Enteral nutrition support for infants with pulmonary hypoplasia: A qualitative evaluation of caregiver and provider perspectives

BACKGROUND

Enteral nutrition is a critical intervention that supports the growth of children with pulmonary hypoplasia (PH). We explored the experiences of caregivers and providers caring for children with PH to better understand gaps in knowledge transfer and identify barriers and facilitators to caregiving to inform interventions that may improve support.

METHODS

This qualitative study included 10 interviews with caregivers and 10 clinical team members at a single integrated care program for children with PH. An inductive and iterative coding strategy was employed to produce a codebook. After cluster analysis, themes were generated to capture participant sentiments.

RESULTS

Themes were defined along a care continuum (1) initiation, (2) adaptation, and (3) maintenance that represented distinct phases of adjustment to enteral nutrition support (1) in the perinatal period and initial neonatal intensive care unit (NICU) admission, (2) from discharge planning through the family's first days at home and establishment of a stable feeding regime, and (3) through long-term follow-up and weaning. Notable subthemes included uncertainty, partnerships in training, and obstacles to adaptation.

CONCLUSIONS

Among children with PH, the caregiver-provider relationship during the perinatal and NICU course is critical to promoting caregiver adaptation to the needs of the child. Ongoing considerations to support resource alignment and transition to a stable feeding regimen may facilitate caregiver adjustment to a "new normal," culminating in successful growth and/or weaning. These findings will inform interventions focused on training curricula, discharge planning, and the provision of follow-up in the context of an integrated care program for PH.

Nutritional support of the pediatric trauma patient

Of all the interventions available to aid recovery of the injured child, few have the power of proper nutritional support. Healing after trauma depends not only on restoration of oxygen delivery, but on "substrate delivery," or provision of calories to support metabolic power and specific nutrients to allow rebuilding of injured tissue. Failure to deliver adequate substrate to the cells is revealed as another form of shock. Nutritional interventions after trauma are most effective when informed by the specific ways that children diverge physiologically (metabolic rate, biomechanics, physiological response to trauma) from adults. This review describes these responses and outlines a general strategy for safely delivering energy and specific substrates to protect and heal injured children, regardless of body size and type of injury.

The Case of the Wretched Retcher

Fundoplication is an effective treatment for severe gastroesophageal reflux disease (GERD) because it provides a mechanical solution to what is essentially a mechanical, not a medical, problem. However, manifestations of feeding intolerance postfundoplasty are well known and include dysphagia, gastric dysfunction, retching, gagging, intestinal dysfunction, and gas bloat syndrome. These difficulties are exacerbated by feeding plans that disregard the mechanical constraints imposed by the operation, particularly limited gastric volume, decreased gastric compliance, diminished ability to burp, sensitivity to osmolarity, and formula composition. These complications are preventable and treatable by informed construction of feeding plans that limit boluses (around 15 mL/kg/bolus), promote proper motility, manage intraluminal air, and limit polypharmacy. This case presentation describes a postfundoplasty infant with severe retching and intolerance treated according to these principles.

Potential deleterious effect of beta-adrenergic stimulation during warm-blood cardioplegia in rabbit hearts

We hypothesized that beta-adrenergic stimulation with isoproterenol during continuous normothermic cardioplegic arrest would enhance the regenerative and regulatory function of the myocardium, resulting in improved cardiac function. We studied isolated rabbit hearts paced at approximately 200 beats per minute (bpm) and perfused by a support rabbit. We measured ventricular pressure over a range of ventricular volumes to determine maximal elastance (Emax) at baseline and 20 and 45 min after discontinuation of cardioplegia. Myocardial oxygen consumption (MVO2) measurements were performed simultaneously and during cardioplegic arrest. Hearts were prospectively randomized to receive either isoproterenol at 0.1 M or control in blinded fashion for 10 min during a 1-h continuous warm-blood cardioplegic arrest. Compared to control hearts, isoproterenol-treated hearts had trends toward longer time to first spontaneous heartbeat (control 141 +/- 43 vs. isoproterenol 200 +/- 74 s, p = .07), and longer time to capture of atrial pacing (control 214 +/- 52 vs. isoproterenol 288 +/- 91 s, p = .06). There was no difference observed in the MVO2 between isoproterenol-treated and control groups of hearts. MVO2 decreased during cardioplegia (p < .01), but there was no significant change in MVO2 during isoproterenol infusion during cardioplegic arrest. There was a significant reduction in Emax compared to baseline 20 min after discontinuation of cardioplegic arrest in both groups (control 7.3 +/- 1.7 mm Hg/microL vs. 9.0 +/- 1.7 mm Hg/microL, p = .02, isoproterenol-treated 6.8 +/- 2.8 mm Hg/microL vs. 8.2 +/- 2.6 mm Hg/microL, p = .01, respectively), with recovery of Emax by 45 min in control hearts only. We conclude that exposure of hearts to isoproterenol during warm cardioplegic arrest has a deleterious effect that may be mediated through mechanisms independent of increased myocardial oxygen consumption.

Effective treatment of hyperhomocysteinemia in heart transplant recipients with and without renal failure

BACKGROUND

Elevated total plasma homocysteine (tHcy) levels have been associated with vascular disease and higher mortality in patients with coronary artery disease. Graft coronary disease is a major cause of mortality in long-term survivors of heart transplantation, and hyperhomocysteinemia may be one of its causes. The objectives of our study were to establish the effectiveness of a 3 stage homocysteine-lowering algorithm in a group of 84 heart transplant (HTx) patients and to evaluate the effect of renal function on the response to homocysteine-lowering therapy.

METHODS

Prospective treatment of 84 Htx patients (64 male; mean age, 48 +/- 13 years) with tHcy > 75th percentile consisted of a 3-stage treatment algorithm: Stage 1, folic acid (FA) 2 mg + vitamin (vit) B(12) 500 mcg daily; Stage 2, addition of vit B(6) 100 mg daily; Stage 3, increase FA to 15 mg daily. Serum creatinine (Cr) and tHcy levels were measured before treatment and 21 +/- 19 weeks after each stage of treatment.

RESULTS

All 3 stages of treatment significantly lowered mean tHcy from 22.4 +/- 16.3 (mean +/- SD) micromol/liter to 16.3 +/- 6.7 micromol/liter (p < 0.00001), from 17.6 +/- 6.1 micromol/liter to 15.2 +/- 5.3 micromol/liter (p < 0.0001), and from 16.8 +/- 5.2 micromol/liter to 15.6 +/- 5.3 micromol/liter (p < 0.05), respectively. The average reduction from baseline was 38%. Creatinine levels did not change significantly during the study period. Total plasma homocysteine levels decreased below the 75th percentile in 55% of patients, with Cr levels significantly lower in this group of patients (126 +/- 36 micromol/liter vs 182 +/- 65 micromol/liter, p < 0.00001). However, we found no significant relationship between % change in tHcy and baseline Cr.

CONCLUSIONS

In a group of 84 heart transplant patients with tHcy levels >75th percentile, treatment with FA and vit B(6) and B(12) according to a 3-stage algorithm resulted in statistically significant declines in mean tHcy levels. Overall, tHcy levels decreased 38%, with target tHcy levels <75th percentile achieved in 55% of the patients. The % change in tHcy was not related to Cr. Further studies are needed to correlate treatment of hyperhomocysteinemia with clinical endpoints, such as the time to development of transplant vasculopathy and long-term survival, and to define the most appropriate targets for therapy.

Treatment of post-transplant lymphoproliferative disease with rituximab monoclonal antibody after lung transplantation

Three patients with diffuse large B-cell type of post-transplant lymphoproliferative disease after lung transplantation were treated with rituximab, an anti-CD20 monoclonal antibody. Treatment resulted in two complete remissions and one non-response.

Effect of immunosuppressive therapy, serum creatinine, and time after transplant on plasma total homocysteine in patients following heart transplantation

OBJECTIVES

To determine the prevalence of hyperhomocysteinemia in heart transplant recipients, and to assess the effect of renal function and immunosuppressive medication on total plasma homocysteine (tHcy) levels.

BACKGROUND

Elevated plasma tHcy levels have been associated with increased risk of mortality in patients with established coronary artery disease. Graft coronary disease is the major cause of morbidity and mortality in long-term survivors of heart transplantation. The tHcy has been found to be elevated in heart and kidney transplant patients, however, the etiologic factors have not been clearly delineated.

METHODS

The study group consisted of 70 heart transplant recipients (56 males, 14 females, mean age 53+/-13 years [range 17 to 69 years]). The parameters evaluated were fasting tHcy level, cumulative cyclosporine (CyA) dose, cumulative prednisone dose, serum creatinine, and time from transplantation.

RESULTS

The mean fasting tHcy level was 20.5+/-10.2 micromol/L (range 5.2 to 59.0 micromol/L). Sixty-one (87%) had fasting tHcy levels greater than the seventy-fifth percentile of the general population (>12.2 micromol/L in males, and >10.1 micromol/L in females). There was no difference in mean post-transplant tHcy level between patients with and without coronary artery disease before transplantation (21.0+/-11.4 vs. 19.3+/-6.7 micromol/L, p = NS). There were significant relationships between the tHcy level and the serum creatinine (r = 0.76, p<0.001), and cumulative exposure to CyA (r = 0.31, p<0.01). There were no significant relationships between tHcy levels and cumulative prednisone dose, or time from transplantation.

CONCLUSIONS

Fasting tHcy levels are markedly elevated in the majority of patients following heart transplantation, and are correlated to serum creatinine. Further studies are needed to determine other etiologic factors of elevated tHcy following heart transplantation, and to examine the impact of elevated tHcy on clinical outcomes.

The use of milrinone in pre-transplant assessment of patients with congestive heart failure and pulmonary hypertension

BACKGROUND

Pulmonary hypertension in patients with congestive heart failure (CHF) is a risk factor for increased mortality after orthotopic cardiac transplantation. Reversibility of elevated pulmonary vascular resistance (PVR) by pharmacologic agents predicts improved outcomes. Milrinone, a phosphodiesterase inhibitor with vasodilating and positive inotropic properties, has been shown to lower PVR in one previous study. However, no study has documented outcomes after cardiac transplantation in patients in whom reversibility of pulmonary hypertension was demonstrated after administration of milrinone.

METHODS

We retrospectively reviewed 19 patients with CHF and pulmonary hypertension defined as PVR > or = 3 Wood units, PVRI (pulmonary vascular resistance index) > or = 4 resistance units, or TPG (transpulmonary gradient = mean pulmonary artery pressure--mean capillary wedge pressure) > or = 12 mmHg being assessed for cardiac transplantation. A sub-group of 14 patients with severe pulmonary hypertension defined as PVR > or = 4, PVRI > or = 6 and TPG > or = 15 was also examined. Milrinone was administered as a bolus (50 ug/kg) and hemodynamic parameters were measured at 5, 10 and 15 minutes. Six patients received cardiac transplants.

RESULTS

Administration of milrinone significantly lowered PVR, PVRI, mean pulmonary artery pressure (PAM)(all p = 0.002) and pulmonary capillary wedge pressure (PCWP)(p = 0.006). Cardiac output (CO) increased significantly (p = 0.001). TPG did not change (p = 0.33). In patients with severe pulmonary hypertension, the magnitude of these changes was greater. In addition, TPG was significantly lowered (p = 0.02).

CONCLUSION

Milrinone lowered PVR by decreasing PAM and increasing CO significantly. In addition, PCWP was significantly lowered. These finding confirm both vasodilatory and inotropic effects of milrinone. Patients with severe pulmonary hypertension had more pronounced effects. There were no deaths in the group of patients proceeding to cardiac transplantation. Our study demonstrates the efficacy of milrinone in lowering PVR as well as suggesting safety in use in patients undergoing cardiac transplantation.

Recurrence of intravenous talc granulomatosis following single lung transplantation

Advanced pulmonary disease is an unusual consequence of the intravenous injection of oral medications, usually developing over a period of several years. A number of patients with this condition have undergone lung transplantation for respiratory failure. However, a history of drug abuse is often considered to be a contraindication to transplantation in the context of limited donor resources. A patient with pulmonary talc granulomatosis secondary to intravenous methylphenidate injection who underwent successful lung transplantation and subsequently presented with recurrence of the underlying disease in the transplanted lung 18 months after transplantation is reported.

Megacystis microcolon intestinal hypoperistalsis syndrome: evidence of a primary myocellular defect of contractile fiber synthesis

Two infant boys with megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) are reported. Presenting with neonatal intestinal obstruction, they underwent laparotomies that showed megacystis, microcolon, and aperistaltic shortened small bowel without any mechanical obstruction. Patient 1 gradually improved and is developing normally at home, on a normal diet without genitourinary or gastrointestinal complaints (now 11 years old). Patient 2, who underwent vesicoamniotic drainage antenatally, never developed adequate gastrointestinal or genitourinary function in spite of appropriate diversion and pharmacologic support. He showed progressive deterioration and died at the age of 7 months. Detailed histo-immuno- and ultrastructural pathology assessment, although confirming results in the existing literature in some aspects, showed previously unreported neuronal dysplastic changes associated with increased laminin and fibronectin. Although patient 1 showed ultrastructural features of vacuolar degeneration of smooth muscle as reported in the literature, patient 2 showed ultrastructural and histochemical evidence of excessive smooth muscle cell glycogen storage with severely reduced contractile fibres displaced to the extreme periphery of the cells, suggesting a fundamental defect of glycogen-energy utilization. A deficiency of fiber synthesis as the alternative primary defect is discussed. In both cases, a two-step genetic defect may explain the variability in clinical outcome and pathological findings.

Efficacy of twice-daily amoxycillin/clavulanate ('Augmentin-Duo' 400/57) in mild to moderate lower respiratory tract infection in children

A new amoxycillin/clavulanate regimen ('Augmentin-Duo' 400/57), to be given orally in two divided doses, has been proposed to overcome the inconvenience of tid dosing. This observer-blind, multicentre study randomised children aged two to 12 years with lower respiratory tract infection to seven days' treatment with either amoxycillin/clavulanate bid at a dose of 25/3.6mg/kg/day (221 patients) or the currently prescribed amoxycillin/clavulanate regimen of 20/5mg/kg/day tid (216 patients). Clinical success (cure) rates at follow up were 81.0% for the bid group and 77.8% for the tid group [difference 3.2%; 95% CI (-4.36, 10.80)], indicating that the regimens were of equivalent efficacy. Both regimens were well tolerated, and there was no statistically significant difference in the incidence of adverse experiences between the two groups. Compliance with study medication was high and similar for both groups (80% compliance: bid 90.0%; tid 87.0%).

Growing up in the hospital: Part II, Nurturing the philosophy of family-centered care

This article is the second in a series that addresses the issues of "growing up in the hospital." Whereas the first article focused on the child and the complex growth and development issues surrounding indefinite hospitalization, this article will focus on the family, the philosophy of family-centered care, and how nursing practice can nurture this ideal when working with children who must "grow up in the hospital."

Growing up in the hospital: Part I, Let's focus on the child

Major advances in medical research and technology have made it possible for many children with complex chronic illnesses to survive, including those who just a few years ago would have died (Hobbs & Perrin, 1985). One goal of health care professionals who care for these children is, and continues to be, discharge of the child to the family and community whenever possible. Complex medical and nursing care, elusive diagnoses, complicated psychosocial issues, and inconsistent community resources often mean discharge must be prolonged. Focusing on the creation of innovative methods for integrating the growth and developmental needs of these special children is a challenging and often overlooked aspect of our pediatric nursing practice. This article is one of a series that will address the issues of growing up in the hospital. What are the implications for the child, family, and professional nurse? What strategies can we devise to assist our patients through what may be a very lengthy and complex hospital course?

Endoscopy-guided balloon dilatation of esophageal strictures and anastomotic strictures after esophageal replacement in children

This study evaluates the safety, efficacy, and technical problems of the new technique of endoscopy-guided balloon dilation (EGBD) in the treatment of strictures of the esophagus and its replacement. Between 1986 and 1990, the authors treated 33 children (aged 3 weeks to 20 years) with EGBD; 18 had esophageal strictures (primary esophageal atresia repair, 13; reflux esophagitis, 5), 13 had anastomotic strictures after esophageal replacement (colon, 12; stomach, 1), and 2 had caustic strictures. The majority (23 of 33) had previously failed to respond to conventional bouginage (mean, 11.2 sessions; range, 1 to 32 sessions). EGBD was performed using flexible endoscopy and flouroscopic screening under general anesthesia. Endoscopy identified and resolved the errors or uncertainties of preoperative contrast studies in 7 patients, 5 of whom had colon interposition. EGBD was achieved in all 31 patients with esophageal or replacement strictures; the mean number of EGDB procedures per patient was 2.1 (range 1 to 7). Symptomatic relief was excellent in 24 and moderate in 7 patients. Both patients with caustic strictures had esophageal perforation from EGBD (excessive inflation, 1; false passage of guide wire, 1). Patients who had experienced both conventional bouginage and EGBD noticed less pain with EGBD and resumed eating sooner. The authors conclude that EGBD is safe and effective for treating esophageal and replacement strictures but not caustic strictures.

Peptic ulceration in a lingual sinus

Heterotopic gastric mucosa is reported in a sinus present since birth in the midline of the anterior two thirds of the tongue. Current theories concerning the presence of heterotopic mucosa in the oral cavity are presented and discussed.

"Disconnected" integral ventriculo-peritoneal shunt systems

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Neonatal ovarian cysts: therapeutic dilemma

Seven cases of neonatal ovarian cysts that presented over the past seven years were studied. Complications included torsion and rupture and usually occurred in cysts more than 5 cm in diameter. Surgical removal, either oophorectomy or cystectomy, was the treatment of choice. Because even cystectomy results in loss of normal ovarian tissue, and because spontaneous regression of cysts less than 5 cm in diameter can occur, a more conservative approach is now proposed. Regular ultrasonography alone is recommended if the cysts are less than 5 cm in diameter, and aspiration of the cysts followed by regular ultrasonographs if the cysts are more than 5 cm in diameter. Operation should be reserved for recurrent cysts or for those with complications. Cysts diagnosed antenatally may be aspirated in utero if there are signs of thoracic compression.

Ovarian cysts and tumours in infancy and childhood

Cysts and tumours of the ovary are not uncommon in childhood. In 33 years between 1950 and 1982 106 patients were operated on at Alder Hey Children's Hospital and the Royal Liverpool Children's Hospital. Of these 71 were pre-menarchal. The mode of presentation, pathology and diagnostic difficulties of the pre-menarchal lesions are reviewed. The value of ultrasound scanning has become apparent in recent years. Most cysts and tumours are benign, but dysgerminomas are the most common malignant tumours encountered. Even when there is evidence of spread of the tumour the prognosis in these remains reasonably good.

Intestinal malrotation beyond the neonatal period

Of 162 children with intestinal malrotation treated during a 13-year period, only 20 were first seen and treated outside the neonatal period. These presented with symptoms that were largely non-specific and there was a delay between the initial consultation and the making of the correct diagnosis of up to 5-years. The clinical features, radiologic findings and management are discussed, the importance of the history and radiographic findings stressed.

Functional intestinal obstruction associated with malrotation and short small-bowel

Two siblings are presented in whom a recognized syndrome of functional small-bowel obstruction with malrotation and short small-bowel was diagnosed. The previously described association with pyloric stenosis was not present in our cases. They do, however, support the view that this syndrome has an autosomal recessive model of inheritance. A deficiency of argyrophil neurones in the myenteric plexus has been noted in this syndrome but more precise neurohistochemical studies are required to define the exact deficit involved.

Congenital auricular and preauricular sinuses in childhood

Congenital auricular and preauricular sinuses, while seemingly trivial and often unnoticed or ignored, can give rise to troublesome symptoms if infection supervenes. Nine of 30 patients (30%) operated upon between 1969 and 1981 had postoperative recurrence, two of whom required two excisions. We would recommend aggressive treatment of infection followed by excision in 2-3 weeks before further infection can occur.

Cardiac toxicity of perchloroethylene (a dry cleaning agent)

Perchloroethylene analysis was performed on plasma of a 24-year-old white man who presented with a history of premature ventricular beats, dizziness, and headaches. There was no clinical, electrocardiographic, radiologic, or echocardiographic evidence of heart disease. The occurrence of premature ventricular beats and the patient's symptoms were more pronounced when the plasma level of perchloroethylene was high (3.8 ppm). Removal of exposure to perchloroethylene relieved the patient's symptoms and the premature beats completely disappeared.

Determination of penicillin residues in milk - a comparison of two methods

Two tests for penicillin residues in milk using the test organisms Sarcina lutea and Bacillus stearothermophilus var. calidolactis respectively are presented. The test methods are described, the results compared and the advantages of the latter test demonstrated.

Short- and long-term effects of para-chloroamphetamine on ingestive behavior

Para-chloroamphetamine (PCA) produces short-term decreases in eating and drinking. PCA also chronically decreases brain serotonin concentration following a single peripheral injection. The present investigation assessed short- and long-term effects of PCA on ingestive behavior and body weight in greater detail. Following an adaptation period, PCA, 0.0, 1.0, 2.0, 5.0 and 10.0 mg/kg, were administered IP, to free feeding rats. A decrease in food and water consumption was observed during the 0--24 hr postinjection period. During the 24--48 hr period, water consumption was significantly increased compared to baseline. Food intakes during this same period returned to baseline levels. No long-term effects on ingestive behavior or body weight were seen during the following 30 days.

Tracheal compression as a cause of respiratory symptoms after repair of oesophageal atresia

A case of tracheal compression in an infant after repair of a tracheo-oesophageal fistula and oesophageal atresia is reported. Tracheopexy completely relieved the symptoms of apnoeic attacks, cyanosis, and convulsions. We suggest that tracheal compression in infants and children with repaired oesophgeal atresia can not only cause life-threatening attacks but also be responsible for recurrent chest infections. All infants and children with signs and symptoms of tracheal compression as shown by the presence of a barking type of cough, recurrent chest infections, or persistent mild respiratory symptoms should be referred for thorough investigation of the tracheobronchial tree.

Microbiological investigation of meat wholesale premises and beef carcases in Johannesburg

Microbiological surveillance by swabbing meat wholesaler premises revealed ineffective cleaning and build-up of bacteria. Proper cleaning, sanitation and handling resulted in a vast improvement during 1975-77. Beef samples from the neck of carcases in the wholesale trade were investigated by microbiological methods. Excessive total bacterial counts were obtained from numerous carcases. Most carcases carried coliform organisms. Roughly 90% of carcases were contaminated with E. coli I; counts exceeded 10(3)/g in 18% of carcases tested. Twenty serotypes of Salmonella were identified. Salmonella contamination decreased from nearly 5% in 1975 to less than 0,5% in 1977, and S. aureus contamination from 52% to 36% during the same period. Approximately 30% of carcases revealed contamination with unidentified clostridial species. The results indicate the need for stricter control over the production and slaughter of animals and over the handling of carcases in the wholesale trade.

The incidence and sources of penicillin in milk supplied to the city of Johannesburg

The incidence of penicillin in bulk milk supplies to the city has varied from 1,2% to 2,6% over the past five years, and 3,2% of 366 pasteurised milk samples examined in 1975 were found to contain penicillin. Investigation of the sources revealed numerous instances of producers, milkers and veterinarians who had not acted responsibly in regard to the marketing of milk from treated cows. Details are provided. The legal and professional obligations of the veterinarian are emphasized. Reference is made to the dye marking registered intramammary formulations for farmer treatment of mastitis.

Experiences in the diagnosis of brucellosis in dairy cows

The Milk Ring, Serum Agglutination, Biological, Mercaptoethanol and Rose Bengal Plate Tests were used in combination to diagnose brucellosis in cows in some herds supplying milk to Johannesburg. The work was done in conjunction with routine testing of bulk milk supplies for public health control. 4 769 cows in more than 76 herds were involved in the tests. Results confirm that no single test can demonstrate all infected cows in a herd and that repeated testing is necessary. In an infected herd in which Strain 19 adult vaccination has been used some negative and suspicious cows will have to be sacrificed in eradicating the disease.

Spina bifida and hydrocephalus

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Operative management of neurogenic bladder dysfunction in children: ureterostomy

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