Michael E. Msall

Television-viewing Habits and Sleep Disturbance in School Children

Objective. To investigate the relationship between specific television-viewing habits and both sleep habits and sleep disturbances in school children. Methods. The parents of 495 children in grades kindergarten through fourth grade in three public elementary schools completed two retrospective survey questionnaires, one assessing their childrens sleep behaviors and the other examining television-viewing habits of both the child and the family. Sleep domains assessed included bedtime resistance, sleep onset delay, sleep duration, anxiety around sleep, parasomnias, night wakings, and daytime sleepiness. Teachers from all three schools also completed daytime sleepiness questionnaires (N = 402) for the sample. Results. Most of the television-viewing practices examined in this study were associated with at least one type of sleep disturbance. Despite overall close monitoring of television-viewing habits, one quarter of the parents reported the presence of a television set in the childs bedroom. The television-viewing habits associated most significantly with sleep disturbance were increased daily television viewing amounts and increased television viewing at bedtime, especially in the context of having a television set in the childs bedroom. The sleep domains that appeared to be affected most consistently by television were bedtime resistance, sleep onset delay, and anxiety around sleep, followed by shortened sleep duration. The parents threshold for defining “problem sleep behavior” in their child was also important in determining the significance of the association between sleep disturbance and television-viewing habits. Conclusion. Health care practitioners should be aware of the potential negative impact of television viewing at bedtime. Parents should be questioned about their childrens television-viewing habits as part of general screening for sleep disturbances and as part of anticipatory guidance in regards to healthy sleep habits in children. In particular, the presence of a television set in the childs bedroom may be a relatively underrecognized, but important, contributor to sleep problems in school children.

Neurologic outcome in children with inborn errors of urea synthesis. Outcome of urea-cycle enzymopathies.

We studied 26 children with inborn errors of urea synthesis who survived neonatal hyperammonemic coma. There was a 92 per cent one-year survival rate associated with nitrogen-restriction therapy and stimulation of alternative pathways of waste nitrogen excretion. Seventy-nine per cent of the children had one or more developmental disabilities at 12 to 74 months of age; the mean IQ was 43 +/- 6. There was a significant negative linear correlation between duration of Stage III or IV neonatal hyperammonemic coma and IQ at 12 months (r = -0.72, P less than 0.001) but not between the peak ammonium level (351 to 1800 microM) and IQ. There was also a significant correlation between CT abnormalities and duration of hyperammonemic coma (r = 0.85, P less than 0.01) and between CT abnormalities and concurrent IQ (r = -0.75, P less than 0.02). These results suggest that prolonged neonatal hyperammonemic coma is associated with brain damage and impairment of intellectual function. This outcome may be prevented by early diagnosis and therapy.

The Functional Independence Measure for Children (WeeFIM) Conceptual Basis and Pilot Use in Children With Developmental Disabilities

Few tools are available to pediatricians for tracking and monitoring disability status in children. We describe the conceptual basis and pilot use of the Functional Independence Measure for Children (WeeFIM) . Our pilot use of this instrument in children with limb deficiency, Downs syndrome, spina bifida, cerebral palsy, and extreme prematurity demonstrates that the WeeFIM is a valid measure for tracking disability in preschool age and middle childhood. The WeeFIM measures the impact of developmental strengths and difficulties on independence at home, in school, and in the community. This allows the pediatrician to prioritize interventions for enhancing comprehensive functional outcomes and supporting families.

WeeFIM Normative Sample of an Instrument for Tracking Functional Independence in Children

A cross-sectional community sample of 417 children, ages 6 months to 8 years without developmental delays or in developmental programs, was seen. The Functional Independence Measure for Children (WeeFIM) was used to assess independence in self-care, sphincter control, transfers, locomotion, communication, and social cognition. Mean total WeeFIM was similar for males and females. There was a significant correlation between the age of the child in months and total WeeFIM scores for children ages 2 to 5 years (n = 222, r = .80, P <.01 ) . There was a progressive increase of functional independence with increasing chronological age across all WeeFIM domains. We conclude that the WeeFIM is a useful instrument for measuring disability in children.A cross-sectional community sample of 417 children, ages 6 months to 8 years without developmental delays or in developmental programs, was seen. The Functional Independence Measure for Children (WeeFIM) was used to assess independence in self-care, sphincter control, transfers, locomotion, communication, and social cognition. Mean total WeeFIM was similar for males and females. There was a significant correlation between the age of the child in months and total WeeFIM scores for children ages 2 to 5 years (n = 222, r = .80, P < .01). There was a progressive increase of functional independence with increasing chronological age across all WeeFIM domains. We conclude that the WeeFIM is a useful instrument for measuring disability in children.

Silent aspiration prominent in children with dysphagia.

Children with neurologically-based dysphagia are at high risk for silent aspiration. Aspiration can lead to complications such as acute pneumonia and chronic lung disease. Thorough evaluation of the oral, pharyngeal, and esophageal phases of swallowing is crucial for patients with dysphagia. The videofluoroscopic modified barium swallow study (MBS) is the procedure of choice for children to delineate the pharyngeal and upper esophageal phases of the swallow that can only be inferred by bedside clinical assessment. This study describes attributes of aspiration and pharyngeal motility in a large sample of infants and children assessed with MBS. Aspiration was observed in 48 (26%) of 186 children, primarily on liquid before or during swallows. Aspiration was trace (less than 10% of a bolus) and silent in 94%. Relationships to clinical history and implications for management are discussed. Given the lack of objective clinical information to identify children at risk for aspiration, MBS should be considered in all children with severe dysphagia to rule out or confirm aspiration.

Characteristics of dysphagia in children with cerebral palsy.

Videofluoroscopic modified barium swallow (VMBS) examinations may provide clinically relevant information regarding deglutition in children with cerebral palsy and dysphagia. A retrospective review of clinical evaluations and VMBS studies on 90 consecutive children with cerebral palsy and dysphagia was completed. Most children were referred because of concerns regarding airway protection during oral feedings. Most children had multiple disabilities and 93% were nonambulatory. The majority of children were totally dependent for oral feedings (80%). Oral and pharyngeal phase abnormalities were present in almost all patients. Abnormalities of deglutition were observed only while swallowing specific food textures in the majority of patients. Aspiration of specific food textures was significantly more common than aspiration of all food textures (p<0.0001). Finally, aspiration was silent in 97% of the patients. VMBS studies can provide clinicians with valuable information regarding the most appropriate food textures and rates of oral feeding for children with cerebral palsy and dysphagia.

Pathophysiology of congenital diaphragmatic hernia III: Exogenous surfactant therapy for the high-risk neonate with CDH

Exogenous surfactant therapy (EST) in surfactant-deficient premature infants has been shown to improve lung compliance, decrease morbidity, and improve survival. Reports have demonstrated that newborns with congenital diaphragmatic hernia (CDH) have lung compliance, pressure-volume curves, and hyaline membrane formation resembling those changes seen in surfactant deficient premature newborns. We hypothesize that EST may also benefit infants with CDH. All high risk cases of prenatally diagnosed CDH at Childrens Hospital of Buffalo from November 1988 to February 1991 were prospectively evaluated for EST. In those families who chose to participate, the surfactant preparation, Infasurf (100 mg/kg), was instilled into the newborns lungs prior to the first breath. The remainder of the perinatal, neonatal, and surgical care was performed in a routine manner. Three high-risk prenatally diagnosed newborns with left CDH were treated with EST. All showed signs of decreased pulmonary compliance, but could still be adequately oxygenated and ventilated. Surgical correction was performed after stabilization and all required patch closures. Two of the three infants suffered no life-threatening episodes of pulmonary hypertension and all survived. These infants had many known indicators for poor outcome in CDH with an expected survival of less than 20%. We believe that EST in these neonates with CDH contributed to their survival with minimum morbidity. These results suggest that surfactant replacement for the high-risk neonate with CDH warrants further consideration and a randomized clinical trial is being planned.

Interrater agreement and stability of the functional independence measure for children (weefim™): Use in children with developmental disabilities

OBJECTIVE Examination of the interrater agreement and stability of ratings obtained using the Functional Independence Measure for Children (WeeFIM) in a sample of children with developmental disabilities. DESIGN A relational design was used in which two sets of WeeFIM scores were collected under four conditions: same rater-short interval; same rater-long interval; different rater-short interval; and different rater-long interval. SETTING WeeFIM scores were collected in outpatient developmental rehabilitation centers, school programs, and the childrens homes. PARTICIPANTS Data were collected for 205 children ranging in age from 11 to 87 months. All children had a medical diagnosis of disability and were receiving habilitative-educational intervention or follow-along services including neurodevelopmental surveillance. INSTRUMENT The WeeFIM instrument examines basic daily living and functional skills in children from birth to 7 years of age. The WeeFIM is modeled after the Functional Independence Measure (FIM) for adults and includes 18 items in the following subscales: self-care, sphincter control, transfers, locomotion, communication, and social cognition. RESULTS Kappa values for items ranged from .44 to .82. Intraclass correlation coefficients (ICC) for the six subscales ranged from .73 to .98. Total WeeFIM ICC values were greater than .95 for all analyses. CONCLUSIONS The WeeFIM ratings for the 205 children with developmental disabilities participating in this investigation were consistent across raters and time.

Neurodevelopmental outcome of infants with hypoplastic left heart syndrome

The neurodevelopmental outcome of hypoplastic left heart syndrome in infants remains unclear. All 11 survivors of staged surgical repair of hypoplastic left heart syndrome received standardized neurodevelopmental assessments at one regional childrens hospital. Seven children (64%) had major developmental disabilities. Quality-of-life outcomes must be considered when management options for children with hypoplastic left heart syndrome are evaluated.

THE STABILITY AND EQUIVALENCE RELIABILITY OF THE FUNCTIONAL INDEPENDENCE MEASURE FOR CHILDREN (WeeFIM)

The reliability of the Functional Independence Measure for Children (WeeFIM) was examined in 37 non‐disabled children and 30 children with disabilities, from 12 to 76 months of age. The WeeFIM is derived from the Functional Independence Measure (FIM) and includes 18 items involving six functional subscalcs. Stability was assessed by administering the WeeFIM instrument to each childs caregiver on two occasions separated by 7 to 14 days. Intraclass correlation co‐efficients (ICCs) for individual items ranged from 0.90 to 0.99. The ICC for the six WeeFIM subscales ranged from 0.94 for social cognition to 0.99 for transfers and locomotion. The ICC value for total WeeFIM test‐retest reliability was 0.98 for children with disabilities and 0.99 for children without disabilities. Equivalence reliability was examined by comparing ratings obtained when using personal assessment with ratings collected during a telephone interview. No statistically significant differences were found for individual items, subscale scores or total WeeFIM values.