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Cote C.J.,MassGeneral Hospital for Children | Posner K.L.,University of Washington | Domino K.B.,University of Washington
Anesthesia and Analgesia | Year: 2014

BACKGROUND:: Obesity is epidemic in the United States and with it comes an increased incidence of obstructive sleep apnea (OSA). Evidence regarding opioid sensitivity as well as recent descriptions of deaths after tonsillectomy prompted a survey of all members of the Society for Pediatric Anesthesia regarding adverse events in children undergoing tonsillectomy. METHODS:: An electronic survey was sent to 2377 members of the Society for Pediatric Anesthesia. Additionally, data from the American Society of Anesthesiologists Closed Claims Project were obtained. Adverse events during or after tonsillectomy with or without adenoidectomy in children were included. Children at risk for OSA were identified as either having a positive history for OSA or a post hoc application of the American Society of Anesthesiologists OSA practice guidelines. These children were compared with all other children by Fisher exact test for proportions and t test for continuous variables. RESULTS:: A total of 129 cases were identified from the 731 replies to the survey, with 92 meeting inclusion criteria for having adequate data. Another 19 cases with adequate data were identified from the 45 from the American Society of Anesthesiologists Closed Claims Project. A total of 111 cases were included in the final analysis. Death and permanent neurologic injury occurred in 86 (77%) cases and were reported in the operating room, postanesthesia care unit, on the ward, and at home. Sixty-three (57%) children fulfilled American Society of Anesthesiologists criteria to be at risk for OSA. Children categorized as at risk for OSA were more likely than other children to be obese and to have comorbidities (P < 0.0001). A larger proportion of at risk children had the event attributed to apnea (P = 0.016), whereas all others had a larger proportion of events attributed to hemorrhage (P = 0.006). CONCLUSIONS:: Deaths or neurologic injury after tonsillectomy due to apparent apnea in children suggest that at least 16 children could have been rescued had respiratory monitoring been continued throughout first- and second-stage recovery, as well as on the ward during the first postoperative night. A validated pediatric-specific risk assessment scoring system is needed to assist with identifying children at risk for OSA who are not appropriate to be cared for on an outpatient basis. Copyright © 2014 International Anesthesia Research Society.

Perrin J.M.,Harvard University | Anderson L.E.,University of Memphis | Van Cleave J.,MassGeneral Hospital for Children
Health Affairs | Year: 2014

Since the early twentieth century, medical and public health innovations have led to dramatic changes in the epidemiology of health conditions among infants, children, and youth. Infectious diseases have substantially diminished, and survival rates for children with cancer, congenital heart disease, leukemia, and other conditions have greatly improved. However, over the past fifty years chronic health conditions and disabilities among children and youth have steadily risen, primarily from four classes of common conditions: asthma, obesity, mental health conditions, and neurodevelopmental disorders. In this article we describe the epidemiological shift among infants, children, and youth and examine sociodemographic and other factors contributing to it. We describe how health systems are responding by reorganizing and innovating. For children with rare complex conditions, concentrating subspecialty care at regional centers has been effective. For the much larger numbers of children with common chronic conditions, primary care providers have expanded diagnosis, treatment, and management options in promising ways. © 2014 Project HOPE.

Malow B.A.,Vanderbilt University | Byars K.,University of Cincinnati | Johnson K.,Oregon Health And Science University | Weiss S.,Holland Bloorview Kids Rehabilitation Hospital | And 5 more authors.
Pediatrics | Year: 2012

OBJECTIVE: This report describes the development of a practice pathway for the identification, evaluation, and management of insomnia in children and adolescents who have autism spectrum disorders (ASDs). METHODS: The Sleep Committee of the Autism Treatment Network (ATN) developed a practice pathway, based on expert consensus, to capture best practices for an overarching approach to insomnia by a general pediatrician, primary care provider, or autism medical specialist, including identification, evaluation, and management. A field test at 4 ATN sites was used to evaluate the pathway. In addition, a systematic literature review and grading of evidence provided data regarding treatments of insomnia in children who have neurodevelopmental disabilities. RESULTS: The literature review revealed that current treatments for insomnia in children who have ASD show promise for behavioral/educational interventions and melatonin trials. However, there is a paucity of evidence, supporting the need for additional research. Consensus among the ATN sleep medicine committee experts included: (1) all children who have ASD should be screened for insomnia; (2) screening should be done for potential contributing factors, including other medical problems; (3) the need for therapeutic intervention should be determined; (4) therapeutic interventions should begin with parent education in the use of behavioral approaches as a first-line approach; (5) pharmacologic therapy may be indicated in certain situations; and (6) there should be follow-up after any intervention to evaluate effectiveness and tolerance of the therapy. Field testing of the practice pathway by autism medical specialists allowed for refinement of the practice pathway. CONCLUSIONS: The insomnia practice pathway may help health care providers to identify and manage insomnia symptoms in children and adolescents who have ASD. It may also provide a framework to evaluate the impact of contributing factors on insomnia and to test the effectiveness of nonpharmacologic and pharmacologic treatment strategies for the nighttime symptoms and daytime functioning and quality of life in ASD. Copyright © 2012 by the American Academy of Pediatrics.

Murphy S.,MassGeneral Hospital for Children | Murphy S.,Harvard University
Neurotherapeutics | Year: 2012

Pediatric neurocritical care is an emerging multidisciplinary field of medicine and a new frontier in pediatric critical care and pediatric neurology. Central to pediatric neurocritical care is the goal of improving outcomes in critically ill pediatric patients with neurological illness or injury and limiting secondary brain injury through optimal critical care delivery and the support of brain function. There is a pressing need for evidence based guidelines in pediatric neurocritical care, notably in pediatric traumatic brain injury and pediatric stroke. These diseases have distinct clinical and pathophysiological features that distinguish them from their adult counterparts and prevent the direct translation of the adult experience to pediatric patients. Increased attention is also being paid to the broader application of neuromonitoring and neuroprotective strategies in the pediatric intensive care unit, in both primary neurological and primary non-neurological disease states. Although much can be learned from the adult experience, there are important differences in the critically ill pediatric population and in the circumstances that surround the emergence of neurocritical care in pediatrics. © 2011 The American Society for Experimental NeuroTherapeutics, Inc.

Mahajan R.,Kennedy Krieger Institute | Bernal M.P.,Kaiser Permanente | Panzer R.,MassGeneral Hospital for Children | Whitaker A.,Columbia University | And 5 more authors.
Pediatrics | Year: 2012

BACKGROUND AND OBJECTIVE: Hyperactivity, impulsivity, and inattention (referred to as "ADHD [attention-deficit/hyperactivity disorder] symptoms") occur in 41% to 78% of children with autism spectrum disorders (ASDs). These symptoms often affect quality of life, interfering with learning or interventions that target primary ASD symptoms. This practice pathway describes the guidelines for evaluation and treatment of children and adolescents with ASD and comorbid ADHD symptoms. METHODS: Current research in this area is limited, and, therefore, these recommendations are based on a systematic literature review and expert consensus in the Autism Speaks Autism Treatment Network Psychopharmacology Committee. RESULTS: The recommended practice pathway includes the Symptom Evaluation Pathway for systematic assessment of ADHD symptoms across settings; examination for comorbid sleep, medical, or psychiatric comorbidities that may contribute to symptoms; and evaluation of behavioral interventions that may ameliorate these symptoms. For children for whom medication is being considered to target the ADHD symptoms, the medication choice pathway provides guidance on the selection of the appropriate agent based on a review of available research, assessment of specific advantages and disadvantages of each agent, and dosing considerations. CONCLUSIONS: These recommendations provide a framework for primary care providers treating children who have ASD and ADHD symptoms. Our systematic review of the current evidence indicates the need for more randomized controlled trials of the medications for ADHD symptoms in ASD. There will also be a need for studies of the effectiveness of these practice pathways in the future. Copyright © 2012 by the American Academy of Pediatrics.

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