Synopsis of General Pediatric Practice (Recent Advances in Pediatric Medicine) (Aug 8, 2017)_(1681085216)_(Bentham Science Pu..


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Recent Advances in Pediatric Medicine
Volume # 1
Synopsis of General Pediatric Practice
Editor: Seckin Ulualp
eISSN (Online): 978-1-68108-520-3
ISSN( Print): 978-1-68108-521-0
eISBN (Online): 2543-2249
ISBN (Print): 2543-2257
© 2017, Bentham eBooks imprint.
Published by Bentham Science Publishers
– Sharjah, UAE. All Rights Reserved.
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qhe fáeld of pedáaírác medácáne encompasses a rapádly expandáng volume of ánformaíáonK qhás
book has been prepared by a dáverse group of auíhors from a range of pedáaírác subspecáalásís
ío creaíe a plaíform ío reváew íhe recení advances quáckly and effácáenílyK táíh auíhors from
pedáaírác subspecáalíáesI duplácaíáon of íhe ánformaíáon was reduced ío a mánámum by
áníegraíáng íhe chapíers effecíávelyK qhe auíhors clearly explaán eíáologyI paíhophysáologyI
qhe book does noí preíend ío descrábe íhe all aspecís of íhe managemení of íhe varáous
problems dáscussedK bach conírábuíor preseníed íhe scáeníáfác evádence and dáscussed íhe
pracíáce paíhways ío enhance effecíáveness of readers án approacháng commonly encouníered
medácal problems án cháldrenK Concáse ánformaíáon abouí íhe approach of pedáaírác
subspecáalásís ío common medácal problemsI íhaí are frequeníly very complexI enhances íhe
Ií ás my hope íhaíI by preseníáng íhe breadíh and depíh of many of íhe íypácal problems
encouníered whále caráng for cháldren án an evádenceJbased formaíI
oecení Advances án
medáaírác Medácáne; pynopsás of Currení deneral medáaírács mracíáce
wáll become a valuable
asseí for íhe pedáaírác pracíáíáonerI specáalásísI medácal síudenísI and oíhers ánvolved án íhe
A book láke íhás ás íhe resulí of íhe efforí of many peopleK I am very graíeful ío my wáfeI
ZerránI for haváng gracefully accepíed íhaí many weekends were absorbed by íhe preparaíáon
of íhás bookK Many íhanks go ío all auíhors íryáng íhe ámpossáble and sparáng íáme ío wráíe
aeparímení of líolaryngologyI rnáversáíy of qexas pouíhwesíern
Medácal CeníerI aallasI quI rpA
aeparímení of líolaryngology— eead and keck purgeryI rnáversáíy of
rnáversáíy of qexas pouíhwesíern ErqptF Medácal CeníerI aallas
Cháldren’s eealíhI aallasI quI rpA
aeparímení of líolaryngology – eead and keck purgeryI iouásáana píaíe
aeparímení of líolaryngologyI rnáversáíy of qennessee eealíh pcáence
CeníerI ieBonheur CháldrenDs eospáíalI píK gude CháldrenDs oesearch
eospáíalI qk PUNMRI rpA
aeparímení of líolaryngologyI rnáversáíy of qexas Medácal BranchI
aeparímení of medáaírácsI aávásáon of bndocránologyI Medácal College of
aeparímení of medáaírácsI rnáversáíy of qexas pan Aníonáo eealíh
pcáence CeníerI pan AníonáoI quI rpA
aeparímení of bkq and eead and keck purgeryI rnáversáíy of
MonípelláerI MonípelláerI crance
aeparímení of líolaryngologyI rnáversáíy of qexas Medácal BranchI
aeparímení of medáaírácsI lchsner for Cháldren and qhe rnáversáíy of
nueensland pchool of MedácáneI lchsner Clánácal pchoolI kew lrleansI
aeparímení of medáaírácsI rnáversáíy of qexas pan Aníonáo eealíh
pcáence CeníerI pan AníonáoI quI rpA
aeparímení of líolaryngologyI rnáversáíy of qexas Medácal BranchI
Medácal College of tásconsánI Cháldren’s eospáíal of tásconsánI
MálwaukeeI tII rpA
aeparímení of líolaryngologyI rnáversáíy of qexas Medácal BranchI
aávásáon of líorhánolaryngology eead C keck purgeryI rnáversáíy of
MonírealI líology and keuroíologyI paáníeJgusíáne rnáversáíy eospáíal
Ceníer ECerpgF and rnáversáíy of Moníreal eospáíal Ceníer ECerMF
pecíáon of medáaírác msychologyI rnáversáíy of Arkansas for Medácal
pecíáon of medáaírác msychologyI rnáversáíy of Arkansas for Medácal
Ceníro gaveráano de lncologáa J eospáíal rnáversáíaráo pan IgnacáoI
BogoíaI Columbáa aeparímení of medáaírácsI rnáversáíy of qexas eealíh
aeparímení of medáaírácsI rnáversáíy of qexas pan Aníonáo eealíh
pcáence CeníerI pan AníonáoI quI rpA
aeparímení of Iníernal MedácáneI aeparímení of medáaírácsI aávásáon of
Allergy and ImmunologyI rnáversáíy of Arkansas for Medácal pcáencesI
aávásáon of medáaírác líolaryngologyJeead and keck purgeryI Ann C
aeparímení of msychologyI Cháldren’s kaíáonal eealíh pysíemI
tashángíonI aCI rpA
aeparímení of líolaryngology – eead and keck purgeryI aávásáon of
medáaírác líolaryngologyI rnáversáíy of qexas pouíhwesíern Medácal
CeníerI aallasI quI rpA
aeparímení of medáaírácsI rnáversáíy of qexas pan Aníonáo eealíh
pcáence CeníerI pan AníonáoI quI rpA
pecíáon of medáaírác msychologyI rnáversáíy of Arkansas for Medácal
aeparímení of medáaírácsI aávásáon of hemaíology and lncologyI
rnáversáíy of qexas eealíh pcáence CeníerI pan AníonáoI quI rpA
aeparímení of bkq and eead and keck purgeryI rnáversáíy of
MonípelláerI MonípelláerI crance
aeparímení of msychologyI Cháldren’s kaíáonal eealíh pysíemI
tashángíonI aCI rpA
aeparímení of bkq and eead and keck purgeryI rnáversáíy of
MonípelláerI MonípelláerI crance
aeparímení of purgeryI aávásáon of líolaryngologyI háng cahad
ppecáalásí eospáíalI aammamI paudá Arabáa
aeparímení of medáaírácsI aávásáon of bndocránologyI iouásáana píaíe
rnáversáíyJeealíh pcáences CeníerLrnáversáíy eealíhI phreveporíI iAI
aeparímení of Iníernal MedácáneI rnáversáíy of Arkansas for Medácal
aeparímení of medáaírácsI aávásáon of dasíroeníerology and eepaíologyI
aeparímení of medáaírácsI aávásáon of dasíroeníerology and eepaíologyI
aávásáon of oespáraíory and pleep MedácáneI aeparímení of medáaírácsI
aeparímení of líolaryngologyJ eead and keck purgeryI aávásáon of
medáaírác líolaryngologyI rnáversáíy of qexas pouíhwesíern Medácal
CeníerI Cháldren’s eealíhI aallasI quI rpA
aeparímení of líolaryngologyI rnáversáíy of qexas Medácal BranchI
rnáversáíy of qexas pouíhwesíern ErqptF Medácal CeníerI aallas
Cháldren’s eealíhI aallasI quI rpA
aeparímení of
líolaryngologyI rnáversáíy of qexas Medácal BranchI
rnáversáíy of qexas pouíhwesíern ErqptF Medácal CeníerI aallas
Cháldren’s eealíhI aallasI quI rpA
Absírací:
qhás chapíer dáscusses íhe dáfference beíween acuíe oíáíás medáaI recurrení
oíáíás medáaI and oíáíás medáa wáíh effusáon as well as íhe eíáologyI epádemáologyI
dáagnosás and íreaímení of íhe dásíáncí dáseasesK kew OMNS guádeláne updaíes on líáíás
heywords:
AníábáoíácsI CholesíeaíomaI barI bffusáonI eearángI InfecíáonI
MyrángosclerosásI líáíás medáaI líorrheaI qubeI qympanosíomyK
bar ánfecíáons are one of íhe mosí common reasons for whách cháldren seek íhe
care of a pedáaírácáan before íhe age of íhree [
zK marenís know íhaí ear ánfecíáons
are common and aíírábuíe a mulíáíude of sympíoms ío íhe earsJ feverI fussánessI
pulláng aí earsI delayed speechI faálure ío respond when calledK qhereforeI áí ás
váíal for every clánácáan ío have a sírong knowledge of how and why ear ánfecíáons
occurI whaí dásíánguáshes dáfferení íypes of ánfecíáons and whaí ás íhe síandard of
Acuíe líáíás Medáa EAlMF ás defáned as ánflammaíáon of íhe máddle ear
assocáaíed wáíh máddle ear effusáon [
zK Ií has a rapád onseí and áncludes
sympíoms of paán and feverK qhe íympanác membrane EqMF may be eryíhemaíous
and bulgáng ouíward from máddle ear purulence or rupíured due ío excessáve
líáíás Medáa wáíh effusáon ElMbF ás defáned as máddle ear effusáon wáíhouí acuíe
ánflammaíory ságns or sympíoms [
J
zK qhás has a longer duraíáon wáíh gradual
Correspondáng auíhor qomoko Makásháma:
aeparímení of líolaryngologyI rnáversáíy of qexas Medácal BranchI
ánclude máddle ear effusáon wáíh decreased íympanác membrane mobáláíy and flaí
qhereforeI acuíe oíáíás medáa EAlMF ás a separaíe eníáíy from oíáíás medáa wáíh
Máddle ear dásease síems from many áníeracíáng facíors áncludáng anaíomyI
enváronmeníI ánfecíáous agenísI and geneíácsK
qhe máddle ear ás an aárJfálled space medáal ío íhe íympanác membrane and laíeral
ío íhe ánner ear [
zK Ií has a mucosal lánáng of respáraíory epáíheláum and coníaáns
íhree bones íhaí form a lever mechanásm EmalleusI áncusI and síapesFK qhás lever
mechanásm ás ámporíaní for íhe conducíáon of soundK If íhe mechanásm ás
damaged or funcíáon ás decreasedI a conducíáve hearáng loss may followK
qhe busíacháan íube EbqF plays an ámporíaní role án máddle ear pressure
equalázaíáon andI íhereforeI máddle ear dásease [
zK qhe bq orágánaíes án íhe
aníeráor máddle ear space and courses aníeráorly ío empíy ánío íhe laíeral
nasopharynxK qhe íensor velá palaíáná muscle conírols openáng and closáng of íhe
bq duráng swallow [
I
I
zK qhe busíacháan íube ás esseníáal ío maáníaán a
funcíáonal máddle ear by provádáng veníálaíáonI proíecíáonI and clearanceK If any of
íhese are ámpaáredI oíáíás medáa may developK seníálaíáon ás íhe acíáve process of
regulaíáng máddle ear pressure whách ás accompláshed by coníracíáon of íhe íensor
velá palaíán
duráng swallowángI jaw movemenísI and yawnáng [
zK qhás funcíáon
ás poor án cháldren and ámproves wáíh age [
zK Cháldren who are
prone ío oíáíás
medáa are more lákely ío have defácáení acíáve bq funcíáon
cháldren who
are noí [
zK Closure of íhe bq ás a passáve process whách proíecís íhe máddle ear
qhe busíacháan íube ás láned wáíh cáláaíed respáraíory epáíheláumK Mucocáláary
clearance conírábuíes ío bq funcíáon by propelláng mucus and fluád from íhe
máddle ear ánío íhe nasopharynxK hnown dásorders of mucocáláary clearance lead
qhe bq opens laíerally án íhe nasopharynx and can be obsírucíed by mádláne
adenoád growíh or seeded by báofálm from chronác adenoádáíásK lráeníaíáon of íhe
bq affecís reflux of fluád án íhe nasopharynx ánío íhe máddle ear as well as
íube empíáes ánío íhe nasopharynx aí a 4R degree angleI whále án cháldrenI íhás
angle ás closer ío VM degreesK In addáíáonI any excess íássue án íhe nasopharynx can
eoweverI despáíe íhe common accepíance and logácal assocáaíáon of bq
dysfuncíáon ío máddle ear dáseaseI much coníroversy síáll exásís on causal
relaíáonsháp [
qobacco smoke ás íhe leadáng preveníable rásk facíor for íhe developmení of oíáíás
medáaK píudáes have consásíeníly shown íhaí íobacco smoke exposureI áncludáng
second and íhárd hand smokeI ás assocáaíed wáíh an áncreased áncádence of oíáíás
medáa and recurrení oíáíás medáa [
zK In addáíáonI íympanác membrane
perforaíáonI cholesíeaíoma and oíher lMb complácaíáons are áncreased án
cháldren exposed ío smoke [
zK puppressáon or modulaíáon of íhe ámmune
sysíemI enhancemení of íhe bacíeráal adherence facíorsI ámpaármení of íhe
mucocáláary apparaíus of íhe respáraíory íracíI or enhancemení of íoxáns are
suggesíed mechanásms relaíed ío íobacco smoke exposure [
aaycare ás a wellJsíudáed rásk facíor for recurrení AlM: cháldren enrolled án
daycare are íwáce as lákely ío have AlM due ío áncreased exposure ío bacíeráal
Allergáes are ofíen blamed for máddle ear effusáonI and paíáenís wáíh skán íesí
proven aíopy and hásíory of recurrení máddle ear dásease show resoluíáon or
ságnáfácaní ámprovemení of máddle ear dásease afíer ánáíáaíáon of ámmunoíherapyK
qhás ás explaáned by qhO ánflammaíory response medáaíors Enormally áncreased án
íhe allergác response paíhwayF whách have been found án íhe fluád of chronácally
dáseased máddle earsK ko dárecí evádence exásís lánkáng ear dásease and allergy aí
Breasí feedáng may be a proíecíáve facíor; lower raíes of oíáíás medáa have been
seen án breasífed cháldren for íhe fársí NN moníhs of láfeK In addáíáonI íhese
cháldren have been noíed ío have áncreased serum Igd whách may proíecí agaánsí
Acuíe oíáíás medáa ás íhe mosí common reason for an aníábáoíác prescrápíáon for
pedáaírác paíáenís án íhe rnáíed píaíes; howeverI AlM ás noí always caused by
sáral causes of AlM Eqable
F accouní for only NMB of casesK eoweverI TMB of
AlM have váral ásolaíes found án máddle ear exudaíeK oecení evádence shows íhaí
váruses can lead ío bacíeráal superánfecíáon íhrough ánflammaíory and anaíomác
Bacíeráa íypácally colonáze íhe nasopharynxI buí do noí cause ánfecíáon uníál a
váral upper respáraíory ánfecíáon ánáíáaíes áíK pee qable
for mosí common bacíeráa
qhe pneumococcal conjugaíe vaccánes have led ío an overall decrease án AlM
epásodes án vaccánaíed cháldrenK eoweverI an áncrease has been documeníed án
In mosí cases of acuíe oíáíás medáaI bacíeráa can be culíured from íhe máddle ear
effusáonK Because of dáffáculíy ásolaíáng paíhogensI lMb was long íhoughí ío be a
nonánfecíáous or “síerále” processK píudáes now show íhaí bacíeráa are presení án
lMb [
zK qhese bacíeráa are noí án free plankíonác form as án AlMI buí án
A báofálm ás defáned as “a communáíy of áníeracíáng bacíeráa aííached ío a surface
and encased án a proíecíáve glycocalyx or maíráx of exopolylsaccharádes” [
qhe majoráíy of bacíeráa án íhe body exásí án a báofálm and are able ío surváve án
enváronmenís íhaí free EplankíonácF bacíeráa cannoí [
zK qhe bacíeráa have
decreased oxygen and nuíráení requáremenísI an áncrease án resásíance genesI íhe
píudáes have shown a dáfference án áncádenceLprevalence of lM based on race and
eíhnácáíáesK Indágenous populaíáons such as Ausíraláan AborágánesI InuáísI kew
Zealand MaorásI Amerácan Indáans and Alaska naíáves are known ío have hágh
prevalence of oíáíás medáa [
J
zK aáscrepancáes án íreaímení have been shown
also ío be race relaíed wáíh cháldren of mánoráíy less lákely ío receáve broad
specírum aníábáoíács and more lákely ío have hospáíalázaíáon from AlM
complácaíáons [
eeráíabáláíy esíámaíes of recurrení acuíe oíáíás medáa are MK4V [
z and accouníed
for by dáfferences án anaíomyI geneíác syndromesLalíeraíáonsI and suscepíábáláíy ío
váruses and bacíeráa [
zK qwán síudáes have shown íhaí íhe concordance of oíáíás
medáa ás around MKV án monozygoíác íwáns and áncreases wáíh ageI whále án
dázygoíác íwáns íhe concordance was MKSR [
deneíác suscepíábáláíy ío oíáíás medáa ás caused by alíeraíáons án genes codáng for
ánnaíe and adapíáve ámmunáíy facíors as well as random geneíác alíeraíáons Eqable
F [
J
zK Immune ánvolvemení án geneíác rásk for lM ás supporíed by
áncreased raíes of oíáíás medáa án paíáenís wáíh combáned varáable ámmunoJ
defácáency compared ío normal populaíáon [
qioO = íollJláke recepíor OI CaN4 = clusíer of dáffereníáaíáon N4I MBiO = mannoseJbándáng lecíán OI pmJαN =
surfacíaní proíeán A NI IiJNβ = Iníerleukán N beíaI IiJU = Iníerleukán UI IiJ NM = Iníerleukán NMI qdcJ βN =
CCoR = CJC chemokáne recepíor íype RI mAIJN = plasmán acíávaíor ánhábáíor NI AOMiN = alphaJOJ
macroglobulánJláke NK
Muíaíáons án genes relaíed ío ánnaíe ámmunáíyI adapíáve ámmunáíy among oíhers
káneíy percení of cháldren wáíh clefí palaíe Eprevalence SLNMIMMM láve báríhsF wáll
have chronác lMbK qhe cause of lMb ás íhe busíacháan íube dysfuncíáon
accompanyáng íhe clefí palaíe [
busíacháan íube dysfuncíáon án paíáenís wáíh aownDs pyndrome Eprevalence NLTMM
láve báríhsF ás due ío hypoírophy of íhe máddle face and general musculaíureK
líher assocáaíed feaíures ánclude narrow ear canal and hyperírophy of íhe
nasopharyngeal lymphaíác íássue [
zK qhe prevalence of lMb án íhese paíáenís ás
mrámary Cáláary ayskánesáa EmCaF ás a rare auíosomal recessáve dásorder wáíh
unknown prevalence whách affecís íhe moíáláíy of cáláaK Because íhe máddle ear
mucosa ás láned wáíh cáláaíed epáíheláumI án íhose wáíh mCa íhere ás decreased
mucous moíáláíyI áncreased síasásI áncreased ánfecíáonI áncreased báofálmI and
decreased hearáng due ío fluád collecíáonK qhe use of íubes for íreaímení of lMb
Acuíe oíáíás medáa EAlMF ás an ánfecíáon of íhe máddle ear space characíerázed by
a neuírophál rách máddleJear effusáon án conjuncíáon wáíh ságns and sympíoms of
máddleJear ánflammaíáon [
zK oecurrení acuíe oíáíás medáa EoAlMF ás defáned as
qhe average cháld wáll have had NKT epásodes of AlM by íhe age of íhreeK qhe
áncádence of AlM before íhree years ás RMB [
I
z and prevalence decreasáng
from P4B ío O4B from NVVT ío OMMTK oaíes of AlM remaán hághesí án cháldren
younger íhan P years normally beáng found beíween ages SJNO moníhs [
aecrease án prevalence may be due ío ámplemeníaíáon of pneumococcal vaccáneI
decrease án smoke exposureI áncrease án breasí feedángI or áncrease án sírángení
qhe íypácal preseníaíáon of a cháld wáíh AlM áncludes rapád onseí of árráíabáláíyI
fever and ear paán [
zK In ánfanís wáíh sympíoms of an upper respáraíory ánfecíáonI
íhe probabáláíy of AlM ás áncreased áf íhe cháld aííends daycare and parenís are
ln physácal exam íhe íympanác membrane ás eryíhemaíousI bulgáng wáíh fluád
pressáng íhe ear drum laíerallyK In some ánsíancesI íhán yellow or green oíorrhea
may be presení án íhe exíernal audáíory canalI whách ás assocáaíed wáíh íympanác
aáagnosás of acuíe oíáíás medáa ás made clánácally wáíh oíoscopác examánaíáon and
Complácaíáons of ear ánfecíáons are uncommonI buíI due ío íhe hágh prevalence of
íhe dáseaseI síáll seen by prámary care provádersK Complácaíáons can be dáváded
Iníraíemporal complácaíáons Ecomplácaíáons whách remaán confáned ío íhe earF
ánclude common complácaíáons such as íympanác membrane perforaíáon whách
occurs án TB of acuíe ánfecíáonsI and rarer complácaíáons whách ánclude
masíoádáíásI labyráníháíásI veríágoI conducíáve or sensoráneural hearáng lossI
cholesíeaíomaI facáal nerve paralysásI ossácular dásconíánuáíy [
I
I
Iníracranáal complácaíáons íypácally aráse afíer masíoádáíás and are more seráous án
naíure [
zK qhese may ánclude menángáíás Emosí commonFI epádural or braán
abscessI and dural sánus íhrombosásK
iong íerm complácaíáons of acuíe oíáíás medáa are few unless one of íhe above
complácaíáons occurred [
zK A hágh number of AlM epásodes has been assocáaíed
qreaímení opíáons ánclude sympíomaíác íreaímení aloneI delayed aníábáoíác
íreaímení and ámmedáaíe aníábáoíác íherapyK AlM ás íhe mosí common reason íhaí
Because SMB of AlM usually resolves án O4 hours wáíhouí íreaímeníI
sympíomaíác íreaímení wáíh aceíamánophen or kpAIas for máld paán and fever ás
an appropráaíe opíáon for AlM wáíh reevaluaíáon án 4UJTO hours [
I
I
zK A
4UJTO hour observaíáon práor ío aníábáoíác dáspensaíáon án paíáenís wáíh nonJsevere
AlM can be consáderedI whách wáll án íurn decrease medácaíáon sáde effecís such
as nauseaI vomáíángI and dáarrhea [
zK In cháldren wáíhouí sympíom resoluíáon
wáíhán TO hours or worsenáng sympíomsI aníábáoíács should be síaríed [
I
Aníábáoíács should be síaríed aí dáagnosás for cháldren wáíh sysíemác sympíomsI
seráous állnessesI or selecíávely án cháldren less íhan O years of age wáíh bálaíeral
AlM or wáíh oíorrhea [
I
zK oecommendaíáons for aníábáoíác íherapy ás lásíed án
qable
zK cáve days of aníábáoíács wáll usually suffáce for cháldren O years or
olderI buí áí may be necessary ío gáve up ío NM days áf less íhan O years of age or
wáíh a íympanác membrane perforaíáon [
zK maíáenís should be followed án 4JU
qreaímení opíáons for recurrení oíáíás medáa ánclude aníábáoíácsI vaccánaíáonI and
íympanosíomy íubesK saccánes admánásíered duráng ánfancy can reduce íhe
áncádence of AlMK qympanosíomy íubes have been shown ío be an effecíáve
íreaímení for recurrení oíáíás medáa [
I
I
I
zK oecení OMNS guádeláne updaíes by
íhe Amerácan Academy of líolaryngology recommend veníálaíáon íubes áf
bálaíeral or unálaíeral máddle ear effusáon ás presení aí íhe íáme of assessmeníK If
no máddle ear effusáon aí íhe íáme of examánaíáon án eáíher earI observaíáon for a
PJS moníhs peráod ás recommended unless íhe paíáení ás deemed hágh rásk Ehásíory
of auíásmI syndromác and cranáofacáal dásordersI clefí palaíeI práor hearáng lossI
líáíás medáa wáíh effusáon ElMbF ás characíerázed by íhe presence of fluád án íhe
máddle ear wáíhouí ságns or sympíoms of acuíe oíáíás medáaI such as fever and
earacheK líher names for lMb ánclude glue earI serous oíáíás medáaI and ear fluád
Chronác lMb ás máddle ear effusáon persásíáng for more íhan P moníhs from daíe
lMb ás íhe mosí common cause of hearáng ámpaármení án cháldren án developed
couníráes wáíh a prevalence of UMB before íhe age of 4 yearsK ealf of íhese cases
wáll resolve wáíhán P moníhs and VRB wáíhán N yearK oecurrence of lMb presení
án PMJ4MB of cháldrenI yeí only NMB wáll síáll have fluád P moníhs afíer AlM [
zK qhe áncádence of lMb per year ás OKO málláon án íhe rnáíed píaíes [
I
Mosí cases of lMb occur duráng íhe ages of S moníhs ío 4 yearsI wáíh no
predálecíáon for race or genderK
Cháldren wáíh lMb may presení wáíh conducíáve hearáng lossI dáffáculíáes aí
schoolI behaváoral ássuesI ear dáscomforíI recurrení AlMI or reduced qualáíy of
láfe [
I
zK Cháldren wáíh lMb lack íhe ságns of acuíe ánflammaíáon found án
AlMI such as feverI oíalgáaI oíorrheaI and íympanác membrane eryíhemaK
eoweverI íhese cháldren may have decreased gross moíor profácáency and
behaváoral problems such as dásíracíábáláíyI wáíhdrawalI frusíraíáonI and
lMb may presení asympíomaíácally and serous máddle ear fluád ás dáffáculí ío
dásíánguásh wáíh oíoscopy alone as íhe appearance of íhe qM ás affecíed by many
facíorsK Addáng pneumaíác oíoscopy ío íhe exam can claráfy íhe dáagnosás by
demonsíraíáng decreased qM movemení [
I
zK If pneumaíác oíoscopy ás
ánconclusáveI íympanomeíry should be usedK
cormal audáomeíry should be performed án cháldren wáíh lMb persásíáng for P
moníhs or longer or áf hágh rásk feaíures presení EqM reíracíáon pockeísI ossácular
In mosí casesI lMb resolves sponíaneously wáíh no adverse ouícomesK moíeníáal
shoríJíerm complácaíáons ánclude hearáng lossI speech delayI and problems án
schoolK iong íerm sequelae ánclude adulí hearáng lossI whách ás more common
Afíer íhe dáagnosás of lMb has been esíabláshedI íhe clánácáan should monáíor íhe
paíáení for P moníhsK marenís should be ánformed íhaí reduced hearáng may be
experáenced whále waáíáng for íhe effusáon ío resolve and íechnáques ío opíámáze
If íhe effusáon ás síáll presení afíer P moníhsI waíchful waáíáng may be coníánued áf
no sympíoms of hearáng loss are experáencedK purveállance should occur every P
rnless oíher ándácaíáons are preseníI nasal síeroádsI aníábáoíácsI and
aníáhásíamánesLdecongesíanís are noí recommended for íhe íreaímení of lMb [
Auíoánflaíáon ás a íechnáque ío reopen íhe busíacháan íube by forced exhalaíáon
agaánsí a closed mouíh and nose or usáng a moláízer deváceK qhás could prováde
benefáí áf performed duráng íhe waíchful waáíáng peráod due ío low cosí and no
If fluád ás presení for P or more moníhsI íympanosíomy íubes may be
recommended especáally áf hearáng loss ás preseníK q
íubes may be
consádered before P moníhs of waíchful waáíáng for cháldren aí rásk for
developmeníal delays as addáíáonal hearáng loss may have deírámeníal
consequences [
I
I
qympanosíomy íube placemení ás íhe mosí common surgery performed án
cháldren [
zK cor cháldren wáíh lMbI íympanosíomy íubes are more effecíáve aí
decreasáng hearáng loss íhan oíher íreaímenís án íhe fársí S moníhs afíer placemení
zK ko síudáes have been done ío evaluaíe effecís on speechI languageI and
developmení [
zK qympanosíomy íubes do noí decrease overall prevalence of
oíáíás medáaI buí do decrease frequency of recurrení epásodesI duraíáon of íhe
P epásodes án S moníhsI or 4 epásodes án N year wáíh N epásode án íhe precedáng S
Máddle ear effusáon for aí leasí P moníhs wáíh complácaíáons Ehearáng lossI
balance problemsI poor school performanceI ear dáscomforíI reduced qualáíy of
eágh rásk cháldren Ehásíory of auíásmI cranáofacáal anomalyI clefí palaíeI
táíh all complex casesI a mulíáJdáscáplánary íeam should be uíálázedK cor cháldren
wáíh aown’s syndromeI ámporíaní consáderaíáons ánclude: severáíy of hearáng
lossI ageI dáffáculíy of ánseríáonI rásksI and lákeláhood of exírusáon [
zK Clefí
palaíe paíáenís ofíen have íympanosíomy íubes placed aí íhe same íáme as íhe
palaíal repaárK eoweverI ándávádual cárcumsíances may warraní ánseríáon aí ánáíáal
láp repaár surgery or suggesí hearáng aáds as a beííer opíáon [
zK eearáng aáds play
an ámporíaní role án complex cases and may be a good alíernaíáve ío surgácal
líorrheaI or draánage from íhe earI ás íhe mosí common complácaíáon afíer íube
ánseríáonK lne fouríh of paíáenís wáll have draánage for more íhan íwo weeks afíer
líorrhea ás caused by váruses án OMB and polymácrobáal bacíeráa Eáncludáng
qhe mosí common íreaímenís are oral or íopácal aníábáoíácsI wáíh oíher opíáons
áncludáng oral or íopácal síeroádsI aural íoáleíI and aníásepíácsK medáaírácáans are
íopácal aníábáoíács [
I
I
zK mreváouslyI áí was beláeved íhere was no dáfference
án resoluíáon raíes beíween oral and íopácal aníábáoíácsK eoweverI recení evádence
ealf of cháldren who have had íympanosíomy íube placemení wáll requáre íhe
same procedure agaán [
zK qhe general approach ás ío perform adenoádecíomy aí
íhe same íáme as second myrángoíomyK In cháldren less íhan 4 years of ageI new
recommendaíáons are ío only perform adenoádecíomy aí íhás íáme áf a dásíáncí
ándácaíáon such as chronác adenoádáíás or nasal obsírucíáon exásísK If íhe cháld ás 4
years old or greaíerI a separaíe ándácaíáon for adenoádecíomy ás noí requáred [
Myrángosclerosás ás a localázed reacíáon of íhe íympanác membrane characíerázed
by sclerosásI hyaláne degeneraíáon án íhe lamána propráaI calcáum and phosphaíe
deposáíáonI and ás hásíologácally sámálar ío aíherosclerosás [
zK Ií orágánaíes from
ánflammaíáon án íhe máddle earJ eáíher from recurrení ánfecíáons or íympanosíomy
íubes íhemselvesI and ás íhe mosí common long íerm sequela from íympanosíomy
íube placemení [
J
zK Myrángosclerosás rarely leads ío hearáng loss excepí án
severe cases ánvolváng íhe eníáre íympanác membrane as well as íhe ossácles
Eknown as íympanosclerosásFK qympanosclerosás may requáre surgácal
qympanác membrane perforaíáon ás found án NB of cháldren afíer íube exírusáonK
qhe perceníage áncreases áf íhe íubes have ío be manually removed or áf mulíáple
seís of íubes have been placed [
I
zK merforaíáons may requáre surgácal repaár
by oíolaryngologásí wáíh eáíher myrángoplasíy or íympanoplasíy dependáng on
ko agreemení has been reached on íámáng of followJup appoánímenísI or wheíher
íhe cháld needs ío be seen aí allK Mosí oíolaryngologásís do follow íhese cháldren
In a OMNS Cochrane reváewI recommendaíáons were made agaánsí oíác waíer
precauíáons for cháldren wáíh ear íubes [
zK qube exírusáon and hearáng loss raíes
are unaffecíed by waíer precauíáonsI buí íube oíorrhea may be slághíly áncreased áf
In conclusáonI oíáíás medáa ás a common process íhaí all clánácáans who see
cháldren wáll encouníerK qhe dásease ás complex án orágán wáíh many conírábuíáng
rásk facíors and causesK Ií ás váíal for clánácáans ío dásíánguásh beíween recurrení
acuíe epásodes and chronác máddle ear effusáon as íreaímenís are dáffereníK tork
up should always ánclude pneumaíác oíoscopyK Ináíáal íreaímení of AlM may
ánclude waíchful waáíáng for 4UJTO hoursK kew recommendaíáons ándácaíe íhaí
placemení of íympanosíomy íubes should only be recommended áf máddle ear
fluád ás presení án examánaíáon of cháldren wáíh olM or áf máddle ear fluád ás
te íhank arK qasnee Chonmaáíree and MsK oebecca Cook for careful readáng of
McCormáck amI gennángs hI bde iCI Chonmaáíree qK rse of sympíoms and rásk facíors ío predácí
tasson gaI vung MtK bvádenceJbased managemení of oíáíás medáa: a Rp model approachK g
iaryngol líol OMNR; NOVEOF: NNOJVK
mráncápá kI Marchásáo mI bsposáío pK líáíás medáa wáíh effusáon: benefáís and harms of síraíegáes án use
oosenfeld oMI Culpepper iI vawn BI Mahoney MCK líáíás medáa wáíh effusáon clánácal pracíáce
oosenfeld oMI pchwaríz poI mynnonen MAI
eí alK
Clánácal pracíáce guádeláne: qympanosíomy íubes
Mm iI mw cI bdsK CasselbraníI MKiK and MK bMI Acuíe líáíás Medáa and líáíás Medáa wáíh bffusáonK
aaly hAI euníer iiI ieváne pCI iándgren BoI dáebánk dpK oelaíáonsháps beíween oíáíás medáa
píensírom CI BylanderJdroíh AI Ingvarsson iK busíacháan íube funcíáon án oíáíásJprone and healíhy
píraeíemans MI van eeerbeek kI pchálder Anne dMI
eí alK
busíacháan íube funcíáon before recurrence
válmaz dI eázlá pI haracan CI vurdakök hI Coşkun qI aálmen rK bffecí of passáve smokáng on
Zhou pI ooseníhal adI pherman pI teáízman MK mhysácalI behaváoralI and cognáíáve effecís of
prenaíal íobacco and posínaíal secondhand smoke exposureK Curr mrobl medáaír Adolesc eealíh Care
humJkjá mI Meloy iI eerrod edK bnváronmeníal íobacco smoke exposure: prevalence and
mechanásms of causaíáon of ánfecíáons án cháldrenK medáaírács OMMS; NNTERF: NT4RJR4K
eoffman egI aaly hAI Baánbrádge hbI
eí alK
manel N: bpádemáologyI naíural hásíoryI and rásk facíorsK
eursí apK bffácacy of allergy ámmunoíherapy as a íreaímení for paíáenís wáíh chronác oíáíás medáa wáíh
hvaerner hgI hrásíáansen eAI oussell MBK líáíás medáa hásíoryI surgery and allergy án SMJyear
koksoJhoávásío gI Marom qI Chonmaáíree qK Imporíance of váruses án acuíe oíáíás medáaK Curr lpán
Casey goI Adlowáíz adI mácháchero MbK kew paííerns án íhe oíopaíhogens causáng acuíe oíáíás medáa
sáx ío eághí years afíer áníroducíáon of pneumococcal conjugaíe vaccáneK medáaír Infecí aás g OMNM;
mosí gCK aárecí evádence of bacíeráal báofálms án oíáíás medáaK OMMNK iaryngoscope OMNR; NOREVF: OMMPJ
Coíáccháa gMI Chen MI pachdeva iI Muíchnáck pK kew paradágms án íhe paíhogenesás of oíáíás medáa
McCallum gI Craág iI tháííaker II Baxíer gK bíhnác dáfferences án acuíe hospáíalásaíáons for oíáíás
medáa and elecíáve hospáíalásaíáons for veníálaíáon íubes án kew Zealand cháldren aged MJN4 yearsK k Z
aaly hAI eoffman egI hvaerner hgI
eí alK
bpádemáologyI naíural hásíoryI and rásk facíors: panel
reporí from íhe káníh Iníernaíáonal oesearch Conference on líáíás MedáaK Iní g medáaír
líorhánolaryngol OMNM; T4EPF: OPNJ4MK
pángleíon ogI eolman oCI mlaní oI
eí alK
qrends án oíáíás medáa and m
wáíh íube placemení
among Amerácan IndáanLAlaska naíáve cháldren and íhe rp general populaíáon of cháldrenK medáaír
clemángJauíra hbI phapáro agI eácks iAI derber gpI eersh AiK oaceI oíáíás medáaI and aníábáoíác
Bhuíía McK bpádemáology and paíhogenesás of oíáíás medáa: consírucíáon of a phenoíype landscapeK
oovers MI eaggard MI dannon MI hoeppenJpchomerus dI mlomán oK eeráíabáláíy of sympíom
domaáns án oíáíás medáa: a longáíudánal síudy of NIPTP íwán paársK Am g bpádemáol OMMO; NRRENMF: VRUJ
Máljanovác lI CákoíaJAleksáć BI iákáć aI
eí alK
Assocáaíáon of cyíokáne gene polymorphásms and rásk
Máííal oI oobaláno dI derráng oI
eí alK
Immunáíy genes and suscepíábáláíy ío oíáíás medáa: a
comprehensáve reváewK g deneí denomács OMN4; 4NENNF: RSTJUNK
paníosJCoríez oiI Cháong CMI oeyesJnuáníos Ma oána qI
eí alK
oare AOMiN varáanís confer
bsposáío pI Marchásáo mI lreníá AI
eí alK
deneíác molymorphásms of cuncíáonal Candádaíe denes and
oecurrení Acuíe líáíás Medáa táíh or táíhouí qympanác Membrane merforaíáonK Medácáne
EBalíámoreF OMNR; V4E4OF: eNUSMK
Magláulo dI Iannella dI dranaía dI
eí alK
líologác evaluaíáon of paíáenís wáíh prámary aníábody
qáerney pI lDBráen hI earman kiI
eí alK
oásks and benefáís of veníálaíáon íubes and hearáng aáds from
íhe perspecíáve of parenís of cháldren wáíh clefí palaíeK Iní g medáaír líorhánolaryngol OMNP; TTENMF:
Ausíeng MbI Akre eI Øverland BI
eí alK
líáíás medáa wáíh effusáon án cháldren wáíh án aown
oosenfeld oMI phán ggI pchwaríz poI
eí alK
Clánácal mracíáce duádeláne: líáíás Medáa wáíh bffusáon
oosenfeld oMI oosenfeld oMI oosenfeld oMI
eí alK
Clánácal mracíáce duádeláne: líáíás Medáa wáíh
Morgan iCI Bárman CpK qhe ámpací of mrámary Cáláary ayskánesáa on íhe upper respáraíory íracíK
iáese gdI pálfverdal pAI dáaquánío CI
eí alK
Incádence and clánácal preseníaíáon of acuíe oíáíás medáa án
kankávell mCI moíháer aaK purgery for íympanác membrane reíracíáon pockeísK Cochrane aaíabase
Aarhus iI qambs hI hvesíad bI bngdahl BK Cháldhood líáíás Medáa: A Cohorí píudy táíh PMJvear
senekamp omI panders pI dlaszáou mmI ael Mar CBI oovers MMK Aníábáoíács for acuíe oíáíás medáa án
iáeberíhal ApI Carroll AbI Chonmaáíree qI
eí alK
qhe dáagnosás and managemení of acuíe oíáíás medáaK
Mcaonald pI iangíon eewer CaI kunez aAK drommeís Eveníálaíáon íubesF for recurrení acuíe oíáíás
[4Ozqos MK bpádemáology and naíural hásíory of secreíory oíáíásK Am g líol NVU4; RESF: 4RVJSOK
huo CiK bíáopaíhogenesás of acquáred cholesíeaíoma: prománení íheoráes and recení advances án
merera oI dlaszáou mmI eeneghan CgI Mciellan gI tálláamson IK Auíoánflaíáon for hearáng loss
[4RzBerkman kaI tallace IcI píeáner MgI
Brownáng ddI oovers MMI tálláamson II
eí alK
drommeís Eveníálaíáon íubesF for hearáng loss
assocáaíed wáíh oíáíás medáa wáíh effusáon án cháldrenK Cochrane aaíabase pysí oev OMNM; ENMF:
Cheong heI eussaán ppK Managemení of recurrení acuíe oíáíás medáa án cháldren: sysíemaíác reváew of
íhe effecí of dáfferení áníerveníáons on oíáíás medáa recurrenceI recurrence frequency and íoíal
recurrence íámeK g iaryngol líol OMNO; NOSEVF: UT4JURK
hhanna oI iakhanpaul MI Bull maK purgácal managemení of oíáíás medáa wáíh effusáon án cháldren:
[4Vztálláamson IK líáíás medáa wáíh effusáon án cháldrenK BMg Clán bvád OMNN; OMNN
san eeerbeek kI ae paar dMI Mulder ggK iongJíerm veníálaíáon íubes: resulís of TOS ánseríáonsK Clán
van aongen qMI senekamp omI tensáng AMI
eí alK
Acuíe oíorrhea án cháldren wáíh íympanosíomy
íubes: prevalence of bacíeráa and váruses án íhe posíJpneumococcal conjugaíe vaccáne eraK medáaír
pírachan aI Clarke pbI bngland ogK qhe effecíáveness of íopácal íreaímení án dáschargáng ears wáíh ánJ
saále iI tálláamson qI taddell AI qaylor dK Iníerveníáons for ear dáscharge assocáaíed wáíh
grommeís Eveníálaíáon íubesFK Cochrane aaíabase pysí oev OMMS; EOF: CaMMNVPPK
aohar gI dáles tI ooland mI
eí alK
qopácal cáprofloxacánLdexameíhasone superáor ío oral
amoxácállánLclavulanác acád án acuíe oíáíás medáa wáíh oíorrhea íhrough íympanosíomy íubesK medáaírács
eong eoI hám qpI Chung gtK iongJíerm followJup of oíáíás medáa wáíh effusáon án cháldren:
comparásons beíween a veníálaíáon íube group and a nonJveníálaíáon íube groupK Iní g medáaír
líorhánolaryngol OMN4; TUESF: VPUJ4PK
hoc AI rnerá CK pex dásírábuíáon án cháldren wáíh íympanosclerosás afíer ánseríáon of a íympanosíomy
ae Beer BAI pchálder AdI Záelhuás dAI draamans hK kaíural course of íympanác membrane
paíhology relaíed ío oíáíás medáa and veníálaíáon íubes beíween ages U and NU yearsK líol keuroíol
CayeJqhomasen mI píangerup pbI gørgensen dI
eí alK
Myrángoíomy
veníálaíáon íubes án
secreíory oíáíás medáa: eardrum paíhologyI hearángI and eusíacháan íube funcíáon OR years afíer
Mohammed eI MaríánezJaevesa mK Complácaíáons of longJíerm veníálaíáon íubesK g iaryngol líol
lDkáel MBI Cassády iaI iánk qoI herschner gbK qrackáng íympanosíomy íube ouícomes án pedáaírác
paíáenís wáíh oíáíás medáa usáng an elecíronác daíabaseK Iní g medáaír líorhánolaryngol OMNR; TVEUF:
ppáelmann mMI Mchee eI Adamson oMI
eí alK
collow up afíer máddleJear veníálaíáon íube ánseríáon:
Moualed aI Masíerson iI humar pI aonnelly kK taíer precauíáons for preveníáon of ánfecíáon án
eeberí oi III háng dbI Bení gm IIIK qympanosíomy íubes and waíer exposure: a pracíácal modelK Arch
Coníemporary Managemení of Cháldren wáíh
aeparímení of purgeryI aávásáon of líolaryngologyI háng cahad ppecáalásí eospáíalI aammamI
aávásáon of líorhánolaryngology eead C keck surgeryI rnáversáíy of MonírealI líology and
keuroíologyI paáníeJgusíáne rnáversáíy eospáíal Ceníer ECerpgF and rnáversáíy of Moníreal
Absírací:
eearáng loss has a ságnáfácaní ámpací on cháldren’s abáláíy ío develop
adequaíe language and communácaíáon skálls and ofíen áníerferes wáíh educaíáonal
performance as well as lámáís longJíerm employmení opporíunáíáesK eearáng loss ás
caíegorázed ánío íhree broad caíegoráes: ConducíáveI pensoráneuralI and MáxedK
Audáology workup aáms ío ádeníáfy íhe caíegory and íhe level of hearáng loss;
evaluaíáon ás dáváded ánío subjecíáve and objecíáve íesísK oehabáláíaíáon ás avaálable ío
almosí all kánds and degrees of hearáng loss áf dáagnosed and managed án a íámely
mannerK cor íhaíI we need ío áncrease íhe awareness of íhe famáláes and healíh care
prováders as well abouí íhe screenáng programs and advocaíe áís ámplemeníaíáon án all
maíernáíy and cháld care ceníersK In íhás chapíerI we dáscuss acquáred and congenáíal
causes of hearáng lossK te wáll also address íhe dáagnosíác workupI and fánally wáll
heywords:
Cochlear ámplaníI CongenáíalI deneíácsI eearáng aádsI eearáng lossI
medáaírác hearáng loss ás íhe mosí common sensory defácáí wáíh an esíámaíed
áncádence of NJ4 per NMMM newborns [
I
zK ClánácallyI OM dB ei án boíh ears ás
consádered íhe normal hearáng íhreshold for cháldrenI adolescenísI and adulís [
Any áncrease án íhe íhreshold level ás regarded as hearáng loss and ás classáfáed
accordáng ío specáfáed degrees of áncrease E
máld EOM ío 4M dB eiFI moderaíe
E4Nío RR dB eiFI moderaíely severe ERS ío TM dB eiFI severe ETN ío VMdB eiF
Correspondáng auíhor Issam palába
: aeparímení of líolaryngologyI paáníeJgusíáne rnáversáíy eospáíal Ceníer
ECer pgFI PNTRI Côíe paáníeJCaíheráneI Moníreal EnCF ePq NCRI Canada; qel: ERN4F RMTJTTOO; cax: ERN4F RMTJVMN4;
has esíámaíed íhaí abouí “PSM málláon people worldwáde have dásabláng hearáng
eearáng loss has a ságnáfácaní ámpací on cháldren’s abáláíy ío develop adequaíe
language and communácaíáon skálls [
I
z; and ofíen áníerferes wáíh educaíáonal
performance as well as lámáís longJíerm employmení opporíunáíáes [
zK qhás
ámpací can be reduced by early dáagnosás íhrough neonaíal hearáng screenáng
programs and cháldcare clánácsI as well as provádáng adequaíe educaíáonal and
Cháldren dáagnosed as clánácally deaf have no or very láííle hearángI do noí
develop normal speechI and have no oíher recourse buí ío use ságn language for
communácaíáonK qhey may howeverI benefáí from cochlear ámplanís and develop
varáably normal speech áf ámplaníed duráng íhe speech developmení peráodI whách
ás roughly before íhe age of fáve years [
zK eoweverI “hard of hearáng” cháldren
who suffer from máld ío severe bálaíeral hearáng loss develop spoken language
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also address íhe dáagnosíác workupI and fánally wáll dáscuss án deíaál íhe recení
eearáng loss ás caused by dáfferení eíáologáes affecíáng íhe exíernalI íhe máddle or
íhe ánner ear íhus obsírucíáng or damagáng a parí of íhe audáíory sysíemK qhe
dáfferení íypes of hearáng loss are caíegorázed ánío íhree broad caíegoráes:
ConducíáveI pensoráneuralI and MáxedK
Conducíáve hearáng loss refers ío an ámpaármení of íhe conducíáve parí E
exíernal and máddle earsF of íhe audáíory sysíem án whách íhe ánner ear ás usually
normalI buí aár conducíed sound ás ánadequaíely delávered or preveníed from
reacháng íhe sensoráneural apparaíus of íhe ánner ear án a normal wayK Alíhough
sensáíáváíy ío sound ás dámánáshedI áí may be percepíáble áf produced aí a suffácáení
In íhás form of hearáng lossI íhe bone conducíáon íhreshold ás normal Eless íhan OM
dB eiF whále íhe aár conducíáon íhreshold ás áncreased resulíáng án whaí ás called
an aárLbone gap EABdFK By defánáíáonI an ABd of more íhan NR dB ei averaged
pensoráneural hearáng loss ás assocáaíed wáíh a paíhologácal changeI damageI or
dysfuncíáon án íhe sírucíures wáíhán íhe ánner ear or án íhe cochlear nerveK then
íhe neural elemenís ánvolved án íhe conducíáon or áníerpreíaíáon of nerve ámpulses
orágánaíáng án íhe cochlea are damaged or are dysfuncíáonalI íhen eáíher íhe
percepíáon or íhe áníerpreíaíáon of sound ás ámpaáredK qhe pure íone audáomeíry
shows an áncrease of aár and bone conducíáons íhresholds Emore íhan OM dB eiFI
howeverI íhe ABd ás less íhan NR dB ei [
zK pensoráneural hearáng loss may
Ceníral hearáng loss Ea rare occurrence of sensoráneuralF ás a resulí of a
Máxed hearáng loss refers ío hearáng loss of a máxed naíureI conducíáve and
sensoráneuralK ln pure íone audáomeíryI aár and bone conducíáon íhresholds are
pome forms of hearáng loss may follow ceríaán paííern accordáng ío íhe ánvolved
frequencáesI such as low frequencáes hearáng loss Eaffecíáng selecíávely
frequencáes less íhan RMM ezFI mád frequencáes or rJshaped hearáng loss Efrom
RMM ío OMMM ezF and eágh frequencáes or slopáng hearáng loss Efrequencáes OMMMJ
curíhermoreI hearáng loss can be defáned as íemporary or permaneníK qemporary
hearáng loss ás mosí commonly of íhe conducíáve íype Ealíhough noí alwaysFI for
exampleI oíáíás medáa wáíh effusáon and oíosclerosásI whách can be reversed
sponíaneouslyI medácally or by surgácal managemeníK mermanení hearáng loss on
saráous forms of hearáng loss can be bálaíeral or unálaíeral Easymmeírácal hearáng
lossF affecíáng only one earK píudáes regardáng Audáomeírác Asymmeírác hearáng
loss defáne áí as a dáfference of NR dB ei or more án aí leasí íwo frequencáes wáíh
cánallyI hearáng loss can be descrábed as progressáve áf íhe hearáng íhreshold
deíeráoraíes by greaíer íhan NR dB ei wáíhán a NMJyear peráod [
ABo íesí íhe audáíory response ío an exíernal audáíory síámulusK oesulís are
ploííed as waveforms represeníáng íhe acíáon poíeníáals generaíed by íhe cochlear
nerve up ío íhe hágher braán audáíory ceníers EcágK
F [
I
zK cáve waveforms are
descrábed as early responses represeníáng íhe audáíory paíhway and áí correlaíes
lAb are produced by íhe coníracíále ouíer haár cells of íhe ánner earK mosáíáve
lAb íesí ándácaíes a hearáng level beííer íhan PM dB ei [
J
zK lAb are mosí
commonly used nowadaysI among oíher ándácaíáonsI as a neonaíal hearángJ
screenáng íesí for newborns [
qympanomeíry coníánuously records íhe máddle ear ámpedance by modulaíáng
íhe aár pressure án íhe sealed exíernal audáíory canal [
I
zK qhree fándáng
Acousíác reflexes: measuremení of íhe coníracíáons of íhe síapedáus muscle án
response ío hágh áníensáíy volumeI more íhan UM dB eiK Ií ás useful án locaíáng
sáíe of paíhology along íhe audáíory paíhway from íhe máddle ear ío íhe
audáíory braánsíemK
mure qone Audáomeíry
measures íhe hearáng sensáíáváíy aí ocíave frequencáes
from ORM ez ío UMMM ezK Ií ás íhe mosí commonly used íesí ío evaluaíe hearáng
íhresholdK An example of bloííed audáogram resulí ás shown án cágK E
FK qhás íesí
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requáres cooperaíáon of íhe cháldI whách ás dáffáculí án young cháldrenK poI
accordáng ío íhe age of íhe cháldI modáfáed forms are used ío evaluaíe hás hearáng
cágK EPFK
bxamples of hearáng loss bloííed on audáogramI A: conducíáve hearáng lossI B: pensoráneural
Behaváoral observaíáonal audáomeíry: for cháldren less íhan S moníhs of
sásual reánforcemení audáomeíry: from S moníhs ío P years of ageK In
cooperaíáve cháldrenI an audáogram can be obíaáned ío deíermáne íhe
hearáng levelK
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mure íone audáomeíry and speech audáomeíry: for cháldren more íhan R
Blo: brancháoJoíoJrenales gik: gervell and iangeJkáelsen MbiAp: Máíochondráal myopaíhyI
encephalopaíhyI lacíác acádosás Mbooc: Myoclonác epálepsy wáíh raggedJred fábers hp: hlánefelíer
Causes of pedáaírác congenáíal hearáng loss fall ánío íwo maán caíegoráes: geneíác
and acquáred EcágK
F [
J
zK Ideníáfyáng íhe cause can be acháeved án more íhan
RMB of íhe casesK mroper dáagnosás can prováde íhe caregáver and íhe cháld’s
famály greaí supporí án plannáng appropráaíe rehabáláíaíáonI and aníácápaíáng íhe
hearáng sense prognosásK Ií ás ámporíaní ío dáffereníáaíe beíween acquáred causes
íhaí occur duráng íhe prenaíal peráod E
as qloCebp ánfecíáonsFI and peránaíal
peráod E
gaundáceI prolonged kICrI
IF from íruly occurráng acquáred
posínaíal causes Esuch as oíáíás medáa wáíh effusáonI írauma and menángáíásF [
Almosí half of íhe congenáíal hearáng loss occurrences án cháldren are acquáred
and may presení wáíh laíe onseí wáíh varyáng degreesI eáíher pre or posí lángual
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qhás classáfácaíáon ás helpful ío reach íhe proper dáagnosásK eowever for
managemení purposesI áí ás noí as much helpful because many of íhose causes can
presení wáíh dáfferení forms of hearáng loss and consequeníly dáfferení íreaímení
zK cor exampleI mendred syndrome Ean auíosomal recessáve syndromác dásease
whách accounís for TKRB of all congenáíal hearáng lossF may presení wáíh varáable
degrees of hearáng loss from máld ío profoundI pre or posí lángually [
zK Anoíher
example ás Cyíomegalovárus ánfecíáonI whách ás íhe mosí common cause of nonJ
geneíác sensoráneural hearáng loss [
zK lnly NMB are sympíomaíác aí báríh whále
íhe majoráíy of ánfecíed cháldren presení wáíh laíe onseí máld ío profoundI
unálaíeral or bálaíeral and preJ or posílángual hearáng loss [
zK ConsequenílyI
when íreaíáng a hearángJámpaáred cháldI áí ás wáse ío consáder íhe íype and degree
of hearáng loss raíher íhan íhe causeK eoweverI íhe eíáologácal workup provádes as
subsíaníáal role án preveníáve managemení such as án cháldren wáíh enlarged
vesíábular aqueducí EbsAFK lnce íhe dáagnosás ás made by hágh resoluíáon Cq
scan Emádpoání dáameíer more íhan NKR mmFI parenís are advásed ío keep íhe cháld
away from coníací sporís because any head írauma mághí exacerbaíe íhe degree of
eearáng rehabáláíaíáon ás dependení on íhe severáíy and íype of hearáng loss raíher
íhan íhe eíáologyK qhe mosí common scenaráo án profoundly deaf cháldren ás when
parenís seek medácal adváce aí approxámaíely P ío S moníhs of age because íhe
cháld ás noí respondáng ío sounds síámuláK In málder forms or progressáve forms of
hearáng lossI dáagnosás mághí be delayed beyond íhaíK MoreoverI áí ás noí
uncommon ío dáagnose unálaíeral forms of hearáng loss aí íoddler’s age because
cor íhe cháld ío develop normal speech áí ás ámporíaní ío have a normal or near
normal audáíory síámulaíáon duráng íhe fársí R years of ageI whách ás íhe speech
acquásáíáon peráodK MoreoverI Cháldren wáíh profound sensoráneural hearáng loss
have íhe maxámum benefáí áf íhey were rehabáláíaíed duráng íhe fársí O4 moníhs of
Conducíáve hearáng loss due ío oíáíás medáa wáíh effusáonI for exampleI can be
correcíed eáíher medácally EAníábáoíács HLJ coríácoíherapyF or surgácally
Eíransíympanác veníálaíáon íubes HLJ adenoádecíomyF [
zK líher causesI such as
juvenále oíosclerosás are correcíable surgácally by síapedecíomy [
zK bxíernal
audáíory canal EbACF aíresáa íradáíáonally ás managed surgácally by reJpermeaíáng
íhe bACK eoweverI receníly íhe rehabáláíaíáon may also be acháeved surgácally by
In cases where medácal of surgácal rehabáláíaíáon ás noí possábleI hearáng
resíoraíáon can be acháeved íhrough íhree mechanásms:
Acousíácal síámulaíáon: eearáng aádsI a medácal deváce íhaí delávers ampláfáed
acousíác ságnal ío íhe earI represení íhás mode of síámulaíáonK Ií ás íhe mosí
common mode of hearáng rehabáláíaíáon [
zK Ií works by ampláfyáng acousíác
ságnals íhrough aár conducíáon paíhwayK oecení model of hearáng aáds are
powerful enough ío fáí for wáde range of hearáng loss up ío severe degreeK
eowever áí has some lámáíaíáons such as: anaíomácal abnormaláíy EbAC aíresáaFI
ánfecíáons Echronác oíorrheaFI skán dásorders EbAC eczemaF and profound
sensoráneural hearáng lossK
Many síyles of hearáng aáds are avaálable and íhe choáce of one síyle over anoíher
Cháldren who presení wáíh unálaíeral hearáng loss Esángle sáded deafnessF may be
aáded íhrough coníralaíeral rouíáng of ságnal EColpF ampláfácaíáonK In íhás síyleI
íhe cháld wears íwo hearáng aáds; íhe sound ságnal ás receáved íhrough íhe hearáng
Basác componenís of mosí hearáng aáds ánclude: a mácrophoneI an ampláfáerI a
receáverI baííeryI volume conírol and onJoff swáích EcágK
FK qhe role of each
qhás mode of rehabáláíaíáon uses íhe bone conducíáon paíhway for hearáng
resíoraíáonK In cases where acousíác síámulaíáon Ehearáng aádsF ás noí appropráaíeI
qhe BoneJAnchored eearáng Aáds are prosíheses ámplaníed surgácally án íhe
íemporal bone íhaí allow for íhe íransmássáon of sound waves ío íhe ápsálaíeral
cochlea íhrough dárecí bone conducíáonK Anoíher mechanásm of hearáng
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resíoraíáon án paíáenís wáíh sángle sáded deafness ás íhrough sound íransfer ío a
normal coníralaíeral cochlea across íhe skull [
zK eoweverI án young cháldrenI
where íhe íemporal bone íháckness ás less íhan P mmI áí ás surgácally
coníraándácaíed due ío íechnácal dáffáculíáesK AlíernaíávelyI áí can be aííached over
a headband uníál íhe age of 4 ío R yearsK Indácaíáon for mechanácal síámulaíáon
áncludes sángle sáded deafnessI máld ío severe conducíáve or máxed hearáng lossI
Also referred ío as Báonác ear EBáonác beáng defáned as applácaíáon of íechnology
and engáneeráng ío báologácal sysíemFK Cochlear ámplaní ás an elecíronác deváce
íhaí íransmáís sound ío íhe ceníral audáíory sysíem Ecochlear nerveF by passáng íhe
exíernalLmáddle and ánner ears EcágK
F [
zK qhás makes áí dáfferení from hearáng
aádsI whách sámply ampláfáes íhe sound ságnal reacháng íhe ánner ear íhrough
exíernal audáíory canal and máddle earsK AddáíáonallyI cochlear ámplaní ás
composed of íwo parísI one ás surgácally ámplaníed under íhe skán and íhe oíher ás
In recení yearsI íhe number of cháldren receáváng cochlear ámplaní for profound
sensoráneural hearáng loss has ságnáfácaníly áncreasedK qhe ámplemeníaíáon of
neonaíal hearáng screenáng programs has led ío a very early dáagnosás of hearáng
loss and consequeníly earláer age of ámplaníaíáonK qhe encouragáng resulísI
coníánuous íechnology ámprovemení and áncreased awareness of áís safeíy have
resulíed án global áncrease án cochlear ámplaní recápáenís [
I
zK qhere has been
a loí of research on íhe advaníages of early ámplaníaíáon suggesíáng íhaí cháldren
receáváng cochlear ámplaní before íhe age of íwo may caích up wáíh íheár normal
Ií was developed án íhe NVTMsI ánáíáally for paíáení wáíh neurofábromaíosás íype OK
qhe ándácaíáons of ABI are expanded ío cháldren who are noí candádaíes of
cochlear ámplanís due cochlear agenesásI labyráníháíás ossáfácans or cochlear nerve
agenesásK Alíhough íhe resulís are less specíacular compared ío cochlear ámplanísI
eearáng loss has a ságnáfácaní ámpací on íhe cháld and hás famályK Ií lámáís íhe
normal acquásáíáon of speech and áníerferes wáíh íhe cháld educaíáonal
performanceK oehabáláíaíáon ás avaálable ío almosí all kánds and degrees of hearáng
loss áf dáagnosed and managed án a íámely mannerK cor íhaíI we need ío áncrease
te acknowledge ar qagrád Alrashádá for her conírábuíáon ío íhás chapíer by
provádáng íhe drawángs
pmáíh ogI Bale gcI tháíe hoK pensoráneural hearáng loss án cháldrenK ianceí iond bngl OMMR;
aavás ACK qhe prevalence of hearáng ámpaármení and reporíed hearáng dásabáláíy among adulís án
tel | aeafness and hearáng loss [IníerneízK telK Avaálable from:
I [cáíed OMNS Apr NUz;
iescanne bI Al Zahraná MI Bakhos aI oobáer AI Moránáère pK oevásáon surgeráes and medácal
áníerveníáons án young cochlear ámplaní recápáenísK Iní g medáaír líorhánolaryngol OMNN; TRENMF: NOONJ
qharpe AMI dusíafson pK Managemení of Cháldren wáíh MáldI ModeraíeI and Moderaíely pevere
haíbamna BI Crumpíon qI maíel aoK eearáng ámpaármení án cháldrenK medáaír Clán koríh Am OMMU;
Iselá CI Buchman CAK Managemení of Cháldren wáíh pevereI pevereJprofoundI and mrofound
pensoráneural eearáng iossK líolaryngol Clán koríh Am OMNR; 4UESF: VVRJNMNMK
[Uzhaíz gK eandbook of Clánácal AudáologyK Tíh edKI mháladelpháa: tolíers hluwer eealíh OMNRK
Audáíory Braánsíem oesponse Audáomeíry I OMNP kov T; [cáíed OMN4 pep NMz; Avaálable from:
eall gtI Mueller edK Audáologásís’ aesk oeference A pángular Audáology qexíK pan aáego: pángular
hemp aqK líoacousíác emássáonsI íheár orágán án cochlear funcíáonI and useK Br Med Bull OMMO; SP:
líoacousíác bmássáons I OMNO gun NT; [cáíed OMN4 pep NMz; Avaálable from:
ColellaJpaníos McI eeán qAaI de pouza diI do Amaral MIoI Casalá oiK kewborn hearáng screenáng
gr gBI tackym mAK Ballenger’s líorhánolaryngology eead and keck purgeryK NTíh edáíáonKI phelíonI
Alzahraná MI qabeí mI palába IK medáaírác hearáng loss: common causesI dáagnosás and íherapeuíác
Cummángs líolaryngology J eead and keck purgeryK PJsolume peí: bxperí Consulí: lnláne and
iammens cI serhaerí kI aevráendí hI aebruyne cI aesloovere CK Aeíáology of congenáíal hearáng
[NUzMoríon kbK deneíác epádemáology of hearáng ámpaármeníK Ann k v Acad pcá NVVN; SPM: NSJPNK
[NVzoeardon tK deneíác deafnessK g Med deneí NVVO; OVEUF: RONJSK
oehm eiK A geneíác approach ío íhe cháld wáíh sensoráneural hearáng lossK pemán meránaíol OMMR;
pchrájver IK eeredáíary nonJsyndromác sensoráneural hearáng loss: íransformáng sálence ío soundK g Mol
pmáíh ogI phearer AbI eáldebrand MpI san Camp dK aeafness and eeredáíary eearáng ioss
lverváewK In: magon oAI Adam MmI Ardánger eeI Bárd qaI aolan CoI cong CJqI bdsK
ae ieenheer bMI ganssens pI madalko bI ioose aI ieroy BmI ahooge IgK bíáologácal dáagnosás án íhe
euang BvI Zdanská CI Casíállo MK medáaírác sensoráneural hearáng lossI parí N: mracíácal aspecís for
euang BvI Zdanská CI Casíállo MK medáaírác sensoráneural hearáng lossI parí O: syndromác and
[OSzhenna MAK Acquáred eearáng ioss án CháldrenK líolaryngol Clán koríh Am OMNR; 4UESF: VPPJRPK
phaukaí pI caíáma ZI Zehra rI taqar ABK pyndromác and nonJsyndromác deafnessI molecular aspecís
of mendred syndrome and áís reporíed muíaíáonsK g Ayub Med Coll Abboííabad gAMC OMMP; NREPF:
medáaírác Cyíomegalovárus Infecíáon I OMNP ceb NV; [cáíed OMN4 Aug NUz; Avaálable from:
henneson AI Cannon MgK oeváew and meíaJanalysás of íhe epádemáology of congenáíal
cyíomegalovárus ECMsF ánfecíáonK oev Med sárol OMMT; NTE4F: ORPJTSK
palába II dángrasJCharland MJbI píJCyr hI aécaráe gJCK Coronal Cq scan measuremenís and hearáng
evoluíáon án enlarged vesíábular aqueducí syndromeK Iní g medáaír líorhánolaryngol OMNO; TSE4F: 4VOJ
dopen nI Zhou dI tháííemore hI henna MK bnlarged vesíábular aqueducí: reváew of coníroversáal
MayJMederake BI huehn eI sogel AI heálmann AI Bohnerí AI Mueller pI
eí alK
bvaluaíáon of
audáíory developmení án ánfanís and íoddlers who receáved cochlear ámplanís under íhe age of O4
moníhs wáíh íhe iáíílbAopF Audáíory nuesíáonnaáreK Iní g medáaír líorhánolaryngol OMNM; T4ENMF:
hosaner gI ponuguler pI llgun iI Amann bK voung cochlear ámplaní users’ audáíory developmení as
measured and monáíored by íhe iáíílbAop® Audáíory nuesíáonnaáre: a qurkásh experáenceK Iní g
oosenfeld oMI phán ggI pchwaríz poI Coggáns oI dagnon iI eackell gMI
eí alK
Clánácal mracíáce
duádeláne: líáíás Medáa wáíh bffusáon bxecuíáve pummary ErpdaíeFK líolaryngolJJeead keck purg
sáncení oI tegner II sonck BMI Báííermann AgI hamalská aMI drolman tK mrámary síapedoíomy án
cháldren wáíh oíosclerosás: A prospecíáve síudy of 4N consecuíáve casesK iaryngoscope OMNS; NOSEOF:
palába II croehlách mI Bouhabel pK lneJsíage
K íwoJsíage BAeA ámplaníaíáon án a pedáaírác
populaíáonK Iní g medáaír líorhánolaryngol OMNO; TSENOF: NUN4JUK
palába II toods lI Caron CK BAeA resulís án cháldren aí one year followJup: a prospecíáve
longáíudánal síudyK Iní g medáaír líorhánolaryngol OMNM; T4EVF: NMRUJSOK
Bouhabel pI Arcand mI palába IK Congenáíal aural aíresáa: boneJanchored hearáng aád
K exíernal
gohnson CbI aanhauer giI bllás BBI gálla AMK eearáng Aád Benefáí án maíáenís wáíh Máld
pensoráneural eearáng ioss: A pysíemaíác oeváewK g Am Acad Audáol OMNS; OTE4F: OVPJPNMK
eol MhI hunsí pgI pnák AcI Cremers CtK máloí síudy on íhe effecíáveness of íhe conveníáonal ColpI
íhe íranscranáal Colp and íhe BAeA íranscranáal Colp án adulís wáíh unálaíeral ánner ear deafnessK
bur Arch líoJohánoJiaryngol lff g bur ced líoJohánoJiaryngol poc brclp Affál der poc líoJ
eol MhI kelássen oCI Agíerberg MgI Cremers CtI pnák AcK Comparáson beíween a new ámplaníable
íranscuíaneous bone conducíor and percuíaneous boneJconducíáon hearáng ámplaníK líol keuroíol lff
Colquáíí giI ioveman bI Baguley aMI Máíchell qbI pheehan mZI earrás mI
eí alK
hearáng aáds for people wáíh bálaíeral hearáng ámpaármení: a sysíemaíác reváewK Clán líolaryngol lff g
phán gJtI hám peI Choá gvI mark eJgI iee pJCI Choá gJpI
eí alK
purgácal and Audáologác Comparáson
Beíween pophono and BoneJAnchored eearáng Aáds ImplaníaíáonK Clán bxp líorhánolaryngol OMNS;
corlá cI Arslan bI Bellellá pI Burdo pI Mancáná mI Maríáná AI
eí alK
pysíemaíác reváew of íhe láíeraíure
on íhe clánácal effecíáveness of íhe cochlear ámplaní procedure án paedáaírác paíáenísK Acía
líorhánolaryngol Iíal OMNN; PNERF: OUNJVUK
slasíarakos msI mroákas hI mapacharalampous dI bxadakíylou II Mochloulás dI kákolopoulos qmK
Cochlear ámplaníaíáon under íhe fársí year of ageJJíhe ouícomesK A cráíácal sysíemaíác reváew and
qomblán gBI Barker BAI ppencer igI Zhang uI daníz BgK qhe effecí of age aí cochlear ámplaní ánáíáal
síámulaíáon on expressáve language growíh án ánfanís and íoddlersK g ppeech iang eear oes OMMR;
phah msI hozán baI haplan ABI iee agK medáaírác Audáíory Braánsíem Implaní purgery: A kew
lpíáon for Audáíory eabáláíaíáon án Congenáíal aeafness? g Am Board cam Med gABcM OMNS; OVEOF:
Absírací:
An undersíandáng of íhe anaíomy and physáology of taldeyer’s íonsállar
ráng ás ámporíaní ío learnáng as how ío dáagnose and íreaí dáseases án íhe upper
aerodágesíáve íracíK qhe physácáan should have an undersíandáng of íhe many dásease
processes íhaí can affecí íhás regáon and how ío íreaí íhemK qhe clánácáan should be
aware of íhe possáble complácaíáons of dáseases án taldeyer’s ráng and íhe common
preseníaíáons so íhese can be recognázed and ámmedáaíe íreaímení can be ánáíáaíedK qhe
physácáan should be knowledgeable of íhe currení ándácaíáons for íonsállecíomy and
adenoádecíomy and be aware of íhe poíeníáal complácaíáons duráng íhe posíoperaíáve
heywords:
AdenoádecíomyI AdenoádsI Clánácal guádelánesI konsuppuraíáve
complácaíáonsI malaíáne íonsálsI mharyngáíásI mosíJíonsállecíomy hemorrhageI
Infecíáous and ánflammaíory dáseases of íhe pharynxI íonsálsI and adenoáds make
up a large poríáon of cháldhood állnesses and healíh care expendáíures resulíáng án
íwo of íhe mosí common pedáaírác surgácal procedures íoday án íhe rnáíed píaíesI
íonsállecíomy and adenoádecíomyK qhe mosí common ándácaíáons for
adenoíonsállecíomy or íonsállecíomy curreníly are obsírucíáve sleep apnea
followed by recurrení íonsálláíásK In íhás chapíerI we wáll reváew pharyngáíás and
adenoíonsállar dásease processesK te wáll reváew currení guádelánes ío help ensure
appropráaíe referral ío specáalásísK cánallyI we wáll reváew some páífalls án íakáng
care of cháldren wáíh íonsállar dásease as well as some pearls for íhose who need
qhe palaíáne íonsáls laíerallyI íhe lángual íonsáls aníeráorlyI and íhe pharyngeal
Correspondáng auíhor earold máne
: aeparímení of líolaryngologyI rnáversáíy of qexas Medácal BranchI
dalvesíonI quI rpA; qel: 4MVJTTOJOTMN; cax: 4MSJTTOJNTNR; bJmaál:
a ráng of lymphoád íássue around íhe upper parí of íhe pharynx known as
taldeyer’s íonsállar ráng whách ás állusíraíed án cágK E
FK All íhree of íhe
aforemeníáoned sírucíures án taldeyer’s íonsállar ráng have sámálar hásíologyI
qhe palaíáne íonsáls are íhe largesí accumulaíáons of íássue and íhe only sírucíure
án íhás ráng wáíh a capsuleK qhe palaíáne íonsál ás more compací íhan íhe oíher
sírucíures and consásís of íonsállar crypísI whách are blánd íubules láned wáíh
síraíáfáed squamous epáíheláum íhaí exíend deep ánío áís core [
zK qhe crypís are
deságned ío maxámáze exposure ío surface aníágenI buí íhey can also hold debrás
and bacíeráa causáng recurrení ánfecíáons [
zK qhe fábrous capsuleI whách ás a
specáalázed poríáon of íhe pharyngobasálar fascáaI covers íhe íonsál and forms
sepía exíendáng deep ánío íhe íonsál ío conducí íhe nerves and vessels [
qhereforeI when surgácally excásáng íhe íonsáls from íhe íonsállar fossa án whách
íhey are housedI íhe dássecíáon should occur along íhe loose connecíáve íássue
plane beíween íhe capsule and íhe íonsállar bed sánce íhe capsule ás noí easály
qhe íonsállar fossa consásís of P muscles predománanílyK qhe aníeráor pállar ás
made up of íhe palaíoglossus muscleI íhe posíeráor pállar ás íhe palaíopharyngeal
muscleI and íhe base of íhe fossa ás made up of íhe pharyngeal consírácíorsI
maánly íhe superáor consírácíor muscle [
zK qhe muscular wall of íhe íonsállar bed
ás íhán and ámmedáaíely under ás íhe glossopharyngeal nerve and deeper íhe
neurovascular sírucíures of íhe caroíád sheaíhK dreaí care needs ío be íaken ío
muscular wall and damagáng íhe nerve duráng a íonsállecíomy [
zK bven wáíhouí
acíual damage ío íhe nerveI paíáenís can síáll experáence íransáení loss of íasíe over
íhe posíeráor íhárd of íhe íongue and referred oíalgáa caused by edema afíer a
qhe aríeráal blood supply of íhe palaíáne íonsáls ás prámarály based aí íhe ánferáor
pole and consásís of several branches from íhe exíernal caroíád aríeryK qhe ánferáor
pole ás suppláed by íhe íonsállar and ascendáng palaíáne branches of íhe facáal
aríery and íhe íonsállar branch of íhe dorsal lángual aríeryK qhe superáor pole geís
áís blood supply from íhe ascendáng pharyngeal aríery and íhe palaíáne branches
of íhe maxállary aríeryK qhe maán blood supply however ás íhe íonsállar branch of
íhe facáal aríery [
zK senous blood draáns íhrough a peráíonsállar plexus ánío íhe
lángual and pharyngeal veánsI whách subsequeníly draán ánío íhe áníernal jugular
veán [
zK iymphaíác draánage ás ío íhe superáor deep cervácal and jugular dágasírác
lymph nodesK qhe nerve supply of íhe íonsállar regáon ás prámarály íhrough íhe
íonsállar branches of íhe glossopharyngeal nerve and íhere ás lesser conírábuíáon
qhe adenoáds or pharyngeal íonsáls are locaíed on íhe posíeráor wall of íhe
nasopharynx and íhe lángual íonsáls are locaíed aí íhe base of íhe íongueI síáll
wáíhán íhe ráng of lymphoád íássue íhaí surrounds íhe oropharyngeal openángK qhe
adenoáds and lángual íonsáls are covered by a specáalázedI pseudosíraíáfáedI cáláaíed
columnar epáíheláum íhaí forms plácaíed surface folds sámálar ío íhe íonsállar
crypís ío maxámáze íhe surface area of íhe íássue [
qhe blood supply of íhe adenoáds áncludes íhe ascendáng pharyngeal aríeryI íhe
ascendáng palaíáne aríeryI íhe pharyngeal branch of íhe maxállary aríeryI íhe aríery
of íhe píerygoád canalI and conírábuíáng braches from íhe íonsállar branch of íhe
facáal aríeryK senous draánage ás ío íhe pharyngeal plexus communácaíáng wáíh íhe
píerygoád plexus and all draánáng ánío íhe áníernal jugular and facáal veánsK
iymphaíác draánage ás ío íhe reíropharyngeal and pharyngomaxállary lymph nodes
qhe lymphoád íássue of taldeyer’s íonsállar ráng consásís predománaníly of BJcell
lymphocyíes wáíh some qJcell lymphocyíes and maíure plasma cellsK qhese cells
are found án four dásíáncí zones of íhe adenoáds and íonsálsI íhe reíácular cell
epáíheláumI íhe exírafollácular areaI íhe maníle zone of íhe lymphoád follácleI and
qhe prámary funcíáons of íhese íássues are ánducáng secreíory ámmunáíy and
regulaíáng ámmunoglobulán producíáon [
zK qhás íássue has specáalázed
endoíheláumJcovered channels íhaí facáláíaíe aníágen upíake dárecíly ánío íhe
íássueI sámálar ío meyer paíches án íhe colonK qhe ándependence of íhás sysíem
from íhe lymphaíács offers an advaníage ío dárecíly upíake aárborne aníágensK qhe
locaíáon and exposure aí íhe enírance of upper aerodágesíáve írací allows dárecí
access ío foreágn aníágens maxámázáng íhe developmení of ámmunologác memoryK
qhese íássues hyperírophy duráng áís mosí acíáve síage from íhe ages of 4JNM and
íhen regress afíer puberíyK Along wáíh decreasáng án sázeI íhe íássue síáll has íhe
bsíabláshmení of normal flora án íhe upper respáraíory írací begáns aí báríhK
Around S–U moníhs of ageI
AcíánomycesI cusobacíeráumI and kocardáa
acquáredK pubsequenílyI
BacíeráodesI iepíoírácháaI mropáonábacíeráumI
íake hold as a parí of íhe normal oral flora [
zK Anaerobác and aerobác
bacíeráa boíh exásí as parí of íhe oral flora and án salávaK aependáng on oxygen
conceníraíáon íhroughouí íhe upper respáraíory íracíI íhe raíáo of anaerobác ío
eealíhy cháldren can carry known aerobác paíhogensI
pírepíococcus pneumonáae
was found án NVBI
eaemophálus ánfluenzae
án NPBI group A
RBI and
Moraxella caíarrhalás
án PSB of healíhy cháldrenK qhe amouní of
bacíeráa ás known ío decrease as cháldren age possábly due ío áncreased ámmunáíyK
auráng peráods of váral upper respáraíory írací ánfecíáon compared ío healíhy
peráodsI íhe oral pharyngeal colonázaíáon for gram negaíáve eníerác organásms and
pK Aureus
was found ío be ságnáfácaníly áncreasedK dram negaíáve eníerác bacíeráa
and
pK Aureus
colonázaíáon duráng healíhy peráods varáes from NOJNUB and RJNRB
respecíávely whereas duráng peráods of állnessI íhe perceníages áncrease ío SMB
and 4PBK A sámálar áncrease ás seen án healíhy
dáseased adenoádsK Bacíeráal
culíures showed no growíh of normal flora án mosí healíhy cháldren
4RB showed no growíh án íhe ánfecíed cháldrenK qhe bacíeráa found án íhe
dáseased síaíe were lákely βJlacíamase producers [
pánce healíhy cháldren are known ío carry aerobác paíhogensI bacíeráal culíures
along wáíh clánácal preseníaíáon are necessary ío dáagnose any íype of upper
respáraíory ánfecíáonK
Many organásms can ánfecí íhe sírucíures of taldeyer’s rángK qhese ánclude
aerobác and anaerobác bacíeráaI váruses and fungáK Because of íhe normal floraI
mosí ánfecíáons án íhás area are polymácrobáal [
zK Mosí common cause of
pharyngáíás ás váral and íhe second mosí common cause ás bacíeráal ánfecíáon of
whách íhe predománaní ás droup A βJhemolyíác sírepíococcus EdABepFI whách
qhe added complácaíáon when addressáng polymácrobáal ánfecíáons ás íhaí many
aníámácrobáal resásíaní organásms can aád sensáíáve organásms by secreíáng a
compound ío degrade íhe aníábáoíácK In addáíáonI because some paíáenís are
carráers of paíhogenác bacíeráaI dáagnosás of an ánfecíáon can be dáffáculí even wáíh
lropharyngeal candádáasásI also referred ío as íhrushI usually presenís án
ámmunocompromásed paíáenís or paíáenís íreaíed wáíh a prolonged course of
aníábáoíácsK maíáenís usually presení wáíh wháíe coííageJcheese appearáng plaques
on an eryíhemaíous base íhaí are adherení ío íhe pharyngeal mucosa and cause
bleedáng áf forcábly removedK qreaímení ás usually íopácal nysíaíánI cloírámazole
lozengesI or sysíemác aníáfungals for refracíory cases along wáíh addressáng any
sáral pharyngáíás ás usually máld án preseníaíáon compared ío áís bacíeráal
couníerparíK maíáenís usually presení wáíh a sore íhroaí and dysphagáaK pome may
have a feverK ln physácal exam eryíhema of íhe pharyngeal mucosa and enlarged
íonsáls wáíh no exudaíe are íhe common fándángs [
zK qhe organásms ámplácaíed án
íhás dásease process ánclude adenovárusI rhánovárusI ánfluenza várusI paraánfluenza
bpsíeán Barr sárus EbBsF causes íhe mononucleosás syndromeI whách manáfesís
as hágh feversI general malaáseI lymphadenopaíhyI hepaíosplenomegalyI sore
íhroaíI odynophagáaI and large edemaíous íonsáls íhaí are covered wáíh a grayáshJ
wháíe exudaíe and can compromáse íhe aárwayK meíecháae aí íhe juncíáon of íhe
sofí and hard palaíes ás anoíher classác ságn of bBs ánfecíáon buí noí
paíhognomonác [
zK bBs ás coníracíed íhrough oral coníací [
aáagnosás of bBs ánvolves a compleíe blood couní characíerásíácally showáng
RMB lymphocyíosás wáíh NMB aíypácal lymphocyíes [
zK A Monospoí íesí ás more
sensáíáve and specáfác íhan a heíerophál aníábody íesíI whách can be falsely
a posáíáve resulí wáíhán íhe fársí O weeks and íhaí perceníage goes ío VMB afíer N
moníhK pome pracíáíáoners order bBs sáral Capsád Aníágen EsCAFJIgd and
sCAJIgM íáíersK qhese íesís for bBs aníábodáes are used ío help dáagnose
ánfecíáous mononucleosás áf a person ás sympíomaíác buí has a negaíáve mono íesí
zK qreaímení of bBs ás mosíly supporíáve wáíh áníravenous fluáds and resíK Care
should be íaken ío avoád any excessáve írauma ío íhe abdomen whále
hepaíosplenomegaly may be presení [
zK Aníábáoíács would only needed áf a
secondary bacíeráal ánfecíáon ás suspecíedK Amoxácállán should be avoáded because
a rash could develop even áf no práor ássues when íakáng íhás aníábáoíác [
cánallyI an evaluaíáon of íhe aárway should be underíaken ío make sure no
ságnáfácaní upper aárway obsírucíáon ás preseníK If enlarged íonsáls cause aárway
obsírucíáonI íhen ánáíáal managemení áncludes a course of sysíemác síeroádsK
oarelyI a nasopharyngeal aárwayI nasoíracheal áníubaíáonI or íracheoíomy may be
droup A βJhemolyíác
EdApF ás íhe mosí common paíhogen causáng
acuíe bacíeráal íonsálláíásK qhás ánfecíáon manáfesís wáíh dry sore íhroaíI malaáseI
feverI cervácal lymphadenopaíhyI odynophagáaI dysphagáaI oíalgáaI headacheI and
chálls [
zK ln physácal examI eryíhemaíous enlarged íonsáls wáíh yellowásh spoís
are usually noíed buí severe cases can have a purulení exudaíeK Acuíe
sírepíococcal íonsálláíás ás prámarály a dásease of cháldhoodI mosíly around íhe
ages of RJS buí has been shown ío occur án cháldren under P years old and án íhe
eoweverI how common ás bacíeráal pharyngáíás án íhe many dáfferení causes of
sore íhroaí? Mosí paíáenís who seek medácal aííeníáon for sore íhroaí are
concerned abouí sírepíococcal íonsállopharyngáíásI buí fewer íhan NMB of adulís
and PMB of cháldren acíually have a sírepíococcal ánfecíáonK droup A beíaJ
hemolyíác sírepíococcá EdApF are mosí ofíen responsáble for bacíeráal
íonsállopharyngáíásI alíhough keásseráa gonorrheaI Arcanobacíeráum
haemolyíácum Eformerly Corynebacíeráum haemolyíácumFI Chlamydáa
pneumonáae EqtAo ageníFI and Mycoplasma pneumonáae have also been
suggesíed as possábleI ánfrequeníI sporadác paíhogensK sáruses or ádáopaíhác
causes accouní for íhe remaánder of sore íhroaí complaánís [
qhe clánácal ámporíance of íhás ánfecíáon ás noí only íhe frequency of íhe ánfecíáon
whách ás íhe basás of íhe maradáse cráíeráa whách guádes clánácáans ío proceed wáíh
surgácal managemení buí also as íhe precursor of íwo seráous sequelaeI acuíe
aáagnosás of acuíe sírepíococcal íonsálláíás ás usually made afíer a clánácal examK
eoweverI dásíánguásháng beíween sírepíococcal and nonsírepíococcal pharyngáíás
ás dáffáculí wáíh jusí clánácal parameíersK qhereforeI íhe gold síandard for
dáagnosíác confármaíáon of sírepíococcal pharyngáíás ás a íhroaí culíureK eowever
íhe downsáde of a íhroaí culíure ás íhe lengíh of íáme ío geí resulís whách can be
anywhere from NUJ4U hours delayáng íreaímení and áncreasáng íhe íáme cháldren
have ío be kepí ouí of school or oíher acíáváíáes and can spread íhe ánfecíáon ío
oíhers [
zK cor íhás reasonI many rapád íesís based on biIpA EenzymeJlánked
ámmunosorbení assayF or laíex aggluíánaíáon have been developed ío deíecí íhe
sírepíococcal aníágenK qhese íesís can be conducíed án íhe offáce or hospáíal
seííáng wáíh resulís avaálable án mánuíes allowáng íreaímení ío be síaríed
ámmedáaíelyK qhe rapád sírep íesíI íhough hághly specáfácI ás noí as sensáíáve as a
íhroaí culíureK qhe accepíed clánácal síandard when a cháld wáíh hágh suspácáon for
acuíe sírepíococcal íonsálláíás presenís ás ío employ íhe rapád sírep íesí and áf
found negaíáve buí suspácáon ás síáll hághI íhen ío proceed wáíh a íhroaí culíure [
aaía from numerous publáshed síudáes án whách a hághJsensáíáváíy aníágen íesí
Erapád sírep íesíF were evaluaíed agaánsí a varáeíy of gold síandardsI íhe sensáíáváíy
and specáfácáíy of íhe hághJsensáíáváíy aníágen íesí were VRB and UVKNBI
respecíávely whách leads ío íhe possábáláíy of a false negaíáve íesíK qhereforeI án
íhese casesI a íhroaí culíure ás doneK qhe sensáíáváíy and specáfácáíy of blood agar
qreaímení ás usually wáíh penácállán; however áf no response ás evádení án 4U
hoursI íhen βJlacíamaseJproducáng organásms should be suspecíed and íherapy
changed ío amoxácállán wáíh clavulanác acádI a βJlacíamase ánhábáíorK Anoíher
alíernaíáve could be clándamycánK cor penácállán allergác paíáenísI a suáíable
alíernaíáve ás eryíhromycánK qhe use of aníábáoíács shoríens íhe course of íhe
állness buí also more ámporíaníly mánámázes íhe chance of suppuraíáve
complácaíáons and developáng acuíe rheumaíác fever [
zK pchwaríz and colleagues
demonsíraíed íhaí a full NM days of íherapy as opposed ío T days have lower
kormallyI íhe coníenís of íhe íonsállar crypís draán ánío íhe oral caváíyI buí án deep
or síenoíác crypísI reíaáned maíeráal and bacíeráal growíh can síagnaíe developáng
ánío concreíáons even áf íhe paíáení does noí have a hásíory of ánfecíáons án íhe
adenoáds or íonsálsK maíáenís wáíh í
can presení wáíh haláíosás or sore
íhroaí wáíh wháíáshI expressábleI foul íasíáng and smelláng concreíáonsK
Managemení of íhás condáíáon ánáíáally begáns wáíh oral hygáene and aííempís ío
clean íhe íonsáls wáíh jeís of waíer and progressáon ío sálver náíraíe ío chemácally
cauíeráze and obláíeraíe íhe crypísK eoweverI áf íhe condáíáon persásísI íhen
íonsállecíomy as defánáíáve íherapy ás needed [
suppuraíáveK qhe maán nonsuppuraíáve complácaíáons ánclude scarleí feverI acuíe
rheumaíác feverI and posísírepíococcal glomerulonephráíásK coríunaíelyI íhe use of
aníábáoíács has decreased íhe áncádence of nonsuppuraíáve complácaíáonsK
eoweverI íhe suppuraíáve complácaíáonsI whách are íhe resulí of abscess
formaíáonI are síáll common [
pcarleí fever follows sírepíococcal ánfecíáon and ás a manáfesíaíáon due ío íhe
endoíoxán produced by íhe bacíeráa [
zK pympíoms of scarleí fever may ánclude
sore íhroaíI feverI lymphadenopaíhyI a yellowásh exudaíe coveráng íhe íonsálsI
pharynx and nasopharynxI a dáffuse eryíhemaíous rashI facáal flushI peíecháae án
body foldsI and a red íongue wáíh desquamaíáon of íhe papállaeI referred ío as
sírawberry íongue [
zK aáagnosás ás made by culíure and íhe aáck íesíI whách ás an
áníradermal ánjecíáon of íhe sírepíococcal íoxán [
zK Alíhough scarleí fever ás noí a
severe complácaíáonI ádeníáfácaíáon and íreaímení are necessary ío prevení oíher
Acuíe rheumaíác fever áncádence has decreased án íhe rnáíed píaíes due ío rapád
íreaímení wáíh aníábáoíács of sírepíococcal pharyngáíásI down ío MKPBK qhás állness
usually occurs NU days afíer beáng ánfecíed wáíh group A βJhemolyíác
qhe basás of íhás állness ánvolves sírepíococcal aníábodáes cross
reacíáng wáíh hearí íássue leadáng ío árreversáble damage of all P layersI
perácardáumI myocardáumI and endocardáumK qhe currení accepíed managemení ás
ío place paíáenís on penácállán prophylaxás and undergo íonsállecíomy ío
compleíely elámánaíe íhe reservoár for furíher ánfecíáons [
mosísírepíococcal glomerulonephráíás usually occurs NM days afíer an acuíe
sírepíococcal íonsálláíás or a skán ánfecíáonK An acuíe nephráíác syndrome develops
aí fársí due ío a common aníágen beíween íhe glomerulus and íhe sírepíococcus
bacíeráaK qhe paíhogenác mechanásm ánvolves ánjury ío íhe glomerulus by
deposáíáon of íhe ámmune complexes and cárculaíáng auíoaníábodáes of íhe
sírepíococcal aníágenK qherapy does noí decrease íhe aííack raíe on íhe kádney or
affecí íhe naíural progressáonK qonsállecíomy may be needed ío elámánaíe íhe
source of ánfecíáon compleíely [
cánallyI a dásease has been ádeníáfáed called mAkaAp Epedáaírác auíoámmune
neuropsycháaírác dásorders assocáaíed wáíh sírepíococcal ánfecíáonsFI whách ás a seí
of obsessáveJcompulsáve dásorders ElCasF and íács assocáaíed wáíh an acuíe
sírepíococcal pharyngáíás ánfecíáonK pympíoms ánclude obsessáve íhoughís and
fearsI ráíualásíác compulsáonsI íácsI and anxáeíy dásordersK mAkaAp usually occurs
wáíhán a few weeks of íhe pharyngoíonsállar ánfecíáonK qhe workáng mechanásm ás
a cross reacíáváíy aníásírepíococcal aníábodáes neurons án íhe basal gangláaK
Managemení áncludes aníábáoíács and íonsállecíomyI whách has shown a decrease
meráíonsállar abscesses mosíly occur án paíáenís wáíh recurrení íonsálláíás or chronác
íonsálláíás íhaí has noí been adequaíely íreaíedK qhe bacíeráal ánfecíáon of íhe
íonsáls exíends beyond íhe íonsállar capsule and ánío surroundáng íássues
developáng ánío a peráíonsállar abscess [
zK qhe abscess ás usually unálaíeral and
develops án íhe space beíween íhe íonsállar capsule and íhe pharyngeal muscle bed
causáng íonsállar dásplacemení ío íhe mádláne or beyond and reflecíáon of íhe uvula
íoward íhe opposáíe sáde [
zK qhe manáfesíaíáon of a peráíonsállar abscess
áncludes sore íhroaíI severe írásmusI dysphagáaI odynophagáaI and
lymphadenopaíhy [
zK qhe odynophagáa can subsequeníly cause dehydraíáon and
droolángK qreaímení ás áncásáon and draánage of íhe abscessK qhás can be done on
an awake paíáení wáíh local anesíhesáaK maíáenís usually fánd ámmedáaíe reláef and
reducíáon án sympíoms afíer íhe procedureK A íonsállecíomy or nuánsy
íonsállecíomyI íonsállecíomy performed when íhe paíáení ás acuíely ánfecíedI may
aeep neck ánfecíáons are anoíher complácaíáon assocáaíed wáíh acuíe or chronác
íonsálláíásK eoweverI wáíh íhe wádespread use of aníábáoíácsI íhese complácaíáons
have ságnáfácaníly decreasedK Clánácal preseníaíáons of severe odynophagáaI
írásmusI and shoríness of breaíh should alerí íhe clánácáan ío a possáble deep neck
ánfecíáonK ln examánaíáonI íhere may be asymmeírác pharyngeal swelláng
exíendáng more ánferáorly íhan íhe íonsállar regáon ánío íhe hypopharynxK
aefánáíáve dáagnosás ás made by compuíed íomography ECqF scan of íhe neck wáíh
conírasíK Managemení áncludes conírol of íhe aárway áf neededI áníravenous
aníábáoíácsI and surgácal draánage of íhe abscess [
qhe Amerácan Academy of líolaryngologyJeead and keck purgery EAAlJekpF
have released evádenceJbased recommendaíáons on íhe preoperaíáveI
áníraoperaíáveI and posíoperaíáve care and managemení of cháldren N ío NU years
old under consáderaíáon for íonsállecíomyK qhe prámary purpose of íhe guádelánes
ás ío prováde clánácáans wáíh evádenceJbased guádance án ádeníáfyáng cháldren who
are íhe besí candádaíes for íonsállecíomyK pecondary objecíáves are ío opíámáze íhe
peráoperaíáve managemení of cháldren undergoáng íonsállecíomyI emphasáze íhe
need for evaluaíáon and áníerveníáon án specáal populaíáonsI ámprove counseláng
and educaíáon of famáláes of cháldren who are consáderáng íonsállecíomy for íheár
cháldI hághlághí íhe managemení opíáons for paíáenís wáíh modáfyáng facíorsI and
qhe followáng síaíemenís were made by íhe panel followed by íheár
píaíemení N – taíchful waáíáng for recurrení íhroaí ánfecíáon: Clánácáans should
recommend waíchful waáíáng for recurrení íhroaí ánfecíáon áf íhere have been
fewer íhan T epásodes án íhe pasí year or fewer íhan R epásodes per year án íhe pasí
O years or fewer íhan P epásodes per year án íhe pasí P yearsK –
píaíemení O – oecurrení íhroaí ánfecíáon wáíh documeníaíáon: Clánácáans may
recommend íonsállecíomy for recurrení íhroaí ánfecíáon wáíh a frequency of aí
leasí T epásodes án íhe pasí year or aí leasí R epásodes per year for O years or aí
leasí P epásodes per year for P years wáíh documeníaíáon án íhe medácal record for
each epásode of sore íhroaí and one of more of íhe followáng: íemperaíure
>PUKP°CI cervácal adenopaíhyI íonsállar exudaíeI or posáíáve íesí for dABepK –
píaíemení P – qonsállecíomy for recurrení ánfecíáon wáíh modáfyáng facíors:
Clánácáans should assess íhe cháld wáíh recurrení íhroaí ánfecíáon who does noí
meeí cráíeráa án píaíemení O for modáfyáng facíors íhaí may noneíheless favor
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ᘀ̔ሃ؏ࠅ؃बनⴕ⠉
㔃ؑఄ།ऍᰔሐ༓̇਒༈လऽࠃܓ̆ऍᰔሐइਓ̋ऊ؉ⰳऄᐾᜉ㜂
ᘀਇଌ഍༆ः␅ጏࠃᜉ㜂
⤊ଌࠌᄃऄԍࠅ؃ऎਆघ؊Ԓऀ#ऀ
∏Аःሌଊጃएܓऌࠀଉᴅ།ఎᰌܘऎ̏ࠅ؃ଉဏጉḃ̇ऋԞଈ༇ࠌ༈̓ञᰀ
Њ܈̔ሊ؏܃ਅଉ܊ࠀ༈ఊ܉ఇएऄഌ܌Џഉ؃Њؓᜉ㜂
उउईဆਏࠉఇฃЈఊ܉ᤌࠐऒ༈ࠃ؇ଉ਎ऎ؃ᴅ̇Мएܓऄഌ܌Џഉฃ༈Ԇ̋ऄਇଌଈ̇ࠉᤌࠐ
ᘐఋऍ་ࠉଈ༈̔̇ࠉ།ഊᤋऄဌഓ؃܉ᤐਉᐃ̈ए഍ऊࠐ̆ऄ،ࠃ،༉ช؉ช܋఍ഃЈਔᰉ̤Ѓለओ਄Ԕ̇ࠀ༈ఊ܉ࠊइਇ̈ဃഃଋझԏഌผऎਆऋԆ᠃؜ऌฉࠐ̉ଏᐃ
ሀ༈ࠃ؇ऊฉ؃ሊ؈̓ऌ഍܃ଋऌଉਞଃؑ̓एܓओ਄Ԕ̇ࠃጉḜईဃऄഌ܌Ќ༇ऌ܉㌉ଅḋ̝ԃ܈ःሌଊጃକऱ̄༅ଃऊฉࠐఋई̇ጃ܄ᰉࠊऌᐒ؊ᄃङఈဉࠌᐃᜉ༉⸳㨔ਇࠐ
íonsállecíomyI whách may ánclude buí are noí lámáíed ío mulíáple aníábáoíác
allergyLáníoleranceI mcAmA Eperáodác feverI
síomaíáíásI pharyngáíásI and
píaíemenís 4I RI and S are guádelánes assocáaíed wáíh sleepJdásordered breaíháng
píaíemení T – Iníraoperaíáve píeroáds: Clánácáans should admánásíer a sángleI
áníraoperaíáve dose of áníravenous dexameíhasone ío cháldren undergoáng
íonsállecíomyK – pqolkd obClMMbkaAqIlk
píaíemení U – meráoperaíáve aníábáoíács: Clánácáans should noí rouíánely admánásíer
or prescrábe peráoperaíáve aníábáoíács ío cháldren undergoáng íonsállecíomyK –
pqolkd obClMMbkaAqIlk
píaíemení V – mosíoperaíáve paán conírol: qhe clánácáan should advocaíe for paán
managemení afíer íonsállecíomy and educaíe caregávers abouí íhe ámporíance of
Mosí pracíáíáoners are avoádáng qylenol wáíh codeáne and only usáng narcoíács án
cháldren wáíh cauíáon and when absoluíely necessaryK A good regámen ío employ
for posíoperaíáve paán conírol could be alíernaíáng qylenol and ábuprofen around
íhe clock for íhe fársí week án essence ío síay ahead of íhe paán so íhe paíáení does
noí avoád eaíángLdránkáng due ío paánK In our pracíáceI we have seen a greaíer
number of posíJíonsállecíomy hemorrhages án cháldren who avoád oral áníake
probably due ío paán and become dehydraíedK
píaíemení NM – mosííonsállecíomy hemorrhage: Clánácáans who perform
íonsállecíomy should deíermáne íheár raíe of prámary and secondary
posííonsállecíomy hemorrhage aí leasí annuallyK – obClMMbkaAqIlk
Based on íhe maradáse Cráíeráa for íonsállecíomyI weI aí íhe rnáversáíy of qexas
Medácal BranchI have creaíed íhe íonsál card feaíured án cágsK E
F and E
FK qhe
íonsál card ás meaní ío aád pedáaírácáans and parenís án keepáng írack of íhe
number of recurrení íonsál ánfecíáons and when a referral ío an oíolaryngologásí ás
warraníedK te have prováded ánsírucíáons on íhe back of íhe card whách can be
read án cágK E
F abouí how ío use íhe card and exacíly when a referral ío an
oíolaryngologásí should be consáderedK te hope íhe íonsál card makes íhe
compláance wáíh íhe maradáse cráíeráa easáer and more accuraíe as well as íakes íhe
qonsállecíomy ás one of íhe mosí common pedáaírác surgácal proceduresI more
íhan RPMIMMM performed annually án íhe rnáíed píaíes [
zK qhe managemení
ȃЅ؆̇ࠉࠊ܋఍ऌ܎̄ࠌਇଉЏ܉ဏᄃएऒ؊ชԇጉ̎ฃЈऊ܉А఍ጆ̇एܓईဃఆऎ༔఍ఃକऀᘐ̉ሀ༌ܗऋԎฃ،ܘᜉഊଋऊฉ଄ည਍एܓऀᤊؚएܓईဃ
،ଚऊฉЊᐒഌЏࠌਇଉᐏᨃଉጌ༘܊ଌܘएܓई؃༈ఇ᠉ࠐ؊༈ऌ܎̄ࠌਇଉఔሊ؈༇ࠕछਈःᄃ؜ऋਆ̉ࠐ؊༈आ̝Ԍ؃ଉ༇ࠌḌਈఄକऀᘐ̉ԋ̉਎आ༒ఓ
ଈ؃ሉࠃଈଉ༇ጉࠐ؊༈ऄԍࠅ؃ଉЏ܉ဃഒऒလଌЌ༇ଉጃЌጃङဃ܉༇ࠌḌਈఄଉ༆̉؃ᴅఆ̓ᔉἐ̇ऄဌഓ؃܉ဏᄃऐ༓ईਊऔ༇ᰉࠊ܋ఀഉఇฃЈఊ܋ᜀ
ଅؘ̆ᰉЏ܉ḃऐ̍ሎԍᔉᘐ̉ᴅ̋ࠌਇऌଉညᤉᐏܜऌଉࠊਉᐏܜᔉᬊࠉ̑̆ᰉА఍ጉᤌࠐआ̄Ԇ؃܈ईਇଌ഍ఈఋइ̃ጋऋԆ᠃؜ᔉᘐఋऌ଀ङဃ؃ईဌଉЏؓ
Џ܉ဃഒᔉ ऌଉ༉ଌᐒഃङ༜ईਉᨃ̒ई؏Кऊฉࠐ̉܅ᐞ̆ऊฉࠊ܋఍ऌ܎̄ࠌਇଉᰊԆऄဌഓऐ་ऊᄃ؉༉ࠐ؃̉ᰃ༆ऒ̆ఊጕऀᘐ̆̉༆̉᠅ఓ̍ఇ̋ईဏࠀ
ဃഒऋԘ᠃ଈङဃ܉ଅؘ̆ᰉఋऌܓఄ༈̓ᔉ!ਅ؉∛ᘀओ਄ࠊ؉Џ܉ᤊؚङఈဉᰊԉ༇ጉᰊԆऒ،ᐏ؜ऒလଌЌ༇ऌ܉ࠆᰌܘईਉጃЌጉᤐ̈ဃ؀ऌࠀ
ᤊԍጉḃञ̇̎ఄఏഉࠊऒ؊Ѓ̓ङఈဉ༉ࠊ܋఍ഃЈਔᰀᔀ
∑̆ᰉࠌᐃजਅञ،ܘजਅ؉А఍ጉࠊईဃओ਄ࠊ؉ᤌࠐएञ༓ऋਆ̉ࠐ؊༈ऊ؉ଅ଒̄ࠃጉଈ؃ሉࠐ؊༈ᜉḆఇ᠉ࠐఋऄ༆ጉᤌࠐजਅᔉ⌋ᨉᰀਅ؉ጊЈਆऌ฀
ࠐ̉̒ఋਓ̉ᐃ̈ଉࠐ̉Іఈ̆ఏएଉጃ଄،ḃጉఇईဃऒလଌЌ༇ऋ̄ࠌਇᔉ‎ऋਗएଚजਅ؉ጊЈਆईਉଌ᠇एܓओ༈̉ࠐ̉༒ሆ਒،༈̉Ḁਤᔉ‎जਅ؉А఍ጀ
ဏଉ┉ఇฃЈఊ܋ऌ܉ਇ̉ᰃ༆ᜉఈ☀ଉࠌᐃईਉଃ̉ࠐ̉∛ᘀओ਄ࠊ؀ᔉ‎जਅ؉А఍ጉဏଉ܊ࠉဏጉ┉ఇฃЈఊ܋ऌ܉ਇ̉ᰃ༆☀ଉࠌᐃᜉḃऋԀ؃ईਉᐊᄃऊ܉ࠊ
ᰃ༆ईᤊᔉȃᐃᐞ̆ᜉࠐ̆̉ᐏᰉḃअ܋ఘ܃ጉḊ␃ଉఇईဌଉЏଃᔉఎजਅ؉А఍ጉဏଉ✉ఇฃЈఊ܋ऌ܉ᰃ༆ऊ܃एܓईဃ܉✉ᐊ؃ऌ܉ᰃༀ؉࠙ਕऌࠦ଀
ࠌᐃईਉଃ̉ࠐ̉∛ᘀओ਄ࠊ؀ᔉ‎जਅ؉
А఍ጉဏଉ⠉ఇฃЈఊ܋ः༄ဉᰃ༆ऎਆए഍ईဆ̃ज̏؋ईဃ܉\f\b&ଉࠌᐃईਉଃ̉ࠐ̉∛ᘀओ਄ࠊ؀ᔉ
ࠐ̉ЏؓईਉଐਙईਉᰊԆढᬖओ਄ࠊ؀ᔉᘐఋङ఍ഉဃഒङఈဉࠐ̉ጃЌଌਇऔ༚ఇ᠉ሆ਄̋ଉช؉ଅؘ̆ᰀᔀ
⤍̏ଃऐ̍ሉጊЅᐃ܈एሒ؊ሆఏࠃञਅࠀଉ਎ऋਆ̉ࠐ؊༈ଉଊङ̉Џ܉ဃഒओ̄ఓ̉ᤐఄဉА఍ጆ̇ङ఍ഉḃ܃ฌࠉฆਔएईਇଌ഍̄ࠊᐜᔉ‎जਅ؀
ሀ༈ః܈औ̃ࠀଉࠐ̉Іఈ̆ఏञ̍ਙᜉል̏ଃऋఘ܉༇ጉጏࠃईဃएሒ؊ሆఏࠃञਤऊ܉ࠐ̉ਈဃ؉ଌጃᔉἐ༈झԏഌฌ̋एଉဏᄌܘऊ܃ःሌ଀ਓ̪
⌕ऀᘀ̔ሃ؏ࠅ؃बनⴕ⠉ਆम⼮र
12\tᘀ̇ጃ؉༇ጉ̇ഏؘ̓इ̄ᨉജᐒဉ܊ጃଉਆब㌄ᐉఇऋఴ̀
"2\t⌇ࠌḌਈఄଉ༓ᐌ܌ଈ̆̓ऌ܉ࠐ̉Њܑ̇ࠌਇ།ओ਋༘̉ช؉ሆ਑̇ऊ؉ଅ଒̄ࠃጉଈ؃ሉࠐ؊༈
ࠐ̉ሀ་ࠉᰃ༆ᜉ਎ऎ̑̆ईဏ܉✉଒ఋਓ̋ऒ̆ज̏؉ఇईဃऒ་ࠉ࠙ਉᰃ༆ଗऊ؉ฃᤃ؉ࠐ༇नःሊଊጃଉሃ؉ᰃ༆ऌ܉ࠐ̉ሀ་ࠉࠐ؃̉ᰃༀ؋ᔉ㜇Ѓ
ሀ༈ః܈ଉဏᄃऔ̈ईဃऄ،ࠃ،༉༞਑̗ऒഃ་̉ဃഒए؆༇᠃एआ̎̆؏ഉࠊए܉∛ᘀओ਄ࠊ؉ࠊओఋЅଋऋԆ᠌Џഉ਒ࠌਇକ
ᘀਇଌഉ㔏ؓ
algoráíhm for paíáenís wáíh recurrení sore íhroaí ás ouíláned án cágK E
FK qhe currení
ándácaíáons for íonsállecíomy and adenoádecíomy afíer ságnáfácaní clánácal research
due ío wádespread performance of íonsállecíomy based on fear ánsíead of íhorough
clánácal managemení of complácaíáons are lásíed án qable
Eándácaíáons for
obsírucíáve dásease ás áncluded for compleíeness even íhough íhás íopác ás noí
beáng covered án íhás chapíerFK táíh rapád dáagnosás and aníábáoíác useI íhe
complácaíáon raíe of íonsálláíás has decreased and no longer ás ámmedáaíe
íonsállecíomy ándácaíed [
zK In all casesI íhe poíeníáal benefáís of íonsállecíomy
should be weághed agaánsí íhe ságnáfácaní morbádáíy of íhe procedure and íhe
poíeníáal posíoperaíáve complácaíáonsK then dáscussáng a íonsállecíomyI íhe
adenoáds haváng íhe same funcíáon and locaíáon should also be evaluaíedK An
adenoádecíomy does noí add ságnáfácaní morbádáíy on íop of a íonsállecíomy and
should be performed sámulíaneously áf ándácaíed [
zK qhe ándácaíáons for an
adenoádecíomy alone are lásíed án qable
qhe íonsállar fossa afíer a íonsállecíomy ío íhe uníraáned eye could lead some
pracíáíáoners ío beláeve paíhology may be presení; howeverI íhe íonsállar fossa for
a couple of weeks afíer surgery wáll have a wháíásh eschar from íhe cauíerázaíáon
íool used ío excáse íhe íonsálK qhás could lasí up ío O weeks and ás normalK qhe
íonsállar fossa on day U ás depácíed án cágK E
FK eoweverI íhe posíoperaíáve course
of a íonsállecíomy can have ságnáfácaní morbádáíy and poíeníáal complácaíáonsK
maíáenís experáence consáderable paánI odynophagáaI and general malaáseK
oecovery can íake anywhere from 4 days ío O weeksK maíáenís can become
dehydraíed from íhe odynophagáa and refusal ío dránk due ío paán requáráng
hospáíal admássáon for áníravenous fluádsK lne of íhe major complácaíáons of
íonsállecíomyI whách can be láfeJíhreaíenáng due ío aárway compromáse ás posíJ
íonsállecíomy hemorrhage [
zK A íradáíáonal adenoádecíomy ánvolves removal of
íhe adenoád íássue under general anesíhesáaK qhe morbádáíy and complácaíáon raíe
In our pracíáceI we have found íhe ámmunologácal sequelae of a íonsállecíomy án
cháldren has been a source of concern for many parenísK qhrough our research and
clánácal pracíáceI we have found íhaí a íonsállecíomy or adenoíonsállecíomy does
noí have any clánácally ságnáfácaní negaíáve effecís on íhe ámmune sysíemK
curíhermoreI Báíar and colleagues reváewed PR separaíe aríácles án íhe láíeraíure
whách áncluded án íoíal NVVT paíáenís and found only 4 síudáes íhaí suggesíed a
ሆ̋̇ࠀ༈ఊ܉਎औਓఎᰌܘ
ᘀਇଌ഍̄ࠊᐜस㤺ऀ⌓̇਌ጃЈਔᰀ
ࠊ܋఍ഌࠌହ⬀ࠆ̒ࠊЊЄ།ऒဏ؜ܘఈఋईဏࠀ
ȃฃ؆།ईਉ∑།ԏࠃऎਆं̄Ԇ؃܈फਆ̉ᘐ؊༈
㬩༆༓ఋ̉Іఈ̆ఏऺऀ⌋ओ̎ఇ̓ऌ܉ᘀ༞ഃम
㬻㰊ጌผఇ᠉ฏЈਆଉ㨉 Ѝԓ̉ḅࠉ༆̉܊ࠉഌᐌࠃጉࠊऔԍࠌል̉༇ࠌḌਈఄए഍̆᠜㤌܈਍̆༇Ѓᜉ⤰#)#ऽሃ،ਓఄऎ̑̆ᜉ༒ဏࠐਅ଀
íonsállecíomy could have negaíáve effecís on íhe ámmune sysíemK bven wáíh íhese
few síudáesI íhere ás enough evádence ío reasonably conclude íhaí a íonsállecíomy
oecurrení íonsálláíás íurns ouí ío be more of a pedáaírác condáíáon íhan adulíI
possábly due ío mulíáple facíorsK cársí íhe íonsáls are more acíáve aí a young age
when íhe ámmune sysíem ás developáng makáng íhem larger án sáze and more
suscepíáble due ío an áncrease án surface area ío a varáeíy of aárborne organásms
zK pecondI íhe locaíáon aí íhe enírance of íhe oropharyngeal aárway makes íhe
palaíáne íonsáls íhe fársí láne of defense for aárborne organásms eníeráng íhe aárway
poíeníáally on each breaíh [
zK AlsoI íhe anaíomy of íhe palaíáne íonsál áncludes
íonsállar crypísI whách may be necessary for ámmunologácal funcíáon buí also lend
ío more organásms seedáng án íhe core of íhe íonsál causáng repeaíed ánfecíáons
zK cánallyI íhe normal flora of íhe oral caváíy does ánclude paíhogenác bacíeráaI
whách are kepí under conírol by oíher bacíeráa án íhe oral caváíyI however wáíh
aníábáoíác useI paíhogenác bacíeráa can ouígrow íheár normal conceníraíáons and
cause dásease [
zK medáaírácáans should keep íonsálláíás án íheár dáffereníáal
dáagnosás when cháldren are preseníed wáíh sore íhroaíI feverI chállsI dysphagáaI
general malaáseI cough or lymphadenopaíhyK then íonsálláíás ás suspecíed and
íreaímení decásáons are beáng consáderedI a rapád sírep íesí ás a useful íool ío geí
an ámmedáaíe dáagnosás of sírepíococcal pharyngáíásI howeverI íhere ás a small
chance for a false negaíáveK In íhe case of a negaíáve rapád sírep buí wáíh hágh
suspácáonI a íhroaí culíure would be íhe nexí síep án managemeníK oapád sírep
íesís help guáde íreaímení decásáons and assásí clánácáans án usáng aníábáoíács
appropráaíely wáíhouí overuseK Many íámesI cháldren could be presení wáíh íhe
above sympíoms and have a váral ánfecíáon whách would noí requáre aníábáoíácsK
eoweverI because of íhe possábáláíy of a false negaíáve rapád sírep and íhe
ánherení naíure of íhroaí culíures whách íake 4UJTO hours ío prováde dáagnosíác
resulísI some clánácáans may choose ío íreaí wáíh aníábáoíács based on íhe hághly
suspácáous naíure of íhe cháld’s sympíoms [
zK medáaírácáans should also keep
good medácal records of acuíe sírepíococcal epásodes as íhese numbers help guáde
surgácal decásáonsK qhe paradáse cráíeráa explaáned above has sírácí guádelánes
abouí when a íonsállecíomy should be performed for recurrení íonsálláíásK then a
cháld meeís íhese guádelánesI a referral ío an oíolaryngologásí ás necessary for
qhe íonsállecíomy coníánues ío be one of íhe mosí common pedáaírác surgácal
procedures íoday; subsequeníly clánácal guádelánes based on exíensáve research
have been developed ío assásí clánácáans wáíh when íhe procedure ás ándácaíed and
phárley tK "mharyngáíás and Adenoíonsállar aásease"K In: clání maul tI bdK Cummángs
líolaryngologyK Ríh edKI OMNMK
[Ozmasha oK líolaryngologyJeead and keck purgeryK 4íh edKI pan aáego: mlural mublásháng Inc OMN4K
velázaveía pI iee hCI Bernsíeán gMK Managemení of Adenoíonsállar aáseaseK Currení aáagnosás and
qreaímení án líolaryngology J eead and keck purgery Anál h ialwanáK Ond edK kew vork: McdrawJ
[4zthaí Are qonsáls? Etáíh mácíuresF wásedbbh kp OMNSK tebK NN kovK OMNSK
qhompson iaK “mharyngáíás” eead C keck purgery J líolaryngology Byron g BaáleyI gonas q
oegauer pK kasopharynx and taldeyerDs oángK maíhology of íhe eead and keck Aníonáo Cardesa and
Carey oobería BK bBs Aníábodáes: qhe qesí | bBs Aníábodáes qesí: bpsíeánJBarr sárus Aníábodáes |
mácháchero MbK Aníábáoíác qherapy for Acuíe líáíásI ohánosánusáíásI and mharyngoíonsálláíásK medáaírác
líolaryngology for íhe Clánácáan oon B Máíchell and heván a mereáraK Nsí edK iondon: eumana mress
Básno AiI derber MAI dwalíney gMI haplan biI pchwaríz oeK mracíáce duádelánes cor qhe
aáagnosás And Managemení lf droup A pírepíococcal mharyngáíásK Clán Infecí aás OMMO; PREOF: NNPJ
Mersch gohnK oapád pírep qesí: deí qhe cacís ln Accuracy lf qhás qesí Medácánekeí kp OMNSK tebK
pchwaríz oeK menácállán s cor droup A pírepíococcal mharyngoíonsálláíásK A oandomázed qráal lf
lrvádas igI plaííery MgK medáaírác Auíoámmune keuropsycháaírác aásorders And pírepíococcal
Infecíáons: oole lf líolaryngologásíK iaryngoscope OMMN; NNNEVF: NRNRJVK [tebzK
Bull maK qhe qonsáls and lropharynxK iecíure koíes on aáseases of íhe barI koseI and qhroaí ma
Baugh ocI Archer pMI Máíchel oBI
eí alK
Clánácal mracíáce duádeláne: qonsállecíomy án CháldrenK
Bull maK qonsállecíomyK iecíure koíes on aáseases of íhe barI koseI and qhroaí ma BullK Víh edK
Báíar MAI aowlá AI Mourad MK qhe bffecí lf qonsállecíomy ln qhe Immune pysíem: A pysíemaíác
qooke dregK qonsállecíomy oecovery qáps qonsállecíomy oecovery qáps kp OMNSK tebK NT MarK
tebb heK aoes Culíure Confármaíáon lf eághJpensáíáváíy oapád pírepíococcal qesís Make pense? A
rnáversáíy of qennessee eealíh pcáence CeníerI aeparímení of líolaryngologyI ieBonheur
CháldrenDs eospáíalI píK gude CháldrenDs oesearch eospáíalI qk PUNMRI rpA
Absírací:
medáaírác Chronác ohánosánusáíás EmCopF ás a common condáíáon án
oíolaryngologácal pracíáceK mCop remaáns állJdefáned as a condáíáon as áí remaáns
dáffáculí ío esíablásh as a dáagnosásK mCop may coJexásí wáíh oíher wádespread
condáíáons such as allergác rhánosánusáíás and adenoádáíásK oecení efforís have been
íargeíed aí defánáng íhás condáíáon and ío develop síepwáse íreaímeníK A consensus of
síaíemení was receníly puí ouí defánáng mCop as aí leasí VM coníánuous days of nasal
sympíoms wáíh correspondáng endoscopác andLor ámage fándángs án a paíáení who ás NU
years old or youngerK táíh a workáng defánáíáonI research has focused on developáng
síepwáse íreaímenís rangáng from medácal managemení ío endoscopác sánus surgeryK
heywords:
AdenoádáíásI Balloon sánuplasíyI Chronác rhánosánusáíásI bndoscopác
medáaírác chronác rhánosánusáíás EmCopF ás a dáffáculíI buí common problem án íhe
oíolaryngologác pracíáce arásáng maánly from poor undersíandáng of íhe dáseaseK
qhe dáffereníáal dáagnosás for mCop áncludes váral upper respáraíory ánfecíáonsI
acuíe bacíeráal sánusáíásI allergác rhánáíásI nasal foreágn bodyI and congenáíal
abnormaláíáes such as choanal aíresáa and pyráform aperíure síenosásK Arráváng aí a
dáagnosás ás ofíen dáffáculíI buí a recení clánácal consensus síaíemení from íhe
Amerácan Academy of líolaryngology has developed a workáng defánáíáon of
mCop wáíh íhe áníení of helpáng wáíh dáagnosás and guádáng íreaímení síraíegáesK
mCop ás defáned as aí leasí VM coníánuous days of sympíoms of purulení
rhánorrheaI nasal obsírucíáonI facáal pressureLpaánI or cough wáíh correspondáng
Correspondáng auíhor Aníhony pheyn
: rnáversáíy of qennessee eealíh pcáence CeníerI aeparímení of
líolaryngologyI ieBonheur CháldrenDs eospáíalI píK gude CháldrenDs oesearch eospáíalI qk PUNMRI rpA; qel: ERNPF
and adenoád dásease [
z and has íhe poíeníáal ío exacerbaíe asíhmaI whách affecís
approxámaíely OJOMB of cháldren [
zK Improvemenís án asíhma have been
observed án cháldren followáng surgery for mCopK
qhe paíhogenesás of mCop án poorly undersíood and ás lákely mulíáfacíoráalK
Mucocáláary clearance defecísI allergác rhánáíásI chronác bacíeráal ánfecíáonI
enváronmeníal facíors and socáal facíors all conírábuíe ío íhe developmení of
dáseaseK lver íhe pasí NMJNR yearsI bacíeráal báofálms have been ádeníáfáed as an
addáíáonal facíor án dásease progressáon [
zK A recení síudy ándácaíed íhaí a
heredáíary conírábuíáon exásís as wellK páblángs of paíáenís wáíh mCop had a RTKR
fold áncreased ráskI fársí cousáns had a VKM áncreased rásk and second cousáns had a
Anaíomác varáanís may also conírábuíe ío íhe dásease processI alíhough
coníroversy síáll exásísK qhe mosí frequení anaíomác varáanís noíed án Cop are
pneumaíázed máddle íurbánaíeI uncánaíe hyperplasáaI deváaíáon of íhe uncánaíeI
large eíhmoád bullaI large agger nasá cellsI and ealler cellsK kasal polyps án
cháldren are rareI excepí án cases of CcK
polyps are more lákely buí
In addáíáon ío healíh relaíed problemsI íhe íreaímení of mCop ás a prománení
publác healíh ássue and áncurs a hágh fánancáal cosíK mCop vásáís are second ío well
cháld vásáís for
pedáaírácáansK qhe acíual cosí of
íreaíáng chronác sánusáíás ás
dáffáculí ío esíámaíeI buí over AO bálláon ás spení annually on overJíheJcouníer
As our undersíandáng of mCop growsI íreaímení opíáons are ámproved and now
occur án a síep wáse fasháonK CurrenílyI long íerm aníábáoíác íherapy ás íhe fársí
láne íherapyK Alíernaíáves ío oral aníábáoíác íherapy and íreaímení of refracíory
dásease ánclude a varáeíy of surgácal íherapáesK Adenoádecíomy ás generally
consádered íhe prámary surgácal íherapyK Addáíáonal procedures ánclude
endoscopác sánus surgery and balloon caíheíer dálaíáonK
qhe dáagnosás of mCop ás based on íhe presence of specáfác sympíoms presení for
P moníhs or more wáíh assocáaíed ámage or endoscopác fándángsK qhe major and
mánor cráíeráa used for dáagnosás are íhe same as íhose used for dáagnosáng acuíe
bacíeráal rhánosánusáíás Eqable
FK qhe usual sympíom complex for cháldren
áncludes coughI nasal congesíáonI and rhánorrhea [
mhysácal examánaíáon should always ánclude an aníeráor rhánoscopy and a nasal
endoscopyK Aníeráor rhánoscopy ás quáíe ofíen unreláable and very nonJspecáfácK
kasal endoscopy ás more sensáíáve procedure for examánáng a paíáení án íhe offáceK
Ií allows for evaluaíáon of sepíalI íurbánaíeI meaíalI and nasopharyngeal
abnormaláíáesK qhese areas should be carefully ánspecíed for presence and qualáíy
of secreíáonsI presence of ánflammaíáonI paíency of choanaeI nasopharyngeal
massesI and adenoád hyperírophyK
oadáologác síudáes are noí rouíánely ándácaíed án íhe ánáíáal managemení of
suspecíed mCopK If necessaryI ámagáng should be Cq Maxállofacáal scan wáíhouí
conírasí ío examáne íhe paranasal sánusesK thále plaán radáographs have been
descrábed as haváng a sensáíáváíy of U4KOB and a specáfácáíy of TSKSB when
compared ío nasal endoscopyI áí ás a challenge ío dáffereníáaíe beíween a massI
polypI ánfecíáonI or mucosal dásease án opacáfáed sánuses [
I
zK táíh CqI íhe
iundJMchay scoráng sysíem can be used ío áncrease íhe predácíáve value of
ámagángK Ií ás ámporíaní ío consáder íhaí án cháldrenI a score of R ás íhe cuíoff for
beáng consásíení wáíh íhe presence of sánus dásease [
zK thále MoI ás beííer aí
examánáng sofí íássuesI áí has worse bony resoluíáon when compared ío CqI and ás
ánadequaíe for surgácal plannáng or áníraoperaíáve guádance áf sánus surgery ás
necessaryK cánallyI áí ás ámporíaní ío remember íhaí abnormal ámagáng fándángs
may persásí for some íáme afíer sympíom resoluíáon [
zK In cases of complácaíed
mCopI especáally wáíh suspácáon of cysíác fábrosás or prámary cáláary dyskánesáaI
mCop ás a very dáffáculí dásease ío íreaí due ío dáffáculíáes wáíh dáagnosás and íhe
many conírábuíáng facíors ío íhe paíhophysáology of íhe dáseaseK qhere ás
agreemení íhaí a síep wáse approach should be adopíed ío íhe íreaímení of
cháldren wáíh íhás dáseaseI begánnáng wáíh medácal managemeníK qreaímení
generally begáns wáíh aníábáoíács and adjuvaní medácal managemeníI progressáng
ío surgácal íreaímení án recalcáíraní casesK A recení consensus has also been
reached íhaí managemení of cháldren NO years and younger ás dásíáncíly dáfferení
iong íerm aníábáoíács should be íhe fársí síep án íreaímení of mCopK qhe Clánácal
Consensus síaíemení came ío íhe conclusáon íhaí OM consecuíáve days of
aníábáoíács may produce a beííer clánácal response when compared ío íhe clánácal
response án paíáenís who receáve shoríer courses [
zK líher auíhors recommend
bmpárác aníábáoíács should be dárecíed aí íhe mosí common bacíeráa causáng
mCop; gramJposáíáve coccá such as coagulaseJnegaíáve síaphylococcá and
as well as gram negaíáve bacállá such as
eK ánfluenza
and
MK caíarrhalás
zK cársí láne íherapy ás usually Amoxácállán or AmoxácállánJClavulanaíeK
menácállán resásíance ás common and ás more common án cháldren aííendáng
daycareI younger íhan OI and íhose who were receníly íreaíed wáíh aníábáoíács and
had a rapád recurrence of sympíoms [
zK In penácállán allergác or resásíaní
paíáenísI fársí láne íherapy may be a second or íhárd generaíáon cephalosporán or a
macroládeK In cháldren older íhan S moníhsI cefdánár has been shown ío be jusí as
effecíáve as AmoxácállánJClavulanaíe [
zK In penácállán resásíaní paíáenísI
clándamycán and Bacírám may also be effecíáveI especáally áf
pK aureus
ás íhe
Culíure dárecíed aníábáoíác íherapy may ámprove ouícomes án íhose paíáenís who
have noí responded ío long íerm empárác íherapy [
zK Maxállary sánus árrágaíáon
and aspáraíáon and máddle meaíus culíure and báopsáes are íwo ways of obíaánáng
specámen for culíureK In one síudy maxállary sánus árrágaíáon had a culíure
sensáíáváíy of UMB and máddle meaíus culíure had a sensáíáváíy of TPB for
paíhogenác bacíeráa [
zK qhe paíáenís án íhás síudy had preváously been íreaíed
unsuccessfullyK Based on culíures íhey were síaríed on double aníábáoíác íherapy
based on culíures and had compleíe resoluíáon of sympíoms beíween 4KV and UKU
Iníravenous aníábáoíács have also been descrábed as an addáíáonal medácal íherapy
án paíáenís who faál oral aníábáoíács án hopes of avoádáng surgácal íreaímenísK
Majoráíy of daía on Is aníábáoíács án mCop ás from unconírolled reírospecíáve
reváewsK phorí íerm resulís range from OVJUVBI buí wáíh a hágh relapse raíe and
complácaíáons [
I
zK Complácaíáons may ánclude superfácáal íhrombophlebáíásI
Adjuvaní íherapáes whách have been descrábed for mCop ánclude íopácal and oral
síeroádsI aníáhásíamánesI nasal saláne árrágaíáon and aníáJreflux medácaíáon wáíh
varyáng degrees of successK qopácal nasal síeroád spray and íopácal nasal árrágaíáon
qopácal nasal síeroáds suppress local ánflammaíáon and come án a wáde varáeíy of
formulaíáons wáíh sámálar effácacáesK qhese medácaíáons are íypácally used án
combánaíáon wáíh aníábáoíác íherapyK píeroáds íend ío shoríen sympíoms buí do noí
appear ío hasíen resoluíáon of mCop [
zK dáven íheár long lásí of poíeníáal
complácaíáonsI sysíemác síeroáds are noí íypácally ándácaíed án uncomplácaíed
mCopK qhe use of sysíemác síeroáds has shown uíáláíy án íhe íreaímení of mCop
Iníranasal árrágaíáons wáíh saláne are also a useful adjuncí ío íhe íreaímení of
mCopK Cháldren can use árrágaíáons wáíh varyáng degrees of assásíance from adulís
dependáng on ageK paláne árrágaíáon has been shown ío cause subjecíáve and
objecíáve ámprovemení án compláaní paíáenís beíween SRKVB and TPKRB [
I
lbjecíáve measures were obíaáned by uíálázáng Cq scans and íhe iundJMchay
scoreK Cháldren án íhe máddle age rangeI beíween S and U years of ageI appear ío
have a beííer compláance raíe wáíh íhás íherapy when compared ío younger and
older cháldren [
zK oeasons for síoppáng use may ánclude dáffáculíy of
admánásíraíáonI aural fullnessI oíalgáaI and láííle perceáved effecíávenessK
pysíemác aníáhásíamánes have no proven benefáí án íhe íreaímení of mCop [
qhey may prováde some reláef of sympíoms such as nasal congesíáon and nasal
draánage buí do decrease íhe overall duraíáon of íhe dáseases processK Ií has also
been shown íhaí íhe effecís of aníáhásíamánes on íhe nasal mucosa may adversely
affecí íhe abáláíy of íhe nose and paranasal sánuses ío manage ánflammaíáon and
qhere have been mulíáple síudáes íhaí have made meníáon of íhe relaíáonsháp
beíween gasíroesophageal reflux EdboF and mCopK In one síudyI dbo was found
ío be presení án 4MB of paíáenís preseníáng wáíh sympíoms of rhánorrheaI nasal
congesíáonI and chronác cough based on esophageal báopsáes [
zK A smaller síudy
of NN paíáenís wáíh mCop and NN conírols wáíh normal Cq fándángsI ádeníáfáed íhaí
pome small scale síudáes have found ámprovemenís án íreaímení of dbo án íhe
resoluíáon of mCop sympíomsI buí íhese were reírospecíáve and had a small
number of paíáenís beíween íhem [
I
qhe presence of báofálms on adenoád íássue has been ámplácaíed án íhe persásíence
of chronác rhánosánusáíás despáíe adequaíe medácal managemeníK Báofálms are
aggregaíes presení on a surface wáíhán a maíráx of polysaccharádesI nucleác acádsI
and proíeáns [
zK Aníábáoíács may suppress sympíoms of ánfecíáon by kálláng free
floaíáng bacíeráa íhaí are released from íhe bacíeráal báofálm; due ío íhe proíecíáve
naíure of íhe polysaccharáde maíráxI aníábáoíács faál ío eradácaíe íhe bacíeráa
compleíelyK then íhe acíáve course of aníábáoíács ás compleíedI íhe remaánáng
bacíeráa may ací as a source of recurrení ánfecíáons [
I
zK In a síudy comparáng
presence of báofálms án cháldren wáíh Cop Ewho faáled aí leasí 4 weeks of
aníábáoíácsF and íhose of cháldren who underwení adenoádecíomy as parí of sleep
apnea proceduresI V4KVB of adenoád surface was found ío be covered wáíh
báofálms compared ío NKVB of surface area coverage án cháldren wáíh sleep apnea
and no Cop sympíoms [
zK qhe presence of báofálms may help explaán why
surgácal íherapy ás íhe besí íherapy for paíáenís who faál adequaíe medácal
managemení as dáscussed before án íhás chapíerK
Adenoád íássue has been ámplácaíed án chronác sánus dásease for a very long íámeK
táíh íhe ádeníáfácaíáon of bacíeráal báofálms on adenoád surfacesI remováng íhe
íássue has become a maánsíay of íreaímení of medácally refracíory mCopK qhe sáze
of adenoád íássue does noí appear ío play a role án íhe presence andLor severáíy of
sympíoms [
zK iack of a sáze relaíáonsháp wáíh severáíy of sympíoms of mCop
makes sense because of íhe growáng amouní of evádence íhaí shows íhaí adenoád
Ií ás agree íhaí adenoádecíomy should be íhe fársí láne surgácal íherapy for mCopK
Ií ás a quáck and easy procedureI whách ás able ío be performed on an ouípaíáení
basás and has very few sáde effecísK qhe effecíáveness of adenoádecíomy appears
ío vary wáíh ageK Adenoádecíomy appears ío be íhe mosí effecíáve án cháldren up
ío age SI wáíh less ámprovemení án íhose aged SJNOK Ií ás unclear wheíher
adenoádecíomy alone offers any benefáí án pedáaírác paíáenís NP years and older
zK qhás may be due ío íhe fací íhaí as cháldren become older íhe adenoád íássue
íends ío recedeI íhereby makáng áí less lákely ío be a conírábuíor ío mCop
sympíomsK qonsállecíomy offers no benefáí án íhe íreaímení of mCopK
A meíaJanalysás of náne síudáes on adenoádecíomy revealed íhaí sympíomaíác
ámprovemení was found án SVKPB of paíáenís [
zK In a práor síudyI TRB of
paíáenís who faáled medácal íherapy benefáíed from an adenoádecíomy [
zK Mosí
síudáes reporí a success raíe of aí leasí RMB or greaíerI and none reporí success
qhere ás no clear consensus on why adenoádecíomy faáls án a large proporíáon of
íhe populaíáonK oamadan aííempíed ío elucádaíe reasons for faálure án anoíher
síudyK qhe síudy found íhaí íhe mean íáme ío faálure was OPKT moníhsK qhe besí
predácíors of faálureI especáally early faálureI were age and íhe presence of asíhmaK
Cháldren younger íhan age T appeared ío have a hágher and earláer faálure raíe
when compared ío older paíáenísK denderI Cq fándángsI and presence of allergác
dáven íhe presence of persásíení dásease despáíe adenoádecíomyI a ságnáfácaní
amouní of research has been on done on ádeníáfyáng adjuncíáve íreaímení whách
can be done án addáíáon ío adenoádecíomyK aeckard
eí al
ánvesíágaíed íwo groups
of paíáenísK lne group underwení maxállary sánus árrágaíáon wáíh aspáraíáon and
adenoádecíomy and second underwení máddle meaíus culíure and báopsáes wáíh
adenoádecíomyK Boíh groups were íhen síaríed on culíure dárecíed aníábáoíács wáíh
resoluíáon raíes of V4KSB and VOKSBI respecíávely [
zK AddáíáonallyI oamadan
compared cháldren who underwení adenoádecíomy wáíh maxállary sánus wash
versus íhose who underwení adenoádecíomy aloneK qhose who underwení a sánus
wash had a sympíom resoluíáon raíe of UTKRB when compared ío íhe
adenoádecíomy alone group of SMKTB [
zK líher síudáes have come ío a sámálar
ko addáíáonal adjuncíáve íreaímenís have been descrábed and íhere coníánues ío be
a relaíávely hágher faálure raíe followáng adenoádecíomyI especáally án older
cháldrenK qhe usual nexí síep was endoscopác sánus surgery EbppFK eoweverI án
íhe pasí several years balloon caíheíer dálaíáon EBCaF or balloon sánuplasíy has
qhe ráse án popularáíy of BCa ás due án parí ío áí beáng a íechnáque of íássue
preservaíáon wáíh less posíJoperaíáve bleedáng and íássue dásrupíáonK In one síudyI
paíáenís wáíh persásíení sympíoms followáng an adenoádecíomy were íreaíed wáíh
BCaK Based on preJ and posíJoperaíáve pkJR EpánoJkasal R qualáíy of láfe
quesíáonnaáre for cháldrenF scoresI UNB of paíáenís were íreaíed successfully [
An earláer síudy by íhe same auíhor án cháldren beíween age O and NN showed no
BCa when performed wáíh adenoádecíomy seems ío have a benefácáal effecí when
compared ío adenoádecíomy aloneK lne síudy had an ámprovemení án sympíoms
án UMB of paíáenís who underwení BCa wáíh adenoádecíomy when compared ío
BCa wáíh eíhmoádecíomy has also been compared ío bppK Boíh íreaímení groups
noíed ámprovemení án sympíomsI wáíh íhe BCa group noíáng a hágher
ámprovemení án sympíoms EUMBF compared ío bpp ES4KPBFK qhe auíhors
hypoíhesáze íhaí íhás may be due ío decreased debrás followáng BCaI buí íhe
followJup ás shorí and a small sample sáze and íhey síaíe íhaí íhe resulís are noí
síaíásíácally ságnáfácaní [
zK AddáíáonallyI íhe ámprovemení án sympíoms
followáng BCa and eíhmoádecíomy may be due ío íhe eíhmoádecíomy alone and
Cháldren wáíh asíhmaI allergác rhánáíásI and dboa were more lákely ío have BCa
when compared ío cháldren wáíhouí íhose coJmorbádáíáes [
zK AddáíáonallyI
operaíáng room íáme does noí appear ío be decreased when comparáng BCa wáíh
síandard maxállary anírosíomy and charges ío íhe paíáení were áncreased wáíh
qhe avaálable láíeraíure shows íhaí BCa ás safe for íreaíáng cháldren wáíh mCopI
buí noí enough daía ás avaálable ío deíermáne áf áí ás jusí as or more effecíáve íhan
qhe exíení of endoscopác sánus surgery án íhe pedáaírác populaíáon depends on íhe
exíení of íhe dásease as well as íhe paíáení’s age due ío íhe progressáve
developmení of íhe paranasal sánusesK In íhe younger populaíáonI bpp ás generally
lámáíed ío a paríáal EaníeráorF eíhmoádecíomy and maxállary anírosíomyK táíh
áncreasáng ageI bpp may ánclude all íhe paranasal sánuses dependáng on íhe exíení
mráor ío bppI áí has been shown íhaí a Cq scan of íhe sánuses ás ándácaíed ío assess
for presence of anaíomácal abnormaláíáes and exíení of dásease [
zK lbíaánáng a
Cq ás also useful áf surgácal guádance ás necessaryI whách áí íypácally ás án
exíensáve dásease and revásáon surgeryK
In íhe pasí íhere has been concern íhaí bpp án íhe pedáaírác populaíáon may effecí
facáal growíhK qhás comes prámarály from síudáes ánvolváng anámal daíaK Carpeníer
showed an ámpací on págleí facáal growíh followáng bpp [
zK píudáes of human
cháldren have noí shown any change án facáal growíh afíer pedáaírác bpp [
J
Based on íhese síudáes íhe clánácal consensus ás íhaí íhere ás a lack of conváncáng
In an early síudy by oosenfeldI NMMB of paíáenís who underwení bpp followáng
faáled medácal managemení and adenoádecíomy reporíed ámprovemení án
sympíoms [
zK Mosí síudáes reporí success raíe beíween UOB J NMMB [
zK bpp
appears ío be íhe mosí benefácáal án íhese paíáenís as well as íhose who have
anaíomác abnormaláíáes whách predáspose íhem ío mCopI such as ealler cellsI
concha bullosaI nasal polypsI and oíhersK maíáenís wáíh mCop have been found ío
have anaíomác abnormaláíáes more ofíen when compared ío paíáenís wáíh acuíe
AddáíáonallyI án paíáenís wáíh persásíení dásease áí may be possáble ío manage íhe
remaánáng sympíoms medácally followáng bppK In a long íerm followJup síudy ES
moníhs – V yearsFI 44B of paíáenís experáenced persásíení mucosal dásease buí all
were able ío be managed medácally [
zK lnly P paíáenís ouí of NNR requáred
qámáng of bpp án íerms of sympíom duraíáon has also been ánvesíágaíedK ko
síaíásíácally ságnáfácaní dáfference has been noíed án íerms of successI alíhough a
hágher success raíe was found án cháldren who underwení bpp wáíh sympíom
duraíáon beíween S and NO moníhs when compared ío cháldren wáíh sympíom
bpp ás an effecíáve and safe procedure án íhe íreaímení of mCopK qhe
complácaíáon raíe has been reporíed ío be NK4B án a reváew of mulíáple síudáes
zK eoweverI áí should be reserved for íhose paíáenís who have faáled medácal
Involvemení of íhe nose and paranasal sánuses nears NMMB án paíáenís wáíh cysíác
fábrosásK kasal polyposás án cháldren ás consádered ío be cysíác fábrosás uníál
proven oíherwáseI and ándeed íwoJíhárds of paíáenís wáíh Cc have nasal polyposás
zK qhe íreaímení of Cc assocáaíed mCop ánvolves medácal and surgácal
managemení íhaí ás beyond íhe scope of íhás chapíer buí does deserve some
Medácal managemení íypácally ánvolves nasal íoáleíI áníranasal síeroádsI íopácal
síeroádsI and nasal saláne árrágaíáonK oecombánaní enzymes have also been used
wáíh some successK purgácal íherapy ás íypácally reserved for nasal polyposás or
mCop sympíoms noí respondáng ío medácal managemeníK bpp án Cc paíáení does
noí ámprove pulmonary funcíáon íesíángI buí do decrease íhe number of ánpaíáení
medáaírác chronác rhánosánusáíás ás a complácaíed dásorder buí recení láíeraíure has
helped defáne clearer dáagnosíác cráíeráaK qhe íreaímení approach should employ a
síep wáse proíocol begánnáng wáíh medácal managemení áncludáng aníábáoíács and
adjuvaní íherapáes such as íopácal síeroáds and nasal saláne árrágaíáonK purgácal
managemení should be employed án íhose who faál medácal íherapyK mrámary
surgácal íherapy has clearly been defáned ío be adenoádecíomyI followed by
endoscopác sánus surgery áf necessaryK Addáíáonal íherapáesI such as balloon
caíheíer dálaíáon requáres furíher research ío deíermáne effecíávenessK
Bráeízke pbI phán ggI Choá pI
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Clánácal Consensus síaíemení: medáaírác Chronác ohánosánusáíásK
pmarí BAK qhe ámpací of allergác and nonJallergác rhánáíás on pedáaírác sánusáíásK Curr Allergy Asíhma
iarsson MI eagerhedJbngman iI págsgaard qI
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aeckard kAI hruper dgI Buá qI Coíáccháa gK Comparáson of íwo mánámally ánvasáve íechnáques for
íreaíáng chronác rhánosánusáíás án íhe pedáaírác populaíáonK Iní g medáaír líorhánolaryngol OMNN; TR:
lrb nI Curíán hI lakley dMI
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camáláal rásk of pedáaírác chronác rhánosánusáíásK iaryngoscope
plack CI aahn hI Abzug MI
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AníábáoíácJresásíaní bacíeráa án pedáaírác chronác sánusáíásK medáaír
[TzMagáí AK medáaírác ohánosánusáíásK líolaryngol Clán koríh Am OMN4; 4T: TPPJ4SK
ieo dI qráulzá cI Consonná aI
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ieo dI qráulzá cI Incorvaáa CK pánus ámagáng for dáagnosás of chronác rhánosánusáíás án cháldrenK Curr
Bhaííacharyya kI gones aqI eáll MI
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qhe dáagnosíác accuracy of compuíed íomography án
Cazzavállan AI Casíelnuovo mI Berlucchá MI
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Managemení of chronác rhánosánusáíásK medáaír
BrozekJMadrá bI Chmáelák imI dalazka AI
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Chronác rhánosánusáíás án cháldren – Bacíeráologácal
merry CMI pcoíí igK Cefdánár: A reváew of áís use án íhe managemení of máldJíoJmoderaíe bacíeráal
aon aMI vellon ocI Casselbraní MiI
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bffácacy of a síepwáse proíocol íhaí áncludes áníravenous
aníábáoíác íherapy for íhe managemení of chronác rhánosánusáíás án cháldren and a
K Arch
qanner pBI cowler hCK Iníravenous aníábáoíács for chronác rhánosánusáíás: are íhey effecíáve? Curr
oose ApI qhorp BaI Zanaíáon AMI
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mham sI pykes hI teá gK iongJqerm luícome of lnce aaály kasal Irrágaíáon for íhe qreaímení of
eong paI hám geI hám evI gang MpI ahong egI Chung phK Compláance and effácacy of saláne
kovembre bI Morá cI muccá kI
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pysíemác íreaímení of rhánosánusáíás án cháldrenK medáaír Allergy
kaíáon gI haufman MI Allen MI pheyn AI Coíáccháa gK Incádence of gasíroesophageal reflux dásease
and posáíáve maxállary aníral culíures án cháldren wáíh sympíoms of chronác rhánosánusáíásK Iní g medáaír
rlualp plI qooháll ogI eoffman oI phaker oK mossáble relaíáonsháp of gasíroesophageal reflux wáíh
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rhánosánusáíásK líolaryngol eead keck purg NVVV; NON: ORRJSOK
mhápps CaI tood tbI dábson tpI
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dasíroesophageal reflux conírábuíáng ío chronác sánus
Coíáccháa gI pheyn AI kaíáon gK qhe oole of Báofálms án líáíás MedáaK líoránolaryngolgáa OMNO; SO:
Adappa kaI Coíáccháa gK Managemení of oefracíory chronác rhánosánusáíás án cháldrenK Am g
líolararyngol eead keck Med purg OMMS; OT: PU4JVK
Coíáccháa gI Zuláaná dI Coleman CI
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keff iI Adál bAK thaí ás íhe rolde of íhe adenoád án pedáaírác chronác rhánosánusáíásK iaryngoscope
Bráeízke pbI Brágger MqK Adenoádecíomy ouícomes án pedáaírác rhánosánusáíás: A meíaJanalysásK Iní g
oosenfeld oMK máloí síudy of ouícomes án pedáaírác rhánosánusáíásK Arch líolaryngol NVVR; NON: TOVJ
oamadan eeK Adenoádecíomy
K endoscopác sánus surgery for íhe íreaímení of pedáaírác sánusáíásK
oamadan eeI qsáu gK caálures of adenoádecíomy for chronác rhánosánusáíás án cháldren: cor whom and
oamadan eeI Cosí giK luícome of adenoádecíomy versus adenoádecíomy wáíh maxállary sánus wash
Buchman CAI vellon ocI Bluesíone CaK Alíernaíáve ío endoscopác sánus surgery án íhe managemení
of medáaírác chronác rhánosánusáíás refracíory ío oral aníábáoíác íherapyK líolaryngol eead keck purg
oamadan eeI Bueller eI eesíer pqI
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oamadan eeI Mciaughlán hI gosephson dI
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oamadan eeI qerrell AMK Balloon Caíheíer pánuplasíy and Adenoádecíomy án Cháldren wáíh Chronác
qhoííam mgI eauperí MI paraáya pI
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Balloon caíheíer sánuplasíy EBCpF and eíhmoádecíomy: A comparaíáve ouícome analysás án pedáaírác
cerence beI pchroeder gtI nureshá eI
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Currení ríálázaíáon of Balloon aálaíáon versus
Carpeníer hMI draham pMI pmáíh ogK cacáal skeleíal growíh afíer endoscopác sánus surgery án íhe
penor BI táríschafíer AI Maá CI
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meíeghem AsI Clemení moK Influence of exíensáve funcíáonal endoscopác sánus surgery EcbppF on
facáal growíh án cháldren wáíh cysíác fábrosásK Comparáson of NM cephalomeírác parameíers of íhe
píokken gI dupía AI hrakováíz mI Anne pK ohánosánusáíás án cháldren: A comparáson of paíáenís
requáráng surgery for acuíe complácaíáons versus chronác dáseaseK Am g líolaryngol eead keck Med
Barakaíe MI eavas qK purgácal managemení of paedáaírác chronác rhánosánusáíás: reváew of NM years
oamadan eeK qámáng of bndoscopác pánus surgery án cháldren: Is íhere an ámpací on ouícome?
[4SzMakary CAI oamadan eeK qhe oole of pánus purgery án CháldrenK iaryngoscope OMNP; NOP: NP4UJROK
ceuálleíJcáeux MkI ienoár dI permeí II
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kasal polyposás and cysíác fábrosás ECcF: reváew of íhe
and Mácrobáal maíhogens án a medáaírác mopulaíáon táíh Cysíác cábrosásK Arch líolaryngol eead keck
aeparímení of líolaryngologyJ eead and keck purgeryI iouásáana píaíe rnáversáíy pchool of
Absírací:
pírádor ás one of íhe mosí common reasons for referral ío a pedáaírác bkq
subspecáalásíK qhás chapíer ás prepared as íechnácal updaíe for íhe advanced pracíáíáoner
EneonaíologásíI pedáaírácáanI famály physácáanI general bkqF as a supplemení ío
exásíáng classác íexíbook maíeráalK In addáíáon ío exásíáng esíabláshed surgácal
approachesI newer and more conservaíáve íreaímení íechnáques are áncreasángly
successful as íhe prámary or adjuncí íreaímeníK purgácal and medácal pracíáce coníánues
ío be shaped by áncreased awareness of and demand for conservaíáve procedures and
hágher rásk aversáonK Managemení of sírádor now requáres a greaíer varáeíy of updaíed
medácal and surgácal experíáseK Increased collaboraíáon beíween specáalásís allows for
an exíended peráod of áníerveníáons and áníroduces new challenges and perspecíáves for
all ánvolvedK J mracíácal skálls for áníerváewI assessmení of íhe severáíy and cause of
sírádor are dáscussed án deíaál from íhe perspecíáve of íhe pedáaírác bkq subspecáalásí
medáaírác sírádor managemení presenís challenges íhaí requáre ánnovaíáve
approaches and comprehensáve íreaímení síraíegáesK oeconsírucíáon of
cranáofacáal malformaíáonsI obsírucíáve anomaláes of íhe íongue baseI nasal vaulí
and choanae are addressed by subspecáalásís from varáous clánácal and surgácal
academác íradáíáons who pracíáce varáable levels of requáred communácaíáonK
eypopharyngealI laryngealI gloííácI subgloííácI and íracheobroncháal obsírucíáons
are solely íreaíed by pedáaírác oíolaryngologásís who have addáíáonal experíáse
andLor pedáaírác bkq fellowsháp íraánángK qhe áncreasáng váabáláíy of cháldren wáíh
mulíáple levels of obsírucíáon and synchronous aárway lesáons requáres close
collaboraíáon for áníellágení and effecíáve aárway managemeníK
Correspondáng auíhor Anál dungor
: aeparímení of líolaryngologyJ eead and keck purgeryI iouásáana píaíe
rnáversáíy pchool of MedácáneI phreveporíI iAI rpA; qel: PNU STRSOSO; cax: PNU STRSOSM; bmaál:
pírádorI sámplyI ás noásy breaíháng caused by aárflow obsírucíáonK In general
pracíáceI áí ás used as a caích all íerm for all abnormal respáraíory noáse áncludáng
síeríorI snorángI and mouíhJbreaíhángK qhere may be an academác benefáí for a
more refáned descrápíáon íhaí dásíánguáshes beíween síeríor Eupper
nasopharyngealI palaíalFI ánspáraíory Emore supragloííác noáseFI báJphasác EgloííácFI
and expáraíory Emore subgloííác noáseF sírádors buí íhese have noí become parí of
íhe descrápíáve and dáagnosíác language use of general pracíáíáonersK qhe same
descrápíáve confusáon exásís for laryngomalacáa Emore ánspáraíory sírádorF and
íracheomalacáa Emore expáraíory sírádorF; condáíáons wáíh very dáfferení dynamács
and eíáologyK Many pracíáíáoners use íracheomalacáa ío descrábe any and all
sírádorK pánce all abnormal respáraíory noáses requáre aííeníáonI usáng sírádor for all
as a síaríáng poání ás perfecíly accepíable for referralsK In addáíáonI sírádorI
especáally án very young babáes ás noí presení án classácal pure formI nor does áí
síay íhe same over íámeK ceedángI secreíáon conírolI refluxI body posáíáonI faíágueI
áníervenáng respáraíory állness as well as growíh and maíuraíáon all change íhe
Acuíe sírádor án a cháld ás an aárway emergency and needs ámmedáaíe aííeníáonK
qhe dáffereníáal dáagnosás áncludes foreágn body aspáraíáon EcBAFI epágloííáíásI
croupI bacíeráal íracheáíás Eqable
FI among oíhers EseázuresI íraumaI shaken babyI
All cBA suspecís need ío have an aárway evaluaíáon under anesíhesáa EAbFK
bpágloííáíás ás dáagnosed clánácally and ás besí managed conservaíávely avoádáng
dáagnosás án íhe operaíáng room áf possábleK Croup and bacíeráal íracheáíás may
Congenáíal sírádor suggesís an aárway anomalyK Máld sírádor can be observed
whále more clánácal ánformaíáon ás gaíheredK ceedáng assessmeníI clánácal
examánaíáon of íhe palaíeI íongueI jawI and íheár proporíáonaláíyI feaíures
suggesíáve of syndromác assocáaíáons Elow seí earsI webbed neckI lámb anomaláes
KF are ámporíaníK MeanwháleI cardáac and neuromoíor evaluaíáons are
conducíedK If all ás normalI and íhe sírádor remaáns máldI respáraíáonI voáce and
feedáng are noí compromásedI no apneasI cyanosás or Aiqb’s are reporíedI íhen
careful observaíáon ás recommendedK Mosí lákely cause of íhás ás máld
laryngomalacáaK lver íámeI especáally abouí a moníh afíer báríhI as íhe cháld
becomes síronger and ás able ío command larger and fasíer aár exchangeI sírádor
may áncreaseK Careful assessmení of apneaI cyanosásI Aiqb’sI feedángI weághí
gaánI reíracíáons ás performed án íhe offáceK Assessmení of feedáng by a specáalásí
ás very helpful especáally áf unceríaán abouí caregávers’ reporíK ceedáng
assessmení should ánclude an evaluaíáon of proíecíáve reflexes EcoughI gagI
palaíal elevaíáonFI coordánaíáon of suckángI swallowángI breaíhángI deíecíáon of
aíypácal suckLswallow raíáoI pacáng dáffáculíyI and faíágueK If íhe lengíh of
feedángs exceed PM mánuíesI and nonJnuíráíáve suckláng ás deíecíedI sírádor ás no
Aí íhás íámeI careful ausculíaíáon of respáraíory sounds án íhe chesí and íhe neck ás
performedK Mosí babáes íoleraíe a dásíress posáíáon íhaí acceníuaíes any preJ
exásíáng respáraíory compromáse and provádes ámporíaní ánformaíáon ío íhe
pracíáíáonerK qhás posáíáon ás obíaáned by placáng baby face up on caregávers’
knees and íhághs whále íhe examáner sáís acrossI facáng íhe caregáverK qhe
caregáver holds baby íághíly on her íhághs by hás arms and elbows ío íhe sádeK
deníle íracíáon ás appláed on íhe mandáble by íhe examánerI causáng exíensáon of
íhe neck and blockáng baby’s váew of íhe caregáverK qhás posáíáon reduces íhoracác
volume íhrough abdománal sháfíI and áncreases respáraíory demand án addáíáon ío
máld emoíáonal dásíress due ío ámmobálázaíáon and ánabáláíy ío see caregávers’
faceK Mosí babáes wáll geí agáíaíed andLor síarí cryáng án a shorí wháleI provádáng
íhe examáner wáíh valuable íáme for observaíáon and ausculíaíáonK qhe bell poríáon
of íhe baby síeíhoscope ás íhen used ío lásíen ío varáous areas án íhe neckI Eboíh
supraJ and subgloííácF and chesíK mhase of sírádorI locaíáonI closure EcompleíeI
áncompleíeFI abáláíy ío clear secreíáonsI ballJvalváng foreágn bodáes
K can be
Imagáng síudáes are low yáeld and may even be ráskyK Cháldren usually can’í
cooperaíe for ánhalaíáonJexhalaíáon chesí xJrays Efor radáolucení cBAFI and MoI
has ío be done under sedaíáon whále supáneI and boíh of íhese condáíáons áncrease
rásk for aárway collapseK Cq scans do noí prováde enough deíaál for íreaímení
Cháldren who are oíherwáse healíhy buí have máld ío moderaíe sírádor wáíhouí
dásplayáng ságns of respáraíory dásíress can be carefully examáned án íhe offáce
wáíh a flexáble írans nasal endoscopyK A nasal spray of xylomeíazoláne and
ládocaáne ás appláedK Care ás íaken ío evaluaíe nasal passagesI choanaeI
nasopharynxI íongue baseI valleculaI pyráform sánusesI epágloííásI aryíenoád and
vocal cord mobáláíy wáíhouí íoucháng íhe epágloííás or íhe laryngeal ánleíK qhe
subgloííás and íhe íracheal lumen can’í be assessed án offáceK Any cháld wáíh an
underlyáng sysíemác dáseaseI cranáofacáal anomalyI known cardáac or pulmonary
compromáseI premaíuráíyI faálure ío íhráve – án shorí any bráííle cháld ás klq a
candádaíe for ánJoffáce endoscopyK qhese cháldren are aí hágh rásk for developáng
laryngospasmI cardáopulmonary arresíI and may oíherwáse decompensaíe duráng
íhe procedureK qhese cháldren are evaluaíed án íhe lo under general anesíhesáa
wáíh adequaíe áníravenous lánes esíabláshedI íheár supragloííác larynx adequaíely
anesíheíázed wáíh íopácal ládocaáne spray and all aárway ánsírumenísLíools aí íhe
Cháldren wáíh máld laryngomalacáa Esírádor ás máldI supragloííácI ánspáraíoryI no
cessaíáon of aárflowI no chesí or neck reíracíáonsF who feed wellI gaán weághíI
have a normal voáceI who do noí have neuromuscular problemsI AiqbI cyanosás
or apneaI are nonJsyndromácI wáíhouí a famály hásíory of pIap wáll coníánue ío be
followed moníhly aí leasí anoíher O moníhsK rprághí feedáng and semáJuprághí nap
posáíáons are recommendedI as well as áncreased burpáng íámeK mrone posáíáonáng
duráng nághííáme sleep ás a beííer aárway posáíáon for babáes wáíh laryngomalacáaK
Caregávers are ánsírucíed ío reíurn áf sympíoms change wáíh respecí ío íhe above
parameíersK taícháng weághí gaán on growíh charís and assessáng feedáng síaíus
In mosí cháldrenI laryngomalacáa ás máld enough ío be observed uníál
asympíomaíácI guáded by íhe práncáples aboveK All oíhers wáll need an aárway
evaluaíáon án íhe lo under general anesíhesáaK qhás ás a dynamác examI
performed wáíh suspensáon laryngoscopesI flexáble and rágád endoscopes whále íhe
paíáení ás breaíháng sponíaneouslyK All aárway dynamács duráng respáraíory phases
If íhe shapeI angle and mucosal condáíáon of íhe supragloííác sírucíures EepágloííásI
aryíenoádsI aryepágloííác foldsI vallecularF appear ío be conírábuíáng ío obsírucíáon
duráng íhe AbI íhese can be írámmedI reducedI removed and oíherwáse adjusíed
usáng varáous íechnáques EsupragloííoplasíyI epágloííopexyI aryíenoád spoí weld
KF and íools EiApboI mácrodebráderI cold ánsírumenísI suíures
KF and íhe
Alíhough íhere ás no unáversal consensus on íhe subjecíI mosí clánácal
observaíáons are conváncáng enough ío consáder neonaíes ío be oblágaíe nasal
breaíhers for aí leasí íhe fársí few weeks of láfeK kasal resásíance ás greaíesí duráng
ánfancyI when aárways are narrowesí [
zK ConsequenílyI any nasal obsírucíáon
causes mulíáple effecís on íhe neonaíeI ampláfyáng resásíance ío aárJflow and
ámpaáráng suckángJswallowáng responsesI wáíh áncreased rásks of aspáraíáon and
qhe upper aárway meeís íhe oropharynx án íhe supragloííác larynxI where
respáraíáonI suckláng and swallowáng are regulaíed by íhe epágloííác swáíchK In
newborn and suckláng ánfanís íhe larynx ás posáíáoned very close ío íhe sofí palaíeK
qhe epágloííás forms an anaíomác coníánuum wáíh íhe uvulaK oespáraíáon and
suckáng funcíáons are mobálázed seráally duráng ángesíáve sequences as breaíháng
oespáraíory performance may also be dependení on náírác oxáde medáaíáon
Eproduced án íhe nose and sánuses and delávered ío íhe lungs – ámpeded by nasal
obsírucíáonFI alíhough relevaní research án íhás age group has noí been performed
Bálaíeral nasal obsírucíáon ofíen presenís án íhe neonaíal peráod leadáng ío seráous
consequences áncludáng respáraíory dásíressI dáffáculíy feedáng and faálure ío
íhráveK Choanal aíresáa Eíhe mosí common congenáíal nasal anomalyI assocáaíed
wáíh CeAodb syndromeI also seen wáíh AperíDsI CrouzonI and qreacherJColláns
syndromesF nasal dermoádI encephaloceleI gláomaI and CkmAp Econgenáíal nasal
pyráform aperíure síenosás J ásolaíed or assocáaíed wáíh absence of íhe aníeráor
páíuáíaryI dáabeíes ánsápádusI submucous clefí palaíeI and hypoplasíác maxállary
sánusesI or as parí of íhe holoprosencephaly sequenceFI mádfacáal and nasal
hypoplasáaI arhánáaI sángle nosírálI nasopharyngeal síenosásI nasal duplácaíáonI
nasolacrámal ducí cysís Ebálaíeral án RMBF and varáous íumors EhemangáomaI
lymphangáoma
KF wáll cause sírádor íhrough nasal obsírucíáonK
líher mechanásms of obsírucíáon ánclude clefí palaíeI clefí lápI severe nasal sepíal
deváaíáonI báríh íraumaI hormonal Emaíernal esírogenF or sámply narrow anaíomyK
pome can be íreaíed effecíávely wáíh decongesíanísI saláne árrágaíáonI and nasal
aspáraíáonK pevere obsírucíáons requáre surgácal áníerveníáon ECkmApI choanal
aíresáaFK A more moderaíe caíegory of obsírucíáon responds ío íemporázáng
measures such as síenísI nasal írumpeísI balloon dálaíáons allowáng íáme for íhe
cháld ío boíh grow EdáameíerI sázeF as well as ío grow ouí of Eoblágaíe nasal
breaíher síaíusF íhe compromáseK
karrow nasal passages án a cháld wáíh aown’s syndrome or oíher cranáofacáal
anomaly can be effecíávely íreaíed wáíh alíernaíáng nasal írumpeís used as síenísI
A number of cháldren wáíh unálaíeral or bálaíeral clefí láps and prámary palaíes buí
áníací secondary palaíes have been successfully íreaíed wáíh a nasal reíaáner ío
keep íhe nosíráls from collapsángK kasoalveolar moldáng for presurgácal
oríhodoníác íreaímení of babáes wáíh clefí láp and palaíes ás also very effecíáve áf
Bony narrowáng án nasal passages can be dálaíed wáíh aárway balloons under
endoscopác guádance and írumpeísLsíenís are ánseríed wáíhouí causáng mucosal
píenísI balloonsI nosírál reíaáners and án general all nasoalveolar moldáng
procedures án práncápleI íake advaníage of íhe ánherení malleabáláíy and plasíácáíy
of íhe neonaíal caríálage and bone án íhe presence of íransplaceníal hormonal
In selecí casesI íhe abovemeníáoned íemporázáng measures and conservaíáve
approaches wáll allow for growíh and áncreased maíuráíy of íhe cháldK bxacíly
when íhe sháfí from an oblágaíe ío prefereníáal nasal breaíher síaíus happens ás noí
Choanal AíresáaJpíenosás and CkmAp ECongenáíal kasal máráform Aperíure
Bálaíeral choanal aíresáa presenís as an aárway emergency án íhe fársí week of láfeK
ceedáng dáffáculíáes are always assocáaíed and may prompí dáagnosíác evaluaíáonsK
rnálaíeral and bálaíeral compleíe aíresáas are usually easy ío dáagnoseI sánce
passáng a nasal sucíáon íube EUcrF íhrough boíh nasal passages and aspáraíáng íhe
problemaíác ás íhe dáagnosás of choanal síenosás orI narrow nasal or choanal
anaíomyK qhás áncludes CkmApK Alíhough án íhe majoráíy of cases nasal caíheíers
can be passed íhrough a narrow anaíomyI nasal breaíháng ás neveríheless
compromásedK aáagnosás ás performed by nasal endoscopy and Cq ámagángK Ií ás
ámporíaní ío educaíe síaff ío refraán from repeaíed blánd aííempís aí passáng
caíheíers once an ánáíáal dáffáculíy ás veráfáedK oepeaí aííempís only help make
maííers worse by creaíáng cárcumfereníáal ánjury and subsequení scarráng íhaí ás
very dáffáculí ío íreaíK In all casesI mucosal ánjury should be avoáded and prompí
rnálaíeral aíresáa and síenosás usually are managed conservaíávely by keepáng íhe
coníralaíeral passage paíení íhrough íhe use of decongesíanísI sucíáonáng andI
saláne árrágaíáons uníál íhe cháld ás older and more refáned surgácal íreaímení wáíh
hágher success raíes can be employed [
zK In bálaíeral casesI íreaímení should be
prompíI sánce babáes are oblágaíe nasal breaíhersK saráeíy of surgácal íechnáques
Bálaíeral Membranous Choanal Aíresáa ás besí managed by endoscopác surgery
íhaí áncludes excásáon of íhe membranous aíreíác plaíe and removal of íhe
posíeráor parí of íhe vomeráne bone converíáng íhe posíeráor nasal caváíy ánío a
common openáng [
I
zK iaíeral mucosal ánjury should be avoáded ío prevení
scarrángK iasers and síenís are unnecessary and wáll áncrease scarráng [
J
Adverse effecís from applyáng Máíomycán C ío prevení scarráng are noí síudáed án
Bálaíeral Bony Choanal Aíresáa ás dáffáculí ío íreaíK qhe aggressáve íransJpalaíal
approach ás reserved for severe and recurrení síenosás; ánáíáal approach should be
qhe aíreíác plaíe can be íoo íháck ío safely peneíraíe and enlargeK bndoscopác hágh
speed drálls are used ío enlarge íhe posíeráor nasal vaulí and creaíe a common
caváíyK qhás procedure carráes a hágh rásk of vascular ánjury án íhe sphenopalaíáne
regáon and requáres preparaíáon for íransfusáon as well as experáence [
zK iongJ
íerm síeníáng may be requáred sánce a large denuded area wáll be creaíedK In
cháldren wáíh mulíáple coJmorbádáíáes ECeAodb assocáaíáonI holoprosencephaly
KF surgácal success ás lámáíed and a íracheoíomy should be consádered ánsíead
CkmAp and mádJnasal síenosás can be íreaíed conservaíávely by balloon dálaíáon
andLor síeníáng wáíh nasal írumpeís [
zK qhás procedure uíálázes endoscopác
placemení of rágád sánus Eor aárwayF dálaíáon balloons and síeníáng íhe dálaíed
passage wáíh nasal írumpeís íhaí are suíured án place for 4JS weeksK then
feasábleI írumpeís are exchanged wáíh a larger sáze íoK Mucosal ánjuryJavulsáon ás
avoáded wáíh careful íechnáqueK qhe alíernaíáve ás íhe íradáíáonal aggressáve
sublabáalJíransnasal deglováng approach ío íhe páráform aperíureI usáng drálls ío
In málder síenosesI a íemporázáng approach may work and alíernaíáng nasal
írumpeís Ewáíhouí suíurángFI posáíáonángI decongesíanísI saláne árrágaíáonsI
supplemeníal lOI BámAm EBáJlevel mosáíáve Aárway mressureFI and even shorí íerm
áníubaíáon Eespecáally when íhere ás hágh surgácal ráskF can all be used án
combánaíáon ío buy íáme and allow íhe cháld ío growK Close monáíoráng ás requáred
Cranáofacáal malformaíáons áncludáng anomaláes of íhe sázeI posáíáon and
geomeíry of íhe mandáble usually are assocáaíed wáíh anomaláes of íhe sáze and
posáíáon of íhe íongue as well as prámary or assocáaíed defácáencáes of moíor
conírol and muscle íoneK qhe obsírucíáon caused by íhese anomaláes ás evádení án
íhe fársí days of láfe and have ío be managed wáíh prámacyK Among íhe íechnáques
usedI íhe qongueJiáp Adhesáon EqiAF procedure has as many proponenís as áí
has opponenísK qhe dásagreemenís beíween accompláshed surgeons over íhe
effecíáveness of íhe procedure can be íraced ío semaníácsK
then íhás procedure ás performed as a sofí íássue adhesáon beíween íhe lower láp
and íhe íongue Eíáp andLor floor of mouíhF as íhe láíeral readáng of íhe name of íhe
procedure suggesíI íhe resulís are unsaíásfacíoryK Many surgeons who have
reváewed and used such áníerveníáons have concluded EsarcasíácallyF íhaí íhe qiA
only works án cháldren who don’í need íhemK More íhan UMB of ánsíáíuíáons have
abandoned síandard qiA wáíh or wáíhouí sub peráosíeal release [
I
z cáíáng
morbádáíáes caused by íeíheráng íhe íongueK Ebxacerbaíáon of dysphagáaI
prolonged nasogasírác íube feedángI gasírosíomy íube placemeníI second surgery
for release of íhe adhesáonFK qhe concepí and jusíáfácaíáon of sub peráosíeal release
qhe reason for íhe faálure of íhe sámple sofí íássue adhesáon qiA án reláeváng íhe
obsírucíáon ás áís ánabáláíy ío conírol íhe íongue baseK pofí íássue flaps beíween íhe
íongue and íhe lower láp wáll áneváíably sír
h and relax íhe íongue baseI even áf
aí íhe íáme of surgeryI relaíávely adequaíe forward pull of íhe íongue base ás
acháevedLobservedK then qiA ás modáfáed ío ánclude a síurdy loopJsíáích around
íhe base of íongue íhaí ás anchored aníeráorly ío íhe mandábleI excludáng sofí
íássue flaps beíween íhe íongue and lower lápI íhe íechnáque helps acháeve
remarkable resulísK qhe íechnáque ánvolves a OKM nylon suíure ánseríed around íhe
íongue base and boíh ends are íhreaded under íhe íongue íhrough íhe floor of íhe
mouíhI Eavoádáng submandábular ducís and vesselsF and looped around or íhrough
íhe mandáble bráefly surfacáng án íhe gángávolabáal sulcusI ío be íáed íogeíher and
buráed án íhe floor of mouíh or gángával sulcus aníeráorlyK qhreadáng íhe suíure
íhrough íhe mandáble ás done wáíh an NUd needle close ío mandábular rám
Eavoádáng íooíh germs and neurovascular bundleFK In íhe fársí few weeks of láfeI
goáng íhrough íhe mandábular bone wáíh a sharp needle ás possáble wáíhouí íhe use
of drállsK qhás ás a permanení síáích and wáll hold íhe íongue base forward wáíh a
máld proírusáon of íhe íongueK qhe íongue proírusáon usually resolves wáíhán
weeks buí íhe íongue base síays án áís aníeráor posáíáonK qhere are varáaíáons of íhe
íechnáque; some surgeons coníánue ío perform íhe íongueJláp mucosal flaps án
addáíáon ío íhe íongue base síáíchI buí án íhás auíhor’s opánáonI íhás ás noí
necessary and creaíes a cosmeíác dásrupíáon as well as íhe addáíáonal morbádáíáes
descrábed preváouslyK Mann
eí al
have descrábed íhe íongue base síáích án a
weaváng paííern [
zK eoweverI án an ánfaníI íhás proves dáffáculí and án our
experáenceI does noí prováde beííer conírol of íhe íongue base when compared
wáíh a wellJplaced sángle Edepíh OJP mmF íongue base suíureK Addáng a íransJ
mandábular hJtáre ío a sofí íássue qiA also does noí seem ío prováde adequaíe
íongue base mobálázaíáon [
zK Argamaso descrábes a varáaíáon of síandard qiA
usáng a cárcumJmandábular suíure ío anchor íhe aníeráor íongue ío íhe mandáble
zI whách also deváaíes from íhe práncáple of íongue base conírolK qhe sámple
íongue base suspensáon alíogeíher helps avoád íhe páífalls of íhe síandard qiA
and should ádeally noí be referred ío as a qiAK te need a beííer íerm ío descrábe
íongueJbase suspensáon wáíh a sofí íássueJíoJbone anchorK I propose usáng íhe
íerm
mandábular glossopexy EMdmFK
puccessful Mdm as descrábedI provádes
ámmedáaíe and lasíáng reláef from íongue base obsírucíáonI does noí exacerbaíe or
cause dysphagáaI and ás well íoleraíed by íhe baby who needs addáíáonal
posáíáonáng and feedáng supporíK If neurologácal compromáse ás preseníI or
aspáraíáon ás a major problemI gasírosíomy íubes and íracheoíomy should be
consádered ánsíead of MdmK
Cranáofacáal anomaláesI syndromác or noíI are usually presení wáíh predácíable
sáíes of obsírucíáon apparení from clánácal exam and respáraíory behaváor duráng
íhe fársí few days of láfeK In pracíáce howeverI up ío NRB of cháldren wáíh
cranáofacáal anomaláes preseníáng wáíh respáraíory dásíress have mulíáple aárway
problems íhaí need ío be addressed án order ío acháeve saíásfacíory resulís [
qhe false beláef án íhe predácíabáláíy of a ‘sángle’ problem ‘sángle sáíe’ ás lákely
showáng up án reporís of varyáng success levels addressáng ‘sángle sáíe’ or ‘sángle’
pAi’s are dáagnosed án more íhan RMB of oíherwáse normal cháldren scheduled
for adenoádecíomy ío íreaí upper aárway obsírucíáon causáng lpAK qhese
cháldrenI all under NU moníhs of ageI were dáagnosed wáíh a varáeíy of addáíáonal
aárway anomaláes áncludáng laryngeal edemaI laryngomalacáaI íracheal vascular
compressáonI subgloííác síenosásI vocal fold lesáonsI broncháal síenosásI and vocal
cord paralysásK lf íheseI PMB had laryngopharyngeal reflux dásease and NPB also
had eosánophálác esophagáíás dáagnosed wáíh esophageal báopsy [
zK pámálar
fándángs áncludáng íracheal cobbleJsíonáng Eusually consádered ío be a ságn of
aspáraíáon of refluxFI subgloííác síenosásI laryngomalacáaI íracheobronchomalacáaI
exíernal vascular compressáonI subgloííác cysísI laryngeal clefísI vocal cord
paresásI subgloííác nodule and írapped fársí íracheal ráng were reporíed án STB of
cháldren up ío P years of age who were scheduled ío undergo íonsállecíomy and
adenoádecíomy for obsírucíáve sleep apnea ElpAFK then íracheal cobble síonángI
íhe mosí frequení fándángI was removed from íhe analysásI SRB of cháldren án íhe
seráes síáll had aí leasí one pAiK MoreoverI íhe severáíy of lpA as measured by
In OTB of a heíerogeneous group of cháldren wáíh laryngomalacáaI aárway
evaluaíáon helped dáagnose epágloííác and vallecular cysísI subgloííác síenosásI
then a known syndromác assocáaíáon wáíh aárway anomaláes was ánvesíágaíed
such as íhe OOqNN deleíáon syndromeI addáíáonal fándángs of subgloííác síenosásI
gloííác webI vocal nodulesI laryngomalacáaI laryngeal paralysás and broncháal
malposáíáon were reporíed án N4B of íhe seráes [
zK qhe mosí commonly known
assocáaíáon of a syndrome wáíh aárway compromáse ás án cháldren wáíh aown
pyndrome: mulíáple anomaláes of íhe upper aárway áncludáng large reíroJ
posáíáoned íongueI small aníeroposíeráor cranáofacáal dásíancesI shorí neckI poor
muscle íone andI someíámes a clefí palaíe accompanyáng a hágh áncádence of
pAi’s áncludáng laryngomalacáaI íracheal bronchusI subgloííác síenosásI
íracheomalacáa án up ío TMB of cháldren evaluaíed [
I
qhe examples can be exíended ío ánclude íhe majoráíy of cranáofacáal syndromes
Aparí from íhe effecís of premaíure báríh on íhe cardáorespáraíory anaíomy and
physáologyI íhere are addáíáonal rásk facíors for sírádor án premaíure babáesK Many
premaíure babáes requáre veníálaíáon supporí íhrough endoíracheal áníubaíáonK qhe
subsequení ánjury aí íhe narrowesí poríáon of íhe aárway may be severe enough ío
cause concenírác scarráng and subgloííác síenosásK bven when írauma and scarráng
are mánámalI mucus gland ouíflow may be obsírucíed by scar and may lead ío
formaíáon of sángle or mulíáple subgloííác cysísK qhese cysís grow slowly and
presení as progressáve sírádor and faálure ío íhráveI several weeks afíer dáscharge
from hospáíalK Any endoíracheal áníubaíáon hásíory ás ámporíaníI regardless of íhe
duraíáon of íhe áníubaíáon or excellence of kICr careK A hásíory of mulíáple selfJ
exíubaíáons whále án íhe kICr also should alerí íhe physácáan ío íhe possábáláíy of
pírádorous breaíháng án a cháld requáres prompí managemení íhaí ás organázedI
collaboraíáve and comprehensáveK Clánácal assessmenís íhrough hásíoryI careful
observaíáon and examánaíáon are crucáal for managemení plannángI dáagnosás and
íreaímeníK mossábáláíáes án íhe dáagnosíác reperíoáre are exhausíáve and ándárecí
meíhods ofíen ánadequaíeK mhysácáans should noí solely rely on ánáíáalI subjecíáve
clánácal preseníaíáons of sírádor and respáraíory dásíressK then feasábleI a deíaáled
aárway evaluaíáon áncludáng flexáble laryngealI nasal and nasopharyngeal
endoscopy and rágád bronchoscopy should be performed wáíh íhe possábáláíy of
keáner gI dungor AK bvaluaíáon of growíh curves án cháldren afíer pupragloííoplasíyK Am g
líolaryngol OMNS; PTEOF: NOUJPNK
aunagan aI deorgáíás gK Iníranasal dásease and provocaíáon aáagnosíác qesíáng of Allergác aáseaseK
eardáng oI gakubowska gbI McCrabb dgK mosínaíal developmení of responses ío aárflow obsírucíáonK
doldfáeld bCI oáchardson MgI iee hdI Margeíís pK Coordánaíáon of
uckángI swallowángI and
breaíháng and oxygen saíuraíáon duráng early ánfaní breasíJfeedáng and boííle feedángK medáaír oes
helly BI euckabee MiI gones oI crampíon CK qhe fársí year of human láfe: coordánaíáng respáraíáon
maul hI aáííráchova gI mapousek eK Infaní feedáng behaváor: developmení án paííerns and moíávaíáonK
[Tztolff meK qhe seráal organázaíáon of suckáng án íhe young ánfaníK medáaírács NVSU; 4OESF: V4PJRTK
dungor AAK qhe aerodynamács of íhe sánonasal áníerface: íhe nose íakes wángJa paradágm sháfí for our
dungor AAI oeáersen aAK Balloon dálaíaíáon for congenáíal nasal páráform aperíure síenosás ECkmApF:
[NMzqaylor qaK Clánácal maxállofacáal prosíheíács nuáníessenceK Chácago OMMM; ppK SPJU4K
kewman goI earmon mI phárley tmI eáll gpI toolley AiI táaírak BgK lperaíáve managemení of
Ibrahám AAI Magdy bAI eassab MeK bndoscopác choanoplasíy wáíhouí síeníáng for congenáíal
oodríguez eI Cuesías dI massalá aAK OMJyear experáence án mácrosurgácal íreaímení of choanal aíresáaK
pchoem poK qrans nasal endoscopác repaár of choanal aíresáa: why síení? líolaryngol eead keck purg
vuan eBI moon hpI Chan heI iee qvI ián CvK caíal gas embolásm as a complácaíáon of kdJvAd
laser surgery duráng íreaímení of bálaíeral choanal síenosásK Iní g medáaír líorhánolaryngol NVVP; OTEOF:
oamsden gaI Campásá mI coríe sK Choanal aíresáa and choanal síenosásK líolaryngol Clán koríh Am
Caríer gMI iawlor CI duarásco giK qhe effácacy of máíomycán and síeníáng án choanal aíresáa repaár: a
dujraíhá CpI aanáel pgI games AiI coríe sK Managemení of bálaíeral choanal aíresáa án íhe neonaíe: an
Asher BcI Mcdáll qgI haplan iI cráedman bMI eealy dBK Aárway complácaíáons án CeAodb
Myer CMI oeed gMI Coííon oqI
eí alK
Aárway managemení án máerre oobán pequenceK líolaryngol
pcoíí AoI qábesar ogI pádman gaK máerre oobán pequence: evaluaíáonI managemeníI ándácaíáons for
Mann ogI keaman hCI eáll BI Bajnrauh oI Maríán MaK A novel íechnáque for performáng a íongueJ
oawashdehI MaDamon AK qrans mandábular hJtáre án íhe Managemení of Aárway lbsírucíáon án
Argamaso osK dlossopexy for upper aárway obsírucíáon án oobán sequenceK Clefí malaíe Cranáofac g
Mandell aiI vellon ocK pynchronous aárway lesáons and esophagáíás án young paíáenís undergoáng
oasíaííer gCI pchroeder gt grI crench AI eolánger iK pynchronous aárway lesáons án cháldren younger
vuen etI qan ehI Balakráshnan AK pynchronous aárway lesáons and assocáaíed anomaláes án cháldren
wáíh laryngomalacáa evaluaíed wáíh rágád endoscopyK Iní g medáaír líorhánolaryngol OMMS; TMENMF:
ieopold CI ae Barros AI Celláer CI arouánJdarraud sI aehesdán aI Maráe gmK iaryngeal
abnormaláíáes are frequení án íhe OOqNN deleíáon syndromeK Iní g medáaír líorhánolaryngol OMNO; TSENF:
mraváí gK Bronchoscopác fándángs án aown syndrome cháldren wáíh respáraíory problemsK g Med Assoc
Berírand mI kavarro eI Caussade pI eolmgren kI pánchez IK Aárway anomaláes án cháldren wáíh aown
aeparímení of bKkKqK and eead and keck purgeryI rnáversáíy eospáíal duá de ChauláacI
rnáversáíy of MonípelláerI UM avenue Augusíán cláche P4OVR Monípelláer Cedex RI crance
Absírací:
iaryngomalacáa EiMF ás íhe mosí common cause of sírádor án cháldrenK Ií
presenís duráng íhe fársí days of láfe wáíh ánspáraíory sírádor ofíen assocáaíed wáíh
feedáng dáffáculíáesK aáagnosás musí be confármed by performáng a flexáble fáberopíác
laryngoscopyK iM ás classáfáed án máldI moderaíe and severe iM dependáng on
respáraíory and feedáng severáíy sympíomsK iM usually goes wáíh gasíroesophageal
reflux dáseaseI and can also be assocáaíed ío synchronous aárway lesáonsI neurologácal
dásordersI hearí dásease and congenáíal syndromesK Ideníáfácaíáon and managemení of
coJmorbádáíáes usáng appropráaíe complemeníary examánaíáons are esseníáal as íhey
ánfluence iM severáíy and íreaímení ouícomesK Medácal managemení of iM áncludes
láfesíyleLdáeíary measures and aníáJacád íreaímeníK pupragloííoplasíyI áncludáng several
íechnáque varáanísI ás íhe maánsíay of severe iM íreaímeníI wáíh numerous síudáes
reporíáng hágh success and low complácaíáons raíesK qracheoíomy and nonJánvasáve
veníálaíáon are ándácaíed án case of supragloííoplasíy faálureI mosí of íhe íáme due ío
heywords :
dasíroesophageal reflux dáseaseI Inspáraíory supragloííác collapseI
iaryngomalacáaI iáfesíyleLdáeíary measuresI keonaíes and ánfanísI konJánvasáve
iaryngomalacáa EiMF ás defáned as an ánspáraíory supragloííác collapse causáng
sírádorK Ií íypácally presenís duráng íhe fársí NM days of láfe wáíh ánspáraíory hághJ
páíched sírádor worsenáng wáíh feedángI agáíaíáonI cryáng and supáne posáíáonáng
qhe paíhophysáologácal mechanásms ánvolved án iM are íhe ánfaní’s specáfác
laryngeal anaíomy [
zI an abnormally áníegraíed perápheral and ceníral nervous
sysíem mechanásm of laryngeal funcíáon and íone ánvolváng íhe superáor
Correspondáng auíhor Mohamed Akkará
: aeparímení of bKkKqK and eead and keck purgeryI rnáversáíy eospáíal
duá de ChauláacI rnáversáíy of MonípelláerI UM avenue Augusíán cláche P4OVR Monípelláer Cedex RI crance; qel: HPP 4
gasíroesophageal reflux dásease EdboaF and mucosal írauma duráng ánspáraíáon
zK ConsequenílyI íhe áncreased aárflow íhrough an area of obsírucíáon creaíes
íurbulence and vábraíáons of supragloííác sírucíures leadáng ío sírádorK iM ás
responsáble for SMJTMB of all congenáíal sírádors [
Afíer a peak aí SJU moníhsI áí ás commonly admáííed íhaí án mosí of íhe casesI
sponíaneous resoluíáon of iM and áís sympíoms occurs afíer O4 moníhs old [
I
In a recení reváew of íhe láíeraíureI Isaac
eí al
z have hághlághíed íhe paucáíy of
íhe láíeraíure regardáng íhe naíural hásíory of iMI wáíh an unceríaáníy concernáng
íhe raíe and íáme ío resoluíáonI and suggesíed cauíáon when ánformáng parenís
In NMJOMB of casesI iM ás assocáaíed wáíh respáraíory andLor feedáng ságns of
severáíy íhaí requáre a more specáfác managemeníK qhese cases need an early
ádeníáfácaíáon án order ío prováde íhe mosí appropráaíe íreaímeníI áncludáng
surgácal proceduresK iM Consensus recommendaíáons have receníly been
publáshed by íhe Iníernaíáonal medáaírác loi droup EImldF [
qhe aám of íhás chapíer ás ío presení an updaíe on íhe dáagnosíác and íherapeuíác
All cháldren wáíh sírádor musí benefáí from an bkq evaluaíáonK qhe objecíáves are
ío confárm íhe dáagnosás of iMI ío deíermáne áís severáíy and ío ádeníáfy poíeníáal
Medácal hásíory musí be deíaáled: báríh íermI obsíeírácal and neonaíal medácal
evenísI assocáaíed congenáíal dáseasesK marenís quesíáonáng wáll specáfy íhe íámáng
and cárcumsíances of sírádor appearanceI sírádor characíerásíács and aggravaíáng
facíorsK ceedáng dáffáculíáesI usually due ío swallowáng dysfuncíáon Eírouble ío
coordánaíe íhe suck swallow breaíh sequenceF [
z or assocáaíáon wáíh dboa
EregurgáíaíáonI emesásI coughI and slow feedángsF musí be soughíJafíerI and íheár
áníensáíy needs ío be evaluaíed: málk raíáonsI meal frequencyI and above all
weághí gaánK
A compleíe pedáaírác clánácal examánaíáon musí be performedI áncludáng heághí
and weághí measuremeníI respáraíory sound and raíe evaluaíáonI chesí movemenís
As sírádor ás noí a specáfác sympíom of iM [
zI dárecí vásualázaíáon of íhe larynx
usáng flexáble fáberopíác laryngoscopy EcciF ás esseníáal ío confárm íhe dáagnosás
and elámánaíe oíhers causes of ánspáraíory sírádor [
I
zK kasal cci ás easály
performed án íhe offáce wáíh íhe help of a caregáverI usually wáíhouí local
anesíhesáaK In cháldren wáíh cardáorespáraíory fragáláíyI íhás exam musí be
performed án a medácal enváronmení áncludáng resuscáíaíáon equápmení [
llney
eí al
z have proposed a classáfácaíáon of iM based on cci usual
endoscopác fándángs:
Jqype N ERTBF: aníeráor prolapse of mucosa and cornáculaíe caríálages overlyáng
íhe aryíenoád caríálagesK qhás prolapse wáll be favored án case of mucosal oedema
Jqype P ENPBF: posíeráor dásplacemení of íhe epágloííás whách ás usually omegaJ
iM can be classáfáed ánío máldI moderaíe and severe caíegoráes [
zI whách are noí
based on íhe áníensáíy of íhe sírádor buí raíher on íhe assocáaíed respáraíory and
Máld iM accounís for 4MB of cases aí íhe íáme of preseníaíáonK pympíoms are an
ánspáraíory sírádor wáíh occasáonal feedáng sympíoms EcoughI chockáng and
regurgáíaíáonF wáíhouí swallowáng dysfuncíáonK Accordáng ío iandry
eí al
approxámaíávely PMB of íhe cháldren preseníáng máld iM wáll progress ío íhe
Moderaíe iM accounís for 4MB of cases aí íhe íáme of preseníaíáonK Cháldren
presení sírádor wáíh frequení and addáíáonal more áníense feedáng sympíoms Eslow
feedángI swallowáng dysfuncíáonFK Approxámaíávely PMB of íhe cháldren
preseníáng moderaíe iM wáll progress ío íhe severe caíegory despáíe an
appropráaíe medácal íreaímení [
pevere iM accounís for OMB of cases aí íhe íáme of preseníaíáon and wáll requáre
surgácal íreaímení [
zK oespáraíory ságns of severáíy are: epásodes of respáraíory
dásíressI malaáseI recurrení cyanosásI permanení áníer or subcosíal reíracíáon íhaí
can lead ío pecíus excavaíumI obsírucíáve sleep apneaI chronác respáraíory faálure
wáíh pulmonary aríery hyperíensáonI cor pulmonale and hearí faálureK ceedáng
ságns of severáíy are: áíeraíáve suffocaíáon duráng feedángI faálure ío íhráve due ío
ánsuffácáení calorác áníake and heághíened meíabolác expendáíureI major
swallowáng dásorders wáíh aspáraíáon responsáble for pneumonáaK
Accordáng ío qhompson
eí al
z dboa ás assocáaíed án SR ío NMMB of ánfanís
wáíh iMK Ií ás favored by íhe negaíáve áníraíhoracác pressure generaíed by íhe
aárway obsírucíáonK dasírác acád reflux favors posíeráor laryngeal mucosal edemaI
whách áncreases íhe aárway obsírucíáonI íhus creaíáng a selfJperpeíuaíáng vácáous
processK MoreoverI acád exposure decreases laryngeal sensaíáon [
zI favoráng
chokáng duráng feedángsI and ánfluences íhe vagal reflexI íhaí ás also responsáble
for lower esophageal spháncíer íone and esophageal moíáláíyI íhus favoráng dboa
J
zK A hágher prevalence of pAi has been reporíed án case of severe iM
zI even áf some auíhors relaíe íhás assocáaíáon ío a selecíáon báas án íhe síudáed
cohorís [
zK Indeed íhe áncreased rásk for pAi án íhese paíáenís mághí raíher be
relaíed ío oíher causes EcardáacLlargeJvessel malformaíáonsI premaíuráíyI repeaíed
qracheomalacáa and subgloííác síenosás are íhe mosí frequení pAiK qhe oíher
reporíed laryngoJíracheal lesáons are vocal cord paralysásI aníeráor gloííás webI
laryngeal dáasíemaI oesoíracheal fásíulaI and laryngeal dyskánesáaK mharyngeal
lesáons may also be observedI such as mácroreírognaíhásmI glossopíosásI
vallecular cysíI palaíal anomalyI choanal aíresáa [
Congenáíal ka such as hypoíonáaI psychomoíor reíardaíáonI cerebral palsyI
mácrocephalyI quadráparesásI Cháará malformaíáonI epálepsy can be assocáaíed ío
iMI especáally severe casesI wáíh a prevalence rangáng from OM ío 4RB [
Acquáred ka such as sírokeI degeneraíáve dáseaseI braán íumour can also lead ío a
iM of laíe onseíK then assocáaíed ío a neurologácal dáseaseI iM can be a parí of
a broader condáíáon descrábed as pharyngoJlaryngomalacáa EmiMFI where sleep
dásordered breaíháng and swallowáng dysfuncíáon are aí íhe forefroní [
Assocáaíáon of iM wáíh ka leads ío a ságnáfácaní reducíáon of supragloííoplasíy
Assocáaíáon wáíh congenáíal hearí dásease ás reporíed án NMB of cháldren wáíh iM
zK Ií ánfluences iM severáíy [
z as áí ás an addáíáve cause of hypoxemáa and
malaáseI and complácaíes íhe surgácal managemení as áí áncreases íhe
peráoperaíáve ráskK
Assocáaíáon wáíh a mulíáple malformaíáon syndrome Eaown syndromeI CeAodb
assocáaíáonI máerre oobán sequenceI OOqNN mácrodeleíáon syndromeF ás reporíed án
U ío RMB of cháldren wáíh iM [
I
zK qhe mosí frequení ás aown syndromeK As
for kaI assocáaíáon wáíh a congenáíal syndrome leads ío a ságnáfácaní reducíáon of
supragloííoplasíy success raíe [
zK qhás ás paríly explaáned by íhe mulíálevel
aárway obsírucíáonI especáally when mácrognaíháa and reírodásplacemení of íhe
íongue base are assocáaíedI such as án CeAodb and máerre oobán sequence [
Anoíher explanaíáon ás íhe presence wáíhán íhe syndrome of íhe oíher assocáaíed
lesáons lásíed aboveK ConsequenílyI íhose paíáenís are more lákely ío requáre
íracheoíomy [
As receníly hághlághíed by Camacho and iee [
I
zI aíypácal
laíe onseí laryngomalacáaI defáned by sympíoms appearance afíer O years old án
síaíe dependení laryngomalacáaI whách approxámaíes íhe occulí laryngomalacáa
relaíed ío sleepI buí wáíh a correlaíáon beíween íhe áníensáíy and íhe level of
Managemení of íhese aíypácal preseníaíáons ás noí clearly defánedI buí íend ío be
íhe same as for congenáíal iMI
a correcí dáagnosás and a íherapeuíác
managemení dácíaíed by íhe severáíy of íhe dáseaseK Isaac
eí al
quesíáon íhe fací
íhaí íhese eníáíáes are dásíáncí from íypácal congenáíal iMI or mághí án fací be a
qhey wáll be dácíaíed by íhe need for severáíy evaluaíáon and íhe suspácáon for
basály performed duráng hospáíal surveállanceI áí evaluaíes íhe consequences on
gas exchange án severe iMI and conírábuíe ío íhe surgácal decásáonK In qhorn’s
severáíy scale [
zI a resíáng palO of USB or under aí íáme of preseníaíáon ás a
qhey are ándácaíed án paíáenís who may be aspáraíáng andLor have pulmonary
qhás examánaíáon wáll be sysíemaíácally performed when surgery ás ándácaíedI
práor ío supragloííoplasíy duráng íhe same procedureI án order ío seek for a pAiK
dáscrepancy beíween íhe severáíy of íhe sympíoms and íhe benágnáíy of íhe cci
qhás examánaíáon ás useful when obsírucíáve sleep apnea assocáaíed ío iM ás
suspecíedK In a recení meíaJanalysásI Camacho
eí al
z have assessed mpd
resulís before and afíer supragloííoplasíyI and hághlághíed a ságnáfácaní
ámprovemení of íhe apnea hypopnea ándex EIAeF afíer surgeryK qanphaácháír
eí al
z have reporíed an áncreased raíe of ceníral sleep apneas assocáaíed wáíh
laryngomalacáaK BesádesI mpd can be useful án case of assocáaíed neurologácal or
cardáac dásorders as áí wáll help dásíánguásh íhe acíual repercussáons of iM and
guáde íhe íherapeuíác decásáonK Ií ás noí rouíánely performed án íhe workJup
síraíegy of iMK IndeedI íhe dáffáculí access ío mpd due ío íhe raráíy of sleep
laboraíoráes and íhe dáffáculíáes ío perform íhás examánaíáon on an ánfaní ás rarely
compaíáble wáíh íhe poíeníáal emergency of íhe surgácal decásáon án case of severe
aIpb has been receníly assessed án cháldren for sáíe of obsírucíáon ádeníáfácaíáon
án obsírucíáve sleep apnea [
zK Ií ás useful ío dásclose an occulí iM relaíed ío
sleep [
z or a síaíeJdependaní iM [
zK In íhe surgery roomI cci ás performed
Baráum or vádeo
fluoroscopác swallow síudy evaluaíes refluxI aspáraíáon and looks
for an assocáaíed malformaíáon such as laryngeal dáasíema and oesoíracheal
gasíroáníesíánal dásorders such as pylorác síenosás án case of severe dboaK
cuncíáonal endoscopác swallow síudy can also be usefulI buí mághí be more
complácaíed ío perform án neonaíesK
qhás examánaíáon ás ándácaíed án case of severe dboa despáíe acád suppressáon
qhás examánaíáon ás ándácaíed án case of congenáíal hearí dáseaseI án order ío
assess íhe peráoperaíáve cardáac ráskI and evaluaíe íhe parí of hypoxemáa unrelaíed
Accordáng ío íhe clánácal preseníaíáonI oíher complemeníary examánaíáons mághí
be performedI such as cerebral MoII íhoracác and abdománal Cq scanI kádney
pámple observaíáon ás usually suffácáeníI án assocáaíáon wáíh láfesíyleLdáeíary
measures: use of íháckened málkI hághJcalorác formulaI uprághí posáíáonáng duráng
A one moníh sympíom check ás recommendedI and áf síable or ámprováng íhe
followJup can be exíended ío a P ío S moníh check [
zK marenís’ reassurance ás
also ámporíaníI as loudness of íhe sírádor can be overwhelmáng ío íhem despáíe íhe
máldness of íhe preseníaíáonK IndeedI iM has been shown ío have a negaíáve
emoíáonal ámpací on parenísI and ío be assocáaíed wáíh a lower qualáíy of láfe [
In addáíáon ío íhe preváous measuresI acád suppressáon íherapy ás ándácaíedK qhe
maán molecules avaálable are hásíamáne íype O recepíor aníagonásís EeOoAF íhaí
can be used aí PmgLkgLdayI and proíon pump ánhábáíors EmmIF íhaí can be used aí N
ío O mgLkgLdayK qherapy can be síaríed wáíh boíh eOoA and mmI and íhen weaned
ío a sángle íherapy when sympíoms ámproveI or síaríed wáíh a sángle moleculeI
and swáíched ío a double íherapy áf sympíoms are noí conírolled [
zK bffácacy of
caA approval for paíáenís under N year oldK mrokáneíác agenís such as
eryíhromycán eíhylsuccánaíeI whách ánfluence gasíroáníesíánal moíáláíyI can be
used án addáíáon ío acád suppressáon íherapyK qhe Imld recommend ío maáníaán
íreaímení for aí leasí P moníhs [
z; íhe average íáme of íherapy reporíed án íhe
In paíáenís preseníáng ságns of severáíy and who faáled ío respond ío conservaíáve
qhe aám of íhás procedure ás ío prevení ánspáraíory collapse by síabálázáng andLor
mreceded by a sysíemaíác rágád laryngoíracheal endoscopyI surgery ás performed
usáng an operaíáng mácroscope afíer suspensáon of íhe larynxK pponíaneous
breaíháng anesíhesáa ás usually usedI as endoíracheal áníubaíáon may áníerfere wáíh
íhe procedureK geí veníálaíáon and áníermáííení apnea have also been proposed buí
pupragloííoplasíy acíually áncludes several surgácal íechnáques íhan can be
performed ándávádually or combánedK qhe endoscopác analysás of íhe supragloííác
obsírucíáon wáll ánfluence íhe choáce of íhe íechnáque: aryepágloííác fold dávásáon
án íype O iMI removal of redundaní mucosal aryíenoád íássue án íype N iMI
epágloííopexy and epágloííác suíure or paríáal epágloííecíomy án íype P iM [
qhe mosí common fársíJláne procedure ás bálaíeral aryepágloííác fold dávásáon
assocáaíed wáíh bálaíeral removal of redundaní mucosal aryíenoád íássue [
zK qhe
posíeráor áníer aryíenoád zone should be sparedI án order ío avoád posíJoperaíáve
supragloííác síenosásK Compresses soaked án adrenaláne saláne ENmg án NMmlF can
be used for hemosíasásK peveral surgácal íools are avaálable: mácrolaryngeal coldJ
síeel ánsírumenísI ClO laser EN taííFI qhuláum laser ENKR taííF [
zI mácroJ
debráder EOKV or PKR mm laryngeal bladeI UMM roíaíáon per mánuíe án oscállaíáng
mode wáíhouí árrágaíáonF [
zK iaser and mácroJdebráder allow a lower
áníraoperaíáve bleedángI whále coldJsíeel ánsírumenís are more cosíJeffecíáveK
iaser ás assocáaíed wáíh a rásk of fáre áf másusedI and an áncreased rásk of oedema
due ío íhe burn of mucosaK As láíeraíure daía show sámálar success raíes beíween
íhese íools [
J
zI íhe choáce of íhe ánsírumeníaíáon should be guáded by íhe
surgeons habáís and íraánángK rnálaíeral and síaged aryepágloííác fold dávásáon and
removal of redundaní mucosal aryíenoád íássue have been proposed as ánáíáal
surgácal procedure ío avoád supragloííác síenosás and posíJoperaíáve aspáraíáon [
zK oecenílyI supragloííoplasíy under PJaámensáonal endoscopy has been
assessed ío ámprove vásualázaíáon of complex aárway anaíomy and allow a more
bpágloííopexyI epágloííác suíure and paríáal epágloííecíomy have been proposedI
maánly when íype P iM ás ánvolvedI buí also by some auíhors regardless of íhe
anaíomácal abnormaláíy [
I
zK qhose P íechnáques can be performed separaíely
or combánedK bpágloííopexy consásís án laser vaporásaíáon of íhe lángual surface of
epágloííás and íongue base allowáng síabálázaíáon of íhe epágloííás [
zK bpágloííác
suíure consásís án placáng a resorbable suíure ío unfold íhe folded epágloííás and
sháfí aparí íhe adjacení aryepágloííác folds [
zK maríáal CJshaped suprahyoád
epágloííecíomyI or sámple excásáon of epágloííác mucosa usáng mácroscássors or
laser have also been descrábedK Cauíáon should be íaken when operaíáng on íhe
epágloííás consáderáng poíeníáal posíJoperaíáve swallowáng dysfuncíáon;
noneíhelessI íeams famáláar wáíh íhese íechnáques do noí reporí an áncreased rásk
A course of sysíemác coríácosíeroáds Emeíhylprednásolone OmgLkgF ás
admánásíered duráng íhe surgácal procedure án order ío mánámáze posíJoperaíáve
Cháldren may requáre a O4 hours posíJoperaíáve áníubaíáon dependáng on íhe
anaesíhesáa seííángsK If no áníubaíáon ás necessaryI íhey are síáll usually admáííed án
an áníensáve care unáí EICrFK pome auíhors receníly suggesíed íhaí ICr
monáíoráng may noí be necessary áf usáng cold síeel ánsírumenís [
keveríhelessI íhás suggesíáon should be íaken wáíh cauíáonI as íhe cháld’s posíJ
operaíáve respáraíory behaváor ás unpredácíableI especáally án íhe case of a
másdáagnosed underlyáng dáseaseK
iáfesíyleLdáeíary measures and acád suppressáon íherapy musí be coníánued afíer
surgeryI án order ío lower íhe rásk of granuloma formaíáon from exposure of íhe
An early cci musí be performed a few days afíer surgery ío elámánaíe any early
synecháae or granulomaI and N moníh afíer surgery ío assess mucosal surface
Improvemení of sympíoms afíer supragloííoplasíy are reporíed án TM ío NMMB of
cases án several cohorís [
I
I
I
zK In san der eeájden
eí al
síudy [
supragloííoplasíy led ío síaíásíácally ságnáfácaní fasíer compleíe ámprovemení íhan
waáíJandJsee polácy ER
OV weeksFK koneíhelessI caráa
eí al
z found no
dáfference án weághí gaán beíween surgery and medácal íreaímení Eacád
suppressáonI speech and swallowáng íherapyI hághJcaloráe formulaFI suggesíáng
exclusáve medácal managemení for appropráaíely selecíed severe iMK oespáraíory
ámprovemení ás usually based on subjecíáve cráíeráa: reducíáon of sírádorI
resoluíáon of apneác and cyanoíác epásodesI cci fándángsK IdeallyI
supragloííoplasíy respáraíory effácacy should be evaluaíed by objecíáve cráíeráa
such as mpd resulís [
I
zI buí áís lámáíed access and cosí avoád ás rouíáne useK
Concernáng feedáng ámprovemení assessmení afíer supragloííoplasíyI clánácal
objecíáve cráíeráa such as heághí and weághí gaán are monáíoredK peveral auíhors
reporíed a ságnáfácaní weághí gaán wáíhán S moníhs of surgeryI wáíh normalázaíáon
pupragloííoplasíy faálureI resulíáng án persásíení respáraíory and feedáng
dáffáculíáesI occurs án approxámaíávely PMB of cases accordáng ío íhe mosí recení
láíeraíure [
I
zK qreaímení opíáons are revásáon supragloííoplasíyI íracheoíomy
or nonJánvasáve veníálaíáonK qhe maán rásk facíor for faálure ás íhe assocáaíáon wáíh
congenáíal syndrome and neurologácal anomaláes [
I
I
zK Anoíher ádeníáfáed
rásk facíor ás íhe presence of severe preJoperaíáve reflux sympíoms [
I
zK eoff
eí al
z found a hágher raíe of revásáon supragloííoplasíy án cháldren undergoáng
surgery aí less íhan O moníhs age compared ío íhose operaíed beíween O and NM
moníhs EPSK4B
RKPBI pYMKMRFK Ií has been shown íhaí premaíuráíy ás neáíher a
qhe aám of íhás procedure ás ío bypass íhe laryngeal obsírucíáonK Ií ás nowadays
rarely performed án íhás ándácaíáonI and ás reserved for supragloííoplasíy faáluresI
presence of pAi and syndromác paíáenís preseníáng mulíálevel aárway obsírucíáon
andLor combánáng neurologácalI cardáac and aárway dáseasesK aespáíe áís effácáency
ío íreaí aárway obsírucíáonI íracheoíomy án ánfanís requáres a complex
managemeníI and ás assocáaíed wáíh a ságnáfácaní posíJoperaíáve complácaíáons
qhe aám of íhás íechnáque ás ío decrease íhe respáraíory work of paíáenís wáíh
upper aárway obsírucíáon such as iM [
I
zK Ií ás used án cases of severe iM án
íhe coníexí of awaáíáng surgeryI when surgery ás noí possábleI or án case of
supragloííoplasíy faálureI as an alíernaíáve ío íracheoíomyK As no consensus
guádelánes are avaálable for kIs ándácaíáons án iMI comparáson of ráskLbenefáí
raíáo ío íracheoíomy ás esseníáal for íherapeuíác decásáonK Coníánuous mosáíáve
Aárway mressure ECmAmF ás usually used [
zI wáíh an áníerface adapíed ío íhe
ánfaní’s face Ecommercáally or handmade nasal maskFK Bálevel mosáíáve Aárway
mressure EBmAmF has also shown áís effácacy [
zI buí can be responsáble for a
respáraíory asynchronásm án case of unadapíed ánspáraíory írágger sensáíáváíy [
páde effecís of kIs compráse skán lesáonsI maxállary reírusáon and global
flaííenáng of íhe face [
zK Because íhás equápmení requáres a hágh level of
experíáseI áí musí be managed by an experáenced mulíádáscáplánary íeamK
aáagnosás of iM musí be sysíemaíácally confármed by performáng a cciK
peveráíy sympíoms musí be íhoroughly assessed án order ío deíermáne íhe besí
íherapeuíác opíáons and followJup scheduleK Ideníáfácaíáon and managemení of coJ
morbádáíáes are esseníáal as íhey ánfluence iM severáíy and íreaímení ouícomesK
pupragloííoplasíyI áncludáng aryepágloííác fold dávásáonI removal of redundaní
mucosal aryíenoád íássueI epágloííopexyI epágloííác suíureI paríáal epágloííecíomyI
ás íhe maánsíay of severe iM íreaímeníI wáíh hágh success and low complácaíáons
raíesK Ií musí be performed by an experáenced íeam án a medácal ceníer equápped
wáíh an ICrK qracheoíomy and kIs are second láne íreaímenísI maánly ándácaíed
án case of supragloííoplasíy faálureI pAi and neurologácal and syndromác
qhorne MCI dareíz piK iaryngomalacáa: oeváew and pummary of Currení Clánácal mracíáce án OMNRK
Mannáng pCI Inglás AcI Mouzakes gI Carron gI merkáns gAK iaryngeal anaíomác dáfferences án
qhompson aMK Abnormal sensorámoíor áníegraíáve funcíáon of íhe larynx án congenáíal
laryngomalacáa: a new of eíáologyK iaryngoscope OMMT; NNT ES mí O puppl NN4F: NJPPK
Ayará pI Auberíán dI dárschág eI san aen Abbeele qI Mondaán MK maíhophysáology and dáagnosíác
approach ío laryngomalacáa án ánfanísK bur Ann líorhánolaryngol eead keck aás OMNO; NOVERF: ORTJ
aanáel pgK qhe upper aárway: congenáíal malformaíáonsK maedáaír oespár oev OMMS; T EpupplK NF: pOSMJ
trághí CqI doudy piK Congenáíal laryngomalacáa: sympíom duraíáon and need for surgácal
áníerveníáonK Ann líol ohánol iaryngol OMNO; NONENF: RTJSMK
oáchíer dqI qhompson aMK qhe surgácal managemení of laryngomalacáaK líolaryngol Clán koríh Am
Isaac AI Zhang eI poon poI Campbell pI blJeakám eK A sysíemaíác reváew of íhe evádence on
sponíaneous resoluíáon of laryngomalacáa and áís sympíomsK Iní g medáaír líorhánolaryngol OMNS; UP:
Caríer gI oahbar oI Brágger MI Chan hI Cheng AI aanáel pgI
eí alK
Iníernaíáonal medáaírác loi droup
pámons gmI dreenberg iiI Mehía ahI cabáo AI Maguáre oCI Mandell aiK iaryngomalacáa and
Zwaríenkoí gtI eoeve eiI Borgsíeán gK IníerJobserver reláabáláíy of localázaíáon of recorded sírádor
[NOzMondaán MI Blancheí CK Arch medáaír OMNM; NTESF: SMOJPK [pírádor or noí sírádorzK
Cheng gI pmáíh imK bndoscopác surgácal managemení of ánspáraíory sírádor án newborns and ánfanísK
llney aoI dreánwald ge grI pmáíh ogI Bauman kMK iaryngomalacáa and áís íreaímeníK iaryngoscope
iandry AMI qhompson aMK iaryngomalacáa: dásease preseníaíáonI specírumI and K Iní g medáaír OMNO;
qhompson aMK iaryngomalacáa: facíors íhaí ánfluence dásease severáíy and ouícomes of managemeníK
aáckson gMI oáchíer dqI MeánzenJaerr gI ouííer MgI qhompson aMK pecondary aárway lesáons án
hrashán bI BenJArá gI ppránger CI aerowe AI Aváíal AI pávan vK pynchronous aárway lesáons án
pchroeder gt grI Bhandarkar kaI eolánger iaK pynchronous aárway lesáons and ouícomes án ánfanís
wáíh severe laryngomalacáa requáráng supragloííoplasíyK Arch líolaryngol eead keck purg OMMV;
oáfaá eAI Benoáí MI blJeakám eK pecondary aárway lesáons án laryngomalacáa: a dáfferení
perspecíáveK líolaryngol eead keck purg OMNN; N44EOF: OSUJTPK
croehlách mI peád ABI aenoyelle cI mransky pMI hearns aBI darabedáan bkI
eí alK
aurvasula spI iawson BoI Bower CMI oáchíer dqK pupragloííoplasíy ouícomes án neurologácally
Masíers IBI Chang ABI maííerson iI taánwrághí CI Buníaán eI aean BtI
eí alK
peráes of
laryngomalacáaI íracheomalacáaI and bronchomalacáa dásorders and íheár assocáaíáons wáíh oíher
Camacho MI pong pAI Cable BBK In response ío supragloííoplasíy for laryngomalacáa wáíh obsírucíáve
iee CcI iee CeI hang hqI esu tCK In reference ío supragloííoplasíy for laryngomalacáa wáíh
oáchíer dqI ouííer MgI deAlarcon AI lrvádas igI qhompson aMK iaíeJonseí laryngomalacáa: a
aágoy dmI Burge paK iaryngomalacáa án íhe older cháld: clánácal preseníaíáons and managemeníK Curr
lomen hmI Modá shK lcculí laryngomalacáa resulíáng án obsírucíáve sleep apnea án an ánfaníK Iní g
Amán MoI Isaacson dK píaíeJdependení laryngomalacáaK Ann líol ohánol iaryngol NVVT; NMSENNF:
Camacho MI aunn BI qorre CI pasaká gI donzales oI iáu pvI
eí alK
pupragloííoplasíy for
laryngomalacáa wáíh obsírucíáve sleep apnea: A sysíemaíác reváew and meíaJanalysásK iaryngoscope
qanphaácháír AI qanphaácháír mI Apáwaííanasawee mI Brockbank gI ouííer MgI pámakajornboon kK
mrevalence and rásk facíors for ceníral sleep apnea án ánfanís wáíh laryngomalacáaK líolaryngol eead
Manáckam msI phoíí poI Boss bcI Cohen AmI MeánzenJaerr ghI Amán opI
eí alK
pysíemaíác reváew
of sáíe of obsírucíáon ádeníáfácaíáon and nonJCmAm íreaímení opíáons for cháldren wáíh persásíení
hálpaíráck iAI Boyeííe goI earízell iaI koríon gAI Boswell gBI Bower CMI
eí alK
mrospecíáve qualáíy
qhoííam mgI pámons gmI Choá pI Maguáre oI Mehía ahK Clánácal relevance of qualáíy of láfe án
táníer eI dunasekaran qI qoláa sI doíírand cI Barker mkI Illueca MK bsomeprazole for íhe
qreaímení of dboa án Infanís Ages NJNN MoníhsK g medáaír dasíroeníerol kuír OMNR; SM EpupplK NF:
Baljosevác II Mánác mI qrajkovác dI MarkovácJpovíác dI oadojácác BI povíác AK purgácal íreaímení of
aáas oI aeshmukh CqI qullu MpI aávecha CI harande pK oare íreaímení opíáon for a common
Ayará pI Auberíán dI dárschág eI san aen Abbeele qI aenoyelle cI Couloágnáer sI
eí alK
AyaráJhhalfallah pI cuchsmann CI croehlách mK qhuláum laser án aárway dáseases án cháldrenK Curr
droblewská gCI phah ohI Zalzal deK MácrodebráderJassásíed supragloííoplasíy for laryngomalacáaK
aenoyelle cI Mondaán MI dresállon kI ooger dI Chaudre cI darabedáan bkK caálures and
complácaíáons of supragloííoplasíy án cháldrenK Arch líolaryngol eead keck purg OMMP; NOVENMF:
oasíaííer gCI pchroeder gtI eoff poI eolánger iaK Aspáraíáon before and afíer pupragloííoplasíy
aouglas CMI phafá AI eággáns dI
eí alK
oásk facíors for faálure of supragloííoplasíyK Iní g medáaír
talner aiI keumann aBI eammáng hhI Máller omK pupragloííoplasíy án Infanís: A píaged
ApproachK Ann líol ohánol iaryngol OMNR; NO4ENMF: UMPJTK
oeddy ahI Maíí BeK rnálaíeral
K bálaíeral supragloííoplasíy for severe laryngomalacáa án cháldrenK
daudreau mI cordham MqI aong qI iáu uI hang pI mrecáado aI
eí alK
sásualázaíáon of íhe pupragloííás
án iaryngomalacáa táíh PJaámensáonal medáaírác bndoscopyK gAMA líolaryngol eead keck purg
thymark AaI Clemení tAI hubba eI deddes khK iaser epágloííopexy for laryngomalacáa: NM yearsD
cordham MqI moííer pMI tháíe aoK mosíoperaíáve managemení followáng supragloííoplasíy for
lDaonnell pI Murphy gI Bew pI hnághí iCK Aryepágloííoplasíy for laryngomalacáa: resulís and
ooger dI aenoyelle cI qrágláa gMI darabedáan bkK pevere laryngomalacáa: surgácal ándácaíáons and
van der eeájden MI aákkers cdI ealmos dBK qreaímení ouícome of supragloííoplasíy
K waáíJandJsee
caráa gI Behar mK Medácal and surgácal managemení of congenáíal laryngomalacáa: a caseJconírol
lDConnor qbI Bumbak mI sájayasekaran pK lbjecíáve assessmení of supragloííoplasíy ouícomes usáng
pesíerhenn AMI Zámmermann AmI Bernhard MI hussán AI qámmesfeld kI píáller pI
eí alK
molysomnography ouícomes followáng íransoral ClO laser mácrosurgery án pedáaírác paíáenís wáíh
Czechowácz gAI Chang htK CaíchJup growíh án ánfanís wáíh laryngomalacáa afíer supragloííoplasíyK
bscher AI mrobsí oI dysán CK Managemení of laryngomalacáa án cháldren wáíh congenáíal syndrome:
ewang bI Chung gI MacCormáck gI Bromwách MI saccaná gmK puccess of supragloííoplasíy for severe
laryngomalacáa: íhe experáence from koríheasíern lníaráoI CanadaK Iní g medáaír líorhánolaryngol
mrecáado aI Zalzal dK A sysíemaíác reváew of supragloííoplasíy ouícomesK Arch líolaryngol eead
eoff poI pchroeder gt grI oasíaííer gCI eolánger iaK pupragloííoplasíy ouícomes án relaíáon ío age
aurvasula spI iawson BoI Bower CMI oáchíer dqK pupragloííoplasíy án premaíure ánfanís wáíh
laryngomalacáa: does gesíaíáon age aí báríh ánfluence ouícomes? líolaryngol eead keck purg OMN4;
lzmen pI lzmen lAI rnal lcK medáaírác íracheoíomáes: a PTJyear experáence án OUO cháldrenK Iní g
aDpouza gkI ievá goI mark aI phah rhK Complácaíáons collowáng medáaírác qracheoíomyK gAMA
bssourá pI kácoí cI Clemení AI
eí alK
konánvasáve posáíáve pressure veníálaíáon án ánfanís wáíh upper
aárway obsírucíáon: comparáson of coníánuous and bálevel posáíáve pressureK Iníensáve Care Med OMMR;
cauroux BI mágeoí gI molkey MII
eí alK
Chronác sírádor caused by laryngomalacáa án cháldren: work of
breaíháng and effecís of nonánvasáve veníálaíory assásíanceK Am g oespár Cráí Care Med OMMN; NS4ENM
cauroux BI ieroux hI aesmaraás dI
eí alK
merformance of veníálaíors for nonánvasáve posáíáveJ
cauroux BI iavás gcI kácoí cI
eí alK
cacáal sáde effecís duráng nonánvasáve posáíáve pressure veníálaíáon
pynopsás of Managemení of aáabeíes Melláíus
Absírací:
aáabeíes ánvolves pancreaíác dysfuncíáon due ío auíoámmune desírucíáon of
íhe beía cells and ánsulán defácáencyK qhe prevalence and áncádence of qype N and qype
O are áncreasáng án íhe general populaíáonK qype N aáabeíes ofíen begáns án cháldhood
and requáres láfelong ánsulán replacemení íherapy and monáíoráng of blood glucose
levelsK iong and shoríJacíáng ánsulán allows for adjusímení of íherapáes around
paíáenís’ lávesI buí close medácal observaíáon and a good paíáeníJprováder relaíáonsháp
ás necessary for opíámal managemeníK qype O aáabeíes ás characíerázed by severe
ánsulán resásíance and paríáal defácáency íhaí has become more prevalení án pedáaírác
paíáenísI ofíen occurráng around puberíyK qherapy ánvolves láfesíyle changes ío promoíe
acíáve weághí lossI healíhy eaíáng habáísI and exercáseK cew pharmacologácal íherapáes
heywords:
Aríáfácáal mancreasI Baráaírác purgeryI Closed ioop ConírolI
Coníánuous dlucose MonáíorángI Coníánuous pubcuíaneous Insulán InjecíáonI
dlucagonI InsulánI iáfesíyle ChangesI MeíformánI Mulíáple aaály Insulán
InjecíáonsI qype N aáabeíesI qype O aáabeíesK
aáabeíes Melláíus ás a láfeJalíeráng dáagnosásI requáráng adjusímení of a paíáení’s
láfe and scheduleK In pedáaírác paíáenísI áí also changes íhe eníáre famály’s focusK
ioss of ánsulánJsecreíáng beía cells resulís án loss of glycemác conírol wáíh
subsequení hyperglycemáa án qype N dáabeíesK Insulán replacemení íherapy
remaáns íhe maánsíay of currení íherapyK Advances án ánsulán pumpsI coníánuous
glucose monáíorsI and closed loop conírol sysíems have resulíed án longJíerm
ámproved glycemác conírolK kew advancemenís án pancreaíác íransplaníI síem cell
íherapyI báomarker screenángsI and preveníáon síraíegáes are beáng publáshed
Correspondáng auíhor Beíhany AK Auble
: Medácal College of tásconsánI Cháldren’s eospáíal of tásconsánI
sírong emphasás placed on dáeíI exercáseI and láfesíyle modáfácaíáonsK qhe medácal
íherapáes for íhe íreaímení of qype O aáabeíes are a growáng fáeld of researchI buí
pharmacoíherapy musí be combáned wáíh láfesíyle changes áf lasíáng healíh
ámprovemenís are ío be acháevedK
In íhe rnáíed píaíesI íhe prevalence of qype N aáabeíes ás esíámaíed for MKORB of
íhe populaíáon [
zK crom OMMN–OMMVI prevalence of qype N dáabeíes áncreased by
nearly OMBI wáíh projecíáons suggesíáng íhaí from OMNM ío OMRMI íhe number of
youíh wáíh qype N dáabeíes may írápleK In íhás same íáme peráodI íhe prevalence of
qype O dáabeíes áncreased by nearly PMB and accounís for 4RB of newly
dáagnosed cases of dáabeíes án íhe pedáaírác populaíáonK mrojecíáons suggesí íhaí
from OMNM ío OMRMI a nearly 4Jfold áncrease mághí occur of paíáenís wáíh qype O
dáabeíesK thále síáll relaíávely uncommonI íhe raíes of new cases of íype O
dáabeíes were greaíer among perápuberíal ándáváduals aged NM–NV years íhan án
younger cháldrenI wáíh hágher raíes among rKpK mánoráíy populaíáons íhan án nonJ
qhe pancreas ás boíh an exocráne gland and an endocráne glandK bndocráne cells
are locaíed wáíhán scaííered Isleís of iangerhans and dáváded ánío íhree caíegoráes:
alphaJcells Eproduce glucagonFI beíaJcells Eproduce ánsulán and amylánF and delíaJ
cells Eproduce somaíosíaíánFK Insulán síámulaíes cells ío upíake free glucoseI
glycogenesás án íhe láverI and upíake amáno acádsI proíeáns and faí from íhe
bloodsíreamK eumans are born wáíh a varyáng amouní of beíaJcellsI and even
wáíhán íhese cellsI íhere ás varáaíáon ío suscepíábáláíy ío auíoJámmune aííack [
zK In
qype N aáabeíesI auíoámmune desírucíáon of beíaJcells produces gradual
dysregulaíáon of glucose and áís sympíoms develop afíer >UMJVMB of cells are
losíK qype O aáabeíes ás caused by íhe relaíáve defácáency of ánsulán due ío severe
dlucagon works prámarály án íhe láver ío converí glycogen ánío glucose ío raáse
blood glucoseK Iís funcíáon becomes dysregulaíed án íype O dáabeíesI leadáng ío
posíprandáal hypersecreíáonI worsenáng overall hyperglycemáaK Amylán ás a
neuroendocráne pepíáde hormone íhaí ás coJsecreíed wáíh ánsulánI uses íhe same
processáng enzymesI and works ío suppress release of glucagonI slows dágesíáon
and slows raíe of ánsulán eníeráng íhe bloodsíreamK qhe benefáí of delayed gasírác
empíyáng ás creaíáng a slower ráseI and overall lower peak level of blood glucose
zK pomaíosíaíán ás a pepíáde hormone íhaí has many dI effecís buí ás acíáve án
slowáng gasírác empíyángI suppressáng ánsulán and glucagon releaseI and
suppressáng exocráne pancreaíác secreíáonsK Increíáns are small hormones released
by áníesíánal mucosa íhaí síámulaíe ánsulán releaseI delay gasírác empíyáng and
ánhábáí glucagon releaseK thále naíáve molecules have shorí halfJlávesI syníheíác
qhe “evení” of síage II mosí lákely ás noí a sángle evení buí some combánaíáon of
enváronmeníal and geneíác írággersK qhe íáme peráod of síage IIIJIs ás hághly
varáableI íhe reasons for why are beáng closely síudáed [
zK maíáenís mosí ofíen
presení wáíh classác sympíoms of onseí: polyuráaI polydápsáaI hyperglycemáa and
keíonuráa duráng píage s Esome presení án full dáabeíác keíoacádosásFK qhe
“honeymoon peráod” beíween píage s and sI ás called such as very low
supplemeníal ánsulán ás requáred ío maáníaán normoglycemáa cágK E
cágK ENFK
qhe básenbaríh model for íhe developmení of qype N aáabeíes ás dáváded ánío sáx síages: NK deneíác
mredásposáíáonI OK qrággeráng “bveníI” PK Acíávaíáon of Auíoámmune oesponseI 4K Immunologác oesponse
wáíh progressáve loss of ánsulán secreíáon wáíh maáníenance of normal blood sugar levelI RK pympíoms
developI buí resádual ánsulán secreíáon ás maáníaánedI SK ioss of resádual ánsulán secreíáon ío a poání of glucose
ȃЅ؇ࠉਉ଀ఋऍค܏܍ଐ
 ଀ఝࠇ᠘Жఓጀ
eemoglobán ANc ás íhe form of hemoglobán produced íhrough nonenzymaíác
glycaíáon wáíhán red blood cellsK mroducíáon varáes dárecíly wáíh plasma glucose
levelsK Monáíoráng conceníraíáon allows for ádea of average glucose levels over
íhe láfe span of íhe red blood cells Eroughly OJP moníhsFK qhe AaA íreaímení
guádelánes recommend: ebANC YTKRB án pedáaírácsI YTB án adulís Elower for
pregnaní womenFI reducíáon án hypoglycemác evenís and preveníáon of longJíerm
complácaíáons of poor glycemác conírolK Mosí adulís are noí meeíáng íhe AaA
ebANc goalI and paíáenís NPJOR years old acíually have íhe worsí conírol based on
Mulíáple aaály Injecíáon EMaIF ánsulán regámen ás íhe síandard íherapeuíác
approach of qype N aáabeíes and ánvolves calculaíáng daály ánsulán requáremeníI
basal ánsulán amouníI carbohydraíe coverage dosángI and mealJíáme sládángJscale
bolus dosesK qoíal daály ánsulán dose ás hághly varáableI buí ás generally
deíermáned by íhe paíáení’s puberíal síaíus Eqable
rse of a basalLbolus dosáng regámení aííempís ío esíablásh paííerns íhaí mosí
closely approxámaíe normal human physáologác release of ánsulánK Advaníages for
íhás síyle of dosáng ánclude: ámproved glycemác conírolI lower ebANcI and may
reduce hypoglycemác evenís overnághíK mreJmeal ánjecíáons allows for a more
flexáble mealJíáme schedule ío accommodaíe láfesíyleK qhe addáíáon of
carbohydraíe coverage dosáng allows for freedom of meal choáce E
K hághJ
carbohydraíe meal wáll need more ánsulán; a lowJcarbohydraíe meal wáll need
lessFK aásadvaníage of basalJbolus dosáng of ánsulán ás íhaí mulíáple ánjecíáons
íhroughouí íhe day are neededI and frequení glucose checks are also requáredK qhe
number of fángersíáck blood glucose checks and ánjecíáons can be dásíressáng ío
some paíáenísK táíh íhe advení of ánsulán pump íherapyI new basalJbolus
approaches became possáble Eqable
Calculaíáon for OM kg
Compací ánsulán pumps were fársí áníroduced án íhe NVVMsI beáng aííracíáve ío
paíáenís due ío less daály ánjecíáons and overall less medácal equápmení ío carryK
qhe áníroducíáon of smarí pumps án íhe OMMM’s saw benefáís such as áncremeníal
dose adjusímenís possábleI alíernaíáve basal paííernsI and íemporary basal raíe
opíáonsK Beííer physáologác undersíandáng of ánsulán effecí án íhe bodyI coupled
wáíh dosáng íechnologyI allowed for maícháng of basal ánsulán ío cárcadáan
varáaíáons án hormones íhaí affecí ánsulán sensáíáváíyK aásadvaníages of ánsulán
pumps áncludeI íhe cosí of íhe unáíI and íhe need for pump ío be consíaníly
aííached ío bodyK Because íhere ás no longJacíáng ánsulánI áf an ánsulán pump ás
Insulán pumps may be an aííracíáve opíáon for paíáenísI and currení síudáes have
shown íhaí pumps resulí án no áncrease án raíe of ahA [
zI no dáfferences án
severe hypoglycemáaI no lasíáng dáfferences án ANc án small cháldren [
zI and only
some ámprovemení án older cháldren wáíh hágh baseláne ANc [
zK qhere ás
howeverI a modesí ámprovemení án qualáíy of láfeK A “síandard” bolus combánes
coníánuous basal ánsulán ánfusáon wáíh shoríJacíáng preJmeal bolus dosángK Ií ás
useful as a basác ánsulán regámenK An “exíended” bolus combánes coníánuous basal
ánsulán wáíh a mealJíáme bolusK qhe bolusI howeverI ás gáven over a prolonged
peráod of íámeK qhás íype of dosáng ás useful for paíáenís wáíh gasíroparesásI meals
hágh án faí or proíeán buí lower án carbohydraíesI or áf paíáení ás eaíáng small
amounís of carbohydraíes over a long peráod of íáme E
mováe popcornI paríy
appeíázersFK A “combánaíáon” bolus funcíáons sámálar ío exíended dosáng buí also
áncludes an ámmedáaíe bolus wáíh íhe exíended bolusK qhás can be useful for meals
hágh án faíI proíeán and carbohydraíes ío address fasí buí susíaáned elevaíáon án
blood glucose E
pázzaFK A “super” bolus combánes basal and bolus dosáng buí
eáíher síops or paríáally reduces basal dosáng práor ío a mealK qhe amouní of
very hágh glycemác ándex foodsI large áníake of carbohydraíesI or sáíuaíáons where
qhe áníroducíáonI and subsequení newer modelsI of coníánuous glucose monáíors
ECdMF opens up new doors for managemení of íype N dáabeíesK qhás íechnology
ánvolves a subcuíaneous monáíor of áníersíáíáal glucose conceníraíáon mulíáple
íámes per hourI allowáng for analysás of írends and warnángs of fuíure
hypoglycemáa as well as monáíoráng for asympíomaíác nocíurnal hypoglycemáaI
an ofíen underJrecognázed problem án paíáenís wáíh dáabeíesK Ináíáal síudáes found
íhaí benefáí of CdMI áncludáng ámproved ebANcI was only seen án adulí
populaíáons [
zK More recení síudáes have shown benefáí án pedáaírác paíáenísK qhe
bndocráne pocáeíy recommends CdM for persons >U years of age wáíh qype N
aáabeíesI áf íhey are able ío wear áí on a nearJdaály basásK Coníánued ánnovaíáon ás
resulíáng án shoríer lag íáme beíween readángs and ámproved accuracy of glucose
levelsK qhe íechnology requáres close coníací wáíh medácal provádersI consásíení
useI and an undersíandáng íhaí áí wáll noí reduce efforís án dáabeíes managemení
Aííempís ío connecí ánsulán pump íechnology wáíh coníánuous glucose monáíoráng
ío funcíáon as sámálarly ío a pancreas are showáng promáseK qhás combánaíáon
ánvolves compuíer module consírucís called “closed loop conírolK” qhe prámary
goal of íhese sysíems ás ío maáníaán normal range glucose levels wáíh real íáme
mácroadjusímenís án ánsulán ánfusáon volumes wáíhouí áncreasáng frequency of
hypoglycemáaK kewer and more sophásíácaíed sysíems and algoráíhms are beáng
developed coníánuously [
zK rses of amylán or glucagon daály ánjecíáons ío
augmení or balance ouí ánsulán are also beáng researchedK pubcuíaneous glucagon
ánjecíáonsI when lánked ío coníánuous glucose monáíoráng and delávered án pulse
fasháonI may ságnáfácaníly decrease íáme spení án hypoglycemáaK Many síudáes are
lookáng ánío íhe feasábáláíy of glucagon pumpsK pánce glucagon does noí lasí long
án soluíáon and musí be reconsíáíuíed práor ío usage án emergency hypoglycemáa
evenísI síudáes are lookáng for síable longJíerm formulaíáons and aí physáologác
acíáváíy of “aged” glucagon [
zK Amylán ánjecíáons have been shown ío ámprove
glycemác conírolI reduce degree of posíprandáal glucose elevaíáonsI and decrease
“then wáll íhey ánvení an aríáfácáal pancreasLwáll a íransplaní be an opíáon?” J
qhe answer ás complácaíedI however progress ás beáng made from íhree
fundameníally separaíe buí áníerrelaíed paíhways: use of currení medácal
equápmení án new novel combánaíáonsI báoJaríáfácáal beíaJásleí cell sheeís for
ámplaníaíáonI and geneíác íherapy wáíh akA váruses ío síámulaíe cells ío
become ánsulánJproducángK Much research ás goáng ánío each of íhese areasI
wáíh advancemenís slowly beáng worked ánío currení pracíáce guádelánes even
“Is íhere a way ío prevení íhe dásease from occurráng án my oíher cháldrenI or
reverse áís acíáváíy curreníly?” J In íhe recení decadesI more dedácaíed focus
has been placed on consáderáng whaí roles agángI dáeíI geographác locaíáonI
ámmune cell meíabolásmI mácrobáomesI váral and mácrobáal paíhogens and
even epágeneíács mághí play on dásease developmeníK bven wáíh new papers
and síudáes beáng released and síaríed every yearI much remaáns unknown wáíh
“Is íhere geneíác íesíáng avaálable for íhose aí rásk for developáng íype N
dáabeíes?” J qhe classác báomarkers íhaí “predácí” íype N dáabeíes are serum
auíoaníábodáesI wáíh four major íargeís: InsulánI dAaSRI IAJO and zánc
íransporíer UK eoweverI despáíe ádeníáfyáng íhese genesI consírucíáng sírong
predácíáve algoráíhms based around geneíács remaáns unable ío be successfully
performedK Aííempís ío use auíoreacíáve qJcellsI báomarkers of beía cell síressI
meíabolomács and proíeomács have all had yeí ío ádeníáfy valádaíed predácíors
“thaí abouí íhe new ánhaled ánsulán íhaí jusí came ouí?” Afrezza ás an
ánhaledI rapádJacíáng ánsulánI whách was released án OMNR buí meí wáíh poor
ánáíáal salesK lnseí of acíáon ás wáíhán NRJOM mánuíesI peak acíáváíy acháeved by
PM mánuíes afíer ánhalaíáonI and remaáns án sysíem for only NUM mánuíesK More
síudáes are needed ío look aí safeíy and effácacy án cháldren as well assessáng
maíáenís wáíh qype O dáabeíes ofíen presení wáíh ánsádáous onseí of sympíomsI and
íhere can be chronác behaváoral and láfesíyle habáís íhaí may worsen dásease
progressáonK qype O aáabeíes occurs more commonly án adulísI buí has been
áncreasángly dáagnosed án pedáaírác paíáenísK Ií ás assocáaíed wáíh obesáíy and a
sírong famáláal predásposáíáonI wáíh many fársíJ and secondJdegree relaíáves ofíen
haváng qype O aáabeíesK In addáíáonI íhere can be hágh raíes of paíáenís losí ío
follow upK A sharp áncrease án prevalence of qype O dáabeíes has prompíed new
research ánío paíhophysáology and íherapeuíác opíáons ío decreaseI reverseI or
prevení complácaíáons of ánsulán resásíance and beíaJcell dysfuncíáon [
zK thále
íhe dásease prevalence among pedáaírác paíáenís ás áncreasángI íherapeuíác
modaláíáes coníánue ío be lámáíedK An absence of daía concernáng íhe varáous
medácaíáon subclasses effácacy and safeíy án pedáaírác paíáenís prevenís usáng
varáous adulí qype O dáabeíes medácaíáon opíáonsK qherapy musí address blood
glucose conírolI buí also needs ío address íhe áncreased rásks of comorbádáíáes
such as hyperíensáonI dyslápádemáa and renal dáseaseK qreaímení goals of qype O
aáabeíes ánclude: weághí managemeníI áncreasáng physácal acíáváíyI acháeváng
glycemác conírol wáíh normalázaíáon of ebANcI and managáng comorbádáíáes such
qhe mosí ámpacíful aspecí of care for qype O aáabeíes ás famályJbased behaváoral
láfesíyle áníerveníáonsK qype O dáabeíes ás a dásease ánvolvángI and worsened byI
obesáíyI so preveníáon of weághí gaán andLor weághí loss are key parís of careK qhe
ámporíance of famályJceníered modáfácaíáons ás based on concerns íhaí mosí
pedáaírác paíáenís do noí ofíen purchase íheár own foodI so láfesíyle changes can
be lámáíed by pareníal choáceK mroper dáeíary counseláng ás cráíácal as exercáse
wáíhouí dáeíary changes ofíen lámáís full resulísK qhás áncludesI elámánaíe sugarJ
coníaánáng beverages and hághJfaí hághJcaloráe foodsI poríáon conírolI ámproved
food choácesI and regular meal scheduleK bxercáse goals ánclude decreasáng
amounís of íáme spení beáng sedeníary E
K íelevásáonI oíher screen íámeI vádeo
Meíformán ás íhe only currení caAJapproved oral íreaímení for youíh wáíh qype O
aáabeíesK ebANc ás lowered and fasíáng plasma glucose ás ámproved án síudáesK
konságnáfácaní decreases án iai cholesíerol were also noíedK páde effecís noíable
from meíformán use áncluded abdománal paánI dáarrheaI nauseaLvomáíáng and
headacheI buí all sympíoms are ámproved wáíh appropráaíe dosáng and passage of
Insulán ás íhe only addáíáonal pharmacologácal agení used ío íreaí unconírolled
qype O aáabeíes án pedáaírác paíáenísI ofíen wáíh ebANc levels >VBK A NSJweek
síudy án adolescenís showed íhaí use of premáxed ánsulán can ámprove ebANc
wáíhouí ságnáfácaní changes án BMI or hypoglycemáaK aoseJadjusímení án
response ío íargeí blood glucose levels even resulíed án many paíáenís requáráng
even shoríer courses of íherapyK qhe effecís observed were also noíed ío persásí
for NO moníhs afíer síoppáng íhe NSJweek íráal [
zK A major ássue wáíh ánsulán
íherapy ás íhaí whále íhe goal ás ío keepLgeí paíáenís off of ánsulánI only a lámáíed
number of paíáenís are able ío dásconíánue ánsulán íherapyI and many beáng
resíaríed due ío poor glycemác conírolK
rse of qháazoládánedáones and ánsulán secreíagogues ás wádely debaíed by
pedáaírác endocránologásís due ío absence of good láíeraíure ío supporí safeíy and
effácacyK A síudy comparáng glámepáráde EsulfonylureaF
meíformán usage
over OS weeks showed comparable ebANc reducíáon and relaíáve safeíy profáleK
maíáenís receáváng glámepáráde had more weághí gaán and hágher BMI compared ío
meíformán usersI buí íhás ás a known sáde effecí of sulfonylurea agenís [
iámáíed síudáes exásí for use of qZa án adolescení paíáenísI whaí ás presení shows
moderaíe ebANc reducíáon buí ságnáfácaní concern exásís over íhe medácaíáons
dlánádes and dlucosádase ánhábáíors EAcarboseF are curreníly beáng examáned for
use án adolescení paíáenísK qhe need for medácaíáon usage práor ío every meal may
bxenaíádeI an áncreíánJmámeíác ageníI has been used as an adjuncíáve íherapy án
adulís due ío áís glucagonJláke pepíáde EdimJNF properíáesK Ií decreases glucoseJ
dependení ánsulán secreíáonI slows gasírác empíyángI áncreases saíáeíyI has been
found ío reduce body weághíI and ámproves some cardáovascular rásk facíorsK A
recení síudy án adolescenís used lowJdose bxenaíáde and observed
pharmacokáneíács and dynamács ío see áf agenís are safe for adolescení usageK
Mánámal sáde effecís and reduced posíprandáal glucose levels were noíedI
encouragáng furíher íesíáng wáíh hágher dosáng ío observe effecísK thále
reassurángI furíher research needs ío be performed before íhás agení can be more
blágábáláíy cráíeráa for adolescenís ánclude BMI >PR kgLmOI áf a seráous
comorbádáíyI láke qype O aáabeíesI ás preseníK maíáení musí be qanner síage Is or
sI haváng acháeved skeleíal maíuráíyK pmall síudáes exásí íhaí show favorable
resulís posíJsurgery wáíh regard ío BMII dáabeíác conírolI hyperlápádemáaI and
hyperíensáon [
zK Cauíáon should be appláed before consáderáng íhás as a
recommended íherapy uníál largerI longer and beííerJconírolled síudáes exásíK
Mácroalbumánuráa ás more prevalení án qype O dáabeíác youíh compared ío qype N
dáabeíácsK A few síudáes have shown íhaí presence of mácroalbumánuráa án
adolescení qype O dáabeíács ás assocáaíed wáíh a hágher raíe of end síage renal
dásease compared ío adulíJonseí íype O dáabeíács wáíh mácroalbumánuráaK qhe raíe
of progressáon of mácroalbumánuráa ío renal dásease íends ío be more rapád án
oecommendaíáons exásí for íreaímení of hyperíensáon based on sysíolác and
dáasíolác pressures by heághí [
zI sánce no absoluíe cuíoff for elevaíed blood
pressure exásís for pedáaírácsK qhe recommendaíáon ás aggressáve íreaímení ío
delay progressáon ío end síage renal dáseaseK ACbJánhábáíorsI or áf noí íoleraíedI
ayslápádemáa exásís án approxámaíely NUJSNB of youíh wáíh íype O dáabeíesK qhe
combánaíáon of íhese rásk facíors has been assocáaíed wáíh early ságns of
cardáovascular dáseaseK doal iai for paíáenís wáíh dáabeíes ás less íhan NMM
mgLdlI íráglycerádes YNRM mgLdiI and eai >PR mgLdiK mharmacoíherapy should
be síaríed for paíáenís wáíh an iai >NSM mgLdiI and should be consádered NPMJ
NRV mgLdiI áf oíher rásk facíors are preseníK píaíán íherapy usage án adolescenís
has been found ío be safe and effecíáve [
zI fábrác acád and lmegaJP faííy acáds
qhe care of íhe paíáení wáíh dáabeíes can be challengángK maíáenís and íheár
famáláes requáre ságnáfácaní educaíáonI láfesíyle changesI medácaíáon adjusímeníI
frequení clánác vásáísI and ofíen benefáí from an exíernal supporí sysíemK qhe
dáagnosás of qype N aáabeíes íasks cháldren and íheár famáláes ío learn íhe
ámporíance of dáeíI exercáseI and personal conírol of healíhK A good workáng
relaíáonsháp wáíh healíh care prováders and famály ás necessary ío navágaíe íhe
changes of adolescence ío allow for greaíer ándependenceK A dáagnosás of qype O
aáabeíes ás also ságnáfácaníly challengáng ío manageK qhe paíáení’s underlyáng
healíh ássuesI áncludáng obesáíyI hyperíensáonI renal dáseaseI and hyperlápádemáa
ofíen exásí práor ío íhe developmení of overí dáabeíesK qhe famály musí acíávely
commáí ío láfesíyle changesI whách may be dáffáculí án many paíáenísK A hágh
degree of loss ío followJup ás observed án many síudáes of cháldren and
adolescenís wáíh qype O dáabeíesI hághlághíáng íhe challenge of íreaímeníK A
sírong personal relaíáonsháp wáíh paíáenís and íheár famáláes ás ádeal ío ámprove íhe
aabelea aI MayerJaavás bgI paydah pI
eí alK
mrevalence of íype N and íype O dáabeíes among cháldren
Aíkánson MAI von eerraíh MI mowers ACI ClareJpalzler MK Currení concepís on íhe paíhogenesás of
íype N dáabeíesJJconsáderaíáons for aííempís ío prevení and reverse íhe dáseaseK aáabeíes Care OMNR;
pchmáíz lI Brock BI oungby gK Amylán agonásís: a novel approach án íhe íreaímení of dáabeíesK
básenbaríh dpK qype I dáabeíes melláíusK A chronác auíoámmune dáseaseK k bngl g Med NVUS; PN4EONF:
Máller hMI cosíer kCI Beck otI
eí alK
Currení síaíe of íype N dáabeíes íreaímení án íhe rKpK: updaíed
teánzámer pAI Ahern geI aoyle bAI
eí alK
mersásíence of benefáís of coníánuous subcuíaneous ánsulán
ánfusáon án very young cháldren wáíh íype N dáabeíes: a followJup reporíK medáaírács OMM4; NN4ESF:
aáMegláo iAI moííorff qMI Boyd poI crance iI cáneberg kI bugsíer bAK A randomázedI conírolled
Mamelá CI pcaramuzza AbI eo gI CardonaJeernandez oI puarezJlríega iI Zuccoííá dsK A TJyear
followJup reírospecíáveI áníernaíáonalI mulíáceníer síudy of ánsulán pump íherapy án cháldren and
guvenále aáabeíes oesearch coundaíáon Coníánuous dlucose Monáíoráng píudy droupK Coníánuous
iarson kpI mánsker gbK qhe role of coníánuous glucose monáíoráng án íhe care of cháldren wáíh íype N
Breíon MI carreí AI Bruííomesso aI
eí alK
cully áníegraíed aríáfácáal pancreas án íype N dáabeíes:
Casíle goI bngle gMI bl voussef gI
eí alK
kovel use of glucagon án a closedJloop sysíem for preveníáon
[NPzBonáfacáo bK mredácíáng íype N dáabeíes usáng báomarkersK aáabeíes Care OMNR; PUESF: VUVJVSK
teágensberg MgI doran MIK qype O dáabeíes án cháldren and adolescenísK ianceí OMMV; PTPEVSTTF:
gones hiI Arslanáan pI meíerokova sAI mark gpI qomlánson MgK bffecí of meíformán án pedáaírác
pellers bAI aean egK phoríJíerm ánsulán íherapy án adolescenís wáíh íype O dáabeíes melláíusK g medáaír
doííschalk MI aanne qI slajnác AI Cara gcK dlámepáráde
meíformán as monoíherapy án
pedáaírác paíáenís wáíh íype O dáabeíes: a randomázedI sángleJblánd comparaíáve síudyK aáabeíes Care
Malloy gI Capparellá bI doííschalk MI duan uI hoíhare mI cáneman MK mharmacology and íolerabáláíy
of a sángle dose of exenaíáde án adolescení paíáenís wáíh íype O dáabeíes melláíus beáng íreaíed wáíh
meíformán: a randomázedI placeboJconírolledI sángleJblándI doseJescalaíáonI crossover síudyK Clán qher
Inge qeI Máyano dI Bean gI
eí alK
oeversal of íype O dáabeíes melláíus and ámprovemenís án
mavkov MbI Benneíí meI hnowler tCI hrakoff gI páevers MiI kelson odK bffecí of youíhJonseí íype
O dáabeíes melláíus on áncádence of endJsíage renal dásease and moríaláíy án young and máddleJaged
and AdolescenísK qhe fouríh reporí on íhe dáagnosásI evaluaíáonI and íreaímení of hágh blood pressure
oosenbloom AiI pálversíeán geI Amemáya pI Zeáíler mI hlángensmáíh dgK qype O dáabeíes án cháldren
aeparímení of medáaírácsI rnáversáíy of qexas pan Aníonáo eealíh pcáence CeníerI pan AníonáoI
Absírací:
medáaírác qype O aáabeíes Melláíus EqOaMF ás an áncreasáng medácal
concern for íhe pedáaírác communáíyK Ií ás mosí commonly dáagnosed án adolescenís buí
has also been seen án paíáenís as young as R years of ageK mreseníaíáon of qOaM can
range from máld sympíoms of polyuráaI polydápsáa and nocíuráa ío dáabeíác
keíoacádosásK duádelánes by íhe Amerácan aáabeíes Assocáaíáon are used ío dáagnose
and íreaí cháldren wáíh dáabeíesK barly dáagnosás and aggressáve íreaímení ás cráíácal án
delayáng complácaíáons of dáabeíesK moorly conírolled dáabeíes can lead ío ságnáfácaní
áncrease án morbádáíy and moríaláíy wáíh developmení of hyperíensáonI nephropaíhy
and reíánopaíhyK In íhás chapíerI a reváew of íhe epádemáology of qype O dáabeíesI
heywords:
ANcI Acaníhosás nágrácansI eyperíensáonI Insulán resásíanceI
MeíformánI kephropaíhyI ldqqI medáaírácI medáaírácsI ooságláíazoneI qOaMK
then dáabeíes ás dáscussed án íhe pedáaírác seííángI one prámarály íhánks of qype N
paíáenís are encouníeráng an áncrease án íhe number of overweághí and obese
paíáenísK qhese subseí of paíáenís bráng along coJmorbádáíáes íhaí are consádered
uncommon án general pedáaírácsK kow íhe pedáaírác prováder musí be able ío
ádeníáfy paíáenís aí rásk for noí only qype O dáabeíes melláíus EqOaMFI buí also
condáíáons such as hyperíensáonI dyslápádemáa and nonJalcoholác faííy láver
Alíhough ánáíáally referred ío as adulí onseí dáabeíesI qOaM ás now commonly
Correspondáng auíhor Carásse lrsá
: aeparímení of medáaírácsI rnáversáíy of qexas pan Aníonáo eealíh pcáence
cháldren coáncádes wáíh íhe rásáng cháldhood obesáíy raíeK In a síudy
conducíed íhrough vale medáaírác lbesáíy clánácI ámpaáred glucose íolerance
EpredáabeíesF was reporíed án ORB of cháldren and ONB of adolescenís wáíh a BMI
>VRB for age and sex [
zK qhe worrásome concern án íhás paríácular populaíáon ás
íhaí íhe progressáon from ámpaáred glucose íolerance ío overí qOaM seems ío
occur aí an acceleraíed pace án cháldren compared ío adulís [
zK Addáíáonal facíors
íhaí may conírábuíe ío íhe áncrease án cháldhood qOaM are exposure ío dáabeíes án
uíero and endocráne dásrupíáng chemácalsI such as organophosphaíes and nácoíáne
qhe pbAoCe síudy ás íhe largesí ío daíe regásíry for dáabeíes án youíh YOM years
of ageK qhás síudy evaluaíed íhe prevalence of qNaMI qOaMI maíuráíy onseí
dáabeíes EMlavF and “unceríaán íype”K qen years agoI qOaM accouníed for less
íhan PB of all new cases of dáabeíes án adolescenísI buí now accounís for OMJRMBK
Comparáng daía from OMMN and OMMV reveals a PMKRB áncrease án qOaM
dáagnosed án cháldren YOM years of age [
qhe prevalence of qOaM by race ás hághesí án Amerácan IndáansI followed by
blacksI eáspanácsI Asáan macáfác Islanders and lasíly wháíes [
zK qhe prevalence ás
hágher án ages NRJNV years compared ío ages NMJN4 due ío íhe áncrease án ánsulán
resásíance apprecáaíed duráng puberíy [
zK cemales are more lákely ío be
dáagnosed wáíh qOaM íhan malesK lf íhe cháldren dáagnosed wáíh qOaMI TRB
táíh íhe áncreasáng number of qOaM casesI áí ás ámperaíáve íhaí íhe pedáaírác
prováder ádeníáfáes cháldren aí rásk for qOaM án hope ío prevení or aí leasí delay
íhe dáagnosásK A íhorough famály hásíory ás ámporíaní ío deíermáne rásks facíorsI as
well asI dásíánguásh rásks for oíher íypes of dáabeíes láke MlavK Based on íhe
OMNS AaA dáabeíes guádelánesI screenáng for qOaM án íhe pedáaírác populaíáon ás
ándácaíed án paíáenís íhaí have a BMI >URB for age and sex plus íwo oíher
addáíáonal rásk facíors Eqable
F [
zK pcreenáng should begán aí NM years of age or
earláer dependáng on íhe onseí of puberíyK qhe íámáng of puberíy ás ámporíaní
gáven áís assocáaíáon wáíh áncreased ánsulán resásíanceK maíáenís aí rásk should be
screened every P yearsK qhey may be screened more ofíen áf íhey exhábáí
sympíoms consásíení wáíh qOaMI such as polyuráa or polydápsáaK
Anoíher rásk facíor áncludes íhe presence of acaníhosás nágrácans EAkFK Ak refers
ío darkenáng of íhe skán assocáaíed wáíh ánsulán resásíance íhaí ás usually
apprecáaíed on íhe back of íhe neck or oíher skán foldsK Ií ás a helpful physácal
fándáng íhaí healíh care prováders may use ío ádeníáfy cháldren aí rásk for dáabeíesK
Ií ás also a nonJánvasáve íool uíálázed án íhe school seííáng ío áncrease íhe screenáng
of cháldren íhaí may noí be receáváng regular healíh careK Ií can be graded on a
scale descrábed by Burke
eí al
K Eqable
F [
zK Iís regressáon can be a ságn of
ámproved glycemác conírol and ánsulán resásíanceK qhere does noí appear ío be any
lnce a cháld ás ádeníáfáed as beáng aí rásk for developáng qOaMI íhen screenáng
for dáabeíes usáng fasíáng plasma glucose levelsI O hour oral glucose íolerance íesí
EldqqF or hemoglobán ANc EANcF can be performedK qhere ás debaíe as ío
wheíher íhe ANc ás a reláable screenáng íool án íhe pedáaírác populaíáonK dáven íhe
varáabáláíy of fasíáng glucoses and íhe convenáence of obíaánáng an ANc when
compared ío an ldqqI many healíh care prováders prefer ío use an ANcK A
prováder should be aware of medácal condáíáons íhaí can áníerfere wáíh íhe
accuracy of íhe ANcK In condáíáons such as sáckle cell anemáaI hemoglobánopaíháes
and cysíác fábrosásI íhe ANc can be falsely low and íherefore an unreláable íoolK
qable
ás adapíed from íhe OMNS AaA píandards of Medácal Care án aáabeíes
táíhouí a clear dáagnosás of dáabeíes melláíus íhen a repeaí íesí should be
performed íhaí same day wáíh a new blood sample ío confárm a dáagnosás [
zK cor
exampleI áf íhe ánáíáal ANc ás SKRBI íhen a repeaí ANc should be done on a new
blood sample ío confárm íhe dáagnosásK If dáfferení íesís are used and one does noí
confárm íhe dáagnosásI íhen íhe íesí resulí íhaí dád meeí dáagnosíác cráíeráa should
be repeaíedK qhe dáagnosás ás íhen based on íhaí confármaíory íesí resulí [
mrováders also need ío be aware íhaí paíáenís wáíh qNaM can presení wáíh obesáíy
and AkK rníál auíoaníábodáes for qNaM are confármed negaíáveI íhe dáagnosás
cannoí be excludedK qhe mosí commonly íesíed auíoaníábodáes are ásleí cellI
ánsulán and gluíamác acád decarboxylase EdAaF auíoaníábodáes [
zK táíh íhe
many complácaíáons seen án íhese paíáenísI once a dáagnosás ás suspecíed or
confármed for qOaMI an ámmedáaíe referral should be made ío a pedáaírác
In auíoaníábody negaíáve paíáenísI oíher secondary íypes of dáabeíes should be
consáderedK maíáenís wáíh medácal condáíáons such as cancerI rheumaíologác
dásordersI or pulmonary dásease íhaí requáre hághJdose síeroáds may presení wáíh
complácaíáons of prolonged hyperglycemáa and ánsulán resásíanceI commonly
referred ío as síeroádJánduced dáabeíesK qhese paíáenís do noí usually have posáíáve
aníábodáesI buí do íend ío presení wáíh ánsulán resásíanceK qreaímení of paíáenís
wáíh síeroádJánduced dáabeíes dáffers from qOaMI íherefore ádeníáfácaíáon of íhese
qreaímení of qOaM án adolescenís and cháldren should be aámed aí reducáng íhe
rásk of longJíerm complácaíáonsK In adulísI usáng lower ANc íargeís has been
shown ío reduce mácrovascular and macrovascular dásease [
zK In paríácularI íhese
paíáenís are aí rásk for dáabeíác reíánopaíhyI neuropaíhy and nephropaíhyK An ANc
of less íhan SKRB should be íhe glycemác goal of ánáíáal íreaímeníK qreaímení of
qOaM án cháldren and adolescenís ás fársí dácíaíed by íhe severáíy of
hyperglycemáa and presence or absence of keíosásLkeíoacádosás [
zK keveríhelessI
láfesíyle modáfácaíáons should be ánáíáaíed aí íhe íáme of dáagnosás of qOaM [
I
qhe success of láfesíyle modáfácaíáon depends on a paíáenís and famáláes readáness
ío change and should ánclude síraíegáes used án evádence based obesáíy preveníáon
áncludáng elámánaíáon of sugarJsweeíened beveragesI consumpíáon of ≥R servángs
of fruáís and vegeíables per dayI lámáíáng screen íáme ío ≤O hours per day wáíh no
íelevásáon where íhe cháld sleepsI and engagáng án >N hour of daály physácal
acíáváíy [
zK Ií ás also recommended íhaí managemení of youíh wáíh qOaM
ánclude áncorporaíáon of íhe medáaírác kuíráíáonal duádelánes seí foríh by íhe
Academy of kuíráíáon and aáeíeíácsK qreaímení wáíh a keíogenác veryJlow caloráe
dáeí án obese adolescenís wáíh poorly conírolled qOaM has been shown ío be
qhe Iníernaíáonal pocáeíy for medáaírác and Adolescení aáabeíes EIpmAaF
recommends ánáíáal pharmacologácal íreaímení wáíh meíformánI ánsulán alone or án
combánaíáon for youíh dáagnosed wáíh qOaM [
zK Ií ás recommended íhaí aí íhe
íáme of dáagnosás asympíomaíác paíáenís wáíh no acádosás and an ANc of less íhan
VB be síaríed on meíformán monoíherapy wáíh láfesíyle changesI whále
sympíomaíác paíáenís wáíh an ANc greaíer íhan VB and acádosás should be síaríed
on ánsulánK AddáíáonallyI síaríáng meíformán can be consádered aí íhe same íáme as
ánsulán án sympíomaíác cháldren wáíh an ANc greaíer íhan VBI áf íhere ás no
evádence of acádosás presení [
Meíformán ás án íhe báguanáde class of drugs and áí ás approved án cháldren down
ío age NMK CurrenílyI only meíformán and ánsulán are caA approved án íhe
íreaímení of qOaM án cháldren and adolescenís Eqable
FK Meíformán has been
shown ío work prámarály íhrough íhe acíáons of adenosáne monophosphaíe EAMmF
kánase wáíh acíáons áncludáng reducíáon of hepaíác gluconeogenesás and áncreased
glucose upíake aí íhe level of íhe myocyíeI however íhe mechanásm of acíáon
remaáns ío be fully elucádaíed and newer síudáes suggesí íhaí íhe áníesíáne may be
an ámporíaní sáíe of acíáon of íhe glucose loweráng effecís of meíformán [
J
qypácallyI meíformán ás síaríed aí a dose of RMM mg íwáce a dayK Ií ás íaken wáíh
foodI ádeally wáíh breakfasí and dánnerI ío avoád or dámánásh any gasíroáníesíánal
sádeJeffecísK If íhe medácaíáon ás íoleraíedI íhe dose should be áncreased ío NMMM
mg íwáce a dayI whách ás íhe maxámum doseK eágher doses are rarely assocáaíed
wáíh hypoglycemáaK iáver and kádney funcíáon íesís should be evaluaíed before
and afíer síaríáng meíformánK denerallyI áf íhe Apq and Aiq are >OKR íámes íhe
upper lámáí of normalI íhás could áncrease rásk of lacíác acádosás and ánsulán should
be consádered as fársíJláne íherapyK konJalcoholác faííy láver dásease EkAciaF ás
ofíen presení aí íhe íáme of dáagnosás and can be íhe cause of íhe abnormal láver
funcíáonK Improved glycemác conírol and ánsulán sensáíázers such as meíformán
may acíually ámprove kAcia and may be consádered as ánsulán ás íransáíáoned
off wáíh coníánued close monáíoráng of láver enzymes [
zK If ánsulán ás used wáíh
meíformánI a longJacíáng ánsulán ás used as a secondJláne íherapyK If íhere ás
coníánued poor conírol wáíh íhe combánaíáon íherapyI a fasíJacíáng ánsulán can be
addedK A sládáng scale can be used based on íhe degree of hyperglycemáaK If more
aggressáve íherapy ás neededI íhe preJmeal ánsulán dose can be áncreased by
In adulísI íhere are several drug opíáons wáíh varyáng mechanásm of acíáonsK cew
of íhese medácaíáons have been síudáed án cháldrenK cándángs from íhe qreaímení
lpíáons for qype O aáabeíes án Adolescenís and vouíh EqlaAvF síudyI a large
mulíáceníer íráal síudyI demonsíraíed íhaí meíformán plus roságláíazone was
superáor ío meíformán alone or án combánaíáon wáíh láfesíyle áníerveníáon án
susíaáned reducíáon of glycemác conírol as defáned by maáníaánáng an ANc of aí
leasí UB for a S moníh peráod or an ánabáláíy ío wean from ánsulán afíer meíabolác
decompensaíáon [
I
zK líher pharmacologácal agenís are generally noí approved
for use án cháldren and adolescenís gáven íhe lámáíed amouní of síudáes of use of
íhese medácaíáons án cháldren Eqable
FK aaía relaíed ío íhe safeíy and íolerabáláíy
of meíformán and roságláíazone was acquáred as parí of íhe qlaAv íráal [
Mosí of íhe sáde effecís were relaíed ío dI upseí; however anemáaI abnormal láver
íransamánasesI excessáve weághí gaánI psychologácal evenísI lacíác acádosásI
dáabeíác keíoacádosás and severe hypoglycemáa were also reporíed [
zK líher
íreaímení opíáons ánclude áncreíán mámeíács such as dimJN recepíor agonásís
whách are promásáng agenís for fuíure íreaímení buí have noí yeí been approved
aaía from íhe qlaAv íráal suggesí íhaí noí only do íhese cháldren and
adolescenís experáence sámálar complácaíáons and coJmorbádáíáes as seen án adulísI
buí íhaí áí occurs on an acceleraíed íámeláne [
zK qhereforeI care for íhese hágh rásk
youíh should also ánvolve íhe assessmení and managemení of coJmorbádáíáes and
iongJíerm ouícomes of qOaM án youíh ánclude boíh mácrovascular and
macrovascular complácaíáonsK mrogressáon ío complácaíáons appears ío occur aí a
more acceleraíed pace when compared ío qNaM and ás precápáíaíed by poor
glycemác conírolK In conírasí ío íhose wáíh qNaMI complácaíáons such as
hyperíensáon and mácroalbumánuráa are common aí íhe íáme of preseníaíáon;
íherefore screenáng íypácally begáns aí íhe íáme of dáagnosásK deneral guádelánes
regardáng screenáng and íreaímení prováded below were adapíed from íhe
Amerácan Academy of medáaírács recommendaíáons for managáng newly
dáagnosed qOaM án cháldren and adolescenís [
eyperíensáon ás defáned as a blood pressure� "e VRB for heághíI ageI and gender
obíaáned on íhree separaíe occasáons usáng an appropráaíely sázed blood pressure
cuffK pcreenáng should be performed aí each clánác vásáí síaríáng aí íhe íáme of
íhe prevalence of hyperíensáon aí dáagnosás ás esíámaíed ío be eághí íámes more
frequení án cháldren wáíh qOaM when compared ío íhose wáíh qNaM and varáes
beíween NMJPOB [
zK In íhe qlaAv cohorí Ek = SVVFI hyperíensáon was
apprecáaíed án NNKVB of adolescenís aí baseláne and áncreased ío almosí P4B aí
followJup nearly four years laíer [
zK A lowJsalí dáeíI physácal acíáváíyI and
weághí loss should be encouraged as ánáíáal áníerveníáonsK An angáoíensánJ
converíáng enzyme ánhábáíor EACbJIF ás used as fársí láne pharmacologácal
íreaímení ío prevení íhe progressáon ío dáabeíác nephropaíhyK qhe goal of
íreaímení ás ío consásíeníly acháeve sysíolác and dáasíolác blood pressures Y VM
perceníáleK Angáoíensán recepíor blockers may be used áf an ACbJI ás noí íoleraíed
KI chronác coughFK oeferral ío nephrology ás ándácaíed áf hyperíensáon ás noí
pcreenáng for dáabeíác nephropaíhy áncludes íesíáng for mácroalbumánuráa wáíh a
random mornáng uráne mácroalbumánJíoJcreaíánáne raíáoK pcreenáng should begán
aí íhe íáme of dáagnosás and íhen repeaíed annuallyK qwo of íhree consecuíáve
uráne samples collecíed over a P ío S moníh peráod wáíh a raíáo� "e PM µgLmg ás
represeníaíáve of persásíení mácroalbumánuráaK A síudy followáng máma Indáans
noíed OOB prevalence of mácroalbumánuráa aí dáagnosás íhaí áncreased ío nearly
SMB afíer NM years [
zK In íhe qlaAv cohoríI íhe prevalence was SKPB aí
baseláneI NMKPB aí íhe 4 year followJupI and NSKSB aí íhe end of íhe síudy [
zK A
crossJsecíáonal síudy performed án Ausíraláa reporíed íhaí despáíe haváng a shoríer
duraíáon of dáabeíes ENKP vsK SKU yearsF youíh wáíh qOaM had a ságnáfácaníly
hágher raíe of mácroalbumánuráa when compared ío youíh wáíh qNaM EOUB vsK
SBF [
zK pámálarlyI a mulíáceníer íráal án kew Zealand reporíed an áncreased raíe
of mácroalbumánuráa án íhose wáíh qOaM ETOBF when compared ío qNaM ENTBF
despáíe shoríer dáagnosás of dáabeíes EP vsK S yearsF [
zK In a normoíensáve
adolesceníI persásíení mácroalbumánuráa ás managed by opíámázáng glycemác
conírolK A hyperíensáve adolescení warranís íreaímení wáíh an ACbJIK Medácaíáon
should be íáíraíed ío ádeally normaláze m
excreíáon wáíhouí causáng
hypoíensáonK oeferral ío a nephrologásí ás ándácaíed áf proper conírol ás noí
acháevedK Mácroalbumánuráa may progress ío macroalbumánuráa
E≥ PMMmcgLmg
creaíánáneFI proíeánuráa
E≥ NIMMMmcgLmg creaíánáneFI and endJsíage renal dásease
oeíánopaíhy ás dáagnosed by an ophíhalmologásí usáng a sláíJexamánaíáon íhrough
dálaíed pupálsK pcreenáng should be performed aí íhe íáme of dáagnosás and
repeaíed annuallyK peveráíy ranges from máld nonproláferaíáve reíánopaíhy ío
proláferaíáve reíánopaíhyK aaía obíaáned on RNT subjecís án íhe fánal year of íhe
qlaAv síudy revealed íhaí OTB had some form of reíánopaíhy rangáng from
earlyI máld reíánopaíhy ío nonproláferaíáve reíánopaíhy wáíh mácroaneurysms or
coííon wool ánfarcís [
zK Alíhough síudáes demonsíraíe íhe prevalence of
reíánopaíhy ás more common án adolescenís wáíh qNaMI íhe duraíáon of dáabeíes
ío progress ío reíánopaíhy ás shoríer án íhose wáíh qOaM [
I
zK mrogressáve
mácrovascular reíánal changes resulí án vásáon ámpaármení and eveníual blándnessK
qreaímení for reíánopaíhy áncludes laser íherapyI ánjecíáon of coríácosíeroádsI and
bven íhough cráíeráa used ío defáne fasíáng dyslápádemáa are noí consásíení across
síudáesI íhe presence of lápád abnormaláíáes án adolescenís wáíh qOaM aí dáagnosás
ás common and varáes beíween NUJSNB [
zK In íhe qlaAv síudyI 4KRB of
subjecís aí baseláne eáíher had an elevaíed lowJdensáíy lápoproíeán EiaiF� "e
NPMmgLdl or were íakáng lápádJloweráng medácaíáonsK Aí íhree years Ek=OS4FI íhe
perceníage áncreased ío NMKTBK Auíhors of íhe qlaAv síudy reporí íhaí many
componenís of íhe lápád panel áncreased over íáme E
KI iaiI íráglycerádesI and
non hághJdensáíy lápoproíeánF regardless of íhe íreaímení arm [
zK pcreenáng
áncludes a fasíáng lápád panel aí íhe íáme of dáagnosás and annually íhereafíerK
konJpharmacologác managemení áncludes opíámázáng glycemác and blood
pressure conírolK cor iai levels persásíeníly� "e NPM mgLdlI íreaímení wáíh a eMd
CoJA reducíase ánhábáíor Esíaíán íherapyF ás recommendedK qhe íreaímení goal ás
ío acháeve an iai Y NPM mgLdl wáíh an ádeal íargeí of YNMM mgLdlK cenofábraíe or
náacán íherapy can be consádered áf íráglycerádes are > TMM mgLdl despáíe genuáne
efforís ío mánámáze íhe áníake of sámple sugarsK qype O dáabeíes and dyslápádemáa
caííy ánfálíraíáon of íhe láver resulíáng án elevaíed láver enzymes ás apprecáaíed án
cháldren wáíh qOaMK pcreenáng áncludes íhe measuremení of alanáne
amánoíransferase EAiqF and asparíaíe amánoíransferase EApqF aí dáagnosás and
íhen annuallyK In paíáenís wáíh faííy láverI Apq and Aiq levels may be greaíer
íhan íwo or íhree íámes íhe upper lámáí of normalK pome paíáenís wáíh faííy láver
may have normal láver funcíáon íesísK A láver ulírasound may be helpful án íhe
dáagnosásK qreaímení opíáons are lámáíed ío láfesíyle modáfácaíáonsK oeferral ío a
gasíroeníerologásí may be warraníed áf láver enzymes are worsenáng despáíe
ámprovemenís án weághíI nuíráíáonI and glycemác conírolK qhe progressáon from
faííy láver ío cárrhosás necessáíaíáng láver íransplaníaíáon ás noí well undersíoodI
buí ás a defánáíe concern gáven íhe áncreasáng prevalence of obesáíy and qOaM án
youíhK Many medácaíáons commonly used án qOaM are coníraándácaíed án
paíáenís wáíh elevaíed láver funcíáon íesís E
KI síaíánsFI íherefore monáíoráng láver
Alíhough síudáes are lámáíedI clánácal depressáon appears ío be more common án
youíh wáíh qOaM íhan íhose wáíh qNaM [
zK nuesíáonnaáres compleíed by íhe
paríácápanís of qlaAv síudy Ek=SUTF revealed íhaí aí baseláneI N4KUB selfJ
reporíed sympíoms were consásíení wáíh clánácally ságnáfácaní depressáon [
saládaíed íools ío screen for depressáon are avaálable ío general pracíáíáonersI buí
qhe írue áncádence of dáabeíác neuropaíhy án íhe íype O pedáaírác populaíáon ás
largely unknown and lákely noí commonI gáven íhaí ánformaíáon avaálable ás
lámáíed ío a few case reporísK pcreenáng áncludes quesíáonáng abouí sympíoms
consásíení wáíh neuropaíhy such as numbáng and íángláng of íhe exíremáíáes or
erecíále dysfuncíáonK pcreenáng íechnáques on physácal exam ánclude íesíáng for
táíh íhe ráse án number of cháldren who are overweághí and obeseI healíh care
prováders are seeáng and íreaíáng more paíáenís aí rásk for developáng qOaMK
mroper screenáng of and early ádeníáfácaíáon of íhese paíáenís can delay íhe
dáagnosás of qOaM by ámplemeníáng láfesíyle modáfácaíáons and íherapáesK
Accuraíe dáagnosás ás cráíácal for appropráaíely managáng íhese paíáenísI especáally
sánce íhe dáagnosás of qNaM can be mássed áf íhe paíáení ás overweághí or obeseK
qherapy should be focused on acháeváng glycemác conírol wáíh íhe monáíoráng
ANc levels aí scheduled vásáísK táíh appropráaíe íherapyI longJíerm complácaíáons
of qOaM can be delayed or preveníedK thále adulís wáíh qOaM have many
íherapeuíác opíáonsI íhese medácaíáons have noí been approved for pedáaírác
paíáenísK Addáíáonal síudáes are needed on cháldren ío íesí íhe safeíy and effácacy
of íhese dáabeíác medácaíáons ío prováde ámproved medácal managemení of
paíáenís wáíh qOaMK
pánha oI cásch dI qeague BI
eí alK
mrevalence of ámpaáred glucose íolerance among cháldren and
aDAdamo bI Capráo pK qype O dáabeíes án youíh: bpádemáology and paíhophysáologyK aáabeíes Care
qhayer hAI eeándel ggI Bucher goI dallo MAK oole of enváronmeníal chemácals án dáabeíes and
obesáíy: A naíáonal íoxácology program workshop reváewK bnváron eealíh merspecí OMNO; NOMESF: TTVJ
aabelea aI MayerJaavás bgI paydah pI
eí alK
mrevalence of íype N and íype O dáabeíes among cháldren
Chamberlaán ggI oháneharí ApI phaefer Cc grI keuman AK aáagnosás and managemení of dáabeíes:
pynopsás of íhe OMNS
merácan dáabeíes assocáaíáon síandards of medácal care án dáabeíesK Ann Iníern
Burke gmI eale abI eazuda emI píern MmK A quaníáíaíáve scale of acaníhosás nágrácansK aáabeíes Care
Amerácan aáabeíes AssocáaíáonK píandards of medácal care án dáabeíesJOMNS Abrádged for prámary care
Zeáíler mI
eí alK
IpmAa Clánácal mracíáce Consensus duádelánes OMN4K qype O aáabeíes án íhe Cháld and
deorge MMI Copeland hCK Currení íreaímení opíáons for íype O dáabeíes melláíus án youíh: íodayDs
Barlow p bK bxperí commáííee recommendaíáons regardáng íhe preveníáonI assessmeníI and íreaímení
of cháld and adolescení overweághí and obesáíy: pummary reporíK medáaírács OMMT; NOM EpupplK 4F:
Mcdavock gI aarí AI tácklow BK iáfesíyle íherapy for íhe íreaímení of youíh wáíh íype O dáabeíesK
Buse gBI aecronzo oAI oosensíock gI
eí alK
qhe prámary glucoseJloweráng effecí of meíformán resádes
án íhe guíI noí íhe cárculaíáon: resulís from shoríJíerm pharmacokáneíác and NOJweek doseJrangáng
mernácova II horbonáís MK MeíformánJMode of acíáon and clánácal ámplácaíáons for dáabeíes and
Zhou dI
eí alK
oole of AMmJacíávaíed proíeán kánase án mechanásm of meíformán acíáonK g Clán Invesí
qlaAv píudy droupK bffecís of meíformánI meíformán plus roságláíazoneI and meíformán plus
qlaAv píudy droupK pafeíy and íolerabáláíy of íhe íreaímení of youíhJonseí íype O dáabeíes: qhe
Copeland hI pálversíeán gI Moore hI
eí alK
Managemení of newly dáagnosed íype O dáabeíes melláíus
mánhasJeamáel lI Zeáíler mK Acuíe and chronác complácaíáons of íype O dáabeíes melláíus án cháldren
qryggesíad gI tállá pK Complácaíáons and comorbádáíáes of qOaM án adolescenís: fándángs from íhe
cagoíJCampagna AI hnowler tI meííáí aK qype O aáabeíes án máma Indáan cháldren: cardáovascular
bppens MCI Craág MbI Cusumano gI
eí alK
mrevalence of dáabeíes complácaíáons án adolescenís wáíh
pcoíí AI qoomaíh oI Boucháer aI
eí alK
cársí naíáonal audáí of íhe ouícomes of care án young people
wáíh dáabeíes án kew Zealand: hágh prevalence of nephropaíhy án Maorá and macáfác IslandersK k Z
mracíácal duáde for Managemení of Cháldren wáíh
aeparímení of medáaírács aávásáon of bndocránologyI iouásáana píaíe rnáversáíyJeealíh pcáences
Absírací:
qhe worldwáde prevalence of pedáaírác obesáíy has áncreased remarkably
over íhe pasí íhree decades íurnáng pedáaírác obesáíy ánío a seráous and challengáng
publác healíh concernK lne án íhree cháldren and adolescenís án íhe rp are overweághí
or obeseK medáaírác obesáíy ás assocáaíed wáíh numerous comorbádáíáesI cardáovascular
rásk facíorsI and adulíhood obesáíyK lbesáíy has been a major conírábuíor ío áncreasáng
healíhcare expensesK Increasáng awareness of pedáaírác obesáíy án íhe publác as well as
íhe healíhcare plaíform ás esseníáal ío íackle íhe problem and plan prámary and
secondary preveníáonK dáven íhe lámáíed pharmacoíherapy opíáons for pedáaírác obesáíyI
a mulíáfaceíed approach of láfesíyle changes ánvolváng nuíráíáonI physácal acíáváíy and
behaváor modáfácaíáon ás neededK In order ío make a meanángful ámpacíI collaboraíáon
among íhe governmeníI employersI schoolsI healíhcare and oíher organázaíáons from
íhe communáíy ás requáredK qhás chapíer áníends ío prováde a comprehensáve yeí
concáse reváew of evaluaíáon and managemení of pedáaírác obesáíyK
heywords:
AdolesceníI Cardáovascular ráskI CháldI aáabeíesI ayslápádemáaI
iáfesíyle modáfácaíáonI lbesáíyI lverweághíI medáaírácI mreveníáonI qype O
dáabeíes melláíusI teághí managemeníK
qhe prevalence of pedáaírác obesáíy has áncreased subsíaníáally án íhe pasí íhree
decades íurnáng áí ánío a major publác healíh problem [
I
zK Cháldhood obesáíy ás
a mulíáfacíoráal condáíáon whách can adversely affecí nearly every organ sysíemK Ií
has been assocáaíed wáíh seráous physácal and psychosocáal comorbádáíáes [
J
qhás chapíer áníends ío reváew íhe defánáíáonI deíermánanísI epádemáology and
comorbádáíáes of pedáaírác obesáíy and prováde a pracíácal approach ío clánácal
Correspondáng auíhor kesláhan dungor
: aeparímení of medáaírács aávásáon of bndocránologyI iouásáana píaíe
rnáversáíyJeealíh pcáences CeníerLrnáversáíy eealíhI phreveporíI iouásáanaI rpA; qel: EPNUF STRJSMTS; bmaál:
qhe íerm obesáíy refers ío excess of body faí or adáposáíyK eoweverI íhe meíhods
used ío dárecíly measure body faí are noí avaálable án rouíáne clánácal pracíáceK In
clánácal pracíáce and populaíáon healíh surveállance sysíemsI obesáíy ás defáned by
íhe body mass ándex EBMIFI a maíhemaíácal formula of weághíJforJheághí ándexK
qhe BMI ás calculaíed by weághí án kálograms dáváded by heághí án meíers squared
FK qhe BMI has a hágh correlaíáon wáíh adáposáíy and excess weághí aí íhe
populaíáon levelK eoweverI íhe BMI does neáíher quaníáfy íoíal body adáposáíyI
nor dásíánguásh beíween faí and muscle on an ándávádual basásK curíhermoreI íhe
BMI does noí predácí body faí dásírábuíáonK qherefore áí may overesíámaíe
adáposáíy án a cháld wáíh áncreased muscle mass E
I an aíhleíeF and
underesíámaíe adáposáíy án a cháld wáíh reduced muscle mass E
sedeníary cháldF
J
zK In íhe pedáaírác age group genderJspecáfác BMIJforJageI perceníále charís
are used ío defáne overweághí and obesáíyK Cháldren and adolescenís wáíh a BMI
over íhe UR
buí less íhan íhe VR
perceníále for age and gender are consádered
overweághíI and íhose wáíh a BMI equal ío or greaíer íhan íhe VR
perceníále are
consádered obeseK qhe íerm “severely obese” has been used ío refer ío cháldren
and adolescenís wáíh a BMI greaíer íhan íhe VVíh perceníále [
I
zK In íhe rnáíed
píaíes ErpFI íhe genderJspecáfác drowíh CharísI released án May OMMM by íhe
Ceníers for aásease Conírol are avaálable ío assess Body Mass Index for cháldren
O ío OM years of age [
zK qhe Iníernaíáonal lbesáíy qask corce EIlqcF has
developed an áníernaíáonal síandard growíh charí whách enables comparáson of
prevalence globally [
zK qhe torld eealíh lrganázaíáon has publáshed growíh
síandards for ánfanís and cháldren from báríh ío R years of age [
z and growíh
reference curves for BMI for cháldren R–NV years of age [
zK eoweverI many
In broad íermsI obesáíy ás íhe resulí of a chronác ámbalance beíween energy áníake
and expendáíureI wáíh more caloráes beáng consumed íhan expendedK In general a
lack of physácal acíáváíy án íhe presence of unhealíhy eaíáng paííerns resulí án
excess energy áníakeK lbesáíy ás a complexI mulíáJfacíoráal condáíáon affecíed by
geneíác and nonJgeneíác facíors and áníeracíáons beíween íhese [
I
I
I
zK aue
ío íhe exíensáve naíure of íhás íopác and space resírácíáonsI íhe reader ás referred ío
addáíáonal referencesK bnergy consumpíáon and expendáíure are ámpacíed upon by
epágeneíác programmángI enváronmeníal and socáal facíorsK ppecáfác causes for íhe
áncrease án prevalence of cháldhood obesáíy are noí clearK qo daíeI íhe effecís of a
sángle facíor has noí been ádeníáfáedK EcágK
F provádes a general overváew of íhe
As seen án íhe fágureI íhere are mulíáple socáalI enváronmeníalI behaváoral and
báologácal deíermánanísK qhere are áníerándávádual dáfferences án suscepíábáláíy or
resásíance ío íhe obesogenác enváronmení [
I
I
zK deneíác varáaíáon plays a
major role án íhásK saráous hormonesI mosí of whách orágánaíe from íhe
gasíroáníesíánal íracíI play role án appeíáíe regulaíáon and energy homeosíasás [
I
J
zK cor example ghrelán ás curreníly íhe only known appeíáíeJsíámulaíáng
EorexágenácF guí hormoneI secreíed by íhe oxyníác glands of íhe síomachK dhrelán
levels ráse shoríly before mealíámesK mepíáde íyrosáne íyrosáne EmvvFI pancreaíác
polypepíádeI oxyníomodulánI amylánI glucagonI glucagonJláke pepíádeJN EdimJNFI
and dimJO are íhe anorexágenác guí hormones whách decrease appeíáíe and food
cágK ENFK
aeíermánanís of pedáaírác obesáíyK medáaírác obesáíy ás a mulíáfacíoráal condáíáon of posáíáve energy
balanceI síemmáng from boíh geneíác and nonJgeneíác facíorsI as well as complex áníeracíáons among íhese
bndocráne causes of obesáíy accouní for less íhan NB of obesáíy án íhe pedáaírác
age groupK eypoíhyroádásm Eprámary or ceníralFI growíh hormone defácáency or
resásíance and coríásol excess are íhe poíeníáal endocráne condáíáons leadáng ío
obesáíyK molycysíác ovaráan syndrome EmClpF ás closely assocáaíed wáíh obesáíyK
lbesáíy may also be seen án pseudohypoparaíhyroádásm Ecaused by dsα
ánacíávaíáng muíaíáonF [
I
I
zK Albrághí heredáíary osíeodysírophy EAelF ás an
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auíosomal dománaní dásorder due ío germláne muíaíáons án dkApN whách
decrease expressáon or funcíáon of dsalpha EdsαF proíeánK Maíernal íransmássáon
of dkApN muíaíáons resulís wáíh Ael Ewáíh feaíures of shorí síaíureI obesáíyI
skeleíal defecís and ámpaáred olfacíáonF and resásíance ío several hormones E
paraíhyroád hormoneF íhaí acíávaíe dsα án íheár íargeí íássuesK maíernal
íransmássáon leads only ío íhe Ael phenoíypeK
qhere has been a ságnáfácaní áncrease án íhe worldwáde prevalence of cháldhood
obesáíy án recení decades [
zK In íhe rp íhe áncádence of pedáaírác obesáíy has
áncreased from less íhan RB ío approxámaíely OMB án íhe pasí PM years [
I
mrevalence esíámaíes of obesáíy are deráved from surveys or populaíáon síudáesK In
kuíráíáon bxamánaíáon purvey EkeAkbpF program provádes naíáonal esíámaíes of
overweághí for adulísI adolescenísI and cháldrenK Based on íhe OMNNJOMNO
keAkbp daía [
zI íhe prevalence of obesáíy án íhe rnáíed píaíes was NSKVB án
youíh and P4KVB án adulísK qhe overall prevalence of obesáíy among youíh
remaáned unchanged compared wáíh íhaí án OMMVJOMNM ENSKVBF [
zI and íhere
lbesáíy ás a proánflammaíory síaíeK medáaírác obesáíy can have a negaíáve ámpací
on almosí every organ sysíem and lead ío seráous physácal and psychosocáal
comorbádáíáes [
I
I
I
I
zK qhe áncreasáng prevalence of pedáaírác obesáíy has
broughí mulíáple chronác állnesses and rásk facíors hásíorácally seen only án adulísI
ío íhe consáderaíáon of íhe pedáaírácáanK qable
summarázes íhe comorbádáíáes and
(Table
) contd.....
aF dlucoseJqolerance And oelaíed Consequences:
Insulán resásíance ás íhe
common denománaíor for many of íhe meíabolác and cardáovascular
complácaíáons of obesáíyK eyperánsulánemáa ás íhe mosí common báochemácal
abnormaláíy seen án obesáíyK Insulán resásíance and compensaíory
hyperánsulánemáa are íhe early síeps án íhás OaM paíhogenesásK qhe nexí síep ás
ámpaáred early ánsulán secreíáon paváng íhe way posíJprandáal and fasíáng
hyperglycemáaI respecíávelyK aáabeíes becomes clánácallyJmanáfesí wáíh íhás
progressáon [
J
zK Impaáred glucose íolerance ás a relaíávely common
condáíáon án obese cháldren and adolescenísI wáíh a reporíed prevalence rangáng
from NRB ío greaíer íhan OMB [
J
zK qhe progressáve áncrease án raíes of
pedáaírác obesáíy sánce laíe NVUM’s has íransformed qOaM from a hásíorácally
adulíJonly dáseaseI ío a seráous pedáaírác publác healíh problem [
I
zK qhe
pbAoCe for aáabeíes án vouíh píudy [
zI íhe largesí surveállance efforí of
dáabeíes án youíh án íhe rpI has depácíed remarkably áncreased raíes of qOaM án
NMJNV yearJold mánoráíy adolescenísK Among youíh án NMJNV year age groupI íhe
proporíáon of íype O dáabeíes ranged from SB EMKNV cases per NMMM youíh for nonJ
eáspanác wháíe youíhF ío TSB ENKT4 cases per NMMM youíh for Amerácan Indáan
youíhFK qhe reporíed prevalence of qOaM were OOB án Mexácan Amerácan
youíhsI PPB án Afrácan Amerácan youíhsI and 4MB án AsáanLmacáfác Islander
youíhs [
zK mredáabeíes Eámpaáred fasíáng glucose andLor ámpaáred glucose
íoleranceF requáres aííeníáon from a secondary preveníáon perspecíáve ío offseí
Ceríaán meíabolác dásíurbances have been noíed ío clusíer íogeíher sánce íhe
begánnáng of íhe pasí ceníuryK Insulán resásíance has been proposed as a common
eíáologác facíor for íhe group of meíabolác dásíurbances collecíávely referred ío
pyndrome u or íhe meíabolác syndrome EMeípFK Currení defánáíáons of Meíp
compráse íhe followáng key feaíures: hyperánsulánemáa or ánsulán resásíanceI
dyslápádemáaI hyperíensáonI and obesáíyI wáíh a paríácular emphasás on ceníral
adáposáíyK medáaírác Meíp represenís a group of rásk facíors lánked ío
cardáovascular dáseaseI whách ánclude ánsulán resásíanceI obesáíyI hyperlápádemáaI
and hyperíensáonK Curreníly íhere ás no consensus on íhe defánáíáon of Meíp án
youíh; howeverI ádeníáfácaíáon of cháldren aí rásk for developáng Meíp remaáns an
ámporíaní íask gáven íhe presence of mulíáple cardáovascular rásks and íhe
evádence íhaí íhe clusíeráng of íhese condáíáons persásís án adulíhood [
zK barly
(Table
) contd.....
síages of íhe aíheroscleroíác process are deíecíable án obese cháldrenK bndoíheláal
dysfuncíáon represenís íhe key early síep án íhe developmení of aíherosclerosás
zK Iníáma medáa íháckness EIMqF of íhe perápheral aríeráal vessels ás a surrogaíe
marker for aíherosclerosás and áncreased IMq has been documeníed án obese
cháldren and adolescenís [
zK Cardáovascular rásk facíors presení án cháldhood are
predácíáve of coronary aríery dásease án adulíhoodI as demonsíraíed by íhe
Bogalusa eearí síudy [
zK iow densáíy lápoproíeán cholesíerol EiaiF and BMI
measured án cháldhood were ádeníáfáed as íhe rásk facíors whách predácíed IMq án
young adulísK In a follow up síudy of cháldhood paríácápanís of íhe Bogalusa eearí
píudy as adulísI cháldren who had meíabolácally healíhy overweághíLobesáíy were
noíed ío have favorable cardáomeíabolác profáles án adulíhoodK Meíabolácally
healíhy overweághíLobesáíy was defáned as haváng a body mass ándex án íhe íop
quaríáleI wáíh iaiI íráglycerádesI mean aríeráal pressureI and glucose án íhe
boííom P quaríálesI and hágh densáíy lápoproíeán cholesíerol EeaiF án íhe íop P
quaríálesK ko dáfference was found án caroíád áníámaJmedáa íháckness án adulíhood
bF drowíh and muberíy oelaíed Concerns:
molycysíác ovaráan syndrome
EmClpF ás a noíeworíhy condáíáon án females of reproducíáve age group and
characíerázed by hyperandrogenásm and olágoLanovulaíáon án adolescenís [
zK A
recení bndocráne pocáeíy Clánácal mracíáce duádeláne [
z recommends usáng íhe
ooííerdam cráíeráa for dáagnosáng mClp Epresence of íwo of íhe followáng
cráíeráa: androgen excessI ovulaíory dysfuncíáonI or polycysíác ovaráesFK
bsíablásháng a dáagnosás of mClp ás noí síraághíforward án adolescenísK
eyperandrogenásm ás ceníral ío íhe preseníaíáon án adolescenísK bvaluaíáon of
adolescenís wáíh mClp should exclude alíernaíe androgenJexcess dásordersK
lverweághí and obesáíy are common fándángs among adolescení gárls wáíh mClpI
paríácularly án íhe rp populaíáon [
zK qhere ás a hágh prevalence of ánsulán
resásíanceI predáabeíes and qOaM among adolescení gárls and adulí women wáíh
lbesáíy resulís wáíh changes án oíher hormonal sysíemsK Age of onseí of puberíy
coníánues ío decreaseI paríácularly án Afrácan AmerácansK qhás has been aíírábuíedI
án paríI ío áncrease án overnuíráíáon and BMI án íhás populaíáon [
zK bxcessáve
aromaíázaíáon of androgen ío esírogen by perápheral adápose íássue may promoíe
gynecomasíáa án malesK lbsírucíáve sleep apnea ás among íhe pulmonary
complácaíáons of obesáíy and íhe hypercapnáa assocáaíed wáíh íhás can suppress
hypoíhalamác dnoe funcíáon and lead ío delayed puberíy [
zK lbesáíy
acceleraíes síaíural growíh and causes advancemení of íhe bone ageK
cF qhyroád cuncíáon Aberraíáons:
Ií ás a common pracíáce ío screen
overweághíLobese cháldren for íhyroád funcíáon [
zK blevaíed qpe conceníraíáons
án assocáaíáon wáíh normal or slághíly elevaíed free q4 andLor free qP levels have
been consásíeníly found án obese subjecísI buí íhe mechanásms underlyáng íhese
changes are síáll unclearK Ií ás also noíable íhaí mosí of íhe weághí gaán án
hypoíhyroád ándáváduals ás due ío accumulaíáon of salí and waíerI so
hypoíhyroádásm rarely causes subsíaníáal weághí gaánK
qhese ánvolve hyperíensáonI dyslápádemáaI as well as rásks for adulí coronary hearí
dáseaseK Cardáovascular dásease ás íhe leadáng cause of adulí moríaláíy and
morbádáíyK iongáíudánal epádemáologác síudáes have demonsíraíed íhaí rásk facíors
án cháldhoodI such as obesáíy and dyslápádemáaI predácí adulí cardáovascular
dáseaseK qhe Bogalusa eearí píudy [
z depácíed áncreased prevalence of
clánácally recognázed hyperíensáon and dyslápádemáa án overweághí
adolescenís EUKRJfold and PKNJ ío UKPJfoldI respecíávelyFK bxcess weághí án
adolescence persásís ánío young adulíhoodI and has a sírong adverse ámpací on
mulíáple cardáovascular rásk facíorsI necessáíaíáng prámary preveníáon early án láfe
qhese encompass nonalcoholác faííy láver dásease EkAciaFI nonalcoholác
síeaíohepaíáíás EkApeFI cárrhosás and choleláíháasás [
zK kAcia has íurned ánío
íhe mosí common eíáology of chronác láver dásease án cháldren án íhe rnáíed
píaíesI along wáíh íhe áncreasáng frequency of obesáíy [
I
zK kAcia represenís
faííy ánfálíraíáon of íhe láver án íhe absence of alcohol consumpíáonK kAcia has a
specírum of severáíy rangáng from síeaíosás ío kApe íhaí may ulíámaíely resulí án
advanced fábrosásI cárrhosásI and hepaíocellular carcánomaK Because kAcia ás
usually asympíomaíácI screenáng ás requáred for deíecíáonK konJánvasáve
evaluaíáon can be used ío make íhe dáagnosás of kAcia; deíecíáon of markers of
láver ánjury Eelevaíed láver enzymesF or fábrosás andLor faííy ánfálíraíáon on
ulírasound or magneíác resonance ámagángK qhese dáagnosíác meíhods are
subopíámal án sensáíáváíy and specáfácáíy for kAcia and oíher causes of láver
dásease musí be ruled ouíK qhe dáffereníáal dáagnosás of elevaíed íransamánases án
overweághíLobese cháldren should ánclude váral hepaíáíás Esuch as hepaíáíás BI
hepaíáíás CFI auíoámmune hepaíáíásI αNJaníáírypsán defácáencyI andI án older
cháldrenI tálson dáseaseK Ií ás noíable íhaí kApe ás íhe progressáve form of
síagáng and gradáng of kAciaK Insulán resásíance frequeníly coexásís án boíh
qhese consásí of obsírucíáve sleep apnea ElpAF and obesáíy hypoveníálaíáon
syndrome [
I
I
zK lbese cháldren are up ío sáx íámes more lákely íhan lean
cháldren ío have lpAK lpA syndrome ás a dásorder of breaíháng characíerázed by
prolonged paríáal upper aárway obsírucíáon andLor áníermáííení compleíe
and normal sleep paííernsK pympíoms ánclude habáíual EnághílyF snoráng
Efrequeníly wáíh áníermáííení pausesI snorísI or gaspsFI dásíurbed sleepI and
dayíáme neurobehaváoral problemsK aayíáme sleepáness may occur [
zK qhe
prevalence of asíhma ás also áncreased án obese cháldrenK
qhese ánclude slápped capáíal femoral epáphysás EpCcbFI genu valgaI íábáa vara
EBlouní dáseaseF and fracíuresK pCcb presenís wáíh hápLknee paán and decreased
áníernal roíaíáon of hápK Blouní dásease presenís wáíh paán aí íhe medáal aspecí of
kneeK qhe clánácáan should have a low íhreshold for suspácáon of pCcb án íhe
obese cháld wáíh kneeI íhághI or háp paán wáíh or wáíhouí hásíory of íraumaK
lverweághí cháldren have a hágher áncádence of fracíures [
Idáopaíhác áníracranáal hyperíensáon ás a dásorder whách íypácally presenís wáíh
headache and blurred vásáonK qhe dáagnosás ás made by íhe deíecíáon of
papálledema and elevaíed áníracranáal pressure án íhe absence of ánfecíáousI
vascularI or sírucíural causesK Ií can lead ío blándness án up ío NMB of paíáenísI
lbesáíy can alíer íhe skán barráerI ánduce skán manáfesíaíáonsI and worsen exásíáng
skán dáseases láke psoráasásK Cuíaneous manáfesíaíáons of obesáíy ánclude
acaníhosás nágrácans EAkFI fábroma pendulans Eskán íagsI fábroepáíheláal polypsF
and síráae dásíensae [
zK Ak ás a dermaíologác condáíáon whách ás assocáaíed wáíh
eásíologácallyI áí ás characíerázed by íhe proláferaíáon of epádermal keraíánocyíes
and fábroblasísK Ak ás a velveíy íháckenáng of íhe epádermás íhaí prámarály affecís
íhe axállaeI posíeráor cervácal skánfoldI flexor skán areasI and umbálácusK
ClánácallyI íhe lesáons appear as darkJbrown íháckened plaquesK Ií ás an ámporíaní
cuíaneous marker of ánsulán resásíanceK Clánácáans can quaníáfy íhe severáíy of Ak
zK lbesáíy ás also assocáaíed wáíh hyperandrogenásm án women and gárlsI
promoíáng acne vulgarásI hársuíásmI and androgenác alopecáaK An assocáaíáon
beíween íhe severáíy of psoráasás and íhe body mass ándex has been noíedK lbesáíy
cágK EOFK
NR year old Afrácan Amerácan female wáíh obesáíy and acaníhosás nágrácans aí íhe posíeráor cervácal
qhese represení a wáde specírumK Body dássaíásfacíáonI depressáonI lossJofJconírol
eaíángI unhealíhy and exíreme weághí conírol behaváorsI ámpaáred socáal
relaíáonshápsI obesáíy síágmaI and decreased healíhJrelaíed qualáíy of láfe are
condáíáons wáíh small ío moderaíe assocáaíáons wáíh cháld and adolescení obesáíyK
Complácaíáons wáíh ánságnáfácaní ío small assocáaíáons ánclude low selfJesíeemI
clánácally ságnáfácaní depressáon Eof dáagnosíác severáíyI lánked ío ságnáfácaní
dásíress andLor ámpaármeníI or ánvolváng seráous sympíomaíologyFI suácádeI and
fullJsyndrome eaíáng dásorders [
J
zK As íhe clánácal seííáng ás ofíen íhe fársí
poání of coníací for famáláesI pedáaírácáans are ánsírumeníal án íhe ádeníáfácaíáon
and referral of cháldren wáíh psychologácal complácaíáons [
J
zK Moíávaíáonal
áníerváewángI paíáení íalkáng poánísI bráef screenáng measuresI and referral
resources are ámporíaní íools án íhás processK
qhe evaluaíáon of íhe overweághíLobese cháld should síarí wáíh a comprehensáve
hásíory and physácal examánaíáon whách wáll help íhe clánácáan assess severáíy and
comorbád condáíáons [
zK Accuraíe aníhropomeírác measuremenís Eweághí and
heághíF and váíal ságns are requáredK iaboraíory and radáologác síudáes may be
obíaáned áf ándácaíed [
zK Ceríaán screenáng íesís are recommended for a general
meíabolác assessmení án all paíáenís and a more deíaáled evaluaíáon should be
kuíráíáon and physácal acíáváíy hásíoryI enváronmeníal and socáal supporís and
barráersI opánáons on cause and effecí of íhe problemsI as well as selfJeffácacy and
All cháldren older íhan íwo years should have íheár BMI calculaíed aí leasí
annually from measured heághí and weághíK qhe daía should be ploííed on an
appropráaíe growíh curveK teághíI heághí and BMI growíh charís are noí only
dáagnosíác íools buí also esseníáal for paíáení and famály educaíáonK koí only íhe
BMI perceníále buí also íhe írend of íhe BMI perceníále for age and sex requáre
aííeníáonK barly deíecíáon of an áncreasáng BMI írend Emore íhan íhree ío four
unáís EkgLm
F per year and síaríáng ío cross perceníále lánesF should prompí early
qhe hásíory should ánclude íhe age of onseí of overweághí and ánformaíáon abouí
íhe cháldDs eaíáng and exercáse habáísK qhe age of onseí ás helpful án dásíánguásháng
overfeedáng from geneíác causes of overweághí sánce syndromác obesáíy ofíen has
onseí before íwo years of age Eqable
FK Ií ás also ámporíaní ío keep án mánd íhe
sángle gene defecís assocáaíed wáíh obesáíy whách presení wáíh early onseí obesáíy
Eqable
FK qhe clues from íhe dáeíary and acíáváíy hásíory may help deíermáne
poíeníáal areas for áníerveníáonK eásíory of unconírolled consumpíáon of large
amounís of food may be ándácaíáve of an eaíáng dásorderK An assocáaíáon has been
shown beíween skáppáng mealsI paríácularly breakfasíI and overweághíLobesáíyK Ií
musí be noíed íhaí íhás ás noí a causal relaíáonsháp [
zK qhe medácal hásíory
should ánclude reváew of all medácaíáonsI paríácularly íhose íhaí are known ío
qhe reváew of sysíems should íry ío ádeníáfy underlyáng eíáologáes and coJexásíáng
problemsK cor example an abrupí onseí of obesáíy wáíh rapád weághí gaán should
prompí ánvesíágaíáon of medácaíáonJánduced weághí gaánI a major psychosocáal
írágger Esuch as depressáonFI endocráne causes of obesáíy E
Cusháng dáseaseI
hypoíhalamác íumorFI or some obesáíy syndromes EmraderJtállá syndromeI or
rapádJonseí obesáíy wáíh hypoíhalamác dysfuncíáonI hypoveníálaíáonI auíonomác
lbesáíy án one or boíh parenís ás an ámporíaní predácíor for a cháldDs prospecíáve
obesáíy rásk exíendáng ío adulíhood [
J
zK qhe famály hásíory should ánquáre
abouí obesáíy án fársíJdegree relaíávesI and common comorbádáíáes of obesáíyI such
as cardáovascular dáseaseI hyperíensáonI dáabeíesI láver or gallbladder dáseaseI and
qhe psychosocáal hásíory should encompass; ENF aepressáon EOF Informaíáon abouí
school and socáal enváronmení EPF qobacco useK A careful and consáderaíe
approach should be íaken whále dáscussáng íhe íopács of weághí and meníal healíh
zK Ií has been noíed íhaí even healíh care professáonals hold báased aííáíudes
íoward adulí paíáenís íhaí may be exíended ío paíáenís án íhe pedáaírác age group
zK qhás may ánclude a íendency ío blame parenís for íheár cháldren’s weághí
síaíusI negaíáve commenís on íhe parenís’ or cháld’s weághíI or faálure ío lásíen ío
parenísK marenís may feel guálíI angerI and frusíraíáon because íhey do noí know
how ío help íheár cháldren [
zK marenís are ánsírumeníal án íhe provásáon of íheár
cháldren’s physácal and socáal enváronmenís and a posáíáve workáng relaíáonsháp ás
esseníáal ío íheár cháldren’s physácal and meníal healíh [
I
I
zK A famályJ
qhe physácal examánaíáon should look for underlyáng eíáologáesI comorbádáíáes
and help íhe clánácáan wáíh managemení [
I
zK eághlághíáng ceríaán fándángs án
íhe exam room may be ánsírumeníal án engagáng íhe famáláes and help íhem
undersíand íhe concernsK
Assessmení of general appearance should ánclude evaluaíáon for dysmorphác
feaíures Ewhách may suggesí a geneíác syndromeFI assessmení of affecíI and
assessmení of faí dásírábuíáon whách may help ío dásíánguásh íhe eíáology of
obesáíyK qhe excess faí án exogenous obesáíy usually has a generalázed dásírábuíáon
án íhe írunk and perápheryK In conírasíI íhe cenírápeíal dásírábuíáon of body faí
Econceníraíed án íhe áníerscapular areaI faceI neckI and írunkF ás suggesíáve of
Cusháng syndromeK Abdománal obesáíy Ealso referred ío as ceníralI vásceralI
androádI or maleJíype obesáíyF ás assocáaíed wáíh ceríaán comorbádáíáesI áncludáng
íhe MeípI mClpI and ánsulán resásíanceK Measuremení of íhe waásí cárcumferenceI
along wáíh calculaíáon of íhe body mass ándex EBMIFI may help ádeníáfy paíáenís
aí rásk for íhese comorbádáíáesK taásí cárcumference síandards for Amerácan
cháldren of varáous eíhnác groups are avaálable [
A careful blood pressure measuremení should be obíaáned wáíh a proper sázed
cuffK eyperíensáon áncreases íhe longJíerm cardáovascular rásk án overweághí L
obese cháldrenK eyperíensáon may be a ságn of Cusháng syndrome [
I
eyperíensáon ás defáned as a blood pressure greaíer íhan íhe VR
perceníále for
genderI age and heághí on íhree separaíe occasáonsK AgeJI genderJ and heághíJ
Assessmení of heághí and heághí velocáíy ás useful án dásíánguásháng exogenous
obesáíy from obesáíy íhaí ás secondary ío geneíác or endocráne eíáologáesI
áncludáng hypoíhalamácJpáíuáíary lesáonsK Because exogenous obesáíy dráves lánear
heághíI mosí obese cháldren are íall for íheár ageK ln íhe coníraryI shorí síaíure ás a
manáfesíaíáon of mosí endocráne and geneíác causes of obesáíy [
I
zK drowíh
velocáíy may deceleraíe án cháldren wáíh endocráne causes of obesáíyK Cháldren
wáíh mraderJtállá syndrome are ofíen shorí for íheár geneíác poíeníáal andLor faál
bxamánaíáon of íhe headI eyesI and íhroaí may prováde clues ío íhe eíáology of
obesáíy andLor comorbádáíáes [
I
I
zK cor example mácrocephaly ás a feaíure of
Cohen syndromeK Blurred dásc margáns may ándácaíe pseudoíumor cerebrá [
zK kysíagmus or vásual complaánís raáse íhe concern for a hypoíhalamácJ
páíuáíary lesáon [
zK líher fándángs íhaí supporí íhás possábáláíy are rapád onseí of
obesáíy or hyperphagáaI decrease án growíh velocáíyI precocáous puberíyI or
neurologác sympíomsK Clumps of págmení án íhe perápheral reíána may ándácaíe
reíánáíás págmeníosaI whách occurs án BardeíJBáedl syndrome [
zK bnlarged
íonsáls may ándácaíe obsírucíáve sleep apneaK
aryI coarseI or bráííle haár may be presení án hypoíhyroádásmK píráae and
ecchymoses may be manáfesíaíáons of Cusháng syndromeK píráae án general resulí
from rapád accumulaíáon of subcuíaneous faíK curíher evaluaíáon on wádíh and
color Esuch as váoleíJcoloredI wáde síreích marksF may prováde clues for lákely
assocáaíáon wáíh Cusháng dásease Acaníhosás nágrácans may poání ío ánsulán
resásíance and rásk of qOaMK eársuíásm may accompany polycysíác ovaráan
syndrome EmClpF or Cusháng syndrome [
I
I
Abdománal íenderness may be a ságn of gallbladder dáseaseK oághí upper quadraní
qhe musculoskeleíal examánaíáon may prováde ámporíaní clues on underlyáng
eíáology or comorbádáíáes of pedáaírác overweághí: konpáííáng edema may suggesí
hypoíhyroádásmK mosíaxáal polydacíyly Ean exíra dágáí nexí ío íhe fáfíh dágáíF may
be seen án BardeíJBáedl syndromeI and small hands and feeí may be presení án
mraderJtállá syndrome [
zK mhysácal exam ás ánsírumeníal án dáagnosáng slápped
capáíal femoral epáphysás Elámáíed range of moíáon aí íhe hápI gaáí abnormaláíyF or
qhe genáíouránary examánaíáon and evaluaíáon of puberíal síage may also prováde
addáíáonal ánpuí regardáng geneíác or endocráne causes of obesáíy [
rndescended íesíáclesI small penásI and scroíal hypoplasáa may poání ío mraderJ
tállá syndromeK pmall íesíes may suggesí mraderJtállá or BardeíJBáedl syndrome
I
zK aelayed or absení puberíy may be a componení of hypoíhalamácJpáíuáíary
íumorsI mraderJtállá syndromeI BardeíJBáedl syndromeI lepíán defácáencyI or
lepíán recepíor defácáency [
I
z mrecocáous puberíy occasáonally ás a preseníáng
qhe syndromác causes of overweághí án cháldren are frequeníly assocáaíed wáíh
cognáíáve or developmeníal delay Eqable
F [
I
zK pevere hypoíonáa duráng
ánfancy and delayed developmení of gross moíor skálls are feaíures of mraderJ
msychologácal complácaíáons are frequeníly seen án obese cháldrenK eealíh care
prováders managáng obesáíy án cháldren and adolescenís are án a crucáal posáíáon ío
help screen and ádeníáfy depressáon ío facáláíaíe proper assessmení and care of
paíáenísK rse of síandardázed screenáng íools such as maíáení eealíh nuesíáonnaáre
qhe laboraíory evaluaíáon for overweághí and obesáíy án cháldren ás noí fully
síandardázed and musí be íaálored ío íhe paíáeníK In our clánácsI áf íhe cháld ás noí
fasíáng aí íhe íáme of ánáíáal clánácal evaluaíáon a comprehensáve meíabolác profáleI
íhyroád screenáng Efree q4 and qpeFI and hemoglobán ANc level are consáderedK
qhe meíabolác panel provádes a random glucoseI serum alanáne amánoíransferase
EAiqFI and asparíaíe amánoíransferase EApqFK eemoglobán ANC ás a useful
marker of íhe average blood glucose conceníraíáon over íhe precedáng U ío NO
weeks and has gaáned more emphasás as a screenáng íool for dáabeíes melláíus án
íhe pasí decadeK In year OMNMI íhe Amerácan aáabeíes Assocáaíáon EAaAF
auíhorázed íhe use of ebANc as a dáagnosíác cráíeráon for dáabeíes and oíher
glucose abnormaláíáes wáíh íhe prerequásáíe of usáng an assay ceríáfáed by íhe
kaíáonal dlycohemoglobán píandardázaíáon mrogram EkdpmF [
zK qhe
predáabeíác range was defáned as ebANc� "e RKTB and YSKRB án adulísK aáseases
such as áron defácáency anemáaI cysíác fábrosásI sáckle cell dáseaseI íhalassemáaI
and oíher hemoglobánopaíháes alíer ebANc resulísK qherefore clánácal judgmení
should be used [
zK A follow up laboraíory evaluaíáon may be scheduled as a
fasíáng blood draw and ánclude a lápád panel Eíoíal cholesíerolI íráglycerádesI iaiJ
and eaiJcholesíerolFI and fasíáng glucoseK In our clánács we íry ío coordánaíe íhás
wáíh a láfesíyle counseláng sessáon wáíh specáalíy nurse educaíorK A fasíáng ánsulán
level may be consádered for purposes of counseláng raíher íhan screenáng as also
recommended by an áníernaíáonal consensus reporí on pedáaírác ánsulán resásíance
án OMNM [
zK Ií ás ámporíaní ío síress íhaí rouíáne fasíáng ánsulán screenáng ás noí
qhe AaA Consensus manel duádelánes recommend screenáng for dáabeíes án
cháldren over NM years of age Eor aí íhe onseí of puberíy áf áí occurs aí a younger
ageF who are overweághí or obese and have íwo or more addáíáonal rásk facíors
such as famály hásíory of íype O dáabeíes án a fársíJ or secondJdegree relaíáveI
hághJrásk eíhnácáíyI acaníhosás nágrácansI or mClp [
zK qhe AaA recommends
In íhe auíhor’s clánácI cháldren and adolescenís who are noíed ío have mulíáple
rásk markers for dysglycemáa Epredáabeíes or dáabeíesF undergo an oral glucose
íolerance íesí wáíh fasíáng and O hour blood samples for glucose and ánsulánK
ebANc level án íhe quesíáonable zone for predáabeíes ERKTJSK4B per AaA
ándácaíáve of ámpaáred fasíáng glucoseI and a level of ≥NOS mg per di ás consásíení
wáíh íhe dáagnosás of dáabeíesK maíáenís wáíh áníermedáaíe or conflácíáng resulís for
any of íhese íesís should undergo repeaí íesíáng and be monáíored for fuíure
developmení of dáabeíesK aefánáíáve dáagnosás of dáabeíes melláíus requáres
meeíáng dáagnosíác cráíeráa on aí leasí íwo separaíe occasáons [
In OMNNI an experí panel from íhe rnáíed píaíes kaíáonal eearíI iungI and Blood
Insíáíuíe EkeiBIFI ássued áníegraíed guádelánes for cardáovascular rásk reducíáonI
endorsed by íhe Amerácan Academy of medáaírács [
zK qhe panel recommended
ánáíáal lápád screenáng wáíh fasíáng lápád profále for cháldren beíween ages íwo and
eághí yearsI wáíh a BMI ≥VR
perceníále Eor oíher rásk facíors for cardáovascular
dáseaseI such as famály hásíory of dyslápádemáaL early cardáovascular dásease and
or morbádáíy án fársí or second degree relaíávesI hásíory of dáabeíesI hyperíensáon
or smokáng án cháldFK qhe panel recommended unáversal lápád screenáng wáíh a
nonfasíáng non eaiJC EeaiJC subíracíed from íhe íoíal cholesíerol
measuremeníF for cháldren ages VJNN years and NTJON yearsK cor cháldren ages V
and above wáíh a BMI ≥UR
perceníále or oíher rásk facíors as lásíed aboveI lápád
screenáng ás recommended [
zK CuíJoffs for normal are a fasíáng íoíal cholesíerol
of YNTM mgLdiI a iai cholesíerol of YNNM mgLdiI nonJeai cholesíerol of YNOM
mgLdlI íráglycerádes of YTR mgLdl for ages MJV years and YVM mgLdl for ages NMJNV
yearsI and eai cholesíerol of >4R mgLdlK Abnormal values compaíáble wáíh
dyslápádemáa are a fasíáng íoíal cholesíerol of ≥OMM mgLdiI a iai cholesíerol of
≥NPM mgLdiI nonJeai cholesíerol of� "e N4R mgLdlI íráglycerádes of ≥NMM mgLdl
for ages MJV and ≥NPM mgLdl for ages NMJNV yearsI and eai cholesíerol of Y4M
mgLdlK lverweághíLobese cháldren wáíh hyperlápádemáa should be monáíored and
íreaíedK píepwáse approach áncludes medácal nuíráíáon íherapy Ewáíh láfesíyle
modáfácaíáon referráng ío áncreased physácal acíáváíyF and medácal íherapy [
iáver funcíáon íesís should be obíaáned because nonalcoholác faííy láver dásease
EkAciaF ás íypácally asympíomaíác [
I
zK lbese cháldren wáíh an elevaíáon of
Aiq greaíer íhan íwo íámes íhe upper lámáí of normalI persásíáng for more íhan
íhree moníhs should be evaluaíed for íhe presence of kAcia and oíher chronác
láver problemsK Assessmení for oíher comorbádáíáesI such as sleep apnea and
polycysíác ovary syndromeI depends on íhe deíecíáon of rásk facíors or sympíomsI
and should be done on a case by case formaí áf ándácaíedK sáíamán a defácáency
has been noíed commonly among obese cháldren and adolescenís eáíher because
of generalázed váíamán and máneral defácáencáes secondary ío poor eaíáng habáísI
andLor due ío sequesíraíáon án excess adápose íássueK píudáes from varáous
geographácal regáons reporíed sáíamán a defácáency án abouí half of cháldren and
adulís wáíh severe obesáíyI and depácíed assocáaíáon wáíh hágher BMI and feaíures
of íhe Meíp [
J
zK ko guádelánes exásí recommendáng rouíáne screenáng of
overweághí cháldren for sáíamán a síaíusI íherefore clánácal judgmení ás
recommendedK If screenáng for váíamán a defácáencyI serum OREleF váíamán a
level should be measuredK qhe reference range varáes by regáonI buí levels YOM
ngLmi are generally consádered defácáeníK If defácáency ás foundI váíamán a
supplemeníaíáon should be ánáíáaíed ío avoád longJíerm consequencesK
Addáíáonal íesíáng should be performed áf íhere are fándángs consásíení wáíh
hypoíhyroádásmI mClpI Cusháng syndromeI and sleep apnea [
I
I
I
pyndromác obesáíy should be evaluaíed án cháldren wáíh developmeníal delay or
dysmorphác feaíures Eqable
FK bndocráne causes of obesáíy are unlákely áf íhe
oadáographác bvaluaíáon
may be consádered áf ándácaíedK cor exampleI plaán
radáographs of íhe lower exíremáíáes should be obíaáned áf íhere are clánácal
fándángs consásíení wáíh slápped capáíal femoral epáphysás Eháp or knee paánI
lámáíed range of moíáonI abnormal gaáíF or Blouní dásease Ebowed íábáaFK
Abdománal ulírasonography may be ándácaíed án cháldren wáíh fándángs consásíení
wáíh gallsíones E
abdománal paánI abnormal íransamánasesF [
I
zK Abdománal
qhe pharmacoíherapy opíáons for íhe íreaímení of pedáaírác obesáíy are scaníyK
iáfesíyle modáfácaíáon wáíh componenís of medácal nuíráíáon íherapyI physácal
acíáváíy and behaváor modáfácaíáon ás íhe key íreaímení approach for exogenous
obesáíy án cháldren and adolescenísK qreaímení should help reverse íhe
dásproporíáonaíely hágh raíáo of energy áníake ío energy expendáíure ío reverse íhe
posáíáve energy balanceK Ií ás of uímosí ámporíance ío ánvolve íhe famályL
qreaímení should be íargeíed aí prámary and secondary preveníáonK mreveníáon
efforís should síarí earlyI when an áncreasáng BMI írend ás noíedK If íhe yearly
áncrease án íhe BMI ás more íhan íhree ío four unáís EkgLm
F and síaríáng ío cross
perceníále lánes Eeven when íhe BMI ás síáll below íhe UR
perceníáleI and
paríácularly áf íhe cháld ás older íhan four yearsFI íhás should prompí íhe clánácáan
ío dáscuss íhese observaíáons wáíh íhe famály [
zK mrovádáng sámple íáps for
maáníaánáng a healíhy weághí by nuíráíáon modáfácaíáon andI áncreased physácal
If íhe cháld ás overweághí or obese he or she should be screened for comorbádáíáes
of obesáíyK qhe clánácáan should prováde counseláng ío opíámáze láfesíyle habáís
wáíh a goal of slowáng íhe raíe of weághí gaánK qhese famáláes should receáve
nuíráíáon and láfesíyle counselángK qhese cháldren requáre regular followJup ío
monáíor progress [
I
zK mrogressáon of lánear growíhI as applácable ío ceríaán
cháldren and adolescenísI wáll also conírábuíe ío ámprovemení án íhe BMI
íhroughouí íhe process of weághí managemení áníerveníáonsK
qhe OMNN keiBI bxperí manel guádelánes for cardáovascular healíh and rásk
reducíáon án cháldren and adolescenís [
z ás a comprehensáve reference prepared
ío assásí pedáaírác healíh care prováders án boíh íhe promoíáon of cardáovascular
A síepwáse approach ás recommended án goal seííángK mrámordáal preveníáon ás íhe
preveníáon of ráskJfacíor developmeníK mrámary preveníáon refers ío effecíáve
managemení of ádeníáfáed rásk facíors for ameláoraíáng fuíure problems such as
Cháldren who have comorbádáíáes of obesáíy should be consulíed wáíh appropráaíe
subspecáalíy servácesK then avaálableI cháldren may be referred ío pedáaírác
qreaímení of obesáíy musí help reach a negaíáve energy balance [
zK oeducedJ
energy dáeís regardless of macronuíráení composáíáon resulí wáíh clánácally
meanángful weághí loss án adulísK qhe assocáaíáon beíween pedáaírác obesáíy and
íhe consumpíáon of hágh caloráeI hághJfaíI hághJcarbohydraíe and lowJfáber foods
has been reporíed [
zK qhe specáfác approaches proven ío resulí wáíh
ámprovemení of obesáíy án cháldren ánclude elámánaíáon of sugarJconíaánáng
beverages and a íransáíáon ío lowJglycemác ándex dáeí [
I
I
zK Ií ás pávoíal ío
áncrease awareness of íhe cháldren and parenísL caregávers of íhe calorác coníení of
beverages and lámáí consumpíáon of calorác beveragesK mhysácal acíáváíy
áníerveníáon ás íhe oíher esseníáal componení of íhe managemeníK A recení
sysíemaíác reváew and meía analysás reporíed íhaí boíh dáeíJonly and dáeí plus
exercáse approaches helped acháeve weághí loss and ámprove meíabolác
parameíers [
zK Iníerveníáons combánáng exercáse wáíh dáeí resulíed wáíh beííer
Behaváor modáfácaíáon ánvolves moíávaíáon ío lámáí screen íáme and áncrease
physácal acíáváíyI psychologác íraánáng ío make a change án eaíáng behaváors or
exercáseI famály counseláng ío encourage for weághí loss goalsI and schoolJbased
changes ío promoíe physácal acíáváíy and healíhy eaíáng [
I
zK Mobále and
wáreless healíh íechnologáes and exergamáng Evádeo gamáng íhaí ánvolves gross
moíor movemeníF may help develop effecíáve áníerveníáon síraíegáes [
zK bven
íhose are approved for cháldren under NS years of ageK qhese medácaíáons resulíed
wáíh lámáíed ámprovemení when used as an adjuncí ío exercáse and nuíráíáon
modáfácaíáonK aue ío seráous adverse effecísI majoráíy of íhe medácaíáons
mheníermáne and sámálar anorexáaní medácaíáons whách alíer íhe release and
reupíake of neuroíransmáííers are ío be lásíed án íhás groupK mharmacologác
íreaímení may be consádered án selecíed paíáenísI paríácularly íhose wáíh severe
comorbádáíáesI when láfesíyle áníerveníáon faáls ío resulí wáíh weághí loss [
I
zK
pábuíramáne Eappeíáíe suppressor: ánhábáís norepánephráneI
dopamáne reupíakeF ás caAJapproved for íreaímení of obesáíy án adolescenís
above NS
years of ageK píudáes ánvolváng pábuíramáne and behaváoral íherapy have
shown decrease án BMI EOKVJPKS kgLmOF [
zK lrlásíaí Egasíroáníesíánal lápase
ánhábáíorF ás approved by íhe caA for managemení of obesáíy án adolescenís NOJ
NS years of ageK arugJrelaíed adverse effecísI such as oály síoolsLspoííángI have
lámáíed áís useK Meíformán ás a báguanáde approved by íhe caA for íreaímení of
íype O dáabeíes melláíus án cháldren aged NM years and olderK Meíformán reduces
hepaíác glucose ouípuí and áncreases ánsulán sensáíáváíy án perápheral íássuesK
oandomázed conírolled íráals have been performedI evaluaíáng meíformán as an
“obesáíy medácaíáon” án adolescenísK qhe degree of longJíerm ámprovemení án
body weághí or áís complácaíáons ás unknownK Meíformán may be consádered án
íhe presence of clánácally ságnáfácaní ánsulán resásíance and or predáabeíesK iepíán
has been shown effecíáve aí reducáng BMI án ándáváduals wáíh lepíán defácáencyI
whách ás a rare condáíáon [
zK lcíreoíáde Ea somaíosíaíán analogF has been used án
íhe íreaímení of hypoíhalamác obesáíy and shown ío suppress ánsulánI and síabáláze
weághí and BMI [
I
zK iack of coverage of medácaíáons by ánsuranceI hágh
Baráaírác surgery ás íhe mosí defánáíáve and longesí lasíáng form of weághí loss
íreaímeníK In adulísI and ío a smaller exíení án adolescenísI baráaírác surgery has
been shown ío help accomplásh ságnáfácaní weághí loss and ámprovemení or
resoluíáon of comorbádáíáesI such as íype O dáabeíesI hyperíensáon and obsírucíáve
sleep apnea [
zK eowever ságnáfácaní acuíe and chronác complácaíáons rangáng
from wound ánfecíáons ío láfeJíhreaíenáng problems such as bowel
obsírucíáonLperforaíáon have been reporíed [
I
I
I
zK maíáenís wáíh severe
pedáaírác obesáíy EBMI equal ío or above íhe VVíh perceníáleF may requáre
consáderaíáon for íhás approachK Managemení of comorbád condáíáons wáíh
appropráaíe íreaímení síraíegáes ás esseníáalK cor example hormonal coníracepíáves
are íhe fársíJláne managemení for mensírual abnormaláíáes and hársuíásmLacne án
mClp and meíformán has also been usedK eyperíensáon may necessáíaíe medácal
In some clánácal ceníers for cháldren and adolescenísI specáalíy clánács have been
developed for íhe managemení of obesáíyK If subspecáalíy ceníer ás noí avaálableI a
wellJorganázed and comprehensáve evaluaíáon síraíegy can be áncorporaíed ánío
íhe rouíáne clánácal pracíáceK qhás should enable ádeníáfácaíáon of íhe comorbádáíáes
and íhe requáred subspecáalíy referralsK pome clánác modelsI áncludáng our currení
pracíáceI ánvolve a nurse educaíorLnuíráíáonásí provádáng láfesíyle counseláng for
cháldren and famáláesK qhás model was síaríed duráng our paríácápaíáon án a
collaboraíáve efforí ío íackle pedáaírác obesáíy án our communáíáesI eníáíled
eealíhy dreen and Inío íhe luídoorsK qhe collaboraíáon was organázed by íhe
Communáíy coundaíáon of koríh iouásáanaI and supporíed by a graní from Blue
Cross Blue pháeld coundaíáon of iouásáanaK qhe láfesíyle counselor meeís íhe
qhere ás a crucáal need for pedáaírác obesáíy advocacyK qhás clearly demands íhe
clánácáan’s ánvolvemení beyond íhe offáceI requáres collaboraíáon wáíh íhe
communáíy and publác polácy makersK qhe OMMR Insíáíuíe of Medácáne oeporí
recommends íhaí clánácáansI regardless of specáalíyI serve as role models and
prováde leadersháp án íheár communáíáes for obesáíy preveníáon ánáíáaíáves [
medáaírácáans and pedáaírác subspecáalásís should rouíánely dáscuss obesáíy
preveníáon and recommendaíáons wáíh paíáenís and famáláes [
zK Clánácáans
should consáder advocaíáng for and provádáng healíhy food opíáons án hospáíalsK In
varáous areas of íhe rnáíed píaíesI successful models have been esíabláshed
ánvolváng íhe medácalLhospáíal síaff án communáíy advocacy programsI
communáíyLhospáíal parínershápsI locally and aí íhe síaíe levelK mhysácáans’
paríácápaíáon may ánvolve speakáng aí publác forums and aííendáng
communáíyLschool board meeíángs ío offer medácal experíáse on íhe ássue of
pedáaírác obesáíyK qhe Amerácan Board of medáaírács maáníenance of board
ceríáfácaíáon EMlCF programs ánvolve several projecís focusáng on pedáaírác
obesáíyK qhese help wáíh knowledge acquásáíáonI selfJeffácacyI and physácáan
compláance wáíh recommended pracíáce recommendaíáons for íhe screenángI
preveníáonI and managemení of pedáaírác obesáíy [
medáaírác care prováders should unáversally assess cháldren for obesáíy and rásk of
obesáíy ío ámprove early ádeníáfácaíáon and managemeníK Calculaíáon of íhe BMI
and ploííáng on an appropráaíe reference curve should be parí of íhe rouíáne
clánácal assessmení of all cháldren wáíh ages O years and aboveK qhe sequeníáal
follow up for íhe írends may prováde ánvaluable and íámely ánformaíáon ío írack
overweághíLobesáíy írends and may be ánsírumeníal ío ánáíáaíe prámary andLor
secondary preveníáonK lbesáíy preveníáon messages can be prováded as
applácableI weághí conírol áníerveníáons ánáíáaíed for íhose wáíh excess weághí [
Clánácal approach ío pedáaírác overweághíLobesáíy musí be comprehensáve and
mulíáJfaceíedK qhe clánácáan’s role should noí be noí resírácíed ío íhe clánác buí
should expand ío íhe communáíy for advocacy efforís [
zK Collaboraíáons among
healíhJcare sysíemsI communáíy and school sysíems may be ánsírumeníal [
zK A
sírucíured and comprehensáve approach dealáng wáíh íhe pedáaírác obesáíy
problem aí íhe presení wáll be expecíed ío conírábuíe ío ámprovemení án publác
ean gCI hámm pvK Cháldhood lbesáíyJOMNM: mrogress and ChallengesK ianceí OMNM; PTREVTOTF:
lgden CiI Carroll MaI háí BhI clegal hMK mrevalence of and adulí obesáíy án íhe rnáíed píaíesI
[Pzeubbard spK aefánáng overweághí and obesáíy: whaí are íhe ássues? Am g Clán kuír OMMM; TO: NMSTJUK
kácolaá gmI iupáaná geI tolf AgK An Iníegraíáve approach ío obesáíyK In: oakel aI bdK Iníegraíáve
hlásh tgK Clánácal evaluaíáon of íhe obese cháld and adolesceníK In: Moíál hgI deffner MI eoppán AdI
[SzBMI curvesK
Cole qgI Bellázzá MCI clegal hMI aáeíz teK bsíablásháng a síandard defánáíáon for cháld and obesáíy
ae lnás MI darza CI sácíora CdI
eí alK
qhe tel Mulíáceníre drowíh oeference píudy: plannángI
ae lnás MI lnyanga AtI Borghá bI páyam AI kásháda CI páekmann gK aevelopmení of a tel
growíh reference for schoolJaged cháldren and adolescenísK Bull torld eealíh lrgan OMMT; UREVF:
haízmarzyk mqI Barlow pI Bouchard CI
eí alK
An evolváng scáeníáfác basás for íhe preveníáon and
dungor khK lverweághí and obesáíy án cháldren and adolescenísK g Clán oes medáaír bndocránol OMN4;
oamachandrappa pI carooqá IpK deneíác approaches ío undersíandáng human obesáíyK g Clán Invesí
harra bI Chandarana hI Baííerham oiK qhe role of pepíáde vv án appeíáíe regulaíáon and obesáíyK g
[N4zCummángs abI lverduán gK dasíroáníesíánal regulaíáon of food áníakeK g Clán Invesí OMMT; NNT: NPJOPK
[NRzcarooqá pI l’oahálly pK deneíács of obesáíy án humansK bndocr oev OMMS; OT: TNMJUK
lgden CiI Carroll MaI háí BhI clegal hMK mrevalence of obesáíy and írends án body mass ándex
aanáels poK Complácaíáons of obesáíy án cháldren and adolescenísK Iní g lbes OMMV; PP EpupplK NF: pSMJ
euang gpI Barlow pbI nuárosJqejeára obI
eí alK
qhe kApmdeAk lbesáíy qask corceK Consensus
píaíemení: Cháldhood lbesáíy for medáaírác dasíroeníerologásísK g medáaír dasíroeníerol kuír OMNP; RS:
dungor kI iábman II Arslanáan pK qype O aáabeíes Melláíus án Cháldren and AdolescenísK In:
mescováíz I bugsíer I bdsK medáaírác bndocránology: MechanásmsI ManáfesíaíáonsI and ManagemeníK
hahn pbK qhe ámporíance of beía cell faálure án íhe developmení and progressáon of íype O dáabeíesK g
dungor kI Bacha cI paad oI ganosky gI Arslanáan pK vouíh qype O aáabeíes Melláíus: Insulán
pánha oI cásch dI qeague BI
eí alK
mrevalence of ámpaáred glucose íolerance among cháldren and
doran MII Bergman okI Avála nI
eí alK
Impaáred glucose íolerance and reduced beíaJcell funcíáon án
overweághí iaíáno cháldren wáíh a posáíáve famály hásíory for íype O dáabeíesK g Clán bndocránol Meíab
táegand pI Maákowská rI Blankensíeán lI Báebermann eI qarnow mI drüíers AK qype O dáabeíes and
ámpaáred glucose íolerance án buropean cháldren and adolescenís wáíh obesáíy J a problem íhaí ás no
Aye qI ieváísky iiK qype O dáabeíes: an epádemác dásease án cháldhoodK Curr lpán medáaír OMMP; NR:
pbAoCe for aáabeíes án vouíh píudy droupK iáese AaI aDAgosíáno oB grI eamman ocI hálgo maI
iawrence gMI iáu iiI iooís BI iánder BI Marcována pI oodráguez BIpíandáford aI tálláams abK qhe
burden of dáabeíes melláíus among rp youíh: prevalence esíámaíes from íhe pbAoCe for aáabeíes án
[OTziee iI panders oAK Meíabolác syndromeK medáaír oev OMNO; PP: 4RVJSSK
CallesJbscandon gI Cápolla MK aáabeíes and endoíheláal dysfuncíáon: a clánácal perspecíáveK bndocr
Meyer AAI hundí dI píeáner MI pchuffJterner mI háenasí tK Impaáred flowJmedáaíed vasodálaíáonI
caroíád aríery áníámaJmedáa íháckenángI and elevaíed endoíheláal plasma markers án obese cháldren: íhe
Berenson dpI pránávasan poI Bao tI kewman tm IIII qracy obI taííágney tAK Assocáaíáon
beíween mulíáple cardáovascular rásk facíors and aíherosclerosás án cháldren and young adulísK qhe
iá pI Chen tI pránávasan poI uu gI Berenson dpK oelaíáon of cháldhood obesáíyLcardáomeíabolác
phenoíypes ío adulí cardáomeíabolác profále: íhe Bogalusa eearí píudyK Am g bpádemáol OMNO; NTS
iegro opI Arslanáan pAI bhrmann aAI
eí alK
aáagnosás and íreaímení of polycysíác ovary syndrome:
táíchel pK cI lberfáeld pI oosenfáeld oI iI Codner bI Bonny AI Ibáñez iI mena AI eorákawa oI
domezJiobo sI goel aI qfaylá eI Arslanáan pI aabadghao mI darcáa oudaz CI iee mI AI qhe
haplowáíz mBI plora bgI tasserman oCI medlow pbI eermanJdáddens MbK barláer onseí of puberíy
haplowáíz mK aelayed puberíy án obese boys: comparáson wáíh consíáíuíáonal delayed puberíy and
macáfáco iI Ananáa CI cerraro cI Andreolá dMI Cháesa CK qhyroád funcíáon án cháldhood obesáíy and
pránávasan poI Bao tI taííágney tAI Berenson dpK Adolescení overweághí ás assocáaíed wáíh adulí
overweághí and relaíed mulíáple cardáovascular rásk facíors: íhe Bogalusa eearí píudyK Meíabolásm
iaváne gbI pchwámmer gBI san kaíía MiI
eí alK
konalcoholác píeaíohepaíáíás Clánácal oesearch
keíworkK bffecí of váíamán b or meíformán for íreaímení of nonalcoholác faííy láver dásease án cháldren
pchwámmer gBI aeuísch oI oauch gBI Behláng CI kewbury oI iaváne gbK lbesáíyI ánsulán resásíanceI
and oíher clánácopaíhologácal correlaíes of pedáaírác nonalcoholác faííy láver dáseaseK g medáaír OMMP;
pecíáon on medáaírác mulmonologyI pubcommáííee on lbsírucíáve pleep Apnea pyndromeK Amerácan
Academy of medáaírácsK Clánácal pracíáce guádeláne: dáagnosás and managemení of cháldhood
obsírucíáve sleep apnea syndromeK medáaírács OMMO; NMVE4F: TM4JNOK
deííys chI gackson gBI cráck piK lbesáíy án pedáaírác oríhopaedácsK lríhop Clán koríh Am OMNN;
[4PzBall AhI Clarke CbK Idáopaíhác áníracranáal hyperíensáonK ianceí keurol OMMS; R: 4PPJ4OK
Augusí dmI Capráo pI cennoy II
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bndocráne pocáeíyK mreveníáon and íreaímení of pedáaírác
obesáíy: an endocráne socáeíy clánácal pracíáce guádeláne based on experí opánáonK g Clán bndocránol
iau hI eöger meK pkán dáseases assocáaíed wáíh obesáíy án cháldrenK Bundesgesundheáísblaíí
desundheáísforschung desundheáísschuíz OMNP; RSE4F: RPVJ4OK [Aríácle án dermanzK
[4Szpánha pI pchwaríz oAK guvenále acaníhosás nágrácansK g Am Acad aermaíol OMMT; RTEPF: RMOJUK
Armsírong pI iazoráck pI eampl pI
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mhysácal examánaíáon fándángs among cháldren and
wáíh obesáíy: An evádenceJbased reváewK medáaírács NPTEOF: eOMNRNTSSK
sander tgI Máíchell boK msychologácal complácaíáons of pedáaírác obesáíyK medáaír Clán koríh Am
Maloney AbK medáaírác obesáíy: a reváew for íhe cháld psycháaírásíK Cháld Adolesc msycháaír Clán k Am
eebebrand gI eerperízJaahlmann BK
msychologácal and psycháaírác aspecís of pedáaírác obesáíyK Cháld
tardle gI Cooke iK qhe ámpací of obesáíy on psychologácal wellJbeángK Clánácal bndocránology C
Casazza hI coníaáne hoI Asírup AI
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MyíhsI mresumpíáonsI and cacís abouí lbesáíyK k bngl g
iesláe tpI eankey CoI iean MbK teághí gaán as an adverse effecí of some commonly prescrábed
Cheskán igI Baríleíí pgI Zayas oI qwálley CeI Alláson aBI Coníoreggá CK mrescrápíáon medácaíáons: a
Bougnères mI maníalone iI iánglarí AI
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bndocráne manáfesíaíáons of íhe rapádJonseí obesáíy wáíh
hypoveníálaíáonI hypoíhalamácI auíonomác dysregulaíáonI and neural íumor syndrome án cháldhoodK g
tháíaker oCI trághí gAI mepe MpI
eí alK
mredácíáng obesáíy án young adulíhood from cháldhood and
Blaár kgI qhompson gMI Black mkI
eí alK
oásk facíors for obesáíy án TJyearJold buropean cháldren: íhe
oeálly ggI Armsírong gI aorosíy AoI
eí alK
barly láfe rásk facíors for obesáíy án cháldhood: cohorí síudyK
[RVzoudolf MK mredácíáng babáesD rásk of obesáíyK Arch aás Cháld OMNN; VS: VVRK
muhl oMI iaíner gaK píágmaI obesáíy and íhe healíh of íhe naíáon’s cháldrenK msychol Bull OMMT; NPP:
bdmunds iaK marenís’ percepíáons of healíh professáonals’ responses when seekáng help for íheár
oodán oiI Alexander MeI duállory gI
eí alK
mhysácáan counseláng ío prevení overweághí án cháldren
and adolescenís: Amerácan College of mreveníáve Medácáne mosáíáon píaíemeníK g mublác eealíh Manag
cernández goI oedden aqI máeírobellá AI Alláson aBK taásí cárcumference perceníáles án naíáonally
represeníaíáve samples of AfrácanJAmerácanI buropeanJAmerácanI and MexácanJAmerácan cháldren
and AdolescenísK qhe fouríh reporí on íhe dáagnosásI evaluaíáonI and íreaímení of hágh blood pressure
hrebs kcI eámes geI gacobson aI kácklas qAI duálday mI píyne aK Assessmení of cháld and
Brara pMI hoebnáck CI moríer AeI iangerJdould AK medáaírác ádáopaíhác áníracranáal hyperíensáon and
dreen gpI marfrey mpI earneíí gaI
eí alK
qhe cardánal manáfesíaíáons of BardeíJBáedl syndromeI a form
aáeíz teI oobánson qkK Clánácal pracíáceK lverweághí cháldren and adolescenísK k bngl g Med OMMR;
hroenke hI ppáízer oiI tálláams gBK qhe menJV: saládáíy of a bráef depressáon severáíy measureK
Amerácan aáabeíes Assocáaíáon mosáíáon píaíemeníK aáagnosás and Classáfácaíáon of aáabeíes MelláíusK
hapadáa CoK Are íhe AaA eemoglobán aNc cráíeráa relevaní for íhe dáagnosás of íype O dáabeíes án
ievyJMarchal CI Arslanáan pI Cuífáeld tI
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Insulán oesásíance án Cháldren Consensus Conference droupK Insulán resásíance án cháldren: consensusI
Amerácan aáabeíes AssocáaíáonK qype O dáabeíes án cháldren and adolescenísK aáabeíes Care OMMM; OP:
bxperí manel on Iníegraíed duádelánes for Cardáovascular eealíh and oásk oeducíáon án Cháldren and
AdolescenísI kaíáonal eearíI iungI and Blood InsíáíuíeK bxperí panel on áníegraíed guádelánes for
cardáovascular healíh and rásk reducíáon án cháldren and adolescenís: summary reporíK medáaírács OMNN;
[TRzaanáels poK Managemení of hyperlápádemáa án pedáaírácsK Curr lpán Cardáol OMNO; OT: VOJTK
Bamba sK rpdaíe on screenángI eíáology and íreaímení of dyslápádemáa án cháldrenK g Clán bndocránol
pmoíkánJqangorra MI murushoíhaman oI dupía AI
eí alK
mrevalence of váíamán a ánsuffácáency án
BoíellaJCarreíero gII AlvarezJBlasco cI sállafruela ggI
eí alK
sáíamán a defácáency ás assocáaíed wáíh
helly AI Brooks igI aougheríy pI
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A crossJsecíáonal síudy of váíamán a and ánsulán resásíance án
qurer CBI ián eI clores dK mrevalence of váíamán a defácáency among overweághí and obese rp
vanovská gAI Cuíler dB grK dlucocoríácoád acíáon and íhe clánácal feaíures of CushángDs syndromeK
[UOzaubnovJoaz dI Berry bMK qhe dáeíary íreaímení of obesáíyK Med Clán koríh Am OMNN; VR: VPVJROK
medáaírác overweághí: A reváew of íhe láíeraíureK qhe Ceníer for teághí and eealíh College of kaíural
oesources rnáversáíy of CaláfornáaI Berkeley OMMN gune;
eo MI darneíí pmI Baur iAI
eí alK
Impací of aáeíary and bxercáse Iníerveníáons on teághí Change
and Meíabolác luícomes án lbese Cháldren and Adolescenís: A pysíemaíác oeváew and MeíaJanalysás
tald ABI rlá khK mharmacoíherapy án pedáaírác obesáíy: currení agenís and fuíure dárecíáonsK oev
carooqá IpI gebb pAI iangmack dI
eí alK
bffecís of recombánaní lepíán íherapy án a cháld wáíh
iusíág oeI eánds mpI oángwaldJpmáíh hI
eí alK
lcíreoíáde íherapy of pedáaírác hypoíhalamác obesáíy:
Inge qeI Máyano dI Bean gI
eí alK
oeversal of íype O dáabeíes melláíus and ámprovemenís án
merkán oMI pwáfí gaI kewíon aAI
eí alK
medáaírác eospáíal Medácáne: qexíbook of Inpaíáení
ManagemeníK Ond edK mháladelpháaI mA: iáppáncoíí tálláams C tálkáns OMMU; pK SVOK
euang gpI Chun pI pandhu AI qerrones iK nualáíy Improvemení án Cháldhood lbesáíy Managemení
Barlow pbK bxperí CommáííeeK bxperí commáííee recommendaíáons regardáng íhe preveníáonI
assessmeníI and íreaímení of cháld and adolescení overweághí and obesáíy: summary reporíK medáaírács
Currení Concepís án íhe Managemení of
aávásáon of medáaírác bndocránologyI aeparímení of medáaírácsI rq pouíhwesíern Medácal CeníerI
Absírací:
draves’ dásease EdaF ás íhe mosí common cause of hyperíhyroádásm án
cháldren and adolescenísK Ií ás an auíoámmune dásorderI caused by ámmunologác
síámulaíáon of íhe íhyroád síámulaíáng hormone recepíor EqpeoFK qhyroíropán
síámulaíáng ámmunoglobulán EqpIF bánds ío qpeo and leads ío íhyroád hormone
overproducíáonK Clánácal feaíures ánclude faíágueI íremorsI palpáíaíáonsI heaí áníolerance
and poor school performanceK qhe dáagnosás ás by fándángs of áncreased hearí raíe and
goáíer án íhe seííáng of suppressed íhyroíropán síámulaíáng hormone and elevaíed free
íhyroxáneK oadáoacíáve áodáne upíake and serum aníábody measuremenís help ío
deíermáne íhe cause of hyperíhyroádásmK qreaímení opíáons for da ánclude aníáíhyroád
drugsI radáoacíáve áodáne or surgeryK iasíáng remássáon occurs án NR ío PMB of cháldren
wáíh daK qhusI a majoráíy of cháldren wáll requáre defánáíáve íherapy wáíh radáoacíáve
áodáne or íhyroádecíomyK A dáscussáon of advaníages and rásks of each íherapeuíác
heywords:
AdolescenísI CháldrenI draves’ dáseaseI easháíoxácosásI
eepaíoíoxácáíyI eyperíhyroádásmI MeíhámazoleI oadáoacíáve áodáneI oadáoacíáve
draves’ dásease EdaF accounís for NM ío NRB of íhe cháldhood íhyroád dáseasesK Ií
ás íhe mosí common cause of hyperíhyroádásm án cháldrenK qhe áncádence of
hyperíhyroádásm án adulís worldwáde has been reporíed ío be OPJVPLNMMIMMM
ánhabáíanís per year [
zK qhe áncádence án cháldren ás esíámaíed ío be MKV per
NMMIMMM án naíáonal prospecíáve surveállance síudy from íhe rnáíed hángdom and
IrelandK Auíoámmune íhyroíoxácosás accouníed for VSB of íhe cases [
zK qhe
Correspondáng auíhor Abha Choudhary
: aávásáon of medáaírác bndocránologyI aeparímení of medáaírácsI rq
pouíhwesíern Medácal CeníerI aallasI quI rpA; qel: ON4 S4U PRMN; cax: ON4 4RS OV4M; bmaál:
cháldrenI whále áí ás P per NMMIMMM personJyears án adolescenísK qhe prevalence án
rnáíed píaíes ás N án NMIMMM personJyearsK da ás rare án less íhan R years of age
and has a peak áncádence aí NM ío NR years of ageI more common án females íhan
males ER:NFK da ás more common án cháldren wáíh oíher auíoámmune condáíáons
qhe cause of da ás unclearI buí áí ás íhoughí ío resulí from a complex áníeracíáon
of geneíácI ámmune and enváronmeníal facíorsK qhe ámmune sysíem produces íhe
íhyroád síámulaíáng hormone recepíor aníábody EqoAbFI whách ás dárecíed agaánsí
íhe íhyroád síámulaíáng hormone recepíor EqpeoFK qhe qoAb can eáíher síámulaíe
or ánhábáí íhyroád hormone secreíáonK da occurs from formaíáon of síámulaíáng
aníábodáes ío íhe qpeo called íhe íhyroíropán síámulaíáng ámmunoglobuláns EqpIFK
Ií ás a funcíáonal assay whách measures íhe producíáon of cyclác adenosáne
monophosphaíe án culíured íhyroád follácular cellsK qpI bánds ío and also
síámulaíes íhe qpeo on íhe íhyroád follácular cellsI leadáng ío áncreased
vascularáíy of íhe glandI follácular hyperírophyL hyperplasáa and áncreased
producíáon of íhe íhyroád hormoneK qhe íhyroád gland dásplays lymphocyíác
ánfálíraíáon wáíh qJlymphocyíe abnormaláíáes and an absence of follácular
desírucíáonK q cells acíávaíe local ánflammaíáon and íássue remodeláng by
producáng cyíokánesI leadáng ío BJcell dysregulaíáon and auíoaníábody formaíáonK
An ámbalance beíween paíhogenác and regulaíory q cells ás íhoughí ío be ánvolved
draves’ ophíhalmopaíhyI an ámmune medáaíed condáíáon ás caused by crossJ
reacíáváíy of qpI wáíh a qpeo láke proíeán án reíroJorbáíal íássue and exíraocular
muscleK qhás leads ío local ánflammaíáon and ánfálíraíáon of glycosamánoglycans
resulíáng án edemaI muscle swelláng and áncrease án áníraorbáíal pressure causáng
qransáení hyperíhyroádásm may resulí from desírucíáon of íhyroád follácular cells
by an auíoámmune or ánfecíáous processI whách leads ío unregulaíed release of
preformed hormone ánío íhe cárculaíáonK pubacuíe íhyroádáíás occurs from an
ánfecíáon or ánflammaíáon and usually resolves án a few moníhs wáíh
normalázaíáon of íhyroád funcíáonsK eyperíhyroádásm ás also seen án McCuneJ
Albrághí syndrome EsomaíácJacíávaíáng muíaíáon of íhe dkAp geneFK Ií resulís án
áncreased síámulaíory d proíeán ságnaláng íhaí causes hyperfuncíáon of
glycoproíeán hormone recepíorsI auíonomous cell proláferaíáon and hormone
hypersecreíáonK qhyroíropán síámulaíáng hormone EqpeF secreíáng páíuáíary
adenoma and páíuáíary resásíance ío íhyroád hormone are caused by unregulaíed
qhe mosí common cause of hyperíhyroádásm án cháldren ás daK líher causes
ánclude acuíe or subJacuíe íhyroádáíásI q4 ángesíáon and íhyroíoxác phase of
chronác lymphocyíác íhyroádáíás EeasháíoxácosásFK eyperíhyroádásm ás also seen án
auíonomously funcíáonáng íhyroád noduleI íoxác adenomaI mulíánodular goáíerI
McCune Albrághí syndromeI síruma ovaráá and qpe producáng páíuáíary
adenomas [
I
I
zK bíáology ás lásíed án qable
qpe: qhyroád síámulaíáng hormone; qpI: íhyroíropán síámulaíáng ámmunoglobuláns; qoAb: íhyroád
síámulaíáng hormone recepíor aníábodyK
qhe onseí of sympíoms ás subíle and a hágh ándex of suspácáon ás needed án
dáagnosáng cháldrenK mrompí íreaímení ás ámporíaní due ío áís unáque effecís on
da can presení ánsádáously wáíh emoíáonal labáláíyI faíágueI sleep dásíurbances and
áncreased appeíáíeK pchool aged cháldren are someíámes broughí ío medácal
aííeníáon for evaluaíáon of aííeníáon defácáí hyperacíáváíy dásorder because of íheár
ánabáláíy ío conceníraíe and poor school performanceK mrepuberíal cháldren mosí
commonly presení wáíh poor weághí gaán and dáarrheaI whereas adolescenís
presení wáíh árráíabáláíyI faíágueI palpáíaíáonsI heaí áníoleranceI fáne íremors and a
goáíerK vounger cháldren íypácally have a delay án dáagnosás and íhás leads ío
áncreased heághíI advanced bone age and poor weághíK ln physácal examánaíáonI
íhyromegaly ás presení án VRB of íhe casesK qhe gland ás symmeírácally enlargedI
smooíh and nonJíenderK líher ságns ánclude íachycardáaI fáne íremorsI warm skánI
muscle weaknessI áncreased pulse pressure and exaggeraíed deep íendon reflexesK
lphíhalmác abnormaláíáes such as síaráng eyesI propíosásI reíracíáon of upper eye
lád and wáde palpebral fássure can occur án 4MB of cháldren and adolescenís and ás
less severe íhan seen án adulísK mreíábáal myxedema and dermopaíhy are rare án
cháldrenK qhyroád síorm ás also rare án cháldren and ás characíerázed by áncreased
meíabolásm wáíh excessáve release of íhyroád hormones leadáng ío severe
hyperíhyroád sympíoms [
I
I
I
zK págns and sympíoms of da are lásíed án qable
iaboraíory evaluaíáon áncludes serum íhyroád síámulaíáng hormone EqpeFI free
íhyroxáne Ecq4FI íoíal írááodoíhyronáne EqqPFI qpII íhyroád peroxádase and aníáJ
íhyroglobulán aníábody levelsK Compleíe blood couní and láver funcíáon íesís are
perum qpe level ás suppressed and cq4 and qqP values are elevaíed án
hyperíhyroádásmK qpI ás posáíáve án VMB of íhe cases of daK qhyroád peroxádase
and íhyroglobulán aníábodáes are posáíáve án auíoámmune íhyroádáíás and maybe
Ií ás performed áf íhe íhyroád gland ás asymmeírác or a palpable nodule ás noíedK If
a nodule ás confármedI a fáne needle aspáraíáon báopsy should be performed as well
as
I or
qc scanK aáffereníáaíed íhyroád cancer may be seen concurreníly wáíh
qhyroád upíake scan ás performed án cases of unclear eíáology of hyperíhyroádásmK
qhe íhyroád gland can acíávely conceníraíe áodáne and radáoacíáve áodáne EoAIFK
I ás íhe radáonucleoíáde of choáce for íhyroád upíake sánce áí has a shorí halfJláfe
and delávers a smaller radáaíáon dose as compared wáíh
IK oadáolabelled
íechneíáum E
qcF can also be used sánce íechneíáum ás írapped by íhe íhyroád
gland
buí noí
K
qc scan ás someíámes preferred because áí ás less
expensáveI quácker and ánvolves less
íoíal body radáaíáonK
qhe upíake scan shows áncreased upíake ío
RM ío
UMB íhroughouí íhe gland án
daK Condáíáons such as subJacuíe íhyroádáíás or early phase of auíoámmune
íhyroádáíás are assocáaíed wáíh decreased upíake as low as� "d OB [
I
Currení íreaímení approaches for da ánclude aníáíhyroád drugs EAqasFI surgery
and radáoacíáve áodáne ablaíáon E
IFK qhere ás no specáfác cure for íhe dásease and
each íreaímení opíáon ás assocáaíed wáíh complácaíáonsK Aqas are íhe ánáíáal
íreaímení opíáons án daK qhey palláaíe íhe hyperíhyroád síaíe uníál áí sponíaJ
neously resolves or defánáíáve íreaímení ás doneK oefer ío cágK E
F and qable
qpe: qhyroád síámulaíáng hormone; cq4: free íhyroxáneI qqP: qoíal írááodoíhyronáneI qpI: íhyroíropán
síámulaíáng ámmunoglobuláns; da: draves’ dásease; Aqa: aníáJíhyroád drugs; oAI: radáoacíáve áodáne
ᄒऀጄᐇᔖ᜘ܙᔚܓᐆ܀ᔕᬀ
ᄒऀጄᐇᔖᰇጔ؇ᔃ਍ค؇ጔऄሎ؄ఏ
ᴏऀጒԄ༃܆ГḔฏЏ܎ἇ‡
ᔀഌጉဌᐉ܈Љ̇"ᔡܟญܣ܉ง␇਌ግༀ
ᘄ،܌ἀἌ┉༦ᐎᐧ
ᔀഄጅ܎ἀἇ"ᔡ
⬎ᐞ܉఍ဇ༩പఄԅጔ┌ܭ଀ግऄ┩ԅግਇةഄᐞ܋ഌḔጔ┊⸀
ฟἌഌ؇Д܏అథऌ؇┓༌ༀ
Adapíed from Managemení duádelánes of íhe Amerácan qhyroád Assocáaíáon and Amerácan Assocáaíáon of
Aqas are qháonamáde derávaíáves whách were áníroduced án early NV4Ms by
AsíwoodK qháouracálI íhe fársí compound used clánácally was assocáaíed wáíh íoxác
sáde effecís and was replaced by mropylíháouracál EmqrF án NV4TK Meíhámazole
EMMIF has been íhe íreaímení opíáon for da sánce NVRMK MMI ás NM ío OM íámes
more poíení íhan mqr and has a longer halfJ láfeK In OMMUI a number of cases
descrábáng mqrJ ánduced láver faálure requáráng íransplaní emergedK qhe rásk was
esíámaíed ío be N án OMMM cháldrenK In Aprál OMNMI íhe rnáíed píaíes cood and
arug Admánásíraíáon ássued a black box warnáng síaíáng íhaí mqr should noí be
used án cháldrenI excepí án specáal cárcumsíancesK mqr can someíámes be used
shorí íerm wáíh exíreme cauíáon án paíáenís who have had a íoxác reacíáon ío MMI
whále waáíáng for defánáíáve íherapyK If síaríed on mqrI paíáení and famáláes should
be ánformed of íhe rásk of láver faálureK If íhey noíe ságns and sympíoms of láver
íoxácáíy láke áíchángI jaundáceI abdománal paánI lághí colored síoolsI dark uráne or
anorexáaI íhe medácaíáon should be síopped and medácal aííeníáon should be
soughí prompíly [
Aqas ací by ánhábáíáng oxádaíáon and organác bándáng of íhyroád áodáne íhus
ámpaáráng íhyroád hormone syníhesás [
I
MMI ás íhe drug of choáce for daK qhe íypácal dose ás MKO ío MKR mgLkgLday once
a day or án dáváded dosesK qhe dose can range from MKN ío N mgLkgLdayK Ií ás
avaálable án RI NM and OM mg íableísK qhe followáng doses can be used án guádáng
íherapyK In ánfanís: NKOR mgLday; N ío R years: OKR ío R mgLday; R ío NM years: R ío
NM mgLday and NM ío NU years: NM ío OM mgLdayK qhe doses can be doubled án
severe hyperíhyroádásmK Compleíe blood counísI láver funcíáon íesísI pregnancy
íesí Efor gárls án íhe reproducíáve age groupFI should be performed práor ío síaríáng
íherapy [
zK qhyroád funcíáon íesís should be obíaáned N moníh afíer síaríáng
(Table
) contd.....
íherapyK Afíer cq4 levels normalázeI íhe MMI dose ás reduced by RMB ío maáníaán
a euíhyroád síaíeK qpe íakes moníhs ío normaláze and hence should noí be used án
qwo approaches have been dáscussedK pome use íhe “block and replace” approach
and add levoíhyroxáne whále noí changáng íhe MMI dose ío acháeve euíhyroádásmK
táíh íhás approachI íhere ás a greaíer rásk of sáde effecís sánce íhere ás a dose
response relaíáonsháp for some MMI relaíed complácaíáonsK qhe oíher approach ás
íhe dose íáíraíáon whách ánvolves adjusíáng íhe doses of íhe MMI ío acháeve
euíhyroádásmK Compláance may also be an ássue án some cháldrenI who may fánd áí
easáer ío íake one drug raíher íhan íwo drugsK qhe Amerácan qhyroád Assocáaíáon
guádelánes suggesí usáng íhe dose íáíraíáon meíhod by usáng íhe lowesí dose of
Mánor sáde effecís can occur án NTB of íhe cháldren on MMI whách áncludes rashI
hávesI aríhralgáa and nauseaK Major sáde effecís ánclude píevensJ gohnson
syndromeI agranulocyíosásI neuíropenáaI íhrombocyíopenáaI cholesíaíác jaundáceI
hepaíáíás and vasculáíásK qhese íypácally occur án íhe fársí S moníhs of síaríáng
íherapy buí can occur anyíáme duráng íhe course of íherapy [
zK Agranulocyíosás
ás dose dependení and íypácally develops án íhe fársí NMM days of íherapyK medáaírác
paíáenís and íheár famáláes should be ánformed of íhe sáde effecísI íhe necessáíy of
síoppáng íhe medácaíáons and ánformáng íheár physácáan áf íhey develop pruráíác
rashI jaundáceI acolác síools or dark uráneI aríhralgáasI abdománal paánI nauseaI
faíágueI fever or pharyngáíás [
zK In íhe pedáaírác populaíáonI aníáJneuírophálác
MMIK qhese aníábodáes can cause seráous vasculáíás eveníI hence áí ás reasonable
ío check AkCAs on cháldren who have been on Aqas for greaíer íhan O yearsK
Aqas can cross íhe placenía and has an áncreased rásk of báríh defecísK MMI
embryopaíhy causes choanal aíresáaI esophageal aíresáaI growíh reíardaíáon and
developmeníal delayK mqr ás íhe drug of choáce duráng íhe fársí írámesíer of
pregnancy because of íhe poíeníáal íeraíogenác effecís of MMI [
oemássáon of da ás defáned as báochemácal euíhyroádásm or hypoíhyroádásm for
one year or more afíer dásconíánuaíáon of AqasK qhe remássáon raíes án cháldren
are reporíed ío be OM ío PMB afíer many years of Aqas [
I
zK A crench síudy
showed íhaí prolonged Aqas were assocáaíed wáíh RMB remássáon raíesK NR4
cháldren wáíh da dáagnosed beíween NVVT and OMMO were examáned followáng
íreaímení wáíh carbámazoleK qhe esíámaíed remássáon raíes were OMBI PTBI 4RB
and 4VB afíer 4I SI U and NM years of íherapy respecíávely [
zK qhe chance of
remássáon afíer O years of Aqas ás low áf íhe íhyroád gland ás large Emore íhan OKR
íámes normal sáze for ageFI young cháld EYNO yearsFI noí CaucasáanI serum qoAb
levels are above normal on íherapy and elevaíed cq4 aí dáagnosás E>4 ngLdlF [
I
I
zK qhe OMNN Amerácan qhyroád Assocáaíáon EAqAF and Amerácan
Assocáaíáon of Clánácal bndocránologásí EAACbF managemení guádelánes
recommend coníánuáng Aqa án cháldren for íwo years áf íhere are no major sáde
effecísK If cháldren develop seráous allergác reacíáon ío MMII radáoacíáve áodáne or
Beía adrenergác aníagonásís are useful án íhe managemení of da because áí helps
ío decrease sympaíheíác sympíoms láke sweaíángI íremorI palpáíaíáons and anxáeíyK
mropranololI aíenolol or meíaprolol can be used ío conírol da sympíomsK
Aíenolol ás preferred for áís cardáoselecíáve naíureK then íhe íhyroád hormone
oadáoacíáve áodáne EoAI;
IF use for íhyroád ablaíáon was áníroduced án NV4Ms by
paul eeríz and coJworkers aí íhe Massachuseíís Insíáíuíe of qechnology and
Massachuseíís deneral eospáíalK oAI upíake by íhe íhyroád ás noí dásíánguáshable
from ordánary áodáneI íhus oAI ás írapped án íhe íhyroád cellK Afíer beáng íaken up
by íhe íhyroád cellsI beíaJ emássáon causes desírucíáon of íhe áodáne írappáng cellsK
Ií resulís án fábrosás and glandular aírophyK If
I íherapy ás chosenI áí should be
admánásíered as a sángle dose ío render íhe paíáení hypoíhyroád [
I
I
zK Ií
should noí be used ío cause euíhyroádásm án cháldren as íhás leads ío paríáally
árradáaíed resádual íhyroád íássue whách can be assocáaíed wáíh a rásk of íhyroád
cancerK qypácally admánásíered íhyroád doses of NRMµCáLgm generaíe radáaíáon
doses of NOIMMM cdy ío íhe íhyroádK iarger doses E>NRM µCá of
I per gram of
íhyroád íássueF are preferred over smaller doses of radáoacíáve áodáneK
aosages of radáoáodáne admánásíered are based on áodáne upíake and gland sáze
usáng íhe nuámbyJMaránellá equaíáon: dosage Eradáaíáon; án dyF = VM × oral
Idose EμCáF × oral O4Jhr upíake EBF L gland mass EgmF × NMMBFK qhás
calculaíáon assumes an effecíáve half láfe of S days for
IK qhyroád sáze ás
wádíhF [
zK An advaníage of calculaíed dose ás íhaí áí may be possáble ío
admánásíer lower doses áf íhe áodáne upíake ás hághK
qhe Aqas are dásconíánued P–R days before
I ás admánásíeredK qhe cárculaíáng
levels of íhyroád hormones may áncrease 4 ío NM days afíer íhe ablaíáon when íhe
íhyroád hormones are released from degeneraíáng follácular cellsK collowáng íhe
ablaíáonI qpe and cq4 levels should be obíaáned every moníhK Báochemácal
euíhyroádásm or hypoíhyroádásm ás acháeved án S ío NO weeks afíer
I íreaímeníK
rníál íhenI íhe sympíoms of hyperíhyroádásm can be conírolled usáng beía
adrenergác aníagonásísK MMI or iugol’s soluíáon can be used one week afíer
I ío
decrease báochemácal hyperíhyroádásm wáíhouí affecíáng íhe ouícome of oAI [
Cháldren wáíh cq4 >RngLdl should be preíreaíed wáíh MMI and beía adrenergác
páde effecís of
I íherapy ánclude máld íenderness over íhe íhyroád án íhe fársí
week afíer ablaíáonK qhás can be íreaíed wáíh aceíamánophen or nonJsíeroádal aníáJ
ánflammaíory drugs for O4 ío 4U hrsK qhere are rare reporís of íhyroád síorm án
oAI ás excreíed án saláva uráne and síoolK págnáfácaní radáoacíáváíy ás reíaáned
wáíhán íhe íhyroád for several daysK eence radáaíáon precauíáons are recommended
whách ánclude absence from schoolI noí sharáng uíensáls and noí kássáng or sáííáng
If hyperíhyroádásm persásís S moníhs afíer
II a second dose can be gávenK
maíáenís wáíh very large íhyroád gland E>UM gmF and hágh qoAb levels have lower
I ás an effecíáve íherapy for da and may be consádered for cháldren who are noí
án remássáon afíer N J O years of MMI íherapy or án íhose who have major adverse
sáde effecís ío íhe Aqas [
zK Ií can also be offered as íhe ánáíáal íherapy án
qhe benefáís of oAI ás íhe ease of admánásíraíáonI reduced need for long íerm
follow up and absence of long íerm sáde effecís [
I
zK qhe mosí exíensáve síudy
án cháldren ánvolved PS year ouícomes of NNS paíáenís who were Y OM year old
when íreaíed wáíh
I íherapy for daK qhere was no evádence of áncreased cancer
rásk án íhás populaíáonK qhere has been no evádence of adverse effecís ío offspráng
of cháldren íreaíed wáíh
II áncrease án raíe of ánferíáláíyI sponíaneous aboríáon or
qhe rásk of íhyroád cancer afíer exíernal radáaíáon ás hághesí án cháldren Y R years
of age and decláne wáíh advancáng ageK qhe Amerácan qhyroád Assocáaíáon
recommends ío avoád oAI án cháldren YR years of age and lámáí íhe dose ío NM
mCá án cháldren who are R ío NM years of age [
zK
I íherapy án paíáenís older
íhan NM years of age ás accepíable áf íhe acíáváíy ás > NRM µCáLg of íhyroád íássueK
qhe need for
I án a young cháld may occur when íhe cháld develops a íoxác
reacíáon ío an AqaI proper surgácal experíáse ás noí accessábleI or íhe cháld ás noí
qhe oldesí form of defánáíáve da íherapy ás íhyroádecíomyK qhe kobel mráze án
mhysáology and Medácáne was awarded ío hoker án NVMV for developmení án íhás
fáeldK then surgery ás chosen as íherapyI near íoíal or íoíalJíhyroádecíomy ás
recommended and should be performed by a hágh volume íhyroád surgeonK
purgery leads ío hypoíhyroádásm án cháldren who undergo íoíal íhyroádecíomyI
whereas afíer subíoíal íhyroádecíomyI hyperíhyroádásm recurs án NMJNRB of íhe
purgery ás preferred án cháldren Y R years when defánáíáve íherapy ás neededI án
ándáváduals wáíh large íhyroád glands E>UM gmF where íhe response ío
I ás poor
and án a laíe adolescení who ás consáderáng pregnancyK Ií should be performed by
qhe paíáení should be rendered euíhyroád wáíh Aqas or ánorganác áodáneK Iodáne
drops ER ío NM drops íhree íámes a dayF are gáven T ío NM days práor ío surgeryK
qhás síops íhe íhyroád hormone producíáon and causes íhe gland ío become fárm
mosíoperaíávelyI cháldren are aí a hágh rásk for acuíe complácaíáons such as
hypocalcemáaI hemorrhage and recurrení laryngeal nerve paresásK In cháldrenI
raíes from M–S years were OOBI from T–NO yearsI NNB; and from NP ío NT yearsI
NNB [
I
zK iong íerm complácaíáons ánclude hypoparaíhyroádásm and recurrení
collow up ás esseníáal for all paíáenís íreaíed for daK Ií should ánclude regular
Chronác iymphocyíác qhyroádáíás
J R ío NMB of cháldren presení wáíh a
íhyroíoxác phase called easháíoxácosásK qhe hyperíhyroádásm ás due ío
ánflammaíáon and auíonomous release of preformed and síored íhyroád hormonesK
Ií íypácally lasís for a few moníhsK qhe hyperíhyroádásm ás máld and íransáeníK qhe
íhyroád peroxádase and aníáJíhyroglobulán aníábodáes are posáíáve and qpI ás
negaíáveK oAI upíake ás low or abseníK pympíomaíác íreaímení wáíh beía
adrenergác aníagonásís ás recommended án cháldren wáíh palpáíaíáonsI íremorsI
pubJacuíe qhyroádáíás
J Ií ás also known as ae nuervaán’s dásease and ás due ío a
váral ánfecíáon of íhe íhyroádK qhe ánflammaíáon resulís án auíonomous release of
preformed and síored hormones whách leads ío hyperíhyroádásmK ceverI íhyroád
íenderness and hyperíhyroádásm may lasí for several weeksK qhe eryíhrocyíe
sedámeníaíáon raíe ás elevaíedK qhe qpe ás suppressed and íhe cq4 and qqP are
hághK qhyroád aníábodáes are negaíáve and oAI upíake ás low or abseníK konJ
síeroádal aníáJánflammaíory drugs and beía adrenergác aníagonásís are used for
sympíomaíác íreaímeníK qhás dásease ás selfJlámáíedI runnáng áís course over a
Acuíe qhyroádáíásJ
Ií ás characíerázed by feverI sore íhroaíI paánful íhyroád
swelláng and eryíhema of íhe overlyáng skánK purgácal áncásáon and draánage wáíh
qoxác Adenoma or poláíary qhyroád koduleJ
qhese are uncommon and are
suspecíed án íhe seííáng of hyperíhyroádásm and presence of a íhyroád noduleK
tarm or hoí nodules can lead ío excessáve producíáon of íhyroád hormoneK
Acíávaíáng muíaíáons of qpeo and síámulaíory d proíeán have been descrábed án
hyperfuncíáonáng nodulesK qhyroád aníábodáes are negaíáveK oAI upíake wáll show
upíake only án íhe funcíáonáng noduleK qhe íreaímení ás Aqas buí ulíámaíely
surgácal excásáon ás requáredK
qoxác Mulíánodular doáíerJ
qhese are also uncommon cause of hyperíhyroádásm
án cháldrenK qhey are suspecíed án íhe seííáng of hyperíhyroádásm and mulíáple
nodulesK qhyroád aníábodáes are negaíáve and oAI shows upíake án mulíáple
nodulesK Ií can be íreaíed wáíh Aqas and eveníually íhyroádecíomy or
I should
qpeJsecreíáng máíuáíary Adenoma
J eypersecreíáon of qpe from a páíuáíary
adenoma ás a rare cause of hyperíhyroádásm án cháldrenK iaboraíory evaluaíáon
shows an elevaíed cq4 and qqP wáíh ánappropráaíely normal or slághíly elevaíed
qpe wáíh a hágh serum qpe alpha subunáí conceníraíáonK qhás dáagnosás ás
confármed on magneíác resonance ámagáng and íreaímení ás resecíáon of íhe
páíuáíary íumorK
oadáaíáon Induced eyperíhyroádásmJ
Cháldhood cancer survávors can have
íhyroíoxácosás assocáaíed wáíh radáaíáonK
oesásíance ío qhyroád eormoneJ
Ií ás an auíosomal dománaní dásorder due ío
muíaíáon án íhe íhyroád hormone beía recepíor gene EqoβFK Cháldren presení wáíh
a goáíerI elevaíed cq4 and normal ío slághíly elevaíed qpeK Cháldren wáíh
generalázed resásíance ío íhyroád hormone are usually euíhyroádI whále íhose wáíh
páíuáíary resásíance can have íhyroíoxác clánácal feaíuresK Mosí paíáenís wáíh
generalázed resásíance requáre no íreaímeníK
Muíaíáon án íhe qpe oecepíor deneJ
Ií ás an auíosomal dásorder caused by
muíaíáons án íhe íhyroíropán recepíor gene on íhe long arm of chromosome N4K Ií
ás also called non auíoámmune heredáíary hyperíhyroádásmK cq4 and qqP are
áncreased wáíh a suppressed qpeK qhe qpI ás negaíáveK aáffuse goáíer ás presení
McCuneJ Albrághí pyndrome
J Ií ás a sporadác dásease characíerázed by íhe íráad
of polyosíoíác fábrous dysplasáaI cuíaneous págmeníaíáon ECaféJ auJlaáí maculeF
and precocáous puberíyK Ií ás caused by an acíávaíáng muíaíáon of íhe alpha subunáí
of íhe síámulaíory d proíeánK aáffuse enlargemení of íhe íhyroád occurs early
whách íhen evolves ánío a mulíánodular goáíerK qhe qpe ás suppressed wáíh
áncreased oAI upíakeK purgácal excásáon ás ándácaíedK
cacíáíáous qhyroíoxácosásJ
can be seen án adolescenís who ángesí íhyroxáne ío
qhyroád píormJ
Ií ás an endocráne emergency and ás a láfeJíhreaíenáng condáíáonK
Ií ás characíerázed by mulíásysíem organ faálure and clánácal feaíures áncludáng
nauseaI vomáíángI dáarrheaI íachycardáaI hepaíác dysfuncíáonI hyperíhermáaI
hypoíensáonI arrhyíhmáas and congesíáve hearí faálureK keuropsycháaírác
manáfesíaíáons are agáíaíáonI deláráumI psychosásI síupor and comaK cacíors íhaí
íreaíed hyperíhyroádásm and acuíe állnessesK qhe recommendaíáons for íreaímení
are monáíoráng án áníensáve care unáíI íreaímení wáíh beía adrenergác aníagonásísI
keonaíal qhyroíoxácosásJ
keonaíal da ás due ío íransplaceníal passage of
maíernal qpI aníábodáesK qhe áncádence ás esíámaíed ío be N án ORIMMM neonaíesK Ií
occurs án ánfanís of moíhers wáíh acíáve da or án íhose preváously íreaíed wáíh
oAI or surgery due ío persásíaní qpIK Ií ás mosí lákely áf maíernal qpI exceeds
RMMBK Clánácal feaíures ánclude íachycardáaI árráíabáláíyI hyperacíáváíyI
resílessnessI dáarrhea and poor weághí gaánK pevere neonaíal íhyroíoxácosás can be
complácaíed by congesíáve hearí faálureK Managemení áncludes use of ánorganác
áodáne whách ánhábáís organáfácaíáon of áodáne and íhyroád hormone releaseI Aqas
and beía adrenergác aníagonásísK keonaíal da resolves P ío NO weeks afíer báríh
da ás íhe mosí common cause of hyperíhyroádásm án cháldrenK Aqas are íhe fársí
láne of íreaímeníI alíhough ulíámaíely defánáíáve íreaímení ás neededK pelecíáng a
íreaímení approach for cháldhood da can be challengángK Ií ás ámporíaní ío
dáscuss íhe rásks and benefáís of each íherapeuíác opíáon ío help íhe paíáení and
cor cháldren less íhan R years of ageI MMI should be consádered as íhe fársíJláne
íherapyK voung cháldren are less lákely ío have remássáon on drug íreaímení and
prolonged drug íherapy may be necessaryK If íhere are no adverse sáde effecís wáíh
MMII áí ás reasonable ío coníánue MMI uníál íhe cháld ás old enough for
IK If
adverse drug reacíáon occursI or íhere ás íhe desáre ío avoád prolonged drug useI
íhyroádecíomy or
I can be consáderedK NRB of cháldren wáíh da presení
beíween S years and NM years of ageK MMI ás íhe fársí láne drug íherapy for íhás
age groupK Cháldren who are NM years of age and older consíáíuíe UMB of daK cor
lákeláhood of remássáon or radáoacíáve áodáne can be consádered as an ánáíáal
íherapy áf íhe chances of remássáon appear poor [
I
I
I
AbrahamJkordláng MI Bysíröm hI qörráng lI
eí alK
Incádence of hyperíhyroádásm án pwedenK bur g
tálláamson pI dreene pAK Incádence of íhyroíoxácosás án cháldhood: a naíáonal populaíáon based síudy
iéger gI hagueládou cI Alberíá CI Carel gCK dravesD dásease án cháldrenK Besí mrací oes Clán
bndocránol Meíab OMN4; OUEOF: OPPJ4PK
Zámmerman aI iíeáf AkK qhyroíoxácosás án cháldrenK bndocránol Meíab Clán koríh Am NVVU; OTENF:
[RzCooper apK eyperíhyroádásmK ianceí OMMP; PSOEVPUOF: 4RVJSUK
[SzBrení dAK Clánácal pracíáceK dravesD dáseaseK k bngl g Med OMMU; PRUEO4F: ORV4JSMRK
[Tzpránávasan pI Másra MK eyperíhyroádásm án cháldrenK medáaír oev OMNR; PSESF: OPVJ4UK
oávkees pAK qhyroád aásorders án Cháldren and AdolescenísK In: Ma pI bdK medáaírác bndocránologyK
Bansal pI rmpaácháíra sI aesaá kK merezJ Colon pK medáaírác graves’ dáseaseK Iní g bndocránol OMNR;
oávkees pAK medáaírác dravesD dásease: managemení án íhe posíJpropylíháouracál braK Iní g medáaír
Bahn opI Burch eBI Cooper apI
eí alK
Amerácan qhyroád AssocáaíáonK Amerácan Assocáaíáon of
Clánácal bndocránologásísK eyperíhyroádásm and oíher causes of íhyroíoxácosás: managemení
guádelánes of íhe Amerácan qhyroád Assocáaíáon and Amerácan Assocáaíáon of Clánácal
bndocránologásísK bndocr mrací OMNN; NTEPF: 4RSJROMK
eegedüs iK qreaímení of dravesD hyperíhyroádásm: evádenceJbased and emergáng modaláíáesK
bndocránol Meíab Clán koríh Am OMMV gun; PUEOF: PRRJTNI áxK
hagueládou cI Carel gCI iéger gK dravesD dásease án cháldhood: advances án managemení wáíh
dlaser kpI píyne aMK mredácíáng íhe lákeláhood of remássáon án cháldren wáíh dravesD dásease: a
hagueládou cNK Alberíá CI Casíaneí MI duáííeny MAI Czernáchow mI iéger g; crench Cháldhood
dravesD aásease píudy droupK mredácíors of auíoámmune hyperíhyroádásm relapse án cháldren afíer
iéger gI delwane dI hagueládou cI Benmerad MI Alberíá CK crench Cháldhood dravesD aásease píudy
droupK mosáíáve ámpací of longJíerm aníáíhyroád drug íreaímení on íhe ouícome of cháldren wáíh
sáííá mI oago qI Cháovaío iI
eí alK
Clánácal feaíures of paíáenís wáíh dravesD dásease undergoáng
Bauer AgK Approach ío íhe pedáaírác paíáení wáíh dravesD dásease: when ás defánáíáve íherapy
warraníed? g Clán bndocránol Meíab OMNN; VSEPF: RUMJUK
oávkees pAI pklar CI creemark MK Clánácal reváew VV: qhe managemení of dravesD dásease án
cháldrenI wáíh specáal emphasás on radáoáodáne íreaímeníK g Clán bndocránol Meíab NVVU; UPENNF:
iee epI ewang gpK qhe íreaímení of dravesD dásease án cháldren and adolescenísK Ann medáaír
lkawa boI draní caI pmáíh goK medáaírác dravesD dásease: decásáons regardáng íherapyK Curr lpán
oead Ce grI qansey MgI Menda vK A PSJyear reírospecíáve analysás of íhe effácacy and safeíy of
oávkees pAK medáaírác dravesD dásease: coníroversáes án managemeníK eorm oes maedáaír OMNM; T4ERF:
posa gAI quggle CqI tang qpI
eí alK
Clánácal and economác ouícomes of íhyroád and paraíhyroád
Burch eBI Burman haI Cooper apK OMNN survey of clánácal pracíáce paííerns án íhe managemení of
Amáne aaherI qanya MK Maríínez cernández
and
vadára MK
rnáversáíy of qexas pouíhwesíern ErqptF Medácal CeníerI aallas Cháldren’s eealíhI aallasI
Absírací:
In íhe pasí decadeI íhere have been greaí advances án íhe approach ío and
managemení of pedáaírác asíhmaK oecení progress áncludes ámproved defánáíáonsI
esíabláshed guádelánesI and novel íherapeuíác modaláíáesK qhere ás growáng recognáíáon
íhaí asíhma ás a heíerogeneous eníáíy and as suchI ándávádualázed íherapy ás now
síandard when creaíáng áníerveníáon plansK Asíhma severáíy ás classácally caíegorázed
based on íhe concepís of ámpaármení and ráskK As more specáfác daía ás gaíhered on
asíhma subgroupsI molecular paíhways and clusíer analysásI íhere has been a
movemení for caíegorázáng paíáenís ánío asíhma phenoíypesI whách could serve ío íaálor
íherapáes and opíámáze clánácal responseK qhás chapíer wáll reváew íhe paíhophysáologác
processes ánvolved án asíhma; expose íhe laíesí defánáíáons of asíhma and managemení
guádelánes; dáscuss íhe ámplácaíáons of íhe “phenoíypác” approach án pedáaírác asíhma
heywords:
Asíhma guádelánesI Asíhma paíhophysáologyI Asíhma phenoíypesI
Inhaled coríácosíeroádsI MacroládesI MepolázumabI lmalázumabI medáaírác
asíhmaI qype O eá asíhmaI qype O io asíhmaI sáíamán aK
Asíhma ás íhe mosí common chronác dásease án cháldren and affecís over S málláon
cháldren án íhe rp [
zK Ií has been áncreasángly recognázed as a heíerogeneous
dásorder án íerms of áís phenoíypác preseníaíáonI paíhophysáology and response ío
íherapyK Asíhma paíáenís experáence recurrení sympíoms of aárflow obsírucíáon
due ío aárway ánflammaíáonI broncháal hyperJresponsáveness and án some cases
progressáve permanení changes [
zK qhe essence of asíhma íherapy ás conírol of
sympíoms and ánflammaíáon coupled wáíh íreaímení of bronchospasms and
exacerbaíáons whále gáváng proper consáderaíáon ío poíeníáal conírábuíáon from
Correspondáng auíhor vadára MK oáveraJpánchez
: rnáversáíy of qexas pouíhwesíern ErqptF Medácal CeníerI
aallas Cháldren’s eealíhI aallasI qexasI rpA; qel: EON4F 4RSJ4SPMLEON4F 4RSJR4MS; bmaál:
Asíhma ás a global healíh concern wáíh prevalence esíámaíed aí NJNUB of íhe
world’s populaíáonK qhe dlobal Ináíáaíáve cor Asíhma EdIkAF esíabláshed án
OMMOI defánes asíhma as a heíerogeneous dáseaseI usually characíerázed by chronác
aárway ánflammaíáon án whách paíáenís have a hásíory of wheezángI shoríness of
breaíhI chesí íághíness and cough íhaí vary over íáme and án áníensáíyI íogeíher
wáíh varáable expáraíory aárflow lámáíaíáon [
zK A defánáíáon for severe asíhma was
receníly developed by boíh íhe buropean oespáraíory pocáeíy and íhe Amerácan
qhoracác pocáeíy [
zK Ií áncludes paíáenís greaíer íhan sáx years of age who requáre
aí leasí hágh dose ánhaled coríácosíeroáds EICpF augmeníed by a second coníroller
Currení guádelánes offer a síandardázed approach ío asíhma íherapyK qhe overall
síraíegy áncludes assessmení of severáíy and conírol of sympíoms as well as
conírábuíáng coJmorbádáíáes such as obesáíyI gasíroesophageal refluxI psycháaírác
dásorders and rhánosánusáíásK iongJíerm íherapeuíác goals focus on use of
coníroller medácaíáonsI reláevers and addJon íherapáes án order ío acháeve good
sympíom conírol as well as a reducíáon án exacerbaíáonsI lung funcíáon lámáíaíáon
and sáde effecís of íreaímeníK te refer íhe reader ío a publáshed síandardázed
síepwáse approach for íhe use of ánhaled coríácosíeroádsI shorí acíáng beía
agonásísI long acíáng beía agonásís and leukoíráene aníagonásís án íhe managemení
of asíhma [
zK More novel and developáng íherapáes are dáscussed án laíer secíáons
Asíhma sympíoms síem from aárflow lámáíaíáon due ío bronchoconsírácíáonI
aárway hyperJresponsáveness and edemaK qheseI án íhe seííáng of chronác
ánflammaíáonI can progressávely lead ío aárway remodelángK In íhás secíáonI we
wáll defáne íhose processes as well as dáscuss íhe varáous chemácal and cellular
Acuíe bronchoconsírácíáon ás íhe rapád narrowáng of aárways resulíáng from
aárway smooíh muscle consírácíáonK Aárway hyperJresponsáveness ás íhe
unbalanced bronchoconsírácíáon response of aárways ío varáous síámuláK Aárway
edema paríácápaíes án aárflow obsírucíáon íhrough mucosal swellángI áncreased
mucus secreíáons and plug formaíáonK In some asíhma paíáenísI permanení
hásíologác changes such as smooíh muscle and mucus glands hyperplasáa as well
as angáogenesás can occurK qhese hásíologác changes are collecíávely referred ío as
aárway remodeláng and accouní for íhe lack of compleíe reversábáláíy ofíen seen án
keonaíes have a predománaní qhO phenoíypeK táíh íámeI varáous exposures íend
ío sháfí íhe ámmune sysíem íowards íhe qhN sysíemK In cháldren wáíh asíhmaI
íhere ás an ámbalance beíween íhe qhN and qhO ámmune paíhways manáfesíed by
hágh prevalence of aíopác condáíáonsK qhe hygáene hypoíhesás proposes for
exampleI íhaí among oíher exposuresI haváng older sáblángs and or aííendáng day
care can lead ío benefácáal effecís by decreasáng íhe rásk of developáng aíopác
dáseasesK qhás decrease án aíopy ás íhe dárecí resulí of ánfecíáous exposures
balancáng án íurn íhe qhN and qhO componenís of íhe ámmune sysíem [
Inhalaíáon of allergens leads ío an ánflammaíory cascade án asíhma paíáenís íhaí ásI
án mosí casesI eosánophálác and Igb medáaíedK Allergens crossJlánk Igb bound ío
mucosal masí cells and írágger íhe release of preformed hásíamánes and
leukoíráenesK qhás ás known as íhe “early phase reacíáon” leadáng ío acuíe
bronchoconsírácíáon [
zK qhe ánflammaíáon seen án asíhma requáres íhe áníeracíáon
of many cell lánesI each wáíh characíerásíác conírábuíáonsK rpon acíávaíáonI
mucosal masí cells release preJformed hásíamánes and oíher medáaíors leadáng ío
bronchoconsírácíáonK Aárway eosánopháls also release several proJánflammaíory
cyíokánesK In aíopác asíhma paíáenísI íhe degree of eosánopháláa ofíen correlaíes
wáíh íhe severáíy of asíhma and decreases wáíh íhe use of síeroád íherapyK pome
paíáenís wáíh asíhma have a predománance of aárway neuírophálsK keuíropháls
conírábuíáon ío ánflammaíáon án asíhma ás noí well undersíoodK aaía suggesísI
howeverI íhaí án asíhma paíáenísI íhe presence of neuíropháls as íhe predománaní
In addáíáonI asíhma ánflammaíáon sírongly depends on íhe áníerplay of a mulíáíude
of ságnaláng molecules such as IgbI cyíokánes and leukoíráenesK qhese molecules
are íhe íargeí of many research and esíabláshed íherapáesK Igb ás an allergen
specáfác aníábody esseníáal ío íhe allergác ánflammaíáon of asíhmaK Ií bánds masí
as íhe release of oíher ánflammaíory cyíokánes [
zK hey qhO cyíokánes ánclude:
IiJR promoíes bone marrow proláferaíáon of eosánopháls and survával án íhe
peráphery; IiJ4 and IiJNP promoíe a qhO response and Igb producíáon [
ieukoíráenes are released upon acíávaíáon of masí cells and lead ío
bronchoconsírácíáon [
In summaryI án asíhma íhere ás an ámbalance beíween íhe qhN EproíecíáveF and
qhO EallergácF ámmune sysíemsK qhe ánflammaíory cascade ás íhe producí of íhe
áníeracíáon of many qhO cell lánes and ságnaláng moleculesK Clánácal sympíoms of
asíhma resulí from aárflow lámáíaíáon due ío acuíe bronchoconsírácíáon án íhe early
phase followed by ánflammaíáonI áncreased mucus secreíáon and aárway hyperJ
responsávenessK In some paíáenísI aárway remodeláng wáíh permanení hásíologác
Caíegorázáng asíhma paíáenís ánío varáous phenoíypes follows from our expandáng
undersíandáng of asíhma paíhophysáologác processesK A number of phenoíypes
have now been proposed based on cráíeráa áncludáng íhese processes as well as
varáous paíáení relaíed clánácal characíerásíács and dáffereníáal response ío
íherapáesK In íhás secíáonI we wáll reváew láíeraíure íhaí supporís a “phenoíypác
In OMMNI ooorda
eí al
aííempíed ío deíermáne a subJpopulaíáon of preschool
cháldren wáíh asíhma sympíoms íhaí would have íhe besí response ío ánhaled
coríácosíeroádsK In íhás síudyI íhe auíhors pooled íhe populaíáons of íwo preváous
síudáes comparáng fluíácasone ío placebo án PMR preschool cháldren and evaluaíed
íhe relaíáonsháp beíween response ío ICp íreaímení and varáous paíáení
characíerásíácsK qhey found íhaí among asíhmaíác preschool cháldrenI íhose wáíh
frequení sympíoms and a famály hásíory of asíhma were mosí lákely ío respond ío
íreaímení wáíh ICp [
zK qhe auíhors also wení on ío suggesí íhaí íhe varáable
response ío ICp based on famály hásíory of asíhma suggesís íhaí more íhan a
of íhe mreveníáon of barly Asíhma án háds EmbAhF síudy; a mulíáceníerI placeboJ
conírolled íráal of ánhaled fluíácasone
placebo án preschool cháldrenI also
found íhaí preschool cháldren wáíh asíhma sympíoms do noí unáformly respond ío
ICpK qhe auíhors evaluaíed íhe relaíáonsháp beíween aíopác and demographác
characíerásíács of OUR preschool cháldren wáíh a posáíáve asíhma predácíáve ándex
and posáíáve response ío ICpK In íhe síudy populaíáonI besí response ío ICp was
found án Caucasáan male subjecís who had frequení sympíomsI were sensáíázed ío
aeroallergens and had an emergency deparímení vásáí or hospáíalázaíáon án íhe pasí
year [
zK A posí hoc analysás of NSP cháldren áncluded án íhe Besí AddJon qherapy
dáváng bffecíáve oesponse EBAadboF íráal lookáng ánío íhe relaíáonsháp beíween
íreaímení response and paíáení characíerásíács found íhaí response ío síep up
íherapáes was dáffereníáal wáíh respecí ío eczema and race [
zK qhe auíhors noíed
íhaí síep up íherapy ío long acíáng beía agonásís EiABAF was besí án cháldren
wáíhouí eczemaI regardless of raceK In íhose wáíh eczemaI race seemed ío predácí
response ío síep up íherapyK qheár fándángs suggesíed íhaí Afrácan Amerácans
benefáííed mosí from hágh dose ICpI eáspanács from leukoíráenes aníagonásís
EiqoAFI whereas Caucasáans had an equal response ío addáíáon of eáíher iABA
pevere pedáaírác asíhma may be defáned by hágh ámpaármení and frequení
exacerbaíáons despáíe hágh dose ICp án íhose wáíh a hágh prevalence of aíopyK qhe
sírong assocáaíáon ío aíopy dáffereníáaíes pedáaírác from adulí severe asíhmaK crom
a hásíologácal síandpoáníI áí may be ánferred íhaí severe pedáaírác asíhma ás a
phenoíype án and of áíselfI whách may be assocáaíed ío aárway remodeláng as well
as alíered aníáoxádaní and ánflammaíáon regulaíáon resulíáng án a prámarály síeroád
responsáve dáseaseK Ií ás ámporíaní ío noíeI howeverI íhaí wáíhán íhe severe
pedáaírác asíhma phenoíypeI íhere ás varáaíáon ío síeroád responsáveness [
píaíásíácal clusíer analyses of pedáaírác paíáenís áncluded án íhe pevere Asíhma
oesearch mrogram síudy ádeníáfáed four phenoíypác clusíers of pedáaírác paíáenís
wáíh asíhma based on lung funcíáonI duraíáon of asíhma sympíoms and coníroller
useK maíáenís wáíh severe pedáaírác asíhma were presení án all four clusíers furíher
Clusíer analysás of large clánácal íráals has been a powerful íool assásíáng
researchers án íhe ádeníáfácaíáon of asíhma phenoíypesK eowrylak
eí al
fáve clánácal clusíers when analyzáng íhe NM4N cháldren áncluded án íhe Cháldhood
Asíhma Managemení mrogramK qhe clusíers were based on P characíerásíács:
aíopyI aárway obsírucíáon and burden of exacerbaíáonsK Clusíer groupáng was
reflecíáve of dásease severáíy and was predácíáve of íáme ío fársí sysíemác síeroáds
courseK merhaps íhe mosí ámporíaní fándáng was íhaí paíáenís remaáned wáíhán íheár
clusíers over íáme and íhaí ICp use dád noí alíer whách clusíer subjecís were
classáfáed áníoK qhe laííer fándáng suggesís íhaí whále ICp use ámproves sympíomsI
In addáíáon ío clánácal and ánflammaíory phenoíypángI asíhma paíáenís can be
characíerázed by molecular phenoíypángK As ádeníáfácaíáon of new báomarkers and
íherapeuíác íargeís aráseI phenoíypác classáfácaíáon based on cyíokáne acíáváíy such
as qype O eá and qype O io may have pracíácal applácaíáonsK qype O eá asíhma ás
assocáaíed ío a prevalení qeO eosánophálác and ánflammaíory cyíokáne response
and has been noíed ío exhábáí a good response ío síeroáds íreaímeníK qype O io
asíhmaI on íhe oíher handI ás assocáaíed ío a more prománení neuírophálác Eor nonJ
eosánophálácF ánflammaíáonI obesáíy relaíed asíhma and compared ío qype O eá
qhe use of daály ánhaled coríácosíeroáds EICpF ás íhe currení gold síandard
maáníenance íherapy for persásíení asíhmaK eoweverI íhere are íwo pedáaírác
populaíáons for whách íhe benefáís of daály ICp remaán ío be conclusávely
esíabláshed: NJ cháldren wáíh áníermáííení wheezáng and sympíom Jfree áníervals;
and OJ preschool aged cháldren wáíh váralJánduced wheezángK qhe pracíácal allure
of lámáíáng ICp admánásíraíáon ío an “as needed” basásI as well as concerns over
íhe adverse effecís of poíeníáally unnecessary síeroáds exposure án cháldren led ío
several síudáes lookáng ánío áníermáííení ICp use án pedáaírác paíáenís wáíh
As early as íwo decades agoI clánácal íráals of áníermáííení ICp use án paíáenís wáíh
epásodes of wheezáng suggesíed poíeníáal ámprovemení án sympíoms buí were noí
conclusáveK In OMMSI íhe mbAh íráal showed an áncrease án sympíomJfree days
wáíh daály admánásíraíáon of ICp compared ío placebo án preschool age cháldren aí
hágh rásk for asíhma [
zK eoweverI a small decrease án heághí gaán án íhe
íreaímení group was noíedK curíhermoreI subsequení analyses showed íhaí
response ío daály ICp was noí unáform wáíhán íhe síudy populaíáon of íoddlers aí
hágh rásk for asíhmaK qhose fándángs reáíeraíed íhe need ío ádeníáfyI among
In OMMVI aucharme
eí al
compared íhe effácacy of hágh dose fluíácasone ETRM µg
íwáce daály for up ío NM days
K placeboF án reducáng oral coríácosíeroád ElCpF
use when admánásíered early án váral állnessesK qhey síudáed NOV cháldren aged N
ío S years preseníáng wáíh recurrení váralJánduced wheezángK qhás síudy dád show
a decrease án lCp need buí raásed concerns of decreased weághí and heághí gaán
án íhe íreaímení group [
zK aespáíe promásáng resulísI íhe auíhors dád noí
recommend íhás regámen of áníermáííení hágh dose fluíácasone wáíh váralJánduced
wheezáng before a beííer undersíandáng of poíeníáal adverse effecísK pubsequenílyI
Zeáger
eí al
compared daály lowJdose EMKR mg nághílyF and áníermáííení hághJdose
EN mg íwáce daály for T daysF nebulázed budesonáde án OTU paíáenís aged NO ío RP
moníhsK qhey found íhaíI án íhe selecí populaíáon of young cháldren wáíh frequení
wheezáng and aí leasí one exacerbaíáon requáráng oral síeroáds án íhe pasí yearI yeí
wáíh low ámpaármení and few severe exacerbaíáons Eless íhan T courses of oral
síeroáds and O admássáons án íhe preváous yearFI daály nebulázed budesonáde was
noí superáor ío áníermáííení hágh dose wáíh regards ío frequency of exacerbaíáons
zK curíhermoreI íhey found íhaí íhe cumulaíáve exposure ío budesonáde was
less án íhe áníermáííení groupK An áníeresíáng remark by íhe auíhors and based on
íhe fándángs of íhe síudy ás íhaí áníermáííení ICp should be ánáíáaíed aí íhe
begánnáng of sympíoms íhaí preváously preceded wheezáng án each cháld raíher
cánallyI a Cochrane reváew meíaJanalysás publáshed án OMNR comparáng
áníermáííení ICp wáíh placebo án íhe managemení of persásíení asíhma found íhaí
án cháldrenI áníermáííení ICp seems ío lead ío a decreased use of oral síeroádsK
lmalázumab: qhe cársí “Báologác” rsed Commercáally for íhe qreaímení of
lmalázumab ás a humanázed muráne monoclonal Igd aníábody specáfác for íhe
masí and basophál bándáng sáíes on human IgbK lmalázumab’s ámmedáaíe effecí ás
ío dramaíácally decrease cárculaíáng levels of free IgbK qhe fársí benefáí of áís use
án íhe managemení of asíhma comes from íhás subsíaníáal reducíáon án avaálable
free Igb whách when preseníI dárecíly áníerferes wáíh íhe allergác ánflammaíory
cascade descrábed earláer án íhás chapíerK In addáíáonI as a consequence of
decreased cárculaíáng free Igb; masí cellsI basopháls and dendráíác cells down
regulaíe íheár Igb specáfác cell surface recepíorsI furíher dampenáng íhe allergác
eumberí
eí al
demonsíraíed íhaí paíáenís wáíh persásíení severe allergác asíhma
whách was poorly conírolled despáíe hághJdose ICp and a iABA had a ságnáfácaní
decrease án boíh asíhma exacerbaíáons and emergency deparímení vásáís wáíh íhe
addáíáon of lmalázumab ío íheár regámen [
zK lf relevance for íhe pedáaírác
pracíáíáonerI ás ío noíeI íhaí íhe populaíáon án íhás síudy consásíed of paíáenís wáíh
unconírolled persásíení severe allergác asíhma whose age ranged from NO ío TR
years and had serum Igb levels whách ranged from PM ío TMM IrLmiK qhe safeíy
and effácacy of lmalázumab án pedáaírác paíáenís age S ío NO years was laíer
demonsíraíed by ianáer
eí al
án OMMVK In íheár síudyI íhey chose a populaíáon of
pedáaírác paíáenís who despáíe opíámal avaálable íherapy had poorly conírolled
persásíení severe allergác asíhma and whose serum Igb levels ranged from PM ío
NPMM IrLmi Emean 4SVKT IrLmiFK qhey concluded íhaí lmalázumab was boíh
pánce íhenI many síudáes án boíh íhe rnáíed píaíes and oíher couníráes have
corroboraíed íhe safeíy and effácacy of lmalázumab án íhe pedáaírác populaíáon of
severe allergác asíhma paíáenís who are� "e S years of age [
I
zK A recení
sysíemaíác reváew of placebo conírolled síudáes of lmalázumab án cháldren
confárms íhe benefáís and accepíable safeíy profále of lmalázumab as addJon
As íhe use of lmalázumab án íhe severe allergác pedáaírác asíhma populaíáon
án nonJaíopác asíhma íhrough áís effecí on local ánflammaíáon [
zK If and how íhás
wáll play a role án íhe managemení of íhe pedáaírác paíáenís wáíh nonJaíopác
asíhmaI ás noí yeí clearK qhe subsíaníáal cosí of íreaímení may also ámpede
expandáng áís use uníál furíher research demonsíraíes clear benefáís ouísáde íhe
As preváously descrábedI IiJR plays a major role án íhe eosánophálác ánflammaíory
cascade seen án asíhmaK Ií ás necessary for producíáonI maíuraíáon and survával of
eosánophálsK As suchI IiJR has been íhe íargeí of many recení asíhma íherapáesK
Mepolázumab ás a humanázed monoclonal aníábody wáíh hágh affánáíy ío IiJR íhaí
ánhábáís áís bándáng ío íhe IiJR recepíor on íhe surface of eosánophálsK Ináíáal
clánácal íráals of Mepolázumab án asíhmaíács faáled ío show ságnáfácaní clánácal
benefáí despáíe a clear decrease án blood and spuíum eosánopháls [
zK qhereforeI
furíher clánácal research was developed ío evaluaíe áf specáfác asíhma populaíáons
kaár
eí al
compared Mepolázumab wáíh placebo án adulís wáíh persásíení spuíum
eosánopháláa despáíe hágh dose ICp and oral síeroádsK qhey found íhaí án íhás
populaíáonI Mepolázumab helped decrease síeroád use wáíhouí clánácal
deíeráoraíáon [
zK qhe auíhors concluded íhaí án order ío furíher síudy íhe
poíeníáal benefáís of Mepolázumab áí ás paramouní ío focus on asíhma paíáenís
wáíh ságnáfácaní aárway eosánopháláa: a conclusáon well án láne wáíh
Mepolázumab’s mechanásm of acíáonK In íhe same yearI a larger síudy of adulís
wáíh refracíory eosánophálác asíhma showed íhaí Mepolázumab led ío ságnáfácaníly
fewer severe exacerbaíáons compared ío placebo despáíe no ámprovemení án day
ío day sympíoms [
zK qhese síudáes shaped íhe paíh for Mepolázumab ío be used
as a síeroád sparáng agení and as preveníaíáve íreaímení for severe asíhma
exacerbaíáons án paíáenís wáíh aárway eosánopháláaK
qwo large clánácal íráals were publáshed defánáng íhe benefáís of Mepolázumab add
on íherapy án severe asíhmaK In íhe MbkpA clánácal íráalI lríega eí al
demonsíraíed íhaíI use of eáíher áníravenous or subcuíaneous formulaíáons of
Mepolázumab resulíed án a reducíáon of asíhma exacerbaíáons án a group of RTS
severe eosánophálác asíhma paíáenís over NO years of ageK In addáíáonI
ámprovemení án qualáíy of láfe and quesíáonnaáre defáned asíhma conírol were
noíed when compared wáíh placebo [
zK qhe pIoIrp clánácal íráal by Bel eí al
found íhaí addáíáon of Mepolázumab íherapy ío a group of NPR paíáenís over NS
years of age wáíh severe síeroáds dependení eosánophálác asíhma led ío successful
decrease án sysíemác síeroáds doses compared ío placebo [
zK In addáíáonI a
recení Cochrane reváew publáshed án OMNR concluded íhaí alíhough íhere ás
evádence favoráng íhe use of Mepolázumab án reducáng exacerbaíáons of severe
eosánophálác asíhmaíácsI furíher research ás necessary ío more dáscreíely ádeníáfy
In summaryI íhe avaálabáláíy of Mepolázumab furíher expands íhe arsenal of
íreaímení opíáons avaálable for severe asíhmaKI Alíhough íhere ás growáng
evádence íhaí Mepolázumab íherapy decreases frequency of severe exacerbaíáons
and síeroáds requáremenís án severe eosánophálác asíhmaíácsI íhere ás no clear
benefáí on daály sympíomsK curíher research ás needed ío shed lághí on a number
of yeí unanswered quesíáons regardáng íhás newly caA approved íherapyK qhese
ánclude íhe ádeníáfácaíáon of báomarkers íhaí may besí predácí response ío íherapyI
poánís ío be used for íherapy as well as effecíáve and safe age range án pedáaírác
qhe aevelopáng oole of sáíamán a aefácáency and pupplemeníaíáon án
In íhe pasí decadeI a number of síudáes aámed ío defáne íhe relaíáonsháp beíween
váíamán a defácáency and asíhmaK qhere ás áncreasáng evádence íhaí sáíamán a has
a role án íhe adapíáve and ánnaíe ámmune responseI whách may resulí án
modulaíáon of boíh asíhma severáíy and íhe response ío respáraíory ánfecíáonsK
Increased maíernal váíamán a áníake duráng pregnancy has been shown ío offer
some degree of proíecíáon agaánsí íhe developmení of wheezáng án ánfanísK
bpádemáologác síudáes suggesí íhaí lower váíamán a levels are presení án pedáaírác
paíáenís wáíh asíhmaK In addáíáonI íhere ás evádence íhaí íhe response ío síeroáds án
sáíamán a recepíors are found on a number of cells ánvolved án íhe ámmune
response [
zK qhese recepíors form parí of íhe síeroád hormone nuclear recepíor
famály and may íhus poíeníáaíe íhe response ío glucocoríácosíeroád íherapy [
sáíamán a appears ío ací on q regulaíory lymphocyíes ánvolved án cyíokáne
regulaíáon [
J
z áncludáng íhe promoíáon of IiJNMI an aníáJánflammaíory
cyíokáneK qhe exací role of váíamán a án asíhma paíhophysáologyI howeverI ás
Brehm
eí al
publáshed a landmark síudy of SNS cháldren wáíh asíhma án Cosía
oáca án whách íhey found íhaí sáíamán a levels consádered ánsuffácáení or
defácáení were prevalení EPK4B and O4KSBI respecíávelyF among cháldren wáíh
asíhmaK curíhermoreI lower levels were assocáaíed wáíh elevaíed Igb and
eosánopháls as well as an áncreased frequency of hospáíalázaíáons [
zK qhe
followáng yearI íhey agaán publáshed an assocáaíáon beíween lower váíamán levels
and íhe frequency of severe asíhma exacerbaíáons án NMO4 máld ío moderaíe
asíhmaíác cháldren enrolled án íhe long síandáng mulíáceníer Cháldhood Asíhma
Managemení mrogram síudy [
zK qhey dád noíI howeverI fánd án íhás larger and
more eíhnácally dáverse cohoríI íhe preváously descrábed assocáaíáon of low
váíamán a levels wáíh markers of aíopyK mubláshed evádence also suggesís lower
váíamán a levels án cháldren wáíh severe íherapy resásíaní asíhmaK In íhás groupI
lower levels were assocáaíed wáíh reduced asíhma conírol and áncreased aárway
smooíh muscle mass suggesíáng a poíeníáal relaíáonsháp wáíh aárway remodeláng
Ií remaáns unclear whách paíáenís would benefáí from váíamán a supplemeníaíáonI
how much ío supplemení and wheíher íámáng of supplemenís E
íreaímení án
younger paíáenísF may lead ío specáfác long íerm benefáís án asíhma conírolK A
recení meíaJanalysás found íhaí íhere ás low qualáíy evádence confármáng a
reducíáon of asíhma exacerbaíáons án cháldren íreaíed wáíh váíamán a [
eoweverI íhere ás lack of consensus as ío íhe váíamán a level requáred for opíámal
ámmune funcíáonK bxperís consáder levels of ORJhydroxy váíamán aI íhe major
cárculaíáng form of váíamán aI below PM ngLmi as ánsuffácáení makáng íhás a
Macroládes as AníáJInflammaíory and íhe aáffereníáal oesponse ío
Macroládes have boíh aníámácrobáal and aníáJánflammaíory effecísI whách have
made íhem íreaímení opíáons for several chronác ánflammaíory respáraíory
állnessesK qhere ás evádence for íhe benefáí of azáíhromycán íherapy as a longJíerm
adjuncí ío íherapy án cysíác fábrosás and broncháecíasásK eoweverI íhe poíeníáal
iámáíed anámal and human daía suggesís íhaí íhere may be some benefáí án
macroláde íherapy án asíhmaK In a muráne model of chronác asíhmaI azáíhromycán
reduced smooíh aárway remodelángI lákely íhrough a neuírophálJrelaíed aníáJ
ánflammaíory effecí [
zK A randomázed placebo conírolled íráal of NMV paíáenís
wáíh severe asíhma looked aí íhe effecís of azáíhromycán as an adjuncí ío síandard
íherapy [
zK Alíhough íhe síudy dád noí fánd benefáí án íhe use of azáíhromycán
addJon íherapy for íhe síudy populaíáon as a wholeI a reducíáon án exacerbaíáons
and respáraíory ánfecíáons was noíed án a subgroup analysás of paíáenís íreaíed
wáíh azáíhromycán who had nonJeosánophálác severe asíhmaK qhese resulís furíher
supporí a phenoíypác approach ío asíhma íherapy [
zK Macroládes wáíh no
aníámácrobáal effecís are beáng síudáed as aníáJánflammaíory adjuncísI buí íhás
In summaryI asíhma ás a heíerogeneous dáseaseK Ií ás íhe mosí common chronác
dásease án cháldrenK Clánácal sympíoms of asíhma resulí from aárflow lámáíaíáon
due ío acuíe bronchoconsírácíáon án íhe early phase followed by ánflammaíáonI
áncreased mucus secreíáon and aárway hyperJresponsávenessK In some paíáenísI íhe
resulí ás aárway remodeláng wáíh permanení hásíologác changes and decreased lung
funcíáonK kew ánsághís ánío íhe varáable phenoíypes of íhás dásease have led ío a
more íargeíed approach ío íhe dáagnosás and managemení of asíhmaK A new
generaíáon of íherapeuíács ás emergáng wáíh báologácal agenís such as omalázumab
beáng áncorporaíed as parí of íhe síandard of care án pedáaírác asíhmaK eoweverI
furíher research ás síáll requáred as we explore newer báologácal agenís and uíáláze
kaíáonal Asíhma bducaíáon and mreveníáon mrogramK bxperí manel oeporí P EbmoJPF: duádelánes for
íhe aáagnosás and Managemení of AsíhmaJpummary oeporí OMMTK g Allergy Clán Immunol OMMT;
[Ozdlobal Ináíáaíáve for AsíhmaK dlobal píraíegy for Asíhma Managemení and mreveníáon OMNRK
Chung hcI tenzel pbI Brozek giI
eí alK
Iníernaíáonal bopLAqp guádelánes on defánáíáonI evaluaíáon
[4zBusse ttI iemanske oc grK AsíhmaK k bngl g Med OMMN; P44ERF: PRMJSOK
ooorda ogI Mezeá dI Básgaard eI Maden CK oesponse of preschool cháldren wáíh asíhma sympíoms ío
Bacharáer iBI duálber qtI Zeáger opI
eí alK
maíáení characíerásíács assocáaíed wáíh ámproved
ouícomes wáíh use of an ánhaled coríácosíeroád án preschool cháldren aí rásk for asíhmaK g Allergy Clán
Malka gI Mauger aqI Covar oI
eí alK
bczema and race as combáned deíermánanís for dáffereníáal
cáízpaíráck AMI BaenaJCagnaná CbI Bacharáer iBK pevere asíhma án cháldhood: recení advances án
eowrylak gAI cuhlbrágge AiI pírunk oCI
eí alK
Classáfácaíáon of cháldhood asíhma phenoíypes and
longJíerm clánácal responses ío ánhaled aníáJánflammaíory medácaíáonsK g Allergy Clán Immunol OMN4;
dauíháer MI oay AI tenzel pbK bvolváng Concepís of AsíhmaK Am g oespár Cráí Care Med OMNR;
eorner CCI Bacharáer iBK Managemení approaches ío áníermáííení wheezáng án young cháldrenK Curr
aucharme cMI iemáre CI koya cgI
eí alK
mreempíáve use of hághJdose fluíácasone for várusJánduced
Zeáger opI Mauger aI Bacharáer iBI
eí alK
CAob keíwork of íhe kaíáonal eearíI iungI and Blood
InsíáíuíeK aaály or áníermáííení budesonáde án preschool cháldren wáíh recurrení wheezángK k bngl g
Chong gI earan CI Chauhan BcI Asher IK Iníermáííení ánhaled coríácosíeroád íherapy versus placebo for
aomángo CK lmalázumab for severe asíhma: effácacy beyond íhe aíopác paíáení? arugs OMN4; T4ERF:
eumberí MI Beasley oI Ayres gI
eí alK
Benefáís of omalázumab as addJon íherapy án paíáenís wáíh
severe persásíení asíhma who are ánadequaíely conírolled despáíe besí avaálable íherapy EdIkA OMMO
ianáer BI Brádges qI hulus MI qaylor AcI Berhane II sádaurre CcK lmalázumab for íhe íreaímení of
exacerbaíáons án cháldren wáíh ánadequaíely conírolled allergác EIgbJmedáaíedF asíhmaK g Allergy Clán
ldajáma eI bbásawa MI kagakura qI
eí alK
lmalázumab án gapanese cháldren wáíh severe allergác
aescháldre AI Margueí CI palleron gI
eí alK
AddJon omalázumab án cháldren wáíh severe allergác
oodrágo dgI keffen eK pysíemaíác reváew on íhe use of omalázumab for íhe íreaímení of asíhmaíác
Menzella cI iusuardá MI daleone CI qaddeá pI Zucchá iK mrofále of aníáJIiJR mAb mepolázumab án
íhe íreaímení of severe refracíory asíhma and hypereosánophálác dáseasesK g Asíhma Allergy OMNR; U:
kaár mI mázzácháná MMI hjarsgaard MI
eí alK
Mepolázumab for prednásoneJdependení asíhma wáíh
ealdar mI Brághíláng CbI eargadon BI
eí alK
Mepolázumab and exacerbaíáons of refracíory eosánophálác
lríega edI iáu MCI mavord IaI
eí alK
MbkpA InvesíágaíorsK Mepolázumab íreaímení án paíáenís wáíh
Bel beI tenzel pbI qhompson mgI
eí alK
pIoIrp InvesíágaíorsK lral glucocoríácoádJsparáng effecí of
mowell CI Málan pgI awan hI Bax iI talíers kK Mepolázumab versus placebo for asíhmaK Cochrane
maííerson McI Borásh iI hennedy giK qhe pasíI preseníI and fuíure of monoclonal aníábodáes ío IiJR
mrovvedáná aMI qsoukas CaI aefíos igI Manolagas pCK NIORJdáhydroxyváíamán aP recepíors án
uysírakás bI husumakar pI Boswell pI
eí alK
oeversáng íhe defecíáve ánducíáon of IiJNMJsecreíáng
dregorá pI Casoraíá MI Amuchasíeguá pI pmároldo pI aavallá AMI Adoráná iK oegulaíory q cells
ánduced by N alphaIORJdáhydroxyváíamán aP and mycophenolaíe mofeíál íreaímení medáaíe
íransplaníaíáon íoleranceK g Immunol OMMN; NSTE4F: NV4RJRPK
dregorá pI dáarraíana kI pmároldo pI rskokovác MI Adoráná iK A NalphaIORJdáhydroxyváíamán aEPF
analog enhances regulaíory qJcells and arresís auíoámmune dáabeíes án kla máceK aáabeíes OMMO;
Brehm gMI Celedón gCI poíoJnuáros MbI
eí alK
perum váíamán a levels and markers of severáíy of
Brehm gMI pchuemann BI cuhlbrágge AiI
eí alK
perum váíamán a levels and severe asíhma
exacerbaíáons án íhe Cháldhood Asíhma Managemení mrogram síudyK g Allergy Clán Immunol OMNM;
dupía AI pjoukes AI oáchards aI
eí alK
oelaíáonsháp beíween serum váíamán aI dásease severáíyI and
oáverán BaI Maguáre giI iá mI sáíamán aK sáíamán a pupplemeníaíáon for Cháldhood Asíhma: A
oance hK qhe emergáng role of sáíamán a án asíhma managemeníK g Am Assoc kurse mrací OMN4;
Crosbáe mAI toodhead MAK iongJíerm macroláde íherapy án chronác ánflammaíory aárway dáseasesK
hang gvI go MoI hang eeI
eí alK
iongJíerm azáíhromycán ameláoraíes noí only aárway ánflammaíáon
Brusselle ddI sandersíáchele CI gordens mI
eí alK
Azáíhromycán for preveníáon of exacerbaíáons án
severe asíhma EAZIpApqF: a mulíáceníre randomásed doubleJblánd placeboJconírolled íráalK qhorax
Cameron bgI Mcpharry CI Chaudhurá oI carrow pI qhomson kCK iongJíerm macroláde íreaímení of
chronác ánflammaíory aárway dáseases: rásksI benefáís and fuíure developmenísK Clán bxp Allergy
aeparímení of medáaírácsI lchsner for Cháldren and qhe rnáversáíy of nueensland pchool of
Absírací:
Broncháoláíás ás íhe mosí common cause of hospáíalázaíáon án ánfanís and
cháldren less íhan O years of ageK maíáenís íypácally presení wáíh ságns of an upper
respáraíory írací ánfecíáon íhaí íhen progress ío sympíoms consásíení wáíh a lower
labs and chesí radáography are noí rouíánely necessary or recommendedK qreaímení ás
largely supporíáve as many of íhe íherapáes íhaí are effecíáve án oíher respáraíory
dáseases are áneffecíáve án íhe íreaímení of broncháoláíásK bmphasás should íherefore be
on preveníáon and reducáng íransmássáon of íhe dáseaseK Areas of focus for íhe
preveníáon of broncháoláíás ánclude admánásíraíáon of palávázumab prophylaxás án
selecíed ánfanís and cháldrenI hand hygáeneI elámánaíáon of íobacco smoke exposureI
heywords:
BreasífeedángI BroncháoláíásI BronchodálaíorsI CháldrenI
CoríácosíeroádsI eand hygáeneI eyperíonác saláneI InfanísI lxygenI malávázumabI
Broncháoláíás ás a clánácally dáagnosed condáíáon án paíáenís less íhan O years of
age íhaí usually begáns wáíh sympíoms of an upper respáraíory írací ánfecíáonK
Ináíáal preseníaíáon wáíh coryza and lowJgrade fever ás commonK qypácally íhás
progresses ío a lower respáraíory írací ánfecíáon manáfesíáng as coughI íachypneaI
reíracíáonsI nasal flarángI wheezesI andLor cracklesK qhe paíhogenesás of
broncháoláíás áncludes acuíe ánflammaíáonI edemaI slougháng and necrosás of
epáíheláal cells of íhe small bronchá and broncháolesI áncreased mucus producíáonI
bronchospasmI obsírucíáon of small aárwaysI and aíelecíasás [
zK Mulíáple váruses
have been ásolaíed as íhe cause of broncháoláíásK oespáraíory syncyíáal várus EopsF
ás by far íhe mosí common cause of broncháoláíásI accouníáng for RMBJUMB of
Correspondáng auíhor aerek iK mepáak
: aeparímení of medáaírácsI lchsner for Cháldren and qhe rnáversáíy of
nueensland pchool of MedácáneI lchsner Clánácal pchoolI kew lrleansI iouásáanaI rpA; qel: RM4JPVMJMO4R; bmaál:
of láfe [
zK qhe hághesí áncádence of ops broncháoláíás occurs án koríh Ameráca
beíween aecember and Aprál [
zK líher váral eíáologáes of broncháoláíás ánclude
rhánovárusI paraánfluenza várus íype PI human meíapneumovárusI ánfluenzaI
adenovárusI coronavárusI and eníerovárus [
zK In koríh AmerácaI broncháoláíás ás
íhe mosí common cause of hospáíalázaíáon án ánfanís less íhan NO moníhs of ageI
accouníáng for approxámaíely NMMIMMM admássáons per year aí an esíámaíed cosí of
auráng íhe fársí few days of állnessI mosí ánfanís presení wáíh a NJ ío PJday hásíory
of máld upper respáraíory írací ánfecíáon sympíoms such as conjuncíáváíásI oíáíás
medáaI nasal congesíáonI rhánáíásI pharyngáíásI and fever [
zK aecreased oral áníake
may also be preseníK rp ío 4MB of paíáenís íhen progress ío a lower respáraíory
írací ánfecíáon wáíh íachypneaI reíracíáonsI wheezángI andLor crackles on days OJP
of állness [
zK pympíoms usually peak on days RJT and íhen gradually resolveK
qhe mean duraíáon of állness ás NR days wáíh resoluíáon of sympíoms wáíhán PJ4
ko clear cráíeráa exásí for deíermánáng whách ánfanís should be admáííed ío íhe
hospáíalK denerallyI hospáíalázaíáon ás consádered for ánfanís who presení wáíh
leíhargyI dehydraíáonI apneaI or moderaíe ío severe respáraíory dásíressI
manáfesíed as nasal flarángI reíracíáonsI or a respáraíory raíe greaíer íhan SMJTM
breaíhs per mánuíe [
I
zK oásk facíors for more severe dásease preseníaíáon
requáráng admássáon ánclude premaíuráíyI age less íhan NO weeksI chronác lung
dáseaseI congenáíal and anaíomácal defecís of íhe aárwayI congenáíal hearí dáseaseI
ámmunodefácáencyI and neuromuscular dásorders [
zK qhe average lengíh of síay
thále broncháoláíás has a hágh degree of morbádáíyI áí ás assocáaíed wáíh a low
degree of moríaláíyK Moríaláíy raíes are esíámaíed ío be around NB [
J
eoweverI moríaláíy raíes can áncrease ío PKRB án paíáenís wáíh broncháoláíás when
addáíáonal cardáac or chronác lung condáíáons are presení [
zK qhe rásk of apnea ás
áncreased án ánfanís wáíh ops broncháoláíásI wáíh raíes rangáng from NKOB ío as
hágh as OPKUB [
I
zK qhe rásk for áníubaíáon án broncháoláíásI eáíher secondary
ío dásease progressáon or due ío apneaI ás approxámaíely RB [
zK Acuíe oíáíás
medáa may be presení án RMBJSMB of paíáenís wáíh broncháoláíás [
I
pecondary bacíeráal ánfecíáonI wáíh íhe excepíáon of acuíe oíáíás medáaI ás
uncommon án ánfanís wáíh broncháoláíás [
zK Cháldren wáíh broncháoláíás have
been reporíed ío have ánappropráaíe secreíáon of aníádáureíác hormoneI and close
Mosí ánfanís wáíh broncháoláíás recover wáíh no longJíerm sequelaeK eoweverI
longJíerm complácaíáons may ánclude developmení of broncháoláíás obláíeransI
allergác sensáíázaíáonI and recurrení wheezáng [
zK pome síudáes have shown an
assocáaíáon beíween broncháoláíás án ánfancy and subsequení developmení of
aíopác állnesses such as asíhma laíer án láfe [
zK eoweverI íhe connecíáon beíween
broncháoláíás and asíhma ás coníroversáal as oíher síudáes have noí supporíed a
qhe dáagnosás of broncháoláíás ás esseníáally a clánácal oneK qhe íypácal hásíory has
been dáscussed earláerK mhysácal examánaíáon fándángs can vary beíween paíáenís
and can also flucíuaíe over íáme án íhe same paíáení; seráal assessmení of an ánfaní
wáíh broncháoláíás ás ofíen necessary ío monáíor íhe progressáon and resoluíáon of
íhe dáseaseK maíáenís ofíen presení wáíh excessáve nasal secreíáons leadáng ío upper
aárway obsírucíáonI manáfesíáng as íransmáííed ánspáraíory and expáraíory
wheezángK kasal obsírucíáon from secreíáons may lámáí íhe abáláíy of íhe ánfaní ío
íake adequaíe nuíráíáonI ulíámaíely leadáng ío dehydraíáonK tork of breaíháng ás
usually áncreased as shown by nasal flarángI áníercosíal reíracíáonsI subcosíal
reíracíáonsI and use of accessory musclesK Ausculíaíáon of íhe chesí ofíen reveals
dáffuse bálaíeral crackles and wheezesI as well as a prolonged expáraíory phase of
respáraíáonK eyperánflaíáon of íhe lungs from aár írappáng may allow íhe láver and
qhe maán goal for íhe hásíory and physácal examánaíáon ás ío deíermáne whách
ánfanís who presení wáíh wheezáng and oíher respáraíory sympíoms lákely have
váral broncháoláíás versus anoíher dásorder [
zK In addáíáon ío broncháoláíásI íhe
dáffereníáal dáagnosás of ánfanís less íhan O years of age who presení wáíh
wheezáng andLor oíher lower respáraíory írací sympíoms áncludes adenoádal
hyperírophyI reíropharyngeal abscessI croupI asíhmaI recurrení váralJánduced
wheezángI bacíeráal pneumonáaI cysíác fábrosásI malacáa of íhe aárwaysI foreágn
body aspáraíáonI aspáraíáon pneumonáaI congenáíal hearí dáseaseI congesíáve hearí
In OMN4I íhe Amerácan Academy of medáaírács EAAmF updaíed íheár guádelánes for
dáagnosásI managemeníI and preveníáon of broncháoláíás [
zK qhe guádelánes
adváse clánácáans ío dáagnose broncháoláíás and assess dásease severáíy on íhe basás
of hásíory and physácal examánaíáon aloneK kumerous scoráng sysíems have been
developed ío aííempí ío classáfy respáraíory dásíress and dásease severáíyK ko
sysíem has been rouíánely adopíed due ío lack of predácíáve valádáíy [
lnce a clánácáan has dáagnosed broncháoláíás based on hásíory and physácal
examánaíáonI chesí radáographs and laboraíory síudáes should noí be rouíánely
obíaánedK A reváew of íhe currení evádence dád noí supporí íhe use of chesí
radáographs án cháldren wáíh broncháoláíás as íhey do noí correlaíe wáíh dásease
severáíy [
zK Chesí ámagáng án broncháoláíás ofíen reveals hyperánflaíáon wáíh
flaííened dáaphragmsI aárway wall íháckenángI perábroncháal ánfálíraíesI and paíchy
consoládaíáonI resulíáng án áncreased use of aníábáoíács and áncreased lengíh of síay
zK qhe currení AAm guádelánes adváse clánácáans ío lámáí chesí radáography ío
paíáenís who may need admássáon ío íhe áníensáve care unáí or who presení wáíh
ságns and sympíoms of oíher aárway compromáse or complácaíáon such as íhe
pensáíáve polymerase chaán reacíáon assays are now readály avaálable for a varáeíy
of váral agenísK pome síudáes have shown íhaí ádeníáfácaíáon of íhe causaíáve váral
agení duráng emergency room evaluaíáon or án hospáíalázed paíáenís can decrease
íhe use of aníábáoíác íherapy and assásí án íhe uíálázaíáon of aníáánfluenza íherapy
J
zK eoweverI íhe currení AAm guádelánes recommend rouíáne várologác
íesíáng only án ánfanís hospáíalázed for broncháoláíás who have been receáváng
moníhly prophylaxás wáíh palávázumabK In íhás caseI íesíáng should be performed
ío see áf ops ás íhe eíáologác ageníK If íesíáng for ops ás posáíáveI áí ás
recommended íhaí moníhly palávázumab prophylaxás be dásconíánued based on íhe
Boíh íhe AAm and íhe pcoííásh Iníercollegáaíe duádelánes keíwork EpIdkF have
ássued comprehensáve evádence based guádelánes for íhe dáagnosásI íreaímeníI and
preveníáon of broncháoláíás [
I
zK qhe pIdk guádelánes were lasí updaíed án
OMMS; íhe AAm guádelánes were updaíed án OMN4K qhe hallmark of íreaímení for
broncháoláíás remaáns supporíáve careK Many ánfanís wáíh only máld sympíoms can
be íreaíed aí homeK Infanís wáíh more severe dáseaseI approxámaíely OBJPB of
ánfanísI are ofíen hospáíalázedK A varáeíy of íreaímení modaláíáes for broncháoláíás
have been proposed and aííempíed over íhe yearsK qhe followáng secíáons dáscuss
Approxámaíely PMB of ánfanís admáííed for broncháoláíás wáll requáre fluád
replacemení íherapy [
zK Infanís wáíh feedáng dáffáculíy secondary ío respáraíory
dásíress may receáve replacemení
áníravenous access or a nasogasírác íube;
íhere ás no clear evádence íhaí one rouíe ás advaníageous over íhe oíherK Infanís
may be aí rásk for fluád reíeníáon secondary ío áncreased producíáon of aníádáureíác
hormone án broncháoláíás [
I
I
zK If hypoíonác fluáds are used for fluád
replacemení or maáníenance needsI ánfanís may be aí rásk for hyponaíremáa;
íherefore ásoíonác fluáds may be saferK In ánfanís wáíh málder sympíoms who are
able ío breasífeedI breasífeedáng should be encouraged as breasí málk has been
shown ío have neuíralázáng acíáváíy agaánsí ops and coníaáns ops
ámmunoglobuláns A and d and áníerferonJα [
I
Bronchodálaíors have ofíen been used án íhe managemení of broncháoláíásK qhe
OMMS AAm guádelánes recommended a íráal of albuíerol for paíáenís wáíh
broncháoláíásK eoweverI as of íhe OMN4 updaíeI íhe AAm now adváses agaánsí íhe
use of albuíerol án ánfanís and cháldren wáíh broncháoláíásK Bronchodálaíors may
ámprove clánácal sympíom scores buí have noí been shown ío affecí dásease
resoluíáonI need for hospáíalázaíáonI or lengíh of síayK qhe adverse effecísI such as
íachycardáa and íremorsI as well as íhe cosí of íhe medácaíáonI ouíweágh íhe
poíeníáal benefáísK In mosí reváewed síudáesI cháldren wáíh severe dásease and
respáraíory faálure were excluded án analyzáng íhe effecí of bronchodálaíors and as
such íhe recommendaíáon agaánsí íhe use of albuíerol may noí apply ío íhese
Anoíher bronchodálaíorI nebulázed epánephráneI ás commonly used án íhe
íreaímení of broncháoláíásK In íwo síudáes comparáng nebulázed epánephráne ío
placebo or albuíerol án hospáíalázed paíáenísI íhere was no ámprovemení án lengíh
of síay or oíher ánpaíáení ouícomes [
I
zK qhereforeI íhe AAm guádelánes do noí
recommend íhe use of epánephráne án íhe hospáíal seííángK qhe Canadáan
Broncháoláíás bpánephráne píeroád qráal ánvolved UMM paíáenís wáíh broncháoláíás
seen án íhe emergency deparímení and compared hospáíalázaíáon raíes over a TJ
day peráodK maíáenís receáved one of íhe followáng: nebulázed epánephráne plus
oral dexameíhasoneI nebulázed epánephráne plus oral placeboI nebulázed placebo
plus oral dexameíhasoneI or nebulázed placebo plus oral placeboK maíáenís who
receáved nebulázed epánephráne and oral dexameíhasone had a lower lákeláhood of
admássáon by day T compared ío íhose who receáved íhe double placebo; howeverI
íhás effecí was noí síaíásíácally ságnáfácaní afíer adjusíáng for mulíáple comparásons
zK qhe currení evádence íherefore does noí supporí íhe use of nebulázed
epánephráne án íhe ouípaíáení seííángI alíhough furíher síudáes are needed [
dáven íhe role of mucus pluggáng án broncháoláíásI íreaímenís aámed aí íhánnáng
íhe aárway secreíáons have been aííempíed án broncháoláíásK eyperíonác saláne ás
one such áníerveníáonK bvádence suggesís íhaí nebulázed hyperíonác saláne
ámproves mucocáláary clearance án boíh normal and dáseased lungs by causáng
osmoíác movemení of waíer ánío íhe aárwaysI íhánnáng aárway mucus [
J
Currení evádence ándácaíes íhaí íhe use of nebulázed PB saláne ás effecíáve án
ámprováng sympíoms of máld and moderaíe broncháoláíás afíer O4 hours of useK Ií
has also been shown ío reduce hospáíal lengíh of síay when íhe duraíáon of síay
exceeds P daysK Ií does noí appear ío be effecíáve án reducáng hospáíalázaíáons
when used án íhe emergency deparímeníK qhe AAm does noí recommend íhe use
of nebulázed hyperíonác saláne án íhe emergency deparímení buí gáves a weak
kasal sucíáonáng ás a common íherapy án broncháoláíás gáven íhe copáous íháck
secreíáons and íhe ámpací of nasal obsírucíáon on feedángK qhere ás láííle evádence
ío supporí frequení deep sucíáonáng wáíh a nasopharyngeal caíheíerK aeep
sucíáonáng
a caíheíer can be íraumaíácI produce edemaI and resulí án furíher
nasal obsírucíáon [
zK Mechanácal aspáraíáon
nasal bulb sucíáon or nasal
aspáraíorI ofíen án combánaíáon wáíh saláne nose dropsI ás commonly usedK
Coríácosíeroáds can ságnáfácaníly ámprove sympíoms án respáraíory dáseases such
as asíhma and croupK eoweverI evádence shows íhaí síeroád use án paíáenís wáíh
broncháoláíás does noí ságnáfácaníly reduce admássáons or reduce lengíh of síay for
ánpaíáenís [
zK As preváously dáscussedI íhe Canadáan bpánephráne píeroád qráal
showed a reducíáon án hospáíalázaíáonI buí íhás reducíáon án lengíh of síay dád noí
reach síaíásíácal ságnáfácance once adjusíed for mulíáple comparásonsK curíher
síudáes are needed before a recommendaíáon for rouíáne use of dexameíhasone
and nebulázed epánephráne can be provádedK Coríácosíeroád íherapy may also
prolong váral sheddáng án paíáenís wáíh broncháoláíás [
zK As of íheár mosí recení
updaíeI íhe AAm adváses clánácáans noí ío admánásíer sysíemác coríácosíeroáds ío
ánfanís wáíh broncháoláíásK qhere ás curreníly no evádence ío recommend íhe use of
qhe need for supplemeníal oxygen based on pulse oxámeíry ás one of íhe major
deíermánanís án íhe hospáíalázaíáon of ánfaní wáíh broncháoláíás; unforíunaíelyI íhe
accuracy of pulse oxámeíryI especáally án íhe range of TSBJVMBI ás poor [
qransáení desaíuraíáons can be a normal fándáng án healíhy ánfanísK lxygen
saíuraíáon ás ofíen a prámary measure íhaí deíermánes lengíh of síay án
broncháoláíás [
I
zK qweníyJfáve percení of paíáenís have an unnecessarály
prolonged hospáíalázaíáon due ío íhe perceáved need for oxygen supplemeníaíáon
zK qhe AAm guádelánes síaíe íhaí clánácáans may choose noí ío use supplemeníal
oxygen for saíuraíáons exceedáng VMB and may choose noí ío use coníánuous
pulse oxámeíryK cor paíáenís requáráng supplemeníal oxygenI delávery
humádáfáedI hághJflow nasal cannula EeckCF ás becománg more wádespreadK
eoweverI íhe absence of íráals evaluaíáng íhe effácacy of eckC precluded any
specáfác recommendaíáon from íhe AAm án íhe OMN4 guádelánesK Coníánuous
posáíáve aárway pressure ECmAmF can be used as a means ío avoád áníubaíáon án
ánfanís wáíh respáraíory faálureK pysíemaíác reváews of CmAm use án broncháoláíás
have been ánconclusáveI and íhere are no specáfác recommendaíáons on áís useK
eeláox íherapy has been used án íhe íreaímení of asíhma exacerbaíáons and has
also been aííempíed án broncháoláíás; curreníly íhere ás noí enough evádence ío
thále chesí physáoíherapy can be a useful íool ío aád án íhe clearance of
secreíáons án a varáeíy of pulmonary and neuromuscular dásordersI currení
láíeraíure has shown no benefáí of áís use án paíáenís hospáíalázed for broncháoláíásI
and íhusI íhe AAm does noí recommend áíK eoweverI án paíáenís admáííed for
broncháoláíás who also have comorbádáíáes íhaí ámpaár clearance of secreíáonsI
ieukoíráenes have been íhoughí ío play a role án aárway ánflammaíáon án
broncháoláíásI and íhe use of leukoíráene modáfáers has been síudáed án íhás
condáíáonK A OMNR meíaJanalysás found no effecí on duraíáon of hospáíalázaíáon or
clánácal síaíus án cháldren wáíh broncháoláíás [
zK qhere ás curreníly ánsuffácáení
dáven íhe young age aí whách paíáenís presení wáíh broncháoláíásI aníábáoíács are
ofíen prescrábed due ío concern for undeíecíed bacíeráal ánfecíáonK cebrále ánfanís
wáíhouí a known source for íheár fever may have a rásk of bacíeremáa as hágh as
TB; paíáenís wáíh a dásíáncí váral syndrome such as broncháoláíás have a less íhan
NB rásk of bacíeráal ánfecíáon of íhe cerebrospánal fluád or blood [
zK In addáíáonI
áí ás unusual for ánfanís wáíh broncháoláíás ío have a bacíeráal pneumonáa [
Currení AAm guádelánes adváse íhaí clánácáans should noí admánásíer aníábacíeráal
medácaíáons ío ánfanís and cháldren wáíh a dáagnosás of broncháoláíás unless íhere
oábavárán ás an aníáváral medácaíáon lácensed for use for ops broncháoláíásK Iís use
may decrease íhe number of days of hospáíalázaíáon and mechanácal veníálaíáonI
buí áí dád noí reduce íhe progressáon of respáraíory dásease or moríaláíy [
Mulíáple síraíegáes exásí ío reduce íhe rásk and severáíy of broncháoláíásK qhese
ánclude admánásíraíáon of palávázumab prophylaxás ío appropráaíe ánfanís and
cháldrenI proper hand hygáeneI elámánaíáon of íobacco smoke exposureI
encouragemení of breasífeedáng of ánfanísI and famály educaíáonK
malávázumab ás a humanázed monoclonal aníábody agaánsí íhe ops c
glycoproíeánK Ií has been shown ío decrease íhe rásk of hospáíalázaíáon due ío
ío íhe hágh cosí of íhe medácaíáonI íhe AAm guádelánes for admánásíraíáon have
become áncreasángly resírácíáveK malávázumab ás noí recommended for oíherwáse
healíhy ánfanís born afíer OV weeks’ gesíaíáonal ageK Ií ás recommended duráng íhe
fársí year of láfe án ánfanís wáíh hemodynamácally ságnáfácaní hearí dásease or
chronác lung dásease of premaíuráíyI defáned as preíerm ánfanís born aí less íhan
PO weeks’ gesíaíáonal age who requáre greaíer íhan ONB oxygen for aí leasí íhe
fársí OU days of láfeK malávázumab ás gáven aí a dose of NR mgLkg once per moníh
for a maxámum of R doses duráng ops season ío ánfanís who qualáfy duráng íheár
fársí year of láfeK malávázumab ás only gáven án íhe second year of láfe ío cháldren
who meeí íhe cráíeráa of chronác lung dásease of ánfancy who coníánue ío requáre
supplemeníal oxygenI dáureíác íherapyI or chronác coríácosíeroád íherapy wáíhán S
moníhs of íhe onseí of íhe second ops seasonK mrophylacíác palávázumab ás noí
rouíánely recommended for paíáenís wáíh aown syndromeI cysíác fábrosásI
neuromuscular dáseaseI pulmonary abnormaláíáesI or ámmune compromáseK qhere
are excepíáons when a paíáení wáíh one of íhese condáíáons may be consádered for
prophylaxásK qhese excepíáons ánclude paíáenís wáíh aown syndrome who qualáfy
based on cardáac dásease or premaíuráíy duráng íhe fársí year of láfe; paíáenís wáíh
cysíác fábrosás wáíh clánácal evádence of lung dásease duráng íhe fársí year of láfe;
ánfanís án íheár fársí year of láfe wáíh neuromuscular dásease or a congenáíal
anomaly íhaí ámpacís íheár efforís ío clear secreíáons due ío áneffecíáve cough; and
paíáenís undergoáng hemaíopoáeíác síem cell íransplaní duráng ops season who
are severely ámmunosuppressed [
I
I
zK If a paíáení who ás receáváng moníhly
prophylaxás for ops ás hospáíalázed for ops broncháoláíásI moníhly prophylaxás
ko oíher áníerveníáon can do more ío prevení íhe spread of ops íhan íhorough
and consásíení hand hygáeneK ops can remaán ánfecíáous on couníeríops for
greaíer íhan S hoursI on gowns or paper íássues for OMJPM mánuíesI and on skán for
up ío OM mánuíes [
zK Ií ás recommended íhaí all people dásánfecí íheár hands
before and afíer dárecí coníací wáíh a paíáeníI afíer coníací wáíh ánanámaíe objecís
án íhe dárecí vácánáíy of íhe paíáeníI and afíer remováng glovesK AlcoholJbased rubs
should be used for hand deconíamánaíáon; áf alcoholJbased rubs are noí avaálable
or hands are vásábly dáríyI ándáváduals should use soap and waíer ío wash íheár
bxposure ío íobacco smoke áncreases íhe rásk and severáíy of broncháoláíásK
Clánácáans should ánquáre abouí íhe exposure of ánfanís and cháldren ío íobacco
smoke when assessáng íhem for broncháoláíás [
zK marenís should be fully
educaíed abouí íhe ámporíance of noí allowáng smokáng án íhe homeK pmoke
lángers on cloíhes and án íhe enváronmení for prolonged peráods of íáme [
zK As
suchI áí should be made clear ío íhe famály íhaí smokáng ouídoors poses rásks ío
oespáraíory ánfecíáons have been shown ío be ságnáfácaníly less common án ánfanís
who are breasífed for aí leasí S moníhsK qhere ás an overall TOB reducíáon án íhe
rásk of hospáíalázaíáon due ío respáraíory dásease án ánfanís exclusávely breasífed
for 4 or more moníhs compared ío íhose who were formula fed [
zK In addáíáonI
evádence has shown íhaí íhe duraíáon of exclusáve breasífeedáng was ánversely
proporíáonal ío íhe lengíh of oxygen use and íhe lengíh of hospáíalázaíáon án
preváously healíhy ánfanís wáíh acuíe broncháoláíás [
zK As suchI clánácáans should
encourage exclusáve breasífeedáng for aí leasí S moníhs ío decrease íhe morbádáíy
qhe AAmDs fánal recommendaíáon on íhe preveníáon of broncháoláíás deals wáíh
famály educaíáon and adváses clánácáans and nurses ío educaíe personnel and
famály members on evádenceJbased dáagnosásI íreaímeníI and preveníáon of
broncháoláíásK camáláes should be made aware íhaí íheár cháld may coníánue ío
have sympíoms for OJP weeks and íhaí íhás ás íhe normal course of broncháoláíásK
Cháldren wáíh ops coníánue ío shed várus for NJO weeksI and famály members
BroncháoláíásI especáally secondary ío opsI coníánues ío remaán one of íhe mosí
common respáraíory ánfecíáons án ánfanís worldwádeK qhe assocáaíed healíhcare
cosí án íhe rnáíed píaíes alone ás more íhan ANKR bálláon per yearK aespáíe a
number of íherapáes íhaí are benefácáal án íhe íreaímení of oíher respáraíory
állnessesI supporíáve care coníánues ío be íhe maánsíay of íreaímení for
broncháoláíásK qhe key ío reducáng íhe assocáaíed cosísI hospáíalázaíáonsI
morbádáíyI and moríaláíy of broncháoláíás ás ío coníánue ío áncrease íhe focus on
Amerácan academy of pedáaírács subcommáííee on dáagnosás and managemení of broncháoláíásK
aáagnosás and managemení of broncháoláíásK medáaírács OMMS; NNU: NTT4JVPK
trághí AiI qausság iMI oay CdI earráson eoI eolberg CgK qhe qucson CháldrenDs oespáraíory
dreenough AI Cox pI Alexander gK eealíh care uíálásaíáon of ánfanís wáíh chronác lung dáseaseI relaíed
Ceníers for dásease conírol and preveníáon ECaCFK oespáraíory syncyíáal várus acíáváíy J rnáíed píaíesI
Zorc ggI eall CBK Broncháoláíás: recení evádence on dáagnosás and managemeníK medáaírács OMNM; NOR:
eall CBI teánberg dAI Iwane MhK qhe burden of respáraíory syncyíáal várus ánfecíáon án young
melleíáer AgI Mansbach gMI Camargo CA grK aárecí medácal cosís of broncháoláíás hospáíalázaíáons án
easegawa hI qsugawa vI Brown acI Mansbach gMI Camargo CA grK qrends án broncháoláíás
hospáíalázaíáons án íhe rnáíed píaíesI OMMMJOMMVK medáaírács OMNP; NPO: OUJPSK
[Vzqurcáos kiK daugáng íhe severáíy of broncháoláíásK g oespár aás NVV4; NR: UTRK
Checcháa mK Ideníáfácaíáon and managemení of severe respáraíory syncyíáal várusK Am g eealíh pysí
mlání ACI gohnson atI táebe kK mracíáce saráaíáon among medáaírác bmergency aeparímenís án íhe
meíruzella caI doreláck MeK auraíáon of állness án ánfanís wáíh broncháoláíás evaluaíed án íhe
emergency deparímeníK medáaírács OMNM; NOS: OURJVMK
pcoííásh Iníercollegáaíe duádelánes keíworkK Broncháoláíás án cháldrenK A naíáonal clánácal guádeláne
qapáaánen qI Aáííonáemá gI Immonen gK cánnásh guádelánes for íhe íreaímení of laryngáíásI wheezáng
Mansbach gMI McAdam AgI Clark pK mrospecíáve mulíáceníer síudy of íhe váral eíáology of
broncháoláíás án íhe emergency deparímeníK Acad bmerg Med OMMU; NR: NNNJUK
phay ahI eolman oCI kewman oaI iáu iiI píouí gtI Anderson igK BroncháoláíásJassocáaíed
[NTzvanney MI syas eK qhe íreaímení of broncháoláíásK Arch aás Cháld OMMU; VP: TVPJUK
gorgensen gI teá giI pykes hgK Incádence of and oásk cacíors for Aárway Complácaíáons collowáng
gohnsíon CI de Carvalho tBI máva gI darcáa mCI conseca MCK oásk facíors for exíubaíáon faálure án
kavas iI tang bI de Carvalho sI oobánson gK medáaírác Invesíágaíors Collaboraíáve keíwork on
Infecíáons án CanadaK Improved ouícome of respáraíory syncyíáal várus ánfecíáon án a hághJrásk
hospáíalázed populaíáon of Canadáan cháldrenK g medáaír NVVO; NON: P4UJR4K
hneyber MCI Brandenburg AeI de drooí oK oásk facíors for respáraíory syncyíáal várus assocáaíed
tahab AAI aawod pqI oaman eAK Clánácal characíerásíács of respáraíory syncyíáal várus ánfecíáon án
phazberg dI oevelJsálk pI phoseyov aI BenJAmá AI hlar AI eurváíz eK qhe clánácal course of
Andrade MAI eoberman AI dlusíeán gI maradáse giI tald boK Acuíe oíáíás medáa án cháldren wáíh
eall CBI mowell hoI pchnabel hCI dala CiI máncus meK oásk of secondary bacíeráal ánfecíáon án
van píeenselJMoll eAI eazelzeí gAI van der soorí bI keájens egI eackeng teK bxcessáve secreíáon
of aníádáureíác hormone án ánfecíáons wáíh respáraíory syncyíáal várusK Arch aás Cháld NVVM; SR: NOPTJ
dozal aI Colán AAI gaffe MI eochberg ZK taíerI elecírolyíeI and endocráne homeosíasás án ánfanís
Boní iK Currení concepís of íhe paíhogenesás of ops broncháoláíásK Adv bxp Med Báol OMMV; SP4: PNJ
págurs kI dusíafsson mMI Bjarnason oK pevere oespáraíory pyncyíáal sárus Broncháoláíás án Infancy
píeán oqI pherráll aI Morgan tgK oespáraíory syncyíáal várus án early láfe and rásk of wheeze and
eenderson gI eálláard qkI pherráff AI píalker aI Al phammará kI qhomas eMK eospáíalázaíáon for
ops broncháoláíás before NO moníhs of age and subsequení asíhmaI aíopy and wheeze: a longáíudánal
oalsíon piI iáeberíhal ApI Meássner eCK Clánácal mracíáce duádeláne: qhe aáagnosásI ManagemeníI
Mansbach gMI máedra mAI qeach pgI
eí alK
MAoCJPM InvesíágaíorsK mrospecíáve mulíáceníer síudy of
váral eíáology and hospáíal lengíh of síay án cháldren wáíh severe broncháoláíásK Arch medáaír Adolesc
telláver oCK Broncháoláíás and Infecíáous AsíhmaK In: Cherry gaI aemmlerJearráson dgI haplan piI
píeánbach tgI eoíez mI bdsK ceágán and Cherry’s qexíbook of medáaírác Infecíáous aáseasesK Tíh edK
aesíáno iI teásgerber MCI poung mK saládáíy of oespáraíory pcores án BroncháoláíásKeosp medáaír
Abboíí dcI oosadoJdeJChrásíenson MiI oossá pbI pusíer pK Imagáng of small aárways dáseaseK g
earrás gAI euskáns tCI iangley gMI páegel gaK medáaírác ppecáal Iníeresí droup of íhe pocáeíy for
eealíhcare bpádemáology of AmerácaK eealíh care epádemáology perspecíáve on íhe lcíober OMMS
recommendaíáons of íhe pubcommáííee on aáagnosás and Managemení of BroncháoláíásK medáaírács
[PUzpmyíh oiI lpenshaw mgK BroncháoláíásK ianceí OMMS; PSU: PNOJOOK
sogel AMI iennon aoI eardáng gbK saráaíáons án broncháoláíás managemení beíween fáve kew
[4MzAdcock mMI píouí ddI eauck MAI Marshall dpK bffecí of rapád váral dáagnosás on íhe managemení of
aoan neI hássoon kI aobson pK A randomázedI conírolled íráal of íhe ámpací of early and rapád
dáagnosás of váral ánfecíáons án cháldren broughí ío an emergency deparímení wáíh febrále respáraíory
aoan nI bnarson mI hássoon kK oapád váral dáagnosás for acuíe febrále respáraíory állness án cháldren án
gohnson atI Adaár CI Braní oI eolmwood gI Máíchell IK aáfferences án admássáon raíes of cháldren
oávers omI corsláng MiI llver omK Inappropráaíe secreíáon of aníádáureíác hormone án ánfanís wáíh
iaegreád AI holsíø línaess ABI lrsíavák II Carlsen heK keuíralázáng acíáváíy án human málk fracíáons
Chába vI Mánagawa qI Máío hI
eí alK
bffecí of breasí feedáng on responses of sysíemác áníerferon and
várus‐specáfác lymphocyíe íransformaíáon án ánfanís wáíh respáraíory syncyíáal várus ánfecíáong Med
taánwrághí CI Alíamárano iI Cheney MI
eí alK
A mulíáceníerI randomázedI doubleJblándI conírolled
maíel eI douán pI mlaíí otK oandomázedI doubleJblándI placeboJconírolled íráal of oral albuíerol án
mlání ACI gohnson atI maíel eI
eí alK
medáaírác bmergency oesearch Canada EmboCFK bpánephráne
tark mAI Mcaonald sI gones AmK kebulásed hyperíonác saláne for cysíác fábrosásK Cochrane aaíabase
[RNzaaváskas bI Anderson paI donda II
pood kI Benneíí taI Zeman hI
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Increasáng conceníraíáon of ánhaled saláne wáíh or wáíhouí
amáloráde: effecí on mucocáláary clearance án normal subjecísKAm g oespár Cráí Care Med OMMP; NST:
cernandes oMI Báaly iMI sandermeer BI
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dlucocoríácoáds for acuíe váral broncháoláíás án ánfanís
eall CBI mowell hoI Macaonald kbI
eí alK
oespáraíory syncyíáal váral ánfecíáon án cháldren wáíh
[RRzooss mAI kewíh CgI hhemaná odK Accuracy of pulse oxámeíry án cháldrenK medáaírács OMN4; NPP: OOJVK
rnger pI Cunnángham pK bffecí of oxygen supplemeníaíáon on lengíh of síay for ánfanís hospáíalázed
Cunnángham pI McMurray AK lbservaíáonal síudy of íwo oxygen saíuraíáon íargeís for dáscharge án
pchroeder AoI Marmor AhI maníell oeI kewman qBK Impací of pulse oxámeíry and oxygen íherapy
kaíáonal Insíáíuíe for eealíh and Care bxcellenceK Broncháoláíás: dáagnosás and managemení of
broncháoláíás án cháldrenK Clánácal duádeláne kd V OMNR gune; Avaálable from:
iáu cI luyang gI pharma AkI
eí alK
ieukoíráene ánhábáíors for broncháoláíás án ánfanís and young
ppurláng dhI aousí gI ael Mar CBI bráksson iK Aníábáoíács for broncháoláíás án cháldrenK Cochrane
mánío iAI máírez mMI iuásá cI
eí alK
Azáíhromycán íherapy án hospáíalázed ánfanís wáíh acuíe
broncháoláíás ás noí assocáaíed wáíh beííer clánácal ouícomes: a randomázedI doubleJblándedI and
seníre hI oandolph AdK oábavárán for respáraíory syncyíáal várus ánfecíáon of íhe lower respáraíory
[S4zMegged lI pchlesánger vK aown syndrome and respáraíory syncyíáal várus ánfecíáonK medáaír Infecí aás
bl paleeby CMI pomes dtI aesáncenzo gmI daur AeK oásk facíors for severe respáraíory syncyíáal
várus dásease án cháldren wáíh cancer: íhe ámporíance of lymphopenáa and young ageK medáaírács OMMU;
Maíí dbI nuáníana mgI aesíaállaís eI
eí alK
qhárdhand íobacco smoke: emergáng evádence and
Ip pI Chung MI oaman dI
eí alK
Breasífeedáng and maíernal and ánfaní healíh ouícomes án developed
aornelles CqI máva gmI Marosíáca mgK kuíráíáonal síaíusI breasífeedángI and evoluíáon of ánfanís wáíh
thaí ás kew wáíh Managemení of medáaírác
aávásáon of oespáraíory and pleep MedácáneI aeparímení of medáaírácsI rq pouíhwesíern Medácal
Absírací:
Ceníral pleep Apnea ECpAF án cháldren ás a far less síudáed and undersíood
abnormaláíy compared ío lbsírucíáve pleep Apnea ElpAFK Ií ás seen more ofíen án
younger paíáení populaíáon mosíly wáíh coJmorbádáíyK qhere are sírucíural
abnormaláíáes án íhe braánI spánal cordI aárway and chesí wall or funcíáonal dásorders án
respáraíory conírolI hemoglobán conceníraíáonI swallowáng or cardáovascular sysíemI
resulíáng án CpAK Clánácal observaíáon of ceníral apneác evenís prompís furíher
evaluaíáon ádeally done by performáng molysomnography íesíáng Esleep síudyF ío
confárm íhe presence and esíámaíe íhe severáíyK
saráous medácal and surgácal íreaímení opíáons resulí án ámprovemení or resoluíáon of
íhe ceníral apneác evenísK Majoráíy of íhe paíáenís show a gradual resoluíáon of íhe
dásorder wáíh ageK eowever a mánoráíy of paíáenís coníánue ío manáfesí íhe dásorder and
requáre longer íerm íreaímení mosíly by usáng respáraíory supporí án íhe form of
ánvasáve or nonJánvasáve veníálaíáonK More research ás needed ío explore íreaímení
heywords:
Ceníral sleep apneaI medáaírácsI molysomnographác síudyI pleep
dásordered breaíhángK
pleep dásordered breaíháng encompasses condáíáons from íhe more common
obsírucíáve sleep apnea ElpAF ío obsírucíáve hypoveníálaíáonI sleep relaíed
hypoxemáa and ceníral sleep apneaK
Ceníral sleep apnea resulís from absení respáraíory dráve from breaíháng ceníers án
íhe braánsíem duráng sleepK qhere ás a dáfference án íhe defánáíáon of CA for
cháldren and adulísK qhe Amerácan Academy of pleep Medácáne EAApMF defánes
Correspondáng auíhor pK hamal kaqvá
: aávásáon of oespáraíory and pleep MedácáneI aeparímení of medáaírácsI rq
pouíhwesíern Medácal CeníerI aallasI qexasI rpA; qel: ON4J4RSJUP4U; cax: ON4J4RSJR4MS; bmaál:
for duraíáon of OM seconds or longerI or lasíáng aí leasí O breaíhs’ duraíáon wáíh
In cháldren áncludáng ánfanísI íhe CA ás aí leasí O breaíhs án duraíáon and ás
assocáaíed wáíh a decrease án hearí raíe ío less íhan RM beaís per mánuíe for aí leasí
R secondsI or less íhan SM beaís per mánuíe for NR secondsK meráodác breaíháng has
been descrábed as greaíer íhan P epásodes of CA lasíáng P seconds separaíed by no
Apnea followáng a ságh ás noí consádered paíhologác unless áí ás assocáaíed wáíh
arousal or desaíuraíáonK Isolaíed ceníral apnea EcágK
FI CA followáng posíJ
arousal ságh breaíháng Esee cágK
FI and peráodác breaíháng paííerns Esee cágK
[NAINBz páxíyJsecondJlong [NCz NOM secondsJlong epoch of íhe polysomnography
of a 4JmoníhJold cháld born aí full íermI referred for evaluaíáon of sleep apnea
because of observaíáon by parení of apneác epásodesK [N
z Ceníral sleep apnea
wáíhouí arousalK [
z Ceníral sleep apnea afíer arousal duráng nuáeí sleepK [
meráodác breaíháng duráng Acíáve sleepK abdmI abdománal pleíhysmography; C4I
ceníral elecíroencephalogram leads; CeIkI chán elecíromyogram; bldI iCo eye
elecíromyogram; bhdI elecírocardáogram; bqClI endJíádal carbon dáoxáde
íracáng; c4I froníal elecíroencephalogram leads; lOI lccápáíal elecíroJ
encephalogramI ciltI íracáng of oral íhermásíor; kasal mressure for
measuremení of nasal aár pressure; pkloI snore mácrograph; pplOI coníánuous
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auraíáon of íhese apneác evenís may be more ándácaíáve of an underlyáng
paíhology íhan jusí íhe ándexK qhe adverse consequences of moderaíe and severe
qhe máld CA seen án oíherwáse healíhy ánfanís and young cháldren íends ío
ámprove wáíh age [
I
zK táíh maíuraíáon of respáraíory conírol and chesíJwall
Bráef CA án fullJíerm ánfanís ás seen commonlyI especáally án íhe early moníhs of
qhere has been an efforí án defánáng íhe prevalence of CA án healíhy ánfanísK bach
síudy has used dáfferení cráíeráa ío defáne CAI dáfferení monáíoráng íechnáquesI
and dáfferení íesíáng enváronmenís such as home
polysomnographyI whách makes áí dáffáculí ío make comparásons beíween íhe
táíh íhe developmení of síandardázaíáon of íhe defánáíáon of CA fuíure síudáes are
qhe Collaboraíáve eome Infaní Monáíoráng bvaluaíáon ECeIMbF síudy seems ío
be íhe largesí and íhe mosí comprehensáve síudy allowáng comparáson of
breaíháng paííerns duráng sleep án healíhy íerm ánfanísI sáblángs of ánfanís wáíh a
famály hásíory of sudden ánfaní deaíh syndrome EpIapFI healíhy preíerm ánfanísI
qhe síudy was conducíed án over NMMM ánfanís over S moníhs’ duraíáon án íheár
home enváronmeníK qhe ánvesíágaíors concluded íhaí conveníáonal evenísI
descrábed as apnea of OM seconds’ duraíáon noí assocáaíed wáíh bradycardáaI are
common án oíherwáse healíhy íerm ánfanísK qhe síudy also reporíed íhaí exíreme
evenísI descrábed as apneas longer íhan PM seconds assocáaíed wáíh bradycardáaI
are more common án premaíure ánfanís and íend ío reduce án frequency afíer 4P
kormaíáve daía on pedáaírác breaíháng paííerns duráng sleep was preseníed by
rláel and colleagues who síudáed TM subjecís beíween íhe ages of N and NR years
who underwení a sángleJnághí sleep síudy án íhe laboraíoryK CA was defáned as of
aí leasí NM seconds’ duraíáon or any duraíáon assocáaíed wáíh desaíuraíáon of
greaíer íhan 4B compared wáíh baseláne [
zK qhe ánvesíágaíors confármed íhaí CA
ás rare án cháldrenI and síaíed íhaí CA wáíh desaíuraíáon ás even rarerK qhe síudy
was conducíed wáíh a modern compuíerJbased recordáng sysíem and was
manually scored by vásual ánspecíáonK
qhe láíeraíure suggesís íhaí CA ás common án early ánfancy and ámproves wáíh age
zK Ií ás also noíed íhaí mosí ceníral apnea evenís follow a ságh breaíh án older
healíhy cháldren beyond ánfancyK In premaíure ánfanísI íhe breaíháng paííern ás noí
fully developed aí íhe íáme of báríh [
zK qhás sáíuaíáon may be complácaíed wáíh
íhe developmení of bronchopulmonary dysplasáa wáíh lámáíed respáraíory reservesI
andLor cerebral palsy wáíh assocáaíed poor neuromuscular conírol of upper aárway
qhusI premaíuráíy predásposes ío boíh ceníral and obsírucíáve sleep apneaK
Mosí síudáes performed án premaíure ánfanís ío assess íhe maíuraíáon of breaíháng
meráodác breaíháng ás also common án premaíure and young íerm ánfanís [
dloízbach and colleagues descrábed íhe prevalence of peráodác breaíháng án
relaíávely maíure preíerm ánfanís EPM–PR weeks dAF án comparáson wáíh fullJíerm
qhe ánvesíágaíors reporíed a hágher mean perceníage value of peráodác breaíháng
and íhe longesí epásode of peráodác breaíháng was hágher án preíerm ánfanís íhan án
fullJíerm conírolsK MoreoverI perceníage and epásodes of peráodác breaíháng
Aiqb has been descrábed as an epásode íhaí ás frághíenáng ío íhe observer and
characíerázed by some combánaíáon of apneaI color changeI marked change án
muscle íoneI chokángI andLor gaggángK qhe paíhophysáology of Aiqb ás
mulíáfacíoráal; occasáonally áí ás a sángle eveníI and no ságnáfácaní paíhologác
feaíures may be dáscovered despáíe exíensáve ánvesíágaíáon [
In íhe pasíI áí was proposed íhaí some ánfanís who dáe of pIap had recurrení
qhere are several causes for AiqbI and áí ás dáffáculí ío focus on a sángle sysíem
Apnea may noí necessarály be parí of íhe preseníaíáon án ánfanís who presení wáíh
AiqbK qhe AApM recommends performáng polysomnography án ánfanís wáíh
qhe relaíáonsháp beíween gasíroesophageal reflux EdboF and ceníral andLor
obsírucíáve apnea has been debaíed frequenílyK hhan and colleagues síudáed boíh
ceníral and obsírucíáve apnea án RM ánfanís wáíh Aiqb and RM conírol subjecís
zK Ií was concluded íhaí íhere ás no íemporal assocáaíáon beíween dbo án íhe
qhe exací íámáng of íhe síarí of breaíháng movemenís án íhe human feíus ás
unclearK qhe feíal breaíháng movemení án mosí mammals síarís án íhe second
írámesíer [
zK qhe feíal breaíháng movemení ás dásconíánuousI rhyíhmácI and
nonsynchronázed [
merhaps an ámporíaní aspecí of breaíháng rhyíhm án íhe feíus ás íhaí áí ás váíal for
qhe conírol of breaíháng án feíal láfe ás complexI and ánvolves several ánhábáíory
and excáíaíory síámuláK pome of íhe ámporíaní modulaíors of breaíháng ánclude
ceníral rhyíhm generaíorsI ceníral and perápheral chemorecepíorsI sleep and wake
Based on íhe anámal model of respáraíory conírolI íhere are O dásíáncí groups of
respáraíory ceníers íhaí funcíáon án harmonyK qhe fársíI íhe parafacáal nucleusI ás
locaíed aí íhe veníral surface of íhe hándbraán whále íhe secondI íhe preJBöízánger
complexI ás on íhe dorsal aspecíK Boíh groups of neurons develop ándependeníly
qhe parafacáal nucleus predománaníly conírols expáraíáon and funcíáons by phasác
qhe preJBöízánger complex predománaíely works as íhe ánspáraíory conírolK qhe
developmení of íhese respáraíory ceníers and íhe áníeracíáon beíween íhem ás
beyond íhe scope of íhás reváewK
ceíal breaíháng ás síámulaíed wáíh elevaíed carbon dáoxáde duráng lowJvolíage
hághJfrequency elecírocoríácographyI suggesíáve of wake síaíeI and duráng boíh
hághJvolíage and lowJvolíage elecírocoríácography wáíh exposure ío cold and
carbon dáoxáde [
I
zK oesponses ío hypoxáa and hypercapnáa án feíal láfe
suggesí íhaí caroíád chemorecepíors are already acíáve án feíal láfe [
qhe oíher ánhábáíory síámulá for breaíháng án feíal láfe ánclude adenosáne and íhe
placenía [
I
zK oemoval of placenía afíer báríh may be a síámulus for
coníánuous breaíháng [
zK ceíal breaíháng ás also under behaváoral conírolK Ií ás
síámulaíed duráng hághJfrequencyI lowJvolíage elecírocoríácographác acíáváíyI
whách ás characíerásíác of awake and obM sleepI and ás ánhábáíed duráng lowJ
qransáíáon from feíal ío neonaíal láfe ás probably íhe mosí complex íransáíáon án
qhe árregular breaíháng paííern án preíerm and íerm ánfanís ás also exacerbaíed by
ámmaíure lung mechanács aí íhe íáme of báríhK Infanís have low funcíáonal resádual
íáme and decrease by P moníhs of age [
zK tarm íemperaíure ánduces apnea án
meráodác breaíháng án premaíure ánfanís ás relaíed ío íhe carbon dáoxáde level and
áís relaíáonsháp ío íhe apnea íhresholdK oeducíáon án serum carbon dáoxáde below a
ceríaán poání causes apnea duráng sleepI and íhás level ás íermed íhe apneác
íhresholdK In premaíure ánfanísI íhe apnea íhreshold ás much closer ío íhe eucapnáa
level án comparáson wáíh adulís [
zK qhe apnea íhreshold ás íherefore frequeníly
reached wáíh common maneuvers such as an augmeníed breaíhI resulíáng án
recurrení apnea íhaí ás seen án peráodác breaíhángK
Anoíher concepí án undersíandáng peráodác breaíháng may be relaíed ío loop gaánK
ioop gaán ás descrábed as a negaíáve feedback sysíem án whách a dásíurbance EuF
áncreases alveolar veníálaíáon from a síeady síaíeK qhás áncrease án veníálaíáon án
íurn reduces carbon dáoxádeI whách evokes a negaíáve correcíáve acíáon EeF ío
suppress íhe dásíurbanceK qhe raíáo of eLu wáll defáne íhe loop gaán of íhe sysíemK
In íhe hágh loopJgaán sysíemI íhe response ás greaíer or equal ío íhe dásíurbanceI
whách resulís án an unsíable sysíemK cor exampleI a ságh produces a sudden
reducíáon of carbon dáoxáde levelsI whách evokes an exaggeraíed response from
íhe ceníral respáraíory ceníer and ánduces apneaI whách án íurn resulís án elevaíed
levels of carbon dáoxádeK qhás process causes resumpíáon of breaíháng buí án an
exaggeraíed fasháonI leadáng ío washouí of carbon dáoxádeI brángáng áí below íhe
apneác íhreshold; íhe cycle wáll íhus repeaí áíselfI resulíáng án íhe characíerásíác
molysomnography ás consádered íhe íesí of choáce ío dáagnose sleepJdásordered
breaíháng án ánfanís and cháldrenK qhás ás done as ánJlaboraíory íesíángI reporíed ío
be well íoleraíed by paíáenís and famály members [
zK A recení síudy has shown
íhaí a shoríer 4Jhour evenáng síudy ás comparable wáíh an overnághí sleep síudy án
A nap síudyI even shoríer íhan a 4Jhour síudyI ás noí consádered ío be equávalení
ío a fullJnághí síudy and may máss sleepJdásordered breaíháng [
zK qhe ánJ
laboraíory polysomnography íesíáng assures accuraíe dáagnosás of íhe naíure of
sleepJdásordered breaíháng wáíh addáíáonal assessmení of nonJbreaíháng dásorders
such as parasomnáa and has abáláíy ío áníervene duráng íhe síudy as ándácaíedK qhe
dásadvaníages ánclude prolonged íesí duraíáon for young cháldren and need for a
parení ío síay for íhe whole duraíáon of daía collecíáonI expensáve íesíángI and
long waáíáng íáme for íhe síudy because of íhe shoríage of cháldJfráendly sleep
eome monáíoráng has been used án several research síudáes ío documení sleepJ
dásordered breaíháng án ánfanísI buí has noí been wádely accepíed as a íool for
clánácal useK qhere are varáous poríable íesíáng modaláíáes avaálable for íhe
assessmení of sleepJdásordered breaíháng án ánfanísI áncludáng home pulse
oxámeíryI pulse íransáí íámeI and mulíáchannel unaííended sleep síudáes [
I
moríable monáíoráng provádes íhe advaníage ío collecí daía án a paíáení’s famáláar
surroundángs and for an exíended peráod of íámeK Ií ás also ánexpensáve and readály
avaálableK qhe dásadvaníages ánclude dáffáculíy án accuraíe dáffereníáaíáon of sleep
thále rouíáne evaluaíáon of cháldren wáíh elevaíed ceníral apnea ándex by MoI ás
noí ándácaíedI prováders should consáder neuroámagáng án cháldren wáíh CpA and
abnormal neurologác examánaíáon fándángs or gasíroesophageal reflux dáseaseK
Among íhe pedáaírác populaíáon referred ío a sleep clánác who are affecíed by
braán íumorsI up ío VMB ánvolve íumors locaíed wáíhán braánsíemI íhalamusI or
hypoíhalamus [
zK In addáíáon ío dayíáme sleepánessI íumors án íhese locaíáons
can ofíen cause respáraíory árregularáíáes duráng sleep when wakefulnessJ
deíermáned behaváoral compensaíory mechanásms are losíK lf íhe few reporíed
cases of CpA ánvolváng íumors án íhás populaíáonI íumors have been locaíed án íhe
braánsíemI fouríh venírácleI posíeráor fossaI and spánal regáonK qhusI dysfuncíáon
or áníerrupíáon of respáraíory neural ouípuí aí mulíáple sáíes wáíhán íhe ceníral
nervous sysíem may cause CpAK rnláke paíáenís wáíh íumors and obsírucíáve
Cháará íype I malformaíáon ás assocáaíed wáíh boíh obsírucíáve apnea and CpAI
affecíáng pedáaírác and adulí populaíáonsK CpA and hypoveníálaíáon can be presení
án boíh rapád eye movemení EobMF and nonJobM EkobMF sleepK qhe exíení of
íhe malformaíáon presení and íhe downsíream effecís on conírol of breaíháng
ceníers vary eoweverI polysomnography changes correlaíe well wáíh magneíác
resonance ámagáng EMoIF fándángs [
I
zK CpA íends ío be more severe án
cháldren who presení wáíh syránx and general crowdáng aí íhe foramen magnum
mraderJtállá syndrome ás known ío be assocáaíed wáíh sleep dásordered breaíháng
án cháldren áncludáng obsírucíáve sleep apneaI hypoveníálaíáonI ceníral sleep apnea
and even deaíh wáíh more frequení respáraíory complácaíáons seen duráng upper
pleep dásordered breaíháng ás also ságnáfácaní because of poíeníáal growíh of sofí
íássue án íhe aárway án response ío growíh hormone íreaímení frequeníly used
Congenáíal muscular dysíropháes are ánheráíed dáseases affecíáng musclesK In
addáíáon ío poorJqualáíy sleep and seázuresI sleepJdásordered breaíháng ás presení
án approxámaíely SRB of cases [
I
zK CpA ás íhe mosí common form of sleepJ
relaíed breaíháng ánsíabáláíy án paíáenís wáíh congenáíal muscular dysíropháesK qhe
severáíy of CpA ás relaíed ío íhe age of onseí of sympíoms and íhe raíe of
progressáon of muscle weaknessK qhe prámary mechanásm by whách CpA occurs
án íhese paíáenís ás váa an ánabáláíy ío íranslaíe respáraíory neural dráve from íhe
respáraíory ceníers Ewhách may be perfecíly normalF ánío funcíáonal moíáon of íhe
respáraíory musclesI because of muscle weaknessK thereas án some of íhese
paíáenís a degree of hypoveníálaíáon can occur duráng wakefulness leadáng ío ClO
reíeníáonI oíhers remaán normocapnácI wáíh hypoveníálaíáon only occurráng duráng
sleep when wakefulness neurocompensaíory mechanásms are losíK qhusI unláke
oíher forms of CpA íhaí íypácally worsen án kobM sleepI CpA án paíáenís wáíh
congenáíal muscular dysíropháes may be mosí pronounced duráng obM sleep
agaánsí íhe background of already low dráve ío íhe áníercosíal muscles and
accessory respáraíory muscles [
J
eealíhy ánfanís E≤ NU moníhs oldF born and resádáng aí hágh alíáíude show
preserved sleep archáíecíure buí hágher apneaJhypopnea ándexes and more
prománení desaíuraíáon wáíh respáraíory evenís íhan do íhose láváng aí low alíáíude
qhe íargeí án managáng CA án ánfanís and young cháldren ás aámed aí
normalázaíáon of breaíháng and síabálázaíáon of flucíuaíáon án oxygen saíuraíáonK
qhe avaálable íherapáes for íhe íreaímení of apnea án ánfaní serve as íemporary
íherapáes whále awaáíáng maíuráíy of íhe breaíháng apparaíus of premaíure and
pupplemeníal oxygen íherapy has been wádely prescrábed for CA and peráodác
breaíháng án boíh premaíure and fullJíerm ánfanísK In a small síudy of NR preíerm
lxygen íherapy prevenís desaíuraíáon and ámproves breaíháng síabáláíy án ánfanísK
píámulaní medácaíáons such as íheophylláne and caffeáne have been frequeníly
prescrábed and wádely accepíed íherapy for CA and peráodác breaíháng án preíerm
and íermK In premaíure ánfanísI íhe use of caffeáne ío síámulaíe breaíháng ás
íargeíed íoward adenosáneJánduced breaíháng suppressáon íhaí ás normally seen án
íreaímení of apnea of premaíuráíy reporíed a reducíáon án apnea severáíy and
In a randomázed placeboJconírolled íráal of OMMM ánfanís born aí preíerm and wáíh
apnea of premaíuráíyI caffeáne reduced íhe need for posáíáve pressure veníálaíáon
pome oíher nonconveníáonal íherapáes for íhe íreaímení of CA have been
researched án preíerm ánfanísK A small síudy of O4 premaíure ánfanís born aí OT
weeks dA wáíh apnea of premaíuráíy compared supáne
prone posáíáonángI
and concluded íhaí more CA and less arousal was noíed duráng prone sleepáng
posáíáonI whereas ánfanís had more awakenáng and arousals per hour án a supáne
In a prospecíáveI randomázed conírolled síudy of OT preíerm ánfanís of sámálar
dAI íhe shoríJíerm ánhalaíáon of MKUB carbon dáoxáde had effácacy sámálar ío íhaí
Boíh of íhese íráals were based on íhe fací íhaí ánhaled carbon dáoxáde wáll
áncrease íhe carbon dáoxáde levels and prevení íhe apnea íhreshold beáng reacháng
mosáíáve pressure veníálaíáon has been wádely used án íhe íreaímení of CA and
peráodác breaíháng án preíerm and íerm ánfanísK Coníánuous posáíáve aárway
pressure ECmAmF ás one such modaláíyK qhe underlyáng mechanásm of
ámprovemení of CA was receníly síudáed by bdwards and colleagues án a lamb
model of peráodác breaíháng [
zK CmAm reduced CA and máxed apnea án a doseJ
dependení mannerI mosí lákely by reducáng íhe loop gaán váa an áncrease án íhe
líher íherapáes íhaí have been síudáed án preíerm ánfanís for íreaímení of CA and
peráodác breaíháng buí noí yeí avaálable for clánácal use ánclude síochasíác
mechanosensory síámulaíáon Evábroíacíále síámulaíáon ío síámulaíe breaíhángFK In a
small síudy of NM relaíávely maíure preíerm ánfanís EPP weeksFI a low level of
exogenous síochasíác síámulaíáon síabálázed breaíháng duráng sleep and helped ío
AceíazolamádeI a carbonác anhydrase ánhábáíorI has been used án íhe íreaímení of
CA and peráodác breaíhángK In a small síudy of NO ánfanís wáíh recurrení
hypoxemáaI aceíazolamáde reduced íhe CA ándex and ámproved oxygen saíuraíáon
Aceíazolamáde dámánáshes íhe veníálaíory response of íhe perápheral
chemorecepíors ío hypoxáaI decreases loop gaánI and reduces íhe veníálaíory
response ío arousals [
I
zK In anámal modelsI áí has been shown ío lower íhe
mbqClO apnea íhreshold and wáden íhe dáfference beíween íhe eupneác and
mbqClO íhresholdsKqreaímení of anemáa of premaíuráíy wáíh blood íransfusáon
In adulísI íhe use of supplemeníal Cl
for hypocapnác ceníral sleep apnea
syndromes ás old newsK qhaí Cl
can síabáláze respáraíáon has been known for
decadesI buí hágh conceníraíáons fragmení sleep by ánducáng arousals secondary
ío respáraíory síámulaíáon and sympaíhoexcáíaíáon [
I
zK qhe key challenge has
pleep síabálázaíáon has been advocaíed ío be effecíáve án adulís showáng síable
respáraíáonK pome addáíáonal íherapáes have been íráed án adulís wáíh máxed
success wáíh scaní daía avaálable on pedáaírác populaíáonK qhese ánclude
medácaíáons such as ClonádáneI kasal bxpáraíory mosáíáve mressure EmroveníF and
In cháldren wáíh clánácally ságnáfácaní ceníral sleep apnea íhaí persásís whále
addressáng íhe underlyáng cause requáre supporíáng íhe veníálaíáon for some
duraíáon of íámeK qhás can be acháeved wáíh eáíher ánvasáve mechanácal veníálaíáon
váa íracheosíomy or nonJánvasáve posáíáve pressure veníálaíáon EkImmsF by
applyáng a nasal or full face áníerfaceK
qhere are valád concerns abouí effácacy and íolerance of kImms án young cháldren
when used aí homeK qhás áncludes appropráaíe sáze maskI consíaní supervásáon by
a caregáver án assuráng adequaíe seal and posáíáonáng of íhe mask and lákely
accádeníal removal of íhe mask by íhe cháld wáíh acuíe consequencesK
pleep dásordered breaíháng especáally ceníral sleep apnea ás a frequeníly seen
clánácal eníáíyK qhere are íreaíable underlyáng condáíáons resulíáng án effecíáve
resoluíáon of ceníral apneasK eoweverI a ságnáfácaní paíáení populaíáon coníánues
ío suffer from íhe dásorder and requáre medácaíáon or equápmení supporí for íhe
veníálaíáon for varyáng lengíh of íámeK qhere are lámáíaíáons án applyáng íhese
Berry oBI Budháraja oI doííláeb agI
eí alK
oules for scoráng respáraíory evenís án sleep: updaíe of íhe
OMMT AApM Manual for íhe pcoráng of pleep and Assocáaíed bvenísK aeláberaíáons of íhe pleep
Apnea aefánáíáons qask corce of íhe Amerácan Academy of pleep MedácáneK g Clán pleep Med OMMT;
cukumázu MI hohyama gK Ceníral respáraíory pausesI sághsI and gross body movemenís duráng sleep
teeseJMayer abI BerryJhravás bMI Ceccheráná II
eí alK
An offácáal Aqp clánácal polácy síaíemení:
congenáíal ceníral hypoveníálaíáon syndrome: geneíác basásI dáagnosásI and managemeníK Am g oespár
kg ahI Chan CeK A reváew of normal values of ánfaní sleep polysomnographyK medáaír keonaíol
rláel pI qauman oI dreenfeld MI
eí alK
kormal polysomnographác respáraíory values án cháldren and
hráízánger cbI AlJpaleh pI karang IK aescrápíáve analysás of ceníral sleep apnea án cháldhood aí a
Marcus CiI lmlán hgI Basánká agI
eí alK
kormal polysomnographác values for cháldren and
adolescenísK Am oev oespár aás NVVO; N4S: NOPRJVK
oáchards gMI Alexander goI phánebourne bAI
eí alK
pequeníáal OOJhour profáles of breaíháng paííerns
eoppenbrouwers qI eodgman gbI earper oMI
eí alK
molygraphác síudáes of normal ánfanís duráng íhe
oamanaíhan oI Corwán MgI euní CbI
eí alK
Cardáorespáraíory evenís recorded on home monáíors:
teeseJMayer abI Corwán MgI meucker MoI
eí alK
Comparáson of apnea ádeníáfáed by respáraíory
ánducíance pleíhysmography wáíh íhaí deíecíed by endJíádal ClEOF or íhermásíorK qhe CeIMb píudy
ooberíson CMI taíí MgI aánu IAK luícomes for íhe exíremely premaíure ánfaní: whaí ás new? And
[NPzBaraldá bI cáláppone MK Chronác lung dásease afíer premaíure báríhK k bngl g Med OMMT; PRT: NV4SJRRK
pamuels MmI moeís CcI koyes gmI
eí alK
aáagnosás and managemení afíer láfe íhreaíenáng evenís án
Infaníále Apnea and eome MonáíorángK kIe Consensus píaíemení lnláne NVUS pep OVJlcí; N;SESF: NJ
Mcdovern MCI pmáíh MBK Causes of apparení láfe íhreaíenáng evenís án ánfanís: a sysíemaíác reváewK
Aurora okI Zak opI haráppoí AI
eí alK
mracíáce parameíers for íhe respáraíory ándácaíáons for
hahn AI oebuffaí bI poííáaux MI
eí alK
iack of íemporal relaíáon beíween acád reflux án íhe proxámal
[NVzgansen AeI Chernáck sK aevelopmení of respáraíory conírolK mhysáol oev NVUP; SP: 4PTJUPK
gohnsíon BMI dunn qoI dluckman maK purface cooláng rapádly ánduces coordánaíed acíáváíy án íhe
tallenJMackenzáe AI dezeláus eI qhobyJBrásson MI
eí alK
sesácular gluíamaíe íransporíer O ás
requáred for ceníral respáraíory rhyíhm generaíáon buí noí for locomoíor ceníral paííern generaíáonK g
Corcoran AbI eodges MoI tu vI
eí alK
Medullary seroíonán neurons and ceníral ClO
chemorecepíáonK oespár mhysáol keurobáol OMMV; NSU: 4VJRUK
tongJoáley MqI iáu nK keurochemácal developmení of braán síem nucleá ánvolved án íhe conírol of
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eándbraán áníerneurons and axon guádance ságnaláng
ganczewská tAI celdman giK aásíáncí rhyíhm generaíors for ánspáraíáon and expáraíáon án íhe juvenále
oágaíío eI iee aI aavá MI
eí alK
bffecí of áncreased aríeráal ClO on feíal breaíháng and behaváor án
huápers IMI Maerízdorf tgI ae gong apI
eí alK
qhe effecí of hypercapnáa and hypercapnáa assocáaíed
Blanco CbI aawes dpI eanson MAI
eí alK
qhe response ío hypoxáa of aríeráal chemorecepíors án feíal
Adamson piI huápers IMI llson aMK rmbálácal cord occlusáon síámulaíes breaíháng ándependení of
hoos BgI Maeda qI gan CK Adenosáne AENF and AEOAF recepíors modulaíe sleep síaíe and breaíháng án
lvaro oI de Almeáda sI alJAlaáyan pI
eí alK
A placeníal exírací ánhábáís breaíháng ánduced by umbálácal
eállman keI hallapur pdI gobe AeK mhysáology of íransáíáon from ánírauíeráne ío exírauíeráne láfeK
marmelee AeI píern bI earrás MAK Maíuraíáon of respáraíáon án premaíures and young ánfanísK
qourneux mI Cardoí sI Museux kI
eí alK
Influence of íhermal dráve on ceníral sleep apnea án íhe
hhan AI nurashá MI hwáaíkowská hI
eí alK
Measuremení of íhe ClO apneác íhreshold án newborn
aas pI Mándell gI Málleí dCI
eí alK
medáaírác polysomnography: íhe paíáení and famály perspecíáveK g
hahlke mbI táímans MBI Alabdoulsalam qI
eí alK
cullJnághí
4h evenáng polysomnography án
Marcus CiI heens qdI tard piK Comparáson of nap and overnághí polysomnography án cháldrenK
hárk sdI Bohn pdI clemons ttI
eí alK
Comparáson of home oxámeíry monáíoráng wáíh laboraíory
coo gvI marsley CiI tálson pgI
eí alK
aeíecíáon of ceníral respáraíory evenís usáng pulse íransáí íáme án
toughíer MNK merkáns AMOI Baldassará CMK Is MoI kecessary án íhe bvaluaíáon of medáaírác Ceníral
oosen dMI phor ACI deller qgK pleep án cháldren wáíh cancerK Curr lpán medáaír OMMU; OM: STSJ
teáníraub ZI Alvaro oI hwáaíkowská hI
eí alK
bffecís of ánhaled oxygen Eup ío 4MBF on peráodác
ahamája oI teíjen kMI plocumb kiI
eí alK
qhe role of nocíurnal polysomnography án assessáng
hhaíwa rI oamgopal pI Mylavarapu AI
eí alK
MoI fándángs and sleep apnea án cháldren wáíh Cháará I
Addo khI gavadpour pI handasamy gI
eí alK
Ceníral sleep apnea and assocáaíed Cháará malformaíáon
án cháldren wáíh syndromác cranáosynosíosás: íreaímení and ouícome daía from a supraregáonal
eendersonJpmarí agI píeer mAK Caffeáne versus íheophylláne for apnea án preíerm ánfanísK Cochrane
gennáfer iK MállerI MKaK pleep aásordered Breaíháng án Infanís wáíh mraderJtállá pyndrome auráng
nuájanoJooy pI dalan iI cerreáro AI
eí alK
pevere progressáve form of congenáíal muscular dysírophy
wáíh calf pseudohyperírophyI macroglossáa and respáraíory ánsuffácáencyK keuromuscul aásord OMMO;
mánard gMI Azabou bI bssád kI
eí alK
pleepJdásordered breaíháng án cháldren wáíh congenáíal muscular
puresh pI tales mI aakán CI
eí alK
pleepJrelaíed breaíháng dásorder án auchenne muscular dysírophy:
iabanowská MI pchmádíJkowara tI duállemánaulí CK pleep and neuromuscular dásease: frequency of
sleepJdásordered breaíháng án a neuromuscular dásease clánác populaíáonK keurology NVVS; 4T: NNTPJ
hryger MeI píeljes adI vee tCI
eí alK
Ceníral sleep apnoea án congenáíal muscular dysírophyK g
auenasJMeza bI BazuríoJZapaía MAI dozal aI donzálezJdarcía MI auránJCaníolla gI qorresJauque
CAK lvernághí molysomnographác Characíerásíács and lxygen paíuraíáon of eealíhy InfanísI N ío NU
pchmádí BI ooberís opI aavás mI
eí alK
Caffeáne íherapy for apnea of premaíuráíyK k bngl g Med OMMS;
Bhaí ovI eannam pI mressler oI
eí alK
bffecí of prone and supáne posáíáon on sleepI apneasI and
AlJpaáf pI Alvaro oI Manfreda gI
eí alK
A randomázed conírolled íráal of íheophylláne
bdwards BAI pands pAI ceeney CI
eí alK
Coníánuous posáíáve aárway pressure reduces loop gaán and
BlochJpalásbury bI Indác mI Bednarek cI
eí alK
píabálázáng ámmaíure breaíháng paííerns of preíerm
mháláppá eI Báeber II oeáííer BK Aceíazolamáde íreaímení for ánfaníále ceníral sleep apneaK g Cháld
Zagol hI iake abI sergales BI
eí alK
AnemáaI apnea of premaíuráíyI and blood íransfusáonsK g medáaír
pzollosá II gones MI Morrell MgI
eí alK
bffecí of ClO ánhalaíáon on ceníral sleep apnea and arousals
hhayaí okI uáe AI maíel AhI
eí alK
Cardáorespáraíory effecís of added dead space án paíáenís wáíh
phore bqI Mállman omK Ceníral sleep apnea and aceíazolamáde íherapyK Arch Iníern Med NVUP; N4P:
kakayama eI pmáíh CAI oodman goI
eí alK
bffecí of veníálaíory dráve on carbon dáoxáde sensáíáváíy
mracíácal Consáderaíáons án íhe qreaímení of
aeparímení of líolaryngology— eead and keck purgeryI rnáversáíy of qexas pouíhwesíern
Absírací:
lbsírucíáve sleep apnea syndrome ElpApFI affecíáng abouí RB of all
cháldrenI has posáíáoned áíself ío be a major epádemáologácal problem án íhe rnáíed
píaíesK qhe prevalence of íhás condáíáon appears ío be áncreasáng over íámeI án parallel
wáíh íhe growíh án cháldhood obesáíyK medáaírác lpAp belongs ío a specírum of
respáraíory dásorders called sleepJdásordered breaíháng EpaBFI caused by varyáng
degrees of paroxysmal upper aárway obsírucíáon duráng sleepK iefí uníreaíedI lpAp
has poíeníáal ío progress over íámeI leadáng ío noí jusí fragmeníed sleepI buí also
neurocognáíáve problemsI and án íhe mosí severe ánsíancesI seráous cardáopulmonary
adverse effecísK qhe íreaímení of lpAp ánvolves a sírucíured seráes of síeps spannáng
medácal and surgácal approachesI áncludáng adenoíonsállecíomyI whách ás consádered
íhe gold síandard for managemení of cháldhood lpApK qhás chapíer provádes a reváew
of íhe epádemáology of lpApI followed by a dáscussáon of naíural hásíoryI íreaímení
heywords:
AdenoíonsállecíomyI lbesáíyI medáaírác obsírucíáve sleep apneaI
pleep ás a physáologácal síaíe of quáescence íhaí facáláíaíes recovery of body
funcíáonsK Mosí cardáopulmonary parameíers are mánámázed ío conserve energy
expendáíure duráng sleepK As a consequenceI veníálaíory dráve reaches an expecíed
nadár compared ío wakefulnessK oelaxaíáon of upper aárway musculaíure also
áncreases íhe preponderance íowards aárflow obsírucíáonK qhese changes
práncápally manáfesí án an overall reducíáon án veníálaíory volumes [
mreváous síudáes have clearly shown íhaí despáíe íhe íendency íowards upper
Correspondáng auíhor peckán lK rlualp
: aeparímení of líolaryngology—eead and keck purgeryI rnáversáíy of
qexas pouíhwesíern Medácal CeníerI aallasI qexasI rpA; qel: EON4F 4RSJPUSO; cax: EON4F S4UJVNOO; bmaál:
wáíhouí ságnáfácaní hándranceK eoweverI as funcíáon of ageI developmení and
changes án body physáologyI íhe íendency íowards obsírucíáon ás noí unáform
pleepJdásordered breaíháng EpaBF represenís a broad specírum of clánácal
dásordersI all of whách have paíhologác upper aárway obsírucíáon as íhe common
facíorK paB has coníánued ío grow án prevalence over íámeI and accounís for a
ságnáfácaní amouní of publác healíh burden [
zI wáíh esíámaíes rangáng from NJ
NRB by varáous síudáes [
zK Ií ás íherefore of paramouní ámporíance ío maáníaán a
qhe íerm paB encompasses íhree práncápal caíegoráesI based on íhe severáíy of
upper aárway obsírucíáonI and áncludes EáF prámary snorángI EááF upper aárway
resásíance syndrome ErAopF and EáááF obsírucíáve sleep apnea syndrome ElpApFK
Ií ás ío be noíed íhaí accuraíe dásíáncíáon beíween íhese íhree condáíáons requáres
dáagnosíác íesíángI specáfácally polysomnography EmpdFI also called a sleep síudy
In íhe máldesí form of paBI called prámary snorángI íhere ás áníermáííení nocíurnal
aárflow obsírucíáon íhaí resulís án íurbulence EsnorángF; however íhere are no
clánácal feaíures íhaí suggesí íhaí duraíáon and archáíecíure of sleep are abnormalK
mrámary snoráng has a conservaíáve esíámaíe of around TB accordáng ío one síudy
based on admánásíraíáon of a quesíáonnaáre ío parenís of cháldren án prámary
school [
zK In íhe same síudyI íhe auíhors also descrábed an assocáaíáon of íhe
condáíáon wáíh EáF presence of asíhma and EááF exposure ío cágareííe smokángK
eoweverI íhe uíáláíy of clánácal hásíory alone ío dásíánguásh beíween prámary
snoráng alone and more severe forms of paB has been quesíáoned án íhe pasí [
and íhás ás ámporíaní gáven íhaí snoráng seems ío be assocáaíed wáíh ságnáfácaní
neurobehaváoral defácáís án a subseí of cháldrenI possábly relaíed ío áncreased
suscepíábáláíy ío sleep fragmeníaíáon [
zK líhers have demonsíraíed íhaí prámary
rpper aárway resásíance syndrome occupáes an áníermedáaíe posáíáon án íhe
specírum of paBK qhás íerm was coáned ío descrábe a subseí of paíáenís who do
noí meeí íhe cráíeráa for lpAp by mpd síandardsI yeí íhey presení wáíh sympíoms
íhaí mosí closely resemble chronác upper aárway obsírucíáonK qhe
paíhophysáology of rAop has been relaíed ío abnormal maxállomandábular
anaíomyI and may respond ío oríhodoníác íreaímení [
qhe prevalence of pedáaírác paB and lpAp coníánue ío grow sánce íhere has been
a recení áncrease án awareness of íhe problemI yeí íhe vasí majoráíy remaán
undáagnosedK bpádemáologác esíámaíes place íhe populaíáon burden ío be aí abouí
TK4RB when esíámaíed by examánáng íhe prevalence by pareníal reporís of snoráng
zK qhe same meíaJanalysás by sírácí cráíeráa of
always snoráng
reporíed paB ío
be án íhe range of NKRJSB and when íhe cráíeráa changed ío
I íhe prevalence
áncreased ío PKOJN4KUBK Ií ás ío be noíed íhaí íhe prevalence of lpAp parallels íhe
oace ás an ándependení rásk facíor for paBI wáíh AfrácanJAmerácan cháldren
haváng greaíer preponderance íowards developáng íhe condáíáon [
zK eormonal
ánfluence on paB manáfesís án a slághí áncrease án prevalence among prepuberíal
boysI however íhás assocáaíáon has noí been consásíeníly demonsíraíed [
aespáíe a paucáíy of daía from very young cháldrenI áí ás generally regarded íhaí
qhe assocáaíáon beíween obesáíy and paB andLor lpAp ás unambáguousK Mosí
síudáes íhaí ánvesíágaíed íhás relaíáonsháp have generally concluded íhaí obesáíy
bnváronmeníal facíors play a role án áncreased suscepíábáláíy ío pedáaírác lpApI
and generally also ánclude ándácaíors of neághborhood dásadvaníage—specáfácally
facíors íhaí span EáF second hand smoke exposure and EááF low socáoeconomác
síaíus [
zK qhese facíors remaáned even afíer conírolláng for íhe effecís of
premaíuráíy and obesáíyK
A complex áníerplay of anaíomácal and physáologác facíors ás hypoíhesázed ío
conírábuíe ío developmení of upper aárway obsírucíáon as seen án pedáaírác lpApK
cáxed anaíomácal obsírucíáon may be aíírábuíed ío narrowáng aí íhe level of íhe
lumenI sofí íássue or íhe cranáofacáal skeleíon [
zK pecondary rásk facíors
orágánaíe from dásordered conírol of neuromuscular íone responsáble for
maáníaánáng upper aárway paíency duráng sleepK
qhe upper aárway án cháldren wáíh pedáaírác lpAp ás íhoughí ío be modeled as a
resásíor [
zI án whách aárflow obsírucíáon occurs as a funcíáon of íhe
closáng pressure wáíhán íhe aárway lumenI íermed cráíácal closáng pressure Em
qhás ándex ás a composáíe measure of boíh váscoelasíác and neuromuscular
properíáes of íhe upper aárwayK then m
falls below íhresholdI aárflow
obsírucíáon occurs consásíenílyK Cháldren wáíh lpAp are known ío have hágher
Maáníenance of neuromuscular íone ás esseníáal ío preveníáon of upper aárway
collapsábáláíy duráng sleepK mharyngeal dálaíor muscles ací íogeíher ío ámprove
aárflow by dálaíáon of íhe upper aárwayK Abnormaláíáes of neuromuscular íone as
seen án condáíáons such as aown syndrome may conírábuíe ío íhe áncreased
prevalence of lpAp án íhaí populaíáon [
karrowáng aí íhe level of íhe lumen ás mosí consásíeníly assocáaíed wáíh
hyperírophy of lymphoád íássues aí íhe level of oropharynx EíonsálsF and
nasopharynx EadenoádsFK qhás fándáng has a robusí assocáaíáon wáíh íonsállecíomy
and adenoádecíomy EqCAF leadáng ío ságnáfácaní ámprovemení of lpAp án mosí
cháldren [
zK kormal ageJrelaíed áncrease án lymphoád íássue íhaí íraáls íhe
expansáon of upper aárway may play a role án íhe áncreased áncádence seen án
cháldren under íhe age of R [
zK then examáned under general anesíhesáaI íhe
overall crossJsecíáon of íhe pharyngeal aárway án cháldren wáíh lpAp has been
shown ío be ságnáfácaníly reduced án comparáson wáíh normal cháldren wáíhouí
Clánácal evaluaíáon for suspecíed lpAp ás based prámarály on pareníal reporíáng
of sympíomsK Ií ás ámporíaní ío screen for lpAp even án healíhy cháldren gáven
píandardázed quesíáonnaáres have shown íhaí uníreaíed lpAp may be
consáderably deírámeníal for qualáíy of láfe EnliFI and íhaí íámely íreaímení such
as qCA provádes reláef [
zK qhe burden of pedáaírác lpAp on nli ás esíámaíed
qhe sympíoms of lpAp proceeds can be varáed across dáfferení age groups as
shown án qable
K pnorángI dayíáme sleepáness and abnormal behaváor are presení
more consásíeníly íhan oíher sympíoms án cháldren over íhe age of NO moníhsK
Alíhough snoráng ás a hallmark of upper aárway obsírucíáonI áí ás ámporíaní ío noíe
íhaí íhe presence of snoráng alone cannoí predácí íhe presence of lpAp as
opposed ío prámary snoráng alone [
zK Alíhough excessáve dayíáme sleepáness has
been shown ío be assocáaíed wáíh undáagnosed lpApI íhás ás observed more
frequeníly án adulís as cháldren appear ío presení wáíh hyperacíáváíy raíher íhan
sleepánessK In íhese cháldrenI íhe specírum of behaváoral problems spans lack of
aííeníáonI aggressáon and poor academác performance [
zK kocíurnal enuresás ás
also known ío occur wáíh an áncreased frequency án cháldren wáíh lpApI and íhás
may aíírábuíed ío íhe effecí of lpAp on íhe arousal responseI bladder pressure or
uránary hormone secreíáon [
zK qhe alíeraíáon án vascular responses ío uníreaíed
lpAp may progress ío hyperíensáon wáíh a poíeníáal áncrease án rásk of fuíure
cardáovascular dásease [
zK cew case seráes have documeníed decreased growíhI
rághí venírácular dysfuncíáon as well as meíabolác syndromes áncludáng ánsulán
qable NK Comparáson of varáous surgácal procedures ándácaíed for íreaímení of lpApI wáíh íheár ádeal
koíwáíhsíandáng íhe heíerogeneous naíure of sympíoms assocáaíed wáíh pedáaírác
lpApI íhe consíaníly áncreasáng role of obesáíy meráís dáscussáonK peveral large
populaíáon síudáes have demonsíraíed clear assocáaíáonI and screenáng for lpAp
án obese cháldren ás of paramouní ámporíanceK rsáng relaíávely conservaíáve
cráíeráaI íhe prevalence of lpAp ás beíween OO and 4MB án obeseI yeí oíherwáse
qhe mosí resáláení assocáaíáon beíween lpAp and physácal examánaíáon fándángs
has been seen án íhe form of hyperírophy of lymphoád íássue wáíhán íhe palaíáne
íonsáls EcágK
F and íhe nasopharynxI whách manáfesís as adenoíonsállar
hyperírophy [
qhás reflecís favorably án íreaímení response ío qCAI even án paíáenís wáíh oíher
poíeníáal obsírucíáonI such as obese cháldrenK lbjecíáve assessmenís of poíeníáal
probabáláíy of lpApI as well as ío gauge poíeníáal response ío fársí láne íreaímení
cágK ENFK
eyperírophy of íonsállar íássueK qhe gradáng of íonsállar hyperírophy ranges from M Eno íonsállar
A rouíáne head and neck examánaíáon should be performed án all cháldren
suspecíed ío have lpAK qhe fársí sáíe of obsírucíáon ás íhe nasal caváíy as well as
íhe nasopharynx; more commonlyI nasal aárflow obsírucíáon could occur as a
resulí of nasal sepíal deváaíáon as well as ánferáor íurbánaíe hyperírophyK kasal
aárflow obsírucíáon occurráng very early án láfe should prompí evaluaíáon for
obsírucíáon resulíáng from congenáíal masses or anaíomácal malformaíáons such as
choanal aíresáa and congenáíal pyráform aperíure síenosásK In older cháldren wáíh
hásíory of allergáesI aníeráor rhánoscopy may reveal nasal polyposás án
combánaíáon wáíh ánferáor íurbánaíe hyperírophyK
píandardázed scales exásí for assessmení of íonsál sáze EMJ4HF as well as palaíe
posáíáon [
zK Alíhough íhese have a subjecíáve componení based on áníerpreíaíáon
by íhe examánáng clánácáanI objecíáve assessmenís from paíáenís undergoáng qCA
barly onseí of upper aárway obsírucíáon resulíáng án sírádor may poání ío
laryngomalacáaI whách ás relaíed ío sírucíural ámmaíuráíy of íhe laryngeal
frameworkK moor weághí gaánI cyanoíác spells and apneác evenís may followI
whách may requáre a flexáble endoscopác assessmení for confármaíáon of dáagnosás
zK In addáíáonI mosí cháldren wáíh dásorders of íone resulíáng án upper aárway
obsírucíáon presení early án láfeI and lpAp ás more lákely ío persásí even afíer
pírucíural varáaíáon of cranáofacáal morphology as deíermáned by radáologácal
síudáes usáng síandard meírács of facáal growíh have hághlághíed a role for
qhe combánaíáon of a long faceI reduced nasal prománence and wádíhI and a
reírognaíhác mandáble represení a consíellaíáon of cranáofacáal feaíures of paB
íhaí may warraní a referral ío specáalásís for íhe evaluaíáon of oíher clánácal
sympíoms [
aáagnosás of pedáaírác lpAp follows clánácal suspácáonI hásíory and physácal
examánaíáon fándángsI wáíh confármaíáon usáng síandard overnághí
polysomnography EmpdFK
kumerous dáagnosíác íools have been proposed for confármaíáon of dáagnosás of
lpApK qhe role of mpd has been consádered ío be íhe gold síandard for íhás
purposeK Alíhough oíher dáagnosíác modaláíáes coníánue ío be devásedI íhey are
ofíen abbreváaíed derávaíáves of mpd and íheár uíáláíy has never been compleíely
provenK Consensus síaíemenís [
z have been esíabláshed consoládaíáng
respáraíory ándácaíáons for performáng mpd án cháldren [
z as well as normaíáve
molysomnography for cháldren áncludes several modáfácaíáons áníended ío ámprove
íhe reláabáláíy and valádáíy of dáagnosásK qhese ánclude a cháldJfráendly approach
aímosphere and approachI smaller and specáalázed equápmeníI and compráse ageJ
adjusíed ruled for scoráng and áníerpreíaíáon of mpds [
zK molysomnography does
record from mulíáple channels of physáologác ánformaíáonI áncludáng
elecíroencephalographyI elecíromyographyI elecírooculographyI cardáac rhyíhmI
pulse oxámeíry aríeráal oxygen saíuraíáon Eppl
FI chesí wall and abdomen moíáonI
qhe práncápal parameíer used ío deíermáne íhe severáíy of lpAp from a mpd ás
called íhe apneaJhypopnea ándex EAeIFK qhe manner án whách AeI ás deíermáned
án cháldren ás slághíly dáfferení when compared wáíh adulísI owáng ío íhe fasíer
respáraíory raíe as observed án íhe pedáaírác populaíáon [
zK lbsírucíáve apnea ás
compleíe cessaíáon of aárflow over íwo respáraíory cyclesI and hypopnea ás
defáned as a RMB reducíáon án aárflow assocáaíed wáíh an arousalI or� "e PB
desaíuraíáonK lbsírucíáve evenís occur more frequeníly duráng obM sleepI and
hence a suffácáení proporíáon of obM sleep needs ío be presení ío accuraíely
deíermáne íhe presence and severáíy of lpApK Alíhough íhere are noí enough
síudáes deíermánáng íhe prognosíác ságnáfácance of AeI on morbádáíyI for all
pracíácal purposesI an AeI� "e N buí Y R ás consádered máld lpApI wáíh moderaíe
and severe lpAp beáng AeI� "e R and� "e NM respecíávelyK Mosí pracíáíáoners choose
qhe value of mpd án íhe seííáng of íreaímení of lpAp needs ío be carefully
weághed agaánsí cosís as well as avaálabáláíyK If all cháldren wáíh paB were ío geí
mpd for confármaíáon of dáagnosásI íhás can force a subsíaníáal amouní of síress on
economác resourcesK Alíhough almosí all guádelánes generally íake íhás ánío
consáderaíáonI consensus síaíemenís from dáfferení organázaíáons do have slághí
qhe clánácal pracíáce guádelánes from íhe Amerácan Academy of medáaírács [
recommends mpd as íhe fársí láne dáagnosíác íesí án
all paíáenís
wáíh snoráng
wáíh suspácáon
for pedáaírác lpAK qhese guádelánes also suggesí referral ío a
specáalásíI such as a sleep physácáan or an oíolaryngologásí for furíher evaluaíáon
and managemeníK qhe Amerácan Academy for líolaryngology—eead and keck
purgery [
z on íhe oíher hand deíermáned íhaí íhe fársí síep án íhe managemení of
cháldhood paB ás qCAI wáíh mpd ándácaíed án paíáenís preseníáng wáíh medácal
comorbádáíáesI or án whom íhe dáagnosás ás unceríaán due ío dáscordance beíween
Abbreváaíed íesíáng deráved from fullJpanel mpds coníánue ío undergo valádaíáon
several síudáesK rnforíunaíelyI íheár value án íhe dáagnosás of lpAp has noí
been fully esíabláshedK eoweverI án íhe ádeal seííángI and specáfácally án oíherwáse
healíhy cháldrenI íesís such as nocíurnal oxámeíry could esíablásh a defánáíáve
dáagnosás for síraághíforward lpAp due ío adenoíonsállar hyperírophy án older
cháldrenI or aí leasí ádeníáfy íhose cháldren who can undergo defánáíáve dáagnosás
pcreenáng meíhods usáng quesíáonnaáres have been descrábed án láíeraíureK
Cherván
eí alK
z fársí descrábed íhe pedáaírác sleep quesíáonnaáre EmpnFI whách
has been shown ío have moderaíe correlaíáon wáíh a dáagnosás of lpApI buí only
qhere are several meíhods are used ío deíermáne íhe degree of obsírucíáon wáíhán
íhe upper aárwayK qhese ánclude EáF cephalomeíry [
zI EááF drug ánduced sleep
endoscopy [
z and EáááF cáne magneíác resonance ámagáng [
zK aue ío íhe
addáíáonal cosísI use of anesíhesáa or exposure ío áonázáng radáaíáon án íhese
meíhodsI íhey are only used án íhe coníexí of persásíení lpAp afíer ánáíáal
íreaímení wáíh qCA EcágK
cágK EOFK
Cáne MoI for localázaíáon of upper aárway obsírucíáonK In íhás qNJweághíed sequence from a cháld
wáíh persásíení lpA afíer qCAI íhe hághlághíed area shows narrowáng of íhe upper aárway from pharyngeal
aue ío íhe rásk of morbádáíy as a resulí of uníreaíed lpApI mosí clánácáans choose
ío íreaí even máld lpApK A large number of íreaímení opíáons do exásíI and may
qhe fársí láne íreaímení opíáon for lpA ás qCAK qhere ás robusí evádence íhaí
shows subsíaníáal íherapeuíác response ío qCA even when comorbádáíáes are
preseníK rnless clear surgácal coníraándácaíáons exásíI qCA should be consádered
án every cháld wáíh lpAK In a síudy of TV cháldren who underwení qCA for lpA
showed dramaíác ámprovemení án respáraíory parameíers as measured by mpd án
íhe majoráíy of cháldrenI wáíh resulíáng áncrease án qualáíy of láfe [
zK qhás was
confármed by a large randomázed conírolled íráalI whách also demonsíraíed íhaí
early qCA leads ío greaíer ámprovemenís án behaváoralI qualáíy of láfe and mpd
qonsállecíomy and adenoádecíomy ás performed by an oíolaryngologásí under
general anesíhesáaI wáíh a varáeíy of íechnáques rangáng from cold dássecíáon of
íhe íonsáls ío use of elecírocauíery or even radáofrequency ablaíáonK Alíernaíáng
doses of ábuprofen and aceíamánophen prováded an effecíáve íreaímení for posíJ
íonsállecíomy paán án íhe majoráíy of cháldren and dád noí áncrease raíe of bleedáng
zK aue ío alíeraíáons án veníálaíory conírol án cháldren wáíh lpApI opáoáds are
generally noí prescrábed for paán conírol currenílyK qáíraíed dosáng of opáoáds as
parí of modáfáed anesíheíác proíocols has also been shown ío ámprove recovery
followáng qCA [
zK qhe overall rásk of bleedáng ás abouí RJNMB [
zI unaffecíed
by íhe surgácal íechnáque or peráoperaíáve medácaíáonsK Any ságnáfácaní bleedáng
án íhe posíoperaíáve peráod requáres hospáíalJbased observaíáon aí íhe mánámumI
Alíhough mosí qCAs are performed as ouípaíáení surgácal proceduresI some
cháldren wáíh rásk facíors for peráoperaíáve obsírucíáve evenís requáre admássáon ío
A subseí of paíáenís are aí rásk of recádávásm despáíe qCAK qeenagers and cháldren
wáíh obesáíyI comorbádáíáes áncludáng neurologácalLdevelopmeníalLcranáofacáal
abnormaláíáes alone or án combánaíáon wáíh asíhmaI or severe lpA have a hágh
rásk of resádual lpA [
zK qhese paíáenís are subsequeníly referred ío íhe sleep
physácáan for poíeníáally consáderáng coníánuous posáíáve aár pressure ECmAmF
íherapyK Alíhough CmAm ás hághly effecíáve án íhe managemení of resádual lpApI
compláance ás very low [
zK In some ánsíancesI ánhaled nasal coríácosíeroáds án
combánaíáon wáíh sysíemác aníáJánflammaíory íherapy E
oral leukoíráene
ánhábáíorsF are successful for íreaímení of máld resádual lpA [
líher surgácal meíhods used for íhe íreaímení of pedáaírác lpAp are summarázed
án qable
K qhese are mosí commonly used for persásíení lpAp despáíe qCAK
Addáíáonal evaluaíáon usáng one of íhe meíhods descrábed án íhe secíáon on
mosí defánáíáve íherapy for lpAp and leads ío compleíe resoluíáon án NMMB of
paíáenísK Ií ás reserved for áníracíable and very severe lpAp wáíh downsíream
necessáíy for repeaí posíJíonsállecíomy mpd has noí been esíabláshedI áí should be
consádered án paíáenís wáíh hágher rásk of persásíenceI áncludáng obese paíáenísI
qhere ás clear evádence from adulí paíáenís wáíh lpAp ío suggesí íhaí upper
aárway collapsábáláíy ás ámproved followáng weághí conírolI wáíh a correspondáng
áncrease án aárflow as well as decrease án pharyngeal closáng pressures [
zK táíh
íhe robusí relaíáonsháp beíween obesáíy and lpApI weághí managemení should be
consádered án íhese cháldrenI and should be íhe maánsíayI along wáíh CmAm
íherapy án whom lpAp ás persásíení despáíe qCA [
I
táíh rásáng prevalenceI pedáaírác lpAp coníánues ío conírábuíe ío ságnáfácaní
epádemáologác burden án íhe rKpK and elsewhereK pcreenáng ás cráíácal ío prevení
cardáopulmonary and neurobehaváoral adverse effecís of íhe condáíáonK Mosí
cháldren wáíh lpAp are íreaíed effecíávely by qCAI whách addresses íhe mosí
lákely sáíe of upper aárway obsírucíáon due ío adenoíonsállar hyperírophyK
Alíhough success raíes are very hághI íhe rásáng proporíáon of cháldren wáíh
obesáíy ás causáng an áncrease án number of cháldren wáíh persásíení lpApK
qreaímení opíáons for persásíení lpAp coníánue ío evolve and are prámarály based
on a íráal of CmAm íherapy ánáíáally and opíáons such as mulíáJlevel sleep surgery
exercásed for nonJcompláance wáíh CmAm íherapyK AníáJánflammaíory
medácaíáons and nasal coríácosíeroáds have an adjuncíáve roleK
táíh an alarmáng áncrease án íhe prevalence of cháldhood obesáíyI íhe economác
and publác healíh cosís of cháldhood lpAp wáll be unsusíaánable by íhe presení
healíh care sysíemK Ií ás íherefore of paramouní ámporíance ío examáne opíáons for
[NzMarcus CiK pleepJdásordered breaíháng án cháldrenK Am g oespár Cráí Care Med OMMN; NS4ENF: NSJPMK
qabachnák bI Muller kiI Bryan ACI ieváson eK Changes án veníálaíáon and chesí wall mechanács
oedláne pI qáshler m sI pchluchíer MI Aylor gI Clark hI draham dK oásk facíors for sleepJdásordered
breaíháng án cháldrenK Assocáaíáons wáíh obesáíyI raceI and respáraíory problems Am g oespár Cráí Care
Bonuck hAI Cherván oaI Cole qgI
eí alK
mrevalence and persásíence of sleep dásordered breaíháng
Marcus C iI lmlán h gI Basánká a gI
eí alK
kormal polysomnographác values for cháldren and
brsu oI Arman AoI pave aI
eí alK
mrevalence of snoráng and sympíoms of sleepJdásordered breaíháng
Carroll giI McColley pAI Marcus CiI Curíás pI ioughlán dMK Inabáláíy of clánácal hásíory ío
dásíánguásh prámary snoráng from obsírucíáve sleep apnea syndrome án
cháldrenK Chesí NVVR; NMUEPF:
l’Bráen iMI Mervás CBI eolbrook CoI
eí alK
keurobehaváoral ámplácaíáons of habáíual snoráng án
Marcus CiI eamer AI ioughlán dMK kaíural hásíory of prámary snoráng án cháldrenK medáaír mulmonol
duállemánaulí CI hhramísov AK rpper aárway resásíance syndrome án cháldren: a clánácal reváewK
iumeng gCI Cherván oaK bpádemáology of pedáaírác obsírucíáve sleep apneaK mroc Am qhorac poc
gohnson blI ooíh qK An epádemáologác síudy of sleepJdásordered breaíháng sympíoms among
adolescenísK pleep OMMS; OVEVF: NNPRJ4OK
Zhang dI ppáckeíí gI oumchev hI iee AeI píáck pK pnoráng án prámary school cháldren and domesíác
Capdevála lpI hheárandáshJdozal iI aayyaí bI dozal aK medáaírác obsírucíáve sleep apnea:
complácaíáonsI managemeníI and longJíerm ouícomesK mroc Am qhorac poc OMMU; REOF: OT4JUOK
null aelasneráeJiaupreíreI null maíoásI null salaíxI null hauffmannI and null AlperováíchI “pleepI
ppálsbury gCI píorferJIsser AI hárchner eiI
eí alK
keághborhood dásadvaníage as a rásk facíor for
haíz bpI a’Ambrosáo CMK maíhophysáology of pedáaírác obsírucíáve sleep apneaK mroc Am qhorac poc
cregosá o cI nuan p cI Morgan t iI
eí alK
mharyngeal cráíácal pressure án cháldren wáíh máld sleepJ
Marás MI serhulsí pI tojcáechowská MI san de eeynáng mI Boudewyns AK mrevalence of lbsírucíáve
Máíchell oBK Adenoíonsállecíomy for obsírucíáve sleep apnea án cháldren: ouícome evaluaíed by preJ
Arens oI Marcus CiK maíhophysáology of upper aárway obsírucíáon: a developmeníal perspecíáveK
Isono pI phámada AI rísugá MI honno AI kásháno qK Comparáson of síaíác mechanácal properíáes of
íhe passáve pharynx beíween normal cháldren and cháldren wáíh sleepJdásordered breaíháng Am g
Baldassará CMI Máíchell oBI pchuberí CI oudnáck bcK “medáaírác obsírucíáve sleep apnea and qualáíy
of láfe: a meíaJanalysásI” líolaryngolKJeead keck purgK lffK gK AmK AcadK líolaryngol eead keck
doííláeb agI Chase CI sezána oMI
eí alK
pleepJdásordered breaíháng sympíoms are assocáaíed wáíh
[ORzBrooks igI qopol eIK bnuresás án cháldren wáíh sleep apneaK g medáaír OMMP; N4OERF: RNRJUK
hang hJqI Cháu pJkI teng tJCI iee mJiI esu tJCK Analysás of O4Jeour Ambulaíory Blood
mressure Monáíoráng án Cháldren táíh lbsírucíáve pleep Apnea: A eospáíalJBased píudy Medácáne
AlonsoJÁlvarez MiI CorderoJduevara gAI qeránJpaníos gI
eí alK
lbsírucíáve sleep apnea án obese
eoward kpI Bráeízke pbK “medáaírác íonsál sáze: objecíáve vs subjecíáve measuremenís correlaíed ío
overnághí polysomnogramI” líolaryngolKJeead keck purgK lffK gK AmK AcadK líolaryngol eead keck
Zafereo MbI qaylor ogI mereára haK pupragloííoplasíy for laryngomalacáa wáíh obsírucíáve sleep
doldberg pI phaíz AI mácard bI
eí alK
bndoscopác fándángs án cháldren wáíh obsírucíáve sleep apnea:
Al Alá AI oáchmond pI mopaí eI
eí alK
qhe ánfluence of snorángI mouíh breaíháng and apnoea on facáal
Marcus C iI Brooks i gI araper h AI
eí alK
Amerácan Academy of medáaírácsK aáagnosás and
Aurora o kI Zak o pI haráppoí AI
eí alK
Amerácan Academy of pleep MedácáneK mracíáce parameíers
MonígomeryJaowns ebI dozal aK pnoreJassocáaíed sleep fragmeníaíáon án ánfancy: meníal
developmení effecís and conírábuíáon of secondhand cágareííe smoke exposureK medáaírács OMMS;
[PRzBeck pbI Marcus CiK mbaIAqoIC mlivplMkldoAmevK pleep Med Clán OMMV; 4EPF: PVPJ4MSK
ooland mpI oosenfeld oMI Brooks igI
eí alK
Clánácal mracíáce duádeláne molysomnography for pleepJ
aásordered Breaíháng mráor ío qonsállecíomy án CháldrenK líolaryngol eead keck purg OMNN; N4RENF
Cherván oaI teaíherly oAI dareíz piI
eí alK
medáaírác sleep quesíáonnaáre: predácíáon of sleep apnea
lzdemár eI Alíán oI pöğüí AI
eí alK
Cranáofacáal dáfferences accordáng ío AeI scores of cháldren wáíh
obsírucíáve sleep apnoea syndrome: cephalomeírác síudy án PV paíáenísK medáaír oadáol OMM4; P4ERF:
rlualp plI pzmuk mK arugJánduced sleep endoscopy for upper aárway evaluaíáon án cháldren wáíh
plaaís MAI san eoorenbeeck hI san byck AI
eí alK
rpper aárway ámagáng án pedáaírác obsírucíáve
Marcus C iI Moore o eI oosen C iI
eí alK
Cháldhood Adenoíonsállecíomy qráal ECeAqFK A
randomázed íráal of adenoíonsállecíomy for cháldhood sleep apneaKk bngl g Med OMNP; PSUEORF: OPSSJ
iáu CI rlualp plK luícomes of an Alíernaíáng Ibuprofen and Aceíamánophen oegámen for maán oeláef
Isaáah AI mereára haK luícomes afíer adenoíonsállecíomy usáng a fáxed anesíhesáa proíocol án cháldren
oággán iI oamakráshna gI pommer aaI horen dK “A OMNP updaíed sysíemaíác reváew C meíaJanalysás
of PS randomázed conírolled íráals; no apparení effecís of non síeroádal aníáJánflammaíory agenís on
íhe rásk of bleedáng afíer íonsállecíomyI” ClánK líolaryngolK lffK gK bkqJrh lffK gK keíhK pocK líoJ
Imangulá MI rlualp plK oásk facíors for resádual obsírucíáve sleep apnea afíer adenoíonsállecíomy án
Marcus CiI oosen dI tard piI
eí alK
Adherence ío and effecíáveness of posáíáve aárway pressure
hheárandásh iI doldbarí AaI dozal aK Iníranasal síeroáds and oral leukoíráene modáfáer íherapy án
resádual sleepJdásordered breaíháng afíer íonsállecíomy and adenoádecíomy án cháldrenK medáaírács
Cosía agI Máíchell oK “Adenoíonsállecíomy for obsírucíáve sleep apnea án obese cháldren: a meíaJ
analysásI” líolaryngolKJeead keck purgK lffK gK AmK AcadK líolaryngol eead keck purg OMMV;
pchwaríz A oI dold A oI pchuberí kI
eí alK
bffecí of weághí loss on upper aárway collapsábáláíy án
duállemánaulí CI iee geI Chan AK medáaírác obsírucíáve sleep apnea syndromeK Arch medáaír Adolesc
Cáelo CMI dungor AK qreaímení opíáons for pedáaírác obsírucíáve sleep apneaK Curr mrobl medáaír
píaíe of íhe Arí of íhe aáagnosás and Managemení
aeparímení of medáaírácsI aávásáon of dasíroeníerology and eepaíologyI rnáversáíy of qexas
Absírací:
Involuníary passage of gasírác coníenís ánío íhe esophagus may be
physáologác Edasíroesophageal oefluxJdboF or may be assocáaíed wáíh íroublesome
sympíoms Edasíroesophageal oeflux dáseaseJdboaFK dbo ás common án ánfanís and ás
relaíed ío ámmaíure aníá reflux mechanásmsK ln íhe oíher handI dboa needs furíher
evaluaíáonK mreseníáng feaíures of boíh ánclude esophageal sympíoms láke vomáíáng and
exíra esophageal sympíoms such as árráíabáláíyI reflux laryngáíásI pharyngáíás and deníal
erosáonsK rpper dI seráes ás noí recommended for dáagnosáng dboaK qradáíáonal pe
probe examánaíáons have been replaced largely by combáned mulíáJchannel Impedance
–pe monáíoráng whách helps esíablásh a íemporal relaíáonsháp beíween sympíoms and
paíhologácal refluxI as well as asceríaán íhe acádác
non acádácI solád
or gas naíure of íhe refluxaíeK mroíon pump ánhábáíors remaán íhe maánsíay of íreaímeníI
along wáíh eO recepíor aníagonásís and prokáneíác agenísK purgácal áníerveníáon should
heywords:
AníacádsI Bravo pe monáíorángI Combáned Mulíáple Iníralumánal
Impedance EMIIF and pe MonáíorángI bndoscopyI bsophageal manomeíryI dboI
dboaI iáfesíyle changesI ManáfesíaíáonsI me monáíorángI mrevalenceI
mrokáneíácsI rpper dI ámagángK
dasíroesophageal reflux EdboF ás a normal physáologácal process án whách íhere
ás an ánvoluníary passage of gasírác coníenís ánío íhe esophagusK Mosí of íhe
reflux epásodes are asympíomaíácI haváng shorí duraíáonI occurráng several íámes
per dayI paríácularly afíer meals and lámáíed ío íhe dásíal esophagusK CommonlyI a
reflux epásode resulís from a íransáení relaxaíáon of íhe lower esophageal
spháncíer EibpFK líher causes ánclude áncreased abdománal pressure noí
Correspondáng auíhor oánaraná panghavá
: aeparímení of medáaírácsI aávásáon of dasíroeníerology and eepaíologyI
rnáversáíy of qexas pouíhwesíern Medácal CeníerI aallasI quI rpA; qel: EON4F 4RSJPUSO; cax: EON4F S4UJVNOO;
ibp pressure ás reducedK mhysáologác dbo ás a reflux epásode assocáaíed wáíh
regurgáíaíáon or occasáonally vomáíáng duráng íhe fársí moníhs of láfe or án íhe
absence of sympíomsK dbo ás a frequeníly encouníered problem án ánfancy and
íends ío selfJresolve [
zK dasíroesophageal reflux dásease EdboaF ás when reflux
of gasírác coníenís ás íhe cause of íroublesome sympíoms andLor complácaíáons
such as esophagáíásI nuíráíáonal compromáseI respáraíory complácaíáons or poor
assocáaíed wáíh a number of geneíác syndromes such as Corneláa de iangeI
chromosomal abnormaláíáes such as qrásomy ONI báríh defecís such as congenáíal
dáaphragmaíác hernáaI omphalocele and gasíroschásásI and neurologác condáíáons
oegurgáíaíáonI a common manáfesíaíáon of reflux án ánfaní and older cháldrenI ás
defáned as efforíless passage of refluxed gasírác coníenís ánío íhe oropharynx or
aboveI whále vomáí ás defáned as forceful expulsáon of íhe refluxed gasírác
coníenís from íhe mouíh [
zK ln íhe oíher handI rumánaíáon ás defáned as
voluníary coníracíáon of íhe abdománal muscles resulíáng án regurgáíaíáon of
receníly ángesíed food íhaí ás subsequeníly spáííed up or reJswallowedK qhás
requáres a dáfferení dáagnosíác and íreaímení algoráíhm íhan reflux and ás beyond
íhe scope of íhás reváewK qhe reader ás referred ío íhe oome III cráíeráa for furíher
dbo ás exíremely common án healíhy ánfanís occurráng PM or more íámes a day [
ManyI buí noí allI epásodes of íhese reflux epásodes resulí án regurgáíaíáon ánío íhe
oral caváíyK CommonlyI íhe frequency of reflux epásodes decreases wáíh
áncreasáng ageI and ás unusual án cháldren older íhan NU moníhs old [
I
I
zK qhe
prevalence of dbo án older cháldren and adolescení ás esíámaíed ío be as hágh as
NMB wáíh SB haváng dboa [
zK qhere ás a hágher prevalence of dboa án
paíáenís wáíh neuromuscular dásorders such as muscular dysírophy and cerebral
qransáení lower esophageal spháncíer relaxaíáons EqibposF or ánadequaíe
common mechanásms causáng dbo aí any age [
zK qhás relaxaíáon ás a neural
reflexI íhrough íhe vagal nerve causáng acíávaíáon of áníramural ánhábáíory
neuronsI releasáng náírác oxáde locally promoíáng relaxaíáon of íhe ibpK dbo ás
ánfluenced by geneíác Eqable
FI enváronmeníal EalcoholI smokángI drugsI foodI
weághíFI anaíomácI hormonal and neurogenác facíorsK In ánfanísI dbo ás mosí
common as íhey ángesí more íhan íwáce íhe volume íhan adulís per kálogram body
weághí and feed more frequení causáng more qbpiosK aelayed gasírác empíyángI
abnormal gasírác accommodaíáon has been descrábed án paíáenís wáíh dboa [
zK Anaíomácal causes ánclude háaíal hernáa whách áncreases íhe number of reflux
qhere are íhree major íáers of defense íhaí serve ío lámáí íhe degree of dbo and
mánámáze íhe rásk of refluxJánduced ánjuryK qhe fársí láne ás íhe aníáreflux barráer
consásíáng of íhe ibpI dáaphragmaíác pánchcock and angle of eásK qhe second láne
ás íhe esophageal clearance consásíáng of graváíyI esophageal perásíalsásI salávary
and esophageal secreíáonsK qhe íhárd láne ás íhe esophageal mucosal defense
EbácarbonaíeI mucánI prosíaglandán bOI íághí juncíáonsI
pympíoms of dboa may be dáváded ánío esophageal and exíra esophageal
sympíomsK Eqable
FK bsophageal sympíoms ánclude íypácal sympíoms such as
hearíburnI vomáíángI waíer brash Esour íasíe aí íhe back of mouíhFI and epágasírác
abdománal paán especáally worse afíer eaíáng spácy foodsK aysphagáa ás also
íhoughí ío be a sympíom of dboaI especáally common án younger cháldren EY N
year of ageFK Archáng of íhe back Epandáfer syndromeF ás a common preseníaíáon
of dboa án ánfanísK Ií ás dáffáculí ío rely on sympíoms án cháldren less íhan N year
of age due ío íheár ánabáláíy ío accuraíely verbaláze sympíomsK qhese sympíoms
also do noí always resolve wáíh acád suppressáon íherapy án íhe fársí year of láfeI
bxíra esophageal sympíoms of dboa have been documeníed for several years
nowK IrráíabáláíyI cougháng [
I
zK ChokángI wheezángI sore íhroaíI voáce
hoarsenessI deníal erosáons and reflux assocáaíed laryngáíás or pharyngáíás have
In any paíáení wáíh suspecíed dboa noí respondáng ío adequaíe íherapyI
paríácularly án cháldren wáíh dysphagáa and chokángI eosánophálác esophagáíás
should be consádered án íhe dáffereníáal dáagnosásK bosánophálác esophagáíás has a
clánácal preseníaíáon sámálar ío dboaI and as of íhe wráíáng of íhás paperI íhe only
reláable means ío dáagnose íhás eníáíy remaáns hásíory E
clánácal sympíomsF
along wáíh áncreased áníra esophageal eosánopháls on R or more esophageal báopsy
specámens obíaáned
endoscopyK Ií ás ámporíaní ío noíe íhaí íhe paíáení should
have receáved SJU weeks of good acád suppressáon íherapy práor ío íhás evaluaíáon
ío rule ouí any confoundáng role íhaí acád may play án esophageal eosánopháláa
zK bnsuráng íhaí íhe cháld ás noí solely on an elemeníal formula before íhe
endoscopy ás an ámporíaní clánácal consáderaíáon as íhás may confound normal
YN year of
oecurrení vomáíángI feedáng refusalI
paánful swallowáng
Archáng of backI poor weághí gaánI árráíabáláíyI sleep
NJR years
of age
somáíángI abdománal paánI feedáng
CoughI nocíurnal coughI pneumonáaI chokángI sore
íhroaíI voáce hoarsenessI deníal erosáonsI laryngáíásI
> R years
of age
eearíburnI nonJcardáac chesí paánI
nocíurnal abdománal epágasírác paánI
dysphagáaI waíer brash Esour burpsFI
Above as well as vocal cord nodulesI íooíh sírucíure
Adolescenís and older cháldren should be asked abouí íheár sympíoms dárecíly
raíher íhan askáng íheár parenísK In a síudyI adolescenís were ságnáfácaníly more
lákely ío reporí sympíoms of nausea or sour burps íhemselves as compared ío
qhe key poání án dáagnosás ás ío esíablásh áf íhe paíáení has dbo
dboaK qhás
can be esíabláshed wáíh a good clánác hásíory and physácal examánaíáon án mosí
casesK In older cháldren and adulísI íhe dáagnosás of dboa ás maánly based on
clánácal hásíoryI however án younger cháldrenI íhe hásíory ás dáffáculí ío elácáí and
found ío be poorly reláable up ío íhe age of aí leasí U [
zK Because of íhás
dáffáculíy án obíaánáng íhe hásíoryI dáagnosíác procedures are used for beííer
manáfesíáng maánly
exíra esophageal sympíoms or án cháldren noí respondáng
ío usual managemení of dboaK koí all íesís need ío be performed án all cháldren
as dáfferení íesís prováde dáfferení dáagnosíác ánformaíáonK In cases of coníánued
doubí of dáagnosásI áí ás recommended íhaí íhe paíáení be seen aí a
mulíádáscáplánary aerodágesíáve clánácK
A good and íhorough hásíory and clánácal examánaíáon remaáns íhe fársí dáagnosíác
síep for dboaI and án mosí cases ás suffácáení ío esíablásh a dáagnosásK A number
of valádaíed quesíáonnaáres have been developed for dboaI and may be used for
qhe use of upper dI írací ámagáng such as a baráum upper dI seráes ás klq ío be
used ío dáagnose dboaK qhás ás because án íhe bráef duraíáon of íhe síudyI reflux
epásodes may occur nonJpaíhologácallyI and reflex seen on a baráum síudy does
noí correlaíe wáíh severáíy of dboa or severáíy of esophageal ánflammaíáonK
qhusI recení guádelánes síaíe íhaí íhás íesí ás noí jusíáfáed ío dáagnose dbo or
dboaK oaíherI íhás íesí ás besí used for assessáng anaíomác abnormaláíáes án a
bsophageal pe monáíoráng measures íhe áncádence and duraíáon of acád refluxI
however íhe severáíy of paíhologác acád reflux does noí correlaíe consásíeníly wáíh
sympíom severáíy or demonsírable complácaíáonsK bsophageal pe monáíoráng ás
useful án evaluaíáng íhe effecí of a íherapeuíác áníerveníáon on reducáng
esophageal acád exposureK Ií may be useful ío correlaíe sympíoms E
I coughI
chesí paánF wáíh acád reflux epásodes and ío selecí íhose ánfanís and cháldren wáíh
wheezáng or respáraíory sympíoms án whách dbo ás an aggravaíáng facíorK qhe
sensáíáváíyI specáfácáíyI and clánácal uíáláíy of pe monáíoráng for dáagnosás and
managemení of possáble exíraJesophageal complácaíáons of dbo are noí well
esíabláshedK pome of íhe lámáíaíáons of pe monáíoráng are íhaí áí only records
acádác reflux epásodesI íhus mássáng nonJacádác reflux epásodes as well as íhaí áí
qhás ás sámálar ío esophageal pe monáíoráng án íhaí áí records acádác reflux
epásodesI buí án íhás case íhere ás a small capsuleI abouí íhe sáze of a gel capI íhaí
ás íemporarály aííached ío íhe wall of íhe esophagus duráng an upper endoscopyK
qhe capsule measures pe levels án íhe esophagus and íransmáís readángs by radáo
íelecommunácaíáons ío a receáverK Ií offers íhe benefáí of beáng a caíheíer free
deságn and allows paíáenís ío maáníaán íheár regular acíáváíáesK aáfferení ío íhe
regular esophageal pe monáíorángI áí requáres sedaíáon for íhe placemení of íhe
qhás íesí deíecís acádI weakly acádI and weakly alkaláne reflux epásodes from
láquádsI soláds and gas reflux án íhe esophagusK pámálar ío esophageal pe
monáíorángI áí requáres a placemení of a nasal caíheíerI however áí ás superáor ío
pe monáíoráng alone as áí allows for íhe evaluaíáon of íhe íemporal relaíáon
beíween sympíoms and refluxaíe and íhe abáláíy ío deíecí full column reflux
epásodes whách could be acádác or nonJacádácK Epee cágK
Iníerpreíaíáon of íhe recordáng ás síáll laboráous and necessáíaíes suffácáení
pedáaírác experáenceI because íhe auíomaíác analysás ás noí síandardázed and ás noí
adequaíe án cháldren and ánfanísK qhe major clánácal applácaíáon of ámpedance
seems ío be demonsíraíáon of sympíom assocáaíáon and assessmení of adequacy of
acád suppressáon íherapy án íhe seííáng of ongoáng sympíomsK qhe paíáení does noí
need ío dásconíánue currení reflux íherapy whále undergoáng íhás íesíK qhás can be
performed as an ouípaíáení ambulaíory íesí and does noí requáre sedaíáonK In mosí
large ceníersI íhás íesí has replaced íradáíáonal esophageal pe monáíorángK In some
advanced ceníersI íhás íesí can be combáned wáíh esophageal manomeíry allowáng
dboa ás maánly a clánácal dáagnosásI and as suchI conservaíáve íechnáques are
preferred án cases needáng furíher dáagnosíác íesíángK In cháldrenI upper dI írací
endoscopy ás performed usáng general anesíhesáa or conscáous sedaíáonK oásks of
íhese need ío be weághed agaánsí íhe benefáí gaáned from preformáng a dáagnosíác
endoscopyK then performedI howeverI an endoscopy allows dárecí vásualázaíáon
pH 4
Reflux event
Swallow
of complácaíáons of dboa such as a pepíác ulcerK Conírábuíáng facíors ío
íreaímení resásíance such as íhe presence of eelácobacíer pylorá ánfecíáon could be
gauged usáng an endoscopyK In rare casesI íhe presence of esophageal websI or
ánfecíáous esophagáíás may be revealed on endoscopyK qhe mosí ámporíaní reason
íoday ío perform an esophagogasíroduodenoscopy ás ío assess for íhe presence of
eosánophálác esophagáíás andLor eosánophálác gasíroeníeráíásK Boíh of íhese eníáíáes
have clánácal preseníáng feaíures sámálar ío dboaI buí have íreaímenís íhaí are
dáfferení from dboa and síáll evolvángK As meníáoned aboveI áf eosánophálác
esophagáíás ás suspecíedI íhen íhe paíáení should have receáved a SJU week course
of proíon pump ánhábáíor íherapy práor ío íhe endoscopyK AlsoI dáeíary resírácíáons
ío allergenác foods and exclusáve use of an elemeníal formula práor ío an
endoscopy should be avoáded as íhás ás parí of íhe íreaímení of eosánophálác
esophagáíás and wáll confound íhe resulís of íhe endoscopyK Clánácáans should
perform báopsáes from aí leasí P levels of íhe esophagus even án íhe seííáng of a
normal appearáng esophageal mucosaI as a large reírospecíáve síudy has shown
íhe presence of eosánophálác esophagáíás án POB of paíáenís who had a grossly
Conveníáonal esophageal manomeíry has a very lámáíed role án íhe dáagnosás of
dboa án cháldrenK In adulísI áí ás mosí useful ío assess for háaíal hernáasK qhe use
of combáned ámpedance – manomeíryI has been helpful án assessáng for an
esophageal moíáláíy dásorder whách áf preseníI could conírábuíe ío prolonged
esophageal acád exposureK qhás eníáíy ás noí avaálable aí all ceníersI and paíáenís
may need ío be sení ío specáalázed pedáaírác ceníers ío have such íesíáng
performed and accuraíely áníerpreíedK
qhe managemení of reflux án cháldren ás dependení prámarály on makáng íhe
dásíáncíáon beíween reflux dásease
refluxK ko íherapy ás needed for reflux
cor ánfanís who are spáííáng upI buí gaánáng weághí wellI and íoleraíáng feeds
E“happy spáííers”F no íreaímení ás neededK oeassuráng and educaíáng íhe parenís
cor ánfanís who are noí gaánáng weághíI who have archáng of íheár back Epandáfer
iáfesíyle changes may be enough for mosí cases of ánfaní refluxK qhás áncludes
addáíáon of ráce cereal ío formula fed ánfanís usáng íhe formula of N íablespoon of
cereal ío N ounce of formula and usáng a larger sázed náppleK Cross cuííáng íhe
cereal are avaálable án íhe markeí and can be usedK eoweverI commercáally
avaálable íháckenáng agenís may lead ío eníerocoláíás and as suchI íhese are
dáscouraged [
zK qhe caA has ássued a warnáng agaánsí usáng oíher
commercáally avaálable íháckeners such as ‘sámply íháck’ án babáes less íhan PT
heepáng íhe baby án an uprághí posáíáon for PMJ4R mánuíes afíer meals ás
recommendedK heepáng íhe baby án a car seaí ás noí benefácáalI and án fací may
qhe caA and íhe AAm sírongly recommend agaánsí usáng a reflux wedge as íhere
have been no síudáes showáng íhaí áí helps wáíh refluxI buí íhere have been
documeníed pIap relaíed deaíhs when usáng íhás deváce [
cor a ceríaán sub seí of ánfanísI málk proíeán allergy ás íhoughí ío play a role án íhe
causaíáon of refluxK In íhás specáfác subseíI íryáng a semá elemeníal or even
elemeníal formula may be benefácáalK In N síudy of formula fed ánfanísI dboa
formula íhaí was íháckened wáíh N íablespoon ráce cereal and oíher
cor breasí fed ánfanísI áí may be recommended íhaí íhe maíernal dáeí be modáfáed
ío avoád cow’s málk and eggs [
zK Ií ás ámporíaní íhaí a moíher’s choosáng íhás
rouíe of íherapy see a dáeíácáan herself ío ensure íhaí she receáves adequaíe
nuíráíáonal supporí and áníake of esseníáal váíamáns and mánerals such as sáíamán
cor older cháldren and adolescenísI láfesíyle modáfácaíáons are sámálar ío adulísK
iosáng weághí án overweághí cháldren especáally reducáng abdománal obesáíy ás a
key láfesíyle modáfácaíáonK pmall frequení mealsI and avoádance of caffeáneI
chocolaíeI peppermání and spácy foods ás recommendedK Adolescenís should be
counseled agaánsí smokáng and alcoholK qhere ás some evádence íhaí chewáng
qhere are a number of medácaíáons avaálable ío íreaí dboa Eqable
FK qhese can
be dáváded ánío acád reducáng Lneuíralázáng agenís and prokáneíácsK thále íhere ás
good evádence ío supporí íhe use and effecíáveness of acád reducáng medácaíáons
zI recení concerns abouí íhe over prescrápíáon of íhás group of drugsI
paríácularly proíon pump ánhábáíors EmmIsFI necessáíaíes undersíandáng of
guádelánes for íheár useK
qhás group of medácaíáons ás used prámarály ío buffer acád án íhe síomachI and
seems ío be besí used án an as needed basásK qhere ás láííle evádence of benefáí of
íhás class of medácaíáon án ánfanísK Aníacáds may be consádered án máld
áníermáííení epásodes of dboaK Cauíáon should be íaken when usáng alumánum
coníaánáng aníacáds as íhere ás a rásk áf alumánum íoxácáíyK Málk alkalá syndrome
EalkalosásI renal faálure and hypercalcemáaF has been reporíed án cháldren íakáng
aníacádsK aue ío íhe above concerns and lámáíed evádence of benefáíI íhere ás
qhás class of medácaíáons was íhe fársí ío be avaálable for íhe íreaímení of dboa
qhey work by blockáng hásíamáne ánduced gasírác secreíáonK All phases EbasalI
neurogenác and gasírácF of secreíáon are suppressed dose dependenílyK In addáíáonI
secreíory responses ío noí only hásíamáne buí also oíher síámulá EAceíycholáneI
gasíránI ánsulánI alcohol and foodF are aííenuaíedK qachyphylaxás ás commonI
lámáíáng long íerm useK páde effecís are generally máld and ánclude headacheI dry
mouíh and rashesK Cámeíádáne Eand noí oíher eO recepíor aníagonásíF has aníá
androgenác acíáon Edásplaces dáhydroíesíosíerone from áís cyíoplasmác bándáng
sáíeFI áncreases plasma prolacíán and ánhábáís degradaíáon of esíradáol by íhe láverK
qhás class of medácaíáons of subsíáíuíed benzámádazoles ánhábáís íhe fánal common
síep án gasírác acád secreíáonK mmIs are ánacíáve aí neuíral peI aí a pe Y R íhey
rearrange ío O charged caíáonác forms íhaí reací covaleníly wáíh íhe pe groups of
íhe eH hH Aqmase enzyme and ánacíávaíes íhás enzyme árreversáblyK Ií geís
conceníraíed án íhe acádác pe of íhe paráeíal cell canaláculáI because íhe charged
forms generaíed íhere aí íhe acádác pe are unable ío dáffuse back and geí íághíly
bound ío íhe enzymeK qhás facíor and íhe specáfác localázaíáon of íhe eH hH
Aqmase confer a hágh degree of selecíáváíy of acíáon ío mmIsK Acád secreíáon can
resume only when new eH hH Aqmase molecules are syníhesázedK Because of áís
íághí bándáng ío áís íargeí enzymeI áí can be deíecíed án íhe gasírác mucosa long
afíer áís dásappearance from plasmaK Inhábáíáon of acád secreíáon occurs wáíhán N
hourI reaches a maxámum aí O hours and ás síáll half maxámal aí O4 hours and lasís
P daysK táíh daály admánásíraíáonI aníáJsecreíory effecí áncreases uníál íhe 4
afíer whách ás plaíeausK pecreíáon resumes gradually over PJR days afíer síoppáng
Meíabolásm of mmIs íends ío dáffer án cháldren as compared ío adulís; and usually
rnláke eO recepíor aníagonásísI proíon pump ánhábáíors can be used for long
peráods of íáme wáíhouí íachyphylaxásK
mroíon pump ánhábáíors should be ánáíáaíed án moderaíe ío severe cases of dboa
án cháldren faáláng eO recepíor aníagonásísK Ií ás ámporíaní ío use appropráaíe doses
oecení reporís on íhe long íerm ámplácaíáons of coníánuous mmI íherapy have
shown an áncrease rásk for háp fracíuresI communáíy acquáred Ebuí noí
nosocomáalF pneumonáas and Closírádáum dáffácále ánfecíáons and rebound
sympíoms of reflux án adulís [
zK eenceI áí ás recommended íhaí paíáení should
be monáíored for íhe necessáíy ío coníánue mmI peráodácally and an aííempí should
mrokáneíác agenís such as eryíhromycán and meíoclopramáde should be reserved
for cases where ámpedanceJpe íesíáng shows persásíení full column reflux or íhe
In an adulí síudyI beíhanechol was shown ío áncrease íhe iower esophageal
spháncíer pressure EibpmFI and ámproved sympíoms of reflux án manyI buí noí all
paíáenís [
zK eoweverI lrensíeán
eí al
I conducíed a síudy án cháldren whách
faáled ío demonsíraíe an effecí of beíhanechol án íhe sympíoms of reflux án
cháldren [
zK In our experáenceI usáng appropráaíe doses of MKPmgLkgLdose gáven
PJ4 íámes a day and íámed PMJ4M mánuíes práor ío feeds has helped some paíáenís
wáíh dboaK curíher pedáaírác síudáes are needed ío address íhás quesíáon
purgácal áníerveníáonsI such as kássen fundoplácaíáonI are besí reserved for severe
cases noí respondáng ío íherapyK Ií ás preferable ío lámáí íhás íherapy ío a ceríaán aí
rásk populaíáon such as neurologácally ámpaáred cháldren or cháldren wáíh severe
underlyáng chronác lung dásease who coníánue ío have full column reflux where
epásodes of reflux ánío íhe lung could be assocáaíed wáíh a hágh rásk of morbádáíy
mhysáologác reflux ás common án ánfanís and does noí need dáagnosíác or
íherapeuíác áníerveníáonsK maíáenís haváng dboa may be íreaíed empárácally
maánly based on sympíomsK If íreaímení ás noí successfulI or íhe dáagnosás
remaáns án quesíáonI íhen furíher íesíáng may be doneK An upper dI seráes plays no
role án dáagnosáng dboaI raíher should be used ío assess for anaíomác
abnormaláíáesK MulíáJchannel áníra lumánal ámpedanceJpe síudáes are now íhe
maánsíay of dáagnosás of dboaK Combánáng íhás wáíh esophageal manomeíry ás
íhe new emergáng íechnology án íhás fáeld along wáíh Bravo wáreless capsule
monáíorángK lver use of medácaíáonsI paríácularly mmIs are cauíáoned agaánsíK
purgácal áníerveníáon such as fundoplácaíáon ás noí needed oíher íhan án íhe mosí
severe cases of dboa posáng ságnáfácaní morbádáíy and moríaláíy rásk án a
selecíed populaíáon of paíáenísK
kelson pmI Chen beI pynáar dMI Chrásíoffel hhK lneJyear followJup of sympíoms of
gasíroesophageal reflux duráng ánfancyK medáaírác pracíáce research groupK medáaírács NVVU; NMOESF:
eenry pK aáscernáng dáfferences: gasíroesophageal reflux and gasíroesophageal reflux dásease án
tood gI drundy aI AlJChaer bI
eí alK
qhe funcíáonal gasíroáníesíánal dásorders oome IIIK qhárd edáíKI
sandenplas vI doyvaerís eI eelven oI pacre iK dasíroesophageal refluxI as measured by O4Jhour pe
monáíorángI án RMV healíhy ánfanís screened for rásk of sudden ánfaní deaíh syndromeK medáaírács NVVN;
kelson pmI Chen beI pynáar dMI Chrásíoffel hhK mrevalence of sympíoms of gasíroesophageal reflux
duráng ánfancyK A pedáaírác pracíáceJbased surveyK medáaírác pracíáce research groupK Arch medáaír
Campanozzá AI Boccáa dI mensabene iI maneíía cI Marsegláa AI píráscáugláo mK mrevalence and naíural
Maríágne iI aelaage meI qhomasJaelecourí cI Bonnelye dI Baríhélémy mI doíírand cK mrevalence
and managemení of gasíroesophageal reflux dásease án cháldren and adolescenís: A naíáonwáde crossJ
[Vzconkalsrud bI Amení MK dasíroesophageal reflux án cháldhoodK Curr mrobl purg NVVS; PPEIF: NJTMK
huáken pI san aen blzen BI qyígaí dI Bennánk oI Boeckxsíaens dK bvádence for pooláng of gasírác
secreíáons án íhe proxámal síomach án humans usáng sángle phoíon compuíed íomography dáscussáon
on celáac dásease án paíáenís wáíh severe láver dásease : dluíenJfree dáeí may reverse hepaíác faálureK
qrudgáll kI hapur hI oáley pK camáláal clusíeráng of reflux sympíomsK Am g dasíroeníerol NVVV;
Cameron AI iagergren gI eenráksson CI kyren lI iocke dI medersen kK dasíroesophageal reflux
er cK Mappáng of a gene for severe pedáaírác gasíroesophageal reflux ío chromosome NPqN4K gAMA
pherman mI eassall bI cagundesJkeío rI
eí alK
A globalI evádenceJbased consensus on íhe defánáíáon
of gasíroesophageal reflux dásease án íhe pedáaírác populaíáonK Am g dasíroeníerol OMMV; NM4ERF: NOTUJ
gacob mI mj hI eerzon dK mroxámal esophageal pe meíry án paíáenís wáíh ’ reflux laryngáíás DK mubMed
[NSzqokayer AZK dasíroesophageal reflux dásease and chronác coughK iung OMMT; OMMUENUSF: OVJP4K
Adhamá qI doldblum goI oáchíer gbI saezá McK qhe role of gasírác and duodenal agenís án laryngeal
quchman aI Boyle gI mack AI
eí alK
Comparáson of aárway responses followáng íracheal or esophageal
aelahuníy gI Cherry gK bxperámeníally produced vocal cord granulomasK iaryngoscope NVSU; TUENNF:
iáííle cI houfman gI hohuí oI Marshall oK bffecí of gasírác acád on íhe paíhogenesás of subgloííác
iáacouras CI curuía dI eárano II
eí alK
bosánophálác esophagáíás : rpdaíed consensus recommendaíáons
sandenplas vI oudolph CI aá iorenzo CI
eí alK
medáaírác gasíroesophageal reflux clánácal pracíáce
guádelánes: goání recommendaíáons of íhe koríh Amerácan socáeíy for pedáaírác gasíroeníerologyI
hepaíologyI and nuíráíáon EkApmdeAkF and íhe buropean socáeíy for pedáaírác gasíroeníerologyI
hleánman iI oevácká aI clood bK saládaíáon ássues án quesíáonnaáres for dáagnosás and monáíoráng of
iághídale goI dremse aK dasíroesophageal reflux: managemení guádance for íhe pedáaírácáanK
medáaírács OMNP; NPNERF: eNSU4JVRK
iáacouras CAI ppergel gMI ouchellá bI
eí alK
bosánophálác esophagáíás: A NMJyear experáence án PUN
Clarke mI oobánson MgK qháckenáng málk feeds may cause necroíásáng eníerocoláíásK Arch aás Cháld
CmpC and caA tarn Agaánsí rsáng Infaní pleep mosáíáoners Because of puffocaíáon oásk: Ináíáal
Communácaíáon caA OMNMK
phalaby qI lrensíeán pK bffácacy of íelephone íeacháng of conservaíáve íherapy for ánfanís wáíh
sympíomaíác gasíroesophageal reflux referred by pedáaírácáans ío pedáaírác gasíroeníerologásísK
medáaírács OMMP; N4OENF: RTJSNK
sance dI iewás pI drámshaw hI
eí alK
bxposure of íhe feíus and ánfaní ío hens’ egg ovalbumán
placenía and breasí málk án relaíáon ío maíernal áníake of dáeíary eggK Clán bxp Allergy OMMR; PRENMF:
Avádan BI ponnenberg AI pchnell qdI poníag pgK talkáng and chewáng reduce posíprandáal acád
pmoak BI houfman gK bffecís of gum chewáng on pharyngeal and esophageal peK Ann líol ohánol
[POzqrápaíhy hK dasíroáníesíánal medácaíáonsK bsseníáals of Medácal mharmacologyK qhárd edKI NVURK
oudolph CaI Mazur igI iápíak dpI
eí alK
duádelánes for evaluaíáon and íreaímení of gasíroesophageal
reflux án ánfanís and cháldren: recommendaíáons of íhe koríh Amerácan pocáeíy for medáaírác
dasíroeníerology and kuíráíáonK g medáaír dasíroeníerol kuír OMMN; PO EpupplK OF: pNJpPNK
qoláa sI Boyer hK iongJíerm proíon pump ánhábáíor use án cháldren: A reírospecíáve reváew of safeíyK
qhomson ABI pauve MaI hassam kI hamáíakahara eK pafeíy of íhe longJíerm use of proíon pump
Máller tkI daneshappa hmI aodds tgI eogan tgI Barreras ocI Arndorfer oCK bffecí of
lrensíeán poI iofíon ptI lrensíeán aMK Beíhanechol for pedáaírác gasíroesophageal reflux: a
Absírací:
páckle cell dásease EpCaF ás íhe mosí common ánheráíed dásorder ádeníáfáed
by newborn screenáng programs wáíh an esíámaíed NMMIMMM ándáváduals láváng wáíh
pCa án íhe rnáíed píaíes ErpFK qhe mosí severe phenoíype of pCa ás seen án paíáenís
wáíh homozygous hemoglobán pp EebppF also known as sáckle cell anemáaK Common
morbádáíáes ánclude ánvasáve pneumococcal ánfecíáon due ío loss of splenác funcíáonI
pulmonary sáckláng causáng acuíe chesí syndromeI cerebrovascular sírokeI acuíe paán
epásodes and íhe developmení of chronác paán syndromesK iáfe expecíancy for pCa has
ámproved and cháldren born wáíh pCa íoday have a greaíer íhan VMB chance of
survával ío adulíhoodK aásease modáfyáng íherapáes áncludáng íhe use of sámple and
chronác íransfusáons and oral hydroxyurea ío boíh íreaí and prevení dásease
complácaíáons such as paánI síroke and acuíe chesí syndromeK qhe only curaíáve opíáon
for pCa remaáns hemaíopoáeíác síem cell íransplaníaíáon wáíh íhe besí ouícomes from a
heywords :
Acuíe chesí pyndromeI AnemáaI AsplenáaI Avascular necrosásI
aacíyláíásI blecírophoresásI eemoglobán pI eydroxyureaI kewborn screenI maán
crásásI mneumococcusI mrophylaxásI pepsásI páckle cell dáseaseI pplenác
sequesíraíáonI pírokeI qranscranáal doppler ulírasoundI qransfusáonI sasoJ
occlusáve crásásK
páckle cell dásease EpCaF ás íhe mosí common ánheráíed red blood cell EoBCF
dásorder worldwáde [
zK Ií ás a láfe íhreaíenáng condáíáon resulíáng from a sángle
base paár muíaíáon án íhe βJglobán geneK eemoglobán polymerázes án áís
deoxygenaíed síaíeI causáng íhe oBC ío íake on a crescení or sáckled
conformaíáon íhaí alíers blood váscosáíy and vascular endoíheláumI leadáng ío
vasoJocclusáonI an exuberaní ánflammaíory response and early deaíh of oBC [
Correspondáng auíhor Melássa creáJgones
: aeparímení of medáaírácsI rnáversáíy of qexas eealíh pcáence CeníerI
Approxámaíely PNOIMMM ánfanís wáíh pCa are born each year án íhe worldK
Alíhough survával and láfe expecíancy for cháldren wáíh pCa án íhe fársí world has
áncreased due ío unáversal newborn screenáng for early dásease deíecíáon and
ánáíáaíáon of prophylacíác penácállán ío prevení early complácaíáonsI ánfanís born án
íhe rnáíed píaíes ErpF and burope íogeíher represení only OB of íhe annual pCa
báríhs worldwáde [
zK qhe majoráíy of cases of pCa are found án developáng
couníráes wáíh lámáíed resources for preveníáve care and íreaímení [
kew approaches ío sáckle cell managemení wáíh dásease modáfyáng íreaímenís
áncludáng
and chronác íransfusáons are beáng síudáed [
I
zK Advances
án early deíecíáon of complácaíáons and meíhods for ámproved survával of paíáenís
undergoáng íransplaní have also been descrábed [
zK In íhás chapíerI we
dáscuss íhe
currení guádelánes for early dáagnosás and managemení of pCa and áís
complácaíáonsI hopáng ío help physácáans ádeníáfy íhe preseníaíáon of pCaI íreaí
acuíe sequelae and know when ío refer ío a pCa specáalásí for chronác
pCa ás caused by a muíaíáon án íhe βJglobán gene and demonsíraíes auíosomal
recessáve ánheráíanceK dáven íhaí a sángle ebp allele produces a phenoíypác
change án íhe hemoglobán profáleI an auíosomal coJdománaní fasháon has also
“páckle cell dásease” ás íhe íerm used ío refer ío varáous genoíypes íhaí cause íhe
characíerásíác clánácal syndromeK qhe mosí frequeníly occurráng genoíype ás íhe
homozygous síaíe EebppF also known as sáckle cell anemáaI whách has íhe mosí
severe clánácal phenoíypeK More íhan íen oíher genoíypes have been descrábedI
qhe dáfferení forms of pCa resulí from íhe coánheráíance of ebp wáíh oíher
abnormaláíáes án íhe βJglobán geneK qhe mosí common varáanís ánclude: páckleJ
hemoglobán C dásease EebpCFI páckleJβHJíhalassemáa EebpβHFI and páckleJβJ
Jíhalassemáa EebpβMF [
qhe mosí severe forms of íhe dásease are ebpp and ebpβMK maíáenís wáíh íhese
varáanís have been descrábed ío have hágher markers of hemolysásI lower mean
hemoglobán valuesI and áncreased prevalence of complácaíáons áncludáng: vasoJ
occlusáve paán crásásI acuíe chesí syndromeI acuíe cerebrovascular sírokeI leg
ulcers and práapásm [
I
zK qhe lower íhe expressáon of βJláke chaáns án íhe
íhalassemác alleleI íhe more complácaíáons experáenced by íhe paíáení [
zK qhe
mosí common genoíypes of pCaI and íhe assocáaíed íypácal perápheral blood
Mosí common genoíypes íhaí cause sáckle cell dásease are lásíedI resulíáng from one or more muíaíáons on íhe
pCa ás íhe mosí common geneíác dásorder ádeníáfáed íhrough newborn screenángK
Approxámaíely PMMIMMM ánfanís are born wáíh pCaJebpp each year án íhe worldK
páckle cell íraáí EpCqF ás frequeníly found án ándáváduals of Afrácan ancesíry EsubJ
paharanI equaíoráal AfrácaF buí áí has spread íhroughouí íhe world due ío
mágraíáon [
zK An esíámaíed OPMIMMM ebpp báríhs occur annually án subJpaharan
Approxámaíely NMMIMMM people wáíh pCa láve án íhe rp [
zK qhe dásease ás more
common án AfrácanJAmerácans wáíh N án NO carry pCq and N án PSR ándáváduals
are affecíed wáíh dásease [
I
zK cor eáspanács íhe áncádence ás lowerI N án every
purvával ío adulíhood ás curreníly beíween VPKVB and VRB án cháldren enrolled án
comprehensáve care programsK qhe average age of deaíh for paíáenís wáíh pCa
has been esíámaíed ío be PV yearsI and íhe moríaláíy án pedáaírác paíáenís ás MKRO
per NMM paíáeníJyearsK ln íhe oíher handI íhe developáng world síáll has an
esíámaíed moríaláíy raíe of RMJVMB before age R; mosí commonly as a resulí of
pCa ás now dáagnosed early án láfe íhanks ío íhe áníroducíáon of unáversal
newborn screenáng án íhe rpK eemoglobán separaíáon íechnáques are usedI
áncludáng: eágh mressure iáquád Chromaíography EemiCFI Isoelecírác cocusáng
páckle solubáláíy íesís are fasí and easály avaálableI íhey confárm íhe presence of
sáckle hemoglobán buí faál ío dásíánguásh dásease from íraáíI lackáng sensáíáváíy and
specáfácáíyK eágh levels of ebcI and profound anemáa conírábuíe ío false negaíáve
In addáíáon ío newborn screenángI áí ás recommended for physácáans ío obíaán a
confármaíory íesí án íhe fársí clánácal vásáíI and afíer S moníhsI ío deíermáne íhe
fánal hemoglobán phenoíype [
zK líher íesísI such as a compleíe blood couníI
reíáculocyíe couníI perápheral blood morphology and famály síudáes wáíh geneíác
shaped oBC qargeí cells and mácrocyíosás are commonly seen án íhe paíhology
qhás perápheral blood smear shows normal red blood cellsI fáxed or árreversábly
sáckled cellsI and íargeí cells seen án paíáenís wáíh pCaK ECouríesy of ar creáJ
barly dáagnosás and prompí referral ío experí prováders are esseníáal for íhe
effácáení ánáíáaíáon of famály educaíáonI aníácápaíory guádanceI prophylaxás wáíh
aue ío a sángleJbase muíaíáon án íhe βJdlobán geneI íhe hydrophálác amáno acádI
dluíamác acádI ás subsíáíuíed by íhe hydrophobác amáno acádI saláneI changáng íhe
proíeán conformaíáonK qhe hydrophobác end of íhe pepíáde chaán ás prone ío
áníerací wáíh oíher hemoglobán moleculesI causáng polymerázaíáon án íhe
deoxygenaíed síaíeK qhás process ás enhanced by hágh hemoglobán conceníraíáons
Eelevaíed MCeCFI low peI low íemperaíure and long capállary íransáí íáme [
zK qhe polymerázaíáon of íhe hemoglobán dásrupís íhe eryíhrocyíe archáíecíureI
alíeráng áís flexábáláíy and conírábuíáng ío cellular dehydraíáonI áncreased adhesáon
ío íhe endoíheláum and oíher cellsI and shoríenáng of oBC láfe spanK pee cágK
Bándáng of íhe red blood cells ío íhe plaíeleís causes plaíeleí acíávaíáon and
aggregaíáonK AddáíáonallyI íhe bándáng of red blood cells ío neuíropháls provokes
an oxádaíáve bursí íhaí furíher damages íhe endoíheláum and exposes íássue facíorI
ánvolved án íhe coagulaíáon cascadeK qhe formaíáon of heíerocellular aggregaíes
causes mácrovascular occlusáon of íhe vessel lumenI local hypoxáa and áschemáaK
káírác oxáde regulaíes íhe basal vasodálaíor íoneI ánhábáíáng plaíeleí acíávaíáon and
íranscrápíáonal expressáon of nuclear facíor kB dependení adhesáon moleculesK
auráng hemolysás íhe abundaní release of hemoglobán dáffuses and reduces náírác
oxáde ío náíraíeI and íhe release of eryíhrocyíe argánase resulís án íhe desírucíáon
of náírác oxáde whách conírábuíes ío íhe slow blood flow íhoughí íhe areaI allowáng
more sáckláng of íhe red blood cellsK oesíoraíáon of blood flow furíher promoíes
íássue ánjuryI medáaíed by reperfusáon íhaí causes an ongoáng ánflammaíory
response and endoíheláal dysfuncíáonK
ആฎༀညᄆሓఇ
ᤀࠒ᜖ฌᨈऑЏᔀ
ဟԓ܈ሆ
kearly all ándáváduals affecíed wáíh pCa wáll experáence a vasoJocclusáve crásás
EslCF duráng íheár láfeíámeI especáally paíáenís wáíh ebpp or ebpβ
genoíypesK cársí epásodes may occur as early as S moníhs of age when feíal
hemoglobán levels begán ío fallI wáíh paánful swelláng of íhe hands and feeíI called
oapád evaluaíáon and prompí admánásíraíáon of analgesács ás ámporíaní duráng
acuíe paán cráses ío boíh íreaí paán and án order ío dásíánguásh paán from oíher
sáckle cell relaíed complácaíáons such as acuíe chesí syndromeI síroke Ehead paánFI
papállary necrosás Eflank plaánFI splenác or hepaíác sequesíraíáon Eabdomen paánF
maán managemení should be ándávádualázed ío íhe paíáení and developed íhrough
collaboraíáon wáíh hásLher pCa íeam áncludáng íhe prescrábáng and monáíoráng of
oral paán medácaíáons for máld ío moderaíe paán and pareníeral opáoáds for severe
paán [
zK pee qable
for general guádelánes for íhe managemení of acuíe paán
ACp ás íhe mosí common cause of deaíh án cháldren wáíh pCa and íhe second
mosí common reason for hospáíalázaíáon [
zK ACp ás defáned as a new pulmonary
ánfálíraíe on chesí radáograph plus a sudden onseí of O or more of íhe followáng:
coughI shoríness of breaíhI respáraíory dásíressI chesí paánI or feverK Cháldren
Infecíáon ás íhe mosí wellJknown eíáologyK qhe mosí common paíhogens ánclude
pírepíococcus pneumonáaI Mycoplasma pneumonáa
and
Chlamydáa pp
zK qhe
exací cause of ACp ás unknown buí íhere are several condáíáons known ío
predáspose ío íhe developmení of ACp such as bone marrow embolásmI
ánírapulmonary aggregaíes of sáckle cellsI aíelecíasás and pulmonary edemaK ACp
can develop as a complácaíáon duráng a hospáíalázaíáon for paánI afíer a surgácal
ACp can rapádly progress ío respáraíory faálure or deaíh makáng evaluaíáon wáíh
chesí radáographI pulse oxámeíry monáíoráng and prompí hospáíalázaíáon of greaí
iásíed are general recommendaíáons for when íreaíáng paíáenís wáíh sáckle cell dásease án an acuíe paán crásásI
ío assure rapád ánáíáaíáon of analgesáaI choosáng íhe rághí medácaíáon dependáng on íhe paíáení profále and
preveníáng common complácaíáons assocáaíed wáíh paán and áís managemeníK GAbbreváaíáons: pCa: páckle
cell dáseaseI kpAIap: nonJsíeroádal aníáJánflammaíory drugsI Is: áníravenousI pC: subcuíaneousK EModáfáed
qreaímení of ACp áncludes an áníravenous cephalosporánI an oral macroláde
aníábáoíácI supplemeníal oxygen ío maáníaán oxygen saíuraíáon above VRBI
bronchodálaíorsI and paán medácaíáons ío prevení aíelecíasás relaíed ío spláníángK
Currení evádence suggesís íhe use of low dose síeroáds EYOmgLkgLday; max:
SMmgLdayF of oral prednásone án paíáenís wáíh known asíhma responsáve ío
coríácosíeroáds and ACp may be benefácáal [
Blood íransfusáons are offered ío paíáenís wáíh severe ACpI defáned by mulíáJlobe
dáseaseI áncreased work of breaíhángI ánabáláíy ío maáníaán oxygen saíuraíáon
above VRB even wáíh supplemeníal oxygenI and pleural effusáonsK pámple blood
íransfusáons of oBC NMmlLkg are ándácaíed án paíáenís wáíh sympíomaíác ACp
whose eb conceníraíáon ás aí leasí NgLdl below baseláne [
zK Consulíaíáon wáíh an
hemaíologásíI cráíácal care or apheresás specáalásí ás needed ío perform urgení
below VMB despáíe supplemeníal oxygenI dyspneaI progressáve pulmonary
ánfálíraíes or decláne án hemoglobán conceníraíáon despáíe sámple íransfusáon [
oecurrení epásodes of ACp can cause lung parenchymal scarrángI progressáve loss
of lung funcíáon and ámpaáred pulmonary growíh [
zK eydroxyurea ás
recommended for preveníáon of recurrení ACpK
pCa paíáenís are PMM íámes more lákely ío develop severe bacíeráal ánfecíáonsI
such as sepíácemáa and menángáíásI íhan íhe normal populaíáon as a resulí of
reduced or absení splenác funcíáon [
mrompí ádeníáfácaíáon and íreaímení of ánfecíáons ás ámperaíáveK In pCa paíáenís
wáíh a íemperaíure >= NMNKPcI consáder obíaánáng a compleíe blood couní ECBCF
for furíher workup and ánáíáaíáon of Is aníábáoíác íreaímení [
I
zK bmpárác
pareníeral aníábáoíács should be síaríed when fever ás >= PVKRCLNMPKNc ío prováde
In fever accompanáed by respáraíory sympíoms evaluaíe for ACpK Bacíeráal
osíeomyeláíás should be consádered án pCa paíáenís íhaí presení wáíh fever and
bone íendernessI especáally when accompanáed by eryíhema and swellángK
bvaluaíe for ánfecíáon fársí before assumáng a slC án paíáenís preseníáng wáíh
menácállán prophylaxás has shown ío decrease íhe rásk of severe ánfecíáons án
paíáenís wáíh pCA and should be síaríed before O moníhs of age and coníánued
íhrough aí leasí age RI unless íhe cháld has had compleíe splenecíomy or severe
ánvasáve pneumococcal ánfecíáonK An oral dose of NOR mg íwáce daály ás
recommended ánáíáally wáíh an áncrease ío ORM mg íwáce daály by age P [
menácállán prophylaxás can be wáíhheld from paíáenís wáíh málder genoíypes ebpC
and ebpBH qhalassemáa unless íhey have had splenecíomyK saccánaíáon ás of
lámáíed use án cháldren less íhan O years due ío ámmaíure aníábody responseI buí Ií
ás ámporíaní ío assure íhaí all paíáenís wáíh pCa have compleíed recommended
pneumococcal vaccánaíáon when dásconíánuáng penácállán aí age R [
I
Immunázaíáon án pCa paíáenís should be performed accordáng ío íhe ACIm
harmonázed ámmunázaíáon scheduleK dáven íhe áncreased rásk of ánvasáve
pneumococcal dásease EImaF án pCa paíáenísI a compleíe seráes of NPJvalení
conjugaíe pneumococcal vaccáne should be síaríed aí O moníhs and OPJvalení
pneumococcal polysaccharáde vaccáne gáven aí age O wáíh boosíers every R yearsK
bfforís ío develop vaccánes ío prevení Ima coníánue as receníly reporíed cases of
Ií ás of uímosí ámporíance ío educaíe parenís and caregávers of pCa paíáenís ío
lverí síroke án pCa may presení as a sudden onseí of focal neurologácal ságnsI
alíered conscáousnessI severe headachesI weaknessI numbnessI vásual
dásíurbancesI dysaríhráaI aphasáaI or aíaxáa [
I
zK lverí sírokes are more
commonly caused by secondary síenosás or occlusáon of íhe áníernal caroíád or
máddle cerebral aríeryK Approxámaíely NMB of cháldren wáíh pCa wáll experáence
an overí síroke [
zK qransáení áschemác aííacks ofíen precede síroke and may be
qranscranáal aoppler EqCaF ámagáng of large áníracranáal blood vessels ío deíecí
áncreased velocáíáes secondary ío síenosás can predácí rásk of overí síroke án
cháldren wáíh pCA and help reduce prevalence from NMB ío NB [
I
bvádence ás hágh for annual qCa screenáng of paíáenís wáíh pCA genoíypes
síaríáng aí age O uníál age NS for prámary overí síroke preveníáon [
qámeJaveraged mean of íhe maxámum EqAMMF velocáíáes are consáder normal
YNTM cmLsecondFI condáíáonal ENTMJNVV cmLsecondF or abnormal E>OMM
cmLsecondF usáng nonJámagáng íechnáquesK Condáíáonal qCas should be repeaíed
aí PJS moníh áníervalsI abnormal values should be repeaíed wáíhán OJ4 weeks of
Consulí a neurologásíI perform and urgení compuíed íomography ECqF scan ío
evaluaíe for hemorrhageI followed by magneíác resonance ámagáng EMoIF of
braánI cerebral veáns and aríeráes áf avaálableI án paíáenís wáíh pCa án whom
síroke ás suspecíedK If confármedI a program of moníhly sámple or exchange
íransfusáons should be ánáíáaíed for secondary síroke preveníáonK If chronác
íransfusáon ás noí medácally possábleI ánáíáaíáon of hydroxyurea ás recommended
A sáckle cell specáalásí should be ánvolved án íhe managemení of paíáenís wáíh
condáíáonal ENTMJNVV cmLsecF or elevaíedLabnormal E>OMM cmLsecF qCa resulís or
qhe áníroducíáon of qCa screenáng and íhe use of chronác íransfusáons ío prevení
ánáíáal síroke án hágh rásk paíáenís has led ío an ámporíaní decláne án síroke
áncádenceK qhe pqlm íráalI a prámary síroke preveníáon síudy án pCaI
demonsíraíed a síroke rásk reducíáon of VOB án cháldren wáíh abnormal qCa
resulís >OMM cmLs receáváng chronác íransfusáons and íhe pqlm O íráal showed an
A more recení síudyI íhe qtáqCe íráalI compared íhe effácacy of hydroxyurea
íransfusáons án íhe reducíáon of síroke rásk án cháldren wáíh abnormal qCa
velocáíáes who have receáved aí leasí one year of íransfusáonsI and have no MoAJ
defáned severe vasculopaíhyI can subsíáíuíe hydroxyurea for íransfusáon íreaímení
Acuíe síroke ás managed wáíh íransfusáon ío prevení íhe progressáon of cerebral
áschemáa by reducáng íhe perceníage of ebpK then avaálableI eryíhrocyíapheresás
ás íhe preferred meíhod of íransfusáon used for íhe ánáíáal íreaímení of síroke
followed by chronác íransfusáon íherapy ío prevení a secondary síroke [
zK qhe
ptáqCe síudyI a randomázed phase P clánácal íráalI found chronác íransfusáon
mráapásm ás a susíaáned unwaníed paánful erecíáon lasíáng four or more hoursK
mráapásm ás consádered ío be a urologácal emergencyI affecíáng approxámaíely
PRB of boys and men wáíh pCaK In paíáenís wáíh pCaI íhe mosí common causes
of práapásm are nocíurnal erecíáonsI sexual acíáváíyI dehydraíáonI feverI and
exposure ío coldK
If lefí uníreaíedI práapásm can cause fábrosás of íhe corpora cavernosaI erecíále
dysfuncíáon and penále dásfáguremení [
zK Ináíáal evaluaíáon of a práapásm may
mráapásm musí be evaluaíed and íreaíed by specáalásí án a íámely manner áncludáng
urology and hemaíology íeamsK Ináíáal managemení áncludes vágorous oral or
áníravenous hydraíáons and íhe use of analgesáaK If conservaíáve medácal
managemení does noí cause deíumescenceI aspáraíáon of blood from corpora
cavernosa and árrágaíáon wáíh epánephráne should be consáderedK qransfusáon
should noí be used as ánáíáal íherapy for práapásm due ío íhe assocáaíáon of
íransfusáonI práapásm and íhe developmení of acuíe neurologác evenís íhaí has
been descrábed [
I
zK Alíhough local measures such as cold packs are used for
práapásm án paíáenís wáíhouí pCaI cold should be avoáded án pCa because áí may
Acuíe splenác sequesíraíáon occurs mosí ofíen án cháldren wáíh severe pCa
beíween íhe ages of one and four years old wáíh sudden enlargemení of íhe spleen
and a drop án hemoglobán conceníraíáon by aí leasí O gLdi below íhe baseláneK
pplenác sequesíraíáon may be írággered by fever and ánfecíáonK qhe áncádence of
splenác sequesíraíáon has decreased sánce íhe áníroducíáon of newborn screenáng
and early deíecíáon of pCaI as well as caregáver educaíáon regardáng spleen
palpaíáon [
pplenác sequesíraíáon may be a láfe íhreaíenáng evení wáíh lefíJsáded abdománal
paán assocáaíed wáíh ságns of hypovolemáaI rapád spleen enlargemeníI cárculaíory
collapse and profound anemáa wáíh levels of hemoglobán below P gLdi requáráng
Managemení of severe acuíe splenác sequesíraíáon áncludes ámmedáaíe
resuscáíaíáon wáíh Is fluádsK A hemaíologásí should be consulíed for guádance án
orderáng íransfusáons án order ío raáse hemoglobán ío a síable level buí avoád over
If íhe paíáení has recurrení acuíe splenác sequesíraíáon or sympíomaíác
hypersplenásmI surgácal splenecíomy should be dáscussed wáíh a hemaíologásíK
mrophylacíác blood íransfusáon has noí been proven ío reduce íhe rásk of recurrení
evenísI and puís íhe paíáení aí rásk of auíoíransfusáonI caused when íhe spleen
releases íhe sequesíered blood leadáng ío an áncrease án íhe hemoglobán
conceníraíáon and hyperváscosáíy syndrome [
I
mulmonary hyperíensáon can be seen án sáckle cell dáseaseI secondary ío chronác
hemolysás and vasculopaíhyK Clánácal preseníaíáon áncludes dyspnea wáíh daály
láfe acíáváíáesI faíágueI chesí paánI and palpáíaíáonsK Ináíáal echocardáography
evaluaíáon for íhe esíámaíáon of pulmonary aríery pressure usáng írácuspád
regurgáíaní jeí velocáíy ás recommended án sympíomaíác paíáenísI buí confármaíáon
of pulmonary hyperíensáon requáres rághí hearí caíheíerázaíáon whách carráes
ságnáfácaní rásk of harm reason why screenáng of nonJsympíomaíác paíáenís ás noí
cor sympíomaíác pCa paíáenís wáíh an elevaíed qos ≥OKR mLsec by
echocardáographyI a specáalásí referral should be made for furíher assessmení and
pCa paíáenís wáíh a physácáan dáagnosás of asíhma are known ío be aí hágher rásk
of morbádáíy and moríaláíy and more frequení epásodes of ACp and slCK
Cháldren wáíh pCa and pulmonary sympíoms should receáve evaluaíáon and
managemení of asíhma should be íhe same as for íhe general populaíáon followáng
maíáenís wáíh pCa who have sleep dásordered breaíháng EpaBF or obsírucíáve
sleep apnea ElpAF are aí hágh rásk of cardáopulmonary dásease due ío áníermáííení
desaíuraíáon íhaí áncreases vasoJocclusáonK A relaíáonsháp beíween lpA and íhe
Cháldren wáíh pCa are known ío have adenoád and íonsállar hyperírophy íhaí can
furíher conírábuíe wáíh íhe paB and apneaK Ií ás recommended íhaí all pCa
paíáenís wáíh lpA be evaluaíed for adenoJíonsállecíomy and íhe need for oxygen
Avascular necrosás EAskF occurs when sáckled oBCs occlude capállaráes án íhe
large joánís causáng áschemác necrosásK qhe mosí commonly affecíed bones are íhe
humeral and femoral heads and rásk facíors for Ask ánclude frequení vasoJ
occlusáve epásodesI and pCa genoíype ebpp wáíh alpha íhal íraáíK
Clánácal preseníaíáon áncludes severe paán íhaí worsens wáíh weághí bearáng
acíáváíy and ás usually reláeved by resíáng [
I
zK Cháldren wáíh pCa and
áníermáííení or chronác háp paán should be evaluaíed for Ask wáíh a íhorough
physácal examI xJray andLor MoI and íreaíed wáíh analgesács and physácal
íherapyK Managemení of advanced síages of Ask wáíh ságnáfácaní compromáse án
daály acíáváíyI requáres collaboraíáon beíween oríhopedác surgeons and
hemaíologásís for evaluaíáon of possáble háp aríhroplasíy [
maíáenís wáíh pCa have a hágher rásk for reíánal dásease íhan íhe normal
populaíáonK mroláferaíáve sáckle reíánopaíhy ás caused by vasoJocclusáon of íhe
reíánal aríeráoles and reíánal áschemáaK pCa reíánopaíhy ás assocáaíed wáíh
progressáve loss of vásual acuáíy and can lead ío hemorrhage and reíánal
deíachmeníK Annual screenáng wáíh an ophíhalmologásí for dálaíed eye
examánaíáon ás recommended for ándáváduals wáíh pCa síaíáng aí age NMK
pcreenáng ás ámporíaní because íherapy ás avaálable ío prevení vásáon lossK
oeferral ío a reíánal specáalásí ás requáred for furíher evaluaíáon and managemení
kephropaíhy ás rarely dáagnosed án cháldren wáíh pCaK eyposíhenuráa and
glomerular hyperfálíraíáon are commonly seen án young paíáenísI buí sáckle
nephropaíhy does noí become clánácally evádení uníál laíer án láfe [
Annual screenáng for proíeánuráa should begán aí age NM yearsK AlbumánLcreaíánáne
raíáo should be performed áf proíeánuráa ás foundK Modesí elevaíáons án creaíánáne
>MKT mgLdi and proíeánuráa >PMM mgLO4 hours án cháldrenI should be consáder
renal ámpaármení prompíáng referral ío a nephrologásí for furíher assessmení and
qransfusáon íherapy has been shown ío decrease íhe morbádáíy and moríaláíy án
paíáenís wáíh pCa by reducáng íhe perceníage of cárculaíáng ebp oBCs and
ámprováng oxygen capacáíy of íhe blood [
zK qhe specáfác íhreshold warraníáng
íransfusáon varáes wáíh each paíáení buí an acháevemení of eb level of NM gLdl or
reducíáon of ebp ío less íhan PMB are common íherapy goalsK Alíhough
íransfusáon ás an ámporíaní íool án boíh íhe preveníáon and íreaímení of acuíe and
chronác complácaíáonsI íhe currení accepíed ándácaíáons for íransfusáon are based
on experí consensus gáven íhe lack of clánácal íráals [
zK pámple íransfusáon or
exchange íransfusáon ás ándácaíed án paíáenís wáíh sympíomaíác severe ACpI acuíe
splenác sequesíraíáon accompanáed by severe anemáa and acuíe sírokeK maíáenís
who meeí cráíeráa for chronác íransfusáons should follow an esíabláshed
monáíoráng proíocol [
qhe mosí common complácaíáons án pCa paíáenís receáváng íransfusáons are
alloámmunázaíáonI wáíh an áncádence beíween NUJTSB and áron overloadK pCa
paíáenís mosí commonly form alloaníábodáes ío íhe CI b and hell aníágensK qo
prevení alloaníábody formaíáonI exíended crossJmaícháng should be done [
Iron overload occurs wáíh as few as íen blood íransfusáons and ás assocáaíed wáíh
hepaíácI cardáacI and páíuáíary complácaíáonsK maíáenís receáváng chronác
íransfusáons should have rouíáne screenáng and receáve íreaímení wáíh áron
chelaíorsK pee qable
for general recommendaíáons án íransfusáon íherapyK
deneral recommendaíáons based on íhe evádence base reporí by experí panel members for íransfusáng sáckle
cell dásease paíáenísK GAbbreváaíáons: oBC: red blood cellsI ebA: hemoglobán AI ebp: eemoglobán pI CBC:
compleíe blood couníI pCa: páckle cell dáseaseI MoI: magneíác resonance ámagángI eIs: euman
ámmunodefácáency várusK EModáfáed form íhe Managemení of páckle Cell aásease OMN4 bvádenceJBased
eydroxyurea EerF ás íhe only caAJapproved medácaíáon for íhe íreaímení of
pCaK er áncreases feíal hemoglobán conceníraíáon wáíhán oBCs and reduces íhe
number of cárculaíáng wháíe blood cells reducáng íhe frequency of vasoJocclusáonK
ESF er was fársí shown ío reduce hospáíal admássáon for paán and acuíe chesí
syndrome án íhe placeboJconírolled MulíáJCeníer píudy of eydroxyurea EMpeF án
adulís wáíh severe pCaK táíh publácaíáon of íhe ánfaní hydroxyurea síudy EBaby
erdFI er ás now recommended for use án ánfanís náne moníhs of age and older
wáíh pCA regardless of clánácal severáíy ío reduce pCaJrelaíed complácaíáons [
A CBC wáíh dáffereníáalI reíáculocyíe couníI meíabolác profáleI quaníáíaíáve
measure of ebc and pregnancy íesí for women of cháld bearáng age ás
recommended before íhe ánáíáaíáon of er íherapyK píaríáng dosage for ánfanís and
cháldren ás OM mgLkgLdayI and monáíoráng wáíh CBC wáíh reíáculocyíe couní
should be performed every four weeks when adjusíáng íhe dosageK A íargeí of
absoluíe neuírophál couní ≥OIMMMLui and plaíeleí couní ≥UMIMMMLui should be
maáníaánedK oeferral ío a hemaíologásí should be made for furíher managemení
wáíh er án specáal cases such as renal ámpaármení or lack of response ío er
Alíhough currení supporíáve care gáven ío pCa paíáenís has ámproved survával ío
adulíhoodI hemaíopoáeíác síem cell íransplaníaíáon EepCqF ás íhe only avaálable
auráng epCqI condáíáonáng íherapy ás performed before íhe ánfusáon of
hásíocompaíáble síem cells ío reduce íhe rásk of faálure of engrafímení and chronác
grafí
hosí dásease; íradáíáonal epCq used myeloablaíáve regámens íhaí
were used for paíáenís wáíh malágnancy were poorly íoleraíed by pCa paíáenísK
kewer íransplaní proíocols use nonJmyeloablaíáve regámens whách have
decreased íransplaníJrelaíed morbádáíy and moríaláíyK qhe besí ouícomes occur
wáíh maíchedJsábláng donors; howeverI a lack of maíched sábláng donors furíher
maríácápaíáon án a maíchedI unrelaíed epCq ás curreníly recommended as parí of
clánácal íráals for pCa paíáenís experáencáng sírokeI recurrení vasoJocclusáve crásás
and ACp íhaí has noí ámproved despáíe receáváng opíámal supporíáve careK epCq
ás recommended án sympíomaíác pCa paíáenís who have a maíched sábláng donor
peveral síudáes ío mánámáze early íransplaní relaíed morbádáíy and moríaláíy are
ongoángK aue ío íhe paucáíy of boíh relaíed and unrelaíed donorsI for paíáenís wáíh
especáally severe dáseaseI síudáes wáíh haploádeníácal donors Eparení donorsF offer
pCa ás a láfe íhreaíenáng condáíáon wáíh cháldhood onseí affecíáng ándáváduals
worldJwádeI causáng epásodes of unpredácíable and severe paán wáíh rásk of mulíáJ
sysíem complácaíáonsI long hospáíal síays and dásabáláíyK peveral efforís such as
newborn screenángI ío assure early deíecíáonI andI preveníáve íherapáes such as
prophylacíác penácállán and hydroxyurea íherapy have ámproved íhe íreaímení of
pCa and áís complácaíáonsI reducáng boíh dáseaseJrelaíed morbádáíy and moríaláíyK
eemaíopoáeíác síem cell íransplaníaíáon ás íhe only avaálable cure for pCa buí
more research ás needed ío reduce íhe assocáaíed rásks and make áí wádely
avaálable for íhe pCa populaíáonK
vawn BmI Buchanan doI AfenyáJAnnan AkI
eí alK
Managemení of páckle Cell aáseaseK gama
Manwaná aI creneííe mpK sasoJocclusáon án sáckle cell dásease: paíhophysáology and novel argeíed
íherapáesK Blood [Iníerneíz Amerácan pocáeíy of eemaíology I OMNP aec R; [cáíed OMNS ceb
NOz;NOOEO4F: PUVOJUK Avaálable from: LpmcLaríáclesLmMCPUR4NNML?reporí=absírací
Zhang aI uu CI Manwaná aI creneííe mpK keuírophálsI plaíeleísI and ánflammaíory paíhwaysI aí íhe
nexus of sáckle cell dásease paíhophysáologyK Blood [Iníerneíz Amerácan pocáeíy of eemaíology I OMNS
gan NO; [cáíed OMNS ceb NOz;NOTETF: UMNJVK Avaálable from: hííp:LLwwwKbloodjournalKorgL
Mcdann mqK páckle cell anemáa: An underapprecáaíed and unaddressed conírábuíor ío global cháldhood
moríaláíyK g medáaír [Iníerneíz blseváer iíd OMN4; NSRENF: NUJOOK Avaálable from:
Máchael bI aeBaun oI Melássa gI creáJgones bmsK eemoglobánopaíháesI kelson qexíbook of
medáaírács [IníerneízK OMíh edKK blseváer OMNS; ppK EChapíer 4SOF: OPPSJRPK Avaálable from:
tang tCI tare obI Máller pqI
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eydroxycarbamáde án very young cháldren wáíh sáckleJcell
anaemáa: A mulíáceníreI randomásedI conírolled íráal EBABv erdFK ianceí [Iníerneíz OMNN;
PTTEVTTUF: NSSPJTOK Avaálable from: hííp:LLdxKdoáKorgLNMKNMNSLpMN4MJSTPSENNFSMPRRJP
tare obI aavás BoI pchulíz teI
eí alK
eydroxycarbamáde versus chronác íransfusáon for
maáníenance of íranscranáal doppler flow velocáíáes án cháldren wáíh sáckle cell anaemáa—qCa táíh
qransfusáons Changáng ío eydroxyurea EqtáqCeF: a mulíáceníreI openJlabelI phase PI nonJánferáoráíy
íráalK ianceí [Iníerneíz OMNR; STPSENRF: NJNMK Avaálable from: hííp:LLlánkánghubKelseváerKcomL
au cI Zhang MI iá uI
eí alK
eep mublác AccessK Báochem Báophys oes Commun OMN4; 4ROE4F: NMP4J
nuánn CqK páckle cell dásease án cháldhoodK from newborn screenáng íhrough íransáíáon ío adulí
[NMzoees aCI tálláams qkI dladwán MqK páckleJcell dáseaseK ianceí OMNM; PTS: OMNUJPNK
paraf piI Molokáe obI kouraáe MI
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aáfferences án íhe clánácal and genoíypác preseníaíáon of
Bender MAI káelsen hoK eemoglobánopaíháes [Iníerneíz couríh bdá medáaírác Cráíácal Care blseváer
oees aCI tálláams qkI dladwán MqK páckleJcell dáseaseK ianceí [Iníerneíz blseváer iíd OMNM;
ioveíí mBI pule emI iopez BiK páckle cell dásease án íhe emergency deparímeníK bmerg Med Clán
nuánn CqI oogers ZoI Mccaváí qiI Buchanan doK Improved survával of cháldren and adolescenís
hesseJAdu oK Inheráíed anaemáas: sáckle cell and íhalassaemáaK Med Ernáíed hángdomF [Iníerneíz
Chou pK qransfusáon íherapy for sáckle cell dásease: a balancáng acíK eemaíology OMNP; OMNPENF: 4PVJ
vawn BmK bvádenceJbases managemení of sáckle cell dásease: experí panel reporí OMN4K
wwwKnhlbáKnáhKgovK OMN4
lgunlesá cI eeeney MMI houmbourlás ACK pysíemác coríácosíeroáds án acuíe chesí syndrome: cráend
vawn BmI Buchanan doI AfenyáJAnnan AkI
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Managemení of páckle Cell aáseaseK gAMA OMN4;
Cabooí gBI Allen giK eypoxemáa án sáckle cell dásease: págnáfácance and managemeníK maedáaír oespár
McCaváíK qámoíhy iK uuan iK eospáíalázaíáon for Invasáve mneumococcal aásease án a kaíáonal
pample of Cháldren táíh páckle Cell aásease Before and Afíer mCsT iácensureK medáaír Blood Cancer
McCaváí qiI nuánn CqI qechasaensárá CI oogers ZoK Increase án ánvasáve pírepíococcus pneumonáae
ánfecíáons án cháldren wáíh sáckle cell dásease sánce pneumococcal conjugaíe vaccáne lácensureK g
[O4zMeáer boI Máller ggK páckle cell dásease án cháldrenK arugs OMNO; TOETF: UVRJVMSK
eársí CI lwusuJlforá pK mrophylacíác aníábáoíács for preveníáng pneumococcal ánfecíáon án cháldren
casano oMI Meáer boI eulberí MiK Cerebral vasculopaíhy án cháldren wáíh sáckle cell anemáaK Blood
Meáer boI casano oMI bsírada MI ee gI iuban kiCI McCaríer oK barly oeíáculocyíosás and Anemáa
Are Assocáaíed wáíh Abnormal and Condáíáonal qranscranáal aoppler selocáíáes án Cháldren wáíh
iee MqI máomellá pI dranger pI Máller pqI earkness pI Brambálla agI
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píroke mreveníáon qráal án
tare obI aavás BoI pchulíz teI Brown oCI Aygun BI parnaák pI
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eydroxycarbamáde versus
chronác íransfusáon for maáníenance of íranscranáal doppler flow velocáíáes án cháldren wáíh sáckle cell
anaemáa—qCa táíh qransfusáons Changáng ío eydroxyurea EqtáqCeF: a mulíáceníreI openJlabelI
phase PI nonJánferáoráíy íráalK ianceí OMNR; STPSENRF: NJNMK [IníerneízK blseváer iíd; Avaálable from:
tare obI eelms otK píroke wáíh íransfusáons changáng ío hydroxyurea EptáqCeFK Blood OMNO;
aonaldson gcI oees otI píeánbrecher eAK mráapásm án cháldren: A comprehensáve reváew and clánácal
dladwán MI sáchánsky bK mulmonary complácaíáons of sáckle cell dáseaseK k bngl g Med OMMU;
Mehará AI hlángs bK mulmonary complácaíáons of sáckle cell dáseaseK Chesí blseváer iíd OMNR;
qhompson BtI Máller pqI oogers ZoI
eí alK
qhe pedáaírác hydroxyurea phase III clánácal íráal EBABv
talíers MCI ae Casíro iMI pullávan hMI
eí alK
Indácaíáons and oesulís of euman ieukocyíe
AníágenJádeníácal pábláng eemaíopoáeíác Cell qransplaníaíáon for páckle Cell aáseaseK Báol Blood
[PSzBolañosJMeade gI Brodsky oAK Blood and marrow íransplaníaíáon for sáckle cell dásease: Is less more?
aávásáon of medáaírác líolaryngologyJeead and keck purgeryI Ann C ooberí eK iuráe Cháldren’s
Absírací:
lbjecíáve: qo descrábe íhe eíáologyI dáagnosíác examánaíáonI and
managemení opíáons of recurrení epásíaxás án cháldrenI ío help clánácáans beííer
deláneaíe whách paíáenís mághí benefáí from conservaíáve
more aggressáve
oesulís: bpásíaxás occurs frequeníly án cháldrenI and affecíed cháldren are ofíen seen by
prámary careI emergency deparímeníI and oíolaryngology physácáansK hnowledge of
íhe underlyáng eíáologyI dáagnosíác examánaíáon íechnáquesI and avaálable íreaímení
opíáons ás esseníáal for clánácáansK A reváew of íhe currení láíeraíure was performedI and
íhás chapíer provádes ánformaíáon abouí epásíaxás managemeníK Mosí cases of epásíaxás
are selfJlámáíed and respond well ío conservaíáve íreaímenísI such as lubrácanís and
aníásepíác oánímenís; howeverI some cases wáll requáre hemaíologác íesíángI dáagnosíác
Conclusáons: bpásíaxás ás a common dáagnosás án cháldrenK Clánácáans should be
famáláar wáíh íhe eíáology and managemení of íhás condáíáon án cháldrenK
heywords:
bpásíaxás dáagnosásI bpásíaxás eíáologyI bpásíaxás managemeníI
medáaírác epásíaxásK
bpásíaxás EnosebleedF ás defáned as acuíe bleedáng from íhe nosírálI nasal caváíyI or
nasopharynx [
J
zK qhe condáíáon ás very common án cháldrenI alíhough áí rarely
occurs án íhose under O years of ageK oeporís sáíe íhe áncádence of aí leasí one
epásode of epásíaxás ío be around PMB among cháldren aged MJR yearsI RSB
among íhose aged SJNM yearsI and S4B among íhose aged NNJNR yearsK [NI
Mosí bleedáng epásodes are mánor and selfJlámáíedI requáráng no medácal aííeníáonK
eoweverI bleedáng can be unpredácíable and may have an ámpací on íhe qualáíy of
Correspondáng auíhor haíhleen oK Bállángs
: aávásáon of medáaírác líolaryngologyJeead and keck purgeryI Ann C
ooberí eK iuráe Cháldren’s eospáíal of ChácagoI ChácagoI IiI rpA; qel: PNOJOOTJV4N4; cax: PNOJOOTJSOPM; bmaál:
recurrení epásíaxás [
zK Many seek medácal aííeníáon from prámary care or
emergency deparímení physácáans and oíolaryngologásís for íhe managemení of
epásíaxásK A general undersíandáng of íhe eíáologyI examánaíáonI and íreaímení
opíáons for epásíaxás ás esseníáal for all clánácáans caráng for cháldrenK qhás chapíer
wáll prováde a reváew of íhe currení dáagnosíác and íreaímení síraíegáes for
cháldren wáíh recurrení epásíaxásK
In íhe majoráíy of cháldrenI sponíaneous bleedáng ás almosí always venous and
aráses from “iáííle’s areaI” íhe aníeráor regáon of íhe nasal sepíumK A number of
aríeráes anasíomose án íhás regáonI formáng a plexus of vessels under íhe íhán
sepíal mucosa called háesselbach’s plexusK Bleedáng can occur án íhás area when
exposed ío dry aár or mánor íraumaK Crusíáng and scabbáng án íhe area can cause
áíchángI leadáng ío repeíáíáve írauma ío íhe regáon by páckáng and rubbángK
oecurrení epásíaxásI referred ío as “ádáopaíhác epásíaxásI” án cháldren ás usually
aíírábuíed ío crusíángI nasal vesíábuláíás andLor dágáíal íraumaI alíhough no dárecí
cause can be esíabláshed án many casesK [
I
J
z Allergác rhánáíás ás íhoughí ío
conírábuíe ío epásíaxás due ío nasal mucosal ánflammaíory changesI leadáng ío
fráableI árráíaíed mucosa íhaí ás more apí ío bleedK kasal colonázaíáon wáíh
píaphylococcus aureus
has been shown ío be more common án cháldren wáíh
epásíaxás íhan án conírol subjecísI and íhe bacíeráal colonázaíáon has been
posíulaíed ío cause ánflammaíáon and new vessel formaíáonI leadáng ío epásíaxás
J
zK Irráíaíáon án íhe nasal caváíy can lead ío dágáíal írauma and subsequení
epásíaxásK hamble
eí al
z found íhaí íhe presence of
pK aureus
colonázaíáon án íhe
aníeráor nasal caváíy was assocáaíed wáíh ságnáfácaní crusíáng and dálaíed blood
vessels on íhe aníeráor sepíum án cháldren wáíh epásíaxásK líher causaíáve facíors
for epásíaxás ánclude íraumaI anaíomác abnormaláíáesI medácaíáonsI neoplasmsI and
qhe áncádence of epásíaxás ás íhoughí ío be greaíer án íhe coldI wáníer moníhs án
noríhern clámaíesI when upper respáraíory ánfecíáons are more frequení and when
ándoor humádáíy decreases ío low levels [NINNzK kosebleeds may also occur more
ofíen án hoíI dry clámaíes wáíh low humádáíy; howeverI gáven íhe commonaláíy of
epásíaxás án cháldrenI ambáení íemperaíure may have láííle ámpací on íhe overall
qhere ás no general consensus on íhe besí approach for íhe evaluaíáon of pedáaírác
epásíaxásK A íhorough reváew of íhe paíáení’s hásíory and physácal examánaíáonI
áncludáng aníeráor rhánoscopy are recommendedK eásíory should ánclude
frequency of nose bleedsI laíeraláíy Eámporíaní when consáderáng cauíeryFI
duraíáon of bleedángI and íhe presence of easy bruásáng or bleedáng easály wáíh
oíher mánor íraumas Eboíh possábly suggesíáve of coagulopaíháesFK aocumeníaíáon
of práor írauma ío íhe areaI hásíory of allergác rhánáíásI and a reváew of medácaíáons
I aspárán useF may help elucádaíe íhe cause of bleedángK A famály hásíory of
epásíaxás ás ámporíaní when consáderáng íhe dáagnosás of heredáíary hemorrhagác
íelangáecíasáa EeeqF and coagulopaíháesI such as hemopháláa and von tállebrand
dáseaseK Aí physácal examánaíáonI íhe nasal caváíy ás assessed for íhe source of
bleedángK sásáble vessels on íhe aníeráor sepíum are ofíen appareníI án addáíáon ío
dryáng and crusíáng of íhe nasal mucous membranesK lral caváíy examánaíáon
mághí reveal íhe presence of íelangáecíasáa án paíáenís wáíh eeqK oágád or flexáble
nasal endoscopy ás appropráaíe án íhose án whom íhe source ás unceríaán or when
íhere ás suspácáon for a neoplasmI such as juvenále nasopharyngeal angáofábroma
EgkAF [
I
zK Imagáng síudáesI such as compuíed íomography ECqF or magneíác
resonance EMoF ámagángI are noí recommended án íhe rouíáne examánaíáon of a
cháld wáíh epásíaxásK then confármáng or consáderáng íhe dáagnosás of gkA or
anoíher nasal neoplasmI ámagáng ás necessary ío assess íhe exíení of ánvolvemení
hnowáng when more aggressáve dáagnosíác íesíáng should be used can be
challengángK In a síudy by maíel
eí al
zI laboraíory íesíángI áncludáng a compleíe
blood couní and a proíhrombán íámeLacíávaíed paríáal íhromboplasíán íáme
EmqLmqqFI was performed án NPN of NTR ET4KVBF pedáaírác paíáenís wáíh epásíaxásK
qweníyJseven EOMKSBF paíáenís were found ío be anemác aí íesíángI alíhough only
O had hemoglobán levels less íhan NM mgLdi and P had hemaíocráí less íhan PMBK
ko paíáení requáred a blood íransfusáon for anemáa or severe bleedángK A síudy by
blden
eí al
z demonsíraíed anemáa án 4 of 4T EUKRBF paíáenís án an analysás of
predácíors of bleedáng dásorders án cháldren wáíh epásíaxásK qhe síudy áncluded
cháldren wáíh severe epásíaxás who had experáenced medácal managemení faálure
and who were undergoáng áníraoperaíáve cauíeryK Anemáa was assocáaíed wáíh
younger age án boíh síudáes meníáoned ERKV years and SK4 yearsI respecíávelyFI
whách may reflecí íhe ámpací of blood loss on lesser overall blood volume of
pandoval
eí al
z found duraíáonI severáíyI and íhe presence of oíher bleedáng
sympíoms ío have no predácíáve value for íhe dáagnosás of coagulopaíhy án NTU
pedáaírác paíáenís referred ío a hemaíology clánác for a dáagnosás of coagulopaíhyK
qhe auíhors dáagnosed coagulopaíhy án RV EPPKMBF of íhe paíáenís analyzed Eage
range NRJONV moníhsFK qhe coagulopaíháes dáagnosed áncluded von tállebrand
dásease án PPI plaíeleí aggregaíáon dásorders án NMI íhrombocyíopenáa án TI máld
facíor sII defácáency án PI BernardJpouláer syndrome án OI and a varáeíy of oíher
facíor defácáencáes án íhe remaánáng paíáenísK lnly a famály hásíory of bleedáng
was predácíáve of íhe dáagnosás of a bleedáng dásorderI and cháldren who receáved
a dáagnosás of coagulopaíhy had a longer medáan mqq íhan dád íhose wáíhouí íhe
dáagnosás EPPKN
PMKRI
=MKMNOF [
zK lf noíeI íhás síudy only áncluded
cháldren referred ío a hemaíology deparímení because of íhe severáíy of íheár
epásíaxás and may noí be reflecíáve of íhe average cháld wáíh rouíáne ádáopaíhác
then lookáng aí íhe áncádence of coagulopaíhy án cháldren wáíh severe epásíaxásI
defáned as íhose experáencáng medácal managemení faálure and requáráng
áníraoperaíáve cauíery by an oíolaryngologásíI blden
eí al
z noíed abnormal
coagulaíáon síudy resulís for NR of 4T EPNKVBF pedáaírác paíáenís wáíh epásíaxásK
dáagnosás of a bleedáng dásorder EP cases of von tállebrand dáseaseI N case of
plaíeleí aggregaíáon dásorderI and N case of máld facíor sII defácáencyFK qhe only
predácíáve facíor for a bleedáng dásorder noíed by íhe analysás of varáables was a
hásíory of emergency deparímení vásáí for epásíaxásK konpredácíors áncluded
addáíáonal personal hásíory of bleedángI famály hásíory of a specáfác bleedáng
dásorderI anemáa due ío epásíaxásI hásíory of emergení nasal áníerveníáonsI práor
nasal cauíeryI sexI ageI duraíáon of epásíaxásI locaíáon of epásíaxásI and frequency
of epásíaxás [
zK Based on íhese práor síudáesI íhere appears ío be no defánáíáve
guádeláne as ío whách cháldren wáíh epásíaxás mághí benefáí from furíher
hemaíologác íesíángK eealíhcare pracíáíáoners musí íherefore rely on clánácal
judgmení of íhe severáíy of a cháld’s epásíaxásI famály hásíory of bleedáng
dásordersI and hásíory of áníerveníáons when makáng decásáons abouí orderáng
Managemení of ádáopaíhác epásíaxás án cháldren ofíen áncludes applácaíáon of
lubrácanís or creams ío íhe aníeráor sepíum andLor íopácal nasal cauíery usáng
sálver náíraíe síácksK kasal packáng ás less ofíen used án íhe offáce seííáng and ás
generally reserved for emergení conírol of bleedángK qhere ás no consensus on íhe
besí síraíegy for managáng epásíaxásK iubrácanís láke peíroleum jellyI aníásepíác
oánímenísI and saláneJbased gels are readály avaálable and ofíen used for
maáníenance managemení of epásíaxásK Aníásepíác creams or gels are used ío
reduce vesíábuláíás and crusíángK Aníásepíác creams may faál ío reduce vesíábular
árráíaíáon due ío repeíáíáve nose páckáng and reJcolonázaíáon of íhe area wáíh
bacíeráaK eoweverI lubrácanís are more easály íoleraíed and generally less
íraumaíác íhan cauíeryI and íhey can be used daály [NI
I
pálver náíraíe acís by oxádázáng organác íássue and desíroyáng íhe underlyáng blood
vessels wáíh acádI causáng íhem ío be replaced by scar íássueK qhere are O dáfferení
conceníraíáons of sálver náíraíeI TRB and VRBK A prospecíáveI doubleJblánd
randomázed clánácal íráal comparáng íhe O án íhe managemení of cháldren wáíh
ádáopaíhác epásíaxás was performed by dlynn
eí al
K [
z qheár resulís showed
greaíer effácacy and fewer adverse effecís wáíh íhe TRB conceníraíáonI and íhás ás
íhe recommended conceníraíáon for cauíerázaíáonK A doubleJblándI randomázed
conírolled íráal comparáng cháldren receáváng sálver náíraíe cauíeryI followed by
aníásepíác cream for 4 weeksI wáíh íhose receáváng aníásepíác cream only was
performed by Calder
eí al
K [
z qhe síudy found íhaí a larger number of cháldren án
íhe sálver náíraíe group had ámprovemení án íheár sympíoms compared wáíh íhose
receáváng aníásepíác aloneK In anoíher prospecíáveI randomázed síudy comparáng
cauíery ío nasal aníásepíác oánímeníI NMM cháldren were asságned ío each of íhe O
groupsK qhe auíhors noíed recurrence of epásíaxás án PUB of íhe sálver náíraíe
cauíery group and ROB of íhe nasal aníásepíác group án íhe P moníhs afíer
íreaímeníK qhe dáfference was noí síaíásíácally ságnáfácaní [
zK A reírospecíáve
analysás of bálaíeral sálver náíraíe cauíery of íhe sepíum noíed íoíal or nearJíoíal
resoluíáon of epásíaxás án 4M of 4P EVPKMBF cháldren síudáed [
zK qhe auíhors
reporíed no subsíaníáal complácaíáons of ánfecíáonI perforaíáonI longJíerm crusíángI
íaííooángI or allergác reacíáons án íheár paíáenísI and íhey cáíed íhe lack of evádence
Concern has been raásed íhaí cauíery can also lead ío aírophy of íhe nasal mucosaI
whách can lead ío sepíal crusíáng and perforaíáon [NzK Accordáng ío reporísI
cauíery causes sclerosás of íhe vessels and íháckenáng of íhe mucosaI alíhough án
cháldrenI bleedáng can occur as a resulí of vesíábuláíásI whách causes ulceraíáons án
íhe mucosaI raíher íhan dáscreíe enlarged vesselsI makáng cauíery áneffecíáve án
íhás coníexíK A Cochrane analysás of áníerveníáons for ádáopaíhác epásíaxás found
no sángle íreaímení of epásíaxás ío be beííer íhan anoíherK ko seráous adverse
effecís of íhe avaálable íreaímení opíáons were noíedI oíher íhan paán relaíed ío
sálver náíraíe cauíery [
zK Clánácal judgmení musí be used when makáng
recommendaíáons for conírol of bleedáng wáíh lubrácanís or aníásepíác creamsI
cauíeryI or boíh án íhe managemení of sámple recurrení ádáopaíhác epásíaxás án
cháldrenK Acíáve bleedáng may requáre nasal packángK qhere are a varáeíy of
opíáons when consáderáng nasal packángI and dássolvable hemosíaíác opíáons may
Iníraoperaíáve managemení of epásíaxás may be requáred án sáíuaíáons of refracíory
bleedángI or án cases of poor paíáení íolerance án íhe offáce seííángK mrecáse
localázaíáon of bleedáng sáíes can be deíermáned by endoscopyI and vessels can be
cauíerázed wáíh sálver náíraíe or a varáeíy of elecírocauíery deváces E
I sucíáon
cauíeryI bápolar cauíeryI laser cauíeryFK A síudy by gohnson
eí alK
zI compared
ouícomes án cháldren undergoáng bápolar elecírocauíery wáíh íhose án cháldren
undergoáng sálver náíraíe cauíery ío íhe aníeráor sepíum án íhe áníraoperaíáve
seííángK lf íhe RM cháldren undergoáng bápolar elecírocauíeryI N EOKMBF had a
recurrence wáíhán O yearsI compared wáíh NP of SM EOOKMBF paíáenís who
underwení sálver náíraíe cauíeryK qhe dáfference was síaíásíácally ságnáfácaní;
howeverI afíer O yearsI íhere was no dáfference beíween íhe O groupsK More
aggressáve íechnáquesI such as lágaíáon íechnáquesI sepíal surgery íechnáquesI
whách less ánvasáve opíáons for conírol of bleedáng have faáledK qhese íechnáques
are more commonly used án adulísI án whom íhe bleedáng sáíe ás more ofíen
posíeráor án íhe nasal caváíy and relaíed ío underlyáng hyperíensáon [
I
peveráíy of íhe bleedáng encouníeredI íhe abáláíy ío locaíe íhe source of bleedángI
then evaluaíáng íeenaged boys wáíh epásíaxásI íhe dáagnosás of gkA should be
consáderedK In íhás sáíuaíáonI nasal endoscopy ás suggesíed ío carefully ánspecí íhe
posíeráor nasal caváíy and nasopharynx for íhe presence of íhás vascular lesáon [
gkA ás a benágnI vascularázed lesáon íhaí íypácally occurs án adolescení boysI aged
N4JOR yearsI preseníáng wáíh epásíaxás and nasal obsírucíáon [
J
zK qhe íumor
ás nonJencapsulaíedI submucosal spreadángI and locally desírucíáveK gkAs
orágánaíe wáíhán íhe superáor posíeráor margán of íhe sphenopalaíáne foramen and
can exíend ánío íhe píerygoplaíáne fossaI paranasal sánusesI and áníracranáally án
NMBJOMB of casesK Mosí paíáenís presení wáíh mánor sympíoms of paánlessI
unálaíeral nasal obsírucíáon and epásíaxásI alíhough láfeJíhreaíenáng epásíaxás can
occur [
zK Because of íhe vascular naíure of íhese lesáonsI báopsy ás noí
recommended for dáagnosás; ánsíead Mo ámagángI Mo angáographyI andLor Cq
scannáng are used for dáagnosíác purposesK píagáng of íhe lesáon can be
accompláshed íhrough ámagáng síudáes based on íhe exíení of spread of íhe lesáon
zK purgery ás íhe maánsíay of íreaímení for gkAI generally án conjuncíáon wáíh
embolázaíáon performed before surgácal resecíáonK purgácal opíáonsI áncludáng
íranshyoádI íranspalaíalI and íransfacáal approaches íhrough a laíeral rhánoíomy or
mádface deglovángI and ánfraíemporal approachesI have been descrábedK purgácal
approaches have changed íhrough íámeI wáíh íhe evoluíáon of mánámally ánvasáve
surgery and endoscopác approaches [
I
zK In addáíáonI ámproved surgácal
ánsírumeníaíáon and íhe use of CqJ or Mo ámagáng–guáded surgácal navágaíáon
kácolaá
eí al
z descrábed íheár experáence wáíh endoscopác surgery for gkAK
cáfíeen paíáenís wáíh a mean age of NRKU years were analyzedK All paíáenís had O
unáís of auíologous blood samples collecíed duráng íhe O weeks leadáng up ío íheár
procedureI and all lesáons were embolázed práor ío surgácal resecíáonK qhe auíhors
concluded íhaí íhe endoscopác approach was a safe and effecíáve íechnáqueI wáíh
low morbádáíyI for removal of small and áníermedáaíe sázed gkAs íhaí dád noí
have exíensáve ánvolvemení of íhe ánfraíemporal fossa and cavernous sánusK qhey
suggesíed íhaí advanced lesáons are besí íreaíed by exíernal approachesK pcholíz
K [
z suggesíed íhaí íhe maán advaníage of íhe endoscopác approach ío gkA
removal was mánámal dásrupíáon ío sofí íássue and bone wáíhouí damage ío
exíernal sírucíuresK aásadvaníages are relaíed ío resírácíed access and íhe
dáffáculíy án sháfíáng ío alíernaíáve endoscopác approaches áf complácaíáons of
hemorrhagáng aráseK rlíámaíelyI íhe surgácal approach should be selecíed based on
íumor sázeI íumor locaíáonI effácacy of íumor embolázaíáonI and experáence of íhe
operaíáng surgeonK mreoperaíáve plannáng for íhe possábáláíy of a blood íransfusáon
and íhe need ío modáfy íhe approach ío íhe lesáon appear ío be esseníáalK collowJ
up wáíh endoscopác assessmení and wáíh áníerval Mo ámagáng for assessmení of
eeqI or lslerJteberJoendu syndromeI ás an auíosomal dománaní vascular
dysplasáa characíerázed by íhe presence of mulíáple aríeráovenous malformaíáons
EAsMsF and íelangáecíasáasK qhe dáagnosás ás made when a paíáení has aí leasí P
of 4 Curacao cráíeráa: recurrení sponíaneous epásíaxásI famály hásíory of eeqI
íelangáecíasáas aí characíerásíác sáíes ElápsI oral caváíyI noseI and fángersFI and
proven vásceral AsMs [
J
zK maíhogenác varáaní ás anoíher consáderaíáonI
because eeq ás caused by paíhogenác varáanís án a number of genesK [
I
bpásíaxás ás íhe mosí common sympíom assocáaíed wáíh eeqI wáíh bleedáng
severáíy rangáng from ánfrequení ío severeI requáráng repeaíed blood íransfusáonsK
Beíween UMB and VMB of paíáenís wáíh eeq wáll receáve íhe dáagnosás by ON
years of ageI begánnáng aí a mean age of NO yearsI and almosí VRB develop
recurrení epásíaxás aí some poáníK
qreaímení of epásíaxás án paíáenís wáíh eeq may ánclude humádáfácaíáonI íopácal
agenísI sysíemác hormonesI oral drug íherapyI laser ablaíáonI sepíal dermoplasíyI
and nasal closureK Avoádance of vágorous nose blowángI elecírác or chemácal
cauíeryI and aníáJánflammaíory agenís ás recommended án paíáenís wáíh eeq [
zK pcreenáng for AsMs íhroughouí íhe áníesíánal írací ás ámporíaní for affecíed
bpásíaxás ás common án cháldren and ás ofíen manageable wáíh lubrácanísI
aníásepíác gelsI saláne sprayI and humádáíyK Mosí cases are selfJlámáíed and do noí
requáre addáíáonal examánaíáon or áníerveníáonK kasal sepíal cauíery wáíh sálver
náíraíe can be performed án íhe offáce seííáng and has a known favorable success
raíeK More aggressáve cauíery íechnáques án íhe operaíáve seííáng can ofíen be
reserved for íhose wáíh refracíory bleedáng íhaí cannoí be conírolled wáíh more
conservaíáve measuresK eemaíologác íesíáng should also be consádered án such
casesK Any íeenaged male preseníáng wáíh epásíaxásI paríácularly án íhe presence of
nasal obsírucíáonI should undergo nasal endoscopy ío assess for íhe presence of
gkAK If preseníI appropráaíe ámagáng and referral should be provádedK camály
hásíory should be asceríaáned án all cháldren wáíh epásíaxás ío assess for íhe
dáagnosás of eeq án famály membersK Clánácáans should be aware of íhe síress on
íhe cháld and famály íhaí ás assocáaíed wáíh recurrení epásíaxás and have a general
undersíandáng of íhe avaálable opíáons for managemení when counseláng íheár
Burían nK Iníerveníáons for recurrení ádáopaíhác epásíaxás EnosebleedsF án cháldren EreváewFK Cochrane
aaváes hI hadambará hI Mehanna oI heogh IK medáaírác epásíaxás: epádemáologyI managemení C
[Pzaamrose gI Maddalozzo gK medáaírác epásíaxásK iaryngoscope OMMS; NNS: PUTJVPK
maíel kI Maddalozzo gI Bállángs hoK An updaíe on managemení of pedáaírác epásíaxásK Iní g medáaír
Calder kI hang pI craser iI
eí alK
A doubleJblánd randomázed conírolled íráal of managemení of
hubba eI MacAndáe CI Boíma MI
eí alK
A prospecíáveI sángle blándI randomázed conírolled íráal
hamble mI paxena pI humar pK kasal bacíeráal colonázaíáon án cases of ádáopaíhác epásíaxás án cháldrenK
thymark AaI Crampsey amI craser iI
eí alK
Cháldhood epásíaxás and nasal colonázaíáon wáíh
pandoval CI aong pI sásáníaáner mK Clánácal and laboraíory feaíures of NTU cháldren wáíh recurrení
blden sI oeánders MI táímer CK mredácíors of bleedáng dásorders án cháldren wáíh epásíaxás: value of
MangussáJdomes gI bnouí MgI Casíro qCI
eí alK
Is íhe occurrence of sponíaneous epásíaxás relaíed ío
clámaíe varáables? A reírospecíáve clánácalI epádemáologácal and meíeorologácal síudyK Acía
líolaryngol OMNSK EpendángF
[NOzMcdarry dtK oecurrení epásíaxás án cháldrenK Clán bvád OMNP; NMEPNNF: NJVK
dlynn cI Amán MI pheahan mI Mcphane aK mrospecíáve double blánd randomázed clánácal íráal
comparáng TRB
VRB sálver náíraíe cauíerázaíáon án íhe managemení of ádáopaíhác cháldhood
lzmen pI lzmen lAK Is local oánímení or cauíerázaíáon more effecíáve án cháldhood recurrení
iánk qoI Conley pcI clanary sI herschner gbK Bálaíeral epásíaxás án cháldren: effácacy of bálaíeral
gohnson kI caráa gI Behar mK A comparáson of bápolar elecírocauíery and chemácal cauíery for conírol
Meláa iI Mcdarry tK bpásíaxás: updaíe on managemeníK Curr lpán líolaryngol eead keck purg
poyka MBI kákolaou dI oufábach hI eolzman aK ln íhe effecíáveness of íreaímení opíáons án
pcholíz AtI Appenroíh bI hammenJgolly hI pcholíz irI qhumfarí tcK guvenále nasopharyngeal
kácolaá mI Berlucchá MI qomenzolá aI
eí alK
bndoscopác surgery for juvenále angáofábroma: when and
Andrews gCI cásch rI salavanás AI Aepplá rI Makek MpK qhe surgácal managemení of exíensáve
nasopharyngeal angáofábromas wáíh íhe ánfraíemporal fossa approachK iaryngoscope NVUV; EVVF: 4OVJ
dlad eI saáner BI Buchwald CI
eí alK
guvenále nasopharyngeal angáofábromas án aenmark NVUN–OMMP:
Mooríhy mI oeddy BI naáyum eI Madhára pI holloju pK Managemení of juvenále nasopharyngeal
angáofábroma: a fáve year reírospecíáve síudyK Indáan g líolaryngol eead keck purg OMNM; SOE4F: PVMJ
euníer BkI qámmons BeI Mcaonald MpI
eí alK
An evaluaíáon of íhe severáíy and progressáon of
epásíaxás án heredáíary hemorrhagác íelangáecíasáa N
heredáíary hemorrhagác íelangáecíasáa OK
[ORzMcaonald gI myeráíz obK eeredáíary hemorrhagác íelangáecíasáaK dene oeváews OMMM gun OS;
MeáJZahav MI ieíaríe MI caughnan MbI
eí alK
pympíomaíác cháldren wáíh heredáíary hemorrhagác
phovlán CiI duíímacher AbI Buscaráná bI
eí alK
aáagnosíác cráíeráa for heredáíary hemorrhagác
aeparímení of líolaryngology – eead and keck purgeryI rnáversáíy of qexas pouíhwesíern
Absírací:
Allergác rhánáíás EAoFI íhe mosí common chronác dásease án cháldrenI ás íhe
fáfíh mosí common chronác dásease án íhe rnáíed píaíesK líolaryngologásís see a large
perceníage of paíáení’s whose dásease process ás ofíen assocáaíed wáíhI or caused byI
upper and lower aárway ánflammaíáonK Because allergy ás a common conírábuíor ío
aárway ánflammaíáonI a workáng knowledge of íhe íreaímení opíáons for pedáaírác
allergác rhánáíás ás esseníáal án íhe evaluaíáon and managemení of cháldren preseníáng ío
heywords:
Allergác rhánáíásI Allergác rhánáíás and Allergác conjuncíáváíásI Allergác
rhánáíás and AsíhmaI Allergác rhánáíás and líáíás medáa wáíh effusáonI Allergác
rhánáíás and ohánosánusáíásI Allergác rhánáíás and pleep dásíurbanceI Allergác
rhánáíás comorbádáíáesI Allergác rhánáíás dáagnosásI AvoádanceI bnváronmeníal
conírolI ImmunoíherapyI mharmacoíherapyI pubcuíaneous ámmunoíherapyI
publángual ámmunoíherapyK
Allergác rhánáíás ás one of several comorbád condáíáons ofíen seen án paíáenís who
suffer from allergác dásease EaíopyFK qhe geneíác predásposáíáon ío develop allergác
dáseasesI
aíopyI ás íypácally assocáaíed wáíh áníensáfáed ámmune responses ío
qhe phenoíype of allergy has a complácaíed and varáable geneíác conírábuíáonI
henceI no sángle geneíác íesí ás used ío ádeníáfy áf an ándávádual ás allergácK In íhe
lághí of íhe genes ádeníáfáedI alíeraíáons án boíh ánnaíe and adapíáve ámmunáíy are
cráíácal án allergác dásease [
zK MoreoverI geneJenváronmení áníeracíáons [
zI add
anoíher layer of varáabáláíy ío íhe developmení of allergác dáseaseK qo daíe
exposure ío cágareííe smokeI hágher socáoeconomác levelI fársí born or only cháldI
Correspondáng auíhor Maráa CK seláng
: aeparímení of líolaryngology – eead and keck purgeryI rnáversáíy of
qexas pouíhwesíern Medácal CeníerI aallasI quI rpA; qelLcax: ON4J4RSJTS44; bmaál:
denerallyI íhe fársí clánácal manáfesíaíáon of allergác rhánáíás dásease án early
cháldhood ás aíopác dermaíáíásK A íypácal sequence of food allergyI rhánáíás and
asíhma follows aíopác dermaíáíásK qhe aíopác march descrábes íhe progressáon of
aíopác manáfesíaíáons from aíopác dermaíáíás ío allergác rhánáíás and asíhmaK A
number of crossJsecíáonal and longáíudánal síudáes subsíaníáaíe áís valádáíy;
howeverI more daía are needed ío supporí íhe aíopác march hypoíhesás [
J
zK qhe
aíopác march may noí be a sámple progressáon as geneíác and enváronmeníal
facíors ánfluence íhe developmení of aíopác dermaíáíásI allergác rhánáíás and
Allergác rhánáíásI affecíáng N ouí of S AmerácansI ás íhe mosí common chronác
dásease án íhe rnáíed píaíesK Ao and relaíed állnesses accouní for UMMIMMM ío O
Allergác rhánáíás ás a chronác dásorder of íhe upper aárways and ás ánduced by IgbJ
medáaíed ánflammaíáon afíer exposure of íhe nasal membranes án sensáíázed
paíáenís ío a specáfác allergen [
zK qhe sympíoms of allergác rhánáíás encompass
nasal congesíáonI nasal draánageI sneezángI nasal áíchángI and posínasal draánageK
Allergác rhánáíás has a mulíáplácáíy of sympíoms wáíh varáed clánácal preseníaíáon
án íhe pedáaírác paíáeníI dependáng on íhe duraíáon of allergy on exposureI ageI and
presence of comorbád dáseaseK In addáíáonI áís sympíoms can be sámálar ío íhose of
recurrení upper respáraíory ánfecíáonsI a common occurrence án cháldhoodI leadáng
qhe prevalence of Ao varáes wáíh facíors áncludángI buí noí lámáíed íoI geneíácsI
epágeneíácsI and enváronmeníal exposureK torldwáde prevalence esíámaíes range
from NKRB ío PVKTB dependáng on geographác locaíáon [
zK In qhe medáaírác
Allergáes án Ameráca purveyI oíolaryngologásís surveyed esíámaíed íhaí 4NB of
íheár pedáaírác paíáenísI aged 4 ío NT yearsI were dáagnosed wáíh allergác rhánáíás
Alíhough allergác rhánáíás ás noí láfe íhreaíenángI áí can have a ságnáfácaní ámpací
on íhe qualáíy of láfe [
zI school performanceI qualáíy of sleepI and physácal and
emoíáonal healíh [
zK In addáíáonI áí can have a subsíaníáal economác ámpací
áncludáng boíh dárecí cosís ío paíáenís and ándárecí cosís íhaí ánclude abseníeeásm
Allergác rhánáíás án cháldren ás dáagnosed based on hásíoryI clánácal assessmení and
allergy íesíángK Allergy íesíáng án íhe absence of clánácal lákeláhood of allergác
dásease yáelds unaccepíable falseJposáíáve raíes and ás noí recommendedK qhás was
állusíraíed by a posáíáve skán práck íesí án RPKVB of NMIRMV Amerácans randomly
qhough íhe receníly publáshed Clánácal mracíáce duádeláne on Allergác ohánáíás
síaíes íhaí skán íesíáng can be used án paíáenís of any age [
zI early sensáíázaíáon
ío ánhalaní allergens án ánfancy occurs ánfrequeníly and íhere ás rarely a need ío
íesí for íhem án cháldren less íhan 4 years of ageK eerr and colleagues [
z used a
síandardázed quesíáonnaáre án NURM ánfanís aí íheár NUíhJmoníh examánaíáon ío
ádeníáfy cháldren wáíh allergác rhánáíásJláke sympíoms defáned as runny noseI
blocked noseI and sneezáng aparí from a coldK lf íhe NURM ánfanísI VKNB were
found ío have allergác rhánáíásJláke sympíomsK All cháldren were íhen assessed
wáíh a specáfác ánhalaní Igb screenI íoíal IgbI and eosánopháláaK qhere was no
dáfference án eosánopháláa or íoíal Igb án íhe “allergác rhánáíásJláke sympíoms”
group compared wáíh íhe “no allergác rhánáíásJláke sympíoms” groupK lnly V of
íhe NURM cháldren had boíh allergác rhánáíásJláke sympíoms and elevaíed ánhalaníJ
specáfác IgbK In comparásonI íhere were 4P of NURM ánfanís wáíh elevaíed ánhalaníJ
specáfác Igb íhaí were ádeníáfáed án íhe “no AoJláke sympíoms groupK” qhás
suggesís íhaí allergác rhánáíás ás rare aí NU moníhs of age and íhaí screenáng ánfanís
for elevaíed specáfác Igb would lack specáfácáíy án ádeníáfyáng ánfanís wáíh clánácal
then íhere ás a hágh degree of suspácáonI íesíáng only for ándoor allergensI may
ádeníáfy íhe majoráíy of sensáíázed cháldren as demonsíraíed by paháner
eí al
In íheár síudyI íhey looked aí 4PO cháldrenI less íhan O years of ageI wáíh asíhmaI
and íesíed íhem wáíh eáíher a full panel of ánhalaní allergensI áncludáng ándoor
allergens
K ándoor allergens aloneK qhey found íhe raíe of sensáíázaíáon ío be
esseníáally equal beíween íhe íwo groups concludáng íhaí án íhe very youngI
Ií ás also ámporíaní ío remember íhaí negaíáve allergy skán íesíáng án early
qreaímení of allergác rhánáíás án cháldren ás sámálar ío íreaímení án adulísI and
consásís of avoádanceI enváronmeníal conírolsI pharmacologác íherapyI and
specáfác allergen desensáíázaíáonK
Alíhough counseláng abouí enváronmeníal conírol of allergác rhánáíás ás
recommendedI clánácal effácacy án conírolled síudáes ás ofíen dásappoáníáng [
qerreehorsí and colleagues [
z performed a randomázed placeboJconírol íráal of
dusí máíe maííress covers án OTV subjecís allergác ío dusí máíeK Alíhough íhey
were able ío demonsíraíe a decrease án dusí máíe counísI no clánácal ámprovemení
án Ao sympíoms was deíecíed beíween íhe síudy and conírol groupsK A recení
Cochrane reváew suggesíed an exíensáve bedroomJbased program áncludáng
acaracádesI máíe ámpermeable coversI and hághJeffácáency paríáculaíe aár EebmAF
Afíer ánJdepíh reváew of íhe currení láíeraíure lookáng aí íhe effecís of
enváronmeníal conírol án Ao paíáenísI íhe Clánácal mracíáce duádeláne on Allergác
ohánáíásI consáders allergen avoádance and enváronmeníal manápulaíáon as an
“opíáon” for paíáenís wáíh ádeníáfáed allergens correlaíáng wáíh clánácal sympíoms
mharmacoíherapy for allergác rhánáíás ás caíegorázed as eáíher íargeíed íherapy
EdecongesíanísI aníáhásíamánesI leukoíráene recepíor aníagonásísI
KF or
ámmunomodulaíors EsíeroádsI ámmunoíherapyI monoclonal aníábodáesFK qhe
selecíáon of a specáfác medácaíáon for a paíáení depends on mulíáple facíors
áncludáng sympíom profáleI medácaíáon cosíI response ío preváous íreaímeníI ease
Iníranasal síeroáds are sírongly recommended for paíáenís wáíh a clánácal dáagnosás
of allergác rhánáíás and whose sympíoms affecí íheár qualáíy of láfe [
zK Iníranasal
síeroáds ámprove íhe qualáíy of láfe and sleep by reducáng nasal sympíoms
áncludáng congesíáonI sneezángI and rhánorrhea án adulís and cháldren wáíh allergác
rhánáíás [
J
zK A concern regardáng íheár use án cháldren ás íhe effecí áníranasal
síeroáds may have on growíhK qhás has been ánvesíágaíed án conírolled síudáes and
alíhough íhe fándángs are máxedI íhey suggesí íhaíI of íhe áníranasal síeroád
preparaíáons síudáed án cháldrenI fluíácasone propáonaíe and momeíasone furoaíe
showed no effecís on growíh compared wáíh placebo [
I
zK eenceI án clánácal
pracíáceI áí seems prudení ío use íhe áníranasal síeroád preparaíáons íhaí have noí
lral aníáhásíamánes have been shown ío be benefácáal án Ao paíáenís wáíh
complaánís of sneezáng and áícháng [
zK oapád onseí of acíáonI once daály dosáng
and lqC avaálabáláíy are advaníages of oral aníáhásíamánesK pecond generaíáon
Iníranasal aníáhásíamánes have been shown ío be equal or superáor ío oral
aníáhásíamánes for íhe íreaímení of nasal sympíoms án numerous wellJ deságned
randomázed síudáes [
zK Iníranasal aníáhásíamánes have íhe advaníage of dárecí
delávery ío íhe affecíed nasal íássues whále lámáíáng sysíemác effecís [
zI however
CurrenílyI oral leukoíráene recepíor aníagonásís EiqoAsF are noí recommended as
prámary íherapy for paíáenís wáíh allergác rhánáíás [
zK eoweverI íhere ás
conflácíáng evádence as ío áís effácacy when íhese are used án combánaíáon wáíh an
oral aníáhásíamáneK pome síudáes have shown beííer clánácal response when used án
combánaíáon íhan when eáíher medácaíáon ás used alone [
I
zI whále oíhers
lverallI íhe majoráíy of allergác rhánáíás paíáenís show some ámprovemení wáíh
medácal managemení and enváronmeníal conírolsK Allergác rhánáíás paíáenís who
faál ío have an adequaíe response of íheár sympíoms ío pharmacologác íherapy
should be offered ámmunoíherapyK Allergen specáfác ámmunoíherapy has íhe
poíeníáal ío change íhe naíural course of AoK Ií ás unáque án áís benefácáal effecí on
allergáes afíer íhe íreaímení ás dásconíánuedI áís effecí on reducáng addáíáonal
sensáíázaíáonsI and reducíáon án íhe developmení of allergác asíhma [
Boíh subcuíaneous and sublángual ámmunoíherapy án cháldren has been shown ío
be effecíáve [
J
zK Immunoíherapy ámproves íhe conírol of comorbád
condáíáons such as asíhma and conjuncíáváíásI and íhe dásease specáfác qualáíy of
láfe [
zK oáskI íámeI and expense of ámmunoíherapy needs ío be carefully
maíched ío severáíy and abáláíy ío conírol allergác dáseaseK
qhe epádemáologác assocáaíáon among íhe aíopác dásorders has been well
esíabláshed and recognáíáon of íhese assocáaíáons has ámpací on boíh dáagnosás and
íherapyK cor ánsíanceI Ao ás rarely found án ásolaíáon and needs ío be consádered
qhere ás a large overlap beíween Ao and allergác conjuncíáváíás and áí ás ofíen
consádered one dásease: rhánoconjuncíáváíásK Báelory [
z summarázes several
epádemáologác síudáes ío esíámaíe íhaí íhere ás UMB overlapI wáíh NMB haváng Ao
alone and NMB haváng allergác conjuncíáváíás aloneK qhe large IpAAC síudáes
looked aí rhánoconjuncíáváíás as sángle dáagnosás and reporíed sympíoms án UKRB
of
S ío T year
old and N4KSB án NP ío N4 year oldK
As suchI cháldren wáíh Ao
should be assessed for allergác conjuncíáváíás and íopácal aníáhásíamáne consádered
qhe close anaíomácal
assocáaíáon beíween íhe nose and paranasal sánuses provádes
a greaí deal of ánfluence over each oíher íhaí ás noí lámáíed ío obsírucíáon or
spállover of ánflammaíáonK bspecáally án aíopác ándávádualsI rhánáíás and
rhánosánusáíás are ándávádual manáfesíaíáons of a sysíemác responseK ohánáíás and
rhánosánusáíás are characíerázed by ánflammaíáon wáíh overlappáng sympíoms such
as ámpaáred nasal breaíháng and rhánorrheaK qhe relaíáonsháp beíween allergác
rhánáíás and rhánosánusáíás has been ánvesíágaíed án boíh íhe adulí and pedáaírác
populaíáonsK Ií has been reporíed íhaí more íhan UMB of cháldren wáíh
rhánosánusáíás have a famály hásíory of allergy whále án a general populaíáon
allergy frequency ás NRJOMB [
ohánosánusáíás ás commonly seen án paíáenís wáíh asíhma and allergác rhánáíás and
has been shown ío be a írágger for asíhma án cháldren and adulís [
zK Allergác
rhánáíás has also been lánked ío cháldren wáíh asíhma and oíáíás medáa wáíh
effusáonI wáíh íhe áncádence of rhánosánusáíás beáng hágher án íhás paíáení
populaíáon [
zK crom íhe síandpoání of íreaímení ouícomesI ámmunoíherapy
before endoscopác sánus surgery án cháldren wáíh allergác rhánáíás ságnáfácaníly
ámproved íhe surgácal success raíe from S4 ío U4B [
zK ln íhe oíher handI íhere
are also síudáes suggesíáng a lack of correlaíáon beíween allergác dásease and
many yearsK bpádemáologácal síudáes have demonsíraíed an assocáaíáon beíween
lMb and aíopác condáíáons such as allergác rhánáíás [
I
zK qhe prevalence of
allergác rhánáíás án paíáenís wáíh chronác or recurrení lMb varáes wádelyI rangáng
from NSKPB ío UVB [
zI and may be hágher íhan íhaí of íhe general populaíáon
qhe síudáes aámed aí examánáng íhe relaíáonsháp beíween allergác rhánáíás and
lMb have yáelded áncongruous resulís suggesíáng eáíher large regáonal
dáfferences or báas án assocáaíáng oíáíás and allergác dáseaseK curíhermoreI a írue
causaíáve assocáaíáon would suggesí íhaí suppressáng íhe ánflammaíory response
would lead ío ámprovemení of oíáíás medáa sympíomsI whách has noí been foundK
Aí íhás íáme íhe resulíáng láíeraíureI áncludáng íhe recení Clánácal mracíáce
duádelánes on líáíás Medáa wáíh bffusáon updaíe [
zI do noí supporí íhe
íreaímení of ásolaíed lMb wáíh aníáhásíamánesI decongesíanísI oral or íopácal
Ií ás however ámporíaní ío noíeI íhaí íhe vasí majoráíy of síudáes examánáng íhe
relaíáonsháp beíween Ao and lMbI do noí consáder íhe allergy síaíus of íhe
cháldren íreaíed for lMbI and áí ás unknown wheíher íhe subgroup wáíh proven
allergác ánflammaíáon mághí respond dáfferenílyK oeceníly age was ádeníáfáed as an
effecí modáfáer án paíáenís wáíh lMb [
zK In cháldren S years old or olderI íhe
presence of Ao ságnáfácaníly áncreased íhe odds of lMb and bqaK tellJdeságned
íráalsI wáíh beííerJdefáned subpopulaíáons are needed ío furíher evaluaíe íhe
possáble causaláíy beíween Ao and lMb án íhe older cháldK
aemonsíraíáon of a síaíásíácal assocáaíáon beíween Ao and asíhma does noí allow
us ío conclude íhaí Ao causes asíhmaK Allergác rhánáíás mághí be an ándependení
rásk facíor for asíhma [
I
zK Alíhough íhe lánk beíween Ao and asíhma ás wellJ
esíabláshedI a causal relaíáonsháp ás noíK Ií ás possáble íhaí Ao and asíhma are boíh
manáfesíaíáons of an underlyáng sysíemác allergác íendency [
zK keveríhelessI íhe
assocáaíáon beíween Ao and asíhma renders cháldren wáíh Ao ío be assessed for
qreaímenís íargeíáng eáíher asíhma or Ao may alleváaíe íhe oíher coexásíáng
condáíáon [
I
zK qreaíáng coJmorbád allergác rhánáíás may resulí án beííer asíhma
ouícomes án íerms of asíhma sympíomsI emergency deparímení vásáís and
hospáíalázaíáonsI and lower overall cosís [
qhe daía on íhe effecí of allergen avoádance or pharmacoíherapy on íhe longJíerm
naíural hásíory of respáraíory allergyI án paríácular íhe developmení of asíhmaI has
been lámáíed [
I
I
zK Much more promásáng ás íhe fáeld of allergen specáfác
ámmunoíherapyK AllergenJspecáfác ámmunoíherapy EpIqF may alíer íhe naíural
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In íhe mAq síudy [
J
zI cháldren wáíh seasonal rhánoconjuncíáváíás receáváng
subcuíaneous ámmunoíherapy wáíh grass andLor bárch síandardázed allergen
exíracís for P yearsI showed longJíerm E>
T yearsF clánácal effecís and a preveníáve
effecí on asíhma developmeníK oandomázed conírolled open íráals of sublángual
ámmunoíherapy án cháldren have also suggesíed a preveníáve asíhma effecí [
In an efforí ío furíher subsíaníáaíe íhe dáseaseJmodáfyáng effecí of pIq on íhe
developmení of asíhmaI íhe ongoáng dAm Edrazax Asíhma mreveníáonF íráal
represenís íhe fársí doubleJblándI placebo conírolled randomázed síudy aámáng ío
assess íhe preveníáve effecí of pIq on asíhma developmení [
zK Awareness of
asíhma ás ámporíaní for oíolaryngologásís because of íhe epádemáologác lánk
beíween chronác upper and lower aárway ánflammaíáon [
I
Asíhma ás under dáagnosedI ámpaárs qualáíy of láfeI and even máld persásíení
asíhma ás poíeníáally láfe íhreaíenáng [
zK qhe abáláíy ío ádeníáfy asíhmaI ánáíáaíe
íreaímeníI and ensure appropráaíe coníánued care should be íhe goal of every
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pleep dásíurbance has been áncreasángly recognázed as one of íhe major ámpacís of
allergác rhánáíásI and has been demonsíraíed ío be more common án paíáenís wáíh
allergác dáseases íhan án íhe general populaíáon [
J
zK kasal congesíáon ás a
hallmark sympíom of allergác rhánáíás and ás consádered ío be íhe mosí ámporíaní
kasal congesíáon has been reporíed ío be íhe cause of dáffáculíy falláng asleep án
4VB of cháldren and 4UB of adulís wáíh AoK Ií ás also reporíed as íhe cause of
arousals from sleep án 4VB of cháldren and RNB of adulís [
zK bpádemáologácal
síudáes boíh supporí and refuíe íhe hypoíhesás íhaí paB and allergác rhánáíás are
koí all research supporís íhe conírábuíáon of allergác rhánáíás ío sleepJdásordered
breaíháng EpaBFK Adenoíonsállecíomy ouícomes for íreaímení of lpA án over RMM
cháldren revealed íhaí over PVKRB of cháldren were ádeníáfáed as haváng allergác
Ao was wáíhán íhe esíámaíes of allergác rhánáíás án íhe general populaíáon [
resulíed án íhás síudy noí beáng able ío ádeníáfy allergác rhánáíás as a facíor
ánfluencáng response ío adenoíonsállecíomy for íhe íreaímení of paB [
In a qualáíaíáve sysíemaíác reváew of íhe assocáaíáon beíween allergác rhánáíás and
paB án cháldren [
zI íwoJíhárds of íhe aríácles demonsíraíed síaíásíácally
ságnáfácaní assocáaíáon beíween allergác rhánáíás and paB whereas oneJsáxíh of íhe
aríácles found no síaíásíácally ságnáfácaní correlaíáonK qhe weakness of íhe daía
áncluded lack of íhe use of formal polysomnography for íhe dáagnosás of lpA and
Ií has been preváously demonsíraíed íhaí sleep dásordersI ándependení of allergác
rhánáíásI affecí íhe normal balance of qhNT and q regulaíory cells EqregF [
I
and íhaí íhe qhNTLqreg raíáo posáíávely correlaíes wáíh íhe severáíy of lpA [
zK qhNT cells íhrough IiNT producíáon play cráíácal roles án íhe developmení of
auío ámmunáíy and allergác reacíáonsK qreg cells are ánvolved án ámmune íolerance
by releasáng aníáJánflammaíory cyíokánesK qhe balance beíween íhe íwo ás cráíácal
for conírolláng íhe developmení of auíoámmune and ánflammaíory responses such
oecenílyI ká and colleagues [
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wáíh lpA and áís relaíáonsháp wáíh allergác rhánáíásK qheár síudy revealed íhaí
compared ío íhe conírol groupI lpA cháldren exhábáíed a ságnáfácaní áncrease án
íhe number of perápheral qhNT cells EproJánflammaíoryF and dramaíác decreases án
íhe number of qreg cells Eánvolved án ámmune íoleranceFK In addáíáonI íhe áncrease
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ío íhe lpA group wáíhouí AoK qhey concluded íhaí qhNTLqreg ámbalance may
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of íhe dáseaseK Ií seems appropráaíe íhaí preoperaíáve evaluaíáon and proper
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Because of our paíáení populaíáonI íhe pedáaírác oíolaryngologásí ás án a unáque
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comorbádáíáes [
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bvaluaíáon of íhe CaN4LJOSM polymorphásm and
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pkoner amK Allergác rhánáíás: defánáíáonI epádemáologyI paíhophysáologyI deíecíáonI and dáagnosásK g
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Burden of allergác rhánáíás: resulís from íhe pedáaírác
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pmáíh aeI Malone aCI iawson hAI
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A kaíáonal bsíámaíe of íhe bconomác Cosís of AsíhmaK
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Clánácal pracíáce guádeláne: allergác rhánáíásK líolaryngol
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aoes allergác rhánáíás exásí án ánfancy? cándángs from íhe
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mesonen MK halláo MgI páámes MAI oanká AK Allergen skán práck íesíáng án early cháldhood:
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doízsche mCI gohansen ehK eouse dusí máíe conírol measures for asíhmaK Cochrane aaíabase pysí
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Mcaonald bI Cook aI kewman qI dráffáíh iI
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bffecí of Aár cálíraíáon pysíems on Asíhma: A
qerreehorsí II eak bI losíáng AgI
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bvaluaíáon of ámpermeable covers for beddáng án paíáenís wáíh
pheákh AI eurwáíz BI kurmaíov rI
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eouse dusí máíe avoádance measures for perennáal allergác
oodrágo dgI keffen eK bffácacy of fluíácasone furoaíe nasal spray
K placebo for íhe íreaímení of
ocular and nasal sympíoms of allergác rhánáíás:
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Clán bxp Allergy
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menagos MI Compalaíá bI qaraníáná cI
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bffácacy of momeíasone furoaíe nasal spray án íhe
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bffácacy of momeíasone furoaíe nasal spray for nasal
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Allen aBI Melízer blI iemanske oc grI
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ko growíh supJ pressáon án cháldren íreaíed wáíh íhe
maxámum recommended dose of fluíácasone propáonaíe aqueous nasal spray for one yearK Allergy
pchenkel bgI pkoner amI Bronsky bAI
eí alK
Absence of growíh reíardaíáon án cháldren wáíh perennáal
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pámons cbI pámons hgK eásíamáne and eNJaníáhásímánes: celebraíáng a ceníury of progressK g Allergy
káckels ApI aámov sI tolf oK mharmacokáneíác evaluaíáon of
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iombardo dI nuaíírocchá mI iombardo doI
eí alK
Concomáíaní levoceíárázáne and moníelukasí án íhe
íreaímení of seasonal allergác rhánáíás: ánfluence on clánácal sympíomsK Iíaláan gournal of Allergy and
Melízer blI Malmsírom hI iu pI
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Concomáíaní moníelukasí and loraíadáne as íreaímení for
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Cáebáada MI Barylská MI dorska Cáebáada MK kasal eosánopháláa and serum soluble áníercellular
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taíanasomsárá AI moachanukoon lI sáchyanond mK bffácacy of moníelukasí and loraíadáne as
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ealken pI iau pI salováría bK kew vásáons án specáfác ámmunoíherapy án cháldren: an ámAC summary
ooder bI Berger MvI de drooí eI
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Immunoíherapy án cháldren and adolescenís wáíh allergác
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publángual ámmunoíherapy for íhe íreaímení of allergác rhánoconjuncíáváíás and asíhma: A
Báelory iK Allergác conjuncíáváíás and íhe ámpací of allergác rhánáíásK Curr Allergy Asíhma oep OMNM;
cok AlI tong dtK thaí have we learní from IpAAC phase III án íhe AsáaJmacáfác rám? Curr lpán
Bjorksíen BI Clayíon qI bllwood mI
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torldwáde íáme írends for sympíoms of rhánáíás and
conjuncíáváíás: phase III of íhe áníernaíáonal síudy of asíhma and allergáes án cháldhoodK medáaír Allergy
phapáro ddI oachelesvsky dpK Iníroducíáon and defánáíáon of sánusáíásK g Allergy Clán Immunol NVVO;
deorgáíás gtI Maííhews BiI píone BK Chronác sánusáíás: characíerázaíáon of cellular ánflux and
Brook II vocum mI phah hK Aerobác and anaerobác bacíeráology of concurrení chronác oíáíás medáa
oamadan eeI eánerman oAK luícome of endoscopác sánus surgery án cháldren wáíh allergác rhánáíásK
ieo dI máaceníáná bI Incorvaáa CK eíalK Chronác rhánosánusáíás and allergyK medáaír Allergy Immunol
Alles oI marákh AI eawk iI
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qhe prevalence of aíopác dásorders án cháldren wáíh chronác oíáíás
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kewacheck mtI píoddard ggK mrevalence and ámpací of mulíáple cháldhood chronác állnessesK g medáaír
ply oMK Changáng prevalence of allergác rhánáíás and asíhmaK Ann Allergy Asíhma Immunol NVVV; UO:
dráffán dI clynn CAK Aníáhásíamánes andLor decongesíanís for oíáíás medáa wáíh effusáon ElMbF án
pámpson pAI iewás gI van der soorí gI
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san Zon AI van der eeájden dgI van aongen qMI
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oodáíá obI seláng MI phán ggK Age: An effecí modáfáer of íhe assocáaíáon beíween allergác rhánáíás and
qogáas AK ohánáíás and asíhma: evádence for respáraíory sysíem áníegraíáonK g Allergy Clán Immunol
san Cauwenberge mI taíeleí gBI san Zele qI
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aoes rhánáíás lead ío asíhma? ohánology OMMT;
deorgalas CI qerreehorsí II cokkens tK Currení managemení of allergác rhánáíás án cháldrenK medáaír
Caámmá aI Marsegláa AI máerá dI Benzo pI Bosa iI Caámmá pK kose and lungs: one wayI one dáseaseK
pazonov hocevar sI qhomas g IIII gonsson iI
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Assocáaíáon beíween allergác rhánáíás and hospáíal
eumberí MI Bouleí imI káven oMI manahloo ZI Blogg MI Ayre dK lmalázumab íherapy: paíáenís who
acháeve greaíesí benefáí for íheár asíhma experáence greaíesí benefáí for rhánáíásK Allergy OMMV; S4ENF:
[SSzqhomas MK Allergác rhánáíás: evádence for ámpací on asíhmaK BMC mulm Med OMMS; S EpupplK NF: p4K
kurmaíov rI van pchayck CmI eurwáíz BI pheákh AK eouse dusí máíe avoádance measures for
Bjornsdoííár rpI gakobánudoííár pI ounarsdoííár sI guláusson pK qhe effecí of reducáng levels of caí
allergen Ecel d NF on clánácal sympíoms án paíáenís wáíh caí allergyK Ann Allergy Asíhma Immunol
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gacobsen iI kággemann BI areborg pI
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ppecáfác ámmunoíherapy has longJíerm preveníáve effecí
kággemann BI gacobsen iI areborg pI
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cáveJyear followJup on íhe mAq síudy: specáfác
ámmunoíherapy and longJíerm preveníáon of asíhma án cháldrenK Allergy OMMS; SNETF: URRJVK
cháldren wáíh seasonal rhánoconjuncíáváíás Eíhe mAqsíudyFK g Allergy Clán Immunol OMMO; NMVEOF: ORNJ
aá oáenzo sI Marcuccá cI muccánellá mI
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iongJlasíáng effecí of sublángual ámmunoíherapy án
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kovembre bI dallá bI iandá cI
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Coseasonal sublángual ámmunoíherapy reduces íhe developmení
llaguábel gMI Alvarez muebla MgK bffácacy of sublángual allergen vaccánaíáon for respáraíory allergy
salováría bI Bersíad AhI de Blác gI
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aeságn and recruáímení for íhe dAm íráalI ánvesíágaíáng íhe
preveníáve effecí on asíhma developmení of an pnJsíandardázed grass allergy ámmunoíherapy íableí án
qsálochrásíou lI aouladárás kI Makrás MI mapadopoulos kK medáaírác Allergác ohánáíás and Asíhma:
kIe duádelánes for íhe dáagnosás and managemení of asíhma–OMMT EbmoJPF I OMMT [Accessed
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of nonrandomázed síudáes án meíaJanalysás I [Accessed kovember 4I OMNOz;
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peííápane oAI Charnock aoK bpádemáology of rhánáíás: allergác and nonallergácK Clán Allergy Immunol
ián pvI Melván qAI Boss bcI Ishman piK qhe assocáaíáon beíween allergác rhánáíás and sleepJ
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qhe Managemení of medáaírác Allergác
aeparímení of Iníernal MedácáneI aávásáon of Allergy and ImmunologyI rnáversáíy of Arkansas
aeparímení of medáaírácsI aávásáon of Allergy and ImmunologyI rnáversáíy of Arkansas for
Absírací:
Anaphylaxás ás a dangerous condáíáon íhaí musí be íreaíed quácklyK qhe
prevalence ás on íhe ráseI and íhe dáagnosás requáres a low ándex of suspácáon án
someone experáencáng íhe íypácal consíellaíáon of sympíoms ánvolváng more íhan one
body sysíem afíer exposure ío a possáble allergenK qreaímení ánvolves íhe
admánásíraíáon of áníramuscular epánephráne before consáderaíáon of any oíher
modaláíáesK thále íreaímení of anaphylaxás wáíh epánephráne always comes fársíI
specáfác laboraíory íesís áncludáng serum írypíase and dárecíed specáfác Igb íesís can be
consádered ío help aád án íhe dáagnosásK cánallyI every paíáení who experáences
anaphylaxás should be dáscharged wáíh ánjecíable epánephráne and an emergency acíáon
heywords:
AnaphylaxásI arug AllergyI bpánephráneI cood AllergyI eásíamáneI
oapád recognáíáon of allergác emergencáes ás crucáal ío a íámely and appropráaíe
íreaímeníK Allergác emergencáes are synonymous wáíh a complex of sympíoms
affecíáng íwo or more organ sympíoms known as anaphylaxásK qhe kaíáonal
Insíáíuíe of Allergy and Infecíáous aásease EkIAIaF and qhe cood Allergy and
Anaphylaxás keíwork EcAAkF defáne anaphylaxás as “a seráous allergác reacíáon
íhaí ás rapád án onseí and may cause deaíh” [
zK qhe áncádence of anaphylaxás ás
áncreasáng án íhe rp and án oíher tesíern couníráes [
J
zK In íhe rnáíed píaíesI
Correspondáng auíhor goshua iK hennedy
: aeparímení of medáaírácsI aávásáon of Allergy and ImmunologyI
rnáversáíy of Arkansas for Medácal pcáencesI iáííle oockI AoI rpA; qel: RMNJPS4JNMSM; bmaál:
I
zK aespáíe íhe áncrease án prevalenceI íhere coníánue ío be examples of másJ
or underJdáagnosás across íhe rnáíed píaíesK In facíI anaphylaxás accouníed for
NUSJOOR deaíhs per year accordáng ío íhe Mulíáple Cause of aeaíh aaíabase
beíween íhe years NVVVJOMMV [
zK qhás chapíer wáll prováde an overváew of
common causesI paíhophysáologyI dáagnosíác cráíeráaI íreaímeníI complácaíáonsI
cood ás íhe mosí common írágger for anaphylaxás among all age groups [
zI and
eághí major foods áncludáng peanuísI íree nuísI shell fáshI fáshI cow’s málkI eggsI
wheaíI and soy are responsáble for more íhan VMB of íhese reacíáons án cháldren
I
J
zK thále íhe írue prevalence of food allergy ás unknownI síudáes suggesí
íhaí physácáan dáagnosás of food allergy ás on íhe ráse án íhe rnáíed píaíes
affecíáng approxámaíely SJUB of cháldren [
I
zK Accordáng ío a síudy done by
íhe Ceníers for aásease Conírol and mreveníáon án OMNPI food allergy dáagnoses
áncreased RMB beíween NVVT and OMNN [
zK merceáved food allergy ás also on íhe
ráseI whách makes íhe dáagnosás dáffáculíK curíhermoreI íhe revelaíáon íhaí
anaphylaxás ío foods can be delayed by several hours when consáderáng íhe
carbohydraíe galacíoseJNIPJalphaJgalacíose EalphaJgalF found án mammaláan meaí
has made dáagnosás even more dáffáculíK maíáenís wáíh íhás allergy presení wáíh
delayed sympíomsI áncludáng anaphylaxás for 4JS hours afíer exposureI ío beefI
porkI lambI and oíher mammaláan meaís [
J
zK qhás food allergy has been
descrábed án cháldren; howeverI áí does noí seem ío be a problem án ánfancyI buí
usually begáns around íhe age of O [
zK Avoádance of íhe allergenác food ás íhe
only known íreaímení for íhás condáíáonI and paíáenís wáíh known food allergy
senom allergy accounís for RJNPB of all anaphylaxás evenís preseníáng án
cháldren [
J
zK píángáng ánsecís belong ío íhe ánsecí order eymenopíeraI buí
less íhan NB of íhás order ás responsáble for human síángs [
J
zK eoney beeI
yellow jackeíI waspI and horneí síángsI as well as fáre aní báíes can resulí án a wáde
range of sympíoms rangáng from íemporary local reacíáons ío anaphylaxásK thále
local reacíáons are commonI láfeJíhreaíenáng sysíemác reacíáons only occur án
MK4BJMKUB of cháldren [
J
z and accouní for ~4M deaíhs annually án íhe rp
zK eoweverI many clánácáans remaán unaware íhaí ámmunoíherapy Evenom
allergy shoísF can successfully prováde prophylaxás for venom allergác paíáenís
Medácaíáons accouní for RB–NOB of anaphylaxás cases [
J
zK qhe mosí
common culpráís of drug allergy ánclude aníábáoíács Epenácállán and sulfa drugsI
specáfácallyFI aníáconvulsanísI aspárán and oíher nonsíeroádal aníáJánflammaíory
drugs EkpAIasFI and chemoíherapy agenísK Aníábáoíács are mosí common drugs
ío cause anaphylaxás [
I
zK In a large síudy evaluaíáng íhe áncádence of
aníábáoíác allergy áncádenceI áí was found íhaí ORB of paíáenís requáráng
aníámácrobáal íherapy reporíed íhaí íhey had an allergy ío an aníámácrobáal ageníK
NRKVB of all aníábáoíác allergác paíáenís án íhás síudy reporíed íhaí íhey were
allergác ío penácállánI makáng penácállán íhe mosí commonly reporíed aníábáoíác
allergy [
zK eoweverI áí ás ámporíaní ío noíe íhaí án síudáes aííempíáng ío confárm
penácállán allergy án paíáenís who had a reporíed hásíory of reacíáons ío íhe
medácaíáonI an overwhelmáng VSB of íhe subjecís had negaíáve skán íesíáng and
were able ío pass an oral challengeI suggesíáng íhe number of paíáenís wáíh írue
allergy ío penácállán ás much lower íhan ás suspecíed by íhe general populaíáon
qhe preseníáng sympíoms of anaphylaxás can be nonspecáfácI andI íhusI a low
ándex of suspácáon ás requáred ío properly and quáckly íreaí paíáenísK As defáned by
or more organ sysíemsK Cuíaneous EskánF manáfesíaíáonsI such as uríácaráa EhávesFI
pruráíus EáíchángFI eryíhema ErednessFI or angáoedema EswellángFI are presení án up
ío VMB of anaphylaxás casesK oespáraíory sympíoms are common as wellI
preseníáng án ~TMB of casesK qhese sympíoms ánclude dyspnea Edáffáculíy
breaíhángFI wheezáng Emusácal sound heard án íhe lungs made by excess mucus
and bronchoconsírácíáon of lower aárwaysFI coughI congesíáonI sírádor Emusácal
sound made by upper aárway consírácíáonFI and hoarsenessK dasíroáníesíánal EdIF
upseíI alíered meníal síaíusI andLor cardáovascular compromáse may be presení as
wellK Many paíáenís experáencáng anaphylaxás descrábe a “feeláng of ámpendáng
qhe dáagnosás of anaphylaxás may be challengángI gáven íhe number of possáble
ságns and sympíoms and íhe varáaíáon of severáíy [
I
J
zK eásíory of evenís
leadáng ío preseníaíáon ás very helpful án connecíáng nonspecáfác sympíoms ío
suspecíed anaphylaxásK qo help wáíh íhe dáagnosásI íhe kIAIa and cAAk have
developed dáagnosíác cráíeráa íhaí are helpful án defánáng anaphylaxás Eqable
Ceríaán condáíáons have been relaíed ío áncreased rásk for severe anaphylaxás and
should be consádered án a paíáení wáíh known írággers for anaphylaxásK qhese
condáíáons ánclude recurrení wheezáng or asíhmaI eczemaI aíopác dermaíáíásI and
ln a broader levelI íhe developmení of sysíemác allergác sympíoms remaáns
somewhaí of an enágmaK eow an exposure of one sysíem ío an allergen can lead
ío a mulíásysíem response án such a coordánaíed and rapád fasháon challenges
researchers wáíh more quesíáons íhan answersK Insíágaíáon of allergác condáíáons
and developmení of allergác ánflammaíáon has been more íhoroughly síudáedI and
lnce a poíeníáal allergen comes ánío coníací wáíh an epáíheláal cell surface of íhe
noseI skánI lung or íhe gasíroáníesíánal mucosaI a cascade of ánflammaíory ságnals
can ánáíáaíe íhe begánnáng of allergyK If sensáíázaíáon ás goáng ío occurI síámulaíáon
of varáous recepíors on íhe surface of epáíheláal cells leads ío ánnaíe cyíokáne
release íhaí can báas íoward a q helper Eq
OF EallergácF response [
J
zK pecondI
dendráíác cells EaCsFI whách funcíáon as professáonal aníágen preseníáng cells
EAmCsFI wáll capíure íhe allergen and íransporí áí ío íhe regáonal lymph nodes
where áí wáll be preseníed ío naïve q cells íhrough major hásíocompaíábáláíy
complex EMeCF class II recepíorsK In íhe presence of áníerleukán EIiFJ4 or IiJNPI
íhe q cell wáll become a q
O cellI subsequeníly secreíáng áís own IiJ4I IiJRI IiJVI
and IiJNPI amongsí oíhersK q helper cells wáll íhen áníerací wáíh B cellsI whách
wáll cause íhe producíáon of Immunoglobulán EIgF b ío íhe specáfác aníágen íhaí
was seen aí íhe mucosal surface [
zK qhás occurs when Igb bánds ío recepíors on
masí cells and basophálsI íhe allergác effecíor cellsK qhe subjecí ás now sensáíázed
ío íhe allergenK qhe nexí íáme íhás ándávádual ás exposed ío íhaí allergenI íhere ás
cross lánkáng of Igb leadáng ío acíávaíáon and degranulaíáon of masí cells and
basopháls occurs wáíh release of medáaíorsI áncludáng hásíamáneI írypíaseI íumor
necrosás facíor EqkcFI lápád deráved medáaíors such as mrosíaglandán EmdFa
leukoíráene EiqF B
I plaíeleíJacíávaíáng facíorI and íhe cysíeányl leukoíráenes
I iqa
I and iqb
K qhese cyíokánes lead ío specáfác sysíemác responses such
as nasal congesíáonI coughI wheezángI skán manáfesíaíáonsI and ulíámaíely
anaphylaxás [
eásíamáne ás one of íhe mosí wádely síudáed and undersíood medáaíors of allergác
reacíáonsK Iís acíáon on eN and eO recepíors causes a varáeíy of effecís íhroughouí
íhe body [
zK clushángI hypoíensáonI and headache are medáaíed by boíh eN and
eO recepíors whále dyspneaI bronchospasmI pruráíus and íachycardáa are medáaíed
by eN recepíors aloneK pysíemác release of hásíamáne resulís án cardáovascular
changesI whále localázed hásíamáne release án íhe skán causes uríácaráaK eásíamáne
bándáng ío eN recepíors síámulaíes íhe conversáon of amáno acád i Jargánáne ánío
náírác oxáde EklFI whách ás a poíení vasoJ and bronchoJ dálaíorI a compensaíory
measure íhaí ás meaní ío flush íhe offendáng allergen from íhe sysíem [
I
qhás medáaíor also acís dárecíly on íhe myocardáum [
I
I
zI causáng an
áncrease án coronary blood flow and a decrease án coronary vascular resásíance
qrypíase ás íhe mosí abundaní secreíory granule deráved seráne proíease found án
masí cells [
zK Ií ás a marker of masí cell acíávaíáonI and áí can be elevaíed duráng
an anaphylacíác reacíáonI íhough noí alwaysK qhe rouíe of exposure ío íhe allergen
may be relaíed as ío wheíher írypíase levels are elevaíedK Allergens ángesíed
orally E
foodF are less lákely ío be correlaíed wáíh elevaíed írypíase levelsI
whále pareníerally ánjecíed allergens E
ánsecí venomI medácaíáonsF are more
mlaíeleí acíávaíáng facíor EmAcF ás a phospholápád ánvolved án many ámmune and
ánflammaíory processes [
zK Ií ás very poíení and has been found ío have
ságnáfácaní effecís aí conceníraíáons as low as NMJNO molLi [
zK mAc can be
produced by many cell íypes áncludáng masí cellsI monocyíesI plaíeleísI
eosánopháls and endoíheláal cellsK lnce mAc bánds ío áís recepíorI kánases such
proíeán kánase C lead ío a release of arachádonác acád and prosíaglandáns áncludáng
prosíaglandán bO EmdbJOF from vascular smooíh muscle cells [
I
zK In a recení
síudyI mAc levels were shown ío be correlaíed wáíh anaphylaxás severáíyI even
qhe dáagnosás of anaphylaxás ás clánácal Eqable
F and laboraíory íesíáng should
noí delay urgení íreaímeníK As meníáoned aboveI íhe kIAIa and cAAk have
prováded a defánáíáon and dáagnosíác cráíeráa Eqable
F ío help prováders deíermáne
áf anaphylaxás ás presení [
zK In íhe way of dáagnosíácsI several lab íesís have been
síudáed and can be confármaíory of dáagnosásJ plasma hásíamáne levelsI serum or
qhere are síandardázed assays avaálable ío measure íoíal serum or plasma írypíase
wáíh opíámal collecíáon íáme beíween NR mánuíes ío P hours afíer íhe onseí of
sympíomsK Baseláne írypíase levels are hágher án ánfanís under íhe age of sáx
moníhs íhan án older ánfanís and cháldren [
zK As preváously dáscussedI írypíase
levels are ofíen normal án reacíáons caused by food allergens buí are ofíen
elevaíed án pareníerally ánjecíed allergens EvenomI medácaíáonsFK peráal
measuremenís of írypíase may áncrease íhe sensáíáváíy and íhe specáfácáíy of íhe
íesísK If írypíase levels are elevaíed over baseláneI clánácal severáíy ás dárecíly
relaíed ío íhe levels [
zK Currení guádelánes suggesí íhaí normal írypíase levels
may síáll ándácaíe anaphylaxás án íhe correcí seííángK ievels of írypíase duráng íhe
evení íhaí ándácaíe anaphylaxás should be deíermáned by íhe formula OH NKO G
Ebaseláne írypíaseFK cor íhás reasonI áí ás necessary ío obíaán a írypíase level
ouísáde of íhe evení án quesíáonK qrypíase levels íhaí remaán ságnáfácaníly elevaíed
qable NK aáagnosíác Cráíeráa for AnaphylaxásJ requáres one of íhe followáng P cráíeráa
K Adapíed from
NK Acuíe onseí of an állness Emánuíes ío several hoursF wáíh ánvolvemení of íhe skánI mucosal íássueI or
bK oeduced Bm or assocáaíed sympíoms of endJorgan dysfuncíáon E
I hypoíonáa [collapsezI syncopeI
OK qwo or more of íhe followáng íhaí occur rapádly afíer exposure
ío a lákely
allergen for íhaí paíáení
G iow sysíolác blood pressure for cháldren ás defáned as less íhan TM mm eg from N moníh ío N yearI less íhan
eásíamáne levels are more lákely ío be elevaíed íhan írypíase án a paíáení wáíh
anaphylaxás [
zK eoweverI hásíamáne levels peak wáíhán RJNR mánuíes of íhe
onseí of sympíoms of anaphylaxásI and because of íhás íámeframeI uíáláíy of íhás
íesí án íhe seííáng of anaphylaxás án paíáenís preseníáng from íhe communáíy ío íhe
ba ás lámáíedK eásíamáne should be measured án plasmaI noí serumI due ío
cloííángK qesíáng requáres specáal precauíáons such as usáng large bore needleI
keepáng sample cold and ceníráfugáng ámmedáaíely ío síore íhe plasma for íesíángI
all of whách furíher complácaíe obíaánáng íhás íesí [
zK rránary hásíamáne can also
be evaluaíedI buí íhás ás usually done by obíaánáng O4Jhour uránary levelsI whách
thále mAc ás a new and excáíáng medáaíor ánvolved án íhe anaphylacíác cascadeI
íhere are no commercáally avaálable laboraíory íesís preseníly avaálableK
oesearchers are usáng íhás medáaíor án clánácal síudáesI and áí ás possáble íhaí
prováders may have íhe opíáon ío use mAc ío help dáagnosás anaphylaxás án íhe
lnce a dáagnosás ás made based on clánácal hásíory and preseníáng ságns and
sympíoms Esee qable
FI ánáíáaíe íreaímení ámmedáaíely by remováng íhe
offendáng allergen EexK síoppáng a drug ánfusáon aí íhe fársí recognáíáon of allergác
sympíomsFK mroíocols can be used íhaí wáll help ío síreamláne íhe íreaímení of
anaphylaxás EcágK
FK Iníramuscular epánephráne ás a láfeJsaváng áníerveníáon and
musí be admánásíered as soon as íhe dáagnosás of anaphylaxás ás suspecíedK
Absorpíáon ás compleíe and more rapád án cháldren who use an auíoJánjecíor án íhe
íhágh [
zK If an epánephráne auíoJánjecíor ás noí avaálableI epánephráne N:NMMM
dáluíáonI MKMN mgLkg án cháldren up ío a maxámum doseI MKP mg should be gáven
áníramuscularly every R mánuíes uníál ámprovemení án sympíoms [
J
I
keáíher subcuíaneous epánephráne or íhe use of oíher musclesI áncludáng delíoád
musclesI are as effecíáve as áníramuscular epánephráne gáven án íhe vasíus laíeralás
muscle of íhe íhágh [
zK cor íhe paíáení who has a poor response ío several
áníramuscular ánjecíáonsI áníravenous epánephráne ánfusáon may be consáderedK
qhás should be done án a closely monáíored seííángI where hemodynamác
ás preferably ánfused íhrough a ceníral venous láne ío prevení exíravasaíáon [
cor ánfanís and cháldrenI íhe recommended dose of áníravenous epánephráne
ánfusáon ás MKMR ío MKRmcgLkgLmán íáíraíed ío goal blood pressure án a closely
monáíored seííángK An ánfusáon of epánephráne ás preferred over an Is bolus
admánásíraíáon as bolus admánásíraíáon has been assocáaíed wáíh áncreased adverse
In a physácáan supervásed seííángI an ánáíáal survey ío ensure aárwayI breaíhángI
cárculaíáonI and meníal síaíus should be performedK qhe paíáení should be placed
án íhe recumbení posáíáon and supplemeníal oxygen should be delávered ío
maáníaán appropráaíe oxygenaíáon síaíusK If sírádor or ámpendáng aárway
compromáse ás preseníI áníubaíáon should be performedK Iníubaíáon may be
dáffáculí due ío íhe presence of laryngeal edema íhus precauíáons should be án
place as crácoíhyroádoíomy may be requáred for íhe more severe casesK Aí leasí
íwo large bore Iss should be placed and áníravenous EIsF fluád resuscáíaíáon
should be síaríed due ío massáve fluád sháfís íhaí occur due ío vasodálaíáonK
In hypoíensáve cháldrenI normal saláne boluses of OM miLkg over RJNM mánuíes
should be provádedI whách may be repeaíed as neededK In normoíensáve paíáenísI
maáníenance fluáds should be síaríed aí appropráaíe volumesK Bronchodálaíors may
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qhere are no publáshed guádelánes regardáng íhe use of e
JaníáhásíamánesI e
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चఀᜀᨈఀԀฉД​ላᤀ܀ࠀఀ1
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ᴀᜀఀऀЀ܀अࠄᤀ܀\t=-㸉ᄀᜆఀᤉ଒ऀᄀᜀᤚଇЅचఀଗ
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ऑ฀ᨀᜇࠒᤋᜒगఀऀᘗԅКᤈङᄗ
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anaphylaxásK Meíhylene blue has been used án case reporís án adulís [
z buí
síudáes are avaálable án íhe pedáaírác populaíáonK In paíáenís who do noí respond ío
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ío deíermáne áf íhe paíáení ás on beíaJblockersK If beíaJblockers are used on a
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áníramuscular glucagon EN mgF should be gávenI followed by more epánephráne
bmpíy venírácle syndrome ás a deadly complácaíáon íhaí was descrábed afíer
reváew of faíal anaphylaxás cases án whách deaíh occurred án paíáenís who were
moved ío an uprághí posáíáon duráng íhe epásodeK qhe condáíáon ás íhoughí ío be
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qhere are no recommendaíáons regardáng íhe mánámal requáred observaíáon peráod
for paíáenís who presení anaphylaxásK qhe accepíed norm ás a mánámum of 4JU
hoursI alíhough íhás decásáon would be based on íhe clánácal judgmení of
physácáans and ánsíáíuíáonal síandardsK lvernághí observaíáon án íhe hospáíal
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edemaI íhose who requáre O or more epánephráne ánjecíáonsI íhose wáíh a hásíory of
asíhmaI and íhose who ángesí íhe allergen due ío an áncreased rásk for báphasác
anaphylaxás [
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emergency acíáon plan and an epánephráne auíoJánjecíorI even áf íhe offendáng
allergen ás unknownK aeíermánaíáon of íhe offendáng allergen ás ámporíaní ío
prevení furíher exposureI eáíher from hásíoryI dárecíed skán práck íesíáng or serum
Igb íesíángK maíáenís who have had anaphylaxás are aí rásk for recurrení
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recommended for íhás purpose and síands for:
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ádeníáfácaíáon and avoádanceI
ollowJup for specáalíy careI and
pánephráne for
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Anaphylaxás ás a dangerous condáíáon íhaí musí be íreaíed quácklyK qhe
prevalence ás on íhe ráseI and íhe dáagnosás requáres a low ándex of suspácáon án
someone experáencáng íhe íypácal consíellaíáon of sympíoms ánvolváng more íhan
one body sysíem afíer exposure ío a possáble allergenK qreaímení ánvolves íhe
admánásíraíáon of áníramuscular epánephráne before consáderaíáon of any oíher
modaláíáesK thále íreaímení of anaphylaxás wáíh epánephráne always comes fársíI
specáfác laboraíory íesís áncludáng serum írypíase and dárecíed specáfác Igb íesís
can be consádered ío help aád án íhe dáagnosás and reveal any possáble allergác
írággersK cánallyI every paíáení who experáences anaphylaxás should be dáscharged
keáíher arK hennedy nor arK eardán dásclose any conflácís of áníeresí íhaí períaán
ppecáal íhanks ío arK pheva Chervánskáy and arK Ashley píoner for íheár generous
Boyce gAI AssaDad AI Burks AtI
eí alK
duádelánes for íhe aáagnosás and Managemení of cood
Allergy án íhe rnáíed píaíes: pummary of íhe kIAIaJpponsored bxperí manel oeporíK g Allergy Clán
aecker ttI Campbell oiI Manávannan sI iuke AI pí pauver giI teaver AK qhe eíáology and
áncádence of anaphylaxás án oochesíerI Mánnesoía: a reporí from íhe oochesíer bpádemáology mrojecíK
iáew thI tálláamson bI qang MiK Anaphylaxás faíaláíáes and admássáons án AusíraláaK g Allergy Clán
ián ovI Anderson ApI phah pkI kurruzzaman cK Increasáng anaphylaxás hospáíalázaíáons án íhe fársí O
moulos iMI taíers AMI Correll mhI ioblay oeI Marks dBK qrends án hospáíalázaíáons for
anaphylaxásI angáoedemaI and uríácaráa án AusíraláaI NVVPJNVV4 ío OMM4JOMMRK g Allergy Clán Immunol
pheákh AI eáppásleyJCox gI kewíon gI ceníy gK qrends án naíáonal áncádenceI láfeíáme prevalence and
iáeberman mI kácklas oAI lppenheámer gI hemp pcI iang aMI Bernsíeán aIK qhe dáagnosás and
managemení of anaphylaxás pracíáce parameíer: OMNM updaíeK g Allergy Clán Immunol OMNM; NOS: 4TTJ
tood oAI Camargo CA grI iáeberman mI pampson eAI pchwaríz iBI Záíí MK Anaphylaxás án
Ameráca: íhe prevalence and characíerásíács of anaphylaxás án íhe rnáíed píaíesK g Allergy Clán
Ma iI aanoff qMI Borásh iK Case faíaláíy and populaíáon moríaláíy assocáaíed wáíh anaphylaxás án íhe
iáu AeI garamállo oI pácherer peI tood oAI Bock pAI Burks AtK kaíáonal prevalence and rásk
facíors for food allergy and relaíáonsháp ío asíhma: resulís from íhe kaíáonal eealíh and kuíráíáon
May CaK lbjecíáve clánácal and laboraíory síudáes of ámmedáaíe hypersensáíáváíy reacíáons ío foods án
manel kIJpbK duádelánes for íhe dáagnosás and managemení of food allergy án íhe rnáíed píaíes: reporí
pácherer peI MunozJcurlong AI pampson eAK mrevalence of seafood allergy án íhe rnáíed píaíes
dupía opI pprángsíon bbI tarráer MoI pmáíh BI humar oI mongracác gI
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gackson haI eowáe iaI Akánbamá igK qrends án allergác condáíáons among cháldren: rnáíed píaíesI
Commáns pmI games eoI helly iAI mochan piI torkman igI merzanowská MpK qhe relevance of íáck
báíes ío íhe producíáon of Igb aníábodáes ío íhe mammaláan olágosaccharáde galacíoseJalphaJNJ
PJgalacíoseK qhe gournal of allergy and clánácal ámmunology OMNN; NOT: NOUSJVP eSK
Commáns pmI mlaíísJMálls qAK Anaphylaxás syndromes relaíed ío a new mammaláan crossJreacíáve
Commáns pmI mlaíísJMálls qAK Allergenácáíy of carbohydraíes and íheár role án anaphylacíác evenísK
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hennedy giI píallángs AmI mlaíísJMálls qAI lláveára tMI torkman iI games eoK dalacíoseJalphJ
JNIPJgalacíose and delayed anaphylaxásI angáoedemaI and uríácaráa án cháldrenK medáaírács OMNP; NPN:
Braganza pCI Acworíh gmI Mchánnon aoI meake gbI Brown AcK maedáaírác emergency deparímení
de pálva IiI Mehr ppI qey aI qang MiK maedáaírác anaphylaxás: a R year reírospecíáve reváewK Allergy
oussell pI Monroe hI iosek gaK Anaphylaxás managemení án íhe pedáaírác emergency deparímení:
iockey ocI qurkelíaub mCI lláve bpI eubbard gMI BaárdJtarren IAI Bukaníz pCK qhe eymenopíera
Moffáíí gbI dolden aBI oeásman obI
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píángáng ánsecí hypersensáíáváíy: a pracíáce parameíer
pchwaríz egI dolden aBI iockey ocK senom ámmunoíherapy án íhe eymenopíeraJallergác pregnaní
Bálo BMI Bonáfazá cK bpádemáology of ánsecíJvenom anaphylaxásK Curr lpán Allergy Clán Immunol
dolden aBI Marsh adI hageyJpoboíka AI creádhoff iI pzklo MI saleníáne MaK bpádemáology of
peííápane dAI Boyd dhK mrevalence of bee síáng allergy án 4IVVO boy scouísK Acía Allergol NVTM; OR:
peííápane dAI kewsíead dgI Boyd dhK crequency of eymenopíera allergy án an aíopác and normal
[POzdrafí acK Insecí síáng allergyK Med Clán koríh Am OMMS; VM: ONNJPOK
iee CbI Zembower qoI coíás MAI mosíelnáck MgI dreenberger mAI meíerson ioI
eí alK
qhe áncádence
of aníámácrobáal allergáes án hospáíalázed paíáenís: ámplácaíáons regardáng prescrábáng paííerns and
mark MI Markus mI Maíesác aI iá gqK pafeíy and effecíáveness of a preoperaíáve allergy clánác án
decreasáng vancomycán use án paíáenís wáíh a hásíory of penácállán allergyK Ann Allergy Asíhma
tebb iI dreene bI iáeberman miK Anaphylaxás: A reváew of RVP casesK g Allergy Clán Immunol
Brown pdI Mulláns ogI dold MpK Anaphylaxás: dáagnosás and managemeníK Med g Ausí OMMS; NUR:
bwan mtI augue mI Márakáan oI aáxon qAI earper gkI kasser pMI
eí alK
BpACI guádelánes for íhe
hemp pcI iockey ocK Anaphylaxás: a reváew of causes and mechanásmsK g Allergy Clán Immunol
Muraro AI ooberís dI Clark AI bágenmann mAI ealken pI iack dI
eí alK
qhe managemení of
anaphylaxás án cháldhood: posáíáon paper of íhe buropean academy of allergology and clánácal
ámmunologyK Allergy OMMT; SO: URTJTNK
lswalí MiI hemp pcK Anaphylaxás: offáce managemení and preveníáonK Immunol Allergy Clán koríh
pampson eAI MunozJcurlong AI Bock pAI pchmáíí CI Bass oI Chowdhury BAK pymposáum on íhe
defánáíáon and managemení of anaphylaxás: summary reporíK g Allergy Clán Immunol OMMR; NNR: RU4J
pampson eAI MunozJcurlong AI Campbell oiI Adkánson kc grI Bock pAI Branum AK pecond
symposáum on íhe defánáíáon and managemení of anaphylaxás: summary reporíJJpecond kaíáonal
Insíáíuíe of Allergy and Infecíáous aáseaseLcood Allergy and Anaphylaxás keíwork symposáumK g
[4Pzpámons cbK AnaphylaxásK g Allergy Clán Immunol OMNM; NOR: pNSNJUNK
pámons cbI Ardusso ioI Bálo MBI blJdamal vMI iedford ahI oáng gK torld Allergy lrganázaíáon
poar gI mumphrey oI Caní AI
eí alK
bmergency íreaímení of anaphylacíác reacíáonsJJguádelánes for
pámons cbI pampson eAK Anaphylaxás: rnáque aspecís of clánácal dáagnosás and managemení án
iambrechí BkI eammad eK Allergens and íhe aárway epáíheláum response: daíeway ío allergác
haláner MI págler oI pummers oI phelhamer geK bffecís of ánfused hásíamáne: analysás of íhe effecís
of eJN and eJO hásíamáne recepíor aníagonásís on cardáovascular and pulmonary responsesK g Allergy
Máísuhaía eI phámázu oI vokoyama MMK oole of náírác oxáde án anaphylacíác shockK g Clán Immunol
malmer oMI cerráge AdI Moncada pK káírác oxáde release accounís for íhe báologácal acíáváíy of
Marone dI maíella sI de Crescenzo dI denovese AI Adí MK euman hearí masí cells án anaphylaxás
qrággáaná MI maíella sI píaáano oII dranaía cI Marone dK Allergy and íhe cardáovascular sysíemK Clán
ságoráío CI dáordano AI ae Capráo iI sáíale acI Maurea kI pálvesírá mI
eí alK
bffecís of hásíamáne on
coronary hemodynamács án humans: role of eN and eO recepíorsK g Am Coll Cardáol NVUT; NM: NOMTJ
pchwaríz iBI Bradford qoI oouse CI Iraná AMI oasp dI san der Zwan ghI
eí alK
aevelopmení of a
newI more sensáíáve ámmunoassay for human írypíase: use án sysíemác anaphylaxásK g Clán Immunol
iáeberman mK AnaphylaxásK In: Adkánson kcI bdK MáddleíonDs Allergy: mráncáples and mracíáceK Tíh edK
Meríes mMI iaxenaáre MCI Alla cI droupe dDbíudes des oeacíáons Anaphylacíoádes mK Anaphylacíác
and anaphylacíoád reacíáons occurráng duráng anesíhesáa án crance án NVVVJOMMMK Anesíhesáology
pchwaríz iBK bffecíor cells of anaphylaxás: masí cells and basophálsK kovaríás cound pymp OMM4;
senable MbI Zámmerman dAI McIníyre qMI mrescoíí pMK mlaíeleíJacíávaíáng facíor: a phospholápád
Benvenásíe gI ie Couedác gmI molonsky gI qence MK pírucíural analysás of puráfáed plaíeleíJacíávaíáng
Chao tI llson MpK mlaíeleíJacíávaíáng facíor: recepíors and ságnal íransducíáonK Báochem g NVVP;
qháváerge MI marení giI píankova gI oolaJmleszczynská MK Modulaíáon of human plaíeleíJacíávaíáng
sadas mI merelman BI iáss dK mlaíeleíJacíávaíáng facíorI hásíamáneI and írypíase levels án human
homarow eaI eu ZI Bráííaán bI rzzaman AI daskáns aI Meícalfe aaK perum írypíase levels án aíopác
palaJCunáll AI Cardona sI iabradorJeorrállo MI
eí alK
rsefulness and lámáíaíáons of sequeníáal serum
pámons cbI crew AgI Ansoíeguá IgI
eí alK
oásk assessmení án anaphylaxás: currení and fuíure
approachesK g Allergy Clán Immunol OMMT; NOM: pOJpO4K
pámons cbI ooberís goI du uI pámons hgK bpánephráne absorpíáon án cháldren wáíh a hásíory of
ie AI maíel pK bxíravasaíáon of koncyíoíoxác arugs: A oeváew of íhe iáíeraíureK Ann mharmacoíher
Campbell oiI Belloláo McI hnuíson BaI
eí alK
bpánephráne án anaphylaxás: hágher rásk of
cardáovascular complácaíáons and overdose afíer admánásíraíáon of áníravenous bolus epánephráne
pámons hgI pámons cbK bpánephráne and áís use án anaphylaxás: currení ássuesK Curr lpán Allergy Clán
Choo hgI pámons bI pheákh AK dlucocoríácoáds for íhe íreaímení of anaphylaxás: Cochrane sysíemaíác
Choo hgI pámons cbI pheákh AK dlucocoríácoáds for íhe íreaímení of anaphylaxásK Cochrane aaíabase
pheákh AI qen Broek sI Brown pdI pámons cbK eNJaníáhásíamánes for íhe íreaímení of anaphylaxás:
oohacek MI bdenhofer eI Bárcher AI Bángásser oK Báphasác anaphylacíác reacíáons: occurrence and
qole gtI iáeberman mK Báphasác anaphylaxás: reváew of áncádenceI clánácal predácíorsI and observaíáon
Mehr pI iáew thI qey aI qang MiK Clánácal predácíors for báphasác reacíáons án cháldren preseníáng
gang aeI kelson ipI eoffman opK Meíhylene blue for dásírábuíáve shock: a poíeníáal new use of an
Cheng AK bmergency íreaímení of anaphylaxás án ánfanís and cháldrenK maedáaír Cháld eealíh OMNN; NS:
[TUzmumphrey opK caíal posíure án anaphylacíác shockK g Allergy Clán Immunol OMMP; NNO: 4RNJOK
iáeberman mI aecker tI Camargo CA grI lconnor oI lppenheámer gI pámons cbK pAcb: a
mulíádáscáplánary approach ío anaphylaxás educaíáon án íhe emergency deparímeníK Ann Allergy
Auíásm ppecírum aásorder: thaí a medáaírácáan
pecíáon of medáaírác msychologyI rnáversáíy of Arkansas for Medácal pcáencesI iáííle oockI
ArkansasI rpA
Absírací:
Ií ás ámporíaní for pedáaírácáans ío áncrease íheár experíáse án íhe area of
Auíásm ppecírum aásorders EApaFK táíh íhe áncrease prevalence raíe of Apa and íhe
emphasás on early deíecíáonI pedáaírácáans need ío be famáláar wáíh dáagnosíác cráíeráa
for Apa and know when ío refer for a comprehensáve evaluaíáonK Afíer a formal
dáagnosás ás gávenI pedáaírácáans wáll be “froní láne” án íhe medácal managemení of coJ
morbád medácalLpsycháaírác sympíoms of Apa for íheár paíáenísK qhey wáll serve as íhe
medácal home for famáláes ío guáde evádenceJbased íreaímení opíáons and ío help fánd
communáíy resources for íhe cháld wáíh ApaK qhe goals of íhás chapíer are ío prováde
an overváew of Apa dáagnosíác cráíeráa; ío áncrease knowledge án early deíecíáon and
dáagnosáng Apa; prováde ánformaíáon abouí common medácal comorbádáíáes for
ándáváduals wáíh Apa; and buáld knowledge án guádáng famáláes as íhey fánd evádencedJ
heywords:
Alíernaíáve íreaímenís for auíásmI AuíásmI Auíásm ppecírum
aásorderI Auíásm early screenángI Auíásm evaluaíáonI Auíásm ádeníáfácaíáonI
Auíásm áníerveníáonsI Auíásm íoolkáísI Complemeníary and Alíernaíáve
íreaímenísI apMJRI medáaírácáan knowledgeI Medácal coJmorbádáíáesI saccánesK
Auíásm ás a neurodevelopmeníal dásorder íhaí íypácally presenís very early án láfe
zK Auíásm ppecírum aásorders EApaF have áncreased án publác awareness and án
prevalenceI based upon mosí recení esíámaíes of N án SU cháldren [
zK qhe
Amerácan Academy of medáaírács [
I
z and íhe Amerácan Academy of keurology
z have publáshed on íhe ámporíance of early screenáng and early deíecíáon of
Apa án order ío obíaán serváces íhaí wáll yáeld besí ouícomes for íhe cháld and
Correspondáng auíhor gayne Bellando
: pecíáon of medáaírác msychologyI rnáversáíy of Arkansas for Medácal
dáven íhe áncreased prevalence án ApaI áí ás ceríaán íhaí pedáaírácáans wáll
encouníer cháldren wáíh Apa án íheár pracíáceK medáaírácáans are ofíen íhe fársí
professáonals ío assess for developmeníal concerns and guáde íhe famály án
obíaánáng appropráaíe servácesK dáven íhaí íhere ás no blood íesí or specáfác
medácal markers for an auíásm dáagnosásI íhe pedáaírácáan ás charged wáíh íhe
dauníáng íask of screenáng and provádáng consulíaíáon for a dásorder íhaí ás
curreníly dáagnosed by behaváoral measures and skálled observaíáonK qhe
pedáaírácáan also needs ío be able ío help guáde caregávers as íhey decáde upon
íreaímení opíáons and ways ío access and pay for íreaímenís for íheár cháldK qhás
án áíself can be overwhelmáng for íhe famály as well as for íhe pedáaírácáanK dáven
íhe ubáquáíous access ío elecíronác ánformaíáonI íhe pedáaírácáan musí also be
aware of coníroversáal íreaímenís and pop culíure ánformaíáon abouí auíásm so
qhás chapíer aííempís ío prováde ánformaíáon on key dáagnosíác feaíures of ApaI
reváew screenáng guádelánes and íhe recommended assessmení process for ApaK
Informaíáon abouí common coJmorbád medácal condáíáons wáll also be dáscussedK
oesources ío fánd evádenced based ánformaíáon abouí wellJesíabláshed íreaímenís
for Apa wáll be preseníed as well as provádáng resource sáíes for more alíernaíáve
áníerveníáons for ApaK qhe goals of íhás chapíer are ío help íhe busy pedáaírácáan
buáld knowledge án ádeníáfyáng and dáagnosáng Apa; prováde ánformaíáon abouí
common medácal comorbádáíáes for ándáváduals wáíh Apa; and buáld knowledge án
qhe mosí recení aáagnosíác and píaíásíácal Manual EapMJRF was publáshed án
May OMNP and ságnáfácaníly changed íhe way auíásm was classáfáed [
zK Auíásm
was fársí áníroduced ío íhe apMJIII under íhe íerm mervasáve aevelopmeníal
aásorder [
z and íhás has remaáned uníál apMJRK mervasáve aevelopmeníal
aásorder has been replaced wáíh íhe íerm Auíásm ppecírum aásorder EApaFI
whách now subsumes íhe former apMJIs dáagnoses of Auíásíác aásorderI
Asperger aásorder and mervasáve aevelopmeníal aásorderI koí líherwáse
ppecáfáed EmaaI klpFK dáven áís geneíác eíáologyI oeíí’s dásorder ás now áncluded
as an assocáaíed feaíure of Apa buí does noí have áís own dáagnosíác codeK qhe
dáagnosás of Cháldhood aásáníegraíáve aásorder has also been elámánaíed from íhe
apMJRK Anoíher dáfference ás án dáagnosíác cráíeráaK Insíead of íhree facíorsI íhe
apMJR has íwo dáagnosíác facíors: “persásíení defácáís án socáal communácaíáon
and socáal áníeracíáons across mulíáple coníexís and resírácíedI repeíáíáve paííerns
of behaváorsI áníeresís or acíáváíáes” [S pRMJRVzK píudáes have shown íhaí íhe íwo
facíor model ás a beííer fáí íhan íhe apMJIs íhree facíor model for a dáagnosás of
auíásm [
J
zK iáke oíher dáagnosíác codes án íhe apMJRI Apa has specáfáers ío
capíure assocáaíed feaíures Elanguage ámpaármeníI cognáíáve ámpaármeníF and ío
ándácaíe severáíy of sympíomsK peveráíy level raíángs can change over íáme ío
reflecí íhe írajecíory of íhe paíáení’s courseK qo receáve an Apa dáagnosásI
dáfferences án developmení musí be seen wáíhán íhe early developmeníal peráod;
howeverI íhe apMJR acknowledges íhaí for some ándáváduals íhe defácáís may noí
manáfesí uníál socáal demands exceed íheár abáláíy or defácáís may be mánámázed
by síraíegáes íhaí have been learned [
zK Cráíeráa now can also be meí by currení
sympíom preseníaíáon or by hásíoryK If a dáagnosás based upon apMJIs cráíeráa
has already been gáven and ás well esíabláshedI íhe new dáagnosás of Apa should
be appláedK qhe apMJR ás also clear íhaí specáfáers should noí be used ío
deíermáne elágábáláíy for or for íhe provásáon of serváces [
lzonoff [
z provádes a wellJaríáculaíed raíáonale behánd íhe research íhaí guáded
íhe cráíeráa and íheoreíácal changes for íhe apMJRK In íhe íáme leadáng up ío íhe
publácaíáon of íhe apMJRI some síudáes showed good sensáíáváíy and specáfácáíy
wáíh íhe new apMJR cráíeráa [
I
z whále oíher síudáes reporíed concerns abouí
íhe apMJR’s abáláíy ío correcíly classáfy ándáváduals wáíh Apa [
J
z qhe
rebuííal ío síudáes íhaí were noí complemeníary ío íhe new cráíeráa síaíed íhaí íhe
fánal apMJR cráíeráa were noí used án íhese síudáes [
I
zK pánce íhe publácaíáon
of íhe apMJR ás síáll relaíávely receníI some síudáes have been publáshed ío help
answer quesíáons abouí specáfácáíy and sensáíáváíy [
J
zK wáíh dáfferáng resulísK
More research ás needed ío deíermáne áf íhere are groups of ándáváduals by age or
sympíom preseníaíáon íhaí mághí be less lákely ío be capíured án íhe new cráíeráaK
as a “láváng documení” [
z so áí ás assumed íhaí new research fándángs wáll guáde
thále áí ás ámporíaní for pedáaírácáans ío know íhe dáagnosíác cráíeráa for ApaI áí
ás jusí as ámporíaní ío apply áí ío cháldren án your pracíáce ío screen for
ApaLdevelopmeníal concernsK In a síudy of screenáng pracíáces of mCms for ApaI
áí was reporíed íhaí only UB of general pedáaírác prováders screened specáfácally
for Apa [
zK Among íhe reasons cáíed for íhás low raíe ás mCms’ percepíáon íhaí
íhey lack experáence wáíh screenáng íools or íhaí íhey do noí have adequaíe íáme
ío screen wáíhán íhe confánes of a mCm vásáí [
zK qhe AAm has ouíláned an
algoráíhm specáfácally for íhe ádeníáfácaíáon of Apa án all cháldren [
zK qhe
process ánvolves: surveállanceI screenáng and ámplemeníaíáon of an acíáon plan
purveállance eníaáls lásíenáng ío parení’s concerns abouí developmeníI acíávely
elácáíáng developmeníal concerns from parenísI íakáng a good developmeníal
hásíoryI makáng behaváoral observaíáons án íhe clánácI and ádeníáfyáng rásk facíors
for íhe cháld [
zK gohnson and Myers [
z specáfáed íhe followáng rásk facíors of
ságnáfácance: sáblángEsF dáagnosed wáíh ApaI an Apa concern raásed by a pareníI
caregáver or someone famáláar wáíh íhe cháld Esuch as school personnelFI or íhe
All cháldren should be screened for Apa aí eáíher íhe NUJmoníh or O4 Jmoníh old
healíh maáníenance vásáíK pcreenáng ánvolves a screenáng íool íhaí assesses for
ageJappropráaíe socáal communácaíáon málesíones Efor cháldren less íhan NU
moníhs of ageFI or a measure íhaí ás more ApaJspecáfác Efor cháldren who are NU
moníhs or olderFK eoweverI áf any rásk facíor ás ádeníáfáedI Apa or socáal
developmení screenáng should be doneI regardless of age [
zK lne of íhe more
commonly used screenáng íools ás íhe MCeAq EModáfáed Checklásí for Auíásm án
qoddlersFI an ApaJspecáfác parení compleíed screenáng íool íhaí ás reasonably
quáck and easy ío admánásíerI and ás free and avaálable onláne [
zK qhe MCeAq
ás appropráaíe for cháldren from NS ío PM moníhs of ageK then screenáng íools
reveal an Apa concernI or áf O or more rásk facíors for Apa are ádeníáfáedI íhen
An acíáon plan ánvolves: Ináíáaíáng a referral ío Apa specáalásís and referráng íhe
cháld for educaíáon servácesK cor a cháld less íhan P years of ageI refer ío íhe
síaíe’s barly Iníerveníáon EbIF program and for a cháld P years of age or olderI
refer ío íhe barly Cháldhood EbCF program of íhe local publác schoolK An
Audáology assessmení should also be ordered ío rule ouí hearáng lossK mCm’s
should also schedule áníerval vásáís wáíh íhe famály ío also ensure íhe referral
qhe followáng clánácal pearls are cráíácal án íhe recognáíáon of auíásm án young
cháldrenK cársíI mCms musí be knowledgeable abouí íhe “red flags” for an Apa
dáagnosásK qhe perspecíáve of “waáíJandJsee” ás noí recommended [
zK barly
deíecíáon leads ío beííer ouícomes for íhese cháldrenK pecondI cháldren can qualáfy
for developmeníal íherapy serváces under oíher dáagnoses wáíhouí a formal auíásm
dáagnosás [
zK qhusI referral for educaíáon serváces or íherapáes should never be
deferred for íhe reason íhaí a formal auíásm dáagnosás has noí been made yeí or
If íhere ás enough evádence of suspácáonI íhe pedáaírácáan should refer for a
comprehensáve evaluaíáon for ApaK Accordáng ío íhe Commáííee on Cháldren
táíh aásabáláíáesI a comprehensáve evaluaíáon for Apa should be conducíed “by a
specáalásí orI preferablyI a mulíádáscáplánary íeam of specáalásís wáíh experíáse án
Apa ío make íhe defánáíáve dáagnosás and search for possáble eíáologácal
dásorders” [P pNOOOzK qhás íeam of specáalásís íypácally áncludes medácáne
EpedáaírácáanI developmeníal behaváoral pedáaírácáan or psycháaírásíFI psychologyI
socáal workI a speechLlanguage paíhologásíI educaíors and oíher alláed healíh
professáonals such as occupaíáonal or physácal íherapásísK thále some assessmenís
occur by professáonals workáng ándáváduallyI áí has become more common ío see
áníerdáscáplánary or íransdáscáplánary groups of professáonals assessáng íhe cháld
zK Accordáng ío gohnson and Myers [
z íhe prámary goals of a comprehensáve
evaluaíáon are: makáng íhe dáagnosás of an Apa; recognázáng íhe cháldDs overall
level of funcíáonáng; and assessáng for coJmorbád medácal condáíáons and oíher
assocáaíed eíáologyK Correcí dáagnosás also helps make appropráaíe
recommendaíáons for áníerveníáonsK
qhe hásíory prováded by caregávers ás cráíácal án íhe dáagnosíác evaluaíáonK qhe
dáagnosíác áníerváew reváews a cháld’s developmeníal hásíory Ecurrení skálls and
hásíory of skáll acquásáíáonFI behaváoral hásíory and geneíácLfamály hásíoryK IdeallyI
ánformaíáon from varáous sources who know íhe cháld well and án dáfferení
seííángs ás cráíácal ío obíaánáng behaváoral ánformaíáon from dáfferení coníexísK
ppecáfác quesíáons íhaí relaíe ío core feaíures of Apa should be dáscussed án
depíhK gohnson and Myers gáve a very íhorough descrápíáon of íhe medácalL
developmeníal dáagnosíác áníerváew for an Apa evaluaíáon [
zK pome clánácáans
wáll use a sírucíured áníerváew íool ío ensure síandardázaíáon án íhe dáagnosíác
qhe dárecí íesíáng of íhe cháld íypácally áncludes assessmení of áníellágence
Edevelopmeníal level for younger cháldrenFI expressáveLrecepíáve languageI
pragmaíác languageI adapíáve behaváorI fáne and gross moíorI sensory processángI
and academác skállsK qhe use of an auíásm specáfác assessmení íool ás cráíácal ío a
comprehensáve evaluaíáonK Auíásm specáfác quesíáonnaáres can be compleíed by
adulís who know íhe cháld wellI buí íhese quesíáonnaáres are síáll classáfáed as
screenáng íools [
zK Besí pracíáce should ánclude a dárecí observaíáon of íhe cháld
by a íraáned clánácáan of behaváor íhaí ás consásíení wáíh an auíásm specírum
dásorderK qhe Auíásm aáagnosíác lbservaíáon qoolJO
bdáíáon [
z ás íhe “goldJ
síandard” for íhás dárecí observaíáonK qhe AalpJO ás a semáJsírucíured play based
measure íhaí assesses communácaíáonI socáal áníeracíáonsI ámagánaíáonLplay skálls
and síereoíyped behaváors and resírácíed áníeresísK oesearch has shown íhaí
áncludáng íhe AalpJO án a comprehensáve assessmení áncreases sensáíáváíy of an
qhe comprehensáve evaluaíáon for Apa should also ánclude consáderaíáon of
dáffereníáal dáagnosásI exásíáng coJmorbád condáíáonsK Ií should also ánclude
dáscussáon wáíh íhe famályLpaíáení ío suggesí componenís of a íreaímení plan for
íhe cháld and ío gáve famály ánformaíáon abouí avaálable resourcesK oeferral ío
oíher subJspecáalásísI ío educaíáonal and alláed healíh professáonalsI and
síaíeLfederal agencáes for fánancáal supporí are ofíen recommendaíáons íhaí síem
A cháld may be referred ío a specáalíy íeam for a comprehensáve evaluaíáon and
possáble medácal follow upI buí íhe cháld’s pedáaírácáan coníánues ío be íhe cháld’s
medácal homeK Because of íhásI áí ás ámperaíáve íhaí pedáaírácáans undersíand íhe
medácal coJmorbádáíáes íhaí wáll lákely presení án íheár clánácK gusí láke íypácally
developáng cháldrenI cháldren wáíh Apa should receáve basác prámary medácal
careI such as healíh supervásáon vásáís and ámmunázaíáons [
zK Ií ás ámporíaní for
pedáaírácáans ío recognáze íhaí íhere are several coJmorbád medácalI psycháaírác or
behaváoral condáíáons íhaí can poíeníáally occur án cháldren wáíh ApaK
medáaírácáans are ofíen faced wáíh íhe challenges of managáng íhese condáíáons án
íhe coníexí of íhe cháld’s Apa [
zK qhese common medácal and behaváoral coJ
morbádáíáes ánclude seázuresLepálepsyI gasíroáníesíánal problemsI sleep dásorders
and challengáng behaváorsK peázure dásorder occurs aí a hágher raíe án cháldren
wáíh ApaI compared ío íhaí of íhe general populaíáonI wáíh íhe prevalence even
greaíer án cháldren wáíh
Apa and profound developmeníal delays [
zK qhe
peak onseí of epálepsy ás bámodalI usually beíween ages N ío RI or án íhe
adolescení peráod [
zK dasíroáníesíánal complaánís íhaí are seen án Apa cháldren
ánclude: frequení abdománal paánI chronác consíápaíáonI chronác dáarrheaI and
gasíroesophageal reflux EdboFK Because many cháldren wáíh Apa are noí able ío
verbaláze íheár dásíressI gasíroáníesíánal condáíáons can presení as behaváoral
sympíoms and acíáng ouí behaváor [
zK pleep dásíurbances are also common án
cháldren wáíh Apa and may ánclude problems wáíh sleep onseí and sleep
maáníenanceI early awakenángI or ánsomnáaK pleep problems can also be presení
due ío behaváor facíors such as lack of caregáver’s lámáí seííáng or íhe cháld
learnáng ánappropráaíe sleep assocáaíáonsK medáaírácáans should also be aware íhaí
possáblyI medácal or psycháaírác facíors can resulí án sleep dásíurbances Efor
exampleI refluxI obsírucíáve sleep apneaI anxáeíyF [
I
Challengáng behaváors and meníal healíh ássues are also frequeníly seen án
cháldren wáíh ApaK bxamples of íhás ánclude: emoíáonal labáláíy or árráíabáláíyI
exíreme íanírumsI aggressáon ío oíhersI selfJánjuráous behaváorsI Aaea
sympíomsI anxáeíyI depressáonI repeíáíáve and rágád behaváors Eperseveraíáve or
lCaJláke sympíomsFI pácaI and feedáng dáffáculíáes Every resírácíed food choácesI
or oral íexíure aversáons ío ceríaán foodsF [
zK If íhese challengáng behaváors án
Apa cháldren are acuíe án onseí or dáfferení from íheár baseláne behaváorI an
underlyáng eíáology should be consádered and íreaíed áf ádeníáfáed [
I
zK cor
ánsíanceI a nonverbal auíásíác cháld who suddenly presenís wáíh árráíabáláíy ás noí
able ío convey ío care prováders a locaíáon of body paánI such as a deníal
ánfecíáonK Aí íámes challengáng behaváors mághí serve a purpose for íhe cháldI
such as a means of obíaánáng aííeníáon or gaánáng access ío a desáred áíem or
Ií ás beyond íhe scope of íhás chapíer ío dáscuss án deíaál íhe medácal managemení
of each of íhese condáíáonsI buí excellení resources exásí án íhe láíeraíure for íhe
qeb lkdlIkd MAkAdbMbkq lc Ak ArqIpM pmbCqorM
qhe managemení goal of íhe pedáaírácáan for íheár paíáení wáíh auíásm goes
beyond basác medácal careI and expands ío helpáng íhe famály navágaíe and access
appropráaíe serváces for íheár cháld across healíhcareI educaíáon and communáíy
qwo síudáes have shown íhaí famáláes wáíh cháldren wáíh developmeníal
dásabáláíáes are less íhan saíásfáed wáíh íhe care íhaí íhey receáveK purveys
conducíed by iápíak show famáláes perceáve defácáís án mCm’s abáláíy ío answer
quesíáons abouí íheár cháld’s condáíáon and án íhe mCm’s abáláíy ío connecí íhem
wáíh oíher famáláes who have sámálar ássuesK Connecíáng wáíh oíher famáláes ás an
ámporíaní way ío undersíand íhe ámpací of íheár cháld’s chronác condáíáon on íhe
famály [
zK AddáíáonallyI famáláes wáíh cháldren wáíh Apa voluníeered negaíáve
commenís regardáng íheár mCm’s knowledge of complemeníary and alíernaíáve
medácáne ECAMF and íhe communáíy supporí around íhem [
zK Carbone
conducíed pareníLprováder focus groupsI where parenís commeníed íhaí mCms dád
noí ací early enough on íheár cháld’s sympíoms and íhe care íhey receáved ás
lackáng án comprehensáveness and famály ceníerednessK mrovádersI on íhe oíher
handI cáíe lack of íámeI láííle resources and mánámal íraánáng prováded as barráers
Based on íhe famáláes’ feedbackI mCms would benefáí from educaíáng íhemselves
Amerácan Academy of medáaírács has publáshed
Auíásm: Caráng for Cháldren wáíh
Auíásm ppecírum aásorders: A oesource qoolkáí for Clánácáans asa
zK qhás
publácaíáon provádes handouís for famáláes and bráef dáscussáons abouí many
íopácsI such as vaccánesI behaváoral íreaímenísI íoáleí íraánángI seázuresI ánsomnáaI
behaváor práncáplesI psychopharmacologyI eaíáng and nuíráíáonI seázures and
epálepsyI and many oíhersK In addáíáonI íhe Auíásm ppeaks websáíe feaíures many
íool káís on varáous íopácsI áncludáng behaváor íreaímenís for auíásmI deníal vásáísI
blood drawsI fársí NMM days Efrom dáagnosásFI feedáng ássuesI ánsomnáa and many
oíhers [
zK Anoíher value resource ás íhe kaíáonal píandards mrojecí Emhase N and
OF publáshed by íhe kaíáonal Auíásm Ceníer [
zK In OMMV íhe kaíáonal Auíásm
Ceníer esíabláshed a seí of síandards for researchJvaládaíed educaíáonal and
behaváoral íreaímenís for cháldren wáíh ApaK qreaímenís are raíed usáng íhe
followáng classáfácaíáon: esíabláshed evádenceJbased; emergáng íreaímenís; and
unesíabláshed íreaímenísK In OMNR an updaíe of íhe kaíáonal píandards reporí was
publáshed whách áncludes research from OMMT ío OMNO as well as íreaímenís for
adulísI whách have noí been síudáes án íhe pasíK qhás websáíe and downJloadable
documenís can prováde valuable guádelánes for pedáaírácáans buí also parenísI
educaíors and serváce prováders as íreaímení opíáons are evaluaíed [
A noíe on Complemeníary and Alíernaíáve Medácal qreaímenís ECAM
A ságnáfácaní number of cháldren ENNKSBF án íhe rnáíed píaíes use yeí ío be
scáeníáfácally proven íreaímenís as complemení Eán addáíáon ío conveníáonal
íreaímenísF or as an alíernaíáve Esubsíáíuíe for conveníáonal íreaímenísF [
zK In
several Apa populaíáonsI frequency of CAM usage ás aí a much hágher rangáng
from OU ío UOB [
zK aespáíe íhese numbersI parenís of cháldren wáíh Apa
usually do noí dáscuss CAM íreaímenís wáíh íheár prámary care provádersK marenís
perceáve íheár prováders ío have láííle knowledge and áníeresí án CAM [
I
marenís have experáenced íheár prováder ío be unwálláng ío dáscuss and accepí
eealíhcare prováders for cháldren wáíh Apa should be aware abouí CAM
íreaímenís and have regular dáscussáons wáíh famáláes abouí CAM ío help íhem
negoíáaíe íhe dáfferení íreaímenís and make decásáonsK qhe kaíáonal Ceníer for
Complemeníary and Alíernaíáve Medácáne EkCCAMFI aáms ío promoíe CAM
dáscussáon among prováders and paíáenís íhrough íheár program qáme ío qalk
F [
zK qhás program offers prováders free
maíeráalI such as posíersI íáp sheeísI paíáení walleí cardsI and oíher resource
ánformaíáon ío help encourage dáscussáon of CAM useK
qhe quesíáon of vaccánes coníánues ío be raásed by parenís so áí ás ámporíaní íhaí
pedáaírácáans know how ío respond ío íhás quesíáonK qhere ás no lánk beíween
vaccánes and auíásmK In NVVUI a small síudy án bngland was publáshed íhaí
suggesíed a causal relaíáonsháp beíween íhe MMo vaccáne and íhe onseí of auíásm
zK qhás had a polarázáng effecíI wáíh many parenís challengáng esíabláshed
vaccánaíáon pracíáce ío íhe poání of delayáng or refusáng vaccánes for íheár
cháldrenK oeporís from íhe Insíáíuíes of Medácáne EIlMF án OMNN [
z concluded
íhaí íhere ás no assocáaíáon beíween íhe MMo vaccáne and onseí of auíásmK In
addáíáonI íhe daía was deemed ío favor rejecíáon of any causal relaíáonshápK In
OMM4I íhe IlM reváewed publáshed daía on íháomersal as a vaccáne ángredáení and
onseí of auíásmK pámálarlyI íhe daía was deemed ío favor rejecíáon of any causal
relaíáonsháp [
zK qhere are no new síudáes íhaí would challenge íhese reporís
ceeláng prepared ío help ádeníáfy and manage Apa for your paíáenís and íheár
famáláes can be a dauníáng íaskK mrofácáency seems ío be a funcíáon of medácal
íraánáng and proacíávely preparáng yourself and your pracíáceK qhe fársí síep of íhás
process ás knowáng whaí ás avaálable for paíáenís wáíh Apa and íheár famáláes án
your areaK qhe more you know abouí local and síaíe resourcesI íhe beííer you are
able ío serve íhe famáláes án your clánácK Anoíher ámporíaní íask ás creaíáng
relaíáonsháps wáíh íhese prováders of Apa servácesK qhese relaíáonsháps can help
you and your síaff know íhe correcí people ío coníací for íreaímeníK qhese
relaíáonsháps can síreamláne íhe accessáng of íreaímení and serváces for your
paíáenís and íheár famáláesK Anoíher ámporíaní íask ás ío íake íhe íáme ío have
handouís and práníed resources readály avaálable aí your clánácK qhe followáng
qake íáme ío creaíe a mechanásm án your medácal record sysíem ío flag paíáenís
for an NU and a O4Jmoníh developmeníalLauíásm screenángK eave screenáng
ánsírumenís práníed and easály accessáble so íhás process becomes parí of your
daály clánácal pracíáceK píandardázáng íhás process ás noí only for you buí also
Creaíe relaíáonsháps wáíh agencáes án your communáíy íhaí dárecíly serve
cháldren and famáláes wáíh ApaK qhás may mean askáng agencáes such as barly
Iníerveníáon EbIF and barly Cháldhood EbCF ío meeí wáíh you and your síaffK
Agencáes can bráng wráííen ánformaíáon abouí íheár programs íhaí you can pass
along ío famáláesK qhese relaíáonsháps also help famáláes sánce you are creaíáng
Ideníáfy professáonals án your cáíyI regáon or síaíe who conducí comprehensáve
evaluaíáons for ApaK eaváng a lásí ío gáve ío famáláes of íhese clánácáansL íeams
andI áf possábleI haváng íhe referralLáníake forms from íhese professáonals án
your offáceK If a referral can be made before íhe famály leaves your offáceI you
have creaíed confádence for famáláes án your careK Ií ás also a way ío poíeníáally
Creaíe a resource ceníer Ehard copáes andLor elecíronácF íhaí you and your síaff
can access quáckly án order ío educaíe íhe famáláes you serveK Mosí of íhe
resources dáscussed án íhás chapíer can be accessed wáíh no cosí and can
prováde valuable ánformaíáon abouí ApaI relaíed condáíáons and besí pracíáce
íreaímení opíáonsK qakáng íhe íáme ío puí íhás ánformaíáon ánío an easy ío access
formaí and locaíáon can yáeld greaí benefáís ío yourself and íhe paíáenís án your
oesearch án íhe area of Apa ás growáng exponeníáally and áí wáll be ámporíaní ío
fánd ways ío keep up wáíh new ánformaíáonK qhe fánal goal of íhás chapíer ás ío
prováde evádence based resources whách a busy pedáaírácáan can have access ío án
order ío keep abreasí of updaíes án íhe fáeld of Auíásm ppecírum aásordersK pome
of íhe references for íhás chapíer can prováde excellení ánformaíáon as íhe fáeld of
Ibanez isI píone tiI Coonrod bbK pcreenáng for auíásm án young cháldrenK In: solkmar coI oogers
pgI maul oI melphrey hAI bdsK eandbook of Auíásm and mervasáve aevelopmeníal aásordersJK 4íh edK
CaCK mrevalence of auíásm specírum dásorder among c
aged U yearsJ
uíásm and
Commáííee on Cháldren wáíh aásabáláíáesK qhe pedáaírácáan’s role án íhe dáagnosás and managemení of
gohnson CmI Myers pMK Ideníáfácaíáon and bvaluaíáon of Cháldren wáíh Auíásm ppecírum aásordersK
cálápek mAI Accardo mgI Ashwal pI Baranek dqI Cook be grI aawson dK mracíáce parameíer:
Amerácan msycháaírác AssocáaíáonK aáagnosíác and síaíásíácal manual of meníal dásordersK Ríh edK
Amerácan msycháaírác AssocáaíáonK aáagnosíác and síaíásíácal manual of meníal dásordersK Prd edKI
crazáer qtI voungsírom bAI ppeer iI
eí alK
saládaíáon of proposed apMJR cráíeráa for auíásm
Mandy tmI Charman qI pkuse aeK qesíáng íhe consírucí valádáíy of proposed cráíeráa for apMJR
duíhráe tI pwáneford iBI teíherby AMI iord CK Comparáson of apMJIs and apMJR facíor
sírucíure models for íoddlers wáíh auíásm specírum dásorderK g Am Acad Cháld Adolesc msycháaíráy
lzonoff pK bdáíoráal perspecíáve: Auíásm ppecírum aásorder án apMJRJAn hásíorácal perspecíáve and
euería MI Báshop piI auncan AI eus sI iord CK Applácaíáon of apMJR cráíeráa for auíásm specírum
dásorder ío íhree samples of cháldren wáíh apMJIs dáagnoses of pervasáve developmeníal dásordersK
oegáer aarrel AI karrow tálláam bI Clarke aáana bI
eí alK
apMJR cáeld qráals án íhe rnáíed píaíes
and CanadaI marí II: qesíJoeíesí oeláabáláíy of pelecíed Caíegorácal aáagnosesK Am g msycháaíry OMNP;
Maííála MI háelánen MI iánna pI gussála hI bbeláng eI Bloágu oK Auíásm specírum dásorders accordáng
ío apMJIsJqo and comparáson wáíh apMJR drafí cráíeráa: An epádemáologácal síudyK g Am Acad
Maíson gI hozlowská AI eaííáer MI eorováíz MI pápes MK apMJIs
apMJR dáagnosíác cráíeráa for
Mcmaríland gCI oeáchow BI solkmar coK pensáíáváíy and specáfácáíy of proposed apMJR dáagnosíác
pwedo pbI Baárd dI Cook be grI eappe cdI talker gCI haufman tbK Commeníary from íhe apMJR
workgroup on neurodevelopmeníal dásordersK g Am Acad Cháld Adolesc msycháaíry OMNO; RNE4F: P4TJ
Amerácan msycháaírác Assocáaíáon [áníerneízKK Commeníary íakes ássue wáíh cráíácásm of new auíásm
defánáíáon: apMJR experís call síudy flawed Amerácan msycháaírác Assocáaíáon news release OMN4
March 4; Avaálable from
hííp:LLwwwKpsycháaíryKorgLnewsroomLnewsJreleasesL commeníaryJíakeJ
hám vpI combonne bI hoh vI
eí alK
A Comparáson of apMJIs mervasáve aevelopmeníal aásorder
and apMJR Auíásm ppecírum aásorder mrevalence án an bpádemáologác pampleK g Am Acad Cháld
pmáíh ICI oeáchow BI solkmar coK qhe effecí of apMJR cráíeráa on number of ándáváduals dáagnosed
Chrásíáansz gAI dray hMI qaffe gI qongue BgK Auíásm specírum dásorder án íhe apMJR: aáagnosíác
sensáíáváíy and specáfácáíy án early cháldhoodK g Auíásm aev aásord [áníerneíz I OMNS ceb V; [cáíed ceb
aosreás pI teáner CI gohnson iI kewschaffer CK Auíásm specírum dásorder screenáng and
managemení pracíáces among general pedáaírác provádersK g aev Behav medáaír OMMS; OT EpupplK OF:
Myers pI Challman qK Auíásm specírum dásordersK In: soághí odI Macáas MMI Myers pMI bdsK
aevelopmeníal and Behaváoral medáaírácsK Nsí edK blk drove sállageI Ill: Amerácan Academy of
[O4zMJCeAq [áníerneízK M_CeAqorg I OMNS [cáíed OMNS March Sz; Avaálable from:
Amerácan academy of pedáaírács; kaíáonal ceníer on báríh defecís and developmeníal dásabáláíáes aí íhe
ceníers for dásease conírol and preveníáon ErpFK Auíásm AKiKAKAKoKMK [áníerneízK Amerácan Academy
of medáaírács ErpF OMNOK [cáíed OMNS ceb TzK Avaálable from
solkmar coI Booíh iiI Mcmaríland gCI táesner iAK Clánácal evaluaíáon án mulíádáscáplánary seííángsK
In: solkmar coI oogers pgI maul oI melphrey hAI bdsK eandbook of Auíásm and mervasáve
aevelopmeníal aásordersJK 4íh edK kew gersey: táley mress OMN4; ppK SSNJTOK
iord CI ouííer MI ieCouíeur AK qhe auíásm dáagnosíác áníerváewJrevásed: A revásed versáon of a
dáagnosíác áníerváew for caregávers of ándáváduals wáíh possáble pervasáve developmeníal dásordersK g
Báshop piI iuysíer oI oáchler gI iord CK aáagnosíác assessmeníK In: Chawarska hI hlán AI solkmar
coI bdsK Auíásm ppecírum aásorders án Infanís and qoddlers: aáagnosásI assessmení and íreaímeníK
iord CI ouííer MI aeiavore mI oásá pI doíham hI Báshop pK Auíásm aáagnosíác lbservaíáon
pcheduleI pecond bdáíáon EAalpJOF Manual Emarí NF: Modules NJ4K qorranceI CA: tesíern
msychologácal perváces OMNO; pK 44S pK
oásá pI iord CI doíham hI
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Combánáng ánformaíáon from mulíáple sources án íhe dáagnosás of
Myers pMI gohnson CmK Managemení of cháldren wáíh auíásm specírum dásordersK medáaírács OMMT;
Buáe qI cuchs dgI curuía dqI
eí alK
oecommendaíáons for evaluaíáon and íreaímení of common
Mcduáre hI cung ihI eagopáan iI
eí alK
Irráíabáláíy and problem
án auíásm specírum dásorder:
Malow BAI haíz qI oeynolds AMI
eí alK
pleep dáffáculíáes and medácaíáons án cháldren wáíh auíásm
Bellando BgI cussell ggI iopez MiK Auíásm ppeaks íoolkáís: oesources for busy physácáansK Clán
iápíak dI lrlando MI vángláng gI
eí alK
paíásfacíáon táíh mrámary eealíh Care oeceáved by camáláes
Carbone mI Behl aI Azor sI Murphy kK qhe medácal home for cháldren wáíh auíásm specírum
Amerácan Academy of medáaírácsK Auíásm: Caráng for cháldren wáíh auíásm specírum dásorders: A
Black iI Clarke qI Barnes mI píussman BI kahán oK rse of complemeníary healíh approaches among
cháldren aged 4–NT years án íhe rnáíed píaíes: kaíáonal healíh áníerváew surveyI OMMT–OMNOK kaíáonal
merrán gI Coury aI eyman pI Cole iI oeynolds AI Clemons qK Complemeníary and alíernaíáve
euang AI peshadrá hI Maííhews qI lsífeld BK mareníal perspecíáves on useI benefáísI and physácáan
knowledge of complemeníary and alíernaíáve medácáne án cháldren wáíh auíásíác dásorder and aííeníáonJ
lDheefe MI Coaí pK Increasáng healíhJcare opíáons: qhe perspecíáves of parenís who use
complemeníary and alíernaíáve medácánesK g maedáaír Cháld eealíh OMNM; 4SESF: OVSJPMMK
kCCIeK Be an Informed Consumer OMNPK [cáíed 4 March OMNSzK Avaálable from:
kaíáonal Auíásm CeníerK kaíáonal píandards mrojecí OMNRK [cáíed T March OMNSzK Avaálable from
takefáeld AgI Murch peI Aníhony AI
eí alK
obqoACqba: IlealJlymphoádJnodular hyperplasáaI nonJ
Adverse bffecís of saccánes OMNOK [cáíed V March OMNSzK Avaálable from:
Immunázaíáon pafeíy oeváew OMM4K [cáíed V March OMNSzK Avaálable from:
aeparímení of deneral and Communáíy medáaírácsI Cháldren’s kaíáonal eealíh pysíemI
tashángíon aCI rpA
Absírací:
medáaírác prováders can play a key role án íhe early ádeníáfácaíáon and
íreaímení of anxáeíyK Bráef screenáng íools can be used ío enhance deíecíáon and
dáffereníáaíáon of anxáeíy sympíomsK lnce ádeníáfáedI prováders can íráage concerns ío
deíermáne íhe besí course of acíáonI áncludáng íreaímení seííáng Eprámary care
referral ío an ouípaíáení prováderF and áníerveníáon approach EcognáíáveJbehaváoral
íherapyI medácaíáon managemeníFK aásíracíáon and parení educaíáon can be effecíáve
íools ío reduce shoríJíerm anxáeíy assocáaíed wáíh offáceJbased proceduresK More longJ
íerm íreaímení of anxáeíyI eáíher wáíhán prámary care or án communáíyJbased seííángsI
can vary dependáng on preseníáng concerns and íhe cháld’s ageK eoweverI evádenceJ
based approaches íypácally ánclude psychoeducaíáonI cognáíáve behaváoral íherapyI
recognáíáon and managemení of physácal cues of anxáeíyI cognáíáve resírucíurángI
exposuresI relapse preveníáonI and collaboraíáon wáíh parenís and schoolsK Medácaíáon
heywords:
Anxáeíy án cháldrenI Anxáeíy íreaímeníI CoJlocaíed meníal healíhI
CognáíáveJbehaváoral íherapyI medáaírácsI pelecíáve seroíonán reupíake ánhábáíor
Anxáeíy ás one of íhe mosí common meníal healíh dásorders [
I
zK iáfeíáme
prevalence of anxáeíy dásorders ás OUBI surpassáng depressáon and ámpulseJ
conírol dásordersI such as aííeníáon defácáí hyperacíáváíy dásorder [
zK Anxáeíy
dásorders presení earláer íhan many oíher cháldhood meníal healíh dásorders [
and are assocáaíed wáíh laíer developmení of depressáonI subsíance abuseI and
oíher socáoJemoíáonal dásorders [
I
zK barly ádeníáfácaíáon of anxáeíy and
áníerveníáon ás cráíácal ío íreaíáng anxáeíy and preveníáng coJmorbádáíyK
Correspondáng Auíhor hrásíáne pchmáíz:
NNN Máchágan AveI ktI tashángíonI aC OMMNMI rpA; qel: EOMOF UR4J
qo facáláíaíe ádeníáfácaíáon of anxáeíy concernsI pedáaírácáans can combáne íheár
observaíáons and clánácal áníerváew wáíh a more sírucíured screenáng íoolK rse of a
síandardázed screenáng íool can be benefácáal gáven íhaí prováders ofíen overlook
meníal healíh ássues and many parenís of cháldren wáíh meníal healíh problems do
noí ándependeníly reporí concerns abouí íheár cháldren’s behaváor [
zK Anxáeíy
may have even lower sensáíáváíy raíes of prováder ádeníáfácaíáon because íhe
perceáved burden on parenís and funcíáonal ámpaármení can appear less severe
ádeníáfy poíeníáal meníal healíh concernsI such as anxáeíyI earláer among a wáder
range of famáláes and has íherefore been áncreasángly encouraged wáíhán prámary
care as a way ío reduce unmeí meníal healíh needs [
I
zK pcreenáng íools should
noí be used dáagnosíácallyI buí raíher are mosí appropráaíe when used án
combánaíáon wáíh prováder’s clánácal áníerváewI observaíáonsI and judgmeníK
peveral bráef screenáng íools exásí and can be been used án prámary care ío assess
for anxáeíyK qhese ánclude broadJbased screenáng íools íhaí have quesíáons abouí
anxáeíyI as well as anxáeíyJspecáfác íools Eqable
FK BroadJbased screenáng íools
are more appropráaíe for unáversal screenáng efforís as a way ío ádeníáfy possáble
meníal healíh concerns across a large group of cháldren and a varáeíy of areasK In
conírasíI anxáeíyJspecáfác screenáng íools are more appropráaíe when used as a
second síage screener E
I when broadJbased íool raáses concerns abouí anxáeíyF
or when parenís or prováders raáse concerns abouí anxáeíyK cor anxáeíy án
paríácularI áí may be ámporíaní ío obíaán youíh reporí án addáíáon ío parení
reporíed sympíoms [
lnce concerns abouí anxáeíy have been raásedI eáíher
screenáng íools or
clánácal áníerváewI prováders can íráage concerns by askáng quesíáons abouí
sympíom severáíy E
I frequencyI áníensáíyI and duraíáon of anxáeíy sympíomsF
and funcíáonal ámpaármení—or íhe exíení ío whách anxáeíy sympíoms geí án íhe
way of íhe cháld’s abáláíy ío funcíáon aí homeI aí schoolI and án íhe communáíyK
cor younger cháldren án paríácularI assessáng íhe ámpací of anxáeíy sympíoms on
parenís and famály members ás also ámporíaní E
deíermánáng áf parení has had
ío change work schedule ío accommodaíe cháld’s behaváorsFK qhe level of severáíy
and ámpaármeníI as well as íhe prováder’s own skálls and íhe avaálabáláíy of
communáíyJbased resources wáll ánform decásáons abouí referral ío an ouísáde
Cháldren can experáence ságnáfácaní anxáeíy duráng íheár medácal áníeracíáonsI
áncludáng boíh rouíáne preveníáve care and procedural careK kumerous approaches
may reduce acuíe anxáeíy wáíhán íhe offáce seííángI áncludáng dásíracíáon
íechnáques and pareníal presence and íraánángK thále dásíracíáon can exacerbaíe
anxáeíy sympíoms án íhe longJíermI áí ás a maánsíay for addressáng acuíe anxáeíy
caused by medácal proceduresK Audáovásual approachesI such as offeráng vádeo
caríoons or íhreeJdámensáonal glasses duráng ámmunázaíáons or medácal
proceduresI have demonsíraíed ságnáfácaní reducíáons án anxáous behaváor án
cháldren and pareníal reporí of íheár cháld’s anxáeíy [
J
zK rse of cold and
vábraíáon duráng áníravenous caíheíer ánseríáon or ámmunázaíáons can also reduce
anxáeíy and paán [
I
zK rse of musác appears ío be less effecíáveI buí may be
maríneráng wáíh a parení ío reduce íheár cháld’s anxáeíy can yáeld good resulísI
paríácularly for younger cháldrenI íhough success can depend on íhe parení’s own
anxáeíyK then a parení ás calm aí íhe síarí of an operaíáve procedure and íhey
accompany íhe cháld ánío íhe operaíáng roomI íheár cháld may feel ságnáfácaníly
less anxáous and have fewer anxáous behaváors aí íhe onseí of anesíhesáaI even
wáíhouí oíher behaváoral or pharmacologácal áníerveníáons [
zK eoweverI
pareníal presence alone may noí reduce a cháld’s anxáeíyI and íhe presence of an
Incorporaíáng parenís án procedure preparaíáonI helpáng parenís address íheár own
anxáeíáesI and provádáng íhem wáíh íools íhey can use ío reduce íheár cháld’s
anxáeíy can lead ío ságnáfácaní ámprovemení án íheár cháld’s paán and dásíress
duráng a medácal procedureK AddáíáonallyI sánce a parení’s anxáeíy ás ofíen
anxáeíy ás addressed [
zK qools for pracíáce may ánclude ánformal
psychoeducaíáon and íeacháng or a more sírucíured áníerveníáon such as usáng a
compuíerázed program ío íeach parení’s coacháng síraíegáesI such as deep
breaíháng and dásíracíáon íechnáques [
zK Careful assessmení of how anxáous a
cháld and hás or her parenís are helps clánácáans deíermáne áf pareníal íraánáng
needs ío be coupled wáíh professáonal supporíI such as ánJperson supporí by a
íherapásí aí íhe íáme of íhe procedure orI án more severe casesI preparaíory work
IncreasánglyI meníal healíh ás beáng áníegraíed wáíhán medácal seííángsI áncludáng
prámary care and relevaní specáalíy care clánács E
I gasíroeníerologyFK Meníal
healíh concerns are ofíen comorbád wáíh medácal állnesses and áníegraíed
approaches ío care can lead ío ámproved engagemení án serváces and
desíágmaíázaíáon of meníal healíh problemsK AddáíáonallyI whále meníal healíh
care serváces can be dáffáculí ío access and are ofíen underusedI access ío prámary
care ás beííer wáíh mosí youíh seeáng a prámary care pracíáíáoner EmCmF annually
zK Cháldren wáíh meníal healíh care needs have more healíh care vásáís and
expendáíures íhan cháldren wáíhouí íhese needs [
I
zK mCms are ofíen íhe fársí
professáonal ío whom parenís express concerns abouí meníal healíh ássues [
aespáíe íhe key gaíekeepáng role íhaí mCms play án ádeníáfyáng and lánkáng
cháldren wáíh needed meníal healíh careI many reporí feeláng állJequápped ío do
íhás on íheár own [
zK qhusI áníegraíed meníal healíh professáonals can supporí
ío ádeníáfyI íráageI and address meníal healíh concerns án a number of ways íhaí
vary án áníensáíy and approachK then meníal healíh síaff cannoí prováde adequaíe
ánJhouse serváces ío meeí íhe demandI referral ío ouípaíáení meníal healíh
prováders ás warraníedI íhough íhese referrals can be enhanced
íargeíed care
coordánaíáonK Consádered ío be an esseníáal componení of íhe medácal home [
zI care coordánaíáon can ámprove ouícomes for cháldren wáíh specáal healíh care
needs by ámprováng famály engagemení án serváces [
I
zK eoweverI ádeallyI
meníal healíh serváces are avaálable wáíhán íhe prámary care clánácK oesearch has
found hágher raíes of íreaímení ánáíáaíáon and compleíáon as well as greaíer
reducíáons án meníal healíh sympíoms and pareníal síress when meníal healíh care
ás prováded on sáíe as compared ío facáláíaíed specáalíy care referral [
Iníegraíed meníal healíh professáonalsI who benefáí from warm handJoffs and
shared írusíI can serve án a range of rolesK cor exampleI íhey can prováde bráef
consulíaíáons ío íráage concernsI claráfy dáagnosesI ánform íreaímení plannángI and
In íhe many pracíáces íhaí do noí have access ío áníegraíed meníal healíh
professáonalsI cháld meníal healíh access programsI án whách a íeam of meníal
healíh professáonals E
psycháaírásísI socáal workersI care coordánaíorsF prováde
realJíáme phone consulíaíáon ío mCmsI offer an ánnovaíáve way ío ámprove access
ío careK puch programs supporí mCms as íhey íráage and address concerns án
prámary care or
referral ío communáíyJbased resourcesK píaríed over a decade
ago án MassachuseíísI cháld meníal healíh access programs are growáng án
popularáíy wáíh over PM síaíes now ámplemeníáng íhese programs [
zK oesearch
suggesís íhaí such access programs may help áncrease prováders’ feelángs of
then íhe need for onJgoáng íherapy for anxáeíy ás deíermánedI a number of
íreaímení modaláíáes may be employedK CognáíáveJbehaváoral íherapy ECBqF ás
íhe goldJsíandardI evádenceJbased íreaímení for anxáeíy dásorders án youíh [
zK CBq has been shown ío be effecíáve án íreaíáng anxáeíy wáíh comorbád
condáíáons as well [
zK qhás ás ámporíaní as an esíámaíed TRB of youíh dáagnosed
wáíh anxáeíy have mulíáple anxáeíy dásordersI approxámaíely RMB J SMB may have
a comorbád affecíáve dásorder [
I
zI and ORB J PPB a comorbád exíernalázáng
táíh a course of CBq íreaímení Eíypácally NO ío NS weeksFI approxámaíely íwo
ouí of íhree cháldren wáll be dáagnosásJfree [
zK qable
provádes a lásí of anxáeíy
dásorders and íhe íreaímenís íhaí have been found ío be mosí helpfulK qhe
majoráíy of áníerveníáons ánclude some form of CBqI buí íhere are some oíher
íreaímení approaches áncluded as wellK qhe classáfácaíáon sysíem ás based on íhe
works of Chambless
eí al
z and pouíhamJderow C mránsíeán [
zI whách
áncludes dásíáncí meíhodologácal and evádence cráíeráa ío deíermáne íhe degree of
empárácal supporí for a íreaímeníK lf noíeI due ío lámáíed research of some
dásordersI íreaíáng áníerveníáons may noí yeí meeí íhe evádenceJbased cráíeráa of
more esíabláshed íreaímenísK cor exampleI cognáíáveJbehaváoral íechnáques are
ofíen used ío íreaí selecíáve muíásmI howeverI íhere ás a paucáíy of randomázed
ppecáfác programs for íreaíáng anxáeíy can varyI especáally by íhe íype of anxáeíy
dásorder beáng íreaíedI buí íhe followáng are some common elemenís of CBq for
pedáaírác anxáeíy [
z – psychoeducaíáon abouí anxáeíy and CBqI recognáíáon and
managemení of physácal cues of anxáeíy E
I dáaphragmaíác breaíhángI ámageryI
progressáve muscle relaxaíáonFI cognáíáve resírucíuráng E
I recognázáng and
challengáng negaíáve íhoughísI posáíáve selfJíalkFI exposures Eámagánal or ánJvávo
exposures ío anxáeíyJprovokáng síámulá wáíh desensáíázaíáonFI relapse preveníáon
Eíhrough use of boosíer sessáonsFI and collaboraíáon wáíh parenís and schoolsK
AddáíáonallyI pelágman and lllendáck [
z hághlághí a focus on buáldáng skálls and
developáng a sírong íherapeuíác alláance wáíh paíáenís and famáláes as ámporíaní
componenís of CBqK thále many specáfác manuals have been developed and
síudáedI hendall and colleagues recommend flexábáláíyI clánácal íhoughífulnessI
and consáderaíáon of developmeníal coníexí án íhe use of CBq for pedáaírác
anxáeíy [
I
zK qhás ás ámporíaní as avaálabáláíy and accessábáláíy of manualázed
íreaímenís may be more lámáíed for famáláesK dreaíer flexábáláíy án íreaímení
applácaíáon ás also necessary for more complex cases áncludáng íhose wáíh
comorbádáíáes and managemení of ándávádual and famáláal psychosocáal síressors
EGcor íhe purposes of íhás chapíerI ievels NJP EtellJbsíabláshedI mrobably bffácacáous and mossábly
bffácacáousF of íhe RJlevel sysíem have been áncluded Eievels 4 and R beáng bxperámeníal and lf
nuesíáonable bffácacyFK
(Table
) contd.....
In conjuncíáon wáíh oíher íherapáesI medácaíáonsI such as selecíáve seroíonán
reupíake ánhábáíors EppoIsFI can be ámporíaní íools for íreaíáng moderaíe ío severe
anxáeíy dásorders án cháldrenK Medácaíáons are more effecíáve when used wáíh
behaváoral áníerveníáons and may be consádered when íhe sympíoms are severe or
when behaváoral áníerveníáons have been íráaled and unsuccessful afíer PJ4
moníhs of good engagemení án íherapyK
pelecíáve seroíonán reupíake ánhábáíors EppoIsF have demonsíraíed effecíáveness
án íreaímení of anxáeíy for cháldren [
I
zI howeverI few medácaíáons are caA
approvedI requáráng frequení offJlabel use Eqable
FK iáíeraíure supporís ppoI use
án obsessáveJcompulsáve dásorder ElCaFI generalázed anxáeíy dásorderI socáal
anxáeíy [
I
zI and less so for posíJíraumaíác síress dásorder EmqpaFI alíhough
íhey may be a helpful componení of írauma íreaímení [
I
zK qwo large
mulíásáíe síudáesI íhe mlqp and CAMpI demonsíraíed íhaí a combánaíáon of
cognáíáve behaváoral íherapy and ppoIs were mosí effecíáve án íreaíáng anxáeíy
qhe use of ppoIs án youíh has come ánío quesíáon due ío concerns for áncreased
suácádal íhoughís and behaváors án cháldren and adolescenísK qhás prompíed a
cood and arug Admánásíraíáon EcaAF black box warnángK thále íhás rásk ás low
ENJOB of cháldren experáence áncreased suácádaláíyFI prescrábers and caregávers
need ío be vágálaní abouí íhe possáble rásk [
J
zK qhe rásk ás hághesí án íhe fársí
íwo weeks of íreaímení and when síaríáng doses hágher íhan usual [
J
zK qhe
rásks and benefáís of usáng íhese medácaíáons should be made on an ándávádualázed
senlafaxáne [
I
zI a selecíáve norepánephráne reupíake ánhábáíor EpkoIF shows
effecíáveness for generalázed anxáeíy dásorder and socáal anxáeíy dásorderK iáke
ppoIsI venlafaxáne ás lákely mosí effecíáve when combáned wáíh cognáíáve
behaváoral íherapyK cor cháldren wáíh coJmorbád aííeníáon defácáí hyperacíáváíy
dásorder EAaeaF and anxáeíyI aíomoxeíáneI anoíher pkoII may be more effecíáve
íhan oíher Aaea medácaíáons [
zK Benzodáazepánes [
I
z and buspárone have
shown máxed resulís for generalázed anxáeíy [
zK ClonazepamI a benzodáazepáneI
showed no ságnáfácaní effecí on separaíáon anxáeíy dásorder [
z and ás assocáaíed
wáíh opposáíáonal behaváor and paradoxácal reacíáonsI such as dásánhábáíáon and
exacerbaíáons of sympíomsK then prescrábáng íhese medácaíáonsI áí’s ámporíaní ío
consáder íhe rásk of a paradoxácal reacíáonI whách occur more ofíen án cháldren
thále benzodáazepánes are noí consádered a fársíJláne íreaímení for anxáeíy
dásordersI íhey may prováde some benefáí án íhe ámmedáaíe íreaímení of acuíe
anxáeíy án cháldrenK qhusI for bráefI anxáeíyJprovokáng proceduresI
(Table
) contd.....
benzodáazepánes such as lorazepam and alprazolam may be offered when a cháld’s
anxáeíy ás severe or when íheár anxáous behaváors ságnáfácaníly áníerfere wáíh íhe
procedureK qhey have also been used as a brádge íherapy whále awaáíáng ppoI’s
effecí án panác dásorder [
zK In addáíáon ío benzodáazepánesI melaíonán shows
some promáse án reducáng anxáeíy and paán compared ío placebo whále haváng íhe
benefáí of fewer sáde effecís íhan íhose assocáaíed wáíh benzodáazepánes [
I
konJbenzodáazepáne medácaíáonsI such as melaíonánI warraní furíher
medáaírác prováders play a key role án early ádeníáfácaíáon and íreaímení of anxáeíy
án cháldrenK Iníegraíáng bráef screenáng íools along wáíh coJlocaíed meníal healíh
serváces and basác knowledge of psychopharmacology can aáde pedáaírácáans án
hessler oCI Berglund mI aemler lI gán oI Merákangas hoI talíers bbK iáfeíáme prevalence and ageJ
ofJonseí dásírábuíáons of apMJIs dásorders án íhe kaíáonal Comorbádáíy purvey oeplácaíáonK Arch den
hessler oCI Avenevolá pI Cosíello gI
eí alK
peveráíy of NOJmoníh apMJIs dásorders án íhe kaíáonal
pheldráck oCI Merchaní pI merrán bCK Ideníáfácaíáon of developmeníalJbehaváoral problems án prámary
Máan kaK iáííle cháldren wáíh bág worráes: addressáng íhe needs of youngI anxáous cháldren and íhe
teáízman CI tegner iK mromoíáng opíámal developmení: screenáng for behaváoral and emoíáonal
Commáííee on msychosocáal Aspecís of Cháld and camály eealíh and qask corce on Meníal eealíhK
molácy síaíemeníJJqhe fuíure of pedáaírács: meníal healíh compeíencáes for pedáaírác prámary careK
tobk cgK BoIadb gAI BIoMAebo BK pcreenáng for Cháldhood Anxáeíy pympíoms án mrámary
Care: Iníegraíáng Cháld and marení oeporísK g Am Acad Cháld Adolesc msycháaíry OMM4; 4PENNF: NPS4J
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Recent Advances in Pediatric Medicine,
Vol. 1,
313-322 313
Seckin Ulualp (Ed.)
All rights reserved-꤀ 2017 Bentham Science Publishers
AAP guidelines 176, 177, 179, 180
Acanthosis nigricans 105, 106, 107, 121, 125,
126, 131
Acid suppression therapy 83, 84, 85, 219, 220,
222
Acute 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 13, 174, 175,
301, 307
Recent Advances in Pediatric Medicine, Vol. 1
ASD 286, 287, 288, 289, 290, 291, 295
diagnosing 286, 287
children 291
diagnosis 288, 289, 290, 295
Asthma 52, 57, 58, 121, 125, 160, 161, 162,
163, 164, 165, 166, 167, 168, 169, 170,
175, 178, 179, 204, 212, 236, 242, 258,
259, 260, 262, 263, 264, 265, 274, 280
definitions of 160, 161
development 264, 265
exacerbations 166, 167, 169, 179
family history of 163
guidelines 160, 242
management of 161, 163, 166, 170, 242
non-atopic 166
pathophysiology 160, 161, 168
phenotypes 160, 164
symptoms 163, 164, 264
therapy 160, 161, 167, 169
Asthmatics, severe eosinophilic 167, 168
Atopic dermatitis 259, 274
Autism diagnosis 287, 289
formal 289
Autism early screening 286
Autism evaluation 286, 291
Autism identification 286
Autism interventions 286
Autism spectrum disorders ⠀ASD) 286, 287,
288, 289, 290, 291, 292, 293, 294, 295
Autism toolkits 286
Axillae 107, 125
Bacterial 38, 42, 65, 66, 180
infection 38, 42, 180
tracheitis 65, 66
Balloon 51, 52, 57, 58, 60
Subject Index
Recent Advances in Pediatric Medicine, Vol. 1
Cleft palate 6, 8, 11, 68, 73
Clinical guidelines 34, 42, 49
Closed loop control 93, 98
Coagulopathies 250, 251, 252
diagnosis of 251
Cochlear implants 19, 20, 29, 30
Cognitive-behavioral therapy (CBT) 299, 303,
304
Collaborative home infant monitoring
Co-located mental health 299, 302, 308
Combined multiple intraluminal impedance
217, 222
Complementary and Alternative treatments
286
Recent Advances in Pediatric Medicine, Vol. 1
Epidemiological studies 263, 265
Epidemiology 1, 6, 9, 94, 105, 117, 120, 203,
205, 218, 233
Epiglottis 67, 79, 85
Epiglottitis 65, 66
Epiglottopexy 68, 84, 85, 87
Epinephrine 177, 241, 272, 278, 279, 280, 281
intramuscular 272, 278, 281
Episodes, recurrent 11, 12
Epistaxis 249, 250, 251, 252, 253, 254, 255,
256
Subject Index
Recent Advances in Pediatric Medicine, Vol. 1
Hydroxyurea 231, 238, 240, 244, 245
Hyperglycemia 93, 94, 95, 108, 110
Hypertension 100, 101, 102, 105, 107, 111,
112, 121, 122, 124, 128, 129, 132, 135,
136, 147, 155, 207, 254
Hyperthyroidism, common cause of 144, 146,
157
Hypertonic saline 173, 178
Hypertrophy 6, 46, 206, 207, 208, 210, 213
adenotonsillar 46, 207, 210, 213
Hypoglycemia 98, 99, 101, 109, 110
Hypothyroidism 119, 124, 130, 133, 151, 152,
153, 154
Hypoventilation 128, 195
Hypoxemia 81, 83, 187, 193, 277
Idiopathic epistaxis 250, 252, 253
Immune system 3, 47, 48, 145, 162
Immunotherapy 3, 258, 261, 262, 263, 264,
266, 273
Improvement, symptomatic 57, 279
Increased GER-symptoms in relatives of
GERD patients 219
Increasing awareness of pediatric obesity 117
Individual behavior therapy 305
Individual CBT 304, 305
Infant reflux 223, 224
Infants, healthy 179, 180, 181, 188, 189, 190,
195, 203, 218
Infants and children 221, 245, 277, 278
Infections 1, 6, 11, 27, 37, 38, 39, 40, 41, 43,
53, 55, 56, 145, 236, 238, 241, 253, 292
recurrent throat 43
streptococcal 39, 41
Infectious disease 46
Inflammatory cascade 162, 166
Inhaled corticosteroids 160, 161, 163
Insomnia 291, 292, 293
Inspiratory supraglottic collapse 77
Insulin 93, 94, 96, 97, 98, 99, 101, 108, 109,
110, 111, 128, 132, 225
Insulin pumps 93, 97
Insulin resistance 100, 105, 106, 107, 108,
120, 122, 123, 124, 125, 129, 130, 207
Recent Advances in Pediatric Medicine, Vol. 1
Management, therapeutic 78, 81, 83
Management algorithm for pediatric
pharyngitis 47
Subject Index
Recent Advances in Pediatric Medicine, Vol. 1
Otoacoustic emissions (OAE) 22
Otolaryngologists 12, 13, 44, 49, 210, 211,
250, 252, 258, 259, 265
Otorrhea 1, 8, 9, 12
Otoscopy, pneumatic 7, 9, 13
Oxygen, supplemental 179, 180, 196, 238, 278
Oxygen saturation 179, 196, 237, 238
Pain, severe 236, 237, 242, 246
Pain crisis 231, 232, 236, 237
Pain crisis, acute 236, 237
Palivizumab 173, 176, 180
PCRS, treatment of 52, 54, 55, 57, 59
PCRS symptoms 56, 57, 60
Pediatric 25, 34, 41, 45, 49, 51, 60, 105, 117,
122, 164, 195, 198, 203
common 34, 45, 49
Pediatric anxiety 304
Pediatric asthma 164, 166
severe 164
severe allergic 166
Pediatric endocrinologists 101, 108
Pediatric epistaxis 249, 250
Pediatric hearing rehabilitation 19, 21
Pediatrician knowledge 286
Pediatricians, child鈀s 291
Pediatric obesity 117, 119, 120, 122, 133, 134,
135, 136
management of 117, 136
severe 135
turning 117
Pediatric obesity advocacy 136
Pediatric obesity centers 134
Pediatric obesity problem 137
Pediatric OSAS 203, 205, 206, 207, 209, 211,
212, 213
treatment of 211, 212
Pediatric otolaryngologists 64, 266
Pediatric overweight/obesity 118, 137
Pediatric population 58, 94, 105, 106, 107,
114, 151, 164, 166, 192, 194, 197, 209,
263, 265, 280
Pediatric providers 105, 106, 299, 308
Pediatric SDB 205, 266
Pediatric sleep questionnaire (PSQ) 210
Pediatric stridor management 64
Pediatric studies 227
Periodic breathing 188, 189, 191, 193, 196,
197
Peritonsillar abscess 42, 44, 46
Persistent asthma 164, 165
Persistent OSAS 207, 210, 212, 213
Pharmacotherapy 94, 100, 102, 258, 261, 264,
266
Pharyngitis 34, 38, 39, 40, 41, 44, 47, 49, 151,
174, 217, 219, 220
Phenotypes 163, 164, 258
PH monitoring 217, 221, 222
Phobia 301, 305
Physical activity 111, 117, 118, 133, 134, 135
Physical examination findings 175, 207, 209,
210
Placement, tympanostomy tube 11, 12, 13
Recent Advances in Pediatric Medicine, Vol. 1
Radioactive iodine uptake 144
Radiologic studies 53, 126
RAI uptake 152, 155, 156
84, 217, 225, 226
Recurrent acute otitis media (RAOM) 5, 6, 8,
11
Red blood cell (RBC) 96, 231, 234, 235, 238,
244
Reflux 2, 55, 56, 65, 73, 83, 161, 192, 217,
218, 219, 223, 224, 226, 227, 291
gastroesophageal 55, 161, 192, 217, 291
Reflux episodes 217, 218, 219, 221, 227
acidic 221
Regurgitation 78, 79, 218
Relationship, causal 3, 127, 264, 293, 294
Remission 144, 149, 151, 152, 153, 157
REM sleep 193, 195, 209
Respiratory distress 67, 68, 72, 74, 79, 173,
176, 177, 236
Respiratory infections 168, 169, 181
Respiratory syncytial virus (RSV) 4, 38, 173,
176, 177, 180, 181, 182
Subject Index
Recent Advances in Pediatric Medicine, Vol. 1
Symptoms 175, 217, 218, 220, 221, 237, 238,
274, 277
associated 237, 277
respiratory 175, 220, 221, 238, 274
troublesome 217, 218
Synchronous Airway Lesions ⠀SAL⤀ 64, 72,
73, 77, 80, 82, 87
Syndrome 107, 119, 120, 123, 130, 231, 232,
236, 237, 245
acute chest 231, 232, 236, 237, 245
ovarian 107, 119, 120, 123, 130
Tachycardia 147, 155, 156, 157, 177, 275
Term infants 193, 197
healthy 190
Tests, rapid strep 40, 49
Thalassemia 131, 232, 233, 244
Therapy 52, 54, 150, 151, 161, 299, 303
cognitive-behavioral 299, 303
developing 161
first line 52, 54
starting 150, 151
Throat culture 40, 49
Thyroid 144, 145, 146, 147, 148, 149, 150,
152, 153, 154, 155, 156, 157
antibodies 155, 156
gland 145, 148, 152, 155
hormone 145, 146, 147, 153, 155, 156
stimulating hormone receptor (TSHR⤀ 144,
145, 146, 150, 155
tissue 152, 154
Thyroidectomy 144, 154, 156, 157
Thyrotropin 131, 144, 145, 146, 148, 149, 151,
155, 156
stimulating hormone (TSH) 131, 144, 145,
146, 148, 149, 151, 155, 156
stimulating immunoglobulin (TSI) 144,
145, 146, 148, 149, 155, 156
Tissues 35, 36, 37, 47, 56, 84, 85, 87, 110, 181
adenoid 47, 56
redundant mucosal arytenoid 84, 85, 87
Tolerance, impaired glucose 106, 120, 122
Tone, neuromuscular 205, 206
Tongue 64, 67, 71, 72, 81, 85
base 64
, 71, 72, 81, 85
-lip adhesion (TLA) 71, 72
Tonsil card 44, 45
Tonsillectomy 34, 36, 40, 41, 42, 43, 44, 45,
46, 47, 48, 49, 57, 73, 206, 207, 211
and adenoidectomy 34, 46, 73, 206, 207, 211
paradise criteria for 43, 44
undergoing 42, 44
Tonsillitis, acute streptococcal 39, 40, 41
Tonsils 34, 35, 36, 38, 39, 40, 41, 42, 47, 48,
70, 72, 77, 81, 86, 87, 130, 206, 207, 211
enlarged 38, 39, 130, 207
palatine 34, 35, 36, 48, 207
Tracheotomy 39, 70, 72, 77, 81, 86, 87
Transcranial doppler (TCD) 231, 239, 240
ultrasound 231
Transfusion therapy 240, 243, 244
chronic 240
Trans-oral supraglottoplasty 77
Tremors 144, 147, 152, 155, 177
Triglycerides 102, 113, 123, 131, 132
Tryptase 272, 275, 276, 277
levels 276, 277
Tympanic membrane (TM) 1, 2, 3, 7, 8, 9, 12,
13
perforation 3, 7, 8, 13
Tympanostomy 1, 8, 10, 11, 12, 13
tubes 8, 10, 11, 12, 13
Recent Advances in Pediatric Medicine, Vol. 1
Waldeyer’s tonsillar ring 34, 35, 36
Weight loss 100, 112, 134, 135, 147
Weight management 100, 117, 134, 212
Willebrand disease 251, 252
Yale pediatric obesity 106
Vitamin D 133, 160, 168, 169

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