Age-Dependent Responsiveness to Smoke Alarm Signals Among Children

OBJECTIVES

Although it has been established that smoke alarms have more difficulty awakening children from sleep than adults, no attempt has been previously made to characterize how smoke alarm responsiveness changes with age during childhood. The objective of this study is to evaluate the age-dependent responsiveness to various smoke alarm signals among children 5 to 12 years old.

METHODS

The effect of age on children's response to 4 types of smoke alarms (human voice, hybrid voice-tone, low-frequency tone, and high-frequency tone) was evaluated using combined data from 3 previous studies.

RESULTS

There were 540 subjects (median age 9 years; 51.7% male). The proportion of children who awakened demonstrated a statistically significant (P < .001) increase of 3.1% to 7.6% for each additional year of age between 5 and 12 years old for the 4 alarm types. Similarly, child age showed a statistically significant (P < .001) effect on the proportion who escaped for each of the 4 alarm types. The proportion of subjects who awakened or escaped did not differ significantly by sex for any of the alarm types. Median time-to-awaken and median time-to-escape decreased with increase in child age for all alarm types.

CONCLUSIONS

This study demonstrates the substantial influence of child age on the effectiveness of audible smoke alarms during childhood. Among 12-year-olds, only 56.3% escaped within 1 minute (and 67.6% within 2 minutes) to a high-frequency tone. However, a hybrid voice-low-frequency tone alarm is >96% effective at awakening and prompting escape within 1 minute among children 9 years and older.

Airway and Feeding Outcomes in Pierre Robin Sequence: A Comparison of Three Management Strategies

BACKGROUND

Controversy remains regarding optimal management of Pierre Robin sequence (PRS). The goal of this study was to compare airway and feeding outcomes in infants with PRS who underwent surgical intervention, specifically mandibular distraction osteogenesis (MDO) or tongue-lip adhesion (TLA), or who had conservative management (CM) without surgery.

METHODS

All consecutive patients treated for PRS at a pediatric academic medical center, with at least one year follow-up, were included. Patients who underwent tracheostomy as an index procedure were excluded. Patients were divided into those who underwent MDO, TLA or CM. Feeding status and data from initial and follow-up polysomnograms were collected. Comparisons between groups were made using the Kruskal-Wallis test, followed by Mann-Whitney pairwise comparison with a Bonferroni correction, when appropriate.

RESULTS

67 neonates were included. 19 underwent TLA, 29 underwent MDO and 19 underwent CM. The proportions of syndromic patients were similar between groups. Patients undergoing CM had the lowest baseline AHI (9.1), but there were no significant differences between TLA (20.1) and MDO (25.4). At follow-up, the three groups had similar mean AHI (MDO 1.3, TLA 4.2, CM 4.5). A similar proportion of patients achieved AHI 5 or less (TLA 89.5%, MDO 96.6%, CM 84.2%). At one year, there were no significant differences in weight percentiles or in risk of failure-to-thrive between groups. One patient from the TLA group required a tracheostomy.

CONCLUSION

The three treatment modalities achieved high airway and feeding success rates. All three modalities should have a place in the armamentarium of the craniofacial surgeon.

Optimizing smoke alarm signals: Testing the effectiveness of children's smoke alarms for sleeping adults

Background

Being asleep is an important risk factor for death during a residential fire; however, the high-frequency tone smoke alarms in many homes will not adequately awaken children who are old enough to self-rescue. In a series of previous studies, we identified smoke alarm signals that effectively awaken children 5–12 years old and prompt their escape. Because it is impractical to have separate alarms for children and adults in a household, the purpose of this study is to test whether alarms that are effective in awakening children and prompting their escape are also effective among adults.

Methods

Using a randomized, non-blinded, repeated measures design, 150 adults 20–49 years old were exposed during stage 4 sleep to four different smoke alarms. Statistical tests included the Kaplan-Meier estimator, generalized Wilcoxon test, and hazard ratios with Wald’s 95% confidence intervals.

Results

The median age of study subjects was 30.0 years and 67.3% were female. Almost all (n = 149) subjects awakened and performed the escape procedure to all four alarms; one individual did not awaken or escape to the high-frequency tone alarm. The median time-to-awaken was 2.0 s for the high-frequency tone alarm and 1.0 s for the other three alarms. The median time-to-escape for the high-frequency tone alarm was 12.0 s, compared with 10.0 s for the low-frequency tone alarm and 9.0 s each for the female and male voice alarms. All pairwise comparisons between the high-frequency tone alarm and each of the other three alarms were statistically significant for the probability functions for time-to-awaken and time-to-escape. There were no significant differences in these outcome measures between the latter three alarms, except for female voice versus low-frequency tone alarms for time-to-escape.

Conclusions

All alarms performed well, demonstrating that smoke alarms developed for the unique developmental requirements of sleeping children are also effective among sleeping adults. Compared with a high-frequency tone alarm, use of these alarms may reduce residential fire-related injuries and deaths among children, while also successfully alerting adult members of the household.

A Randomized Trial of a Self-Administered Parenting Intervention for Infant and Toddler Insomnia

Self-administered treatments may overcome access barriers to evidence-based care for pediatric sleep problems. Two hundred thirty-nine families participated in a randomized controlled trial with 3 study arms: a DVD intervention condition (the Sleep Easy Solution), a Website comparison condition, and a Wait-List comparison condition. The primary outcome was trichotomous-Do you consider your child's sleep a problem? (not a problem at all, a small problem, a very serious problem). DVD was superior to Wait-List in terms of the primary outcome ( P = .03; odds ratio = 0.44; 95% confidence interval = 0.21-0.93). Similarly, regarding secondary outcomes, DVD was superior to Wait-List in terms of longer continuous sleep periods ( P = .003), more favorable perceptions of the child's overall sleep ( P = .001), and higher parental confidence in managing the child's sleep ( P = .001). Results suggest that the DVD intervention is a promising self-administered treatment for pediatric insomnia.

Effectiveness of a Voice Smoke Alarm Using the Child's Name for Sleeping Children: A Randomized Trial

OBJECTIVES

To test maternal voice alarm effectiveness under residential conditions and determine whether personalizing the maternal voice alarm message with the child's first name improves effectiveness.

STUDY DESIGN

Using a randomized, nonblinded, repeated measures design, we compared 3 maternal voice smoke alarms with respect to their ability to awaken 176 children 5-12 years old from stage 4 slow-wave sleep and prompt their performance of an escape procedure. A conventional residential high-frequency tone smoke alarm was used as a comparative reference. Children's sleep stage was monitored in a residence-like research setting.

RESULTS

Maternal voice alarms awakened 86%-91% of children and prompted 84%-86% to escape compared with 53% awakened and 51% escaped for the tone alarm. A sleeping child was 2.9-3.4 times more likely to be awakened by each of the 3 voice alarms than the tone alarm. The median time to awaken was 156 seconds for the tone alarm and 2 seconds for each voice alarm. The proportions of children who awakened and escaped differed significantly between the tone alarm and each voice alarm, but no significant differences were found between each pair of the voice alarms, regardless of whether the child's first name was included in the alarm message.

CONCLUSIONS

The maternal voice alarms significantly outperformed the tone alarm under residential conditions. Personalizing the alarm message with the child's first name did not increase alarm effectiveness. These findings have important implications for development of an effective and practical smoke alarm for children.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01169155.

Sleep-disordered breathing and reaction time in children

Background

The incidence of obstructive sleep apnea (OSA) and sleep-disordered breathing (SDB) in children exceeds the availability of polysomnography (PSG) to definitively diagnose OSA and identify children at higher risk of perioperative complications. As sleep deficits are associated with slower reaction times (RTs), measuring RT may be a cost-effective approach to objectively identify SDB symptoms.

Aim

The aim of this study is to compare RT on a standard 10-minute psychomotor vigilance test (PVT) based on children’s history of OSA/SDB.

Methods

Children, 6–11 years of age, were enrolled from two different clinical groups. The SDB group included children undergoing adenotonsillectomy with a clinical history of SDB, OSA, or snoring. The control group included children with no history of SDB, OSA, or snoring who were scheduled for surgery other than adenotonsillectomy. RT was measured via 10-minute PVT (Ambulatory Monitoring Inc., Ardsley, NY, USA). Median RT was calculated for each patient based on all responses to stimuli during the PVT assessment and was compared to published age-sex-specific norms. The proportion of children exceeding RT norms was compared between study groups.

Results

The study included 72 patients (36/36 male/female, median age 7 years), 46 with SDB and 26 without SDB. There was no difference in the RT between the two groups. Fifty-four percent of patients with SDB exceeded norms for median RT vs 42% of control patients (95% CI of difference: – 12, 36; P=0.326).

Conclusion

Approximately half of the patients in both groups exceeded published norms for median RT on PVT. Despite its convenience, measurement of RT did not distinguish between patients with probable SDB/OSA for preoperative risk stratification.

Improving Communication Delay of Outpatient Sleep Study Results to Pediatric Otolaryngology Patients and Families

Objective

We undertook this quality improvement project to improve communication of outpatient pediatric sleep study results to families in a consistent and timely manner.

Methods

Based on the Institute for Healthcare Improvement quality improvement methodology, multiple key drivers were identified, including standardizing documentation and communication for sleep study results among the otolaryngology department, sleep center, and families. Meaningful interventions included developing standard electronic medical record documentation and utilizing otolaryngology nurses and advanced practice nurses to assist with communication by sending the results from the sleep center to both the referring otolaryngology provider and the triage nurses. The primary outcome measure was the monthly proportion of sleep studies communicated by the otolaryngology department to families within 3 business days.

Results

Average monthly sleep study results communicated to families within 3 business days increased from 31% to 92.9% over the study period ( P < .0001). Sleep study results were personally communicated via telephone and voicemail in 60.88% and 34.0% of cases, respectively. Approximately 50.0% of families receiving voicemails later contacted our department for their children’s study results.

Discussion

Novel documentation strategies and involvement of our entire clinical team (physicians, nurses, and advanced practice nurses), allowed us to significantly improve the consistency and timeliness of our communication of outpatient sleep study results to families in a proactive manner.

Implications for Practice

With time-sensitive clinical test results, such as those from pediatric sleep studies, intra- and interdepartmental collaboration and standardization of the communication process and documentation may allow for more expedient care of children with suspected obstructive sleep apnea.

Utility of screening questionnaire and polysomnography to predict postoperative outcomes in children

INTRODUCTION

The prevalence of pediatric obstructive sleep apnea (OSA) has increased concurrently with the increasing prevalence of obesity. We have previously validated a short questionnaire predicting the occurrence of OSA on polysomnography (PSG). This follow-up study assessed the utility of the questionnaire in predicting postoperative outcomes.

METHODS

Children undergoing surgery and completing a sleep study were prospectively screened for OSA using a short questionnaire. Procedures within 1 year of PSG were included in the analysis. Questionnaires were scored according to a cutoff previously deemed optimal for predicting OSA (apnea-hypopnea index ≥ 5) on the sleep study. Postoperative outcomes included prolonged (>60 min) length of stay (LOS) in the post-anesthesia care unit (PACU) and oxygen requirement in the PACU.

RESULTS

The study cohort included 185 patients (100/85 male/female) age 8 ± 4 years, undergoing adenotonsillectomy (n = 109), other ear, nose, and throat (ENT) procedures (n = 18), or non-ENT procedures (n = 58). There were 45 patients with OSA documented by PSG and 122 patients identified as likely to have OSA according to questionnaire responses (89% sensitivity, 41% specificity). PACU LOS was prolonged in 55/181 (30%) cases and supplemental oxygen was used in the PACU in 29/181 (16%) cases. In separate multivariable models, supplemental oxygen use in the PACU was more common if a patient scored ≥2/6 points on the short questionnaire scale (OR = 5.0; 95% CI: 1.3, 19.9; p = 0.023) or if the patient was diagnosed with OSA on PSG (OR = 4.6; 95% CI: 1.6, 13.5; p = 0.005). Neither OSA on PSG nor questionnaire score ≥2/6 were associated with prolonged PACU stay.

CONCLUSION

Both OSA diagnosis based on the AHI and the questionnaire scale achieved comparable predictive value for the need for oxygen use in the PACU. The utility of the questionnaire in predicting rare adverse events (e.g., unplanned admission or rapid response team activation) remains to be determined. Our preliminary results support using a brief questionnaire scale for preoperative risk stratification among children with suspected OSA who have not had a formal sleep study.

Impact of functional status and medical comorbidities on tracheostomy decannulation in pediatric patients

To determine if medical or functional factors influence the ability of a pediatric patient with a tracheostomy to tolerate decannulation. Retrospective evaluation of patients at a tertiary Children's Hospital undergoing evaluation with capped tracheostomy polysomnogram (cPSG) for possible tracheostomy decannulation. Charts were reviewed for demographic information, functional status, cPSG characteristics, and success or failure of decannulation. Statistical analysis was performed to determine which patient factors were predictive of successful decannulation. A total of 139 sleep studies were analyzed in 104 unique children followed for at least 1 year after a cPSG was performed to determine readiness for decannulation. At 1 year after most recent PSG, 79.8% of children were decannulated. There was no significant association between any single comorbid condition and the ability to decannulate. There was no association between individual or total functional status score and successful decannulation. Patients with at least 3 comorbid conditions investigated and a total functional score less than 7 were less likely to be decannulated successfully than other patients (71% vs. 93%, p= 0.04). Functional status and comorbid conditions do not independently predict successful decannulation. Regular multi-disciplinary team reevaluation is indicated in patients with lower functional status, as removal of tracheostomy tube may be successfully accomplished.

Effect of Severity of Esophageal Acidification on Sleep vs Wake Periods in Infants Presenting with Brief Resolved Unexplained Events

OBJECTIVES

To describe the pattern of gastroesophageal reflux (GER) events in wake and sleep states with increasing acid reflux index (ARI) in neonates and to test the hypothesis that GER-related symptoms are frequent in ARI >7% in wake state.

STUDY DESIGN

Infants underwent 24-hour pH-impedance studies with 6-hour concurrent video-polysomnography studies. Data were stratified based on the 24-hour ARI (% duration that esophageal pH is <4) into ARI < 3% (normal), ARI 3 ≥ to ≤7% (intermediate), and ARI >7% (abnormal). GER frequency, clearance mechanisms, and symptoms were distinguished during wake state and sleep state.

RESULTS

Total wake and sleep duration was similar (P ≥ .2) in all ARI groups. Acidic events were frequent with increasing ARI in wake state vs sleep state (P ≤ .03). The symptom index increased with increasing ARI (P ≤ .02) in both wake state and sleep state. Acid clearance time increased with increasing ARI in wake state (P ≤ .02). In ARI > 7% vs ARI ≤ 7%, frequency of acidic GER events was higher (P ≤ .02) in wake state and sleep state; proximal migration of acid (P = .03) and acid clearance time were higher in wake state (P = .0005) only. Symptom index was higher in ARI >7% vs ARI ≤ 7% in wake state (P < .0001), comparable in normal vs intermediate (P = .4), and higher in abnormal vs intermediate (P = .0004) groups.

CONCLUSIONS

Severe esophageal acid exposure (ARI >7%) is associated with increased reflux-associated symptoms in wake state. Sleep state appears to be protective regardless of ARI, likely because of greater chemosensory thresholds. Attention to posture and movements during wake state can be helpful. Scrutiny for non-GER etiologies should occur for infants presenting with life-threatening symptoms.

Utility of screening questionnaire, obesity, neck circumference, and sleep polysomnography to predict sleep-disordered breathing in children and adolescents

BACKGROUND

Polysomnography (PSG) remains the gold standard for diagnosing obstructive sleep apnea (OSA) and sleep-disordered breathing in children. Yet, simple screening tools are needed as it is not feasible to perform PSG in all patients with possible OSA.

AIM

The study adapted questions from the Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder (SRBD) Questionnaire to develop a predictive scale for OSA identified on PSG. We also tested whether adding anthropometric measurements (body mass index and neck circumference) improved prediction of OSA.

METHODS

After IRB approval, OSA questionnaires and anthropometric measurements were collected on 948 consecutive patients scheduled for PSG, aged 4 months to 24.5 years (median = 8.5 years). The sample was reduced to 636 patients in the age range (6-18 years old) where normative values for neck circumference are defined. OSA was characterized using the obstructive apnea-hypopnea index (AHI). After identifying questions related to OSA in univariate logistic regression, multivariable models were fitted to select questions for a short scale, and points for exceeding body mass or neck circumference cutoffs were added to assess improvement in predictive value.

RESULTS

A long scale of 16 questionnaire items was constructed using univariate models, while six items were selected for the short scale by multivariable regression. The short scale was associated with greater odds of moderate/severe OSA (OR = 1.964; 95% CI = 1.620, 2.381; P < 0.001) and attained good predictive value (area under receiver operating characteristics curve [AUC] = 0.74), which was not significantly improved by addition of BMI and neck circumference data (AUC = 0.75).

CONCLUSIONS

We developed a six-question scale with good predictive utility for OSA. These findings may contribute to developing a preoperative clinical tool to help clinicians identify children with OSA for determining risk stratification and postoperative disposition.

Gastroesophageal Reflux Affects Sleep Quality in Snoring Obese Children

PURPOSE

This study was performed to evaluate the quality of sleep in snoring obese children without obstructive sleep apnea (OSA); and to study the possible relationship between sleep interruption and gastroesophageal reflux (GER) in snoring obese children.

METHODS

Study subjects included 13 snoring obese children who were referred to our sleep lab for possible sleep-disordered breathing. Patients underwent multichannel intraluminal impedance and esophageal pH monitoring with simultaneous polysomnography. Exclusion criteria included history of fundoplication, cystic fibrosis, and infants under the age of 2 years. Significant association between arousals and awakenings with previous reflux were defined by symptom-association probability using 2-minute intervals.

RESULTS

Sleep efficiency ranged from 67-97% (median 81%). A total of 111 reflux episodes (90% acidic) were detected during sleep, but there were more episodes per hour during awake periods after sleep onset than during sleep (median 2.3 vs. 0.6, p=0.04). There were 279 total awakenings during the sleep study; 56 (20.1%) of them in 9 patients (69.2%) were preceded by reflux episodes (55 acid, 1 non-acid). In 5 patients (38.5%), awakenings were significantly associated with reflux.

CONCLUSION

The data suggest that acid GER causes sleep interruptions in obese children who have symptoms of snoring or restless sleep and without evidence of OSA.

Forced Expiratory Volume in 1 Second Variability Helps Identify Patients with Cystic Fibrosis at Risk of Greater Loss of Lung Function

OBJECTIVE

To evaluate several alternative measures of forced expiratory volume in 1 second percent predicted (FEV1 %pred) variability as potential predictors of future FEV1 %pred decline in patients with cystic fibrosis.

STUDY DESIGN

We included 13,827 patients age ≥6 years from the Epidemiologic Study of Cystic Fibrosis 1994-2002 with ≥4 FEV1 %pred measurements spanning ≥366 days in both a 2-year baseline period and a 2-year follow-up period. We predicted change from best baseline FEV1 %pred to best follow-up FEV1 %pred and change from baseline to best in the second follow-up year by using multivariable regression stratified by 4 lung-disease stages. We assessed 5 measures of variability (some as deviations from the best and some as deviations from the trend line) both alone and after controlling for demographic and clinical factors and for the slope and level of FEV1 %pred.

RESULTS

All 5 measures of FEV1 %pred variability were predictive, but the strongest predictor was median deviation from the best FEV1 %pred in the baseline period. The contribution to explanatory power (R(2)) was substantial and exceeded the total contribution of all other factors excluding the FEV1 %pred rate of decline. Adding the other variability measures provided minimal additional value.

CONCLUSIONS

Median deviation from the best FEV1 %pred is a simple metric that markedly improves prediction of FEV1 %pred decline even after the inclusion of demographic and clinical characteristics and the FEV1 %pred rate of decline. The routine calculation of this variability measure could allow clinicians to better identify patients at risk and therefore in need of increased intervention.

Pilot trial of light therapy for depression in hospitalized patients with cystic fibrosis

BACKGROUND

Depression is common in cystic fibrosis (CF) and linked with worse outcomes during hospitalization. Bright-light therapy during hospitalizations augments antidepressant regimens and reduces length of stay (LOS) in depressed non-CF patients, but has not been examined in CF METHODS: Thirty subjects used a light box emitting 10,000lx for 30min each day for 7 straight days following hospital admission for pulmonary exacerbation. Depressive symptom severity (QIDS-C) and quality of life factors (CFQ-R) were recorded pre/post light therapy.

RESULTS

Eighty percent of subjects had at least mild depressive symptoms upon admission. Hospitalized CF patients had a significantly lower mean LOS of 11.0±3.6 days compared to a historical cohort from the year prior (13.3±4.4 days, p value=0.038). There was a significant decrease in depressive symptoms for all subjects receiving light therapy (p value<0.0001). There was no relation between depressive symptoms and lung function or vitamin D. Six out of twelve quality of life indicators improved with light therapy including the domains of vitality, emotion, and health perceptions. There were no adverse events reported.

LIMITATIONS

As a pilot study, the design was limited by a lack of a control group and possible confounding effects of hospitalization treatment on systemic symptoms.

CONCLUSIONS

Light therapy was well tolerated by hospitalized CF patients and resulted in improved depressive symptoms and quality of life. Light therapy was associated with a reduced length of stay. Large, randomized trials of light therapy may be indicated for hospitalized CF patients.

Interactive Cohort Identification of Sleep Disorder Patients Using Natural Language Processing and i2b2

Nationwide Children's Hospital established an i2b2 (Informatics for Integrating Biology & the Bedside) application for sleep disorder cohort identification. Discrete data were gleaned from semistructured sleep study reports. The system showed to work more efficiently than the traditional manual chart review method, and it also enabled searching capabilities that were previously not possible.

OBJECTIVE

We report on the development and implementation of the sleep disorder i2b2 cohort identification system using natural language processing of semi-structured documents.

METHODS

We developed a natural language processing approach to automatically parse concepts and their values from semi-structured sleep study documents. Two parsers were developed: a regular expression parser for extracting numeric concepts and a NLP based tree parser for extracting textual concepts. Concepts were further organized into i2b2 ontologies based on document structures and in-domain knowledge.

RESULTS

26,550 concepts were extracted with 99% being textual concepts. 1.01 million facts were extracted from sleep study documents such as demographic information, sleep study lab results, medications, procedures, diagnoses, among others. The average accuracy of terminology parsing was over 83% when comparing against those by experts. The system is capable of capturing both standard and non-standard terminologies. The time for cohort identification has been reduced significantly from a few weeks to a few seconds.

CONCLUSION

Natural language processing was shown to be powerful for quickly converting large amount of semi-structured or unstructured clinical data into discrete concepts, which in combination of intuitive domain specific ontologies, allows fast and effective interactive cohort identification through the i2b2 platform for research and clinical use.

Risk factors for sleep apnea in children with bipolar disorder

BACKGROUND

While studies have suggested an increased prevalence of Obstructive Sleep Apnea (OSA) in adults with Bipolar Disorder (BPD), little is published about children with BPD. Behavioral difficulties including emotional liability, depression and poor school performance are commonly reported in children with either BPD or OSA. Comorbid medical disorders may exacerbate the course of BPD. We reviewed demographic and polysomnogram characteristics of children with BPD to help outpatient identification of OSA.

METHODS

A single center retrospective chart review of children with BPD referred for a polysomnogram (PSG) over a ten-year period was conducted. There were 27 children identified whose diagnosis of BPD was independently verified by a child psychiatrist using DSM-IV standard criteria.

RESULTS

Six (22%) children had OSA with a median apnea-hyponea index of 7.5 events per hour. Variables that were significantly different between the OSA and non-OSA groups were: median BMI (47 vs 30 kg/m(2), p=0.001); sleep efficiency (78.2% vs 91%, p=0.009); and oxygen saturation nadir (82% vs 92%, p=0.0003). There was no difference found in snoring percentage on PSG between the two groups.

LIMITATIONS

The retrospective design from a single tertiary center limited the cohort size. Only secondary verification of the diagnosis of BPD from the available medical record was possible.

CONCLUSIONS

Our findings suggest that extreme obesity (BMI >40 kg/m(2)), oxygen desaturation during sleep and frequent nocturnal awakenings are associated with OSA in children with BPD. Traditional clinical parameters for obesity and snoring, per se, are poor predictors of OSA in children with BPD.

Urine toxicology screen in multiple sleep latency test: the correlation of positive tetrahydrocannabinol, drug negative patients, and narcolepsy

OBJECTIVE

Drugs can influence results of multiple sleep latency tests (MSLT). We sought to identify the effect of marijuana on MSLT results in pediatric patients evaluated for excessive daytime sleepiness (EDS).

METHODS

This is a retrospective study of urine drug screens performed the morning before MSLT in 383 patients <21 years old referred for EDS. MSLT results were divided into those with (1) (-) urine drug screens, (2) urine drug screens (+) for tetrahydrocannabinol (THC) alone or THC plus other drugs, and (3) urine drug screens (+) for drugs other than THC. Groups were compared with Fisher exact tests or one-way ANOVA.

RESULTS

38 (10%) urine drug tests were (+): 14 for THC and 24 for other drugs. Forty-three percent of patients with drug screen (+) for THC had MSLT findings consistent with narcolepsy, 0% consistent with idiopathic hypersomnia, 29% other, and 29% normal. This was statistically different from those with (-) screens (24% narcolepsy, 20% idiopathic hypersomnia, 6% other, 50% normal), and those (+) for drugs other than THC (17% narcolepsy, 33% idiopathic hypersomnia, 4% other, 46% normal (p = 0.01). Six percent (6/93) of patients with MSLT findings consistent with narcolepsy were drug screen (+) for THC; 71% of patients with drug screen (+) for THC had multiple sleep onset REM periods (SOREMS). There were no (+) urine drug screens in patients <13 years old.

CONCLUSION

Many pediatric patients with (+) urine drug screens for THC met MSLT criteria for narcolepsy or had multiple SOREMs. Drug screening is important in interpreting MSLT findings for children ≥13 years.

Outcomes of adenotonsillectomy in patients with Prader-Willi syndrome

OBJECTIVE

To assess the efficacy of upper airway surgical intervention in patients with Prader-Willi syndrome (PWS). Due to reports of sudden death in children undergoing treatment with growth hormone for PWS, detection of sleep-disordered breathing by polysomnography (PSG) has been recommended.

DESIGN

Retrospective study.

SETTING

Multidisciplinary PWS Center at a tertiary care children's hospital.

PATIENTS

Thirteen pediatric patients with PWS who underwent adenotonsillectomy (T&A) with pre-PSG and post-PSG.

MAIN OUTCOME MEASURES

Comparison of PSG results before and after T&A.

RESULTS

Six of our patients were girls (46%); 8 had genetic characteristics consistent with deletion (61%), and the remaining 5 had genetic characteristics consistent with uniparental disomy (39%). The median age at T&A was 3 years (age range, 6 months to 11 years), and the median age at start of growth hormone treatment was 8.5 months (range, 2 months to 6 years). Nine of the 13 patients had mild to moderate obstructive sleep apnea (OSA) or obstructive hypoventilation (69%); in 8 of these 9, breathing normalized after T&A. Four children had severe OSA prior to surgery (31%). Breathing normalized in 2 of these after surgery, but 2 had PSG findings of residual combined obstructive and central apneas postoperatively.

CONCLUSIONS

Adenotonsillectomy, while effective in most children with PWS who demonstrate mild to moderate OSA, may not be curative in children with severe OSA. An increase in central apneas can occur in some children with PWS postoperatively, and it is important to repeat PSG after surgery. Further studies are necessary to determine optimal treatment for some children with PWS and sleep-disordered breathing.

Treatment of cataplexy in a three-year-old using venlafaxine

Narcolepsy with cataplexy is rare in children under 5 years of age. There is limited information on safe and effective treatment of cataplexy in young children. We describe successful treatment of cataplexy in a 3-year-old using venlafaxine and subsequently followed for over 2 years.

Maturation of upstream and downstream esophageal reflexes in human premature neonates: the role of sleep and awake states

We tested the hypothesis that the sensory-motor characteristics of aerodigestive reflexes are dependent on stimulus type and volumes, sleep or awake states, and maturation. Thirteen neonates were studied at 33.6 ± 0.5 wk (time 1) and 37.3 ± 0.5 wk (time 2) postmenstrual age using multimodal provocative esophageal manometry concurrent with video polysomnography. Effects of graded volumes (399 infusions at time 1, 430 infusions at time 2) of midesophageal stimulation with air, water, and apple juice on the sensory thresholds and recruitment frequency of upper esophageal sphincter (UES), esophageal body, and lower esophageal sphincter (LES) reflexes were investigated during sleep and awake states. Sensory thresholds for aerodigestive reflexes between maturational stages were similar. Increased frequency recruitment of UES contractile reflex, LES relaxation reflex, and peristaltic reflexes were noted at time 2 (all, P < 0.05). Graded stimulus-response relationships were evident at time 1 and time 2 during awake and sleep states (P < 0.05). Secondary peristalsis vs. esophago-deglutition response proportions during sleep at time 1 vs. time 2 (P = 0.001) and awake vs. sleep at time 2 (P = 0.02) were distinct. We concluded that sensory-motor effects of esophageal mechanosensitivity, osmosensitivity, and chemosensitivity are advanced in sleep with maturation. Sleep further modulates the frequency recruitment and the type of aerodigestive reflexes.

Esophageal sensation in premature human neonates: temporal relationships and implications of aerodigestive reflexes and electrocortical arousals

Electrocortical arousal (ECA) as an effect of visceral provocation or of its temporal relationships with aerodigestive reflexes in premature neonates is not known. We tested the hypothesis that esophageal provocation results in both esophageal reflex responses and ECAs during sleep and that ECAs are dependent on the frequency characteristics of esophageal neuromotor responses. We defined the spatiotemporal relationship of ECAs in relation to 1) spontaneous pharyngoesophageal swallow sequences and gastroesophageal reflux (GER) events and 2) sensory-motor characteristics of esophageal reflexes. Sixteen healthy premature neonates born at 27.9 ± 3.4 wk were tested at 36.8 ± 1.9 wk postmenstrual age. Ninety-five midesophageal and 31 sham stimuli were given in sleep during concurrent manometry and videopolysomnography. With stimulus onset as reference point, we scored the response latency, frequency occurrence and duration of arousals, peristaltic reflex, and upper esophageal sphincter contractile reflex (UESCR). Changes in polysomnography-respiratory patterns and esophageal sensory-motor parameters were scored by blinded observers. Significantly (for each characteristic listed, P < 0.05), swallow sequences were associated with arousals and sleep state changes, and arousals were associated with incomplete peristalsis, response delays to lower esophageal sphincter relaxation, and prolonged esophageal clearance. GER events (73.5%) provoked arousals, and arousals were associated with response delays to peristaltic reflexes or clearance, sleep state modification, and prolonged respiratory arousal. Midesophageal stimuli (54%) provoked arousals and were associated with increased frequency, prolonged latency, prolonged response duration of peristaltic reflexes and UESCR, and increased frequency of sleep state changes and respiratory arousals. In human neonates, ECAs are provoked upon esophageal stimulation; the sensory-motor characteristics of esophageal reflexes are distinct when accompanied by arousals. Aerodigestive homeostasis is defended by multiple tiers of aerodigestive safety mechanisms, and when esophageal reflexes are delayed, cortical hypervigilance (ECAs) occurs.

Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study

RATIONALE

The overall efficacy of adenotonsillectomy (AT) in treatment of obstructive sleep apnea syndrome (OSAS) in children is unknown. Although success rates are likely lower than previously estimated, factors that promote incomplete resolution of OSAS after AT remain undefined.

OBJECTIVES

To quantify the effect of demographic and clinical confounders known to impact the success of AT in treating OSAS.

METHODS

A multicenter collaborative retrospective review of all nocturnal polysomnograms performed both preoperatively and postoperatively on otherwise healthy children undergoing AT for the diagnosis of OSAS was conducted at six pediatric sleep centers in the United States and two in Europe. Multivariate generalized linear modeling was used to assess contributions of specific demographic factors on the post-AT obstructive apnea-hypopnea index (AHI).

MEASUREMENTS AND MAIN RESULTS

Data from 578 children (mean age, 6.9 +/- 3.8 yr) were analyzed, of which approximately 50% of included children were obese. AT resulted in a significant AHI reduction from 18.2 +/- 21.4 to 4.1 +/- 6.4/hour total sleep time (P < 0.001). Of the 578 children, only 157 (27.2%) had complete resolution of OSAS (i.e., post-AT AHI <1/h total sleep time). Age and body mass index z-score emerged as the two principal factors contributing to post-AT AHI (P < 0.001), with modest contributions by the presence of asthma and magnitude of pre-AT AHI (P < 0.05) among nonobese children.

CONCLUSIONS

AT leads to significant improvements in indices of sleep-disordered breathing in children. However, residual disease is present in a large proportion of children after AT, particularly among older (>7 yr) or obese children. In addition, the presence of severe OSAS in nonobese children or of chronic asthma warrants post-AT nocturnal polysomnography, in view of the higher risk for residual OSAS.

Web-survey of pharmacological and non-pharmacological sleep interventions for children with early-onset bipolar spectrum disorders

BACKGROUND

A web-based survey was developed to explore the effect of pharmacological and non-pharmacological interventions for sleep difficulties associated with Early-Onset Bipolar Spectrum Disorders (EBSD).

METHOD

Four hundred ninety four parents of 4-12 year-olds, identified by parents as being diagnosed with EBSD, provided information about which professionals were consulted regarding their child's EBSD-sleep problems and pharmacological and non-pharmacological interventions that helped or worsened sleep.

RESULTS

Most parents reported consulting at least one medical, mental health, and/or school professional regarding their child's sleep problems. Psychiatrists and other physicians were most often consulted. The majority of parents reported several medications/supplements as helpful, most commonly, atypical antipsychotics (54.4%). Over half identified various pharmacological agents that worsened sleep, most commonly, stimulants (35.0%). Most parents also reported several non-pharmacological interventions that aided sleep problems, most frequently, a sleep routine. Over two-thirds reported a variety of non-pharmacological interventions that worsened sleep, most notably, punishment (34.8%).

LIMITATIONS

The sample was non-random consisting of self-selected and web-savvy parents who self-identified their children as having EBSD and provided only parent derived data.

CONCLUSIONS

Although exploratory and despite limitations, this is the first survey to report data on both pharmacological and non-pharmacological treatments for EBSD-sleep problems. It highlights clinical interventions that may improve or worsen EBSD-sleep and provides directions for future research.

Mood-related sleep problems in children and adolescents

Sleep problems are an essential part of the current diagnostic criteria for depressive and bipolar disorders in children and adolescents. Whereas many studies have reported subjective sleep problems in youth with depression or bipolar disorder, except for reduced rapid eye movement latency associated with depression, few objective mood-related sleep abnormalities have been consistently identified. Recent technologic advances, such as spectral EEG and actigraphy, hold promise for revealing additional objective disturbances. There are presently few evidence-based published practice recommendations for mood-related sleep problems in youth. In this article, the authors chronologically review research on the phenomenology and treatment of sleep difficulties in youth with depressive and bipolar disorders and present research-based and clinically guided recommendations for the assessment and treatment of these problems.

Serotonin effects on sleep and emotional disorders in adolescent migraine

OBJECTIVE

To determine frequency of emotional disorders and sleep disturbances in adolescent migraineurs with episodic and chronic headaches. To determine the relationship of whole blood serotonin, caffeine consumption, and frequency of sleep and mood disorders.

BACKGROUND

The neurotransmitter serotonin has been implicated to play a role in the initiation and maintenance of sleep and in modulating mood. A putative role in migraine pathophysiology is also known.

METHODS

Adolescents from 13 to 17 years of age were identified from our headache clinic with episodic or chronic migraine (according to International Classification of Headache Disorders-Second Edition criteria) and healthy controls enrolled. Psychological rating scales were completed, including Adolescent Symptom Inventory (4th Edition) and Child Depression Inventory. Sleep questionnaires (Pediatric Sleep Questionnaire and Child Sleep Habit Questionnaire) were completed by the teenager's parents/guardian. Whole blood serotonin levels were drawn and analyzed and caffeine consumption obtained by history.

RESULTS

A total of 18 controls (8 girls) and 15 patients each with episodic migraines (9 girls) and chronic migraine (10 girls) were studied. Patients with headache had significantly more sleep problems than controls. Patients with chronic migraines had increased daytime sleepiness and dysthymia compared with teenagers with episodic migraines. Serotonin levels were not significantly different, and no association was noted between serotonin levels and sleep abnormalities or emotional rating scales. Increased caffeine intake was related to sleep and depressive complaints.

CONCLUSIONS

Sleep and emotional disorders were common in adolescents with migraine. Sleep disorders and dysthymia were more prevalent with increased headache frequency. No correlation was noted with whole blood serotonin levels.

Web survey of sleep problems associated with early-onset bipolar spectrum disorders

OBJECTIVE

As research on sleep difficulties associated with Early-Onset Bipolar Spectrum Disorders (EBSD) is limited, a web-based survey was developed to further explore these problems.

METHODS

494 parents of 4-to-12 year-olds, identified by parents as being diagnosed with EBSD, completed a web survey about past and current EBSD-related sleep problems. The survey included Children's Sleep Habits Questionnaire (CSHQ) items and sleep problems from the International Classification of Sleep Disorders 2nd edition.

RESULTS

Nearly all parents reported some type of past or current EBSD-sleep problem. Most occurred during a worst mood period, particularly with mixed manic-depressive symptoms. Symptoms caused impairments at home, school, or with peers in 96.9% of the sample and across all three contexts in 64.0% of children. Sleep problems were also noted after three-day weekends and Spring and Fall Daylight Savings time changes.

CONCLUSIONS

Findings, study limitations, and implications for treatment and etiology are discussed.

Parent and child reports of sleep problems associated with early-onset bipolar spectrum disorders

Despite sleep problems being part of the diagnostic criteria for mood disorders, research on sleep difficulties related to early-onset bipolar spectrum disorders (EBSDs) is sparse. The authors examined the parent and child agreement, frequency, and severity of EBSD-related manic, depressive, and comorbid sleep problems. A sample of one hundred thirty-three 8- to 11-year-olds with EBSDs was assessed with parental and self-report measures of EBSD-related sleep problems. Dimensional and categorical measures indicated low agreement and high discrepancy between parent and child reports of EBSD sleep problems. Subsequent combination of parent-child data revealed the majority (96.2%) of children had moderate-to-severe sleep problems related to manic, depressive, or comorbid symptoms, either currently or during their worst mood period. More depression-related sleep problems than mania-related sleep problems were reported, especially initial insomnia. Over half the sample had sleep problems associated with current comorbidity, particularly separation anxiety disorder. These findings, their implications, and study limitations are discussed.

Impairment of Reaction Time Among Children Awakened During Stage 4 Sleep

STUDY OBJECTIVE

Sleep inertia refers to impairments in cognitive/motor performance and the tendency to return to sleep after awakening. As part of a project studying the effect of different types of 100 decibel (dB) sounds on awakening children during stage 4 sleep (S4S), we hypothesized that children with the greatest impairment in auditory arousal during S4S, manifested by the inability to either awaken to 100 dB sounds or successfully perform a self-rescue sequence (SRS), would have greater impairments in reaction time (RT) upon awakening than children who awoke and successfully accomplish a SRS.

DESIGN

Observational study.

SETTING

Pediatric hospital-based sleep center.

PARTICIPANTS

Healthy children aged 6-12 years.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

RT was measured in 44 children approximately 90 minutes before bedtime and again after awakening by either 100 dB alarms or manually during the first and second cycles of S4S. Overall, mean and median RT slowed significantly by 37% and 22%, respectively, from baseline. Slowing of RT was most evident in the youngest children (aged 6-7 years) and after awakening from the second S4S cycle. Impairments in RT were not significantly different among children who successfully awakened to the alarm and performed a SRS compared with children who did not.

CONCLUSIONS

The degree of slowing of RT was not significantly different among children who awakened and performed an SRS compared with children who did not. The greatest slowing of RT was seen among younger children and after awakening from the second S4S cycle.

Comparison of a personalized parent voice smoke alarm with a conventional residential tone smoke alarm for awakening children

BACKGROUND

Conventional residential tone smoke alarms fail to awaken the majority of children during slow wave sleep. With the objective of identifying a more effective smoke alarm for children, we compared a personalized parent voice smoke alarm with a conventional residential tone smoke alarm, both presented at 100 dB, with respect to their ability to awaken children 6- to 12-years-old from stage 4 sleep and prompt their performance of a simulated self-rescue escape procedure.

METHODS

Using a randomized, nonblinded, clinical research design, a volunteer sample of healthy children 6- to 12-years-old was enrolled in the study. Children were trained how to perform a simulated self-rescue escape procedure when they heard a smoke alarm. Each child's mother recorded a voice alarm message, "First name! First name! Wake up! Get out of bed! Leave the room!" For each child, either the voice or tone smoke alarm was randomly selected and triggered during the first cycle of stage 4 sleep, and then the other alarm was triggered during the second cycle of stage 4 sleep. Children's sleep stage was monitored by electroencephalography, electro-oculography, and chin electromyography. The 4 main outcome measures included the number of children who awakened, the number of children who escaped, the time to awakening, and the time to escape.

RESULTS

Twenty-four children were enrolled. The median age was 9 years, and 11 (46%) were boys. One half of the children received the parent voice alarm first, and one half received the tone alarm first; however, the order that the alarm stimuli were presented was not statistically associated with awakening or escaping. Twenty-three (96%) of the 24 subjects awakened to the parent voice alarm compared with 14 (58%) to the tone alarm. One child did not awaken to either stimulus. Nine children awakened to their parent's voice but not to the tone, whereas none awakened to only the tone and not the voice. Twenty (83%) of the subjects in the parent voice alarm group successfully performed the escape procedure within 5 minutes of alarm onset compared with 9 (38%) in the tone alarm group. The median time to awaken was 20 seconds in the voice alarm group compared with 3 minutes in the tone alarm group. The median time to escape was 38 seconds in the voice alarm group compared with the maximum allowed 5 minutes in the tone alarm group. When exposed to the tone alarm, older children were more likely to awaken and were more likely to escape than younger children. There was no association between child's age and awakening or escaping for children exposed to the parent voice alarm. There was no association between child's gender and awakening or escaping for either alarm type.

CONCLUSIONS

To our knowledge, this study is the first to compare the ability of different types of smoke alarms to awaken children while monitoring sleep stage. The personalized parent voice smoke alarm at 100 dB successfully awakened 96% of children 6- to 12-years-old from stage 4 sleep with 83% successfully performing a simulated self-rescue escape procedure, significantly outperforming the 100-dB conventional residential tone smoke alarm. These findings suggest a clear direction for future research, as well as important fundamental changes in smoke alarm design, that address the unique developmental needs of children. The development of a more effective smoke alarm for use in homes and other locations where children sleep provides an opportunity to reduce fire-related morbidity and mortality among children.

Sleep problems in children with common medical disorders

Sleep problems are common in many pediatric medical disorders and complicate management and patient outcomes. A wide range of conditions, including asthma, cystic fibrosis, sickle cell disease, gastroesophageal reflux, neuromuscular diseases, scoliosis, craniofacial abnormalities, obesity, and chromosomal disorders, have various sleep disturbances, including sleep-disordered breathing, ventilatory dysfunction, sleep-onset and sleep maintenance problems, and circadian rhythm disturbances. Given the adverse neurocognitive and physiologic outcomes associated with a deranged night's sleep, it is important for pediatricians to be able to anticipate, recognize, and appropriately manage these problems. This article reviews the known sleep-related problems of a few relatively common pediatric disorders.

Comprehensive analysis of risk factors for acquisition of Pseudomonas aeruginosa in young children with cystic fibrosis

The objective of this study was to identify risk factors of significance for acquisition of Pseudomonas aeruginosa by children with cystic fibrosis (CF). Our working hypothesis is that exposure of infants and young children with CF to older, infected patients increases their risk for acquiring this organism. A special opportunity arose to study this question in detail, as we have been performing a randomized clinical trial of neonatal screening for CF throughout the state of Wisconsin during the period of 1985-1994. Patients were selected for this study based on either early identification through screening or diagnosis by standard methods. A longitudinal protocol employed at Wisconsin's two CF Centers includes routine cultures of respiratory secretions and collection of clinical, demographic, and activity information on patients and their families. Previous observations in our trial revealed that one center at an old hospital in an urban location showed a significantly shorter time to acquisition of P. aeruginosa for CF patients followed there. To study the center effect further, we performed statistical analyses using survival curves and stepwise regression analysis of all life history covariates available. The results of these analyses showed that the statistically significant correlations involve the following risk factors: 1) center and old hospital (r=0.42); 2) center and original physician (r=0.61); 3) center and exposure to pseudomonas-positive patients (r=0.29); and 4) population density and urban location (r=0.49). The final statistical model demonstrated that increased risk due to aerosol use (odds ratio=3.45, P=0.014) and a protective effect associated with education of the mother (odds ratio=0.81, P=0.024) were the most significant factors for acquisition of P. aeruginosa. The previously observed center effect was confined to the 1985-1990 interval at the old hospital (odds ratio=4.43, P < 0.001). We conclude that multiple factors are involved in increasing the risk of young children with CF to acquire P. aeruginosa, and that the observed center effect can best be explained by a combination of factors. These results suggest that facilities and methods used to care for young children with CF can significantly influence their likelihood of acquiring pseudomonas in the respiratory tract.

Acquisition of Pseudomonas aeruginosa in children with cystic fibrosis

OBJECTIVE

This study was pursued as an extension of a randomized clinical investigation of neonatal screening for cystic fibrosis (CF). The project included assessment of respiratory secretion cultures for pathogens associated with CF. The objective was to determine whether patients diagnosed through neonatal screening and treated in early infancy were more likely to become colonized with Pseudomonas aeruginosa compared with those identified by standard diagnostic methods.

METHODOLOGY

The design involved prospective cultures of respiratory secretions obtained generally by oropharyngeal swabs at least every 6 months and more often if clinically indicated. Patients were managed with a standardized evaluation and treatment protocol at the two Wisconsin certified CF centers; however, there were community and environmental variations associated with the follow-up period as described below.

RESULTS

Overall, there were no differences in acquisition of respiratory pathogens between the screened and the control (standard diagnosis) groups. Evaluation of the data between and within the two centers, however, revealed significant differences with earlier acquisition of P aeruginosa in the center with the following distinguishing characteristics: urban location; following patients with the standard US approach in which newly diagnosed, young children were interspersed with older CF patients; and where there were more opportunities for social interactions with other CF patients. The differences were confined to the screened group followed in the urban center in which the median pseudomonas-free survival period was 52 weeks contrasted with 289 weeks in the other center. In addition, assessment of data for the entire CF populations followed at the two centers revealed that the urban center showed a significantly higher prevalence of P aeruginosa colonization in patients between the ages of 3 and 9 years.

CONCLUSIONS

These results present questions and generate hypotheses on risk factors for acquisition of P aeruginosa in CF and suggest that clinic exposures and/or social interactions may predispose such patients to pseudomonas infections.

Nutritional benefits of neonatal screening for cystic fibrosis. Wisconsin Cystic Fibrosis Neonatal Screening Study Group

BACKGROUND

Many patients with cystic fibrosis are malnourished at the time of diagnosis. Whether newborn screening and early treatment may prevent the development of a nutritional deficiency is not known.

METHODS

We compared the nutritional status of patients with cystic fibrosis identified by neonatal screening or by standard diagnostic methods. A total of 650,341 newborn infants were screened by measuring immunoreactive trypsinogen on dried blood spots (from April 1985 through June 1991) or by combining the trypsinogen test with DNA analysis (from July 1991 through June 1994). Of 325,171 infants assigned to an early-diagnosis group, cystic fibrosis was diagnosed in 74 infants, including 5 with negative screening tests. Excluding infants with meconium ileus, we evaluated nutritional status for up to 10 years by anthropometric and biochemical methods in 56 of the infants who received an early diagnosis and in 40 of the infants in whom the diagnosis was made by standard methods (the control group). Pancreatic insufficiency was managed with nutritional interventions that included high-calorie diets, pancreatic-enzyme therapy, and fat-soluble vitamin supplements.

RESULTS

The diagnosis of cystic fibrosis was confirmed by a positive sweat test at a younger age in the early-diagnosis group than in the control group (mean age, 12 vs. 72 weeks). At the time of diagnosis, the early-diagnosis group had significantly higher height and weight percentiles and a higher head-circumference percentile (52nd, vs. 32nd in the control group; P=0.003). The early-diagnosis group also had significantly higher anthropometric indexes during the follow-up period, especially the children with pancreatic insufficiency and those who were homozygous for the deltaF508 mutation.

CONCLUSIONS

Neonatal screening provides the opportunity to prevent malnutrition in infants with cystic fibrosis.

Survival and functional outcome of children requiring endotracheal intubation during therapy for severe traumatic brain injury

OBJECTIVE

To determine the predictors of survival and functional outcome of pediatric patients with traumatic brain injury severe enough to require endotracheal intubation and mechanical ventilation.

DESIGN

Retrospective, observational cohort study.

SETTING

Pediatric intensive care unit (ICU) at a tertiary care children's hospital.

PATIENTS

All children (n = 105) admitted over a 5-yr period with traumatic brain injury severe enough to require endotracheal intubation and mechanical ventilation. The median age was 43 months (range 1 month to 14 yrs). Of these children, 74% were male and 70% were white.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Variables studied included vital signs during the first 24 hrs of admission, Pediatric Risk of Mortality (PRISM) score, Glasgow Coma Score, duration of mechanical ventilation, and number of pediatric ICU and hospital days. Functional status was graded as normal, independent, partially dependent, or dependent in the areas of locomotion, self-care, and communication. This status was assessed at hospital discharge by chart review and at follow-up by telephone interview. The median Glasgow Coma Score was 6 (range 3 to 14) and the median PRISM score was 13 (range 1 to 51). There were 19 (18.1%) deaths, 17 in the pediatric ICU and two after hospital discharge. Of the patients who survived to hospital discharge, 39 (37.1%) patients were completely normal or independent, 42 (40%) patients were partially dependent, and seven (6.7%) patients were dependent in all three areas of function. Follow-up evaluations were available for 80 patients, with a median follow-up time of 24.5 months (range 8 to 70). Of the 78 patients who survived and were available for follow-up, the number who were functionally normal or independent increased to 69 (65.7%). At follow-up, there were eight (7.6%) patients remaining with partial dependency in at least one area of function while one (0.9%) patient continued to be dependent in all three areas of function. Mortality and dependent functional outcome were more likely in patients with younger age, lower Glasgow Coma Score, and higher PRISM score at hospital admission. Of the 27 patients with a Glasgow Coma Score of < or = 5, 11 (40.7%) survived with normal or independent functional status at follow-up. Of the 24 patients with PRISM scores of > 20, only five (20.8%) were functionally normal or independent at follow-up. The relative risk of a bad outcome for patients with a Glasgow Coma Score of < or = 5 and a PRISM score of > or = 20 was ten times higher than the group of patients with a Glasgow Coma Score of < or = 5 but a PRISM score of < 20.

CONCLUSIONS

Children with severe traumatic brain injury who survive to hospital discharge will continue to improve in their functional status over the next few years. Although low Glasgow Coma Score is strongly associated with death or poor functional outcome after therapy for traumatic brain injury, many patients with Glasgow Coma Score of < or = 5 can survive with good function. PRISM scores add to the power of Glasgow Coma Score to predict survival and functional outcome in tracheally intubated pediatric patients with Glasgow Coma Score of < or = 5.

Newborn screening for cystic fibrosis in Wisconsin: comparison of biochemical and molecular methods

OBJECTIVES

To evaluate neonatal screening for cystic fibrosis (CF), including study of the screening procedures and characteristics of false-positive infants, over the past 10 years in Wisconsin. An important objective evolving from the original design has been to compare use of a single-tier immunoreactive trypsinogen (IRT) screening method with that of a two-tier method using IRT and analyses of samples for the most common cystic fibrosis transmembrane regulator (CFTR) (DeltaF508) mutation. We also examined the benefit of including up to 10 additional CFTR mutations in the screening protocol.

METHODS

From 1985 to 1994, using either the IRT or IRT/DNA protocol, 220 862 and 104 308 neonates, respectively, were screened for CF. For the IRT protocol, neonates with an IRT >/=180 ng/mL were considered positive, and the standard sweat chloride test was administered to determine CF status. For the IRT/DNA protocol, samples from the original dried-blood specimen on the Guthrie card of neonates with an IRT >/=110 ng/mL were tested for the presence of the DeltaF508 CFTR allele, and if the DNA test revealed one or two DeltaF508 alleles, a sweat test was obtained.

RESULTS

Both screening procedures had very high specificity. The sensitivity tended to be higher with the IRT/DNA protocol, but the differences were not statistically significant. The positive predictive value of the IRT/DNA screening protocol was 15.2% compared with 6.4% if the same samples had been screened by the IRT method. Assessment of the false-positive IRT/DNA population revealed that the two-tier method eliminates the disproportionate number of infants with low Apgar scores and also the high prevalence of African-Americans identified previously in our study of newborns with high IRT levels. We found that 55% of DNA-positive CF infants were homozygous for DeltaF508 and 40% had one DeltaF508 allele. Adding analyses for 10 more CFTR mutations has only a small effect on the sensitivity but is likely to add significantly to the cost of screening.

CONCLUSIONS

Advantages of the IRT/DNA protocol over IRT analysis include improved positive predictive value, reduction of false-positive infants, and more rapid diagnosis with elimination of recall specimens.

Failure of aggressive therapy to alter outcome in pediatric near-drowning

OBJECTIVES

To identify predictors of outcome in pediatric near-drowning victims, and to measure the effectiveness of therapy in pediatric near-drowning victims by assessing clinical outcome as a function of injury severity at presentation and therapeutic interventions during hospitalization.

DESIGN

Retrospective chart review at a tertiary care university associated Children's Hospital from January 1976 to July 1992.

MEASUREMENTS AND MAIN RESULTS

Initial intensive care unit (ICU) assessment included a Glasgow Coma Score (GCS) and a Pediatric Risk of Mortality (PRISM) Score. Outcome was assessed using a standard scoring system classifying functional abilities at hospital discharge as no functional disability, independent, partially independent, or total dependence on caregivers for function. Forty (49%) of 81 died. Of the survivors, 26 (63%) had no functional disability or were partially dependent at hospital discharge. Of the 47 (64%) patients with a GCS < or = 4 on presentation to the ICU, 37 (79%) died and 10 (21%) were dependent in all areas of function at discharge. Of the 40 (60%) patients who had a PRISM score < 20, 98% either died or were completely dependent at discharge. Of the 49 patients who were asystolic upon arrival to the emergency department (ED), 76% died, and the rest were completely dependent. Logistic regression showed that therapy had no independent effect on outcome when disease severity was accounted for.

CONCLUSIONS

Severity of illness measured by GCS and PRISM score in the ICU can be useful in predicting outcome. For patients cared for in a Pediatric Intensive Care Unit, those with asystole on arrival at the ED had uniformly poor outcome. Currently available therapies do not alter outcome.

Pancreatitis associated with remote traumatic brain injury in children

Vomiting, abdominal distension, and feeding intolerance are common findings following brain injury in children, and are usually attributed to the brain injury or to delayed gastric emptying: a specific cause is usually not sought. We report six children who developed mild to moderate pancreatitis at least 7 days following apparently isolated brain injury, a previously unreported association. Five of the six patients received drugs that are known or suspected pancreatotoxins; all recovered without changes in the medications. When children develop feeding intolerance or upper gastrointestinal symptoms following traumatic brain injury pancreatitis should be suspected.

Home care of the ventilator-dependent child: realities and limitations

More ventilator-dependent children have been discharged to the home over the past few years. While some data indicate that home care can be beneficial to both the child and the family, there are risks. Some children can not be home care candidates. The psychological consequences of home care on the children and their families needs more study. More sophisticated cost accounting is needed to analyze the care costs.