Pediatrics Subject Collection: Heart & Blood Vessels

Index of Suspicion [ARTICLES]

Vo, M. — 2009-11-01

Case 1 Presentation Case 1 Presentation Case 2 Presentation Case 3 Presentation Case 1 Discussion Case 2 Discussion Case 3 Discussion A previously healthy 9-year-old girl presents with a 1-week history of intermittent confusion, dysphagia, visual changes, and involuntary movements of the face and left hand. During this period, she has had two episodes of disorientation and memory loss that were not associated with alteration in consciousness or behavioral changes. The involuntary movements of the left arm and leg have become progressively worse throughout the week. The facial movements are described as lip smacking and excessive blinking. Four days ago, she complained of one episode of diplopia. She denies nausea, vomiting, fever, symptoms of uppe ...

Acute Heart Failure Syndromes in the Pediatric Emergency Department [ARTICLES]

Macicek, S. M. — 2009-11-01

OBJECTIVE: The objectives of this study were to (1) describe the clinical presentation of acute heart failure syndromes (AHFS) in the pediatric emergency department (ED) and (2) determine the physician treatment regimens and outcomes in the same population. METHODS: This was a cross-sectional study of patients who presented with AHFS to the ED at our institution from January 2003 to October 2006. We defined AHFS as "the gradual or rapid deterioration in heart failure signs and symptoms resulting in a need for urgent therapy." Patients were included when they had documented signs or symptoms of HF attributable to ventricular dysfunction. Patients were excluded when they were older than 21 years or had HF symptoms that were attributable to left-to-right intracardiac shunting or left-sided obstructive lesions. All eligible ED patient visits were adjudicated by a pediatric HF specialist. RESULTS: Fifty-seven patient visits to the ED met inclusion criteria. There was a significant difference in time from arrival to treatment with a diuretic when the therapy was started in the ED rather than in the inpatient units. Median time to initiation of a vasoactive agent was significantly less for patients whose infusions were started in the ED compared with the ICU. Two patients died in the ED, and overall mortality or need for mechanical circulatory support for hospitalized patients was 18% (n = 10). CONCLUSIONS: These data yield important insight into the clinical features and initial treatment of children who present with AHFS in the ED and may allow for improved recognition and treatment of this clinical syndrome.

Parent- Versus Child-Reported Functional Health Status After the Fontan Procedure [ARTICLES]

Lambert, L. M. — 2009-11-01

OBJECTIVE: We sought to compare perceptions of functional health status between children who had undergone a Fontan procedure and their parents. METHODS: Fontan procedure survivors 10 to 18 years of age were included in the study if the child completed the Child Health Questionnaire (CHQ) and the parent completed the parent form to assess the child's functional health status. Comparisons were made between raw domain scores for the parent- and child-completed CHQs. RESULTS: Between March 2003 and April 2004, 1078 Fontan survivors were screened. Of the 546 eligible and consented patients, 354 were 10-18 years of age and 328 parent/child pairs completed the CHQs. Parents reported significantly lower scores (worse functioning) for their children than the children reported for themselves in the domains of physical functioning (P < .01), impact on school or activities from emotional and behavioral problems (P < .01), impact on school or activities from physical health issues (P < .01), general behavior (P < .01), mental health (P < .01), self-esteem (P < .01), and general health perceptions (P < .01). No significant differences were noted for the domains of bodily pain, family cohesiveness, or family activities. For the physical functioning domain, factors contributing to lower scores for parent versus child reports included pulmonary artery anomalies and fenestration at the time of the Fontan operation. Lower parent-reported scores also were associated with more noncardiac health problems in the child. CONCLUSIONS: Parents' perceptions of the functional health status of their children after the Fontan procedure were worse than the children's perceptions.

Index of Suspicion [ARTICLES]

George, R. P. — 2009-10-01

Case 1 Presentation Case 1 Presentation Case 2 Presentation Case 3 Presentation Case 1 Discussion Case 2 Discussion Footnotes Case 3 Discussion A 3[1/2]-year-old boy, who lives in the southeastern United States, is referred for evaluation of eosinophilia that was detected on laboratory tests performed during a routine health supervision visit. A few days ago, he had loose stools, without blood or mucus, associated with low-grade fever. He has no history of significant illness, allergies, respiratory symptoms, weight loss, sick contacts, or travel. He is not taking any medications. He lives with his mother, aunt, three siblings, four cousins, and two dogs in a rural area that has city water ...

Dramatic Increase in Venous Thromboembolism in Children's Hospitals in the United States From 2001 to 2007 [ARTICLES]

Raffini, L. — 2009-10-01

OBJECTIVES: The goals were to determine whether there has been an increase in the rate of venous thromboembolism (VTE) in pediatric tertiary care hospitals and to evaluate the use of anticoagulants in the treatment of hospitalized pediatric patients with VTE. METHODS: A retrospective cohort study of patients <18 years of age who were discharged from 35 to 40 children's hospitals (depending on the year) across the United States in 2001-2007 was performed. By using the Pediatric Health Information System administrative database, cases were assessed for discharge diagnosis codes for VTE; the use of anticoagulants was assessed by using patient-specific pharmacy files. RESULTS: During the 7-year study period, in which 11337 hospitalized patients were diagnosed with VTE, the annual rate of VTE increased by 70%, from 34 to 58 cases per 10000 hospital admissions (P < .001). This increase was observed in neonates, infants, children, and adolescents. The majority (63%) of children with VTE had [≥]1 coexisting chronic complex medical condition. Pediatric malignancy was the medical comorbid condition associated most strongly with recurrent VTE (P < .001). The proportion of children with VTE who were treated with enoxaparin increased from 29% to 49% during this time period (P < .001); the use of warfarin decreased slightly from 11.4% to 9.6% (P = .02). Increasing age was associated with increased likelihood of patients with VTE being treated with either enoxaparin or warfarin. CONCLUSION: This multicenter study demonstrates a dramatic increase in the diagnosis of VTE at children's hospitals from 2001 to 2007.

Thrombocytopenia in the Neonatal Intensive Care Unit [ARTICLES]

Saxonhouse, M. A. — 2009-09-01

As the survival of neonates cared for in the neonatal intensive care unit (NICU) has improved, hematologic issues have been recognized as clinically significant problems in this population. Thrombocytopenia, in particular, is a common finding among sick neonates, but there is considerable debate regarding the appropriate evaluation and management of affected infants. This article provides state-of-the art information on the pathophysiology, diagnosis, and treatment of neonatal thrombocytopenia. Specifically, the risks associated with low platelet counts in neonates are discussed, and a practical approach to the differential diagnosis of neonates who develop thrombocytopenia is provided. Current recommendations for the management of immune and nonimmune varieties of thrombocytopenia also are reviewed, with an emphasis on the risks and benefits associated with platelet transfusions in this age group.

Immune-mediated Neutropenia in the Neonate [ARTICLES]

Black, L. V. — 2009-09-01

Neutropenia is a relatively common finding in ill neonates, occurring in approximately 32,000 infants each year in the United States. In this patient population, immune-mediated neutropenia results from the antibody-mediated destruction of neutrophils and is associated with such disorders as alloimmune neonatal neutropenia, neonatal autoimmune neutropenia, and autoimmune neutropenia of infancy. Such conditions only recently have begun to be understood and often are problematic in terms of clinical identification and laboratory confirmation. This article reviews the clinical presentation, laboratory diagnosis, and treatment options for these three disorders.

Preeclampsia and Neonatal Neutropenia [ARTICLES]

Moallem, M. — 2009-09-01

Neutropenia is a common hematologic disorder in the newborn intensive care unit, particularly in preterm neonates. Although its cause varies, a significant proportion of the episodes are associated with pregnancy complicated by preeclampsia. In this review, we provide a brief overview of preeclampsia and neonatal neutropenia, with a focus on the neonatal neutropenia associated with maternal preeclampsia. We discuss potential contributory mechanisms to and the natural history of this type of neutropenia, as well as reasonable management strategies in affected neonates.

Index of Suspicion in the Nursery [ARTICLES]

Arevalo, A. — 2009-09-01

Case Presentation Case Presentation Case Discussion Suggested Reading A 1-day-old male infant develops lower extremity cyanosis after feeding. The infant was born at 38 weeks' gestation and had Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. There were no prenatal complications. Today he has lower extremity saturations of 80% and upper extremity saturations of 97%. Results of limited/preliminary echocardiography are reported as "pulmonary hypertension and possible aortic arch obstruction." After starting an infusion of prostaglandin E1, the infant is transferred to a tertiary care center for cardiac evaluation. The initial physical examination reveals a warm, pink neonate who is experiencing no significant distress. His length is at the 75th percentile and weight is a ...

In Utero Valvuloplasty for Pulmonary Atresia With Hypoplastic Right Ventricle: Techniques and Outcomes [ARTICLES]

Tworetzky, W. — 2009-09-01

BACKGROUND: Prenatal intervention for fetuses with pulmonary atresia with an intact ventricular septum (PA/IVS) has the potential to alter right heart physiologic features in utero, facilitating right heart growth and improving the prospect of a biventricular outcome after birth. METHODS: Since 2002, we have considered prenatal intervention for fetal PA/IVS in patients with (1) membranous pulmonary atresia, with identifiable pulmonary valve (PV) leaflets or membrane; (2) an intact or highly restrictive ventricular septum; and (3) right heart hypoplasia, with a tricuspid valve annulus z score of -2 or below and an identifiable but small right ventricle. Intervention was performed through direct cardiac puncture under ultrasound guidance, with percutaneous access or access through a limited laparotomy. RESULTS: Ten fetuses underwent attempted balloon dilation of the PV in utero. The first 4 procedures were technically unsuccessful, and the most-recent 6 were technically successful. Compared with control fetuses with PA/IVS who did not undergo prenatal intervention and had univentricular outcomes after birth, the tricuspid valve annulus, right ventricle length, and PV annulus grew significantly more from midgestation to late gestation in the 6 fetuses who underwent successful interventions. CONCLUSIONS: In utero perforation and dilation of the PV in midgestation fetuses with PA/IVS is technically feasible and may be associated with improved right heart growth and postnatal outcomes for fetuses with moderate right heart hypoplasia in midgestation. There is an important learning curve for this procedure, and much remains to be learned about the selection of appropriate fetuses for prenatal intervention.