The Two-bag System for Intravenous Fluid Management of Children with Diabetic Ketoacidosis: Experience from a Community-Based Hospital.

Objectives: Intravenous fluid (IVF) administration using the two-bag system compared with the one-bag system in children with diabetic ketoacidosis (DKA) admitted between January 1, 2015 and December 31, 2016. Design: Retrospective cohort study. Setting: Community-based hospital. Results: A total of 109 patients were enrolled with a mean age of 13.24 years. The 2 groups had comparable demographics. Initial laboratory results were similar except for initial PH and Sodium. The two bag system had significantly less number of calls compared to one bag system (25.2 vs 5.2 P = .0001). One bag system had fewer hypoglycemia <60 mg/dl (4 vs 12 P = .049). No statistically significant observations noted in regards to glucose drop rate, number of intravenous fluid bags used, amount of fluid boluses given, hospital stay and Pediatric ICU stay. Conclusions: The two-bag system has less resource utilization and slower blood glucose drop rate, but higher hypoglycemic events.

Blood Lead Levels in Females of Childbearing Age in Flint, Michigan, and the Water Crisis.

OBJECTIVE: To compare blood lead levels in females of childbearing age, 12-50 years, living within and adjacent to Flint, Michigan, before, during, and after the Flint River water exposure and compare the levels to those that have been shown to cause fetal loss and preterm birth. METHODS: The switch in the community water source to the Flint River occurred on April 25, 2014, and was reverted to the original source on October 15, 2015. Using a retrospective cross-sectional study design using geocoded blood lead levels obtained from all females of childbearing age available from a single hospital database, we compared blood lead levels for the following 18-month time periods: April 25, 2012-October 15, 2013 (PRE), April 25, 2014-October 15, 2015 (DURING), and April 25, 2016-October 15, 2017 (POST). RESULTS: Results are reported as geometric mean (95% CI). Within Flint, PRE blood lead levels in females of childbearing age were 0.69 micrograms/dL (95% CI 0.63-0.75), DURING blood lead levels were 0.65 micrograms/dL (95% CI 0.60-0.71), and POST blood lead levels were 0.55 micrograms/dL (95% CI 0.54-0.56). DURING Flint River water exposure blood lead levels were not significantly different than the PRE Flint River water time period. POST Flint River water exposure blood lead levels were significantly lower than both PRE and DURING levels. Overall, lower blood lead levels were found outside the Flint boundary in all cohorts. CONCLUSION: Blood lead levels in Flint females of childbearing age did not increase during the Flint River water exposure and subsequent 18-month time period. Mean blood lead levels during the Flint River water exposure are not consistent with the markedly higher blood lead levels reported in the literature to be associated with fetal loss, low birth weight, or preterm birth.

Analysis of blood lead levels of young children in Flint, Michigan before and during the 18-month switch to Flint River water.

Background: The toxicity of lead, like any xenobiotic, is directly linked to the duration of exposure and toxin concentration in the body. The elevation in blood lead levels (BLLs) in young Flint, Michigan children noted in time-periods before, and during the 18-month exposure to Flint River water (FRW) from 25 April 2014 to 15 October 2015 is well-known internationally. The length of time BLLs were elevated is unknown, yet key in understanding the potential health impact of the event. The objective of this study was to evaluate whether BLLs in Flint children were increased during the entire 18-month FRW exposure compared to similar earlier time periods. Methods: We conducted a retrospective study analyzing BLLs from Flint children aged 5 years and under. The geometric mean (GM) BLLs and percentages of BLLs ≥5.0 µg/dL in Period I: 25 April 2006 to 15 October 2007 (earliest timeframe available for study) and Period II: 25 April 2012 to 15 October 2013 (timeframe immediately before the water switch), were compared to Period III, 25 April 2014 to 15 October 2015 (FRW exposure). Results: There were 5663 BLLs available for study. GM ± SE BLLs decreased from 2.19 ± 0.03 µg/dL in Period I to 1.47 ± 0.02 µg/dL in Period II [95% CI, 0.64, 0.79]; p<.001 and decreased further to 1.32 ± 0.02 µg/dL during the FRW Period III [95% CI, 0.79, 0.95]; p<.001. The percentage of BLLs ≥5.0 µg/dL decreased from Period I (10.6%) to Period II (3.3%) [95% CI, 5.7, 8.8]; p<.001 and from Period I to Period III (3.9%) [95% CI, 5.0, 8.2]; p=.002. The 0.6% increase from Period II to Period III was not statistically significant [95% CI, -1.9, 0.57]; p=.30. Conclusion: Analyses of GM and percentages ≥5.0 µg/dL of BLLs do not support the occurrence of a global increase in BLLs in young children of Flint during the entire 18-month period of FRW exposure.

Blood Lead Levels of Children in Flint, Michigan: 2006-2016.

OBJECTIVE: We evaluated the increases in blood lead levels (BLLs) observed in young children in Flint, Michigan, during their exposure to corrosive Flint River water during the years 2014 and 2015 and compared their BLLs to those of Flint children measured during the years 2006-2013 and 2016. STUDY DESIGN: This was a retrospective study design using BLLs extracted from databases from 2006 to 2016. We analyzed a population sample of 15 817 BLLs from children aged ≤5 years with potential exposure to contaminated Flint River water. Percentages of BLLs ≥5.0 µg/dL and geometric mean (GM) BLLs were analyzed over time. RESULTS: A significant decline in the percentages of BLLs ≥5.0 µg/dL from 11.8% in 2006 to 3.2% in 2016 was observed (P < .001). GM ± SE BLLs decreased from 2.33 ± 0.04 µg/dL in 2006 to 1.15 ± 0.02 µg/dL in 2016 (P < .001). GM BLLs increased twice: from 1.75 ± 0.03 µg/dL to 1.87 ± 0.03 µg/dL (2010-2011) and from 1.19 ± 0.02 µg/dL to 1.30 ± 0.02 µg/dL (2014-2015). Overall, from 2006 to 2016, there was a 72.9% decrease in the percentage of children with BLLs ≥5.0 µg/dL and a 50.6% decrease in GM BLLs. CONCLUSION: These findings suggest that the 11 year trend of annual decreases in BLLs in children in Flint, Michigan, reversed to a degree consistent with random variation from 2010 to 2011, and again during the exposure to Flint River water in 2014-2015. Historically, public health efforts to reduce BLLs of young children in Flint have been effective over the 11-year period studied.

Association of the Family Nutrition and Physical Activity Screening Tool with Weight Status, Percent Body Fat, and Acanthosis Nigricans in Children from a Low Socioeconomic, Urban Community.

OBJECTIVE: To examine the association of the Family Nutrition and Physical Activity (FNPA) screening tool with weight status, percent body fat, and acanthosis nigricans (AN) in 6- to 13-year-old children from a low socioeconomic, urban community. METHODS: Children (n=415) from four elementary schools located around Flint, Michigan were assessed for body mass index, percent body fat, and AN. The FNPA screening tool was completed by parents. Mann-Whitney U tests were used to assess differences in FNPA score by sex and presence of AN. Logistic regression was used to evaluate the association of the FNPA (tertiles) with weight status and AN. RESULTS: Children with AN (13.7%) had a significantly lower FNPA score (56.3 + 7.1) compared with children without AN (61.0 + 7.1; P<.05). Children with FNPA scores in the lowest tertile (high-risk) had odds ratios of 1.74 (95% CI =1.05 - 2.91) and 2.77 (95% CI =1.22 - 6.27) compared with children with FNPA scores in the highest tertile (low-risk) for being overfat and having AN, respectively. CONCLUSION: Although the FNPA screening tool did not predict risk for being overweight or obese, it was significantly associated with an increased odds of children at risk for being overfat or having AN.

Forme Fruste of HLH (haemophagocytic lymphohistiocytosis): diagnostic and therapeutic challenges.

Infants and young children often present with a persistent febrile episode, sick appearance and negative infectious disease work-up. These patients present serious diagnostic and therapeutic problems to those who provide medical care, particularly since these children are clinically sick. We present a 13 month old child who presented with this clinical challenge. She was ultimately thought to have an incomplete form of HLH with underlying pathophysiology of hypercytokinemia, but also could have been a case of incomplete form of Kawasaki disease. She responded to IVIG, but this does not differentiate one diagnosis from another. Unfortunately we failed to obtain tests to exclude genetic etiologies of HLH, which would be important for predicting severity and risks of future recurrence. We wish to present this case so that one should do a thorough work up to establish a firm diagnosis of HLH and to search for genetic causes of this disorder.

Acute haemolytic anaemia and myolysis due to G6PD deficiency.

A 2-year-old African-American male patient with sickle cell trait developed cough, red coloured urine, pallor and fatigue. The patient was hospitalised. Diagnostic workup showed that he was glucose 6 phosphate dehydrogenase (G6PD) deficient in erythrocytes. He also had chest X-ray findings of pneumonia. His urine examination showed the presence of haemoglobin and myoglobin. On repeated questioning it was found that he had a moth ball in his mouth a few days prior to this medical episode. This case illustrates a rarely described complication of myolysis in G6PD deficient persons on exposure to a strong oxidant. A review of the literature showed that most people with G6PD deficiency tolerate exercise well without untoward effect in muscles. However, assay of myoglobin in urine has not been routinely performed in these patients during acute haemolytic episode, and thus it is uncertain how frequent myoglobulinaemia occurs in a similar stress situation.

Symptomatic erythrocytosis associated with a compound heterozygosity for Hb Lepore-Boston-Washington (δ87-ß116) and Hb Johnstown [ß109(G11)Val→Leu, GTG>TTG].

Hb Johnstown [ß109(G11)Val→Leu, GTG>TTG] has previously been described as a high oxygen affinity variant in a heterozygous state and in combination with ß(0)-thalassemia (ß(0)-thal). Because the variant does not separate from Hb A by routine methods it may be easily missed unless clinical suspicion is high. Hb Lepore-Boston-Washington (Hb LBW; δ87-ß116) is a 뫧 hybrid variant that clinically manifests similarly to a ß(+)-thal. Hb LBW is not detected by routine polymerase chain reaction (PCR) sequencing but is easily detected by electrophoretic methods. We describe a 19-year-old African American male with a compound heterozygosity for Hb Johnstown and Hb LBW. The patient presented with progressively worsening chest pains, headaches and erythrocytosis. He was repeatedly phlebotomized with symptomatic improvement and subsequently was confirmed to have the high oxygen affinity hemoglobin (Hb) variant. The lowest Hb and hematocrit (packed cell volume, PCV) achieved by phlebotomy was 16.1 g/dL and 0.51 L/L, respectively. Currently, he is no longer being phlebotomized, and is feeling relatively well except for minor chest pain. It is unclear to what degree the phlebotomies contributed to his subjective improvement. The combination of Hbs Johnstown and LBW has not been heretofore described, and in this case, was associated with marked symptomatic erythrocytosis. This unique combination results in a more pronounced phenotype, similar to or slightly more severe than, compound Hb Johnstown/ß(0)-thal. This compound hemoglobinopathy will likely not be correctly classified using a single method of Hb detection and underscores the need for multiple characterization methods when indicated by the clinical picture.

What influences parents' decisions to limit or withdraw life support?

OBJECTIVE: Decisions to forgo life support from critically ill children are commonly faced by parents and physicians. Previous research regarding parents' perspectives on the decision-making process has been limited by retrospective methods and the use of closed-ended questionnaires. We prospectively identified and described parents' self-reported influences on decisions to forgo life support from their children. Deeper understanding of parents' views will allow physicians to focus end-of-life discussions on factors important to parents and help resolve conflicts. DESIGN: Prospective, qualitative pilot study. SETTING: Pediatric intensive care unit of a university-affiliated children's hospital. PARTICIPANTS: A total of 14 parents of ten children whose pediatric intensive care unit physician had made a recommendation to limit or withdraw life support. INTERVENTIONS: : In-depth, semistructured interviews were conducted with parents during their decision-making process. MEASUREMENTS AND MAIN RESULTS: Factors influencing the parents in this study in their decision to forgo life support included their previous experience with death and end-of-life decision making for others, their personal observations of their child's suffering, their perceptions of their child's will to survive, their need to protect and advocate for their child, and the family's financial resources and concerns regarding life-long care. Parents in this study expressed the desire to do what is best for their child but struggled with feelings of selfishness, guilt, and the need to avoid agony and sorrow. Physician recommendations, review of options, and joint formulation of a plan helped parents gain a sense of control over their situation. Parents of eight children agreed to forgo life support and parents of two did not. CONCLUSIONS: Prospective interviews with open-ended questions identified factors influencing parents' decision making not previously described in the critical care literature such as parents' past experiences with end-of-life decisions and their anticipated emotional adjustments and future resources. Inclusion of these factors into discussions is important to parents and may facilitate decisions regarding the limitation or withdrawal of life support.

What is the right dose of epinephrine?

OBJECTIVE: To review the findings and discuss implications of studies on high-dose epinephrine (0.1 mg/kg) during cardiopulmonary resuscitation in children. DESIGN: A critical appraisal of "A Comparison of High-Dose and Standard-Dose Epinephrine in Children with Cardiac Arrest" by Perondi et al. (N Engl J Med 2004; 350:1722-1730), with literature review. FINDINGS: Retrospective studies investigating the use of high-dose epinephrine during pediatric cardiopulmonary resuscitation demonstrate conflicting results with respect to return of spontaneous circulation and survival. The randomized controlled trial by Perondi et al. demonstrates decreased survival with the use of high-dose epinephrine and no difference in return of spontaneous circulation when compared with the standard dose. CONCLUSIONS: There is no benefit from the use of high-dose epinephrine in pediatric cardiopulmonary resuscitation. There is potential harm from such dosing. The cumulative evidence against the use of high-dose epinephrine during pediatric cardiopulmonary resuscitation is strong.