From the category archives:

Pediatrics

Cameron with Galina Lipton, MD

By the time Cameron Shearing arrived at the South Shore Hospital Emergency Department (ED) during a December snowstorm, he wasn’t breathing. He didn’t have much time. The two-year-old had aspirated a chocolate-covered pretzel, which sent tiny bits of material into his lungs.

The odds of a good outcome were not high. Pretzel is one of the worst foods to aspirate for two reasons: The small pieces can block multiple small airways, and the salt, which is very irritating, causes a lot of inflammation.

“Cameron was one of the sickest patients I ever cared for as an emergency physician. I did everything I could within my scope of practice, but he needed the tools and expertise of pediatric subspecialists,” recalls Galina Lipton, MD, from Boston Children’s Department of Emergency Medicine, who was staffing the South Shore Hospital emergency room that evening. Full story »

Leave a comment

A clinician's-eye view of a patient with spinal muscular atrophy during a telemedicine visit.

A clinician's-eye view of a patient with spinal muscular atrophy during a telemedicine visit.

The jury is still out on telemedicine. Proponents and many patients appreciate its ability to deliver virtual patient care and to extend the reach of experts beyond the brick-and-mortar setting of a hospital. But the real question about telemedicine is: Does it make it difference? Does is it improve care and if so, in what circumstances?

TeleCAPE, a small pilot project at Boston Children’s Hospital, inches the dial toward “yes” for some patients—in particular, home-ventilated patients.

Home-ventilated patients require an inordinate amount of health care resources for even minor conditions. Costs for a simple urinary tract or viral respiratory infection that might be managed without hospitalization can reach up to $83,000 because the child’s complex medical needs require ICU admission. Full story »

Leave a comment

CatScan-00663

Robert MacDougall is clinical medical physicist for Boston Children’s Hospital Department of Radiology. Michael Callahan, MD, is a radiologist in Boston Children’s Department of Radiology and a member of the steering committee for the Alliance for Radiation Safety in Pediatric Imaging.

A recent opinion piece published in the New York Times, titled “We Are Giving Ourselves Cancer” (Op-Ed, Jan. 31), has provoked fear and anxiety in patients and parents over the use of computed tomography (CT) scans. This op-ed is the latest in a series of lay press articles to focus on the potential harm of radiation in medical imaging.

While the authors raise several important points, they fail to provide context and acknowledge the benefits of CT imaging, including the elimination of many unnecessary surgeries and improved diagnosis of cancer and other serious health conditions. This unbalanced view potentially presents a real and immediate risk to patients, who may forego CT exams that could improve their care because of concerns related to radiation exposure.

The relationship between cancer risk and radiation exposure is not well understood. Estimation of future cancers in a large population is not based on sound science: The principal data source—studies of survivors of the atomic bomb explosions in Japan—does not translate well to medical radiation and can be misused to create sensationalistic estimates of future cancer incidence and deaths.

In a policy statement, the American Association of Physicists in Medicine explains: “Discussion of risks related to radiation dose from medical imaging procedures should always be accompanied by acknowledgement of the potential benefits the procedure provides. Risks of medical imaging at effective doses below 50 mSv for single procedures … are too low to be detectable and may be nonexistent.” The vast majority of routine CT scans fall well below this level.

Nonetheless, once an exam is ordered, it must be performed in the safest way possible. Full story »

Leave a comment

butterflyThe butterfly effect is defined as “the sensitive dependence on initial conditions, where a small change at one place in a deterministic nonlinear system can result in large differences to a later state.” In medicine, the identification of a rare disease or a genetic mutation may provide insights that spread well beyond the initial discovery.

And in genetics, scientists are learning just how widespread the effects are for mutations in one gene: filaminA (FLNA).

FLNA is a common cause of periventricular nodular heterotopia (PVNH), a disorder of neuronal migration during brain development. The syndrome was first described by the late Peter Huttenlocher, MD, and the gene was identified by Christopher Walsh, MD, PhD, of Boston Children’s Hospital.

In normal brain development, neurons form in the periventricular region, located around fluid-filled ventricles near the brain’s center, then migrate outward to form six onion-like layers. In PVNH, some neurons fail to migrate to their proper position and instead form clumps of gray matter around the ventricles. Full story »

Leave a comment

A project that set out to build better shunts ended with potential ways to help kids avoid them altogether.

A project that set out to build better shunts ended with potential ways to help kids avoid shunts altogether.

Shunts often are surgically placed in the brains of infants with hydrocephalus to drain excess cerebrospinal fluid. Unfortunately, these devices eventually fail, and the problem is hard to detect until the child shows neurologic symptoms. CT and MRI scans may then be performed to check for a blockage of flow—followed by urgent neurosurgery if the shunt has failed.

Early detection of shunt failure was the problem pitched last fall at Hacking Pediatrics in Boston. Two bioengineers, Christopher Lee, a PhD student at Harvard-MIT Health Sciences and Technology program, and Babak Movassaghi, PhD, an MBA candidate at MIT Sloan, took the bait.

“We heard that parents would not take vacations in areas without an experienced neurosurgeon around,” says Movassaghi, a former Philips Healthcare engineer with 32 patents in cardiology and electrophysiology. “We were intrigued to solve that.” Full story »

1 comment

chopping block CHIP

Some believe that ACA's insurance exchanges leave gaps in pediatric protection.

Funding for the federal Children’s Health Insurance Program (CHIP) will run out in 2015. Will this leave many kids without health insurance?

About 8 million children currently receive health insurance through CHIP, created in 1997 to bring coverage to children whose families earn too much to qualify for Medicaid but not enough to buy private insurance. States administer the program and receive federal matching funds to cover costs. In 2009, Congress reauthorized funding for CHIP through 2015.

What will happen to CHIP beyond 2015 is uncertain, not just because of the funding deadline but also because of changes brought on by the 2010 Affordable Care Act (ACA). Many believe that the ACA’s Medicaid enrollment incentives and expanded tax credits will add so many lower-income kids to the insurance rolls that CHIP will become unnecessary and simply go away. Others, however, say that the plans sold through the ACA’s insurance exchanges could produce gaps in coverage for children, making it crucial to keep CHIP funded. Full story »

Leave a comment

Newborn baby neonatal sepsis developing world

Courtesy Anne Hansen, MD, MPH

Reducing child mortality is high on the list of the United Nations’ Millennium Development Goals—the eight global health, economic and development benchmarks set by the U.N. in 2000 for 2015.

While mortality among children under age 5 has improved greatly, the gains have largely been among children at the older end of that grouping. When it comes to mortality in the first week of life, little has changed.

“Early neonatal mortality rates haven’t decreased in the last two decades,” says Grace Chan, MD, PhD, a pediatrician at Boston Children’s Hospital, who conducts global health research at Harvard School of Public Health. “In developing countries, they still hover near 30 deaths per 1,000 live births.”

Early-onset infections—ones that arise within a week of birth—account for a significant portion of those deaths. Such infections may arise when a newborn picks up bacteria present in the mother’s birth canal during delivery, or from maternal infections during pregnancy.

In developed countries, interventions like prophylactic antibiotics and quick diagnoses help to keep neonatal infection rates low. But these kinds of interventions are less available in developing nations, where they could have the most impact. And while risk factors for neonatal infections have been well studied in developed nations, they are less  well known in resource-poor environments, where the infections most frequently occur.

To put it another way, when it comes neonatal sepsis in developing countries, there’s a lot we don’t know.

Full story »

Leave a comment

Despite its increased use, ondansetron has not decreased IV rehydration.

Ondansetron has not decreased IV rehydration as originally intended.

Acute gastroenteritis is one of the leading causes of emergency department (ED) visits for children, accounting for more than 1.7 million trips each year. Its standard treatment has traditionally been rehydration by giving fluids orally or intravenously. Though both methods are equally effective, oral rehydration is preferred as it results in less discomfort and helps stop diarrhea sooner. The IV route is often employed in children who are vomiting and unable or unwilling to drink a large amount of liquids.

About a decade ago, ED physicians began orally administering the anti-nausea medication ondansetron to vomiting patients with gastroenteritis who were unable to hold down oral fluids. Once the ondansetron has stemmed their nausea, children have a much easier time with oral rehydration.

However, the lack of standardized use of this drug has led to its overuse. Though intended to reduce the use of IV rehydration, ondansetron proved so effective at reducing vomiting that its use skyrocketed in the course of just a few years. Full story »

Leave a comment

Doctor handshake pediatric research partnershipOn the minds of everyone involved in the care of sick children is the pressing need for more pediatric research funding. Last November, Congress finally passed the National Pediatric Research Act. It authorizes the National Institutes of Health to support a nationwide network of up to 20 pediatric research consortia, but it falls short of actually increasing NIH spending. Indeed, the next step in implementing the Act is to secure a specific funding commitment from the NIH or Congress.

Currently, only about 5 percent of NIH’s budget goes to pediatric research. Rather than wait for the government, an editorial in Vector’s new sister publication, Innovation Insider, proposes that foundations and companies become active participants in the consortia.

The prospects for such alliances are good. Patient advocacy foundations are increasingly active in research, and academic-industry partnerships are on the rise. At Boston Children’s Hospital alone, sponsored research and collaborations with foundations and industry have tripled from nine in 2009 to 29 in 2013. Alan Crane, MBA, a partner at Polaris Partners and an advisor to Boston Children’s Technology and Innovation Development Office, points out that drug discovery is much harder and more complex today than it used to be—just as many products are coming off patent.

Read more on what makes these partnerships work.

If you’d like to receive Innovation Insider in your inbox, sign up here.

Leave a comment

chest x-ray

New workflows and protocols reduced chest x-rays by 23 percent, testing for respiratory syncytial virus by 11 percent, albuterol use by 7 percent and time infants spent in the ED by 41 minutes.

Bronchiolitis, a common respiratory illness among infants, is responsible for hundreds of thousands of emergency department (ED) visits each year. Best practices for managing it, established by the Academy of American Pediatrics (AAP), are fairly simple: Offer supportive therapies and let the disease runs its course, as most interventions have little or no benefit for these patients.

But despite these guidelines, bronchiolitis costs the U.S. health care system millions of dollars a year, much of that cost coming from unnecessary diagnostic tests such as chest x-rays and respiratory syncytial virus (RSV) testing.

“When a mother comes to the ED with a baby who is having difficulty breathing, it can be very frightening for her,” says Boston Children’s Hospital’s Ayobami Akenroye, MBChB, MPH,lead author of a study looking at resource utilization of bronchiolitis patients, recently published by Pediatrics. “In many cases, to help alleviate worry and ensure everything is being done to help the child, EDs will order various tests and sometimes give medication to temporarily relieve symptoms, but rarely do any of these steps impact how care is delivered or affect the clinical course of the disease. They’re usually unnecessary.” Full story »

Leave a comment