Current Pediatric Reviews (v.13, #1)

Meet Our Editorial Board Member by Wanda Phipatanakul (1-1).

Preface (2-2).

Recent improvements in therapy of children with cancer have resulted in an increase in cure rates which lead to long-term survivorship. Assessment of short- and long-term complications and late effects of cancer therapies is accomplished by pediatric oncologists and multi-disciplinary team, including continuation of care from pediatric to adult primary care. The late complications of cancer treatment include growth and development, reproduction, vital organ function (cardiac, pulmonary, renal, gastrointestinal), dental, ocular, esthetic sequellae, and second neoplasms (benign or malignant), which are cited as the second most frequent cause of death in the Children Cancer Survivors Study cohort.

Long-term follow-up guidelines for survivors of childhood cancers has been established by international specialists, the main aim is to decrease severe late complications by individualizing prevention care and treatment. Preventive measures include reduction of radiotherapy doses, or omission, introduction of new radiotherapy techniques, decrease doses of alkylating drugs, and anthracyclines, cardio protectors, fertility preservations guidelines, new surgical techniques, introduction of biological treatments.

The multidisciplinary team monitors certain treatments including risk-based care not only of the tumor, but also premorbid conditions, and health behaviors. More comprehensive and high-quality evaluations of survivorship programs are needed, for long term outcome, quality of life and psychosocial support.

At least 20 million children would benefit from Pediatric Palliative Care (PPC) annually, and 8 million children would need specialized PPC services. In the USA alone, more than 42,000 children 0-19 years died in 2013, fifty-five percent of them infants younger than 1 year. This article aims to critically review eight common assumptions, myths and barriers, which may hinder the implementation of PPC into the care of a child with advanced serious illness. Interdisciplinary PPC is about matching treatment to patient goals and is considered specialized medical care for children with serious illness. It is focused on relieving pain, distressing symptoms, and stress of a serious illness and appropriate at any age and at any stage, together with curative treatment. The primary goal is to improve the quality of life of the child and his or her family. Emerging evidence shows, that palliative care involvement results in improved quality of life as well as prolongation of life.

Cancer is a global health problem particularly in developing countries where the burden of cancer is ever increasing and claiming the lives of about 100,000 children under the age of 15 years every year. Majority of these occur in the Low and Middle Income Countries (LMICs) where 90% of world children live. Contributing factors to this trend is the reduction of communicable diseases and emergence of new infections, improvement of nutrition and socio-economic conditions, industrialization and urbanization. However, due to its complexity, childhood cancer is given the least priority by the governments' funding. The weak health systems, poor and late access to diagnosis and care, fewer numbers of trained health care professionals and lack of cancer drugs are amongst the many challenges faced. A major challenge for the future is extending the work to reach the many children who die without access to cancer treatment and palliation. Given the inequalities in the survival rates of children with cancer there is therefore an urgent need to close the gap between developed and developing countries.

Strategies at individual, institutional, country, regional and global levels must be implemented to improve cancer survival and its effects on human suffering. These strategies are able to strengthen the health systems, improve care and research, increase awareness and coordinate training of professionals thus meeting the challenges. Financial support should be an integral part of the strategy as the cost of drugs is often a substantial barrier to treatment of cancer in poor countries.

However, in resource-limited settings without specialized services, much can still be done to support and offer curative and palliative treatment. As have been shown for several cancers, life can be extended with low-tech treatment protocols, which are effective at the same time, decrease sepsis and toxicity. The concept of twinning with privileged nations is paramount to the success of any national cancer program. International partnership offers the opportunity to provide expertise, advice, support and transfer technology from established pediatric oncology unit. Their mission is to build capacity for cancer treatment and research with a vision of developing network of dedicated advocates. The LMIC teams must locally drive projects and volunteers and funding organizations can help to make progress possible. This will require a tremendous effort on the part of both high and low-middle-income countries, if we are all to work together to achieve this goal.

Background: Cancer treatment can have profound effects on the growth and development of pediatric patients. Different models of psychosocial development and behavioral treatment approaches aid children receiving medical treatment. Providing education, anticipatory guidance, and individualized support to child and their families is a psychosocial standard.

Objective: Clarify the different models of psychosocial development and applicable psychosocial interventions to better prepare and tailor cancer treatment to pediatric patients.

Methods: Authors reviewed existing evidenced-based literature in oncology, psychology, developmental, and psychiatric while drawing on case examples and expert knowledge to illustrate the impact of cancer treatment on pediatric patients, analyze developmentally individualized needs, and describe facilitative interventions.

Result: Pediatric patients of all ages cope and adjust better to all phases of treatment when their care is delivered in a developmentally-informed and psychosocially thoughtful way.

Conclusion: Providers can comprehensively prepare their patients and families for treatment better by utilizing a psychosocially- and developmentally-informed framework while meeting individualized unique needs of patients. An integrated multidisciplinary psychosocial support team is facilitative in anticipating and meeting the needs of pediatric cancer patients and has recently become a psychosocial standard of care.

Secondary Neoplasms in Children Treated for Cancer by Rejin Kebudi, Gul Nihal Ozdemir (34-41).
The survival of children with cancer has improved dramatically in the last decades. Survivors of childhood cancer are at increased risk of long-term complications of therapeutic exposure. Second malignant neoplasms are one of the most severe side effects of cancer treatment. The frequency and type of secondary cancers may vary depending on the initial diagnosis, treatment administered and genetic predisposition. This review highlights the risk factors in the development of SMNs in survivors of pediatric cancers and their differences according to primary cancer type, genetic predisposition and treatment admistered. Finally, the review emphasizes the need for life-time follow-up of survivors of childhood cancer for the development of second malignancies.

Five Pediatric Cancers - Update on Genetic Implications by Stacy Cooper, Jeffrey Rubens, Joann Bodurtha (42-48).
Pediatric cancer has undergone significant improvements in survival over the past several decades, in part due to a better understanding of the underlying genetic aberrations of each oncologic diagnosis, which has allowed for more effective targeted therapies. Pediatric brain tumors, leukemia, lymphoma, Wilms tumor, and retinoblastoma are exemplary pediatric cancers that each has specific epidemiology regarding children at risk as well as characteristic associated genetic lesions. These genetic features are more commonly being used to provide risk stratification, as well as to identify novel pathways for targeted therapy. With these advances, the overall survival of pediatric cancers continues to be improved.

Management of Pneumonia in the Pediatric Critical Care Unit: An Area for Antimicrobial Stewardship by Aimee M. Dassner, David P. Nicolau, Jennifer E. Girotto (49-66).
Background: Pediatric pneumonia is one of the most common causes of childhood infection requiring hospitalization and is a substantial driver of antimicrobial use among hospitalized children. About 12-20% of pediatric patients hospitalized with community-acquired pneumonia (CAP) require critical care. Additionally, nosocomial pneumonias (i.e. hospital-acquired and ventilator- associated pneumonias) are responsible for 15-53% of hospital-associated infections and are the most common indication for empiric antibiotics in the pediatric intensive care unit.

Objective: Respiratory infections, especially pneumonias, are a strong area for antimicrobial stewardship program (ASP) interventions, as they have been shown to improve patient outcomes while reducing inappropriate antimicrobial use, antimicrobial resistance, and overall costs.

Method: Optimizing the selection of appropriate antimicrobial therapies is difficult for pediatric pneumonias because of the ill-defined definitive diagnostic criteria and difficulty differentiating between viral and bacterial etiology.

Result: The aim of this review is to highlight the role of antimicrobial stewardship efforts in the treatment of pneumonias in critically ill children by discussing the emerging role of diagnostic criteria, the etiology of disease, appropriate targeted antimicrobial selection, and the optimization of antibiotic dosing and pharmacodynamic targets.

Newborn Bilirubin Screening for Preventing Severe Hyperbilirubinemia and Bilirubin Encephalopathy: A Rapid Review by Kalpana Bhardwaj, Tiffany Locke, Anne Biringer, Allyson Booth, Elizabeth K. Darling, Shelley Dougan, Jane Harrison, Stephen Hill, Ana Johnson, Susan Makin, Beth Potter, Thierry Lacaze-Masmonteil, Julian Little (67-90).
According to the 2004 American Academy of Pediatrics guideline on the management of hyperbilirubinemia, every newborn should be assessed for the risk of developing severe hyperbilirubinemia with the help of predischarge total serum bilirubin or transcutaneous bilirubin measurements and/or assessments of clinical risk factors. The aim of this rapid review is 1) to review the evidence for 1) predicting and preventing severe hyperbilirubinemia and bilirubin encephalopathy, 2) determining the efficacy of home/community treatments (home phototherapy) in the prevention of severe hyperbilirubinemia, and 3) non-invasive/transcutaneous methods for estimating serum bilirubin level. Methods: In this rapid review, studies were identified through the Medline database. The main outcomes of interest were severe hyperbilirubinemia and encephalopathy. A subset of articles was double screened and all articles were critically appraised using the SIGN and AMSTAR checklists. This review investigated if systems approach is likely to reduce the occurrence of severe hyperbilirubinemia. Results: Fifty-two studies met the inclusion criteria. Included studies assessed the association between bilirubin measurement early in neonatal life and the subsequent development of severe hyperbilirubinemia and chronic bilirubin encephalopathy/kernicterus. It was observed that, highest priority should be given to (i) universal bilirubin screening programs; (ii) implementation of community and midwife practice; (iii) outreach to communities for education of prospective parents; and (iv) development of clinical pathways to monitor, evaluate and track infants with severe hyperbilirubinemia. Conclusions: We found substantial observational evidence that severe hyperbilirubinemia can be accurately predicted and prevented through universal bilirubin screening. So far, there is no evidence of any harm.