TAG: "Pediatrics"

Minor head injury not reason enough for CT scan in children


Study helps emergency physicians avoid CT scans that carry cancer risks for young patients.

Nathan Kuppermann, UC Davis

A nationwide study of more than 40,000 children evaluated in hospital emergency departments for head trauma found that if children had only loss of consciousness, and no other signs or symptoms related to the head trauma, they are very unlikely to have sustained serious brain injuries. Children who have only isolated loss of consciousness after head trauma do not routinely require computed tomography (CT) scans of the head, reported researchers from UC Davis Health System and Boston Children’s Hospital.

Although CT scans are the standard way to determine if a child has life-threatening bleeding in the brain that may necessitate surgical intervention, the radiation involved carries a small but quantifiable long-term risk of cancer. As such, the data indicates CT evaluation for children with head trauma should not be routinely used if they are at low risk for clinically significant traumatic brain injuries.

The findings were published today in the journal JAMA Pediatrics in an article titled “Isolated loss of consciousness in children with minor blunt head trauma.”

“Fear of missing a clinically significant head injury, and the wide availability of CT scanners, have been the main factors driving an increase in the use of CT imaging over the past two decades,” said Nathan Kuppermann, professor and chair of the UC Davis Department of Emergency Medicine, and principal investigator of the original study from which the data and current analysis of head injuries were derived. “Our findings can help doctors confidently make a decision to forego CT testing when their patients are unlikely to benefit from it, enabling physicians to first observe their patients for a period of time before deciding on CT use.”

Whether the presence of a single factor suggestive of brain injury is reason enough to justify obtaining a CT scan has been a question Kuppermann and colleagues with the Pediatric Emergency Care Applied Research Network (PECARN) have been actively exploring through a series of studies over the past few years. The current study found that children who lost consciousness after head trauma, but then were awake and alert in the emergency department, and had none of the other five factors determined important by PECARN guidelines for identifying children at low risk for clinically significant brain injuries after head trauma (called the PECARN traumatic brain injury prediction rules), had a very low rate of clinically important brain injuries – only 0.5 percent, or 1 in 200 children.

If a child had isolated loss of consciousness without any other signs or symptoms of head trauma (i.e., including factors outside of the PECARN traumatic brain injury prediction rules), the incidence of an important brain injury dropped to only 0.2 percent, or 1 in 500 children. Furthermore, the duration of the loss of consciousness did not significantly affect risk.

“Children with clinically important brain injuries rarely have loss of consciousness alone, and almost always present other symptoms, such as vomiting or showing signs of neurological problems,” said Lois K. Lee, lead author of the current study and director of trauma research at Boston Children’s Hospital. “Being able to make treatment decisions backed by strong data helps doctors and parents feel better about deciding whether further testing is really needed.”

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UC Davis Children’s Hospital receives Excellence in Life Support Award


Award recognizes exceptional commitment to evidence-based processes, patient care.

UC Davis Children’s Hospital has received the Excellence in Life Support Award from the international Extracorporeal Life Support Organization (ELSO) for its Extracorporeal Life Support Program. The program provides lifesaving support for failing organ systems in infants, children and, in some cases, adults.

The Excellence in Life Support Award recognizes centers worldwide that demonstrate an exceptional commitment to evidence-based processes and quality measures, staff training and continuing education, patient satisfaction and ongoing clinical care. UC Davis Children’s Hospital also received this award in 2012.

The ELSO Award signifies to patients and families a commitment to exceptional patient care. It also demonstrates to the health care community an assurance of high-quality standards, specialized equipment and supplies, defined patient protocols and advanced education of all staff members.

Extracorporeal life support (ECLS), also known as extracorporeal membrane oxygenation or ECMO, is one of the most advanced forms of life support available to patients experiencing acute failure of the cardiac and respiratory systems. The ECLS machine does the work of the heart and lungs, artificially oxygenating the blood and returning it to the body, allowing the patient’s heart and lungs to rest and heal.

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Videoconferencing with family, friends lowers stress for pediatric patients


UC Davis study finds access to Family-Link significantly reduces patient stress.

A patient uses teleconferencing in her hospital room.

To ease isolation during extended hospitalizations, UC Davis Children’s Hospital offers secure videoconferencing for patients and families. While anecdotal accounts have suggested the Family-Link program enhances quality of life during long hospital stays, clinicians wondered if the technology also offered clinical benefits.

To answer that, a team led by UC Davis professor James Marcin studied 367 children who were hospitalized for at least four days. They found that access to Family-Link significantly reduced patient stress. The study was published in the journal Pediatrics.

As the popularity of applications like Skype and FaceTime have increased, so has the number of patients interested in using these applications to communicate with family and friends. UC Davis Children’s Hospital pioneered the Family-Link program, which provides patients with laptops, webcams and secure internet connections.

“We have many children who transfer from other hospitals and even other states,” said Nikki Yang, first author on the study. “Because they are too far away for family and friends to visit, they often ask for laptops so they can teleconference. That was the origin of Family-Link.”

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First pediatric autism study conducted entirely online


UCSF shows success of randomized clinical trial for kids with autism.

UC San Francisco researchers have completed the first Internet-based clinical trial for children with autism, establishing it as a viable and cost effective method of conducting high-quality and rapid clinical trials in this population.

In their study, published in the June issue of the Journal of the American Academy of Child and Adolescent Psychiatry, the researchers looked at whether an Internet-based trial was a feasible way to evaluate whether omega-3 fatty acids helped reduce hyperactivity in children with autism. The authors found that not only was it a valuable platform for conducting the randomized clinical trial, but that it was both cost and time effective, as well.

“Recruitment for clinical trials in children with autism is one of the biggest challenges we face in studying potential treatments, and we found that process to be accelerated and streamlined by using existing online communities for enrollment,” said lead author Stephen Bent, associate professor of medicine at UCSF. “This trial can serve as a model for how to efficiently test potential treatments through the growing power of online communities.”

Using the Interactive Autism Network’s (IAN) robust online community of parents, the researchers enrolled 57 children from 28 states into the randomized trial.

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Redesigning the well-child checkup


UCLA study suggests new models for improving preventive care to low-income families.

Sandra Contreras, a parent coach, meets with Kioki Johnson and her family during a well-child checkup at Wee Care Associates. (Photo by Sandra Chacon)

Well-child visits are the foundation of pediatric primary care in the U.S. Accounting for more than one-third of all outpatient visits for infants and toddlers, the appointments are intended to give doctors the opportunity to identify health, social, developmental and behavioral issues that could have a long-term impact on children’s lives.

However, several studies have shown that the current system of well-child care leaves room for improvement. One major concern is that well-child care guidelines issued by the American Academy of Pediatrics call for physicians to provide more services than can realistically be completed within a 15-minute office visit. As a result, many children do not get all of the preventive care services that they need — and the problem is more acute for low-income families, thanks largely due to their greater psychosocial and developmental needs for and greater need for parenting education.

In a yearlong study led by Dr. Tumaini Coker, an assistant professor of pediatrics at Mattel Children’s Hospital UCLA, researchers developed a new design for preventive health care for children from birth through age 3 from low-income communities. The team partnered with two community pediatric practices and a multisite community health center in greater Los Angeles.

“The usual way of providing preventive care to young children is just not meeting the needs of the low-income families served by these clinics and practices,” said Coker, who also is a researcher with the hospital’s UCLA Children’s Discovery and Innovation Institute. “Our goal was to create an innovative and reproducible — but locally customizable — approach to deliver comprehensive preventive care that is more family-centered, effective and efficient.”

The researchers created two working groups of pediatric clinicians, staff, clinic leadership and parents to design the new models of care. One working group was at South Bay Family Health Care, and another working group combined the efforts of two pediatric practices, the Yovana Bruno Pediatric Clinic in Duarte and Wee Care Associates (led by Dr. Toni Johnson-Chavis), in Compton and Norwalk.

To design the new models of care, researchers gathered input from two sources. First, they solicited ideas from pediatricians, parents and health plan representatives about topics such as having non-physicians provide routine preventive care and using “alternative visit formats” — meeting with health care providers in alternative locations, meeting in groups as opposed to one-on-one, or getting providers’ advice electronically instead of in person, for example. Secondly, the teams surveyed existing literature on alternative providers, locations and formats for well-child care.

Using that input, the clinic working groups developed four possible new models of care that it submitted for review by a panel of experts on preventive care practice redesign. Based on the panel’s rankings, the working groups selected two models to implement and test — one for the private practices and the other for the community clinic.  The private practices adopted a one-on-one visit format while the community clinic used a group-visit format, but the two models shared several characteristics:

  • A trained health educator, or “parent coach,” at each facility who relieves the physician of some of the more routine services and provides preventive health education and guidance, parenting education, and comprehensive but efficient preventive health services related to development, behavior and family psychosocial concerns.
  • A considerably longer preventive care visit.
  • A website that enables parents to customize their child’s specific needs prior to their visit.
  • Scheduled text messages or phone calls enabling the health care team to communicate with parents.

These findings were reported online today (June 16) in the journal Pediatrics.

The next stage of research is already under way: The team is testing the model selected by the two private practices in those clinical settings, with families randomly chosen to receive the care using either the new delivery model and or the old one. Researchers will compare outcomes for the two groups of children by the end of 2014. The community clinic is currently implementing its selected model, and testing will begin there in July.

“For clinics and practices that provide child preventive health care to families living in low-income communities, the process we used to develop the new models — or the new models themselves — could help them bring innovation to their own practices,” Coker said.

The study was funded by grants from the National Institutes of Health’s National Institute of Child Health and Development and the Health Resources and Service Administration.

The study’s other authors were Dr. Paul Chung and Dr. Paul Shekelle of UCLA, Candice Moreno of the University of Illinois College of Medicine and Dr. Mark Schuster of Harvard Medical School. The authors have no financial ties relevant to this article to disclose.

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Neonatal neurologist awarded grant from The Hartwell Foundation


UC San Diego’s MJ Harbert seeks to improve methods of neonatal brain monitoring.

MJ Harbert, UC San Diego

MJ Harbert, .M.D, assistant clinical professor in the Department of Neurosciences at the UC San Diego School of Medicine, has been named a recipient of an Individual Biomedical Research Award by The Hartwell Foundation for her project “Brain Activity During Birth for Prediction of Newborns at Risk for Brain Injury.” The award will support Harbert’s research in the field of neonatal neurology for three years at $100,000 per year.

Harbert is the director of the UC San Diego neonatal neurology service, which serves newborns with, or at risk for, brain injury in the neonatal intensive care units at Rady Children’s Hospital-San Diego, UC San Diego Medical Center in Hillcrest and Sharp Mary Birch Hospital for Women and Newborns. The service is one of just five such programs in the United States.

“When I went into neonatal neurology, I saw a huge need for research to help newborns in San Diego, and throughout the world,” said Harbert. “What’s so great about The Hartwell Foundation is that they are willing to risk supporting my very early-stage ideas. I am honored to win this award.”

By improving methods of neonatal brain monitoring, Harbert’s research will help clinicians identify infants at risk for brain injury. Abnormal electrical brain activity during the first minutes of the birth transition may be predictive of asphyxia, which occurs when the newborn is deprived of oxygen, and which places the newborn at risk for neurocognitive impairment and physical disabilities, including cerebral palsy.

Conventional technology for measuring brain activity consists of bulky wired electrodes and instrumentation that requires special expertise and a lengthy set-up time. To address the need for quick and early recognition of abnormal electrical brain activity in newborns, Harbert is working on a wireless approach using a thin patch of micro-circuitry, sometimes called “tattoo electronics.” Such technology could enable early detection of asphyxiated newborns and identify those infants who would benefit most from therapeutic hypothermia, a method of reducing risk of injury by chilling the newborn to bring down body temperature.

Harbert is also the principal investigator for a clinical trial of temporary tattoo electronics for the evaluation of newborn seizures, for which she is collaborating with Todd Coleman, Ph.D., an associate professor in bioengineering at the UC San Diego Jacobs School of Engineering.

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Hospital sanctuary aims to soothe or stimulate young patients’ senses


Multisensory room also expected to help children disabled by severe chronic pain.

Josiah Madrid, 22 months, diagnosed with Wiskott-Aldrich Syndrome and receiving his second bone marrow transplant, enjoys the Vecta mobile sensory station's colored light show with his mother, Amanda, in their hospital room at UCSF Benioff Children's Hospital San Francisco. (Photo by Susan Merrell, UC San Francisco)

It’s a sick child’s sanctuary, with a big difference.

Instead of a hospital bed, there’s a mat and chair placed under a shimmering waterfall of fiber optics, a disco ball and stars that dance around the ceiling and change color. Instead of a TV screen, there are toys with fun textures, some that gently vibrate or light up on touch, a giant column of swirling bubbles and a 15-rung ladder of lights with changing colors. And the rubber flooring is interspersed with brightly colored floor squares that make music or silly sounds when you step on them.

Welcome to the multisensory room of the new UCSF Benioff Children’s Hospital San Francisco, which will open Feb. 1, 2015, at Mission Bay.

While multisensory rooms have been introduced to select patient populations at a few other hospitals, staff at UCSF’s Child Life Services believe they will be beneficial to a broad spectrum of children, based on their ongoing experience in the Parnassus facility of using a “Vecta,” a modified version of this equipment that is wheeled around in a single compact unit that has been used for about eight years.

“Children with varying developmental abilities and sensory regulation problems, children in pain or who feel anxious, have been calmed and soothed by watching images that can be projected on the wall of their room or by manipulating toys that change color,” said Beatrix Musil, of Child Life Services, who was instrumental in establishing the multisensory room at the new hospital.

“As well as this, the equipment can provide stimulation and offer opportunities to explore using different senses – tactile, visual or hearing,” Musil added. “This multisensory exploration can help increase communication for children who may not have the verbal means of communication, and it can increase motivation and build developmental skills.

“Being able to completely change the ambiance of an entire room with the touch of a button can help children feel empowered and in control, which is often lost when they are in the hospital,” she said.

A further anticipated use of the room will be for inpatients in the UCSF Amplified Pain Rehabilitation Program, which was set up to help children disabled by severe chronic pain.

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UC children’s hospitals rank among best in U.S.


U.S. News highlights excellence in pediatric care.

The University of California’s three children’s hospitals – Davis, Los Angeles and San Francisco – all rank among the nation’s top pediatric hospitals, according to the new 2014-15 Best Children’s Hospitals survey conducted by U.S. News & World Report.

This year’s report, published today (June 10), can be viewed online at www.usnews.com/childrenshospitals. The rankings highlight U.S. News’ top 50 pediatric facilities in 10 specialties.

UCSF Benioff Children’s Hospital was recognized for excellence in all 10 specialties, Mattel Children’s Hospital UCLA in eight and UC Davis Children’s Hospital in four. In addition, UC’s two other medical center campuses are affiliated with ranked children’s hospitals – UC Irvine is affiliated with Children’s Hospital of Orange County (ranked in seven specialties) and UC San Diego is affiliated with Rady Children’s Hospital (ranked in all 10 specialties).

The rankings for UCSF Benioff Children’s Hospital include diabetes and endocrinology (10), urology (12), nephrology (18), gastroenterology and gastrointestinal surgery (21), neurology and neurosurgery (21), cardiology and heart surgery (23), cancer (25), neonatology (26), orthopedics (28), and pulmonology (45).

The rankings for Mattel Children’s Hospital UCLA include nephrology (10), neonatology (13), gastroenterology and gastrointestinal surgery (15), cardiology and heart surgery (25), orthopedics (27), neurology and neurosurgery (36), cancer (38), and diabetes and endocrinology (44).

Together with Shriners Hospital for Children – Northern California, its longstanding partner in caring for children with burns, spinal cord injuries, urological issues and orthopedic disorders, UC Davis Children’s Hospital ranked No. 22 in orthopedics and No. 47 in urology. UC Davis also ranked No. 23 in nephrology and No. 28 in neonatology.

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Possible source of Kawasaki disease found


Deadly childhood condition may be triggered by aerosols from northeast China.

Jane Burns, UC San Diego

An international team of scientists, including researchers at the UC San Diego School of Medicine and Scripps Institution of Oceanography, report that the likely cause of Kawasaki disease in Japan is a windborne agent originating from northeast China, a region characterized by dense cereal croplands.

Kawasaki disease (KD) is the most common cause of acquired heart disease in children, most notably in Japan, though incidence rates are also rising in the United States and Western Europe. For decades, it has stubbornly resisted scientific explanation. The disease is difficult to diagnose and, without treatment, 25 percent of children with the condition develop coronary artery aneurysms – balloon-like bulges of heart vessels – that may eventually result in heart attacks, congestive heart failure or sudden death. Prevalence rates of KD are rising among children in Asia, the United States and Western Europe. Predictive models estimate that by 2020 one in every 1,600 adults in the U.S. will be affected by the disease.

First described in Japan in 1967 and named after its discoverer, Dr. Tomisaku Kawasaki, the cause of KD has eluded two generations of researchers. Dr. Jane C. Burns, professor and director of the Kawasaki Disease Research Center at the UC San Diego School of Medicine and Rady Children’s Hospital-San Diego, assembled an international team to help decipher the distinct seasonality of this devastating childhood illness.

Noting that the timing of KD outbreaks in Japan coincides with certain wind patterns from Asia, climate scientist Xavier Rodó and colleagues at the Catalan Institution for Research and Advanced Studies and the Catalan Institute of Climate Sciences, both in Barcelona, used computer models to simulate air currents and airborne particle transport for all days since 1977 with high numbers of KD cases in Japan, based on data compiled by Dr. Yoshikazu Nakamura and colleagues at Jichi Medical University in Japan. The modeling indicated that KD cases in many Japanese locations, both in and out of epidemic years, peaked only when winds originated from a densely-cultivated region in northeastern China characterized by vast cereal croplands.

In 2011, the Barcelona researchers equipped an aircraft based in Japan with a newly designed large-volume air-filtering device to collect aerosol samples. With help from Hiroshi Tanimoto and colleagues at the National Institute of Environmental Science in Tsukuba, Japan, the plane sampled at altitudes between two and three kilometers above Japan to avoid surface contaminants, and on days during the KD season when air currents originated only from northeastern China. Detailed microbiome analyses of the samples by Brent Williams and Dr. Ian Lipkinat Columbia University in New York City identified Candida species as the dominant airborne fungus, a finding not previously reported from other aerosol sampling campaigns in other regions of the globe. Candida is a genus of yeasts and the most common cause of diverse human fungal infections worldwide.

In their new PNAS paper, the multidisciplinary team of Rodó; Burns; Dan Cayan, a climate researcher at UC San Diego’s Scripps Institution of Oceanography; and co-authors in New York, Barcelona and Japan, say the new evidence suggests that the most likely cause of KD is a “preformed toxin or molecule” originating from northeastern China, possibly related to Candida, which has been linked to Kawasaki-like coronary artery vasculitis in mouse models.

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UCSF Mission Bay hospitals to introduce patient-friendly scan suites


Design intended to help put patients at ease.

A model of a cable car-themed scan suite planned for the new UCSF Benioff Children's Hospital San Francisco.

Patients undergoing imaging at the new UCSF Medical Center at Mission Bay will be transported to the tranquility of Muir Woods, or take in the sights of San Francisco from a cable car or boat, thanks to images projected on the suites’ walls and ceiling. They can admire lush visuals, such as a sunset over Golden Gate Bridge, and listen to the sounds of nature or soothing music that they select themselves.

Younger patients at the new UCSF Benioff Children’s Hospital San Francisco may prefer a more active role. Instead of a stark room with a table and scanning equipment, they may opt for the driver’s seat of a trolley car, where they can trundle around the city, take in local landmarks and participate in hands-on activities working with a cast of animated critters. Or perhaps they prefer to captain a boat for a nautical expedition.

These suites will be available when UCSF Medical Center at Mission Bay opens on Feb. 1, 2015, for patients undergoing MRI or SPECT and CT, two imaging techniques that look inside the body and help doctors pinpoint any areas of disease. The procedures can take from 30 minutes to an hour and are used to diagnose a variety of conditions from tumors and congenital abnormalities, to skeletal trauma such as ACL injury.

Among cancer patients, scanning may be especially stressful because it determines the success or failure of treatment.

The design of the rooms was the result of collaboration between GE Healthcare and a UCSF team comprising faculty, staff, patients and their families participating in workshops and “visioning sessions” in which optimal features of the suites were identified and the feasibility of implementing them were discussed. Opinions were also sought from pediatric patients who viewed suite mock-ups.

Making the scan suites child-friendly was the primary focus, said John MacKenzie, M.D., chief of radiology at UCSF Benioff Children’s Hospital San Francisco, who provided a physician’s perspective and worked with the team from UCSF and GE Healthcare.

“Most children have never encountered an MRI machine before – it’s not something they see in a playground. Typically they enter an MRI room and hesitate when they’re told to hop on the table. But if instead they’re told, ‘Let’s go take a ride on the boat,’ they’re more likely to be intrigued than anxious,” said MacKenzie.

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Solution to helping teens with chronic disease may be at fingertips


Study shows technology improves transition into adulthood for teens with chronic disease.

Adolescents with chronic diseases (ACD), such as cystic fibrosis, gastrointestinal disorders (including Crohn’s disease) and Type 1 diabetes, often find the transition of managing their health care needs into adulthood to be challenging. Preparations for this transition are often clinic-based, costly and do not fully or effectively engage with this patient population. A new study by researchers at the UC San Diego School of Medicine found the answer to developing independent, self-management skills in ACD could be right at the patient’s fingertips.

The study is published in the June issue of Pediatrics.

Eighty-one patients, ranging from 12-to-20-years-old, participated in the eight-month study. Those assigned to the intervention group received an Internet and mobile phone system. Patients were asked to use a secure website weekly to receive theme-based materials and lifestyle tips. Automated text messages were also sent three to five times a week to help patients perform a variety of tasks, such as monitoring symptoms, keeping appointments and interpreting medical bills.

“Parents usually take a leading role when treating adolescents with chronic disease, but we want teenage patients to have a voice and become advocates for their own health,” said principal investigator Jeannie Huang, M.D., with the Department of Pediatrics at UC San Diego School of Medicine and Rady Children’s Hospital-San Diego. “The goal of the program is ultimately to improve communications between affected teens and their doctors.”

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Hazardous flame retardants found in preschool, child care settings


Young children potentially exposed to harmful chemicals at child care centers, study finds.

A new study of preschools and day care centers finds that flame retardants are prevalent indoors, potentially exposing young children to chemicals known to be hazardous.

The study, published online today (May 15) in the journal Chemosphere, was led by researchers at UC Berkeley and funded by the California Air Resources Board. Although many infants and young children spend up to 50 hours per week in day care, the study authors noted that this paper represents the first systematic review of flame retardants in early child care settings.

The researchers covered 40 child care centers serving 1,764 children in Monterey and Alameda counties. The facilities were located in a mix of urban, rural and agricultural areas. The researchers collected air and floor dust samples when the children were present, and tested for 14 different PBDEs, or polybrominated diphenyl ethers, and four non-PBDE flame retardants, including tris phosphate compounds.

The study found both PBDEs and tris phosphate compounds in 100 percent of the dust samples collected. Median levels of PBDEs were somewhat lower than those found in homes in other studies, but median levels of chlorinated tris were similar to or higher than household levels found in other studies.

“These findings underscore how widespread these materials are in indoor environments,” said study lead author Asa Bradman, associate director of the Center for Children’s Environmental Health Research at UC Berkeley. “A growing body of research has found links between flame retardants and a range of human health effects, including neurodevelopmental delays in children. Children are more vulnerable to the health effects of environmental contaminants, so we should be particularly careful to reduce their exposure to harmful chemicals.”

While flame retardants were commonplace in dust, the good news is that levels of the chemicals were generally low in air samples.

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