Andrea de Melo Alexandre Fraga

Aspiração de corpo estranho em crianças: aspectos clínicos, radiológicos e tratamento broncoscópico

OBJECTIVE To describe the clinical manifestations and bronchoscopic treatment of foreign body aspiration in children under 14 years of age, correlating the clinical aspects with the bronchoscopic findings. METHODS A retrospective, descriptive study analyzing data related to children under 14 years of age undergoing bronchoscopy due to clinical suspicion of foreign body aspiration at the State University at Campinas Hospital das Clinicas from January of 2000 to December of 2005. RESULTS The sample consisted of 69 patients, ranging in age from 8 months to 12 years/7 months (75.4% under 3 years of age), 62.3% of whom were male. The principal complaint was sudden-onset cough (75.4%), auscultation was abnormal in 74%, and dyspnea was observed in 29%. Radiological abnormalities were seen in 88% of the cases. Aspirations were primarily into the right lung (54.8%), and 30.7% of the foreign bodies were of vegetal origin (principally beans and peanuts). In the follow-up period, 29% presented complications (most commonly pneumonia), which were found to be associated with longer aspiration time (p = 0.03). Mechanical ventilation was required in 7 children (10.1%), and multiple bronchoscopies were performed in 5 (7.2%). CONCLUSION A history of sudden-onset choking and cough, plus abnormal auscultation and radiological findings, characterizes the profile of foreign body aspiration. In such cases, bronchoscopy is indicated. Longer aspiration time translates to a higher the risk of complications. The high prevalence of foreign bodies of vegetal origin underscores the relevance of prevention programs aimed at children younger than 3 years of age.

Fatores associados às complicações em crianças pré-escolares com pneumonia adquirida na comunidade

OBJECTIVE: To identify socioeconomic factors and clinical factors associated with the development of complications in preschool children hospitalized with community-acquired pneumonia (CAP). METHODS: This was a prospective longitudinal study involving children (12-59 months of age) diagnosed with CAP and admitted to the pediatric wards of two hospitals in the metropolitan area of Campinas, Brazil. Children with cystic fibrosis, heart disease, pulmonary malformations, neurological disorders, or genetic diseases were excluded. The diagnosis of CAP was based on clinical and radiological findings. Data were collected from the medical records and with a semi-structured questionnaire. The subjects were divided into two groups (complicated and uncomplicated CAP). Socioeconomic and clinical variables were compared, and multivariate logistic regression analysis was performed. RESULTS: Of the 63 children included, 29 and 34, respectively, presented with uncomplicated and complicated CAP. No statistically significant differences were found between the groups regarding age at admission, gestational age, birth weight, gender, or socioeconomic variables. Significant differences were found between the groups regarding history of pneumonia (p = 0.03), previous antibiotic therapy (p = 0.004), time elapsed since the onset of CAP (p = 0.01), duration of fever prior to admission (p < 0.001), duration of antibiotic therapy (p < 0.001), and length of hospital stay (p < 0.001). In the multivariate analysis, only duration of fever prior to admission remained in the model (OR = 1.97; 95% CI: 1.36-2.84; p < 0.001). CONCLUSIONS: Biological variables, especially duration of fever prior to admission, appear to be associated with the development of complications in children with CAP.OBJECTIVE To identify socioeconomic factors and clinical factors associated with the development of complications in preschool children hospitalized with community-acquired pneumonia (CAP). METHODS This was a prospective longitudinal study involving children (12-59 months of age) diagnosed with CAP and admitted to the pediatric wards of two hospitals in the metropolitan area of Campinas, Brazil. Children with cystic fibrosis, heart disease, pulmonary malformations, neurological disorders, or genetic diseases were excluded. The diagnosis of CAP was based on clinical and radiological findings. Data were collected from the medical records and with a semi-structured questionnaire. The subjects were divided into two groups (complicated and uncomplicated CAP). Socioeconomic and clinical variables were compared, and multivariate logistic regression analysis was performed. RESULTS Of the 63 children included, 29 and 34, respectively, presented with uncomplicated and complicated CAP. No statistically significant differences were found between the groups regarding age at admission, gestational age, birth weight, gender, or socioeconomic variables. Significant differences were found between the groups regarding history of pneumonia (p = 0.03), previous antibiotic therapy (p = 0.004), time elapsed since the onset of CAP (p = 0.01), duration of fever prior to admission (p < 0.001), duration of antibiotic therapy (p < 0.001), and length of hospital stay (p < 0.001). In the multivariate analysis, only duration of fever prior to admission remained in the model (OR = 1.97; 95% CI: 1.36-2.84; p < 0.001). CONCLUSIONS Biological variables, especially duration of fever prior to admission, appear to be associated with the development of complications in children with CAP.

Fatores associados ao óbito em lactentes após eventos com aparente risco de morte (apparent life-threatening event, ALTE)

OBJECTIVE To detect factors associated with greater risk of death in infants after an apparent life-threatening event (ALTE). METHODS This cross-sectional, retrospective, descriptive and analytic study evaluated infants younger than 12 months who had a sudden event of cyanosis, pallor, hypotonia or apnea and were seen in the emergency department of a tertiary university hospital. Forward stepwise logistic regression (Wald) was used to calculate and adjust odds ratios to evaluate associations. RESULTS Mean age of the 145 patients included in the study was 105 days (median = 65 days). Eleven (7.6%) died, and their mean age was 189 days (median = 218 days). Mean age of survivors was 98 days (median = 62 days) (p = 0.003). Activity before the event, prematurity and number of events were not associated with death. A significant association was found with pallor. Of the 11 infants, 3 had spontaneous resolution of ALTE, whereas 8 patients [27.6%; p < 0.001; OR = 14.3 (95%CI 3.51-58.3)] did not. The associations with respiratory or cardiovascular disease were also significant. In multivariate analysis, immediate spontaneous resolution [p = 0.015; OR = 6.06 (95%CI 1.02-35.94)] and diagnosis of cardiovascular disease [p = 0.047; OR = 164.27 (95%CI 7.34-3.673.78)] remained statistically significant. CONCLUSION Infants who experienced an ALTE had a higher risk of subsequent death when their age was greater than 6 months and the event had a long duration, particularly when ALTE was associated with cardiovascular disease.OBJECTIVE: To detect factors associated with greater risk of death in infants after an apparent life-threatening event (ALTE). METHODS: This cross-sectional, retrospective, descriptive and analytic study evaluated infants younger than 12 months who had a sudden event of cyanosis, pallor, hypotonia or apnea and were seen in the emergency department of a tertiary university hospital. Forward stepwise logistic regression (Wald) was used to calculate and adjust odds ratios to evaluate associations. RESULTS: Mean age of the 145 patients included in the study was 105 days (median = 65 days). Eleven (7.6%) died, and their mean age was 189 days (median = 218 days). Mean age of survivors was 98 days (median = 62 days) (p = 0.003). Activity before the event, prematurity and number of events were not associated with death. A significant association was found with pallor. Of the 11 infants, 3 had spontaneous resolution of ALTE, whereas 8 patients [27.6%; p < 0.001; OR = 14.3 (95%CI 3.51-58.3)] did not. The associations with respiratory or cardiovascular disease were also significant. In multivariate analysis, immediate spontaneous resolution [p = 0.015; OR = 6.06 (95%CI 1.02-35.94)] and diagnosis of cardiovascular disease [p = 0.047; OR = 164.27 (95%CI 7.34-3.673.78)] remained statistically significant. CONCLUSION: Infants who experienced an ALTE had a higher risk of subsequent death when their age was greater than 6 months and the event had a long duration, particularly when ALTE was associated with cardiovascular disease.

Accidents involving children in the region of Campinas, Brazil

OBJECTIVE: Evaluate prospectively the frequency and cause of accidents in children seen at the Pediatric Emergency Service of a University Hospital. The main aim is to subsidize the development of education and preventive programs.METHODS: Data of all children, less than 14 years old, from March 1997 to February 1998 were collected with a standard questionnaire.RESULTS: Accidents in 3,214 children were studied, 11.4% of the total. Males predominated (62.1%). Accidents were more common in the 9 to 13 year age group (33.4%), 2 to 5 year age group (27.2%) and 5 to 9 year group (25,5%). Traumatism, mainly due to falls, was the cause in 74%. Head trauma was important in the younger than 1 year, and trauma involving the extremities in the 9 to 13 age group. Bites and stings predominated in the 5 to 13 year age group, intoxication and foreign bodies in the 2 to 5 years age group. Burns predominated in the younger than 5 years. Most accidents (89.7%) were of low complexity but 20 patients had to be admitted to an ICU and 4 died in the Emergency Room.CONCLUSIONS: The child older than 9 years, male, with trauma of the extremities due to a fall was the most frequent case of accident. Prevention programs must be targeted to specific age ranges. Accidents are responsible for a great part of the overload of Emergency Services as 89.7% were of low complexity. Primary care health facilities personnel must be trained to manage accidents that do not involve complex procedures.

Sala de emergência em pediatria: casuística de um hospital universitário

AbStRAct Objective : Describe the clinical course of pediatric patients treated at a pediatric emergency room in a university hospital. Methods : This retrospective descriptive study was conducted between January 1 st and December 31 st , 2004. Data retrieved were: demographical and clinical characacteristics, diagnostic hy-potheses, need of tracheal intubation, deaths, transfers and need of hospitalization of children between zero and 14 years old. Patients were divided in four groups: no deaths; deaths 24 hours; transfers to other hospitals after initial care. Results : 203 children were treated: 59.1% boys; mean age of 3.4 years; 65% previously healthy. The most common diag-nosis was respiratory failure (31.1%). Of the 22 deaths, 3.5% took place during the first 24 hours and 7.4% after this; 172 children (84.7%) were discharged after a mean hospital length of stay of 19.2 days. Nine children (4.4%) were transferred to other hospitals. Among the 203 children, 50 children (24.6%) were intubated after admission and 86 children (42.4%) had to be admitted to a pediatric intensive care unit.

Clinical features and outcome of children and adolescents hospitalized with influenza A (H1N1) virus infection compared with flu-like symptoms and negative rapid tests for influenza A (H1N1) admitted in the same period of time.

This report describes the clinical features and outcome of 61 pediatric hospitalized patients with influenza-like infection. Fever, cough and respiratory distress were the most common symptoms of the infection. Fifteen patients presented positive RT-PCR results for influenza A (H1N1). The group with positive results was compared with the negative one. The main significant difference was antibiotic usage and the need of mechanical ventilation in the patients with H1N1-virus infection. Among the 11 patients who required intensive care due to respiratory failure, 3 from the positive group died and none from the negative group.

Recurrent apparent life-threatening event as the first manifestation of congenital myasthenia

OBJECTIVE To alert pediatricians about the importance of a careful investigation on recurrent apparent life-threatening events. Reports of the association of these events with congenital myasthenic syndromes were not found. CASE DESCRIPTION A seven-month-old infant with recurrent apparent life-threatening events was admitted for investigation. During hospital stay, she presented cyanosis and respiratory failure, requiring mechanical ventilation for three days. After clinical improvement, hypotheses of gastroesophageal reflux and pulmonary aspiration were ruled out. The presence of eyelid ptosis, general hypotonia and weak crying led to the suspicion of congenital myasthenia, which was confirmed. Treatment with oral piridostigmine led to neurological and nutritional normalization, without any other apparent life-threatening event during the next three years. COMMENTS The careful etiological investigation of apparent life-threatening events may lead to rare diagnosis that requires specific treatments, such as congenital myasthenia.Objective: To alert pediatricians about the impor- tance of a careful investigation on recurrent apparent life-threatening events. Reports of the association of these events with congenital myasthenic syndromes were not found. Case description: A seven-month-old infant with re- current apparent life-threatening events was admitted for investigation. During hospital stay, she presented cyanosis and respiratory failure, requiring mechanical ventilation for three days. After clinical improvement, hypotheses of gastroesophageal reflux and pulmonary aspiration were ruled out. The presence of eyelid ptosis, general hypotonia and weak crying led to the suspicion of congenital myasthenia, which was confirmed. Treatment with oral piridostigmine led to neurological and nutritional normalization, without any other apparent life-threatening event during the next three years. Comments: The careful etiological investigation of apparent life-threatening events may lead to rare diagno- sis that requires specific treatments, such as congenital myasthenia.

Bilateral spontaneous chylothorax after severe vomiting in children

Abstract Objective: To report the case of a child with bilateral chylothorax due to infrequent etiology: thoracic duct injury after severe vomiting. Case description: Girl, 7 years old, with chronic facial swelling started after hyperemesis. During examination, she also presented with bilateral pleural effusion, with chylous fluid obtained during thoracentesis. After extensive clinical, laboratory, and radiological investigation of the chylothorax etiology, it was found to be secondary to thoracic duct injury by the increased intrathoracic pressure caused by the initial manifestation of vomiting, supported by lymphoscintigraphy findings. Comments: Except for the neonatal period, chylothorax is an infrequent finding of pleural effusion in children. There are various causes, including trauma, malignancy, infection, and inflammatory diseases; however, the etiology described in this study is poorly reported in the literature.

Evento com aparente risco de morte recorrente como manifestação inicial de síndrome miastênica congênita

OBJECTIVE To alert pediatricians about the importance of a careful investigation on recurrent apparent life-threatening events. Reports of the association of these events with congenital myasthenic syndromes were not found. CASE DESCRIPTION A seven-month-old infant with recurrent apparent life-threatening events was admitted for investigation. During hospital stay, she presented cyanosis and respiratory failure, requiring mechanical ventilation for three days. After clinical improvement, hypotheses of gastroesophageal reflux and pulmonary aspiration were ruled out. The presence of eyelid ptosis, general hypotonia and weak crying led to the suspicion of congenital myasthenia, which was confirmed. Treatment with oral piridostigmine led to neurological and nutritional normalization, without any other apparent life-threatening event during the next three years. COMMENTS The careful etiological investigation of apparent life-threatening events may lead to rare diagnosis that requires specific treatments, such as congenital myasthenia.Objective: To alert pediatricians about the impor- tance of a careful investigation on recurrent apparent life-threatening events. Reports of the association of these events with congenital myasthenic syndromes were not found. Case description: A seven-month-old infant with re- current apparent life-threatening events was admitted for investigation. During hospital stay, she presented cyanosis and respiratory failure, requiring mechanical ventilation for three days. After clinical improvement, hypotheses of gastroesophageal reflux and pulmonary aspiration were ruled out. The presence of eyelid ptosis, general hypotonia and weak crying led to the suspicion of congenital myasthenia, which was confirmed. Treatment with oral piridostigmine led to neurological and nutritional normalization, without any other apparent life-threatening event during the next three years. Comments: The careful etiological investigation of apparent life-threatening events may lead to rare diagno- sis that requires specific treatments, such as congenital myasthenia.

Reexpansion pulmonary edema in children

OBJECTIVE To present a case of a patient with clinical and radiological features of reexpansion pulmonary edema, a rare and potentially fatal disease. CASE DESCRIPTION An 11-year-old boy presenting fever, clinical signs and radiological features of large pleural effusion initially treated as a parapneumonic process. Due to clinical deterioration he underwent tube thoracostomy, with evacuation of 3,000 mL of fluid; he shortly presented acute respiratory insufficiency and needed mechanical ventilation. He had an atypical evolution (extubated twice with no satisfactory response). Computerized tomography findings matched those of reexpansion edema. He recovered satisfactorily after intensive care, and pleural tuberculosis was diagnosed afterwards. COMMENTS Despite its rareness in the pediatric population (only five case reports gathered), the knowledge of this pathology and its prevention is very important, due to high mortality rates. It is recommended, among other measures, slow evacuation of the pleural effusion, not removing more than 1,500 mL of fluid at once.ABSTRACT Objective: To present a case of a patient with clinical and radiological features of reexpansion pulmonary edema, a rare and potentially fatal disease. Case description: An 11-year-old boy presenting fe-ver, clinical signs and radiological features of large pleural effusion initially treated as a parapneumonic process. Due to clinical deterioration he underwent tube thoracostomy, with evacuation of 3,000 mL of fluid; he shortly presen-ted acute respiratory insufficiency and needed mechanical ventilation. He had an atypical evolution (extubated twice with no satisfactory response). Computerized tomography findings matched those of reexpansion edema. He recovered satisfactorily after intensive care, and pleural tuberculosis was diagnosed afterwards. Comments: Despite its rareness in the pediatric popula -tion (only five case reports gathered), the knowledge of this pathology and its prevention is very important, due to high mortality rates. It is recommended, among other measures, slow evacuation of the pleural effusion, not removing more than 1,500 mL of fluid at once.