Children In Coma Research Articles

Incidence of chikungunya virus infections among Kenyan children with neurological disease, 2014-2018: A cohort study.

BackgroundNeurological complications due to chikungunya virus (CHIKV) infection have been described in different parts of the world, with children being disproportionately affected. However, the burden of CHIKV-associated neurological disease in Africa is currently unknown and given the lack of diagnostic facilities in routine care it is possible that CHIKV is an unrecognized etiology among children with encephalitis or other neurological illness.Methods and findingsWe estimated the incidence of CHIKV infection among children hospitalized with neurological disease in Kilifi County, coastal Kenya. We used reverse transcriptase polymerase chain reaction (RT-PCR) to systematically test for CHIKV in cerebrospinal fluid (CSF) samples from children aged <16 years hospitalized with symptoms of neurological disease at Kilifi County Hospital between January 2014 and December 2018. Clinical records were linked to the Kilifi Health and Demographic Surveillance System and population incidence rates of CHIKV infection estimated. There were 18,341 pediatric admissions for any reason during the 5-year study period, of which 4,332 (24%) had CSF collected. The most common clinical reasons for CSF collection were impaired consciousness, seizures, and coma (47%, 22%, and 21% of all collections, respectively). After acute investigations done for immediate clinical care, CSF samples were available for 3,980 admissions, of which 367 (9.2%) were CHIKV RT-PCR positive. Case fatality among CHIKV-positive children was 1.4% (95% CI 0.4, 3.2). The annual incidence of CHIKV-associated neurological disease varied between 13 to 58 episodes per 100,000 person-years among all children <16 years old. Among children aged <5 years, the incidence of CHIKV-associated neurological disease was 77 per 100,000 person-years, compared with 20 per 100,000 for cerebral malaria and 7 per 100,000 for bacterial meningitis during the study period. Because of incomplete case ascertainment due to children not presenting to hospital, or not having CSF collected, these are likely minimum estimates. Study limitations include reliance on hospital-based surveillance and limited CSF sampling in children in coma or other contraindications to lumbar puncture, both of which lead to under-ascertainment of incidence and of case fatality.ConclusionsIn this study, we observed that CHIKV infections are relatively more common than cerebral malaria and bacterial meningitis among children hospitalized with neurological disease in coastal Kenya. Given the wide distribution of CHIKV mosquito vectors, studies to determine the geographic extent of CHIKV-associated neurological disease in Africa are essential.

How to encounter the child in coma

Article type Review article Non-traumatic coma is a medical emergency and should be evaluated as soon as possible. Pediatric coma is more serious because of patient's capacity of pathological stressor tolerance is limited especially in neonates. Several etiologies could be listed for loss of consciousness (LOC) and coma in childhood. According to the epidemiological studies, causes of coma are different all around the world. Glasgow Coma Scale has been used for coma scaling. In this review, we focused on some highlight causes of coma in pediatric medicine.

Toxic Leukoencephalopathy Due to Transdermal Fentanyl Overdose

Children with altered mental status who present to the emergency department have a broad differential diagnosis. We report a case of a 19-month-old girl who presented in coma and who was later found to have a fentanyl patch adhered to her back. She was found to have changes on brain magnetic resonance imaging consistent with a toxic spongiform leukoencephalopathy but had a good neurologic outcome. This case report illustrates the importance of a thorough physical examination in children in coma and a rarely reported magnetic resonance imaging finding that has been seen in opioid intoxication and is usually associated with severe morbidity and mortality.

Alterações eletrencefalográficas como fator prognóstico no coma agudo em crianças não epilépticas

Introdução: embora o exame neurológico permaneça como o principal parâmetro de avaliação do comprometimento cerebral em muitas UTIs pediátricas do Brasil, o EEG é um exame de fácil realização, baixo custo e que não oferece riscos significativos ao paciente. Nosso objetivo foi avaliar as alterações específicas e inespecíficas, particularmente a presença de paroxismos epileptogênicos, no EEG de crianças em estado de coma e relacionar esses achados com o risco de morte. Métodos: estudo de delineamento retrospectivo. Resultados: foram analisados 36 EEGs de 18 crianças, 10 do sexo masculino (55,6%), com idade entre dois meses e 15,5 anos (mediana: 3,2±4,7 anos). As etiologias do coma foram diversas. Todos os EEGs foram anormais, sendo o alentecimento e a depressão de voltagem as alterações mais observadas. Somente em um exame foi registrada assimetria entre os hemisférios cerebrais. Em 30,6% dos exames foram observados paroxismos epileptogênicos focais, multifocais ou generalizados. A taxa de mortalidade foi 38,9%. Dos 19 EEGs obtidos nas sete crianças que morreram durante o internamento na UTI, 21,1% apresentavam paroxismos epileptogênicos. Conclusão: embora nossa casuística seja relativamente pequena, inferimos que a presença de paroxismos epileptogênicos no EEG de crianças não epilépticas em estado de coma é relativamente frequente, embora não tenhamos observado uma associação consistente desse achado com maior risco de morte.

Search for clinical and neurophysiological prognostic patterns of brain coma outcomes in children

The aim of the study was to evaluate the possible predictive values of clinical examinations combined with the recordings of electroencephalography and brainstem auditory-evoked potentials in traumatic coma of pediatric patients. A total of 43 children in coma with severe acute head trauma were included in the study. They were investigated and treated in pediatric intensive care unit using standard evaluation and treatment protocol. Evaluation of coma was performed using Glasgow Coma Scale. Electroencephalography for 35 patients and brainstem auditory-evoked potentials for 24 patients were recorded. Glasgow coma scale statistic pool median was equal to 4 points as measured in presence of brain edema, meanwhile it was 6 as measured in absence of edema. In case of supratentorial damage, median duration of consciousness recovery was 10 days. In absence of above-mentioned supratentorial damage, recovery of the consciousness was earlier - median was 5 days. Determined duration of artificial lung ventilation was statistically significantly shorter for those who had edema (P=0.048). In 20 patients (57% of all cases), constant or alternating slow wave activity was observed during the first electroencephalographic recording. In other cases, "alpha coma" or low amplitude of arrhythmic activity and local slowing activity corresponding to brain damage seen on computerized tomography were recorded. For 24 patients, brainstem auditory-evoked potentials were recorded. In 9 cases, they were abnormal; in these cases, the consciousness of the patients recovered after 44 days or did not recover. Glasgow coma scale results alone may have limited prognostic value in absence of other objective neurophysiologic investigation data concerning the coma outcome in children. Prognosis may be worse if pathological brainstem auditory-evoked potentials correlate with pathological dynamic changes in electroencephalography and brain lesions, diagnosed during computerized tomography scan.

A Brief Overview of the Use of Evoked Potentials in Pediatrics

.Evoked potential (EP) testing of all modalities has specific uses and particular challenges in the pediatric population. Methods and techniques for encouraging cooperation for the test vary with the modality. For example, auditory and somatosensory evoked potentials are recorded best from sleeping children; visual evoked potentials are more accurate when recorded from awake children. A major use of the brainstem evoked potentials (BAEPs) is the evaluation of hearing in children at risk for hearing difficulties whether that risk is congenital or postnatal. BAEPs help in the diagnosis and follow-up of children with inherited demyelinating conditions. Visual evoked potentials (VEPs) can be used to evaluate conditions that affect the optic nerve, i.e., compression, tumor, or demyelination. VEPs are less reliable in determining cortical blindness. Normative data for both age and size are especially important in somatosensory evoked potentials (SEPs) to take into account both the length of the pathway and the changes in transmission time with maturation and myelination. SEPs serve as a very good prognostic tool in children in coma, especially coma following head injury. They are also widely used to monitor surgical procedures on the spine.

Neurological intensive care in children.

This review of the highly complex area of pediatric NIC allows several conclusions: 1. The relative importance of primary injury has probably been underestimated. Secondary, hypoxemicischemic injury was, incorrectly, thought to be easily managed with improvement in prognosis. For this reason equal or even more efforts should be put into prophylaxis rather than into highly sophisticated corrective measures after the insult. 2. Every method of monitoring the child in coma has its strong and weak points and may therefore give misleading data. For this reason a combination of inter-independent monitoring techniques has to be applied. 3. The main aim of NIC is to enable an injured child and his family to resume a normal and happy life. If, early after the critical event, there are signs of poor outcome, particularly of persistent vegetative state or severe disability, consideration should be given to early withdrawal of support, always in accordance to the local socio-ethical customs. The decision to stop vital support can be taken only after extremely careful and repeat, but speedy analysis of the case, using inter-independent and reliable methods of evaluation. 4. The history of NIC underlines again the need of carefully conducted, controlled and prospective clinical studies. Only in this way can swings of over-enthusiasm and disillusionment be avoided. This seems to be particularly important as there is a whole series of new concepts on the horizon ranging from calcium blocking agents to free radical scavengers (including 21-aminosteroids) and antagonists of excitatory neurotransmitters and excitotoxins [135].

The effects of head injury in children on neuropsychological and behavioural functioning

In a prospective study 76 children were divided into three groups on the basis of severity of head injury as defined by the Glasgow Coma Scale and duration of increased intracranial pressure. The children were administered a neuropsychological test battery and behavioural ratings were made by parents and teachers at three intervals: time of hospital discharge and 3 and 9 months post-initial testing. There were cognitive deficits related to severity of injury with the greatest difference in abilities observed between the severe and the other two groups. The greatest differences in skills were on the Performance IQ and timed tests of visual-motor speed and co-ordination. The greatest improvement in skills occurred in the first 3 months post-injury. Several children in coma for up to 4 weeks were able to obtain normal IQ scores. In the mild and moderate injury groups very few had behavioural change while in the severe group approximately 90% had one learning or adjustment difficulty and 40% had three or more problems.

Comparison of the prognostic utility of VEPs and SEPs in comatose children

Visual evoked potentials and somatosensory evoked potentials were recorded in 37 children in coma soon after admission and then repeatedly during coma and emergence from coma. Evoked potentials were graded in 4 categories, ranging from normal to absent, and then related to patient outcome. Somatosensory evoked potentials were reliable predictors of outcome, particularly if both the initial and early repeated somatosensory evoked potentials were considered. Visual evoked potentials were not as reliable predictors as somatosensory evoked potentials; however, the presence or absence of both was significantly related to outcome. These data are generally consistent with the adult literature. We suggest that somatosensory evoked potentials be the evoked potential of choice in evaluating the prognosis of comatose children.

ICU Monitoring of Children in Coma

ICU Monitoring of Children in Coma

Coma at the onset of young insulin-dependent diabetes in Japan. The results of a nationwide survey. Japan and Pittsburgh Childhood Diabetes Research Groups

The descriptive epidemiology of diabetic coma at onset was investigated in a nationwide survey of insulin-dependent diabetic (IDDM) children (age at onset less than 18 yr) throughout Japan for the years 1970-81. Of the 1172 cases, 148 (12.6%) were unconscious at onset. Diabetic coma was highly associated with abnormalities in the biochemical variables. There was no sex difference in the frequency of coma; however, there was an inverse association with age wherein children under 5 yr of age were approximately two times more likely to present in coma than older children. There was a strong association with reported infections wherein patients with coma were more than twice as likely to report infection than patients without coma. It seemed that the frequency of coma did not decline during the study period. The risk of dying at onset was very high; diabetic children in coma (4.7%) were 12 times more likely to die than patients without coma.

Coma at the Onset of Young Insulin-dependent Diabetes in Japan: The Results of a Nationwide Survey

The descriptive epidemiology of diabetic coma at onset was investigated in a nationwide survey of insulin-dependent cdiabetic(IDDM) children (age at onset &amp;lt;18 yr) throughout Japan for the years 1970–81. Of the 1172 cases, 148 (12.6%) were unconscious at onset. Diabetic coma was highly associated with abnormalities in the biochemical variables. There was no sex difference in the frequency of coma; however, there was an inverse association with age wherein children under 5 yr of age were approximately two times more likely to present in coma than older children. There was a strong association with reported infections wherein patients with coma were more than twice as likely to report infection than patients without coma. It seemed that the frequency of coma did not decline during the study period. The risk of dying at onset was very high; diabetic children in coma (4.7%) were 12 times more likely to die than patients without coma.

The Value of Encephalography as a Diagnostic and Therapeutic Agent

The procedure of encephalography as a diagnostic and therapeutic agent has become more popular in the past few years. As in all new ventures in medicine and surgery, extravagant claims have been made for the relative merits for this addition to our armamentarium. There is no question but that encephalography has been of distinct advantage in certain conditions and guilty of providing misleading or worthless clues in pursuing the cause of other disease entities: Thus, it is the purpose of this paper to present a critical review of a series of cases, taken in consecutive order, and to discuss the relative merits of encephalography in each individual instance. It seems unnecessary to repeat the history of the development of this procedure, with its gradual evolution into the present technic, which is practically standardized. Thus, each type of disease condition in which the following cases have been applied will be briefly discussed. Brain Tumors.—There are certain instances in which the presence of an intracranial growth is suspected, with a paucity of localizing signs. No case of suspected brain tumor should be submitted to a mechanical means of diagnosis until every neurologic, opthalmologic, and roentgenographic clue has been carefully investigated. There are, however, instances in which further efforts are indicated so that a proper diagnosis and localization can be made. It has been emphasized repeatedly that encephalography is dangerous in the presence of increased intracranial pressure as evidenced by choked discs and a high spinal manometric reading. Thus, encephalography is of value in cases of suspected tumor in which the signs of pressure are absent. It is necessary, however, at times to supplement ventriculography when the encephalographic findings are not conclusive, as stressed by Dandy and illustrated in three of the following cases. Adson presented an excellent evaluation of this procedure in 1931 and I am taking the liberty to borrow his means of critical analysis. The above ten cases had variable signs and points in each history which would lead to a suspicion of brain tumor. In no case was there presence of choked discs or an increase of spinal fluid pressure above 20 cm. of water. Eight of the ten cases were explored and in six the encephalograms were found to have been of definite localizing value. In two instances (Cases 2 and 5) the localization was definitely misleading as no tumor was found. There was one instance (Case 8) in which the ventricles did not fill satisfactorily and subsequent ventriculography was necessary before a definite diagnosis could be made. The one death (Case 9) following encephalography was in a nine-year-old girl with a third ventricle tumor. The neurologic picture consisted of a child in coma who suffered from a bizarre type of convulsive seizures many times each day.