Evaluation of risk factors associated with fragility fractures and recommendations to optimise bone health in children with long-term neurological condition

INTRODUCTION@#The growing years are paramount for bone growth and mineral accrual. Children with long-term neurological condition (LTNC) have multiple risk factors for poor bone health and fragility fractures. In Singapore, this has not been studied systematically. Therefore, we aimed to evaluate the risk factors associated with fragility fractures in children with LTNC.@*METHODS@#In this study, the search for fragility fractures was done by a retrospective review of patients with LTNC on follow-up in the paediatric neurology clinic and patients who presented with fracture to the paediatric orthopaedic clinic. Information on patients' demographics, medical history, intervention, biochemical bone markers and fracture history was collected.@*RESULTS@#In a tertiary clinic population of 136 patients with LTNC, 65% were dependent on mobility (Gross Motor Function Classification System [GMFCS] V), 60% were underweight and 60% were fed via gastrostomy or nasogastric tube, or were on oral pureed diet. Furthermore, 60% were on anticonvulsants. The fracture rate was 3% in this population and was associated with low-impact activities such as transfer and dressing. Only 7.4% and 33% of the patients had undergone measurements of vitamin D and calcium levels, respectively.@*CONCLUSION@#The local prevalence of fragility fractures in children with LTNC on follow-up at the neurology clinic was found to be 3%. Risk factors identified were limited ambulation and compromised nutritional status associated with feeding difficulty. Recommendations to optimise bone health in children with LTNC were made. These include promoting weight-bearing activities, looking out for underweight children, avoiding vitamin D deficiency and ensuring adequate calcium intake.

Causes, functional outcomes and healthcare utilisation of people with cerebral palsy in Singapore

INTRODUCTION@#A voluntary cerebral palsy (CP) registry was established in 2017 to describe the clinical characteristics and functional outcomes of CP in Singapore.@*METHODS@#People with CP born after 1994 were recruited through KK Women's and Children's Hospital, National University Hospital and Cerebral Palsy Alliance Singapore. Patient-reported basic demographics, service utilisation and quality of life measures were collected with standardised questionnaires. Clinical information was obtained through hospital medical records.@*RESULTS@#Between 1 September 2017 and 31 March 2020, 151 participants were recruited. A majority (n=135, 89%) acquired CP in the pre/perinatal period, where prematurity (n=102, 76%) and the need for emergency caesarean section (n=68, 50%) were leading risk factors. Sixteen (11%) of the total participants had post-neonatally acquired CP. For predominant CP motor types, 109 (72%) had a spastic motor type; 32% with spastic mono/hemiplegia, 41% diplegia, 6% triplegia and 21% quadriplegia. The remaining (42, 27.8%) had dyskinetic CP. Sixty-eight (45.0%) participants suffered significant functional impairment (Gross Motor Functional Classification System levels IV-V). Most participants (n=102, 67.5%) required frequent medical follow-up (≥4 times a year).@*CONCLUSION@#Optimisation of pre- and perinatal care to prevent and manage prematurity could reduce the burden of CP and their overall healthcare utilisation.

Cost of inpatient rehabilitation for children with moderate to severe traumatic brain injury

AIM@#To evaluate the cost of inpatient rehabilitation for children with moderate to severe traumatic brain injury (TBI). Secondary aim was to identify factors associated with high inpatient rehabilitation cost.@*METHOD@#Retrospective review of a tertiary hospital's trauma registry was performed from 2011-2017. All patients aged 16 years or younger who sustained TBI with Glasgow Coma Scale ≤13 were included. Data on patient demographics, mechanism and severity of injury, hospital duration and inpatient rehabilitation cost were collected. We performed a regression analysis to identify factors associated with high rehabilitation cost.@*RESULTS@#There were a total of 51 patients. The median duration of inpatient rehabilitation was 13.5 days (interquartile range [IQR] 4-35), amounting to a median cost of SGD8,361 (IQR 3,543-25,232). Daily ward costs contributed the most to total inpatient rehabilitation cost. Those with severe TBI had longer duration of inpatient rehabilitation that resulted in higher cost of inpatient rehabilitation. Presence of polytrauma, medical complications, post-traumatic amnesia and TBI post-non-accidental injury (NAI) were associated with higher cost of inpatient rehabilitation.@*CONCLUSION@#The cost of inpatient rehabilitation for paediatric patients post-TBI is significant in Singapore. Patients with TBI secondary to NAI had significantly higher cost of inpatient rehabilitation. Ways to reduce duration of hospitalisation post-TBI and early step-down care or outpatient rehabilitation should be explored to reduce cost.

Long-Term Morbidities in Children with Critical Illness: Gaps and Opportunities

<p><b>INTRODUCTION</b>Improved mortality rates in paediatric critical care may come with the cost of increased morbidity. Goals of modern paediatric intensive care unit (PICU) management should focus on restoring long-term function of paediatric critical illness survivors. This review outlines our current knowledge on trajectories and risk factors of long-term morbidities in PICU survivors. Specifically, we aimed to identify current limitations and gaps in this area so as to identify opportunities for future investigations to reduce the burden of morbidities in these children.</p><p><b>MATERIALS AND METHODS</b>A review of primary studies published in PubMed, EMBASE, and Cochrane databases in the last decade (2008-2017) describing long-term morbidities in PICU survivors was conducted.</p><p><b>RESULTS</b>Children surviving critical illness continue to experience morbidities after discharge. A set of risk factors modify their long-term trajectories of recovery, with some children achieving their premorbid level of function, while some others deteriorate or die. Limitations in current methodologies of morbidity research impair our understanding on the causes of these morbidities. Opportunities for future endeavours to reduce the burden of these morbidities include identifying patients who are more likely to develop morbidities, evaluating the efficacy of early rehabilitation, identifying patients who might benefit from tight glycaemic control, characterising the optimal nutritional intervention, and improving management of increased intracranial pressure.</p><p><b>CONCLUSION</b>Survivors of paediatric critical illness experience differing trajectories of recovery from morbidities. Future research is needed to expand our repertoire on management strategies to improve long-term function in these children.</p>

Nonimmune hydrops fetalis in a children's hospital: a six-year series

<p><b>INTRODUCTION</b>We aimed to study the profile of nonimmune hydrops fetalis (NIHF) in the local population and identify its outcomes and causes.</p><p><b>METHODS</b>We carried out a retrospective review of the medical records in KK Women's and Children's hospital, a single tertiary referral centre, for pregnancies with an antenatal diagnosis of NIHF in the six-year period from 1 January 2005 to 31 December 2010.</p><p><b>RESULTS</b>A total of 29 cases of NIHF were identified; 19 (66%) cases underwent karyotype evaluation, 17 (59%) underwent intrauterine infection screening, and all underwent antenatal thalassaemia screening. The median gestational age at diagnosis was 27 (range 12-37) weeks, median gestational age at birth was 33 (range 27-37) weeks, and median birth weight of live births was 2,480 (range 1,230-3,900) g. The aetiologies for NIHF were identified in 20 (69%) cases, which included cardiac anomalies (n = 5), haematological problems (n = 4), congenital tumours (n = 4), genetic/metabolic disorders (n = 4) and cystic hygromas (n = 3). The cause of NIHF was not identified in the remaining 9 (31%) cases. There were 19 live births - 8 (42%) survived and 11 (58%) died in the neonatal period - and one stillbirth. Nine women opted for medical termination of pregnancy following the diagnosis of NIHF.</p><p><b>CONCLUSION</b>It is important to thoroughly investigate all cases of NIHF and identify its causes in order to provide appropriate antenatal and postnatal counselling. In our series, almost one-third of NIHF cases had no identified aetiology. The neonatal mortality rate was approximately 58%.</p>