In a randomised, multicentre trial of 1316 infants born between 24 weeks 0 days and 27 weeks 6 days of gestation, infants were randomly assigned to intubation and surfactant treatment (within 1 hour after birth) or to CPAP treatment initiated in the delivery room, with subsequent use of a protocol-driven limited ventilation strategy. The primary outcome was death or bronchopulmonary dysplasia as defined by the requirement for supplemental oxygen at 36 weeks.
Infants who received CPAP treatment, as compared with infants who received surfactant treatment, less frequently required intubation or postnatal corticosteroids for bronchopulmonary dysplasia (P<0.001), required fewer days of mechanical ventilation (P=0.03), and were more likely to be alive and free from the need for mechanical ventilation by day 7 (P=0.01). However the rates of the primary outcome did not differ significantly between the CPAP group and the surfactant group (47.8% and 51.0%, respectively; relative risk with CPAP, 0.95; 95% confidence interval [CI], 0.85 to 1.05).
The infants randomised to CPAP could receive limited invasive ventilation if necessary; 83.1% of the infants in the CPAP group were intubated. They did not include infants who were born at a gestational age of less than 24 weeks, since the results of a pilot trial showed that 100% of such infants required intubation in the delivery room.
This study had a 2-by-2 factorial design in which infants were also randomly assigned to one of two target ranges of oxygen saturation.
Early CPAP versus Surfactant in Extremely Preterm Infants
N Engl J Med. 2010 May 16. [Epub ahead of print]
Category Archives: Kids
Acute Paediatrics
Vital signs of severely injured children
Systolic blood pressures of severely injured children are very often hypertensive compared with APLS ‘norms’. A lower pulse rate is associated with more severe brain injury
Comparing the systolic blood pressure (SBP) and pulse rate (PR) in injured children with and without traumatic brain injury
Resuscitation. 2010 Apr;81(4):418-21
Optimum depth of neonatal chest compressions
A retrospective study of infant chest CT scans using mathematical modelling and a number of assumptions suggests that neonatal CPR according to AAP/AHA guidelines of compressing to one third anteroposterior chest wall diameter should provide a superior ejection fraction to 1/4 depth and should generate less risk for over-compression than 1/2 AP compression depth.
Evaluation of the Neonatal Resuscitation Program’s recommended chest compression depth using computerized tomography imaging
Resuscitation. 2010 May;81(5):544-8
Compare their conclusions with those of the authors of this case series of arterial-line monitored cardiac arrests in infants with a median age of one month
Crystalloids vs colloids and cardiac output
It is said that when using crystalloids, two to four times more fluid may be required to restore and maintain intravascular fluid volume compared with colloids, although true evidence is scarce. The ratio in the SAFE study comparing albumin with saline resuscitation was 1:1.3, however.
A single-centre, single- blinded, randomized clinical trial was carried out on 24 critically ill sepsis and 24 non-sepsis patients with clinical hypovolaemia, assigned to loading with normal saline, gelatin 4%, hydroxyethyl starch 6% or albumin 5% in a 90-min (delta) central venous pressure (CVP)-guided fluid loading protocol. Haemodynamic monitoring using transpulmonary thermodilution was done each 30 min to measure, among other things, global end-diastolic volume and cardiac indices (GEDVI, CI). The reason sepsis was looked at was because of a suggestion in the SAFE study of benefit from albumin in the pre-defined sepsis subgroup.
Independent of underlying disease, CVP and GEDVI increased more after colloid than saline loading (P = 0.018), so that CI increased by about 2% after saline and 12% after colloid loading (P = 0.029).
Their results agree with the traditional (pre-SAFE) idea of ratios of crystalloid:colloid, since the difference in cardiac output increase multiplied by the difference in volume infused was three for colloids versus saline.
Take home message? Even though an outcome benefit has not yet been conclusively demonstrated, colloids such as albumin increase pre-load and cardiac index more effectively than equivalent volumes of crystalloid in hypovolaemic critically ill patients.
Greater cardiac response of colloid than saline fluid loading in septic and non-septic critically ill patients with clinical hypovolaemia
Intensive Care Med. 2010 Apr;36(4):697-701
Scalp veins
While clearing up after teaching with my bald colleague Dr Phil Hyde yesterday I noticed his bulging scalp veins and this reminded me that we don’t talk about this route much in our Paediatric Emergency Medicine Course.
This prompted me to look up the complications of scalp vein access in neonates and infants, which include:
- scalp abscess
- alopecia
- intracranial abscess
- thrombophlebitis
- intracranial venous sinus air embolism
- scalp necrotising fasciitis
Suggested ways to decrease the risk of complications include:
- A vein should not be used for more than 24 h at a time
- The needle entry point should not be covered
- The butterfly needle should be immobilized to avoid movements of the needle into the tissue with consequent extravasation of fluid
- The infusion site should be monitored by regular examination
- If a swelling or leakage of fluid is noted, the infusion should be discontinued immediately from that site
- The hair should be properly shaved
- If the line is required for more than 24 h, a peripheral venous cutdown or central venous line should be considered, after initial resuscitation
- An alternative route for rehydration (e.g. intraosseous infusion) should be considered initially, rather than risk multiple, unsuccessful attempts at scalp vein cannulation.
Complications of scalp vein infusion in infants
Trop Doct. 2005 Jan;35(1):46-7
Air emboli in the intracranial venous sinuses of neonates
Am J Perinatol. 2002 Jan;19(1):55-8
Child development milestones
Does anyone else find these hard to remember as a non-paediatrician?
I’ve written a crappy little poem to act as a mnemonic for some important milestones and age-related features pertinent to ED assessment and communication. If someone wants to turn it into something sounding more like Gangsta Rap it might catch on.
At zero months some tone is neat
And keep them pink and warm and sweet
At two months head control is more
and smiles are something to adore
At four months when they find things funny
They laugh and roll back from their tummy
Roll both ways when half a year
Hand to hand and turn to hear
Should be sitting up by nine
Put things in mouth and waving fine
Speaking when a year has passed
They’re crawling with a pincer grasp
They’ll walk alone at 15 months
And use a spoon to eat their lunch
By month eighteen they’ll point to faces
Scribble pics and climb staircases
At two they run and have some dress sense
Rides trike at three and speaks full sentence
At four they have imagination
From five you try negotiation
At months nine up to fifteen
Stranger anxiety’s often seen
Distraction helps things seem less mean
But you may need some ketamine
**2104 Update** The amazing Grace Leo has recorded this as a song. I have no idea why but I’m impressed as always by her creativity and drive.
Here it is:
Kids need 'proper' CPR if non-cardiac cause of arrest
The American Heart Association recommends cardiopulmonary resuscitation (CPR) by bystanders with chest compression only for adults who have cardiac arrests, but not for children. These recommendations have new support in a large observational study from Japan examining outcomes in 5170 out-of hospital paediatric arrests over a 3 year period.
For children who had out-of-hospital cardiac arrests from non-cardiac causes, conventional CPR (with rescue breathing) by bystander was associated with improved outcomes compared with compression-only CPR (7·2% [45/624] favourable one month neurological outcome vs 1·6% [6/380]; OR 5·54, 2·52–16·99). In children who had arrests of cardiac causes conventional and compression-only CPR were similarly effective. Infants < 1 year had uniformly poor outcomes.
An editorial points out that this is the largest study that has analysed out-of-hospital cardiac arrest in children, and the overall survival of 9% with only 3% of children having a good neurological outcome, is consistent with previous reports.
Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study
Lancet. 2010 Apr 17 345:1347-54
A human suction unit for choking
A case is described of a 12 month old who completely obstructed her airway from an inhaled plastic ketchup container. As she did not improve with backslaps or chest thrusts her father, a physician, suctioned her airway using his own mouth (intermittently spitting out secretions) until the obstruction was relieved and the object removed. Something to think about if you’re at the end of your own child’s choking algorithm and you have no airway equipment with you.
Maneuver for the recovery of a foreign body causing a complete airway obstruction: illustrative case.
Pediatr Emerg Care. 2010 Jan;26(1):39-40
Extreme white cell counts
Febrile children aged three months to three years with a white cell count over 25000/mm3 and fever were compared with controls whose leucoytosis was less extreme (15000-24999). The ‘extreme’ group had serious bacterial infection (SBI) in 39% compared with 15.4% controls. Pneumonia was the commonest SBI.
The authors conclude that in febrile children aged 3–36 months, the presence of extreme leucocytosis is associated with a 39% risk of having SBIs. The increased risk for SBI is mainly due to a higher risk for pneumonia. I conclude that leucocytosis is like fever: the cause may be benign, but the higher the number the less likely that is, even though the majority still won’t have SBI.
Extreme leucocytosis and the risk of serious bacterial infections in febrile children
Arch Dis Child. 2010 Mar;95(3):209-12
WHO Guidelines for Pandemic Influenza A(H1N1) 2009
The World Health Organisation has published updated guidelines on drug treatment of Influenza A(H1N1)2009 and other influenza viruses. Their recommendations are summarised in this table:
Full text of the guidelines is available here
WHO Guidelines for Pharmacological Management of Pandemic Influenza A(H1N1) 2009 and other Influenza Viruses
WHO website