Respiratory disturbances in rett syndrome: don't forget to evaluate upper airway obstruction

Rett syndrome is characterized by loss of motor and social functions, development of stereotypic hand movements, seizures, and breathing disturbances. This study evaluates the presence of overnight respiratory disturbances. Polysomnography in combination with a questionnaire (the Sleep Disturbance Scale for Children) was performed in 12 Dutch patients with Rett. Respiratory disturbances were present in all, clinically relevant in 10 (apnea hypopnea per hour 1.0-14.5). In 8 children, central apneas were present during the day often with obstructive apneas at night. In 6, obstructive sleep apnea syndrome was diagnosed, in 3 severe, with frequent oxygen desaturations. Significant respiratory complaints were present in 3 patients, all had obstructive sleep apnea syndrome. Of the 12 patients with Rett, 8 (67%) snored, and in 5 obstructive sleep apnea syndrome was present. In children, hypertrophied tonsils and adenoids are a common cause of obstructive sleep apnea syndrome, which may benefit from therapeutic intervention. We recommend performing polysomnography in patients with Rett syndrome and respiratory complaints.

Surveillance study of apparent life-threatening events (ALTE) in the Netherlands

SIDS and ALTE are different entities that somehow show some similarities. Both constitute heterogeneous conditions. The Netherlands is a low-incidence country for SIDS. To study whether the same would hold for ALTE, we studied the incidence, etiology, and current treatment of ALTE in The Netherlands. Using the Dutch Pediatric Surveillance Unit, pediatricians working in second- and third-level hospitals in the Netherlands were asked to report any case of ALTE presented in their hospital from January 2002 to January 2003. A questionnaire was subsequently sent to collect personal data, data on pregnancy and birth, condition preceding the incident, the incident itself, condition after the incident, investigations performed, monitoring or treatment initiated during admission, any diagnosis made at discharge, and treatment or parental support offered after discharge. A total of 115 cases of ALTE were reported, of which 110 questionnaires were filled in and returned (response rate 97%). Based on the national birth rate of 200,000, the incidence of ALTE amounted 0.58/1,000 live born infants. No deaths occurred. Clinical diagnoses could be assessed in 58.2%. Most frequent diagnoses were (percentages of the total of 110 cases) gastro-esophageal reflux and respiratory tract infection (37.3% and 8.2%, respectively); main symptoms were change of color and muscle tone, choking, and gagging. The differences in diagnoses are heterogeneous. In 34%, parents shook their infants, which is alarmingly high. Pre- and postmature infants were overrepresented in this survey (29.5% and 8.2%, respectively). Ten percent had recurrent ALTE. In total, 15.5% of the infants were discharged with a home monitor. In conclusion, ALTE has a low incidence in second- and third-level hospitals in the Netherlands. Parents should be systematically informed about the possible devastating effects of shaking an infant. Careful history taking and targeted additional investigations are of utmost importance.

[The transport of severely ill children in the Amsterdam region; 1995-2001]

OBJECTIVE

To inventory experiences of the transport of critically ill children in the Amsterdam region.

DESIGN

Retrospective, observational.

METHOD

Data were collected from the 1299 children who were transported to our paediatric intensive-care unit from 1 January 1995 until 31 December 2001. Severity of illness was scored and mortality risk calculated. Data on 535 children who were retrieved by our intensive-care team were compared to those from the 764 who were attended by the referring team. The impact on the outcome of distance and duration of transports from both inside and outside the Amsterdam region was analyzed.

RESULTS

Two thirds of the transports took place during the evening and night. The median age of the children was 7.5 months. Main indication for admission was respiratory or circulatory insufficiency. During the stabilizing procedure before retrieval, one or more interventions were conducted by our team in 368 (69%) of the 535 retrieved children. 940 children were transported within our region. There were no significant differences between retrieval and non-retrieval groups with respect to length of stay, length of ventilation and mortality. In patients from outside our region the mortality in the retrieval group was higher than in the non-retrieval group.

CONCLUSION

Retrieval by a specialized team did not always contribute to a favourable outcome. However, from both a logistical and a medical point of view, a retrieval system seems warranted in order to guarantee a higher level of care. There is a need for more clarity regarding the indications for retrieval by an intensive-care team.