Children, Volume 5, Issue 7 (July 2018) – 19 articles

The term, ‘intestinal failure’, signifies the inability of the body to meet the digestive, absorptive and nutritive needs of the body. As such, these individuals require parenteral nutrition (PN) for survival. The subsequent nutritional, medical and surgical facets to the care are complex. Improved care has resulted in decreased need for intestinal transplantation. This review will examine the unique etiologies and management strategies in pediatric patients with intestinal failure. Full article

Neonatal hypoxic ischemic encephalopathy (HIE) presents a significant clinical burden with its high mortality and morbidity rates globally. Therapeutic hypothermia (TH) is now standard of care for infants with moderate to severe HIE, but has not definitively changed outcomes in severe HIE. In this review, we discuss newer promising markers that may help the clinician identify severity of HIE. Therapies that are beneficial and agents that hold promise for neuroprotection are described, both for use either alone or as adjuncts to TH. These include endogenous pathway modifiers such as erythropoietin and analogues, melatonin, and remote ischemic post conditioning. Stem cells have therapeutic potential in this condition, as in many other neonatal conditions. Of the agents listed, only erythropoietin and analogues are currently being evaluated in large randomized controlled trials (RCTs). Exogenous therapies such as argon and xenon, allopurinol, monosialogangliosides, and magnesium sulfate continue to be investigated. The recognition of tertiary mechanisms of brain damage has opened up new research into therapies not only to attenuate brain damage but also to promote cell repair and regeneration in a developmentally disorganized brain long after the perinatal insult. These alternative modalities may be especially important in mild HIE and in areas of the world where there is limited access to expensive hypothermia equipment and services. Full article

Advances in developmental resilience science are highlighted with commentary on implications for pediatric systems that aspire to promote healthy development over the life course. Resilience science is surging along with growing concerns about the consequences of adverse childhood experiences on lifelong development. Resilience is defined as the capacity of a system to adapt successfully to challenges that threaten the function, survival, or future development of the system. This definition is scalable across system levels and across disciplines, applicable to resilience in a person, a family, a health care system, a community, an economy, or other systems. Robust findings on resilience in childhood underscore the importance of exposure dose; fundamental adaptive systems embedded in the lives of individuals and their interactions with other systems; developmental timing; and the crucial role of healthcare practitioners and educators as well as family caregivers in nurturing resilience on the “front lines” of lived childhood experience. Resilience science suggests that human resilience is common, dynamic, generated through myriad interactions of multiple systems from the biological to the sociocultural, and mutable given strategic targeting and timing. Implications for pediatric practice and training are discussed. Full article

Siblings of children with life limiting conditions (LLC) are an important part of the broader family system and require consideration in the holistic care of the family. There can be considerable variation in the functioning and adjustment of these siblings. The current paper explores the resilience paradigm, particularly in the context of siblings of children with LLC and serious medical conditions. The potential impact of children living with a seriously ill brother or sister will be overviewed, and a range of functional outcomes considered. Factors contributing to sibling resilience are detailed, including individual, family, and broader external and social factors. Given the limited research with siblings of children with LLC, literature has also been drawn from the siblings of children with serious and/or chronic medical conditions. Implications for clinical practice and future research are considered. Pediatric palliative care services may be well placed to contribute to this body of research as they have commonly extended relationships with the families of children with LLC, which span across the child’s disease trajectory. Full article

Youth who experience homelessness have worse health and well-being than housed youth. Internal assets, including social competency and positive self-identity, are factors that promote healthy development. This study compared internal assets between homeless and housed youth, and examined whether connectedness with parents moderates the association between homelessness and internal assets. Using data from a large population-based survey of middle- and high-school aged youth, we found that homelessness was associated with lower levels of internal assets. However, having high connectedness with a parent significantly predicted the strength of these assets, suggesting opportunities to promote health equity among homeless youth. Full article

Childhood obesity is associated with low socioeconomic status in developed countries, and community programs can deliver cost-effective obesity interventions to vulnerable children and adolescents at scale. Evaluating these programs in a low-cost, time-efficient, and culturally appropriate way with valid and reliable measures is essential to determining their effectiveness. We aimed to identify existing valid and reliable short-form instruments (≤50 items for diet, ≤15 items for physical activity) suitable for the assessment of change in diet, physical activity, and sedentary behaviour in an Australian obesity intervention program for children and adolescents aged 7–13 years from low socioeconomic groups, with a focus on Aboriginal and Torres Strait Islander children. Relevant electronic databases were searched, with a focus on Australian literature. Validity and/or reliability studies using diet instruments (5), physical activity/sedentary behaviour instruments (12), and diet and physical activity/sedentary behaviour instruments used with Aboriginal and Torres Strait Islander (3) children were identified. Seven questions on diet, one question on physical activity, and no questions on sedentary behaviour were recommended. These questions can be used for evaluation in community-based obesity programs among Australian children and adolescents, including those from low socioeconomic groups and Aboriginal and Torres Strait Islander children. Full article

Near-infrared spectroscopy (NIRS) allows for continuous, non-invasive monitoring of end-organ tissue oxygenation. The use of NIRS, cerebral NIRS (cNIRS) in particular, in neonatal care has increased significantly over the last few years. This dynamic monitoring technique provides real-time information on the cerebral and haemodynamic status of the neonate and has the potential to serve as an important adjunct to patient care with some centres routinely utilising cNIRS to aid decision-making at the bedside. cNIRS values may be influenced by many variables, including cardiac, respiratory and metabolic parameters, and therefore it is essential to understand the pathophysiology behind alterations in cNIRS values. Correct interpretation is required to direct appropriate patient-specific interventions. This article aims to assist clinicians in deciphering cNIRS values by providing an overview of potential causes of fluctuations in cNIRS values, illustrated by common clinical scenarios, with particular emphasis on the preterm infant. Full article

Mindfulness has gained attention in the treatment of obesity. However, there is a paucity of data on family-based training in mindful eating in children. The objective of this pilot randomized clinical trial was to evaluate the feasibility and acceptability of a family-based mindful eating intervention (MEI) in adolescents with obesity, and to compare the efficacy of the MEI versus standard dietary counseling (SDC) for decreasing weight and improving cardiometabolic risk markers. Twenty-two adolescents (age 14.5–17.9 years) and parent pairs were randomized to the MEI or SDC. The MEI was administered in four 90-min sessions over 10 weeks and SDC was provided at baseline, 12 weeks, and 24 weeks. Despite the requirement of more frequent visits with the MEI, adolescents and parents attended 100% of the sessions and there were no dropouts in that group. High density lipoprotein (HDL) cholesterol increased in the SDC group, but not in the MEI group. Adolescents receiving the MEI demonstrated an increase in awareness at 24 weeks (p = 0.01) and a decrease in distraction during eating at 12 weeks (p = 0.04), when compared with the SDC group. The family-based MEI showed feasibility and acceptability in adolescents with obesity. Future studies with more intense therapy and larger sample sizes are warranted to examine the role of mindful eating in treating pediatric obesity. Full article

Obesity negatively impacts the kinematics and kinetics of the lower extremities in children and adolescents. Although yoga has the potential to provide several distinct benefits for children with obesity, this is the first study to examine the benefits of yoga for gait (primary outcome) in youths with obesity. Secondary outcomes included health-related quality of life (HRQoL), physical activity, and pain. Feasibility and acceptability were also assessed. Nine youths (11–17 years) participated in an eight-week Iyengar yoga intervention (bi-weekly 1-h classes). Gait, HRQOL (self and parent-proxy reports), and physical activity were assessed at baseline and post-yoga. Pain was self-reported at the beginning of each class. Significant improvements were found in multiple gait parameters, including hip, knee, and ankle motion and moments. Self-reported and parent-proxy reports of emotional functioning significantly improved. Time spent in physical activity and weight did not change. This study demonstrates that a relatively brief, non-invasive Iyengar yoga intervention can result in improved malalignment of the lower extremities during ambulation, as well as in clinically meaningful improvements in emotional functioning. This study extends current evidence that supports a role for yoga in pediatric obesity. Full article

Cystic fibrosis (CF) is the most common fatal genetic diseases in the United States in Caucasians. More than 2000 genetic mutations have been described and CF is now known to affect other races. The incidence of CF in individuals of Hispanic descent is estimated to be 1:9200. An uncommon mutation, 1811+1643G>T, was recently reported. We report four patients with the 1811+1643G>T mutation (homozygous or heterozygous) and describe their clinical features and compare them to the remainder of our Hispanic cohort group. The homozygous patients had a more severe phenotype compared to the Hispanic cohort in the following areas: their pancreatic status, forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC), chronic Pseudomonas aeruginosa (PA) colonization, pulmonary exacerbations requiring oral and intravenous antibiotics, and hospitalization rate. These preliminary findings suggest that future studies investigating the clinical trajectory with a larger cohort of patients homozygous for the 1811+1643G>T mutation are needed. Full article

Witnessing intimate partner violence (IPV) among parents negatively impacts millions of children in the United States each year. Low-income families are disproportionately affected by IPV compared to middle- and high-income individuals, and are beginning to be the focus of IPV secondary prevention interventions, including relationship education programs. Despite these developments, few studies have examined changes in psychosocial functioning among children of parents participating in relationship education programs. The current study examined the extent to which changes in specific couple dynamics among individuals from low-income backgrounds participating in a couple relationship education program, Within My Reach, were associated with changes in child mental health symptoms. A second purpose of this paper is to examine whether changes in parent–child relationship quality mediates the association between changes in couple dynamics and changes in child mental health difficulties. Participants (n = 347) were parents who participated in Within My Reach as part of programming offered at a large community agency. Decreases in negative couple conflict behaviors, including conflict engagement, withdrawal and compliance, over the course of the program were linked to decreases in child mental health difficulties. In addition, increases in parent–child relationship quality partially mediated the associations between decreases in compliance, as well as increase in overall couple relationship quality, and decreases in child symptoms. Community-based couple relationship education programs for low-income families can potentially have multiple positive impacts throughout the family system, including for children. Full article

Non-communicable diseases (NCDs) are the leading cause of mortality globally with an estimated 39.5 million deaths per year (72% of total death) in 2016, due to the four major NCDs: cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. In the Eastern Mediterranean Region (EMR), almost 68% of all deaths are attributed to NCDs commonly known as chronic or lifestyle-related diseases. Two-thirds of NCD premature deaths are linked to 4 shared modifiable behavioral risk factors: tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. These unhealthy behaviours lead to 4 key metabolic/biological changes; raised blood pressure, overweight/obesity, high blood glucose levels/diabetes, and hyperlipidemia (high levels of fat in the blood), that increase the risk of NCDs. Globally, countries are already working towards agreed global goals on maternal and infant nutrition and on the prevention of NCDs. In both fields the goals include halting the increase in overweight and obesity and reducing NCD diet-related risk factors including reducing saturated fatty acids (SFAs) and trans fatty acids (TFAs) intake. The objective of this review is to present an up-to-date overview of the current fat (SFAs and TFAs) intake reduction initiatives in countries of the Eastern Mediterranean Region (EMR) by highlighting national and regional programs, strategies and activities aiming at decreasing the intakes of dietary fat (SFA and TFA). The literature review shows that the average intake of SFA is estimated to be 10.3% of the total energy intake (EI), exceeding the WHO (World Health Organization) upper limit of 10%. The average TFA intake is estimated at 1.9% EI, which also exceeds the WHO upper limit of 1% EI. The highest SFAs intake was reported from Djibouti, Kuwait, Saudi-Arabia, Lebanon and Yemen, while the highest TFAs intakes were reported from Egypt and Pakistan. If countries of the EMR receive immediate public health attention, that toll of NCD-related morbidity and mortality would be considerably decreased through the implantation of evidence-based preventive interventions. In this context, reductions in SFAs and TFAs intakes have been highlighted as cost-effectives strategies that may hamper the growth of the NCD epidemic. Full article

Pediatric heart failure (HF) represents an important cause of morbidity and mortality in childhood. There is an overlapping relationship of HF, congenital heart disease, and cardiomyopathy. The goal of treatment of HF in children is to maintain stability, prevent progression, and provide a reasonable milieu to allow somatic growth and optimal development. Current management and therapy for HF in children are extrapolated from treatment approaches in adults. There are significant barriers in applying adult data to children because of developmental factors, age variation from birth to adolescence, and differences in the genetic expression profile and β-adrenergic signaling. At the same time, there are significant challenges in performing well-designed drug trials in children with HF because of heterogeneity of diagnoses identifying a clinically relevant outcome with a high event rate, and a difficulty in achieving sufficient enrollment. A judicious balance between extrapolation from adult HF guidelines and the development of child-specific data on treatment represent a wise approach to optimize pediatric HF management. This approach is helpful as reflected by the increasing role of ventricular assist devices in the management of advanced HF in children. This review discusses the causes, epidemiology, pathophysiology, clinical manifestations, conventional medical treatment, clinical trials, and the role of device therapy in pediatric HF. Full article

In the rural areas of China, there is a high occurrence of parental migration, wherein adults are flushed into urban areas to search for employment opportunities, leading to millions of left-behind children (LBC) in rural China. LBC attracts more attention from the social community and Chinese government. Here, we compared the life satisfaction and academic achievement of left-behind children (LBC) and non-left-behind children (NLBC) in rural regions that send out migrant labor in Hubei province, central China. We investigated 1031 LBC and 992 NLBC students in grades 4 to 9 in ten elementary and four middle schools, using a structured questionnaire including sociodemographic characteristics, life satisfaction, and academic achievement scores. The results showed that LBC have a lower life satisfaction and lower academic achievement than NLBC (p < 0.01). Meanwhile, as the child’s age at separation from parents decreased, their life satisfaction decreased. Additionally, correlations were observed between life satisfaction and academic achievement scores in LBC (p = 0.004) as well as in NLBC (p = 0.064). Collectively, these findings provide novel insights into a comprehensive understanding of LBC and suggest that the life satisfaction levels of LBC should be improved in rural China. Full article

Methadone has the potential to assist in the management of pain in children with life-limiting illness, but its use is limited by its complex pharmacokinetic profile and limited research on its use in children. This is a retrospective review of the use of methadone as an analgesic in 16 children with life-limiting illness. Efficacy, dosing and side effect profile were analysed. Fifteen (94%) patients had improvements in their analgesia with minimal observed adverse effects. Patients were either rapidly converted from a prior opioid in one change or received methadone as an adjunct medication. Conversions were calculated using ratios frequently in the range of 10:1 to 20:1 from the oral morphine equivalent total daily dose (MEDD). Adjunct initial dosing was a low dose trial, often beginning with 1 mg at night. Only two patients required a dose adjustment due to side effects attributed to methadone. This was despite the cohort having significant underlying illnesses, extensive concurrent medications, and high methadone dosing where needed. Analysis of dosing and ratios indicates that an individualised approach is required. Based on this and on the infrequency of methadone use in this population, specialist assistance with dosing is recommended. Further research, including prospective and pharmacokinetic studies, is recommended. Full article

The well-being of parents is essential to the well-being of children with life-limiting illness. Parents are vulnerable to a range of negative financial, physical, and psychosocial issues due to caregiving tasks and other stressors related to the illness of their child. Pediatric palliative care practitioners provide good care to children by supporting their parents in decision-making and difficult conversations, by managing pain and other symptoms in the ill child, and by addressing parent and family needs for care coordination, respite, bereavement, and social and emotional support. No matter the design or setting of a pediatric palliative care team, practitioners can seek to provide for parent needs by referral or intervention by the care team. Full article

Breakfast is an important contributor to the daily dietary intake of children. This study investigated the nutritional composition of ready to eat (RTE) children’s breakfast cereals, which display fictional cartoon characters and themes, compared to other cereals available in Australia. Nutrient content claims on packaging were also examined. Data were collected from RTE breakfast cereal packages (N = 347) from four major supermarkets in Sydney. Cereals were classified based on product type and promotional information displayed. Overall, 46% of children’s cereals were classified as “less healthy” as per nutrient profiling score criteria. Children’s cereals had a similar energy and sodium content per 100 g compared to other cereals but contained significantly higher levels of total sugar and lower levels of protein and dietary fibre compared to other varieties. Children’s cereals with nutrient content claims had improved (lower) nutrient profiling scores than those that did not (2 vs. 13, p = 0.021), but total sugar per 100 g was similar: 25 g (interquartile range (IQR) 14 g) vs. 32 g (IQR 19 g). In conclusion, RTE children’s breakfast cereals were found to be less healthy compared to other cereals on the market and the use of nutrient content claims on children’s cereals may mislead consumers regarding their overall nutrient profile. Full article

The current study evaluated a model of youth academic self-concept which incorporates practical executive functioning behaviors and academic achievement. Though greater academic achievement has been linked to both positive self-concept and better executive functioning, these constructs have not been examined simultaneously. It was hypothesized that academic achievement would mediate the association between problems with executive functioning and academic self-concept such that youth with more problems with executive functioning would have lower academic achievement and, in turn, lower academic self-concept. Clinical data was analyzed from a diagnostically heterogeneous sample of youth (n = 122) who underwent neuropsychological evaluation. Problems with executive functioning were assessed using the Behavior Rating Inventory of Executive Function. Academic achievement was assessed using the Woodcock–Johnson Tests of Achievement or Wechsler Individual Achievement Test. Academic self-concept was assessed using the youth-report version of the Behavioral Assessment System for Children. Surprisingly, findings indicate that academic achievement is not significantly associated with problems with executive functioning or academic self-concept. However, greater problems with executive functioning are associated with decreased academic self-concept. The overall model included several covariates and accounted for 10% of the variance in academic self-concept. Findings suggest that executive skills may be essential for aligning academic achievement with classroom performance. Though various child characteristic covariates were included, the model accounted for a small amount of variance suggesting that future studies should examine contributing contextual factors. Full article

A high prevalence of sleep problems exists in children and adolescents with life-limiting conditions (LLC) and severe psychomotor impairment (SPMI). This study aimed to compare the impacts of various child-related (pain, epilepsy, repositioning, medical care) and environment-related (light, noise, TV/radio, open door) factors on sleep in this vulnerable population. Data were obtained through the “Sleep Questionnaire for Children with Severe Psychomotor Impairment” (SNAKE) by proxy assessment. n = 212 children (mean age: 10.4 years) were included in the analyses. Logistic and linear regression models were used to compare child- and environment-related factors against the global rating of children’s sleep quality, five SNAKE scales, children’s sleep duration, and sleep efficacy. Pain increased the risk of sleeping poorly four-fold (OR (odds ratio) = 4.13; 95% CI (confidence interval): 1.87–9.13) and predicted four sleep problems as assessed by the SNAKE. Children who needed to reposition during the night were at three times greater risk of sleeping poorly (OR = 3.08; 95% CI: 1.42–6.69). Three of the five SNAKE scales were predicted through nocturnal repositioning. Repositioning and epilepsy predicted a reduced sleep duration and low sleep efficacy. None of the environment-related factors exhibited statistically significant results. This study emphasizes the urgent need for reliable pain detection in the context of sleep disturbances in severely ill children. Full article