RESUMO
OBJECTIVE: The objective of this study was to assess respiratory responses of newborn infants with myelomeningocele through pneumograms and carbon dioxide challenge, and to evaluate the possibility of predicting which patients with myelomeningocele acquired respiratory symptoms related to the Arnold-Chiari deformity and brain-stem dysfunction. METHODS: All surviving infants with spina bifida who were born at the University of Iowa Hospitals and Clinics (UIHC) or were transferred there on the first day of life between January 1987 and January 1991 were assessed with a pneumogram and CO2 challenge once they were medically stable, and were followed for a mean of 30 months (10 to 53 months). RESULTS: Thirty patients met the inclusion criteria for this study; four died before being studied. Of the 26 remaining patients, 12 were born at the UIHC and 14 were transferred to the UIHC on the first day of life. Of the 26 infants studied, 12 (46%) had abnormalities on the pneumogram, including 2 with significant periodic breathing and 10 with episodes of desaturation below 87%. Of the 26 infants studied, 4 had no detectable response to an increasing fraction of CO2 in inspired air on the CO2 challenge and 12 had an increase in exhaled minute ventilation per increase in the alveolar fraction of CO2 in exhaled air more than 2 SD below the mean. Only 10 patients (38.5%) had normal ventilatory responses to the increasing fraction of CO2 in inspired air. On follow-up, only one study patient had symptoms related to Arnold-Chiari deformity and brain-stem dysfunction (bilateral vocal cord paralysis). His neonatal CO2 challenge results and his pneumogram were normal. CONCLUSION: We conclude that these two tests are not useful in predicting which patients will have symptoms related to Arnold-Chiari deformity. Specificity for the pneumogram and the CO2 challenge was 0.52 and 0.36, respectively. Sensitivity was zero for both tests, although this result is limited by the low incidence of symptomatic Arnold-Chiari deformity in this sample. As previous investigators have found, a significant number of patients with meningomyelocele had abnormal ventilatory patterns. These ventilatory abnormalities indicate that even in the absence of severe symptoms, the control of the ventilatory response is somewhat impaired in many patients with meningomyelocele. This alteration in ventilatory control is probably related to abnormalities in the development of the brain stem.
Assuntos
Malformação de Arnold-Chiari/etiologia , Meningomielocele/fisiopatologia , Respiração , Dióxido de Carbono , Pré-Escolar , Humanos , Lactente , Recém-Nascido , Meningomielocele/complicações , Disrafismo Espinal/complicações , Disrafismo Espinal/fisiopatologiaRESUMO
To determine how pediatricians' prognostications and decisions about the treatment of infants with meningomyelocele are affected by varying degrees of hydrocephalus, we randomly selected a sample of pediatricians to receive written surveys. This questionnaire assessed the relationship between the decisions and the prognostications, and compared their accuracy with that of outcome studies. Each pediatrician completed a questionnaire for two of three possible cases, which were identically described as infants with meningomyelocele and complete paraplegia varying only in the degree of hydrocephalus at birth from none to moderate to severe. Recommendations for treatment and prognostications (the Prognostics Belief Scale of Impressions of adult functional capabilities and likely residential and vocational placements) were compared. Significantly fewer pediatricians would present information to parents in an encouraging light, and significantly fewer would treat their own child, if the case involved severe hydrocephalus in comparison with no hydrocephalus. Pediatricians' prognostications were the least optimistic for the infant with severe hydrocephalus and most optimistic for the infant without hydrocephalus, and they were considerably less optimistic than seems justified on the basis of follow-up studies. Last, physicians' less-than-optimistic prognoses were significantly related to their decisions concerning surgery for the infants with moderate and severe hydrocephalus. The major import of the findings is that pediatricians' prognoses reflect, in part, a misconception of the impact of hydrocephalus on children born with meningomyelocele and that these prognoses then have and impact on the pediatricians' decisions concerning treatment.
Assuntos
Hidrocefalia/complicações , Meningomielocele/cirurgia , Seleção de Pacientes , Pediatria , Suspensão de Tratamento , Tomada de Decisões , Humanos , Recém-Nascido , Meningomielocele/complicações , PrognósticoRESUMO
A challenge design was used in two separate studies to investigate the effects of sucrose ingestion on the behavior and learning of hyperactive boys. In both studies, 16 boys were admitted to a clinical research center for 3 successive days, on each of which they were given a sucrose-free diet. On day 1, baseline levels on the learning tasks were established; on days 2 and 3 a challenge drink of either sucrose 1.75 gm/kg or a placebo (aspartame in equivalent sweetness) was presented, in a counterbalanced order. In the first study the challenge drink was administered 1 hour after lunch; in the second study it was given in the morning after an overnight fast. On days 2 and 3 of both studies, 37 behavioral (playroom observation and examiner ratings) and cognitive (learning and memory tasks) measures were collected, starting 1/2 hour after ingestion of the drink. The results of both studies revealed no differences between the boys' performance on the two challenge days. These findings undermine the hypothesis that sucrose plays a major role in accounting for the inappropriate behavior of hyperactive boys.