Article Reviews and Commentary
Vesicoureteral reflux and evidence-based management.
Editorial Arant. BS J Pediatr 2001;139-620-1
Outcome at 10 years of severe vesicoureteral
reflux managed medically; Report of the International reflux Study in Children.
Smellie JM, Jodal U, Lax H et al J Pediatr 2001;139-656-63
This paper and accompanying editorial discuss the medical management of the common pediatric problem for which children often come to the OR, vesicoureteral reflux (VUR). One hundred forty nine children were recruited for the study and were managed medically and monitored with serial cystograms. Medical management consisted of "…continuous low dose antibacterial prophylaxis, attention to fluid intake and bowel and bladder function with regular clinical supervision". The antibiotic administration was generally discontinued after the child reached the age of 8 years. Voiding cystourethrograms were scheduled at 0.5, 1.5, 3, 4.5, 6, 8 and 10 years until 2 successive negative exams were obtained. The reflux showed continuing improvement throughout the 10 years of the study. The proportion of children with no reflux increased from 14% at 5 years into the study to 52% after 10 years. Grade III or IV was seen in 48% of the children at 5 years but only in 23% at the 10 year mark. The authors note also that in 20% of children with grade II or IV at initial voiding cystourethrogram, the reflux had disappeared or significantly decreased at the second radiologic exam.
The editorial generally supports medical management of VUR, provided that the medical care is a careful and the follow-up as thorough as employed in the study above: maintenance of sterile urine, good patient education and consistent follow-up. The author concludes that medical management can be recommended for at least the first year after the initial diagnosis for any grade VUR, although he admits that when surgical correction is readily available and safe (this is where we come in), the exceptionally high cure rate may outweigh the inconvenience of repeated medical visits and several voiding cystourethrograms.
Comment:
This is an interesting paper on several levels. It is good to reconsider well-established
therapies in light of new or better evidence since tradition is a poor reason
for continuing a medical practice. It also points out the difficulty in evaluating,
in a meaningful and scientific way, some surgical interventions that have become
part of common practice never having been subject to randomized controlled trials.
It is very rewarding to care for children with VUR in the OR and afterward since they are generally well and the surgical procedure is curative in 98% of cases. But, based on these papers, it may be that fewer of these children come for surgical correction.
A two year pilot study of hydroxyurea
in very young children with sickle-cell anemia.
Wang WC, Wynn LW, Rogers ZR et al J Pediatr 2001;139:790-6
This report describes a 2 year, open-label trial of 20mg/kg/day of hydroxyurea treatment in 28 very young (6-28 months old) children with sickle-cell anemia. Currently, hydroxyurea (HU) is the only chemotherapeutic agent approved for the treatment of sickle-cell anemia in the US. HU has been used to treat adults with SS anemia with good results; fewer episodes of pain and acute chest syndrome, transfusions and hospitalizations. These beneficial effects are due to several effects including increased levels of fetal hemoglobin and prevention of severe cellular dehydration of sickled cells possibly preventing the formation of irreversibily sickled cells. HU treatment also improves rbc deformability, increases rbc survival time and decreases adhesion of rbc's to vascular endothelium.
After the 2 years of treatment, mean Hgb levels and HbF levels were significantly higher than predicted age-specific levels. In addition, radionuclide uptake by the spleen was absent in 47% of the study subjects, compared to the predicted 80% incidence of functional asplenia in these patients had they not been treated with HU.
The predominant toxicity noted, transient neutropenia, is not too surprising given HU's known myelosupression. Seven patients did not complete the study, 5 for non-compliance, one for development of a mild stroke and one fatality. this was from a splenic sequestration. No children had decreased growth velocity. Three children had a total a of 7 episodes of acute chest syndrome, but none had severe respiratory distress. In this investigation, no clear neurologic toxicity was observed but neurodevelopmental testing, MRI and MRA are difficult to interpret in this age group, especially given the limited data available for untreated children in the age range of the study. A recent mouse study suggests adverse effects of HU on brain development, but it's relevance to human administration of HU is very uncertain. The authors conclude that administration of HU to young children is certainly possible. Side effects were relatively minor and transient and that HbF levels were maintained at or near the 20% levels over a 2 year period.
Evaluation and Preparation of Pediatric Patients
Undergoing Anesthesia (RE9633)
Section on Anesthesiology and Pain Management
Pediatrics Vol. 98 No. 3 Sept 1996
http://www.aap.org/policy/01566.html
This statement is directed to pediatricians and other primary care providers for children who will be called upon to evaluate children for their fitness to undergo anesthesia and surgery. The objectives are stated at the outset
1. to describe medical issues of concern to anesthesiologists
and surgeons
2. to encourage communication among surgeons, anesthesiologists
pediatricians and other primary care providers for children
3. to provide guidelines to pediatricians and others who
are preparing patients and families for anticipated procedures The roles of
the anesthesiologists and surgeon are described following which is a list of
information of importance to the anesthesiologists and surgeons, including pertinent
history, physical exam and laboratory information. Special issues of concern
are then addressed including children with URI's, cystic fibrosis, former preterm
infants, cardiac murmurs. Other common problems noted in the statement include:
seizure disorders, MMC, sickle cell anemia and Diabetes Mellitus.
The report concludes with a discussion of reason for cancellation of surgery on the day of surgery and a list of common parental questions with suggested answers.
Comment
This AAP policy statement is worth review since it guides
the pediatrician Upon whom we rely for pertinent health information about the
children who we meet for the first time in the preanesthetic holding area.
The AAP has many policy statements covering
a variety of topics related to the physical, emotional and psychological health
of infants and children. I will on occasion summarize those statements of interest
to members of the SPA. The URL for each statement will be included with the
reference.
Guidelines for the Pediatric Perioperative Anesthesia Environment
(RE9820) Policy Statement of the American Academy of Pediatrics by the Section
on Anesthesiology and Pain Management
Pediatrics Vol. 103 No.2 February 1999
http://www.aap.org/policy/re9820.html
This statement, authored by the sections on anesthesiology and pain managments; QA committee, under the direction of Al Hackel, MD FAAP, describes the components of the perioperative environment which should be in place to assure a safe and pleasant experience for infants and children undergoing surgical procedures. The guidelines contained are a supplement to ASA standards and guidelines in print.
The document describes the policies needed to define the exact types of procedures performed at the facility including minimum numbers recommended to assure competence. The statement recommends careful record keeping of outcomes, categorizing pediatric patients by age as follows; 0-1 month, 1-6 months, 6 months-2 years, and older than 2 years. Further categories of children greater than 2 years of age is recommended by not specifically stated.
The statement also describes both regular and special clinical for anesthesiologists who care for children at the facility. The need for pain management in the perioperative period is mentioned in the statement, but the development of specific policies is left to the individual facility.
The physical plant of the facility is described in some detail, with the importance of age and size appropriate equipment in all patient care areas, the preoperative areas, the Or and the PACU, emphasized. The clinical, laboratory and radiology support services should also be prepared for infants and children of all ages and sizes in facilities providing anesthesia for children undergoing procedures as described in the statement. The report also emphasizes the importance of maintenance well-stocked and current resuscitation and difficult airway carts in the facility as well as devices for the delivery of positive pressure ventilation and fluid and patient warming. There should be available appropriately sized monitoring equipment to allow routine monitoring as recommended by the ASA.
Comment
The initial impetus for this statement came from Dr. Hackel
who recognized the need for the AAP, acting as an advocate for the health of
children, to publish guidelines that dedicated practitioners could use in their
own advocacy for improved perioperative care of children.
Individual anesthesiologists, negotiating with their institutions, can expect more success in their efforts to advocate for pediatric patients with the force of this AAP policy statement behind them. Evaluation and Preparation of Pediatric Patients Undergoing Anesthesia (RE9633)
Section on Anesthesiology and Pain Management
Pediatrics Vol. 98 No. 3 Sept 1996
http://www.aap.org/policy/01566.html
This statement is directed to pediatricians and other primary care providers for children who will be called upon to evaluate children for their fitness to undergo anesthesia and surgery. The objectives are stated at the outset:
1. to describe medical issues of concern to anesthesiologists
and surgeons
2. to encourage communication among surgeons, anesthesiologists pediatricians
and other primary care providers for children
3. to provide guidelines to pediatricians and others who are preparing patients
and families for anticipated procedures.
The roles of the anesthesiologists and surgeon are described following which is a list of information of importance to the anesthesiologists and surgeons, including pertinent history, physical exam and laboratory information. Special issues of concern are then addressed including children with URI's, cystic fibrosis, former preterm infants, cardiac murmurs. Other common problems noted in the statement include: seizure disorders, MMC, sickle cell anemia and Diabetes Mellitus.
The report concludes with a discussion of reason for cancellation of surgery on the day of surgery and a list of common parental questions with suggested answers.
Comment
This AAP policy statement is worth review since it guides
the pediatrician Upon whom we rely for pertinent health information about the
children who we meet for the first time in the preanesthetic holding area.
Reviewed by: Thomas J. Mancuso, MD, FAAP
Children's Hospital, Boston, MA
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