Exogenous Surfactant Treatment in Children with ARDS

Since the Food and Drug Administration (FDA) approved exogenous surfactant in the early 90s for the treatment of neonates with Hyaline Membrane Disease (HMD), many studies have focused on enlarging its indications for others types of lung injuries and for other age groups. Although in the past 20 years no studies have shown clear results about the efficacy of exogenous surfactant treatment in paediatric Acute Respiratory Distress Syndrome (ARDS), many of them were able to point out and better define very important aspects of this treatment like dosage, timing, ways of administration and usage of different types of surfactant (natural and synthetic). In this review we retrace the development of studies looking at the role of exogenous surfactant treatment in paediatric ARDS

Diluted porcine surfactant lung lavages in children with severe ARDS

Acute respiratory distress syndrome (ARDS) is characterized by damage to the arteriolar-capillary endothelium and alveolar epithelium that leads to surfactant deficiency and atelectasis. Alveolar collapse and pulmonary edema will further induce surfactant inactivation. Surfactant supplementation has been suggested but results are unpredictable. Poor response may be due to inhibition of administered surfactant by plasma components filling the alveolar space, severity of lung injury, time of surfactant application and inadequate dose. We report the course of gas exchange and pulmonary mechanics after instillation of surfactant in 14 children (3 months-7 years) with severe ARDS, defined as an oxygenation index (OI) > 30 and a partial pressure of oxygen/ fraction of Inspired oxygen (PaO2/FiO2) <150 . We used a diluted concentration of Curosurf (8 mg/ml) divided into 4 aliquots, for a total dose of 25 mg/kg. An additional aliquot was used for bronchoalveolar lavage before surfactant treatment. All children showed a dramatic response to surfactant with rapid and progressive increase in compliance and improvement of all respiratory mechanics. Mechanical ventilation settings were rapidly reduced and gas exchange improved with a PaO2/FiO2 >200 for more than 12 hours. Diluted surfactant lung lavages were able to increase blood gas exchange in all our patients despite previously severe gas exchange impairment

Diluted porcine surfactant lung lavages in children with severe ARDS

Acute respiratory distress syndrome (ARDS) is characterized by damage to the arteriolar-capillary endothelium and alveolar epithelium that leads to surfactant deficiency and atelectasis. Alveolar collapse and pulmonary edema will further induce surfactant inactivation. Surfactant supplementation has been suggested but results are unpredictable. Poor response may be due to inhibition of administered surfactant by plasma components filling the alveolar space, severity of lung injury, time of surfactant application and inadequate dose. We report the course of gas exchange and pulmonary mechanics after instillation of surfactant in 14 children (3 months-7 years) with severe ARDS, defined as an oxygenation index (OI) > 30 and a partial pressure of oxygen/ fraction of Inspired oxygen (PaO2/FiO2) <150 . We used a diluted concentration of Curosurf (8 mg/ml) divided into 4 aliquots, for a total dose of 25 mg/kg. An additional aliquot was used for bronchoalveolar lavage before surfactant treatment. All children showed a dramatic response to surfactant with rapid and progressive increase in compliance and improvement of all respiratory mechanics. Mechanical ventilation settings were rapidly reduced and gas exchange improved with a PaO2/FiO2 >200 for more than 12 hours. Diluted surfactant lung lavages were able to increase blood gas exchange in all our patients despite previously severe gas exchange impairment

Activity of ethanolic extracts of Asparagopsis taxiformis against the major molecular types of Cryptococcus neoformans/C. gattii complex

Infections due to Cryptococcus neoformans/C. gattii complex have been reported to afflict, not only humans but also other mammals including seabirds and cetaceans, proving that the actual animal exposure to these fungi in nature could be underestimated. In this study, antifungal activity of ethanolic extracts obtained from red alga Asparagopsis taxiformis was evaluated against eight major genotypes of the C. neoformans/C. gattii complex, using both disk diffusion and microdilution broth methods. The algal extracts were active against all fungal strains tested and were not cytotoxic to human red blood cells. This study suggests that Asparagopsis taxiformis extracts possess attractive antifungal properties which should encourage the search for new drugs derived from marine algae

Five-year follow-up of children with perinatal HIV-1 infection receiving early highly active antiretroviral therapy

<p>Abstract</p> <p>Background</p> <p>Early highly active antiretroviral therapy (HAART), started within the first months of age, has been proven to be the optimal strategy to prevent immunological and clinical deterioration in perinatally HIV-infected children. Nevertheless, data about long-term follow-up of early treated children are lacking.</p> <p>Methods</p> <p>We report data from 40 perinatally HIV-infected-children receiving early HAART, with a median follow-up period of 5.96 years (interquartile range [IQR]:4.21–7.62). Children were enrolled at birth in the Italian Register for HIV Infection in Children. Comparison with 91 infected children born in the same period, followed-up from birth, and receiving deferred treatment was also provided.</p> <p>Results</p> <p>Nineteen children (47.5%) were still receiving their first HAART regimen at last follow-up. In the remaining children the first regimen was discontinued, after a median period of 3.77 years (IQR: 1.71–5.71) because of viral failure (8 cases), liver toxicity (1 case), structured therapy interruption (3 cases), or simplification/switch to a PI-sparing regimen (9 cases). Thirty-nine (97.5%) children showed CD4⁺T-lymphocyte values>25%, and undetectable viral load was reached in 31 (77.5%) children at last visit. Early treated children displayed significantly lower viral load than not-early treated children, until 6 years of age, and higher median CD4⁺T-lymphocyte percentages until 4 years of age. Twenty-seven (29.7%) not-early treated vs. 0/40 early treated children were in clinical category C at last follow-up (P < 0.0001).</p> <p>Conclusion</p> <p>Our findings suggest that clinical, virologic and immunological advantages from early-HAART are long-lasting. Recommendations indicating the long-term management of early treated children are needed.</p

Height and timing of growth spurt during puberty in young people living with vertically acquired HIV in Europe and Thailand

Objective: The aim of this study was to describe growth during puberty in young people with vertically acquired HIV. Design: Pooled data from 12 paediatric HIV cohorts in Europe and Thailand. Methods: One thousand and ninety-four children initiating a nonnucleoside reverse transcriptase inhibitor or boosted protease inhibitor based regimen aged 1-10 years were included. Super Imposition by Translation And Rotation (SITAR) models described growth from age 8 years using three parameters (average height, timing and shape of the growth spurt), dependent on age and height-for-age z-score (HAZ) (WHO references) at antiretroviral therapy (ART) initiation. Multivariate regression explored characteristics associated with these three parameters. Results: At ART initiation, median age and HAZ was 6.4 [interquartile range (IQR): 2.8, 9.0] years and -1.2 (IQR: -2.3 to -0.2), respectively. Median follow-up was 9.1 (IQR: 6.9, 11.4) years. In girls, older age and lower HAZ at ART initiation were independently associated with a growth spurt which occurred 0.41 (95% confidence interval 0.20-0.62) years later in children starting ART age 6 to 10 years compared with 1 to 2 years and 1.50 (1.21-1.78) years later in those starting with HAZ less than -3 compared with HAZ at least -1. Later growth spurts in girls resulted in continued height growth into later adolescence. In boys starting ART with HAZ less than -1, growth spurts were later in children starting ART in the oldest age group, but for HAZ at least -1, there was no association with age. Girls and boys who initiated ART with HAZ at least -1 maintained a similar height to the WHO reference mean. Conclusion: Stunting at ART initiation was associated with later growth spurts in girls. Children with HAZ at least -1 at ART initiation grew in height at the level expected in HIV negative children of a comparable age

Time to Switch to Second-line Antiretroviral Therapy in Children With Human Immunodeficiency Virus in Europe and Thailand.

Background: Data on durability of first-line antiretroviral therapy (ART) in children with human immunodeficiency virus (HIV) are limited. We assessed time to switch to second-line therapy in 16 European countries and Thailand. Methods: Children aged <18 years initiating combination ART (≥2 nucleoside reverse transcriptase inhibitors [NRTIs] plus nonnucleoside reverse transcriptase inhibitor [NNRTI] or boosted protease inhibitor [PI]) were included. Switch to second-line was defined as (i) change across drug class (PI to NNRTI or vice versa) or within PI class plus change of ≥1 NRTI; (ii) change from single to dual PI; or (iii) addition of a new drug class. Cumulative incidence of switch was calculated with death and loss to follow-up as competing risks. Results: Of 3668 children included, median age at ART initiation was 6.1 (interquartile range (IQR), 1.7-10.5) years. Initial regimens were 32% PI based, 34% nevirapine (NVP) based, and 33% efavirenz based. Median duration of follow-up was 5.4 (IQR, 2.9-8.3) years. Cumulative incidence of switch at 5 years was 21% (95% confidence interval, 20%-23%), with significant regional variations. Median time to switch was 30 (IQR, 16-58) months; two-thirds of switches were related to treatment failure. In multivariable analysis, older age, severe immunosuppression and higher viral load (VL) at ART start, and NVP-based initial regimens were associated with increased risk of switch. Conclusions: One in 5 children switched to a second-line regimen by 5 years of ART, with two-thirds failure related. Advanced HIV, older age, and NVP-based regimens were associated with increased risk of switch

Hematological effects of zidovudine prophylaxis in newborn infants with and without prenatal exposure to zidovudine

Postnatal prophylaxis with oral zidovudine (ZDV) is associated with hematological effects. However, it is still unknown whether selection of non-ZDV-based regimens in pregnancy may reduce hematological toxicity associated with postnatal ZDV prophylaxis. The aim of this study was to define the hematological effects of ZDV prophylaxis in newborns with and without prenatal exposure to ZDV. Sixty-five newborns from mothers infected with HIV who, during pregnancy, received HAART regimens with (n:44) and without (n:21) ZDV were evaluated. Virological and hematological data were compared at birth and at 4 weeks and 6 months of life. Newborns with prenatal ZDV exposure had significantly worse hematological values at birth, with lower levels of hemoglobin (14.3 g/dl vs. 16.2 g/dl, P=0.001), red blood cell count (3.45 × 10(6) cells/mm(3) vs. 4.48 × 10(6) cells/mm(3), P<0.001), and hematocrit (41.0% vs. 46.8%, P<0.001), and higher values of mean corpuscular volume (119 fl vs. 103 fl, P<0.001). The start of ZDV prophylaxis determined significantly greater adverse hematological changes in newborns without prenatal ZDV exposure, and at 4 weeks and 6 months of life the two groups had substantially identical hematological values. The selection of non-ZDV-based regimens in pregnancy does not reduce the final hematological effects of postnatal ZDV at 4 weeks and at 6 months of life. However, two distinct pathways may be observed: newborns exposed prenatally to ZDV have worse hematological values at birth, while newborns without prenatal ZDV exposure have particularly marked postnatal effects. The distinct effects of these two pathways should be considered

Feasibility of whole body hypothermia for neonates without congenital heart defects surviving in-hospital cardiac arrest unrelated to perinatal asphyxia

feasibility whole body hypothermi

Early versus late tracheostomy in pediatric intensive care unit: Does it matter? A 6-year experience

BACKGROUND: The aim of this study is to examine the clinical data of children who underwent tracheostomy during their stay in Pediatric Intensive Care Unit (PICU), in order to describe the relationship between the timing of tracheostomy, the length of PICU stay and the occurrence of ventilator-associated pneumonia (VA P). METHODS: This is a retrospective cohort study that collects all patients undergoing tracheostomy during their PICU stay over a six-year period. Data collection included PICU length of stay, days of intubation, days of mechanical ventilation, primary indication for tracheostomy, information about VA P and decannulations. The early tracheostomy group was defined as patients who had ten or fewer days of continuous ventilation, whereas the late tracheostomy group had more than ten days of continuous ventilation. RESULTS: A significant decrease in the rate of VAP incidence was noticed in the early tracheostomy group vs. late group (P=0.004, OR=0.39, 95% CI : 0.18-0.85). No differences were observed about decannulation, need of long-term ventilation and death rate. Significant decreases of days of mechanical ventilation and PICU stay were found in subgroup of patients who underwent early tracheostomy and were decannulated within 18 months. CONCLUSIONS: No standard timing for tracheostomy placement has been established in the pediatric population. Early tracheostomy can shorten the days of ventilation and hospitalization in PICU and reduce the incidence of VA P, but further studies are needed to identify patient categories in which it can be of benefit