Monitoring Of Children Research Articles

Comparisons of Office and 24-Hour Ambulatory Blood Pressure Monitoring in Children with Obstructive Sleep Apnea

To compare office blood pressure (BP) and 24-hour ambulatory BP (ABP) monitoring to facilitate the diagnosis and management of hypertension in children with obstructive sleep apnea (OSA). Children aged 4-16 years with OSA-related symptoms were recruited from a tertiary referral medical center. All children underwent overnight polysomnography, office BP, and 24-hour ABP studies. Multiple linear regression analyses were applied to elucidate the association between the apnea-hypopnea index and BP. Correlation and consistency between office BP and 24-hour ABP were measured by Pearson correlation, intraclass correlation, and Bland-Altman analyses. In the 163 children enrolled (mean age, 8.2 ± 3.3 years; 67% male). The prevalence of systolic hypertension at night was significantly higher in children with moderate-to-severe OSA than in those with primary snoring (44.9% vs 16.1%, P = .006). Pearson correlation and intraclass correlation analyses revealed associations between office BP and 24-hour BP, and Bland-Altman analysis indicated an agreement between office and 24-hour BP measurements. However, multiple linear regression analyses demonstrated that 24-hour BP (nighttime systolic BP and mean arterial pressure), unlike office BP, was independently associated with the apnea-hypopnea index, after adjustment for adiposity variables. Twenty-four-hour ABP is more strongly correlated with OSA in children, compared with office BP.

Carving Metacognition at Its Joints: Protracted Development of Component Processes.

Two experiments investigated the development of metacognitive monitoring and control, and conditions under which children engage these processes. In Experiment 1, 5-year-olds (N=30) and 7-year-olds (N=30), unlike adults (N=30), showed little evidence of either monitoring or control. In Experiment 2, 5-year-olds (N=90) were given performance feedback (aimed at improving monitoring), instruction to follow a particular strategy (aimed at improving control), or both. Across conditions, feedback improved children's monitoring, and instruction improved both monitoring and control. Thus, children's poor metacognitive performance likely reflects a difficulty engaging the component processes spontaneously rather than a lack of metacognitive ability. These findings also suggest that the component processes are distinct, with both undergoing protracted development.

Audiological Monitoring in Children Treated with Platinum Chemotherapy

Platinum compounds constitute the standard treatment for solid tumors in pediatric oncology. The purpose of this study is to assess the impact of platinum compounds in the development of ototoxicity in children following chemotherapy. This study included 160 patients treated with cisplatin and carboplatin for malignant solid diseases from 2007 to 2014. Their audiograms were classified according to the Boston SIOP ototoxicity scale. Twenty-five percent of the children treated with platinum compounds developed ototoxicity. The incidence of ototoxicity was correlated with the type of platinum derivative (i.e. cisplatin vs. carboplatin), coadministration of both drugs and concomitant cranial radiotherapy, but not with sex and age. Cumulative dose was correlated only with the cisplatin administration. Nine patients (8.6%) showed further progression of hearing impairment after the end of chemotherapy. The low rate of ototoxicity suggests the pivotal role of auditory monitoring in children treated with platinum compounds in order to be able to identify hearing loss at an early stage and to provide, jointly with pediatric oncologists, strategies to reduce further progression of cochlear toxicity.

Therapeutic Drug Monitoring in Children and Adolescents Treated with Second-Generation Antipsychotics in Daily Clinical Practice

Therapeutic Drug Monitoring in Children and Adolescents Treated with Second-Generation Antipsychotics in Daily Clinical Practice

An Ethnographic Observational Study to Evaluate and Optimize the Use of Respiratory Acoustic Monitoring in Children Receiving Postoperative Opioid Infusions.

Respiratory depression in children receiving postoperative opioid infusions is a significant risk because of the interindividual variability in analgesic requirement. Detection of respiratory depression (or apnea) in these children may be improved with the introduction of automated acoustic respiratory rate (RR) monitoring. However, early detection of adverse events must be balanced with the risk of alarm fatigue. Our objective was to evaluate the use of acoustic RR monitoring in children receiving opioid infusions on a postsurgical ward and identify the causes of false alarm and optimal alarm thresholds. A video ethnographic study was performed using an observational, mixed methods approach. After surgery, an acoustic RR sensor was placed on the participant's neck and attached to a Rad87 monitor. The monitor was networked with paging for alarms. Vital signs data and paging notification logs were obtained from the central monitoring system. Webcam videos of the participant, infusion pump, and Rad87 monitor were recorded, stored on a secure server, and subsequently analyzed by 2 research nurses to identify the cause of the alarm, response, and effectiveness. Alarms occurring within a 90-second window were grouped into a single-alarm response opportunity. Data from 49 patients (30 females) with median age 14 (range, 4.4-18.8) years were analyzed. The 896 bedside vital sign threshold alarms resulted in 160 alarm response opportunities (44 low RR, 74 high RR, and 42 low SpO2). In 141 periods (88% of total), for which video was available, 65% of alarms were deemed effective (followed by an alarm-related action within 10 minutes). Nurses were the sole responders in 55% of effective alarms and the patient or parent in 20%. Episodes of desaturation (SpO2 < 90%) were observed in 9 patients: At the time of the SpO2 paging trigger, the RR was >10 bpm in 6 of 9 patients. Based on all RR samples observed, the default alarm thresholds, to serve as a starting point for each patient, would be a low RR of 6 (>10 years of age) and 10 (4-9 years of age). In this study, the use of RR monitoring did not improve the detection of respiratory depression. An RR threshold, which would have been predictive of desaturations, would have resulted in an unacceptably high false alarm rate. Future research using a combination of variables (e.g., SpO2 and RR), or the measurement of tidal volumes, may be needed to improve patient safety in the postoperative ward.

Continuous Multimodality Monitoring in Children after Traumatic Brain Injury-Preliminary Experience.

IntroductionMultimodality monitoring is regularly employed in adult traumatic brain injury (TBI) patients where it provides physiologic and therapeutic insight into this heterogeneous condition. Pediatric studies are less frequent.MethodsAn analysis of data collected prospectively from 12 pediatric TBI patients admitted to Addenbrooke’s Hospital, Pediatric Intensive Care Unit (PICU) between August 2012 and December 2014 was performed. Patients’ intracranial pressure (ICP), mean arterial pressure (MAP), and cerebral perfusion pressure (CPP) were monitored continuously using brain monitoring software ICM+®,) Pressure reactivity index (PRx) and ‘Optimal CPP’ (CPPopt) were calculated. Patient outcome was dichotomized into survivors and non-survivors.ResultsAt 6 months 8/12 (66%) of the cohort survived the TBI. The median (±IQR) ICP was significantly lower in survivors 13.1±3.2 mm Hg compared to non-survivors 21.6±42.9 mm Hg (p = 0.003). The median time spent with ICP over 20 mm Hg was lower in survivors (9.7+9.8% vs 60.5+67.4% in non-survivors; p = 0.003). Although there was no evidence that CPP was different between survival groups, the time spent with a CPP close (within 10 mm Hg) to the optimal CPP was significantly longer in survivors (90.7±12.6%) compared with non-survivors (70.6±21.8%; p = 0.02). PRx provided significant outcome separation with median PRx in survivors being 0.02±0.19 compared to 0.39±0.62 in non-survivors (p = 0.02).ConclusionOur observations provide evidence that multi-modality monitoring may be useful in pediatric TBI with ICP, deviation of CPP from CPPopt, and PRx correlating with patient outcome.

Assessment of Clinical Symptoms and Multichannel Intraluminal Impedance and pH Monitoring in Children After Thoracoscopic Repair of Esophageal Atresia and Distal Tracheoesophageal Fistula.

Motility disturbances of the esophagus and gastroesophageal reflux disease (GERD) are observed frequently in children after repair of congenital esophageal atresia with distal tracheoesophageal fistula (EA/TEF). Recently, in many pediatric surgical centers, thoracoscopic repair was introduced, which theoretically would change the postoperative course. The goal of the study was to assess physical development, disease symptoms, and GERD symptom frequency in children who underwent thoracoscopic surgery of congenital EA/TEF. The study comprised 22 children (14 boys and 8 girls), aged 16 to 79 months (average age 47.3 months) after surgery of EA/TEF. Clinical symptoms and physical development were analyzed. In 19 children, multichannel intraluminal esophageal impedance connected with pH-metry (MII/pH) was performed. In 11 patients, esophagogastroduodenoscopy with a histological study of mucosa samples was done. The most frequent symptoms were dysphagia, belching, cough and recurrent bronchitis. In 31.5% of the children, body mass deficiency was observed and in 28.6%, low body mass and short stature. Prematurity was present in half of the patients. Depending on the result of the MII/pH study, the children were divided into two groups: 10 children with GERD and 9 children without diagnosis of gastroesophageal reflux. In the 10 with GERD, acid reflux was diagnosed in 9 and non-acid reflux was diagnosed in one. MII/pH demonstrated statistically significant differences in the number of reflux episodes, reflux index, bolus exposure index, mean time of esophageal exposure and acid exposure and mean acid clearance time in children with GERD in comparison to children without this disease. In 36.4% of children who underwent endoscopy, esophagitis was diagnosed, esophageal stricture in 18% and gastric metaplasia in 9.1%. In children who underwent corrective thoracoscopic surgery of EA/TEF, GERD caused by motility disorders of the esophagus was frequently observed. These children require constant monitoring and early treatment of the complication.

The Correlation between Endoscopic Reflux Esophagitis and Combined Multichannel Intraluminal Impedance-pH Monitoring in Children

Gastroesophageal reflux (GER) is the retrograde flow of gastric contents into the esophagus and may induce a variety of complications. Endoscopically visible breaks in the distal esophageal mucosa are the most reliable evidence of reflux esophagitis. Combined multichannel intraluminal impedance and pH-metry (MII-pH) is a technique that enables monitoring of GER independent of its acidity. The aim of this study is to investigate the GER patterns in children with the aid of MII-pH monitoring and determine the correlation between endoscopically proven reflux esophagitis and reflux types by MII-pH monitoring. One hundred and twenty children were enrolled from January 2010 to October 2011 for MII-pH monitoring. We studied the GER patterns by means of pH (acid and nonacid reflux) and composition (liquid, mixed, and gas reflux) by the esophageal MII-pH signals. Meanwhile, 34 (28.3%) patients received esophagogastroduodenoscopy examination at the same time. The severity of reflux esophagitis was graded with Los Angeles classification. MII-pH monitoring significantly increased the detection of numbers of reflux compared with traditional 24-hour pH monitoring (p<0.001). The significant cutoff value of MII-pH parameters including DeMeester score ≥ 21, duration of longest acid reflux ≥ 17minutes, and occurrence of acid reflux for more than 5minutes showed good correlation in the prediction of the presence of endoscopic reflux esophagitis. The odds ratios of the above mentioned parameters were 12.6, 8.94, and 7.5, respectively (p=0.02, p=0.01, and p=0.01). Furthermore, ≥ 3 episodes per day of acid reflux for more than 5minutes can predict the occurrence of severe reflux esophagitis (odds ratio 12.78, p=0.009). MII-pH monitoring not only raised the diagnostic yield in identifying GER, but it also showed significant correlation with the presence of endoscopically proven reflux esophagitis in children.

Reducing CD4 Monitoring in Children on Antiretroviral Therapy With Virologic Suppression.

Ongoing CD4 monitoring in patients on antiretroviral therapy (ART) with viral suppression has been questioned. We evaluated the probability of CD4 decline in children with viral suppression and CD4 recovery after 1 year on ART. We included children from 8 South African cohorts with routine HIV-RNA monitoring if (1) they were "responders" [HIV-RNA < 400 copies/mL and no severe immunosuppression after ≥1 year on ART (time 0)] and (2) ≥1 HIV-RNA and CD4 measurement within 15 months of time 0. We determined the probability of CD4 decline to World Health Organization-defined severe immunosuppression for 3 years after time 0 if viral suppression was maintained. Follow-up was censored at the earliest of the following dates: the day before first HIV-RNA measurement >400 copies/mL; day before a >15-month gap in testing and date of death, loss to follow-up, transfer out or database closure. Among 5984 children [median age at time 0: 5.8 years (interquartile range: 3.1-9.0)], 270 children experienced a single CD4 decline to severe immunosuppression within 3 years of time 0 with probability of 6.6% (95% CI: 5.8-7.4). A subsequent CD4 measurement within 15 months of the first low measurement was available for 63% of children with CD4 decline and 86% showed CD4 recovery. The probability of CD4 decline was lowest (2.8%) in children aged 2 years or older with no or mild immunosuppression and on ART for <18 months at time 0. This group comprised 40% of children. This finding suggests that it may be safe to stop routine CD4 monitoring in children older than 2 years and rely on virologic monitoring alone.

The Clinical Significance of Voriconazole Therapeutic Drug Monitoring in Children With Invasive Fungal Infections

Voriconazole is an antifungal drug used to treat fungal infections. This was a retrospective study of 61 children with hemato-oncologic diseases or solid organ transplantation who were administered voriconazole for invasive fungal infections. Of the 61 patients, 31 (50.8%) were in the therapeutic drug monitoring (TDM) group, and 30 (49.2%) were in the non-TDM group. At 12 weeks, treatment failure rate in the non-TDM group was higher than the TDM group (78.6% versus 40.0%, p = 0.038). Drug discontinuation due to adverse events was less frequent in the TDM group than the non-TDM group (26.0% versus 92.3%, p = 0.001). Children required higher dosages to maintain drug levels within the targeted therapeutic range: an average of 8.3 mg/kg/dose in patients <12 years old and 6.9 mg/kg/dose for those ≥12 years old. Treatment failure rates were higher in patients whose voriconazole levels remained below 1.0 mg/L for more than 50% of their treatment duration than those above 1.0 mg/L (71.4% vs. 9.1% after 12 weeks, p = 0.013). Serial monitoring of voriconazole levels in children is important for improving treatment response and preventing unnecessary drug discontinuation. Higher dosages are needed in children to reach therapeutic range.

Analysis of 24-Hour Ambulatory Blood Pressure Monitoring in Children With Obstructive Sleep Apnea: A Hospital-Based Study.

In the present study, we aimed to verify associations between ambulatory blood pressure (ABP) and pediatric obstructive sleep apnea (OSA) in a hospital-based population.This was a cross-sectional observational study on children aged 4 to 16 years with OSA-related symptoms from a tertiary referral medical center. All children received overnight polysomnography and 24-hour recording of ABP. Severity of the disease was classified as primary snoring (apnea-hypopnea index, AHI <1), mild OSA (AHI 1–5), and moderate-to-severe OSA (AHI >5).For 195 children enrolled in this study (mean age, 7.8 ± 3.4 years; 69% boy), ABP increased as severity of OSA increased. During daytime, children with moderate-to-severe OSA had significantly higher systolic blood pressure (BP) (117.0 ± 12.7 vs 110.5 ± 9.3 mmHg), mean arterial pressure (MAP) (85.6 ± 8.1 vs 81.6 ± 6.8 mmHg), and diastolic BP load (12.0 ± 9.6 vs 8.4 ± 10.9 mmHg) compared with children with primary snoring. During nighttime, children with moderate-to-severe OSA had significantly higher systolic BP (108.6 ± 15.0 vs 100.0 ± 9.4 mmHg), MAP (75.9 ± 9.6 vs 71.1 ± 7.0 mmHg), systolic BP load (44.0 ± 32.6 vs 26.8 ± 24.5 mmHg), systolic BP index (0.5 ± 13.1 vs −6.8 ± 8.5 mmHg), and higher prevalence of systolic hypertension (47.6% vs 14.7 %) compared with children with primary snoring. Multiple linear regression analyses revealed an independent association between AHI and nighttime systolic BP and MAP after adjusting for adiposity variables.This large hospital-based study showed that children with moderate-to-severe OSA had a higher ABP compared with children who were primary snorers. As elevated BP in childhood predicts future cardiovascular risks, children with severe OSA should be treated properly to prevent further adverse cardiovascular outcomes.

Assessing the Current Practice of Physical Health Monitoring for Children and Young Adults On Antipsychotic Medications in St Helens and Knowsley Mental Health Services

Introduction Extensive evidence that people with severe mental illness have higher rates of morbidity and mortality for common physical illness than general population. Therefore it is very important to monitor the physical health in children and adolescent who are on antipsychotics which can cause significant physical side effects Objectives To assess physical health monitoring in children and young people who are on antipsychotic medications within CAMHS Knowsley and St Helens Aim To improve the monitoring of physical health on initiation and throughout treatment with antipsychotic medications Audit standard 5 Boroughs Partnership NHS trust recommendation, Sept 2012: FBC, UE,LFT, Prolactin: Baseline, 6 weeks, 6 months, yearly Lipid, glucose, weight: Baseline,6weeks, 3months, 6 months and yearly ECG: Baseline,6 weeks, yearly Pulse, BP: Baseline,regularly Target: 100% compliance Methods In March 2014, using a comprehensive audit tool approved by local Research and Audit Governance Group, data collection was completed by retrospective case analysis All patients (n=9) within CAMHS Knowsley and St Helens who are on antipsychotics since September 2012 were included Results Pulse and BP was monitored in 60% cases at baseline which dropped subsequently. Baseline blood test was done in 20%cases with some improvement at the end of one year to 33%. Again only 15% had baseline ECG with no further follow up Conclusions The study demonstrates that the standards set by the trust is not met in current practice. Recommendation is to promote greater awareness of the importance of monitoring of physical health within the service

Biochemical Markers for Brain Injury Monitoring in Children with or without Congenital Heart Diseases.

Perinatal asphyxia (PA) still constitutes a common complication involving a large number of infants with or without congenital heart diseases (CHD). PA affects 0.2-0.6% of full-term neonates, 20% of which suffer mortal hypoxic-ischemic encephalopathy, and among survivors 25% exhibit permanent consequences at neuropsychological level. Each year, about one third of 1000 live births underwent to surgical intervention in early infancy and/or are at risk for ominous outcome. Advances in brain monitoring, in anesthetic and cardiothoracic surgical techniques, including selective or total body cooling, cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest, have essentially reduced mortality expanding the possibility to address functional neurologic and cardiac outcomes in long-term survivors. However, open-heart surgery constitutes a time-frame of planned ischemia-reperfusion injury, which is a price to pay in the treatment or palliation of CHD. Infants who underwent heart surgery and non-CHD infants complicated by PA share similarities in their neurodevelopmental profile and a common form of brain damage due to hypoxic-ischemic injury. The purpose of the present review was to evaluate different mechanisms implicated in brain injury following CPB and PA and how it is possible to monitor such injury by means of available biomarkers (S100B protein, Activin A, Adrenomedullin).

Voriconazole monitoring in children with invasive fungal infections.

The primary objective of this study was to determine the optimal daily dose of voriconazole required to achieve therapeutic trough concentrations in children 1 month to 18 years of age. The secondary objective was to analyze the association between voriconazole trough concentrations and clinical and microbiological outcomes, toxicity, and mortality. This study was a retrospective chart review (October 2009 to August 2012) of pediatric oncology/bone marrow transplant patients with proven or probable invasive fungal infections treated with intravenous or oral voriconazole. Patients were excluded if they were older than 18 years of age, had no voriconazole concentrations drawn during the study period, or received voriconazole prior to the study period. Thirty-four patients were reviewed; 11 patients met all criteria for inclusion. There were 6 males and 5 females, with a median age of 8 years (range: 0.8-14.8) and a median weight of 27 kg (range: 9-74). Doses were adjusted to a median 6 mg/kg/dose (range: 3-8.7 mg/kg/dose) given every 8 (n = 5) to 12 (n = 6) hours; dose regimens varied greatly. All but 1 child achieved a voriconazole trough concentration above 1 mg/L; 7 children had a trough concentration above 2 mg/L. The median time to achieve a therapeutic trough concentration was 11 days (range: 6-37 days). Therapy failed for 4 of 11 patients, including 3 of the 4 youngest patients (p=0.022). Three of the 4 for whom therapy failed also had voriconazole trough concentrations less than 2 mg/L; this did not reach statistical significance. Voriconazole therapy was discontinued in 2 patients due to toxicity. This study confirmed that voriconazole pharmacokinetics vary greatly in pediatric oncology/bone marrow transplant patients. "Optimal" doses varied over nearly a 3-fold range. Younger patients may be at greater risk of poor outcomes and may require additional monitoring and dose adjustment.

Diagnostic Yield of Patch Ambulatory Electrocardiogram Monitoring in Children (from a National Registry)

The diagnostic yield of continuous electrocardiographic (ECG) monitoring in children for periods longer than a Holter monitor is unclear. The aim of this study was to characterize diagnostic yield, arrhythmia type, and time to first arrhythmia using a clinical repository of national ambulatory ECG data in children. A cross-sectional study was performed in 3,209 consecutive children receiving a 14-day adhesive patch monitor (Zio Patch) for clinical indications from January 2011 to December 2013. Of the 3,209 children (56% female, mean age 12.5 ± 4.4 years, range 1 month to 17 years), 390 had arrhythmias detected, making the diagnostic yield 12.2%. Of these, 137 patients (4.3%) had arrhythmias deemed clinically significant to warrant urgent physician notification. The most frequent indications for monitoring were palpitations (n = 1,138 [35.5%]), syncope (n = 450 [14.0%]), unspecified tachycardia (n = 291 [9.1%]), supraventricular tachycardia (n = 264 [8.2%]), and chest pain (n = 261 [8.1%]). Arrhythmias were detected in 10.0% of patients with palpitations, 6.7% of patients with syncope, 14.8% of patients with tachycardia, 22.7% of patients with supraventricular tachycardia, and 6.5% of patients with chest pain. The mean times to first detected and first symptom-triggered arrhythmias were 2.7 ± 3.0 and 3.3 ± 3.3 days, respectively. Forty-four percent of first detected arrhythmias and 50.4% of the first symptom-triggered arrhythmias occurred beyond 48 hours of monitoring. In conclusion, the diagnostic yield of continuous ECG patch monitoring in children was substantial beyond 48 hours and should be considered in children who are candidates for longer term ECG monitoring.

Cost-Effectiveness of Real-Time Medication Monitoring in Children with Asthma.

Cost-Effectiveness of Real-Time Medication Monitoring in Children with Asthma.

Novel Use of Dried Blood Spots for Home Monitoring in Children After Kidney Transplanation.

Novel Use of Dried Blood Spots for Home Monitoring in Children After Kidney Transplanation.

Early hyperglycemia detected by continuous glucose monitoring in children at risk for type 1 diabetes.

OBJECTIVEWe explore continuous glucose monitoring (CGM) as a new approach to defining early hyperglycemia and diagnosing type 1 diabetes in children with positive islet autoantibodies (Ab+).RESEARCH DESIGN AND METHODSFourteen Ab+ children, free of signs or symptoms of diabetes, and nine antibody-negative (Ab−) subjects, followed by the Diabetes Autoimmunity Study in the Young, were asked to wear a Dexcom SEVEN CGM.RESULTSThe Ab+ subjects showed more hyperglycemia, with 18% time spent above 140 mg/dL, compared with 9% in Ab− subjects (P = 0.04). Their average maximum daytime glucose value was higher, and they had increased glycemic variability. The mean HbA1c in the Ab+ subjects was 5.5% (37 mmol/mol). Among Ab+ subjects, ≥18–20% CGM time spent above 140 mg/dL seems to predict progression to diabetes.CONCLUSIONSCGM can detect early hyperglycemia in Ab+ children who are at high risk for progression to diabetes. Proposed CGM predictors of progression to diabetes require further validation.

Use of Prolonged VEEG Monitoring in Children with First Unprovoked Seizure (P5.054)

Use of Prolonged VEEG Monitoring in Children with First Unprovoked Seizure (P5.054)

Effects of Problem Solving after Worked Example Study on Primary School Children's Monitoring Accuracy

SummaryResearch on expository text has shown that the accuracy of students' judgments of learning (JOLs) can be improved by instructional interventions that allow students to test their knowledge of the text. The present study extends this research, investigating whether allowing students to test the knowledge they acquired from studying a worked example by means of solving an identical problem, either immediately or delayed, would enhance JOL accuracy. Fifth grade children (i) gave an immediate JOL, (ii) a delayed JOL, (iii) solved a problem immediately and then gave a JOL, (iv) solved a problem immediately and gave a delayed JOL, or (v) solved a problem at a delay and then gave a JOL. Results show that problem solving after example study improved children's JOL accuracy (i.e., overestimation decreased). However, no differences in the accuracy of restudy indications were found. Results are discussed in relation to cue utilization when making JOLs. Copyright © 2014 John Wiley &amp; Sons, Ltd.