Journal of Comprehensive Pediatrics
Volume:10 Issue: 2, Mar 2019

Neurally adjusted ventilatory assist (NAVA) is a novel mode of ventilation that coordinates the mechanical ventilator and the patient via electrical impulses of the diaphragm. Using these impulses as neural triggers, the patient’s respiration synchronizes with the ventilator. Ventilation with NAVA has successfully been performed in adults with various lung diseases but the application of NAVA in neonates is a novel issue. The aim of this review study was to emphasize the NAVA as a new way of neonatal ventilatory support and the importance of ventilator-neonate synchrony in neonatal intensive care units.
Study Selection: Several studies have evaluated NAVA in the neonatal period but we described here the cardinal studies. Therefore, we included studies performing NAVA in the neonatal and pediatric population. The review of 10 studies showed that asynchrony was less frequent when using NAVA than when using the pneumatic modes of ventilation. Most of the studies observed a reduction in peak inspiratory pressure (PIP) and FIO2 with NAVA. A reduction in mean airway pressure and work of breathing and an improvement in gas exchange were also observed in some of the studies. We concluded that according to recent studies, the NAVA should be administered in neonates for better synchronization with ventilator and improving the gas exchange and outcomes.

To normally grow and develop, children with congenital heart diseases (CHD) in the hypermetabolic state need 50% more energy than healthy ones. This study aimed to investigate the prevalence of malnutrition and its association with other factors among the non-syndromic acyanotic patients with CHD undergoing palliative or corrective surgery. A retrospective study of medical records of 812 children with acyanotic congenital heart disease undergoing palliative or corrective surgery was performed from March 2011 to March 2017. Collected data consisted of the age at the time of the surgery, gender, weight at the time of the surgery, height at the time of the surgery, birth weight, length of ICU stay, and 1-year mortality. The WAZ, WLZ, LAZ, and BMI Z-scores were calculated based on World Health Organization (WHO) standards. We classified the Z-scores into 4 groups, including normal (Z-scores > -1), mild (-2 to > -1), moderate (-3 to > -2), and severe (< -3) malnutrition groups. Total amount of 812 patients, 375 (46.2%) were female and 437 (53.8%) male, participated in this study. The average age, weight, and height at the time of the surgery were 23.52 + 29.38 months, 9.086 + 6.71 kilograms, and 76.93 + 23.37 centimeters, respectively. Moreover, 68.7% and 66.4% of the patients suffered from mild to severe forms of malnutrition based on WAZ and WLZ, respectively (P value < 0.0001, 0.025). There was no significant difference between males and females in WAZ, WLZ, LAZ and, BMIZ (P value: 0.154, 0.265, 0.965, and 0.667, respectively). Generally, in acyanotic defects, we found that more severe malnutrition causes an increment in length of ICU stay (P value = 0.001) and lesser birth weight has a significant relationship with the severity of growth failure in infancy or childhood (P value < 0.0001). In our study, the high prevalence of the malnutrition and related complications during and after surgical repair shows the importance of nutritional support and interventions in patients with CHD.

The Tei index is used to evaluate the overall performance of the right ventricle. The index can be measured with pulsed Doppler echocardiography (PW) and tissue Doppler imaging (TDI). Some studies show that severe pulmonary valve regurgitation (PR) can influence the Tei index calculated by the PW method. The purpose of this study was to compare PW and TDI in calculating the Tei index in PR patients following TOF reconstruction. We evaluated 21 patients with severe PI who were reconstructed and 21 age-matched normal children. All the children went through PW or TDI. The intensity of Sa, Ea, Aa, IVCT, and the Tei index were calculated. The mean age of the patients and controls was 3.8 ± 3.2 and 3.7 ± 2.7 years, respectively. There was no difference in the Tei index between healthy children and TOF patients calculated by the PW method (0.30 ± 0.10 vs. 0.35 ± 0.06; P = 0.059). However, TOF patients had a lower intensity of Sa, Ea, and Aa than healthy children. Furthermore, the isovolumic interval of both IVCT and IVRT was longer in TOF patients than in healthy children (43.53 ± 8.82 vs. 25.77 ± 10.14 and 87.73 ± 10.91 vs. 68.36 ± 8.96, respectively; P = 0.001 for both) but the S duration had no difference between the groups (265.1 ± 18.1 in TOF patients vs. 266.8 ± 28.0 in controls). The Tei index calculated by TDI was significantly higher in TOF patients than in healthy children (0.50 ± 0.10 vs. 0.36 ± 0.06; P = 0.001). Moreover, the Tei index calculated by TDI was higher than the Tei index calculated by PW in TOF patients (0.50 ± 0.10 vs. 0.30 ± 0.10; P = 0.001). TDI is a more accurate method for calculating the Tei index for evaluating the overall performance of the right ventricle in PR patients after TOF reconstruction, and the Tei index calculated through PW had limitations for this purpose.

This secondary study is the first to assess the trend of mortality rate and its variations among Iranian children. The mortality data of under-five children were extracted from the WHO reports. All-cause and cause-specific mortality rates were calculated per 1000 live births and by age groups for each year from 2000 to 2015. The average annual rate of reduction (AARR) was used to determine the changes in mortality rates. Of 21011 under-five children who died in 2015, 52.3% were attributed to infectious causes. The overall mortality rate among children under five years decreased from 35 per 1000 live births in 2000 to 16 per 1000 live births in 2015, representing a decline of 55.5% over the 16-year period with an AARR of 5.5%. There was a significant decreasing trend in the mortality rates of all causes except for HIV/AIDS and pertussis. The overall all-cause mortality rate decreased from 2000 to 2015 in Iran although this pattern varied according to the causes of death. There is still a relatively high proportion of mortality rates among children due to congenital anomalies, prematurity, birth asphyxia, sepsis, and acute lower respiratory infections.

Tonsillectomy is regarded as one of the most commonly used pediatric surgical procedures whose anxiety-related consequences can bring about several changes in the physiological characteristics of children. Therefore, the use of low-cost anxiety-relieving techniques in this domain can be of utmost importance to stabilize vital signs in this age group. Accordingly, the purpose of the present study was to investigate the effects of acupressure on physiological indicators of pain including respiratory rate, heart rate, and levels of arterial oxygen saturation in children undergoing tonsillectomy. This study was a three-group single-blind clinical trial conducted on 144 children aged five to 12 years undergoing a tonsillectomy. To this end, the subjects were allocated into three groups of 48 individuals including control, intervention, and placebo ones. In this respect, the intervention (experimental) group received acupressure applied to three pressure points three times a day for one hour, two to four hours, and six to eight hours following a tonsillectomy. However, in the placebo group, acupressure was applied to a false (sham) acupoint. The control group also received only routine care services. Before and after all three phases of the intervention, the physiological indicators of pain (heart and respiratory rate, blood pressure) were measured and recorded in all three study groups. The data were finally analyzed using descriptive statistics (mean and standard deviation) and inferential ones (Wilcoxon signed-rank test, chi-square test, one-way analysis of variance (ANOVA), and Kruskal-Wallis test). The results of this study revealed significant differences in heart rate (P = 0.001), respiratory rate (P = 0.001), and levels of arterial oxygen saturation (P = 0.001) after three intervals of acupressure in the intervention group compared to those in other two groups. Accordingly, the means of heart rate and respiratory rate decreased and the levels of arterial oxygen saturation increased in the intervention group indicating a small number of fluctuations and much more balance in physiological indicators of pain. The findings of the present study showed that parasympathetic activity, following acupressure in the intervention group, could cause several changes in physiological responses, and also create a sense of relief and moderate anxiety in children. Therefore, anxiety in children undergoing a tonsillectomy could be lowered with the use of a simple, low-cost, and non-invasive technique contributing to the maintenance of physiological indicators of pain as well as decreased complications driven by vital signs, not in a normal range.

Medication consumption and drug abuse are considered important socio-economic and medicolegal issues all around the world. The significance of the problem is highlighted during pregnancy. We aimed to evaluate the prevalence of medication and drug consumption during pregnancy in Tehran. In this descriptive study, we selected several maternity hospitals as the sources of our study population. All women of postpartum period willing to participate in the study were included. We prepared self-designed questionnaires to be filled out by trained personnel while interviewing women face to face. All the data were collected and analyzed by SPSS16 software. In this study, we evaluated 3279 mothers who delivered in 10 different hospitals in Tehran. The result showed that the most common medications used during pregnancy were iron (85.2%), folic acid (81.7%), and calcium (48.2%). In this population, insulin, levothyroxine, and antihypertensive medications were used in 7.1%, 5.9%, and 1.8% of the mothers, respectively. Overall, 14.5% of our population used medications for medical conditions during pregnancy. Cigarette smoking, alcohol, and substance abuse before or during pregnancy had a very low prevalence in comparison with other developed countries. The use of medication during pregnancy increases the risk of several complications. Careful pharmaceutical monitoring during pregnancy and national surveys are recommended for obtaining up-to-date information and making a better decision by policymakers.

Newer technologies in neonatal ventilation such as combining volume guarantee with other modes of ventilation could reduce some complications of artificial ventilation by reducing the duration of ventilation and oxygen needs and fluctuations. Retinopathy of prematurity (ROP) is a multifactorial problem mainly affecting preterm infants with different risk factors. Although gestational age (GA) is the main risk factor for ROP, oxygen saturation and fluctuations, arterial pressure of carbon dioxide, and some other parameters of ventilation such as ventilation duration have great impacts on ROP incidence and severity. One hundred and twelve infants with birthweight (BW) under 2000 g or GA under 36 weeks that needed artificial ventilation after admission to the neonatal intensive care unit were randomly assigned into two groups. In the first group, neonates underwent synchronized intermittent mandatory ventilation (SIMV), pressure support ventilation (PSV), or SIMV + PSV with volume guarantee (VG); and in the second group, neonates received ventilation without VG mode. All of the survived infants had ophthalmologic examination at the proper age by a retinal subspecialist to find the different stages of ROP. Mean duration of ventilation was reduced using VG mode from 74.08 ± 47.99 to 47.91 ± 30.47 hours (P < 0.05). The oxygen requirement was less in the ones underwent VG modes and the peak fractional inspired oxygen (FiO2) was higher in infants receiving SIMV + PSV without VG compared to that of infants ventilated with VG mode (52.8 ± 18.4 vs. 40.3 ± 13.0, respectively). The difference between highest and lowest FiO2 was more in the group ventilated without VG (∆FiO2 = 9.52 in the group I and 18.30 in the group II, P < 0.05). Fluctuation of arterial pressure of carbon dioxide (PaCO2) was less prominent in the VG group as compared to the ones ventilated without VG and the mean difference between maximum and minimum PaCO2 was 7.16 in the group I and 13.36 in the group II (P < 0.05). Only three infants were diagnosed with ROP in the group I (with VG mode) in comparison with eight infants in the group II (odds ratio (OR) = 3.25, 95% confidence interval (CI): 1.13 - 9.36). Severe ROP needing treatment was diagnosed in one infant in the group I vs. four infants in the group II (OR = 3, 95%CI: 0.63 - 14.23). ROP incidence in preterm infants could be reduced using VG mode of ventilation, since it is a safer ventilation mode in neonates due to reduction in the mean duration of ventilation, peak FiO2 requirement, and PaCO2 fluctuation.

Corticosteroids are options for the treatment of juvenile idiopathic arthritis (JIA) although with adverse effects. Adrenal insufficiency (AI) may happen after therapeutic glucocorticoid administration. We designed a study to assess the adrenal insufficiency in children with JIA undergoing treatment with low-dose glucocorticosteroids for at least six months. This cross-sectional study was conducted at Imam Khomeini hospital and Children Medical Center hospital on 36 JIA patients after at least three months of cessation of low-dose, long-term corticosteroid therapy. Data regarding age, sex, age at diagnosis, the subtype of disease, and duration of treatment with corticosteroid were recorded. Fasting cortisol and cortisol after ACTH administration were measured. The AI diagnosis was made if the first level of cortisol was less than 3 µg/dL and the second level was less than 20 µg/dL. The sample included 25 women (69.4%) with an overall mean age of 8.2 ± 3.4 years. The mean age at the time of diagnosis was 6.3 ± 3.2 years. The type of disease was oligoarticular in 32 (88.9%) cases and systemic in four (11.1%). Four cases had AI, all of whom were female with oligo-articular arthritis. In all the four cases, the adrenal function became normal three months after prednisolone cessation. The age at the time of study and the age at the time of disease diagnosis were significantly different between cases with and without AI. Adrenal insufficiency is not prevalent in children with JIA treated with low-dose glucocorticoids for a short time.

Nephrotic syndrome (NS) is a common renal disease in the pediatric population, which can be complicated with venous thromboembolic events. In the present study, the researchers evaluated the risk factors of venous thrombotic events in children with nephrotic syndrome. In this descriptive cross sectional study, the researchers evaluated 43 cases of NS including 35 uncomplicated and eight complicated patients with venous thrombotic events, who were admitted to the nephrology ward of Ali-Asghar Children Hospital from 2011 to 2015. Two groups were matched for age onset of NS. Data were recorded on age, gender, body mass index (BMI), histopathologic varieties of NS, and serum albumin level. The mean age of cases with venous thrombotic events was 7.31 ± 4.1 years. There were six females. Of eight cases with venous thrombotic events, five cases suffered of pulmonary thromboembolism (PTE) and five cases of deep vein thrombosis (DVT). The mean serum albumin level in the thrombotic group was 1.87 ± 0.4 g/dL. The histopathologic results showed two cases of membranous proliferative glomerulonephritis (MPGN), three cases of minimal change disease (MCD) and one case of focal segmental glomerulosclerosis (FSGS). The researchers found significant differences between mean serum albumin level and histopathologic results in the case and control groups. Venous thrombosis and pulmonary emboli are important complications in pediatric NS. The risk of VTE increases with lower serum albumin level. The risk of VTE increases with lower serum albumin level. The researchers suggest the use of anti-thrombotic agents as prophylaxis in nephrotic patients with serum albumin level of less than 2 g/dL.

The pediatric risk of mortality (PRISM III), pediatric index of mortality (PIM3), and pediatric logistic organ dysfunction (PELOD-2) are of the most used predictive models in predicting the risk of mortality in the pediatric intensive care unit (PICU). The current study aimed at comparing the predictive ability of these three modes in medical/surgical ICUs (MICU/SICU). A total of 90 consecutive patients, aged ≤ 18 years, admitted to MICUs or SICUs were enrolled in the current observational, prospective study. The PRISM III, PIM3, and PELOD-2 as well as demographic characteristics of the subjects were recorded on admission. A receive operator characteristic (ROC) curve, logistic regression, and the Hosmer-Lemeshow goodness-of-fit test were used for statistical analyses [95% confidence interval (CI)]. Data analysis showed a significant difference in PRISM III, PIM3, and PELOD-2 scores between survivors and nonsurvivors (P < 0.001, P < 0.001, P < 0.001, respectively). The discrimination power was moderate for PRISM III (area under ROC curve (AUC): 77.3%; standard error (SE): 6.0%), and good for PIM3 and PELOD-2 (AUC: 82.4%, SE: 5.5% and AUC: 80.3%, SE: 4.9%, respectively). All the three models were well calibrated (χ2 = 4.73, P = 0.79; χ2 = 3.09, P = 0.93; and χ2 = 5.01, P = 0.66, respectively). PRISM III, PIM3, and PELOD-2 had good performance in predicting outcomes in children admitted to MICUs or SICUs. Further studies on different ICUs may provide more conclusive results with greater generalization of the validity of these predictive models.