David Munson

Guidelines for the Management of Extremely Premature Deliveries: A Systematic Review.

BACKGROUND AND OBJECTIVES: Available data on survival rates and outcomes of extremely low gestational age (GA) infants (22–25 weeks’ gestation) display wide variation by country. Whether similar variation is found in statements by national professional bodies is unknown. The objectives were to perform a systematic review of management from scientific and professional organizations for delivery room care of extremely low GA infants. METHODS: We searched Embase, PubMed, and Google Scholar for management guidelines on perinatal care. Countries were included if rated by the United Nations Development Programme’s Human Development Index as “very highly developed.” The primary outcome was rating of recommendations from “comfort care” to “active care.” Secondary outcomes were specifying country-specific survival and considering potential for 3 biases: limitations of GA assessment; bias from different definitions of stillbirths and live births; and bias from the use of different denominators to calculate survival. RESULTS: Of 47 highly developed countries, 34 guidelines from 23 countries and 4 international groups were identified. Of these, 3 did not state management recommendations. Of the remaining 31 guidelines, 21 (68%) supported comfort care at 22 weeks’ gestation, and 20 (65%) supported active care at 25 weeks’ gestation. Between 23 and 24 weeks’ gestation, much greater variation was seen. Seventeen guidelines cited national survival rates. Few guidelines discussed potential biases: limitations in GA (n = 17); definition bias (n = 3); and denominator bias (n = 7). CONCLUSIONS: Although there is a wide variation in recommendations (especially between 23 and 24 weeks’ GA), there is general agreement for comfort care at 22 weeks’ GA and active care at 25 weeks’ GA.

Supporting bereaved parents: practical steps in providing compassionate perinatal and neonatal end-of-life care – A North American perspective☆

Providing compassionate bereavement support challenges care-givers in perinatal medicine. A practical and consistent approach tailored to individual families may increase the care-givers ability to relieve parental grief. This approach includes: (1) clear and consistent communication compassionately delivered; (2) shared decision-making; (3) physical and emotional support; and (4) follow-up medical, psychological and social care. Challenges to providing comprehensive end-of-life care include care-giver comfort, consistency of care, cultural and legal barriers, and lack of adequate training.

Regoaling: a conceptual model of how parents of children with serious illness change medical care goals

BackgroundParents of seriously ill children participate in making difficult medical decisions for their child. In some cases, parents face situations where their initial goals, such as curing the condition, may have become exceedingly unlikely. While some parents continue to pursue these goals, others relinquish their initial goals and generate new goals such as maintaining the child’s quality of life. We call this process of transitioning from one set of goals to another regoaling.DiscussionRegoaling involves factors that either promote or inhibit the regoaling process, including disengagement from goals, reengagement in new goals, positive and negative affect, and hopeful thinking. We examine these factors in the context of parental decision making for a seriously ill child, presenting a dynamic conceptual model of regoaling. This model highlights four research questions that will be empirically tested in an ongoing longitudinal study of medical decision making among parents of children with serious illness. Additionally, we consider potential clinical implications of regoaling for the practice of pediatric palliative care.SummaryThe psychosocial model of regoaling by parents of children with a serious illness predicts that parents who experience both positive and negative affect and hopeful patterns of thought will be more likely to relinquish one set of goals and pursue a new set of goals. A greater understanding of how parents undergo this transition may enable clinicians to better support them through this difficult process.

Immunohistochemical Detection of S -Nitrosylated Proteins

Accumulating evidence shows that S-nitrosothiols, formed by the addition of nitric oxide (NO) to a cysteine thiol, S-nitrosylation, are involved in basal cellular regulation. It has been proposed that SNO formation/removal may be disrupted in a variety of pathophysiological conditions. Two types of methodology are presently available to identify specific S-nitrosylated proteins: (1) derivatization and (2) post-purification chemical detection. Neither of these techniques allows for in situ visualization of SNOs. Recently, we demonstrated that an antibody generated to the SNO moiety could be used to detect SNO formation from each of three isoforms of NOS by immunohistochemistry. This chapter details the immunohistochemical methodology used to detect SNOs in situ, offering a potentially powerful alternative for detection of SNO within tissue sections.

Percutaneous closure of patent ductus arteriosus in small infants with significant lung disease may offer faster recovery of respiratory function when compared to surgical ligation

To describe our experience with percutaneous closure of patent ductus arteriosus (PDA) in small infants and compare outcomes to matched surgical patients.

Oxygen tension and inhaled nitric oxide modulate pulmonary levels of S-nitrosocysteine and 3-nitrotyrosine in rats.

The oxidative environment within the lung generated upon administration of oxygen may be a critical regulator for the efficacy of inhaled nitric oxide therapy, possibly as a consequence of changes in nitrosative and nitrative chemistry. Changes in S-nitrosocysteine and 3-nitrotyrosine adducts were therefore evaluated after exposure of rats to 80% or >95% oxygen for 24 or 48 h with and without 20 ppm inhaled nitric oxide. Exposure to 80% oxygen led to increased formation of S-nitrosocysteine and 3-nitrotyrosine adducts in lung tissue that were also associated with increased expression of iNOS. The addition of inhaled nitric oxide in 80% oxygen exposure did not alter any of these adducts in the lung or in the bronchoalveolar lavage (BAL). Exposure to >95% oxygen led to a significant decrease in S-nitrosocysteine and an increase in 3-nitrotyrosine adducts in the lung. Co-administration of inhaled nitric oxide with >95% oxygen prevented the decrease in S-nitrosocysteine levels. The levels of S-nitrosocysteine and 3-nitrotyrosine returned to baseline in a time-dependent fashion after termination of exposure to >95% oxygen and inhaled nitric oxide. These data suggest the formation of S-nitrosating and tyrosine-nitrating species is regulated by oxygen tensions and co-administration of inhaled nitric oxide restores the nitrosative chemistry without a significant impact upon the nitrative pathway.

Integration of palliative care into the care of children with serious illness.

1. Tammy I. Kang, MD, MSCE* 2. David Munson, MD* 3. Jennifer Hwang, MD, MHS* 4. Chris Feudtner, MD, PhD, MPH* 1. *The Children’s Hospital of Philadelphia, Philadelphia, PA * Abbreviations: AAP: : American Academy of Pediatrics CCC: : concurrent care for children NICU: : neonatal intensive care unit PPC: : pediatric palliative care The 2013 American Academy of Pediatrics (AAP) Policy Statement “Pediatric Palliative Care and Hospice Care: Commitments, Guidelines, and Recommendations” urges broader integration of palliative care into overall medical care plans not only for terminally ill infants and children but also for those with life-threatening or life-shortening illnesses. Despite supportive federal legislation, the AAP recommendations have not been implemented consistently because of inadequate training, lack of funding, entrenched professional attitudes, and lack of an evidence base for assessments and interventions. To overcome these barriers, pediatric health care clinicians should educate themselves, their patients, their practices, and their health care systems on the benefits of earlier palliative care intervention. During the past decade the field of pediatric palliative care (PPC) has transformed. Palliative care services, once thought to be suitable only for patients in the last stages of life or reserved for patients engaging hospice services, are now being used much more broadly. No longer restricted to just the provision of end-of-life care, palliative care for children is now best understood as encompassing a combination of medical, psychosocial, and spiritual care that enables children with serious, life-threatening illnesses to maximize quality of life while making medical decisions based on the goals and values of the patient and family. Integrating palliative care into the overall plan of medical care for children with serious illness is a key therapeutic goal. In 2013, the American Academy of Pediatrics (AAP) published a policy statement entitled “Pediatric Palliative Care and Hospice Care: Commitments, Guidelines, and Recommendations” that aimed to promote the welfare of infants and children living with life-threatening or inevitably life-shortening conditions and their …

A Proposed Model for Perinatal Palliative Care

ABSTRACT Perinatal palliative care allows for an active partnership among a pregnant woman, her family, and her multidisciplinary treatment team and addresses her specialized medical care, emotional, social, and familial needs when a life‐limiting fetal diagnosis is confirmed. The purpose of this article is to highlight the multidisciplinary care model used within a perinatal palliative care program. A case study provides a unique perspective on support needed for parents who anticipate that their newborn may die before or shortly after birth.

Anti-gastroesophageal reflux surgery in infants with severe bronchopulmonary dysplasia.

Gastroesophageal reflux may exacerbate lung disease in infants with bronchopulmonary dysplasia (BPD). Anti‐reflux surgery may therefore reduce the severity of this disease in some infants. We report a retrospective series of 22 infants with severe BPD who underwent anti‐reflux surgery. Our experience indicates that these procedures can be safely performed in this population and that early post‐operative initiation of gastric feeds is well tolerated. Modest post‐operative reductions in required oxygen and median respiratory rate were observed. Pediatr Pulmonol. 2015; 50:584–587.

US-Guided Placement and Tip Position Confirmation for Lower-Extremity Central Venous Access in Neonates and Infants with Comparison versus Conventional Insertion

PURPOSE To describe experience with the use of ultrasound (US)-guided placement and tip position confirmation for direct saphenous and single-incision tunneled femoral noncuffed central venous catheters (CVCs) placed in neonates and infants at the bedside. MATERIALS AND METHODS A retrospective review of the interventional radiology (IR) database and electronic medical records was performed for 68 neonates and infants who received a CVC at the bedside and for 70 age- and weight-matched patients with CVCs placed in the IR suite between 2007 and 2012. Technical success, complications, and outcomes of CVCs placed at the bedside were compared with those in an age- and weight-matched sample of children with CVCs placed in the IR suite. RESULTS A total of 150 primary insertions were performed, with a technical success rate of 100%. Total catheter lives for CVCs placed at the bedside and in the IR suite were 2,030 catheter-days (mean, 27.1 d) and 2,043 catheter-days (mean, 27.2 d), respectively. No significant difference was appreciated between intraprocedural complications, mechanical complications (bedside, 1.53 per 100 catheter-days; IR, 1.76 per 100 catheter-days), or infectious complications (bedside, 0.39 per 100 catheter-days; IR, 0.34 per 100 catheter-days) between groups. CONCLUSIONS US-guided placement and tip position confirmation of lower-extremity CVCs at bedside for critically ill neonates and infants is a safe and feasible method for central venous access, with similar complications and catheter outcomes in comparison with CVCs placed by using fluoroscopic guidance in the IR suite.