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Article Reviews and Commentary

Seeing is Believing: What do boys do when they find a real gun?

Jackman GA, Farah MM, Kellerman AL et al. Pediatrics 107:6; 1247-1250

The authors state that the objectives of this paper were to learn the behavior of boys when the find a handgun in a presumably safe environment and the determine whether parental expectations of the boy's behavior matched the actual behavior. The sample of boys aged 8-12 was obtained from the group of families who had completed a survey on firearm ownership and practices related to firearm ownership. Pairs or trios of boys were observed, through a one-way mirror, for up to 15 minutes in a room in which there were two water pistols and a handgun hidden. The handgun contained a transmitter which activated whenever the trigger of the gun was activated with sufficient force to discharge the weapon. Sixty-four boys, divided into 29 groups of 2 or 3 took part in the investigation. Twenty-one groups discovered the handgun, 16 groups (76%) handled it and one or more of the children in 10 of the groups (48%) depressed the trigger with enough force to discharge the gun. Approximately one-half of the boys were unsure whether or not the gun was real. Parental estimates of their child's interest did not predict which of the children would handle the gun and more than 90% of the boys reported receiving some gun safety instruction.

Commentary Thomas J. Mancuso, MD, FAAP

I realize that the only professional relevance this paper has to pediatric anesthesiologists is the care they will render to the victims of accidental shootings. Nevertheless, many of us are the parents of such boys and I though the findings of this paper would be of great interest. One criticism of this important paper comes to mind. Since the parental assumptions about their boys' supposed lack of interest were inaccurate, it seems plausible to me that the authors limiting their investigation to boys may mislead parents of girls into the false assumption that their daughter's have little interest in handguns.

Snoring During Early Childhood and Academic Performance at Ages Thirteen to Fourteen Years.

Gozal DG, Pope DW Pediatrics 2001 107:6; 1394-1399

The authors sought to discover the long-term impact, if any, that sleep-disordered breathing (SDB) had on school performance. A survey was mailed to families of seventh and eighth grade children who were either in the top 25% or the bottom 25% of academic rank. The parents were queried about their child's snoring between the ages of 2-6 years, snoring at present, airway surgery, smoking in the household and other medical conditions of the child, if any. The demographics of the two groups were similar. Slightly more than 82% of the questionnaires were returned and 1588 were analyzed with nearly equal numbers in the two academic groups. In the low performance group, frequent and loud snoring was reported in 103 children (12.9%) while in
the children ranked in the top 25% of their classes, the incidence of reported loud and frequent snoring was 5.1%. More children in the low performance group underwent T&A. The authors also note that smoking was more frequent in the homes of low performance children (31% vs 24%). The authors conclude that children with lower academic performance are more likely to have snored during early childhood and to have undergone T&A for snoring compared to children with higher academic performance.

Commentary Thomas J. Mancuso, MD, FAAP

This provocative paper provides us, as pediatric anesthesiologists, with interesting background information about the children who come our way for T&A's. It appears that neuro cognitive impairments may indeed be associated with the airway obstruction seen in some children with hypertrophy of the tonsils and adenoids and that some deficits may persist even after correction of the airway compromise.

Experience With Ketogenic Diets in Infants

Nordli DR, Kuroda MM, Carroll J et al. Pediatrics 2001 108:1: 129-133

The authors reviewed the course of 32 infants who had been placed on a ketogenic diet as treatment for refractory epilepsy. Seventy-one per cent of the infants maintained ketosis, showing consistently moderate to large ketones in the urine. Overall 80% of the patients had improvement in their seizures. Growth and weight gain were within normal limits in the 28 children who had been on the diet for > 3 months. Adverse events reported, all of which occurred in one patient each, were severe vomiting, GI bleeding from erosive esophagitis (? related to an NG tube), type I hyperlipidemia, renal stones and ulcerative colitis. Another patient became comatose with hypoglycemia and acidosis after having been on the diet for 8 days. The authors conclude "...the ketogenic diet is an effective...treatment for appropriate conditions in infants.

Commentary Thomas J. Mancuso, MD, FAAP

This rather old treatment for seizures is gaining favor once again and we will see these children in our pre-anesthesia clinic or in the day surgery units. The complications reported were all reversible. However, these children do require particular attention in the perioperative period. NPO times should be short, the glucose content of pre medications and oral analgesics must be considered and IV fluid administration may require changes from routine.

Effect of Caffeine in Oxygen Consumption and Metabolic Rate in Very Low Birth Weight Infants With Idiopathic Apnea.

Bauer J, Maier K, Linderkamp O et al. Pediatrics 2001 107:4; 660-663

The authors studied 18 infants with idiopathic apnea whose gestational ages were 28-33 weeks and whose birth weights were 890-1680 gm. Nine received caffeine while nine served as controls. Oxygen consumption was measured by indirect calorimetry before during and after caffeine treatment. The duration of the study was 4 weeks The caffeine was given IV as caffeine citrate with a 10 mg/kg loading dose followed by 5 mg/kg Q 24 hours. Infants treated with caffeine had a significant increase following the institution of caffeine treatment. The increase noted was from 7.0 cc/kg/min to 8.8 cc/kg/min with a similar increase in energy expenditure. The treated infants also maintained normothermia in a lower environmental temperature. The control infants had a higher daily weight gain than the treated infants during the period of the study (42 vs 21 gm/day). Apnea did decrease significantly in the treatment group.

Commentary Thomas J. Mancuso, MD, FAAP

Caffeine citrate is a recognized treatment for post anesthetic apnea in the ex-preterm infant. The dose which has been found to be effective is 10 mg/kg and it is sometimes repeated 12 hours later. In this paper the first post-caffeine measurements of 02 consumption and energy expenditure were not made until 48 hours after the start of the caffeine so it cannot be assumed that the administration of that drug for only a few doses in the immediate postoperative period will increase 02 consumption to the degree found by the investigators. However, after anesthesia, mild degrees of hypoventilation with the attendant hypoxia are not unexpected, especially in preterm or ex-preterm infant. Any increase in 02 consumption could be detrimental in this setting. On the other hand, it would be nice if temperature maintenance were improved by caffeine administration in these little patients.

Death as a complication of peripherally inserted central catheters in neonates.

Nadroo AM, Lin J, Green RS et al. J Pediatrics 2001: 138;599-601

The authors report 2 deaths caused by cardiac tamponade which was related to peripherally inserted central catheters (PICC). A survey was sent to NICU directors in the US to inquiring about neonatal deaths related to PICC lines. Twenty-four of the respondents reported deaths due to PICC lines. Of the 100 questionnaires sent 83 were returned and 82 of these reported that PICC lines were used routinely in their NICU's. Twenty-nine percent of respondents reported that the catheters perforated the myocardium, 43% reported pericardial effusions and 70%
reported pleural effusions. The causes of death related to PICC lines which were reported were: cardiac tamponade (20% of respondents), arrhythmias (4% of respondents), migration of the catheter tip into the brain (1% of respondents)

Commentary Thomas J. Mancuso, MD, FAAP

The authors do not report the total number of PICC lines or PICC line-days involved. The percentages reported are of the total number of NICU's which responded to the survey which reported a particular complication. The percentages are NOT of the total number of PICC lines placed. The authors do not report the frequency of the various complication. Nevertheless, this report make it clear that PICC lines clearly have risks and those of us who place them or who use them in caring for these newborns must assure ourselves that the catheter tip is correctly placed.

Effect of jaw thrust and continuous positive airway pressure in tidal breathing in deeply sedated infants.

Hammer J, Reber A, Trachsel D et al. J Pediatrics 2001; 188: 826-830

The authors of this investigation examined the physiologic impact of the jaw thrust maneuver or CPAP on tidal breathing in deeply sedated infants. These infants were undergoing fiberoptic bronchoscopy while supine and measurements were made using a spirometer attached to a face mask. The infants were sedated with propofol, 1-2 mg/kg given intermittently and monitored with ECG, Sp02 and NIBP with an anesthesiologist caring for the infant. Jaw thrust increased tidal volume, minute ventilation as well as peak flow during both inspiration and exhalation.

Commentary Thomas J. Mancuso, MD, FAAP

This paper demonstrates what all pediatric anesthesiologist would predict to be the case, based on daily clinical experience as well as published data.. It is of interest for other reasons in addition to the beneficial effects of CPAP and jaw thrust. The propofol doses used are roughly one-half to two thirds of an induction dose yet the authors call the infants' state sedation, not general anesthesia. Although an anesthesiologist was present during the "sedation" in these cases, the discussion makes no case for the necessity of an anesthesiologist to care for infants who receive the general anesthetic agent, propofol. The authors do comment that the jaw thrust maneuver is taught in life support courses, anesthesia and critical care medicine, but again do not comment at all on the importance an anesthesiologist in settings where children receive potent agents such as propofol.

"Conscious Sedation": Time for this oxymoron to go away! C Cote Conscious Sedation and oxymorons: A response

Wilson SW MA, PhD J Pediatrics 2001; 139: 15-17

These invited editorials, by Charles Cote, a prominent pediatric anesthesiologist, Vice Chairman of the Department of Anesthesiology at Children's Memorial Hospital and a major figure in the development of sedation guidelines by the AAP and Stephen Wilson, Director of Pediatric Dentistry Program a member of the Section of Pediatric Dentistry of the College of Dentistry at Columbus Children's Hospital take on the very difficult subject of sedation of children, with emphasis on sedation for dental procedures.

Commentary Thomas J. Mancuso, MD, FAAP

As a pediatrician and pediatric anesthesiologist, I certainly have my own opinion and bias on this subject. Dr. Cote elegantly outlines the evolution of the AAP, ASA, JCAHO positions and regulations on the topic. Dr. Wilson looks at the issue as a pediatric dentist and discusses the AAP and AAPD guidelines. I will not summarize their arguments. These papers should be read in their entirety.

Cerebral palsy in term infants-birth or before birth?

Paneth, N J Pediatrics 2001; 138:791-791

The association of apgar score with subsequent death and cerebral palsy: A population-based study in term infants

Moster D, Lie RT, Irgnes LM et al. J Pediatrics 2001; 138: 798-803

Congenital abnormalities among children with cerebral palsy: More evidence for prenatal antecedents

Croen LA, Grether JK, Curry CJ et al. J Pediatrics 2001; 138: 804-810

These two papers and an accompanying editorial by Paneth, are all related to the etiology of cerebral palsy in term infants. Moster et al found, in their population-based cohort study which followed the children until 8-12 years of life, that children with 5 minute apgar scores of 0-3 had an 81 fold increased chance of having the diagnosis of CP. These same infants also had a 386 fold increased likelihood of death compared to infants with 5 minute apgar scores of 7-10. The study was performed in Norway among a group with a low incidence of low apgar scores., with 0.1% of newborns. 2500 gm having 5 minute apgar scores of 0-3. The receipt National Health Insurance Scheme benefits was used to track those children identified as having CP. The authors conclude that this paper strengthens the value of the Apgar score as a predictor of serious and fatal conditions. In the paper by Croen et al, the definition of CP used was " a chronic disability of central nervous system origin characterized by aberrant control of movement or posture, appearing early in life and not the result of a progressive disease". This was a population based case control study of 155,6363 live births in California, USA with follow-up until 3 years of age The authors report that, among singletons, congenital anomalies were present in 19% of infants who were later diagnosed with CP as compared to 5% in those who did not carry that diagnosis. Structural CNS anomalies were more common in CP subjects, while the percentage of infants with non-CNS anomalies was similar in the two groups. They conclude that this provides further evidence that prenatal factors contribute significantly to the etiology of CP. The editorial by Paneth discusses the different conclusion possible from the two papers, one suggesting prenatal contribution to CP, the other perinatal (ie., obstetric and resuscitative events) events. After reviewing previous data from the national collaborative perinatal project (NCPP), he concludes his paper with the recommendation that all is not gloomy in newborns with low apgar scores and that in infants in whom the diagnosis of CP is considered, a careful search must be undertaken for other anomalies.

Commentary Thomas J. Mancuso, MD, FAAP

Yes, this is a pediatric paper, but children with CP regularly visit the OR for a variety of orthopedic and other types of procedures and we should know the latest thinking regarding etiology. In addition, those of you with general practices may , and occasion, provide analgesia/anesthesia for labor and deliveries, attend to distressed newborns and even assign apgar scores. Lastly, let us not forget that Virginia Apgar, who developed the apgar score, was an anesthesiologist.

A Randomized Comparison of Helium-Oxygen Mixture (Heliox) and Racemic Epinephrine for the Treatment of Moderate to Severe Croup.

Weber JE, Chudnofsky CR, Younger JG et al. Pediatrics 2001 107:6; e96

In this prospective, randomized double-blinded study, the authors compared Heliox (70% He, 30% 02) to nebulized racemic epinephrine (0.5 cc in 2.5 cc NS) as treatment for moderately severe croup. Twenty-nine patients were analyzed. The children in the groups did not exhibit significant differences in initial croup scores, heart rates, respiratory rates and Sp02 measurements. The age range of the subjects was 24 +/- 6 months. All children received 0.6 mg/kg dexamethasone IM, a now recognized effective treatment for infectious croup. A modification of a well-known croup score was used to asses the children's condition and response to therapy. This measure of croup severity is a 0-15 scale consisting of 5 measures scored from 0-3 with 0 representing normal and 3 severely abnormal. The variables measured are: color, air entry, retractions, level of consciousness and stridor. These are not independent variables meaning that as a child worsens, the score increases in a more than linear fashion. For example, a child who is obtunded is not likely to have normal color, Sp02 or air entry. Nevertheless, all children were assessed by blinded observers using that same score, despite it's limitations. The mean croup score of the children at enrollment was 6.7 and at the conclusion of the 4 hour study period is had dropped to 3. Children in both treatment groups improved over time. There were no significant differences in mean croup score, HR, RR or Sp02 either at baseline, as mentioned or at the end of the 4 hour study period. Although the croup score was significantly lower in the Heliox group at intervals after 90 minutes, the overall results using repeated measures of variance showed no significant differences at the conclusion of the 4 hour period of the study. The authors mention a prior report of hypoxemia in children with BPD and subglottic stenosis who received Heliox and comment that there were 3 children in the Heliox group who presented with Sp02 measurements of </= 90%. All three exhibited normal Sp02 measurements following administration of Heliox,

Commentary by Thomas J Mancuso, MD, FAAP:

We don't treat infectious croup but post-intubation stridor is common among the problems seen in the PACU. The pathophysiology, sub-glottic edema, in the same for both conditions. Based on these results, Heliox might be an effective treatment for children who have post-intubation stridor. The authors do not comment on side effects, but it is possible that the children who received racemic epinephrine had higher heart rates and perhaps exhibited jitteriness during therapy. Perhaps instead of an alternate therapy for subglottic edema, Heliox might be useful in addition to racemic epinephrine. #include ./footer_include.iphtml