Gastrointestinal
Symptoms in Patients with Asthma
Caffarelli
C, Deriu FM, Terzi V et al Archives
of Diseases of Childhood 2000;82:131-135.
The authors of this paper survey and interviewed a group of families and children with asthma and a control group regarding the frequency and severity of various gastrointestinal symptoms. There were 75 children in each group. The groups were similar mean age, height, weight and there were 48 boys in each group. The questionnaire included items relating to the symptoms of asthma and atopy as well as gastrointestinal symptoms. The series of questions relating to GI symptoms included queries regarding infantile colic, abdominal pain, diarrhea, vomiting, constipation and heartburn. The survey included questions about whether or not the various GI complaints were current or in the past.
All parents consented to complete the questionnaire. As expected atopy and atopic symptoms were much more common in the group with asthma than the control group. Abdominal pain, vomiting and diarrhea were reported significantly more frequently in the asthma group than in the control group. Infantile colic was reported with equal frequency in both groups. Abdominal complaints preceded the onset of asthma in 50 of the 58 children in the asthma group who reported abdominal complaints. Children in the asthma group were separated based on the severity of the illness. The frequency of GI complaints did not vary among children with varying severity of asthma.
The authors speculate on the reasons for these findings. Possible reasons mentioned include immunologic, with interleukins and other mediators found in the GI mucosa by some investigators or physical, with transdiaphragmatic pressure being increased in asthmatics. The authors found no association between various asthma treatments the children were receiving and the GI symptoms, nor any association between the symptoms and any particular foods.
Comments: The data presented in this paper was obtained from a questionnaire only and the validity of the information so obtained must be addressed. All eligible parents completed the questionnaires and all with the help of a research assistant who emphasized that there were no "correct" answers. If the findings are taken as accurate, the information is of interest to anesthesiologists. In many children, the GI symptoms did not occur during acute exacerbations of asthma but beforehand. Do asthmatic have delayed gastric emptying? Do have delayed gastric emptying only before and during acute attacks? The authors, pediatricians not anesthesiologists, do not even speculate on these possibilities. Having read this paper, I certainly do not plan to treat all asthmatics coming to the OR as though they present with “a full stomach” but I may include some questions about GI symptoms in the preanesthetic history.
Developmental
Outcomes of Extremely Preterm Infants
Yu
V, American Journal of Perinatology 2000; 17
In the late 1970’s the first report of survival of > 50% of a cohort of infants born weighing < 1000g was published. The author begins this report with a discussion of the various demographic factors which might affect survival statistics. These include whether or not the infants were transferred from other facilities or inborn, whether survival is for the neonatal period (28 days) or 1 year and whether or not delivery room deaths are excluded from analysis. Definitions the author uses in describing outcome are the following. Impairment means medical disorders such as cerebral palsy, blindness and developmental delay; while disability refers to interference with functioning as a result of an impairment. A severe disability would preclude attendance at regular school.
In comparing cohorts of patients born 1979-1980 to a cohort born 1985-1987 there was an increase in survival as well as a significant reduction in disability. There is a further increase in survival of these infants noted in the 1991-1992 cohort, a group born when surfactant administration was practiced, but the rate of severe disability is unchanged compared to the ’85-’87 cohort. Part of the results of the various outcomes in the extremely low birth weight (ELBW) groups are summarized below:
|
1979-1980
|
1985-1987
|
1991-1992
|
|
| survival |
25%
|
38%
|
56%
|
| severe disability |
18%
|
11%
|
11%
|
| IQ < 2SD below mean |
21%
|
7%
|
The children in the more recent cohorts attended regular school in high percentages. At 8 and 14 years, 91% and 93%, respectively, attended regular school and 75% did not require special educational assistance. The paper concludes with an overview of the progress made in the care of the ELBW newborn. While survival has more than doubled in just over a decade, the incidence of severe disability has decreased substantially.
Comments: We are anesthesiologists, not neonatologists. Nevertheless, this review of the outcome of infants born weighing less than 1000g ELBW from Australia is of interest because of the high and increasing survival rates of these infants, many of whom will come to the OR either during or after their time in the neonatal intensive care unit. For example, the incidence of inguinal hernia is much higher in the preterm than the full term newborn and these hernias are generally larger, making surgical repair more difficult and lengthy.
Necrotizing
Enterocolitis in Neonates with Congenital Heart Disease: Risk Factors and Outcomes
McElhinney, DB, Hedrick HL, Bush DM, et al, Pediatrics
2000;106:1080-1087
The authors of this paper conducted a case-control study of neonates with cardiac disease over the four-year period from January 1995 to December 1998. The authors were interested in learning the risk factors for the development of necrotizing enterocolitis (NEC) in the term newborn. Of the 643 inpatient cohort of newborns with heart disease, 21 newborns developed NEC and these were compared with 70 controls taken from the inpatient cohort matched by cardiac diagnosis and age at admission.
NEC is a disease generally seen in the preterm newborn, occurring with decreasing frequency as infants approach term. For the occasions when NEC occurs in term infants several risk factors have been proposed including polycythemia, exchange transfusion, peripartum asphyxia, and enteral feeding but there is disagreement about the significance of these factors. The authors here investigate the possible association between congenital heart disease and NEC. The authors report that in the experience at their institution, infants with congenital heart disease not only develop NEC with regularity, but the outcome is often poor.
Twenty-one (3.3%) of the infants with congenital heart disease in this study developed NEC as defined by modified Bell criteria. The specific diagnoses were as follows: Hypoplastic Left Heart Syndrome (HLHS) 10, Pulmonary Atresia with Intact Septum 2, Arteriosus 2, Tetralogy of Fallot 2, Coarctation of the aorta 2, Critical AS 1, Aortopulmonary window 1, Double Outlet Right Ventricle 1. While the hospital mortality was no different in the infants who developed NEC compared to those who did not, the hospital stay was significantly longer in the NEC group. T The deaths in the NEC group were directly attributable to NEC or associated complications. Using multivariable regression analysis only the diagnoses of HLHS, Truncus Arteriosus and Aortopulmonary window were significant independent risk factors for the development of NEC. The authors point out that all of these leisons all exhibit univentricular physiology with obstruction of the aortic arch.
Comments: Although an incidence of 3.3% may not seem particularly high, the incidence of NEC in all infants is 1-5/1000 live births or 0.2%-0.5%. Infants with NEC are certainly among the most challenging and are even more so when their condition is complicated by congenital heart disease. This report is of interest in documenting that certain forms of congenital heart disease are associated with significantly increased risk of NEC. It also should alert us to carefully search for congenital heart disease in full-term infants who present with NEC.
Acute
Pain in Children
Pediatric
Clinics of North America, 47 (3), June 2000
guest editor M Yaster.
This volume in the ongoing series is the first issue devoted to the topic of pain management since it was last addressed in 1989. The authors of the various chapters are all well known contributors to the area. The editor, Myron Yaster, is a prominent expert in pediatric pain treatment, having co-edited along with Drs. Berde and Schecter, the first textbook devoted to pediatric pain. I will not review the contents of this 250-page, hard-bound volume since it is virtually a text on acute pain in children but I will summarize the contents of some of the chapters.
Pain Assessment in Children reviews developmental neurophysiology of pain as well as methods for assessment. Behavioral and Cognitive Interventions in the Treatment of Pain in Children discusses various psychologic interventions using painful procedures as a framework. The chapter also includes evidence for efficacy and discusses logistics involved. Weak Analgesics and non-steroidals; Anti-Inflammatory Agents in the Management of Children with Acute Pain focuses on treatment of childhood pain with a combination of pharmacologic and complimentary methods. Pediatric Acute Pain Management describes pain assessment and reviews a variety of techniques for providing analgesia following surgery or acute injury in children. Treatment of Pain in the Neonatal Intensive Care Unit critically reviews a broad range of pharmacologic, behavioral and environmental interventions used for treatment of pain from a variety of causes in the newborn. The Management of Pain in Sickle Cell Disease includes discussion of the pathophysiology of vaso-occlusive pain crises as well as definition of other acute and chronic pain in sickle cell disease. A comprehensive approach to these patients including education, cognitive therapies, anti-inflammatory drugs, opioids and other modalities is included. Pain and Symptom Control in Terminally Ill Children reviews not only pain but also other very distressing symptoms such as agitation, nausea and dyspnea in terminally ill patients with many diagnoses including cancer, HIV, cystic fibrosis. In addition to medication with adjuvant drugs and analgesics interventional techniques are discussed.
Comments: This volume is a wonderful addition to the bookshelf of any pediatric anesthesiologist. Pediatric Clinics of North America (PCNA) is also a useful way to keep current in the specialty in general. Information about subscription to PCNA or purchase of an individual volume is available at: http://www.wbsaunders.com
Reviewed by Thomas J. Mancuso, MD, FAAP
Children’s Hospital, Boston
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