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Pediatric intensive care units are growing in size and number
Surfactant for RDS: When and how?
Guidelines for treatment of bronchiolitis
This issue of The Journal contains two articles about surfactant therapy for respiratory distress syndrome (RDS). The big picture is that surfactant treatments for RDS are safe and very effective and are the standard of care. However, considerable controversy remains about when to treat infants at risk for or with RDS, how to give those treatments, and what sort of ventilatory support is best and for how long. Variables generating uncertainty are timing of treatment (at delivery/after initial stabilization), ventilatory support before and after treatment (continuous positive airway pressure [CPAP]/mechanical ventilation and type of mechanical ventilation), techniques for treatment (pharyngeal at delivery, number and volumes of boluses for each treatment, management after treatment). Each variable is further complicated by the gestational age/birth weight of each infant and the clinical status of the infant at birth. The Texas Neonatal Research Group performed a multicenter randomized trial to ask if larger infants ($1250 g) with RDS and an oxygen requirement of $40% would benefit from immediate intubation and surfactant treatment compared with expectant management with surfactant treatment if the respiratory disease progressed. For this group of infants, an early intervention with surfactant treatment was of no benefit. This result supports the current clinical trend to use CPAP therapy for larger infants with RDS. Kaiser, Gauss, and Williams evaluated the effect of surfactant treatment on cerebral blood flow in very-low-birth-weight (VLBW) infants using continuous monitoring. They demonstrate that routine surfactant treatments result in a peak increase in Pco2 of about 20 mm Hg 15 minutes after the surfactant treatment. The increase in Pco2 is associated with an increase in cerebral blood flow velocity, demonstrating intact autoregulation of cerebral blood flow in these VLBW infants. The peak increase in Pco2 at 15 minutes probably results from airway occlusion with the surfactant suspension. The importance of the study is that it points out that surfactant therapy does cause transient physiologic changes that need to be balanced against benefit. For example, the decision to treat an infant on CPAP with surfactant requires intubation followed by surfactant instillation. Both procedures cause physiologic abnormalities that need to be recognized. Strategies for when to treat which patient and how remain hot topics in neonatology.
Care for children with bronchiolitis varies remarkably across hospitals and geographic regions. The care is made more complex by the lack of evidence supporting the use of bronchodilators and several other commonly used therapies. Unwarranted variation in care processes can lead to increased utilization of health care resources. One way to attempt to mediate this is through the use of practice guidelines. In this issue of The Journal, Muething et al describe the impact of a guideline for the treatment of bronchiolitis applied at the point of care. They documented a significant decrease in bronchodilator use and in the use of other tests, such as a nasopharyngeal swab and chest radiograph. This reduced utilization was primarily seen in the emergency department, and they found that decreasing use in this setting impacted use during the hospitalization. They attribute their success to the broad involvement of key stakeholders in the development of the guidelines. Importantly, they describe their quality improvement process with enough detail that other institutions can model their efforts after these.
—Alan H. Jobe, MD Page 804 (Texas Neonatal Research Group) Page 809 (Kaiser)
—John G. Frohna, MD, MPH Page 703
Neuroimaging reveals intracranial injury in asymptomatic infants who are physically abused The study by Laskey et al of children evaluated because of suspected physical abuse has striking findings. Twenty-nine percent of neurologically asymptomatic children younger than 48 months who had neuroimaging performed had unexpected evidence of intracranial injury. Neither history nor finding of retinal hemorrhage was a sensitive predictor of neuroimaging abnormalities. An age less than one year was the only significant factor associated with performance of the neuroimaging study. With so little data in this field, and such vulnerability of affected children, until further studies are available, the editors agree with the authors—clinicians should consider performing a neuroimaging study when physical abuse is suspected in a young child.
—Sarah S. Long, MD Page 719
Got exercise? Pediatric intensive care units are growing in size and number In this issue of The Journal, Adrienne Randolph and colleagues from the Children’s Hospital, Boston, report on the number and size of pediatric intensive care units (PICUs) in the United States in the period 1995 to 1996 compared with the period 2001 to 2002. In 2001 there was a 24% increase in the number of PICU beds and an increase in the number of PICUs by 14%. The largest growth was in PICUs with 15 beds or more which had increased by 34%. These increases occurred faster than the growth of the pediatric population. The authors comment on the factors that may have led to this growth and analyze the geographic distribution of the units.
—Robert W. Wilmott, MD Page 792
With the recognition that the seeds of osteoporosis may be sown in childhood, there is an increasing interest among pediatricians in skeletal health. Much of this, of course, has been directed at dietary calcium intake. A study in this issue of The Journal by Lloyd et al at Penn State University reminds us that diet is only part of the solution. Using a cohort of young women who were followed for 10 years, these workers examined the role of dietary calcium, exercise, and oral contraceptive use on both bone density and bone strength. Neither dietary calcium nor oral contraceptive use proved to be important determinants. Self-reports of exercise, however, proved to be very important correlates to both bone strength and bone density. All of these girls were receiving at least 500 mg of dietary calcium daily. While insuring this intake is likely important, the data in this study suggest that, beyond this modest intake, exercise is the most important modifiable variable contributing to adolescent and young adult bone health.
—Thomas R. Welch, MD Page 776
2A
June 2004
The Journal of Pediatrics
Guidelines for treatment of bronchiolitis
This issue of The Journal contains two articles about surfactant therapy for respiratory distress syndrome (RDS). The big picture is that surfactant treatments for RDS are safe and very effective and are the standard of care. However, considerable controversy remains about when to treat infants at risk for or with RDS, how to give those treatments, and what sort of ventilatory support is best and for how long. Variables generating uncertainty are timing of treatment (at delivery/after initial stabilization), ventilatory support before and after treatment (continuous positive airway pressure [CPAP]/mechanical ventilation and type of mechanical ventilation), techniques for treatment (pharyngeal at delivery, number and volumes of boluses for each treatment, management after treatment). Each variable is further complicated by the gestational age/birth weight of each infant and the clinical status of the infant at birth. The Texas Neonatal Research Group performed a multicenter randomized trial to ask if larger infants ($1250 g) with RDS and an oxygen requirement of $40% would benefit from immediate intubation and surfactant treatment compared with expectant management with surfactant treatment if the respiratory disease progressed. For this group of infants, an early intervention with surfactant treatment was of no benefit. This result supports the current clinical trend to use CPAP therapy for larger infants with RDS. Kaiser, Gauss, and Williams evaluated the effect of surfactant treatment on cerebral blood flow in very-low-birth-weight (VLBW) infants using continuous monitoring. They demonstrate that routine surfactant treatments result in a peak increase in Pco2 of about 20 mm Hg 15 minutes after the surfactant treatment. The increase in Pco2 is associated with an increase in cerebral blood flow velocity, demonstrating intact autoregulation of cerebral blood flow in these VLBW infants. The peak increase in Pco2 at 15 minutes probably results from airway occlusion with the surfactant suspension. The importance of the study is that it points out that surfactant therapy does cause transient physiologic changes that need to be balanced against benefit. For example, the decision to treat an infant on CPAP with surfactant requires intubation followed by surfactant instillation. Both procedures cause physiologic abnormalities that need to be recognized. Strategies for when to treat which patient and how remain hot topics in neonatology.
Care for children with bronchiolitis varies remarkably across hospitals and geographic regions. The care is made more complex by the lack of evidence supporting the use of bronchodilators and several other commonly used therapies. Unwarranted variation in care processes can lead to increased utilization of health care resources. One way to attempt to mediate this is through the use of practice guidelines. In this issue of The Journal, Muething et al describe the impact of a guideline for the treatment of bronchiolitis applied at the point of care. They documented a significant decrease in bronchodilator use and in the use of other tests, such as a nasopharyngeal swab and chest radiograph. This reduced utilization was primarily seen in the emergency department, and they found that decreasing use in this setting impacted use during the hospitalization. They attribute their success to the broad involvement of key stakeholders in the development of the guidelines. Importantly, they describe their quality improvement process with enough detail that other institutions can model their efforts after these.
—Alan H. Jobe, MD Page 804 (Texas Neonatal Research Group) Page 809 (Kaiser)
—John G. Frohna, MD, MPH Page 703
Neuroimaging reveals intracranial injury in asymptomatic infants who are physically abused The study by Laskey et al of children evaluated because of suspected physical abuse has striking findings. Twenty-nine percent of neurologically asymptomatic children younger than 48 months who had neuroimaging performed had unexpected evidence of intracranial injury. Neither history nor finding of retinal hemorrhage was a sensitive predictor of neuroimaging abnormalities. An age less than one year was the only significant factor associated with performance of the neuroimaging study. With so little data in this field, and such vulnerability of affected children, until further studies are available, the editors agree with the authors—clinicians should consider performing a neuroimaging study when physical abuse is suspected in a young child.
—Sarah S. Long, MD Page 719
Got exercise? Pediatric intensive care units are growing in size and number In this issue of The Journal, Adrienne Randolph and colleagues from the Children’s Hospital, Boston, report on the number and size of pediatric intensive care units (PICUs) in the United States in the period 1995 to 1996 compared with the period 2001 to 2002. In 2001 there was a 24% increase in the number of PICU beds and an increase in the number of PICUs by 14%. The largest growth was in PICUs with 15 beds or more which had increased by 34%. These increases occurred faster than the growth of the pediatric population. The authors comment on the factors that may have led to this growth and analyze the geographic distribution of the units.
—Robert W. Wilmott, MD Page 792
With the recognition that the seeds of osteoporosis may be sown in childhood, there is an increasing interest among pediatricians in skeletal health. Much of this, of course, has been directed at dietary calcium intake. A study in this issue of The Journal by Lloyd et al at Penn State University reminds us that diet is only part of the solution. Using a cohort of young women who were followed for 10 years, these workers examined the role of dietary calcium, exercise, and oral contraceptive use on both bone density and bone strength. Neither dietary calcium nor oral contraceptive use proved to be important determinants. Self-reports of exercise, however, proved to be very important correlates to both bone strength and bone density. All of these girls were receiving at least 500 mg of dietary calcium daily. While insuring this intake is likely important, the data in this study suggest that, beyond this modest intake, exercise is the most important modifiable variable contributing to adolescent and young adult bone health.
—Thomas R. Welch, MD Page 776
2A
June 2004
The Journal of Pediatrics