Single-center review on safety of biodegradable airway stenting in pediatric population.

BACKGROUND: Tracheobronchomalacia (TBM) and airway stenosis are recognized etiologies of airway obstruction among children. Their management is often challenging, requiring multiple interventions and prolonged respiratory support with associated long-term morbidity. Metallic or silicone stents have been used with mixed success and high complication rates. More recently biodegradable Ella stents (BES) provided an attractive interventional option. OBJECTIVES: We report our experience in the treatment of TBM and vascular airway compression using BES. We deliberately downsized them to minimize intraluminal granulation tissue formation. MATERIALS AND METHODS: Retrospective study over an 8-year period between November 2012 and December 2020 of pediatric patients with severe airway obstruction requiring airway stenting for extubation failure, malacic death spells, recurrent chest infections, or lung collapse. RESULTS: Thirty-three patients (5 tracheal and 28 bronchial diseases) required 55 BES during the study period. The smallest patient weighed 1.8 kg. Median age of patient at first stent implantation was 13.1 months (IQR 4.9-58.3). The majority of the bronchial stents were in the left main bronchus (93%), of which 57% for vascular compression. Repeat stents were used in 19 patients (57.7%), with a range of two to four times. We did not experience erosion, infection, or obstructive granuloma needing removal by forceps or lasering. Three stent grid occluded with secretions needing bronchoscopic lavage. Stent migration occurred in three patients. CONCLUSIONS: BES holds promise as a treatment option with low rate of adverse effects for a specific subset of pediatric patients with airway malacia or vascular compression. Further studies are warranted.

Thrombophilia in Pediatric Patients with Multisystem Inflammatory Syndrome in Children Secondary to Coronavirus Disease 2019 Supported on Extracorporeal Membrane Oxygenation.

Coronavirus disease 2019 (COVID-19) in adults has been associated with thrombosis. Multisystem inflammatory syndrome in children (MIS-C) with COVID-19 case series have reported high fibrinogen levels, but it is not known whether this causes thrombophilia. We report two patients needing extracorporeal membrane oxygenation (ECMO) who both suffered thrombotic complications. We retrospectively reviewed patients with MIS-C needing ECMO support admitted to a single Paediatric and Cardiac Intensive Care Unit within a regional center for MIS-C in South East England. Two children required ECMO for cardiovascular support. Both developed thrombotic events despite receiving heparin infusions at dosing higher than the interquartile range for our ECMO population. Case 1 developed a right anterior and middle cerebral artery infarct, which led to his death. Case 2 had a right atrial thrombus, which resolved without complication. When compared with patients undergoing ECMO in the same institution in pre-MIS-C era, fibrinogen levels were consistently higher before and during ECMO therapy. MIS-C patients presenting with hyperfibrinogenemia are likely to have a propensity toward thrombotic complications; this must be considered when optimizing the anticoagulation strategy on ECMO.

Nasal irrigation with saline solution significantly improves oxygen saturation in infants with bronchiolitis.

AIM: Published guidelines do not recommend nasal irrigation in bronchiolitis, but it is common practice in Italy, despite a lack of data on its benefits or adverse effects. This single-blind, multicentre, randomised controlled trial compared nasal irrigation using either isotonic 0.9% sodium chloride or hypertonic 3% sodium chloride with simple supportive care in infants with bronchiolitis. METHODS: We randomly assigned 133 infants up one year of age, who were admitted to the emergency department with bronchiolitis and an oxygen saturation (SpO2) of between 88 and 94%, to the isotonic (n = 47), hypertonic (n = 44) or standard care (n = 42) groups. Variations in SpO2 and the wheeze, air exchange, respiratory rate, muscle use (WARM) respiratory distress score were recorded at zero, five, 15, 20 and 50 minutes. RESULTS: Five minutes after the intervention, the median SpO2 value (95%) in the isotonic group was higher than both the hypertonic (94%) and the standard care (93%) groups. The differences between the isotonic and standard treatment groups were statistically significant at each time point, while the hypertonic group only reached significantly higher values after 50 minutes. However, the WARM score did not improve. CONCLUSION: A single nasal irrigation with saline solution significantly improved oxygen saturation in infants with bronchiolitis.

Sublingual ketorolac versus sublingual tramadol for moderate to severe post-traumatic bone pain in children: a double-blind, randomised, controlled trial.

OBJECTIVES: To assess the effectiveness of sublingual ketorolac versus sublingual tramadol in reducing the pain associated with fracture or dislocation of extremities in children. PATIENTS AND METHODS: A double-blind, randomised, controlled, non-inferiority trial was conducted in the paediatric emergency department of a research institute. One hundred and thirty-one children aged 4-17 years with suspected bone fracture or dislocation were enrolled. Eligible children were randomised to ketorolac (0.5 mg/kg) and placebo, or to tramadol (2 mg/kg) and placebo by sublingual administration, using a double-dummy technique. Pain was assessed by the patients every 20 min, for a maximum period of 2 h, using the McGrath scale for patients up to 6 years of age, and the Visual Analogue Scale for those older than 6 years of age. RESULTS: The mean pain scores fell significantly from eight to four and five in the ketorolac and tramadol groups, respectively, by 100 min (Wilcoxon sign rank test, p<0.001). The mean pain scores for ketorolac were lower than those for tramadol, but these differences were not significant at any time point (Mann-Whitney U Test, p values: 0-20 min: 0.167; 20-40 min: 0.314; 40-60 min: 0.223; 60-80 min: 0.348; 80-100 min: 0.166; 100-120 min: 0.08). The rescue dose of paracetamol-codeine was administered in 2/60 children in the ketorolac group versus 8/65 in the tramadol group (Fisher exact test, p=0.098). There were no statistically significant differences between the two groups in the frequency of adverse effects. CONCLUSIONS: Both sublingual ketorolac and tramadol were equally effective for pain management in children with suspected fractures or dislocations.

Acute and recurrent pancreatitis in children: exploring etiological factors.

OBJECTIVE: Etiologies of acute pancreatitis (AP) in children are more variable than in adults, including drugs, traumas, infections and multisystem disorders as well as biliary anomalies. While causes of pancreatitis have been extensively analyzed, different series reported different causes. The aims of this study were: 1) to assess the etiological factors of acute and recurrent pancreatitis in a pediatric population from a tertiary care hospital; 2) to assess the usefulness of imaging studies in diagnosing etiologies of pancreatitis. MATERIAL AND METHODS: Thirty-four children (median age 11 years, 23 males) with AP and 11 with recurrent pancreatitis were retrospectively studied to assess etiology of pancreatitis in children. RESULTS: The most common etiologies of AP were medications (11/34) and biliary tract diseases (9/34), whereas systemic diseases accounted for a small percentage of case. Among patients with recurrent episodes, biliary anomalies were the most common cause (6/11), whereas only 2 out of 11 patients with recurrent pancreatitis presented a hereditary cause. CONCLUSIONS: This study highlights that etiologies of AP in children are variable. Epidemiology of AP could be influenced by single center's characteristics. Anatomic anomalies should be ruled out and genetic causes should be considered in recurrent cases.

Safety and efficacy of high-dose acarbose treatment for dumping syndrome.

Dumping syndrome (DS) is a complication of Nissen fundoplication. Dietary strategies can ameliorate symptoms, but this approach is not always foolproof. Limited evidence reports the efficacy of acarbose for children who are unresponsive to feeding manipulations. We report 8 patients with DS aged between 7 and 24 months. In 4 of 8 nutritional strategies failed, and acarbose treatment was started. The initial dose was 25 mg for meals, and increased until postprandial glucose was stable. In 3 of 4 children the final dose was higher than previously reported, without adverse effects. Acarbose is useful to treat DS in cases of failure of dietary strategies.

Antidepressant drugs and breastfeeding: a review of the literature.

The use of antidepressants in breastfeeding mothers is controversial: Manufacters often routinely discourage breastfeeding for the nursing mother despite the well-known positive impact that breastfeeding carries on the health of the nursing infant and on his or her family and society. We conducted a systematic review of drugs commonly used in the treatment of postpartum depression. For every single drug two sets of data were provided: (1) selected pharmacokinetic characteristics such as half-life, milk-to-plasma ratio, protein binding, and oral bioavailability and (2) information about lactational risk, according to some authoritative sources of the literature: Drugs in Pregnancy and Lactation edited by Briggs et al. (Lippincott Williams, Philadelphia, 2008), Medications and Mothers' Milk by Hale (Hale Publishing, Amarillo, TX, 2010), and the LactMed database of TOXNET ( www.pubmed.gov ; accessed June 2010). Notwithstanding a certain variability of advice, we found that (1) knowledge of pharmacokinetic characteristics are scarcely useful to assess safety and (2) the majority of antidepressants are not usually contraindicated: (a) Selective serotinin reuptake inhibitors and nortryptiline have a better safety profile during lactation, (b) fluoxetine must be used carefully, (c) the tricyclic doxepine and the atypical nefazodone should better be avoided, and (d) lithium, usually considered as contraindicated, has been recently rehabilitated.