a cost-effectiveness analysis. Our decision analytic model included patients aged 5 to 20 years with NMS and a Cobb angle ≥50°, with a base case of 15-year-old patients. We estimated costs, life expectancy, quality-adjusted life-years (QALYs), and incremental cost-effectiveness from published literature and conducted sensitivity analyses on all model inputs. RESULTS We estimated that PSF resulted in modestly decreased discounted life expectancy (10.8 years) but longer quality-adjusted life expectancy (4.84 QALYs) than nonoperative management (11.2 years; 3.21 QALYs). PSF costs $75 400 per patient. Under base-case assumptions, PSF costs $50 100 per QALY gained. Our findings were sensitive to quality of life (QoL) and life expectancy, with PSF favored if it significantly increased QoL. CONCLUSIONS In patients with NMS, whether PSF is cost-effective depends strongly on the degree to which QoL improved, with larger improvements when NMS is the primary cause of debility, but limited data on QoL and life expectancy preclude a definitive assessment. Improved patient-centered outcome assessments are essential to understanding the effectiveness of NMS treatment alternatives. Because the degree to which PSF influences QoL substantially impacts health outcomes and varies by patient, clinicians should consider shared decision-making during PSF-related consultations.
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Affiliation(s)
- Jody L Lin
- Divisions of Pediatric Hospital Medicine and .,Clinical Excellence Research Center, Stanford University, Stanford, California.,Division of Inpatient Medicine, Department of Pediatrics, School of Medicine, The University of Utah, Salt Lake City, Utah; and
| | | | - Ribhav Gupta
- Division of Biomechanical Engineering, School of Engineering.,Divisions of Infectious Diseases and Geographic Medicine, and
| | | | - Eran Bendavid
- Primary Care and Population Health, Departments of Medicine and
| | - Douglas K Owens
- VA Palo Alto Health Care System, Palo Alto, California.,Stanford Health Policy, Freeman Spogli Institute for International Studies, School of Medicine, and
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Karaarslan U, Topal S, Ayhan Y, Ağın H. The Differences in Viral Etiologies between Children with and without Severe Disability Admitted to the Pediatric Intensive Care Unit with Acute Respiratory Illness. J PEDIAT INF DIS-GER 2020. [DOI: 10.1055/s-0040-1718541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Objectives The objectives of this study were to evaluate the differences in the viral etiologies and variability in the clinical course between children with and without severe disability (SD) admitted to the pediatric intensive care unit (PICU) with acute respiratory illness (ARI).
Methods The medical records of patients admitted to our PICU between June 2017 and July 2019 were retrospectively reviewed for viral etiology and clinical course.
Results Forty-eight of 136 patients included in the study had SD. The rates of requiring positive pressure ventilation (43.5% vs. 20.5%) or inotropic support (39.9% vs. 15.9%), and the median length of stay (11 [10] vs. 5 [8]) were significantly higher in children with SD (p < 0.01, each). Influenza infection was significantly higher in children with SD (20.8% vs. 2.3%; p < 0.01) whereas respiratory syncytial virus (RSV) infection was more common in children without SD (47.7% vs. 4.2%; p < 0.01). There was no statistically significant difference in terms of other viruses between study groups.
Conclusion In this present study, influenza was an important pathogen for children with SD, while RSV was the main cause of ARI-associated PICU admission in children without SD. By focusing on increasing the rate of immunization against influenza in children with SD and their caregivers the burden of influenza-associated PICU admissions could be decreased.
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Affiliation(s)
- Utku Karaarslan
- Department of Pediatric Critical Care, University of Health Sciences Behçet Uz Children’s Hospital, Izmir, Turkey
| | - Sevgi Topal
- Department of Pediatric Critical Care, University of Health Sciences Behçet Uz Children’s Hospital, Izmir, Turkey
| | - Yüce Ayhan
- Department of Medical Microbiology, University of Health Sciences Behçet Uz Children’s Hospital, Izmir, Turkey
| | - Hasan Ağın
- Department of Pediatric Critical Care, University of Health Sciences Behçet Uz Children’s Hospital, Izmir, Turkey
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Zhao J, Sang Y, Zhang Y, Zhang D, Chen J, Liu X. Efficacy of levetiracetam combined with sodium valproate on pediatric epilepsy and its effect on serum miR-106b in children. Exp Ther Med 2019; 18:4436-4442. [PMID: 31777547 PMCID: PMC6862620 DOI: 10.3892/etm.2019.8098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 08/21/2019] [Indexed: 12/28/2022] Open
Abstract
Efficacy of levetiracetam (LEV) combined with sodium valproate (SV) on pediatric epilepsy and its effect on serum miR-106b in children were investigated. One hundred and twenty children with epilepsy in Xuzhou Children's Hospital from July 2015 to July 2017 were enrolled, and divided into control group (n=60) and observation group (n=60) according to random sampling. Additionally, 100 children undergoing normal physical examination were collected as normal group. Patients in the control group were treated with SV, and patients in the observation group were treated with SV and LEV. RT-qPCR was used for detecting the relative expression of serum miR-106b in children. The clinical efficacy was evaluated. After treatment, the relative expression of serum miR-106b in the control group was significantly higher than that in the observation group (P<0.05). The difference in the control group was smaller than that in the observation group (P<0.05). According to the ROC curve analysis, when the cut-off value was 1.442, the sensitivity, specificity and area under curve (AUC) of miR-106b in the diagnosis of pediatric epilepsy were 94.00, 64.17 and 0.833 respectively. The clinical efficacy in the observation group was significantly better than that in the control group (P<0.05). Spearman's test showed that the expression of miR-106b gradually decreased with the continuous improvement of the clinical efficacy (P<0.05). The AUC of miR-106b was 0.833, 95% CI: 0.779 to 0.887, the cut-off was 1.442. LEV combined with SV is effective in the treatment of children with epilepsy, and does not increase the clinical ADR. The expression of serum miR-106b in children can be used as a clinical prognostic indicator and a potential diagnostic indicator.
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Affiliation(s)
- Jiaqiang Zhao
- Department of Neurology, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou, Jiangsu 221006, P.R. China
| | - Yan Sang
- Department of Neurology, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou, Jiangsu 221006, P.R. China
| | - Yuan Zhang
- Department of Neurology, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou, Jiangsu 221006, P.R. China
| | - Dongli Zhang
- Department of Neurology, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou, Jiangsu 221006, P.R. China
| | - Jiao Chen
- Department of Neurology, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou, Jiangsu 221006, P.R. China
| | - Xiaoming Liu
- Department of Neurology, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou, Jiangsu 221006, P.R. China
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Akcan FA, Dündar Y, Uluat A, Cebeci D, Sungur MA, Salman N, Ünlü İ. Pediatric Tracheotomies: A 5-Year Experience In 152 Children. ENT UPDATES 2018. [DOI: 10.32448/entupdates.458961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Millman AJ, Finelli L, Bramley AM, Peacock G, Williams DJ, Arnold SR, Grijalva CG, Anderson EJ, McCullers JA, Ampofo K, Pavia AT, Edwards KM, Jain S. Community-Acquired Pneumonia Hospitalization among Children with Neurologic Disorders. J Pediatr 2016; 173:188-195.e4. [PMID: 27017483 PMCID: PMC4897771 DOI: 10.1016/j.jpeds.2016.02.049] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 01/28/2016] [Accepted: 02/18/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe and compare the clinical characteristics, outcomes, and etiology of pneumonia among children hospitalized with community-acquired pneumonia (CAP) with neurologic disorders, non-neurologic underlying conditions, and no underlying conditions. STUDY DESIGN Children <18 years old hospitalized with clinical and radiographic CAP were enrolled at 3 US children's hospitals. Neurologic disorders included cerebral palsy, developmental delay, Down syndrome, epilepsy, non-Down syndrome chromosomal abnormalities, and spinal cord abnormalities. We compared the epidemiology, etiology, and clinical outcomes of CAP in children with neurologic disorders with those with non-neurologic underlying conditions, and those with no underlying conditions using bivariate, age-stratified, and multivariate logistic regression analyses. RESULTS From January 2010-June 2012, 2358 children with radiographically confirmed CAP were enrolled; 280 (11.9%) had a neurologic disorder (52.1% of these individuals also had non-neurologic underlying conditions), 934 (39.6%) had non-neurologic underlying conditions only, and 1144 (48.5%) had no underlying conditions. Children with neurologic disorders were older and more likely to require intensive care unit (ICU) admission than children with non-neurologic underlying conditions and children with no underlying conditions; similar proportions were mechanically ventilated. In age-stratified analysis, children with neurologic disorders were less likely to have a pathogen detected than children with non-neurologic underlying conditions. In multivariate analysis, having a neurologic disorder was associated with ICU admission for children ≥2 years of age. CONCLUSIONS Children with neurologic disorders hospitalized with CAP were less likely to have a pathogen detected and more likely to be admitted to the ICU than children without neurologic disorders.
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Affiliation(s)
- Alexander J. Millman
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA,Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA,Reprint requests: Alexander J. Millman, MD, Influenza Division, Centers for Disease Control and Prevention, 1600 Clifton Rd, Mailstop G-37, Atlanta, GA 30329.
| | - Lyn Finelli
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA
| | - Anna M. Bramley
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA
| | - Georgina Peacock
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Sandra R. Arnold
- Le Bonheur Children's Hospital, Memphis, TN,University of Tennessee Health Science Center, Memphis, TN
| | | | | | - Jonathan A. McCullers
- Le Bonheur Children's Hospital, Memphis, TN,University of Tennessee Health Science Center, Memphis, TN,St. Jude Children's Research Hospital, Memphis, TN
| | - Krow Ampofo
- University of Utah Health Sciences Center, Salt Lake City, UT
| | - Andrew T. Pavia
- University of Utah Health Sciences Center, Salt Lake City, UT
| | | | - Seema Jain
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA
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Winfield NR, Barker NJ, Turner ER, Quin GL. Non-pharmaceutical management of respiratory morbidity in children with severe global developmental delay. Cochrane Database Syst Rev 2014; 2014:CD010382. [PMID: 25326792 PMCID: PMC6435315 DOI: 10.1002/14651858.cd010382.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Children with severe global developmental delay (SGDD) have significant intellectual disability and severe motor impairment; they are extremely limited in their functional movement and are dependent upon others for all activities of daily living. SGDD does not directly cause lung dysfunction, but the combination of immobility, weakness, skeletal deformity and parenchymal damage from aspiration can lead to significant prevalence of respiratory illness. Respiratory pathology is a significant cause of morbidity and mortality for children with SGDD; it can result in frequent hospital admissions and impacts upon quality of life. Although many treatment approaches are available, there currently exists no comprehensive review of the literature to inform best practice. A broad range of treatment options exist; to focus the scope of this review and allow in-depth analysis, we have excluded pharmaceutical interventions. OBJECTIVES To assess the effects of non-pharmaceutical treatment modalities for the management of respiratory morbidity in children with severe global developmental delay. SEARCH METHODS We conducted comprehensive searches of the following databases from inception to November 2013: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Allied and Complementary Medicine Database (AMED) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We searched the Web of Science and clinical trials registries for grey literature and for planned, ongoing and unpublished trials. We checked the reference lists of all primary included studies for additional relevant references. SELECTION CRITERIA Randomised controlled trials, controlled trials and cohort studies of children up to 18 years of age with a diagnosis of severe neurological impairment and respiratory morbidity were included. Studies of airways clearance techniques, suction, assisted coughing, non-invasive ventilation, tracheostomy and postural management were eligible for inclusion. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by The Cochrane Collaboration. As the result of heterogeneity, we could not perform meta-analysis. We have therefore presented our results using a narrative approach. MAIN RESULTS Fifteen studies were included in the review. Studies included children with a range of severe neurological impairments in differing settings, for example, home and critical care. Several different treatment modalities were assessed, and a wide range of outcome measures were used. Most studies used a non-randomised design and included small sample groups. Only four randomised controlled trials were identified. Non-randomised design, lack of information about how participants were selected and who completed outcome measures and incomplete reporting led to high or unclear risk of bias in many studies. Results from low-quality studies suggest that use of non-invasive ventilation, mechanically assisted coughing, high-frequency chest wall oscillation (HFCWO), positive expiratory pressure and supportive seating may confer potential benefits. No serious adverse effects were reported for ventilatory support or airway clearance interventions other than one incident in a clinically unstable child following mechanically assisted coughing. Night-time positioning equipment and spinal bracing were shown to have a potentially negative effect for some participants. However, these findings must be considered as tentative and require testing in future randomised trials. AUTHORS' CONCLUSIONS This review found no high-quality evidence for any single intervention for the management of respiratory morbidity in children with severe global developmental delay. Our search yielded data on a wide range of interventions of interest. Significant differences in study design and in outcome measures precluded the possibility of meta-analysis. No conclusions on efficacy or safety of interventions for respiratory morbidity in children with severe global developmental delay can be made based upon the findings of this review.A co-ordinated approach to future research is vital to ensure that high-quality evidence becomes available to guide treatment for this vulnerable patient group.
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Affiliation(s)
- Naomi R Winfield
- Physiotherapy Department, Milton Keynes Hospital NHS Foundation Trust, Milton Keynes, Buckinghamshire, UK
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Delgado-Charro MB, Guy RH. Effective use of transdermal drug delivery in children. Adv Drug Deliv Rev 2014; 73:63-82. [PMID: 24333231 DOI: 10.1016/j.addr.2013.11.014] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 11/29/2013] [Indexed: 12/16/2022]
Abstract
Transdermal administration offers a non-invasive and convenient method for paediatric drug delivery. The competent skin barrier function in term infants and older children limits both water loss and the percutaneous entry of chemicals including drugs; but the smaller doses required by children eases the attainment of therapeutic concentrations. Transdermal patches used in paediatrics include fentanyl, buprenorphine, clonidine, scopolamine, methylphenidate, oestrogens, nicotine and tulobuterol. Some patches have paediatric labelling supported by clinical trials whereas others are used unlicensed. Innovative drug delivery methods, such as microneedles and sonophoresis are being tested for their safety and efficacy; needleless injectors are primarily used to administer growth hormone; and two iontophoretic devices were approved for paediatrics. In contrast, the immature and rapidly evolving skin barrier function in premature neonates represents a significant formulation challenge. Unfortunately, this population group suffers from an absence of approved transdermal formulations, a shortcoming exacerbated by the significant risk of excessive drug exposure via the incompletely formed skin barrier.
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11
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Winfield NR, Barker NJ, Quin GL, Turner ER. Non-pharmaceutical management of respiratory morbidity in children with severe global developmental delay. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [DOI: 10.1002/14651858.cd010382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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