Six-month-old conjoined twin sisters separated in Haiti

On Friday, May 22, physicians and nurses separated a pair of six-month-old conjoined Haitian twins, the first such operation ever performed on Haitian soil.

Henri Ford, Md, chief of Surgery, Children's Hospital Los Angeles, holds formerly conjoined twins Michelle and Marian three days after their separation surgery in Haiti.

Credit: Image courtesy of Childrens Hospital Los Angeles

On Friday, May 22, an 18-member team of physicians and nurses from Children's Hospital Los Angeles (CHLA) and Keck Medicine of the University of Southern California (USC) led an international collaboration to separate a pair of six-month-old conjoined Haitian twins, the first such operation ever performed on Haitian soil.

Marian Dave-Nouche Bernard and Michelle Dave-Nouche Bernard, born as one on Nov. 24, 2014, were separated after a seven-hour surgery at University Hospital of Mirebalais (HUM), in Mirebalais Haiti, a poor rural community in the country's Central Plateau, about 36 miles northeast of the capital city of Port-au-Prince.

"The girls are doing fantastic," said surgical team leader Henri Ford, MD, MHA, the Haitian-born surgeon in chief at Children's Hospital Los Angeles and vice dean for Medical Education, professor and vice chair for Clinical affairs, Department of Surgery, Keck School of Medicine of USC. "It was an extremely exhilarating day; not only did our preparations pay off and the surgery succeed in spectacular fashion, but this was also a time to put politics aside and celebrate our national pride."

Marian and Michelle -- "omphalopagus" twins since they are connected at the abdomen -- are actually triplets (sister Tamar is healthy and normal). The two sisters had faced each other since birth, but recuperated in separate beds in HUM's neonatal intensive care unit. They were ready to be discharged 12 days after surgery. "We anticipate Marian and Michelle will recover fully and go on to lead healthy and happy lives," Ford says.

Conjoined twins occur in roughly 1 in 200,000 births and omphalopagus twins represent about 30 percent of all conjoined twin births. As triplets, these girls are considered even rarer, occurring 1 in an estimated 1 million births. Fused together by the breastbone (or xiphoid bone) in the lower portion of the sternum, Marian and Michelle also had attached livers that would be separated during the procedure.

It took the international surgical team almost seven hours to separate the conjoined twins.

The mother, Manoucheca Ketan, 35, gave birth to all three of her daughters at HUM after carrying them for 36 weeks. The twins shared a crib until 10 a.m. on May 22, when Ketan and her husband, David Bernard, 31, watched as their infant daughters were wheeled into surgery as one. Ten hours later, after the surgery, the parents wept when they next saw the twins -- resting in separate cribs.

By then, the girls were already feeding on formula and breast milk. "It was an extraordinary moment," Ketan said, describing her reaction when she first laid eyes on her separated daughters. "When I first met Dr. Ford, he told me he was confident we could separate my children, but I didn't know how it would turn out when the day started. Now I am feeling a lot of joy and want to recognize and thank the hospital for everything."

The complex surgical procedure got underway within 24 hours of the arrival of the 18-member surgical team of surgeons, anesthesiologists and nurses from Children's Hospital Los Angeles. The Los Angeles team was joined by 12 medical staff from Centres GHESKIO, Hospital Bernard Mevs-Project Medishare and Hopital Universitaire de Mirebalais (HUM), led by Dr. Maclee Jean-Louis, director of Surgery at HUM. The group comprised what Ford described as an international medical "Dream Team."

The family received free treatment from HUM, which is supported by the Haitian Ministry of Health and Partners in Health, an international health organization. Keck Medicine and CHLA covered the travel expenses of the medical team and donated supplies to ensure the success of the operation.

Anticipating a six- to eight-hour procedure, doctors made the first incision along the abdominal wall that connected Marian and Michelle at 1:14 p.m. At 2:50 p.m., the girls were surgically separated to a burst of applause from the team and Marian was moved to an adjacent table. Donning red caps, Marian's team of six doctors and nurses hovered over her to close her incision, while Michelle's team worked in yellow caps -- ironically reflecting the colors of USC. "The mom gave them red and yellow bands months ago to identify them," Ford explains. "They were destined to be separated by Trojan surgeons."

Michelle was wheeled out of the surgery suite at 4:45 p.m., followed by Marian at 4:58 p.m.

"This surgery took less time than previous conjoined twin separations we have performed at CHLA, since there was no pelvic attachment," explains James Stein, lead surgeon during the separation and associate chief of surgery at Children's Hospital. Stein, an associate professor of surgery at Keck School of Medicine, has now separated six pairs of conjoined twins. "There are surgeries that require the expanded expertise of a place like CHLA, but the twins' anatomy and our team's expertise allowed us to undertake the surgery in Haiti, and compile the appropriate resources to do the surgery there safely."

Ford said that by doing the operation in Haiti, the children would benefit emotionally from the proximity of their parents and the surgery could be done more cost-effectively than if it were done in Los Angeles.

After completing the first ever surgery in Haiti to separate conjoined twins, part the international team takes a break in the surgery suite at University Hospital in Mirebalais.

During the seven-hour operation, the girls underwent 11 separate procedures, with only a few minor complications. Early on, surgeons and anesthesiologists encountered a "cross circulation" -- when fluids, blood and medication pass through one twin's liver to the other without benefiting the first.

Michelle's heart rate elevated, but the surgeons -- Stein, Ford and Aaron Jensen, MD, along with CHLA anesthesiologists Duc Nguyen, MD, and Joanna E. Green, MD -- remedied the situation by expeditiously separating the livers and individually hydrating the girls intravenously.

Doctors also removed an ovarian cyst in Michelle and surgically inserted patch material in both girls to reconstruct their abdominal walls after separation. They also formed new belly buttons for the twins, whose midline vertical scars should nearly disappear over time, Stein says.

One moment during the operation seemed to sum up the enormity of the procedure for Ford. "Their lower chests were connected so we had to remove a piece of the sternum, the breastbone, and then you could see their lungs and their hearts beating," he recalled.

Once the girls were moved to intensive care, a team of intensivists led by a graduate of CHLA's pediatric residency program, Peggy Han, MD, now an attending intensivist at Weill-Cornell, and neonatal intensive care unit nurses worked with HUM staff to oversee the twins' recovery. Volunteers from two other U.S. hospitals would fly in later to join the team and help oversee care after the CHLA team departed. Forty-eight hours after surgery, the girls were breathing independently, and after 72 hours they were being fed with a combination of breast milk and formula, Ford says.

Ford started recruiting his team back in September after his first conversation with the twins' doctors at HUM. Ford and team members would make almost monthly trips to Haiti between the November births and the May 22 surgery, checking up on the health of the girls and making sure that the proper human and material resources or equipment were available to safely do the surgery at HUM. By March, the team was set and the girls, strong and healthy, were scheduled for the May procedure.

Hours after the surgery, the Haitian media reported on the milestone operation and, three days postoperatively, the famous twins were paid a visit by Haitian First Lady Sophia Martelly and Minister of Health Florence Guillaume.

In the coming weeks, the girls will recover from their incisions and undergo physical therapy to help strengthen neck muscles weakened due to facing in a single direction for such a long time. "The girls look great; we don't expect any more surgeries," Stein says. "This was all about planning and organization. The amazing part for all of us is conducting seven hours of surgery, and then seeing two kids side by side, when they used to be just one. It's just awe-inspiring."

"I liken the entire international team of surgeons, anesthesiologists, intensivists, respiratory therapists and nurses to a symphony orchestra," says team leader Ford, who no doubt would make Gustavo Dudamel proud.

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Surgical anesthesia in young children linked to effects on IQ, brain structure

Children who received general anesthesia for surgery before age 4 had diminished language comprehension, lower IQ and decreased gray matter density in posterior regions of their brain, according to a new study. The authors of the study recommend additional studies to determine anesthesia's precise molecular effects on the brain and contribution to diminished brain function and composition.

Young children who received general anesthesia for surgery had diminished language comprehension, lower IQ and decreased gray matter density in posterior regions of their brain, according to a new study. (stock image)

Credit: © garagundi / Fotolia

Children who received general anesthesia for surgery before age 4 had diminished language comprehension, lower IQ and decreased gray matter density in posterior regions of their brain, according to a new study in the journal Pediatrics.

Researchers from Cincinnati Children's Hospital Medical Center report their findings in the journal's June 8 online edition. The authors recommend additional studies to determine anesthesia's precise molecular effects on the brain and contribution to diminished brain function and composition. Researchers say this knowledge could make it possible to develop mitigating strategies for what the authors describe as a potential dilemma for child health.

"The ultimate goal of our laboratory and clinical research is to improve safety and outcomes in young children who have no choice but to undergo surgery with anesthesia to treat their serious health concerns," said Andreas Loepke, MD, PhD, FAAP, lead study author and an anesthesiologist in the Department of Anesthesiology at Cincinnati Children's. "We also have to better understand to what extent anesthetics and other factors contribute to learning abnormalities in children before making drastic changes to our current practice, which by all measures has become very safe."

Loepke and his research colleagues have published previous studies showing widespread cell death, permanent deletion of neurons and neurocognitive impairment in laboratory rats and mice after exposure to general anesthesia. Those studies have raised concerns about similar effects in young children during a particularly sensitive neurodevelopmental period in early life, which researchers say could interfere with the refinement of neuronal networks and lead to long-term functional abnormalities.

For their current retrospective study, the authors compared the scores of 53 healthy participants of a language development study (ages 5 to 18 years with no history of surgery) with the scores of 53 children in the same age range who had undergone surgery before the age of 4.

The authors stress that average test scores for all 106 children in the study were within population norms, regardless of surgical history. Still, compared with children who had not undergone surgery, children exposed to anesthesia scored significantly lower in listening comprehension and performance IQ. Researchers also report that decreased language and IQ scores were associated with lower gray matter density in the occipital cortex and cerebellum of the brain.

Researchers, who used extensive analysis of surgical and other medical records, said the children were matched for age, gender, handedness and socioeconomic status -- all confounding factors of cognition and brain structure. The authors also factored into their calculations the types of surgeries and length of exposure to anesthetics. The anesthetics used during the surgeries included common agents such as sevoflurane, isoflurane or halothane (used alone or in combination) and nitrous oxide.

Children included in the study did not have a history of neurologic or psychological illness, head trauma or any other associated conditions. Neurocognitive assessments included the Oral and Written Language Scales and the Wechsler Intelligence Scale. Brain structural comparisons were conducted by MRI scans.

Estimated Social Cost

Extending their study a step beyond the medical data, the research team also considered the potential societal impact of their findings. Earlier research from 2008 had estimated the loss of 1 IQ point to decrease a person's lifetime earnings potential by $18,000. Factoring in the potential loss of 5 or 6 IQ points found in their current study, the researchers report that, based on the estimated 6 million children who undergo surgery in the United States each year the lifetime potential earnings loss could total $540 billion.

Emphasis on Safety

Although data in the current study highlight the need to look for improved methods of administering anesthesia, Loepke and his colleagues emphasize that current methods are very safe. Loepke advises parents who are concerned to discuss with their pediatrician and surgeon the risks of a surgical procedure -- and the potential risk of anesthetic exposure -- versus the risks of not having a surgery.

"It is important to note that no surgeries are truly elective in young children," Loepke said. "Many surgical procedures early in life treat life-threatening conditions, avert serious health complications, or improve quality of life. These cannot be easily postponed or avoided."

Loepke also stressed that researchers at Cincinnati Children's are actively looking for alternative anesthetic techniques in their ongoing laboratory studies. Drugs are being tested that show potential for lessening the harmful effects of anesthetics in laboratory rats and mice, and this research is ongoing. Additionally, the medical center is participating in an international clinical trial to test an alternative anesthetic regimen in young children undergoing urological procedures.

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Data scientists find connections between birth month and health

This data visualization maps the statistical relationship between birth month and disease incidence in the electronic records of 1.7 million New York City patients.

Credit: Dr. Nick Tatonetti

Columbia University scientists have developed a computational method to investigate the relationship between birth month and disease risk. The researchers used this algorithm to examine New York City medical databases and found 55 diseases that correlated with the season of birth. Overall, the study indicated people born in May had the lowest disease risk, and those born in October the highest. The study was published in the Journal of American Medical Informatics Association.

"This data could help scientists uncover new disease risk factors," said study senior author Nicholas Tatonetti, PhD, an assistant professor of biomedical informatics at Columbia University Medical Center (CUMC) and Columbia's Data Science Institute. The researchers plan to replicate their study with data from several other locations in the U.S. and abroad to see how results vary with the change of seasons and environmental factors in those places. By identifying what's causing disease disparities by birth month, the researchers hope to figure out how they might close the gap.

Earlier research on individual diseases such as ADHD and asthma suggested a connection between birth season and incidence, but no large-scale studies had been undertaken. This motivated Columbia's scientists to compare 1,688 diseases against the birth dates and medical histories of 1.7 million patients treated at NewYork-Presbyterian Hospital/CUMC between 1985 and 2013.

The study ruled out more than 1,600 associations and confirmed 39 links previously reported in the medical literature. The researchers also uncovered 16 new associations, including nine types of heart disease, the leading cause of death in the United States. The researchers performed statistical tests to check that the 55 diseases for which they found associations did not arise by chance.

"It's important not to get overly nervous about these results because even though we found significant associations the overall disease risk is not that great," notes Dr. Tatonetti. "The risk related to birth month is relatively minor when compared to more influential variables like diet and exercise."

The new data are consistent with previous research on individual diseases. For example, the study authors found that asthma risk is greatest for July and October babies. An earlier Danish study on the disease found that the peak risk was in the months (May and August) when Denmark's sunlight levels are similar to New York's in the July and October period.

For ADHD, the Columbia data suggest that around one in 675 occurrences could relate to being born in New York in November. This result matches a Swedish study showing peak rates of ADHD in November babies.

The researchers also found a relationship between birth month and nine types of heart disease, with people born in March facing the highest risk for atrial fibrillation, congestive heart failure, and mitral valve disorder. One in 40 atrial fibrillation cases may relate to seasonal effects for a March birth. A previous study using Austrian and Danish patient records found that those born in months with higher heart disease rates--March through June--had shorter life spans.

"Faster computers and electronic health records are accelerating the pace of discovery," said the study's lead author, Mary Regina Boland, a graduate student at Columbia. "We are working to help doctors solve important clinical problems using this new wealth of data."

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The infant gut microbiome: New studies on its origins and how it's knocked out of balance

A fecal sample analysis of 98 Swedish infants over the first year of life found a connection between the development of a child's gut microbiome and the way he or she is delivered. Babies born via C-section had gut bacteria that showed significantly less resemblance to their mothers compared to those that were delivered vaginally.

Bäckhed et al. assessed the gut microbiomes of 98 Swedish mothers and their infants during the first year of life. Cessation of breast-feeding was identified as a major factor in determining gut microbiota maturation, with distinct shifts in signature species being hallmarks of its functional maturation.

Credit: Bäckhed et al./Cell Host & Microbe 2015

A fecal sample analysis of 98 Swedish infants over the first year of life found a connection between the development of a child's gut microbiome and the way he or she is delivered. Babies born via C-section had gut bacteria that showed significantly less resemblance to their mothers compared to those that were delivered vaginally.

The study, which appears May 11 in Cell Host & Microbe's special issue on "The Host-Microbiota Balance," also found nutrition to be a main driver of infant gut microbiome development--specifically the decision to breast-feed or bottle-feed.

"Our findings surprisingly demonstrated that cessation of breastfeeding, rather than introduction of solid foods, is the major driver in the development of an adult-like microbiota," says lead study author Fredrik Bäckhed of The University of Gothenburg, Sweden. "However, the effect of an altered microbiome early in life on health and disease in adolescence and adulthood remains to be demonstrated."

Gut bacteria are suspected to be a source of nutrients and vitamins for a growing infant. Our intestinal tenants are able to interact with normal cellular processes to, for example, produce essential amino acids. Understanding the role individual gut microbes play in metabolism, immunity, and even behavior is an active area of investigation.

This new study, led by Bäckhed and Jovanna Dahlgren at the University of Gothenburg, Sweden, and Wang Jun at the Beijing Genomics Institute-Shenzhen, China, supports previous observations that most early bacterial colonizers of the gut are derived from the mother. The investigators noted that while C-section babies receive less of their mother's microbes, they are still able to be passed on through the skin and mouth.

Once bacteria take hold in an infant's gut, their populations shift depending on what a child eats. The researchers believe that the cessation of breast-feeding is such a significant moment in microbiome development because certain types of bacteria thrive on the nutrients breast milk provides. Once these nutrients are no longer available, other bacteria emerge that are more commonly seen in adults.

"Our results underscore the role of breast-feeding in the shaping and succession of gut microbial communities during the first year of life," the authors write. "The gut microbiota of children no longer breast-fed was enriched in species belonging to Clostridia that are prevalent in adults, such as Roseburia, Clostrium, and Anaerostipes. In contrast, Bifidobacterium and Lactobacillus still dominated the gut microbiota of breast-fed infants at 12 months."

The Infant Gut and Antibiotics: Long-Term Effects

Antibiotics account for one quarter of all medications given to children, with a third of prescriptions considered unnecessary. In addition to concerns about antibiotic resistance, these drugs are known to disrupt a child's gut microbiome in ways that a growing amount of evidence suggests may have long-term consequences, including obesity, allergies, and autoimmune diseases.

Based on a review of the literature, biotechnologist Dan Knights, of the University of Minnesota, and colleagues developed a framework for how antibiotics may be acting in the gut to cause these outcomes. In the case of allergies, for example, the use of antibiotics may eradicate key gut bacteria that help immune cells mature. These cells would have been essential for keeping the immune system at bay when confronted with allergens. Even if these bacteria return, the immune system remains impaired.

"The framework presented here links together the existing epidemiological and mechanistic studies on antibiotics and various gut-mediated disease outcomes," the authors write. "Large, integrated studies designed to focus on short- and long-term impact of antibiotics, in terms of both microbiome composition and disease risk, with careful consideration of the factors presented here, will be critical as we move toward an increased understanding of related disease etiologies."

The researchers also developed a diagnostic test that can calculate the developmental age of a baby's gut microbiome relative to healthy babies. A similar test could be used by pediatricians to identify and potentially treat infants more than a month behind normal development.

The Gut Microbiome's Role in Asthma

The search for answers in the medical mystery around the recent increase in asthma prevalence, especially for children up to age four, has led researchers to consider changes in the gut and airway microbiome as a contributing environmental factor in the development of this treatable, but uncomfortable, condition.

Susan Lynch and Kei E. Fujimura of the University of California San Francisco present the latest research in mice exploring this relationship, especially how specific types of bacteria alter the presence of different immune cells. Though still an emerging body of work, they believe it is evidence that manipulation of the airway/gut microbiome at an early age could lead to new strategies to prevent or manage asthma.

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Do newborns delivered by C-section face higher risk of chronic health problems later in life?

The evidence as to whether newborns delivered by C-section are more likely to develop chronic diseases later in life has been examined by investigators. The authors of a new study find that their evidence warrants concerns that C-section may lead to worse long-term child health.

Cesarean section is sometimes a medical necessity, or even an emergency. But it is increasingly a choice made in cooler moments, and the request is growing globally. At the same time, while repeat cesarean is not necessarily medically indicated for women with otherwise low obstetrical risk, there is a 90% repeat cesarean rate among women giving birth who have had a prior cesarean, in the US.

Credit: © Vivid Pixels / Fotolia

A new paper in the British Medical Journal by Jan Blustein, MD, PhD, of New York University's Wagner School and a professor of Medicine and Population Health at NYU School of Medicine and Jianmeng Liu of Peking University examines the evidence as to whether newborns delivered by C-section are more likely to develop chronic diseases later in life. While the jury is still out and research is ongoing, recent studies underscore the need for health care providers to discuss with expectant parents the risk of babies born through cesarean section developing obesity, asthma, and diabetes, according to the paper by Blustein and Liu.

Cesarean section is sometimes a medical necessity, or even an emergency. But it is increasingly a choice made in cooler moments. C-section on mothers' request is growing globally. At the same time, while repeat cesarean is not necessarily medically indicated for women with otherwise low obstetrical risk, there is a 90% repeat cesarean rate among women giving birth who have had a prior cesarean, in the US.

While cesarean and vaginal deliveries are both associated with well-known acute risks, recent studies link C-section to long-term child chronic disease. The authors review this evidence from a variety of sources. These include observational studies where researchers locate large samples of children, assess the extent of disease, and look back to see how the children were delivered. They also include a clinical trial, in which mothers were prospectively randomized to undergo cesarean or vaginal delivery. The authors find that the evidence warrants concerns that C-section may lead to worse long-term child health.

These risks have yet to be mentioned in clinical guidelines, which are the official documents that are used to educate doctors and midwives. "It's time to update the guidelines to include information about possible risks to long-term child health," comments Dr. Blustein.

She acknowledges that the evidence linking cesarean to worse child health is not unequivocal. "It is clear that cesarean-born children have worse health, but further research is needed to establish whether it is the cesarean that causes disease, or whether other factors are at play," Dr. Blustein says. "Getting definitive answers will take many years of further research. In the interim, we must make decisions based on the evidence that we have. To me, that evidence says that it is reasonable to believe that cesarean has the potential for long-term adverse health consequences for children."

"It takes awhile for research findings to reach clinicians and patients," says Blustein. "This research isn't widely known. It is time for that to change, so that doctors, midwives and patients can weigh the risks and benefits of elective cesarean, and decide accordingly."

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Impact of insecticides on the cognitive development of 6-year-old children

Researchers have provided new evidence of neurotoxicity in humans from pyrethroid insecticides, which are found in a wide variety of products and uses.

Exposure of children to pyrethroids is common.

Credit: © TMAX / Fotolia

In an article published in the journal Environment International, researchers from Inserm (Inserm Unit 1085 -- IRSET, the Institute of Research in Environmental and Occupational Health, Rennes), in association with the Laboratory for Developmental and Educational Psychology, LPDE (Rennes 2 University), provide new evidence of neurotoxicity in humans from pyrethroid insecticides, which are found in a wide variety of products and uses. An increase in the urinary levels of two pyrethroid metabolites (3-PBA and cis-DBCA) in children is associated with a significant decrease in their cognitive performances , particularly verbal comprehension and working memory. This study was carried out on nearly 300 mother and child pairs from the PELAGIE cohort (Brittany).

Pyrethroid exposure

Pyrethroids constitute a family of insecticides widely used in a variety of sectors: agriculture (various crops), veterinary (antiparasitics) and domestic (lice shampoo, mosquito products). Their mode of action involves blocking neurotransmission in insects, leading to paralysis. Because of their efficacy and relative safety for humans and mammals, they have replaced older compounds (organochorides, organophosphates, carbamate) considered more toxic.

Exposure of children to pyrethroids is common. It is different to adult exposure, due to the closer proximity of children to ground-level dust (which stores pollutants), more frequent hand-to-mouth contact, lice shampoos, etc. In children, pyrethroids are mainly absorbed via the digestive system, but are also absorbed through the skin. They are rapidly metabolised in the liver, and mainly eliminated in the urine as metabolites within 48 hours.

Given these elements and the mode of action (neurotoxicity) of pyrethroid insecticides, the researchers proposed the hypothesis of a possible effect of these contaminants on the nervous system and its development in children.

Contribution of the PELAGIE mother-child cohort

Pregnancy is also an important period of life for the future health of the child. For this reason, the researchers studied the PELAGIE mother-child cohort established between 2002 and 2006, which monitors 3,500 mother-child pairs. This cohort simultaneously considers exposure to pyrethroid insecticides during fetal life and childhood.

A total of 287 women, randomly selected from the PELAGIE cohort and contacted successfully on their child's sixth birthday, agreed to participate in this study.

Two psychologists visited them at home. One assessed the child's neurocognitive performances using the WISC scale (verbal comprehension index, VCI, and working memory index, WMI). The other psychologist characterised the family environment and stimuli that might have had a role on the child's intellectual development, collected a urine sample from the child, and collected dust samples.

Exposure to pyrethroid insecticides was estimated by measuring levels of five metabolites (3-PBA, 4-F-3-PBA, cis-DCCA, trans-DCCA and cis-DBCA) in urine from the mother (collected between the 6th and 19th weeks of pregnancy) and from the child (collected on his/her 6th birthday).

A decrease observed in child cognitive performances

Results show that an increase in children's urinary levels of two metabolites (3 PBA and cis-DBCA) was associated with a significant decrease in cognitive performances, whereas no association was observed for the other three metabolites (4-F-3-PBA, cis-DCCA and trans-DCCA). With respect to metabolite concentrations during pregnancy, there was no demonstrable association with neurocognitive scores.

"Although these observations must be reproduced in further studies in order to draw definite conclusions, they indicate the potential responsibility of low doses of deltamethrine in particular (since the metabolite cis-DBCA is its main metabolite, and selective for it), and pyrethroid insecticides in general (since the metabolite 3-BPA is a degradation product of some twenty of these insecticides)," explains Cécile Chevrier, Inserm Research Fellow, the main author of this work.

"The consequences of a cognitive deficit in children for their learning ability and social development constitute a handicap for the individual and for society. The research effort needs to be pursued in order to identify causes that could be targeted by preventive measures," emphasises Jean-François Viel, a co-author of this work.

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Stroke: not just an adult's condition

When you hear the word "stroke," the first picture that pops into your mind is likely to be of an elderly individual. It's true that older adults are at greater stroke risk; the chance of having a stroke doubles with each decade of life after the age of 55. But did you know that infants and children can also suffer stroke? It can even occur before birth.'

Stroke affects 6 in every 100,000 children in the US and is one of the 10 leading causes of death among children in the country.

According to the National Stroke Association, stroke affects 6 in every 100,000 children in the US. It is also one of the 10 leading causes of death among children in the country.

The rate of stroke is much higher in adults than children. Every year, more than 795,000 men and women suffer a stroke and around 130,000 die from the condition. However, studies have found stroke rates are on the rise in children in the US.

In 2011, a study published in the Annals of Neurology reported a 51% increase in ischemic stroke incidence among boys aged 5-14 from the period 1995-96 to 2007-08, while girls aged 5-14 saw a 3% rise in ischemic stroke in the same period.

In many ways, stroke in children - commonly referred to as pediatric stroke - can present more challenges than stroke in adults.

The early signs of stroke in children are much more subtle than in adults, meaning they often go unrecognized. According to the International Alliance for Pediatric Stroke (IAPS), newborns who suffer stroke may not even begin to show any symptoms until the age of 4-8 months.

What is more, because parents, caregivers and even health care professionals do not often associate stroke with children, it may be ruled out as a possibility. As a result, many children fail to receive adequate treatment.

A 2014 study conducted by Dr. Mark Mackay, director of the Children's Stroke Program at the Royal Children's Hospital and Murdoch Children's Research Institute in Melbourne, Australia, and colleagues found that only half of interviewed parents whose children suffered stroke thought their child's symptoms were serious enough to call 911, while 21% of parents adopted a "wait-and-see" approach. What is more, only 36% considered stroke as a possible cause of their child's symptoms.

As with most health conditions, early treatment for stroke is key. Unfortunately, around 20-40% of children die after a stroke, and of those who do survive, around 50-80% will have lifelong neurological problems, such a partial or total paralysis.

May is American Stroke Awareness Month. In this Spotlight, we investigate the risk factors for pediatric stroke, the signs and symptoms to look out for, as well as the treatment options for the condition.

Perinatal stroke and childhood stroke

There are two types of pediatric stroke: perinatal stroke and childhood stroke.

Perinatal stroke, also referred to as fetal or prenatal stroke, occurs between the last 18 weeks of pregnancy and the first 30 days of birth. In the US, perinatal stroke occurs in about 1 in every 2,800 live births.

Most cases of perinatal stroke are ischemic, caused by blood clots breaking off from the placenta and becoming lodged in the child's brain.

Childhood stroke occurs between the ages of 1 month and 18 years. Unlike adults, in whom ischemic stroke is most common, children are equally as likely to have ischemic stroke as they are hemorrhagic stroke - caused by a brain bleed from a ruptured blood vessel.

Around 60% of all pediatric strokes occur in boys, and African-American children are at greater stroke risk than Caucasian and Asian children.

The risk factors for pediatric stroke

Among adults, high blood pressure, irregular heartbeat and atherosclerosis - hardening of the arteries - are some of the most common risk factors for stroke. These factors rarely cause stroke in children, however.

According to the American Stroke Association, around half of all pediatric strokes are triggered by an underlying condition, most commonly sickle cell disease - an inherited blood disorder - and congenital heart disease.

Other underlying conditions that may raise a child's stroke risk include head and neck infections, abnormal blood clotting, head trauma and systemic conditions, such as autoimmune disorders.

Maternal history of infertility, premature rupture of membranes during pregnancy, maternal preeclampsia and chorioamnionitis - inflammation of the fetal membranes due to a bacterial infection - may also increase a child's stroke risk.

Though cardiovascular-related risk factors for stroke in adults are rare in children, recent studies have indicated an increase in these risk factors among the younger population. This is down to a rise in high blood pressure, obesity, diabetes, high cholesterol and tobacco and alcohol use among youth.

A 2014 study published in the journal Neurology also suggested colds and other minor infections in childhood may temporarily raise a child's stroke risk.

"We've seen this increase in stroke risk from infection in adults, but until now, an association has not been studied in children," commented study author Dr. Heather Fullerton, director of the University of California-San Francisco Pediatric Stroke and Cerebrovascular Disease Center.

"It is possible that inflammatory conditions contribute more to the stroke risk in children, however, further research is needed to explore this possible association."

It is important to note, however, that in around half of all childhood stroke cases, no previous risk factor can be determined.

What are the signs and symptoms to look out for?

As mentioned previously, it can be very hard to spot stroke symptoms among very young children. Around 40% of infants do not show symptoms of early stroke; a parent may not know their baby has suffered stroke until months later when they show reduced movement or weakness on one side of their face.

As well as weakness or numbness on one side of the body, other signs of stroke in children may include severe headache, dizziness and vomiting.

Repetitive twitching of the face, arm or leg can be an indicator of stroke in newborns, as can a pause in breathing alongside prolonged staring and extreme fatigue.

As children develop, the signs of symptoms of stroke are very similar to those in adults. Weakness or numbness on one side of the body and problems speaking or understanding language - such as slurred speech or problems understanding simple instructions - may be signs of stroke.

Other signs of stroke among children may include severe headache, vomiting, fatigue, severe dizziness and appearance of seizures.

The American Stroke Association stress that the F.A.S.T. acronym is an easy way to remember the sudden signs of stroke in both children and adults:

• Face drooping. Is one side of the face numb or drooping? Is the individual able to smile?
• Arm weakness. Is one arm numb or weak? Ask the individual to lift both arms. Does one arm drift downward?
• Speech difficulty. Is the individual's speech slurred? Do they find it hard to speak or are they hard to understand? Can they correctly repeat a simple sentence, such as "the sky is blue?"
• Time to call 911. If the individual shows any of these symptoms, call 911 immediately, even if the symptoms disappear. Check the time at which first symptoms appear.

"Think stroke, act fast and call 911. That message applies to adults and children," says Dr. MacKay. "Getting to the hospital quickly is an essential first step to develop strategies to improve access to emergency treatment in children."

Treatment options for pediatric stroke

For adults suffering ischemic stroke, the first port of call in terms of treatment is the medication tissue plasminogen activator (tPA), which works by dissolving any blood clots that are blocking the arteries, restoring blood flow to the brain. Such treatment must be administered within 3 hours of symptom onset - 4.5 hours for some patients.

The use of tPA among young children with ischemic stroke, however, is controversial. Since children and adults have physiological differences, health care professionals are concerned about the drug's safety and efficacy among children - something that is currently being investigated.

As such, stroke treatment for children tends to vary depending on the cause of their stroke and any underlying medical conditions they may have. A child whose stroke was caused by a heart defect, for example, may be treated with blood-thinning medication, such as warfarin or aspirin.

Children who suffer stroke have around a 15-18% chance of suffering another stroke. Therefore, many children may receive treatment to prevent stroke recurrence, such as antithrombotic therapy - medication that stops blood clots from forming or growing.

One crucial treatment for the majority children who suffer stroke is rehabilitation therapy, which can involve physiotherapy, occupational therapy and speech therapy.

Sixty percent of children experience neurological problems, such as hemiplegia or hemiparesis cerebral palsy, following stroke. Rehabilitation therapy can really help reduce the neurological effects of stroke, and the earlier treatment is started, the more likely it is to succeed.

Severe delays in diagnosis of pediatric stroke

But as Dr. MacKay's study showed, many parents either do not consider the possibility that their child is suffering a stroke or are unable to recognize the signs, which can severely delay treatment.

Dr. MacKay's findings revealed that the average time from symptom onset of pediatric stroke to arrival at the emergency room was 1.8 hours, with some arrivals taking up to 4 hours.

And it is not only parents who may overlook the signs and symptoms of pediatric stroke - doctors can too. Studies have found that in the US, it can often take longer than 24 hours to diagnose stroke in children.

A report from ABC News in 2011 provides evidence of this, revealing how it took more than 25 hours for doctors to diagnose a 15-year-old boy from Ohio with stroke.

Because of the delay in diagnosis, the boy had to have a part of his skull removed to ease pressure from the build up of blood in his brain.

In a 2008 interview, Dr. Fullerton said she believes a delay in diagnosis of pediatric stroke has fallen into a gap in clinical care. "It is a rare disorder in general, and so most child neurologists will not be very comfortable in caring for children with stroke," she said, adding:

"Stroke is considered more a disease of adults, but then adult stroke neurologists aren't familiar of the etiologies of stroke in children or how to manage stroke in children, and so they're often uncomfortable with caring for a stroke in a child.

It can be difficult to diagnose the etiology of their strokes. It often takes sophisticated imaging studies and studies that are done by very experienced practitioners. It really often does take a team approach to figure out why a child has had a stroke and figure out what is the best way to prevent more strokes in that child."

While stroke is much rarer in children than adults, it is important that parents, caregivers and health care professionals are aware that children can be affected by the condition and take note of the signs and symptoms that may arise.

Not only is May American Stroke Awareness Month, 2nd-8th May is dedicated to World Pediatric Stroke Awareness Week. Set up by the IAPS and not-for-profit organization Brendon's Smile last year, the campaign aims to raise awareness of pediatric stroke around the globe and educate communities about how the condition can impact children's lives.

Visit the IAPS website to find out more about pediatric stroke and how you can help raise awareness of the condition.

Continue to Read more ...

Stroke: not just an adult's condition

When you hear the word "stroke," the first picture that pops into your mind is likely to be of an elderly individual. It's true that older adults are at greater stroke risk; the chance of having a stroke doubles with each decade of life after the age of 55. But did you know that infants and children can also suffer stroke? It can even occur before birth.

Stroke affects 6 in every 100,000 children in the US and is one of the 10 leading causes of death among children in the country.

According to the National Stroke Association, stroke affects 6 in every 100,000 children in the US. It is also one of the 10 leading causes of death among children in the country.

The rate of stroke is much higher in adults than children. Every year, more than 795,000 men and women suffer a stroke and around 130,000 die from the condition. However, studies have found stroke rates are on the rise in children in the US.

In 2011, a study published in the Annals of Neurologyreported a 51% increase in ischemic stroke incidence among boys aged 5-14 from the period 1995-96 to 2007-08, while girls aged 5-14 saw a 3% rise in ischemic stroke in the same period.

In many ways, stroke in children - commonly referred to as pediatric stroke - can present more challenges than stroke in adults.

The early signs of stroke in children are much more subtle than in adults, meaning they often go unrecognized. According to the International Alliance for Pediatric Stroke (IAPS), newborns who suffer stroke may not even begin to show any symptoms until the age of 4-8 months.

What is more, because parents, caregivers and even health care professionals do not often associate stroke with children, it may be ruled out as a possibility. As a result, many children fail to receive adequate treatment.

A 2014 study conducted by Dr. Mark Mackay, director of the Children's Stroke Program at the Royal Children's Hospital and Murdoch Children's Research Institute in Melbourne, Australia, and colleagues found that only half of interviewed parents whose children suffered stroke thought their child's symptoms were serious enough to call 911, while 21% of parents adopted a "wait-and-see" approach. What is more, only 36% considered stroke as a possible cause of their child's symptoms.

As with most health conditions, early treatment for stroke is key. Unfortunately, around 20-40% of children die after a stroke, and of those who do survive, around 50-80% will have lifelong neurological problems, such a partial or total paralysis.

May is American Stroke Awareness Month. In this Spotlight, we investigate the risk factors for pediatric stroke, the signs and symptoms to look out for, as well as the treatment options for the condition.

Perinatal stroke and childhood stroke

There are two types of pediatric stroke: perinatal stroke and childhood stroke.

Perinatal stroke, also referred to as fetal or prenatal stroke, occurs between the last 18 weeks of pregnancy and the first 30 days of birth. In the US, perinatal stroke occurs in about 1 in every 2,800 live births.

Most cases of perinatal stroke are ischemic, caused by blood clots breaking off from the placenta and becoming lodged in the child's brain.

Childhood stroke occurs between the ages of 1 month and 18 years. Unlike adults, in whom ischemic stroke is most common, children are equally as likely to have ischemic stroke as they are hemorrhagic stroke - caused by a brain bleed from a ruptured blood vessel.

Around 60% of all pediatric strokes occur in boys, and African-American children are at greater stroke risk than Caucasian and Asian children.

The risk factors for pediatric stroke

Among adults, high blood pressure, irregular heartbeat and atherosclerosis - hardening of the arteries - are some of the most common risk factors for stroke. These factors rarely cause stroke in children, however.

According to the American Stroke Association, around half of all pediatric strokes are triggered by an underlying condition, most commonly sickle cell disease - an inherited blood disorder - and congenital heart disease.

Other underlying conditions that may raise a child's stroke risk include head and neck infections, abnormal blood clotting, head trauma and systemic conditions, such as autoimmune disorders.

Maternal history of infertility, premature rupture of membranes during pregnancy, maternal preeclampsia and chorioamnionitis - inflammation of the fetal membranes due to a bacterial infection - may also increase a child's stroke risk.

Though cardiovascular-related risk factors for stroke in adults are rare in children, recent studies have indicated an increase in these risk factors among the younger population. This is down to a rise in high blood pressure, obesity,diabetes, high cholesterol and tobacco and alcohol use among youth.

A 2014 study published in the journal Neurology also suggested colds and other minor infections in childhood may temporarily raise a child's stroke risk.

"We've seen this increase in stroke risk from infection in adults, but until now, an association has not been studied in children," commented study author Dr. Heather Fullerton, director of the University of California-San Francisco Pediatric Stroke and Cerebrovascular Disease Center.

"It is possible that inflammatory conditions contribute more to the stroke risk in children, however, further research is needed to explore this possible association."

It is important to note, however, that in around half of all childhood stroke cases, no previous risk factor can be determined.

What are the signs and symptoms to look out for?

As mentioned previously, it can be very hard to spot stroke symptoms among very young children. Around 40% of infants do not show symptoms of early stroke; a parent may not know their baby has suffered stroke until months later when they show reduced movement or weakness on one side of their face.

As well as weakness or numbness on one side of the body, other signs of stroke in children may include severe headache, dizziness and vomiting.

Repetitive twitching of the face, arm or leg can be an indicator of stroke in newborns, as can a pause in breathing alongside prolonged staring and extreme fatigue.

As children develop, the signs of symptoms of stroke are very similar to those in adults. Weakness or numbness on one side of the body and problems speaking or understanding language - such as slurred speech or problems understanding simple instructions - may be signs of stroke.

Other signs of stroke among children may include severe headache, vomiting, fatigue, severe dizziness and appearance of seizures.

The American Stroke Association stress that the F.A.S.T. acronym is an easy way to remember the sudden signs of stroke in both children and adults:

• Face drooping. Is one side of the face numb or drooping? Is the individual able to smile?
• Arm weakness. Is one arm numb or weak? Ask the individual to lift both arms. Does one arm drift downward?
• Speech difficulty. Is the individual's speech slurred? Do they find it hard to speak or are they hard to understand? Can they correctly repeat a simple sentence, such as "the sky is blue?"
• Time to call 911. If the individual shows any of these symptoms, call 911 immediately, even if the symptoms disappear. Check the time at which first symptoms appear.

"Think stroke, act fast and call 911. That message applies to adults and children," says Dr. MacKay. "Getting to the hospital quickly is an essential first step to develop strategies to improve access to emergency treatment in children."

Treatment options for pediatric stroke

For adults suffering ischemic stroke, the first port of call in terms of treatment is the medication tissue plasminogen activator (tPA), which works by dissolving any blood clots that are blocking the arteries, restoring blood flow to the brain. Such treatment must be administered within 3 hours of symptom onset - 4.5 hours for some patients.

The use of tPA among young children with ischemic stroke, however, is controversial. Since children and adults have physiological differences, health care professionals are concerned about the drug's safety and efficacy among children - something that is currently being investigated.

As such, stroke treatment for children tends to vary depending on the cause of their stroke and any underlying medical conditions they may have. A child whose stroke was caused by a heart defect, for example, may be treated with blood-thinning medication, such as warfarin or aspirin.

Children who suffer stroke have around a 15-18% chance of suffering another stroke. Therefore, many children may receive treatment to prevent stroke recurrence, such as antithrombotic therapy - medication that stops blood clots from forming or growing.

One crucial treatment for the majority children who suffer stroke is rehabilitation therapy, which can involve physiotherapy, occupational therapy and speech therapy.

Sixty percent of children experience neurological problems, such as hemiplegia or hemiparesis cerebral palsy, following stroke. Rehabilitation therapy can really help reduce the neurological effects of stroke, and the earlier treatment is started, the more likely it is to succeed.

Severe delays in diagnosis of pediatric stroke

But as Dr. MacKay's study showed, many parents either do not consider the possibility that their child is suffering a stroke or are unable to recognize the signs, which can severely delay treatment.

Dr. MacKay's findings revealed that the average time from symptom onset of pediatric stroke to arrival at the emergency room was 1.8 hours, with some arrivals taking up to 4 hours.

And it is not only parents who may overlook the signs and symptoms of pediatric stroke - doctors can too. Studies have found that in the US, it can often take longer than 24 hours to diagnose stroke in children.

A report from ABC News in 2011 provides evidence of this, revealing how it took more than 25 hours for doctors to diagnose a 15-year-old boy from Ohio with stroke.

Because of the delay in diagnosis, the boy had to have a part of his skull removed to ease pressure from the build up of blood in his brain.

In a 2008 interview, Dr. Fullerton said she believes a delay in diagnosis of pediatric stroke has fallen into a gap in clinical care. "It is a rare disorder in general, and so most child neurologists will not be very comfortable in caring for children with stroke," she said, adding:

"Stroke is considered more a disease of adults, but then adult stroke neurologists aren't familiar of the etiologies of stroke in children or how to manage stroke in children, and so they're often uncomfortable with caring for a stroke in a child.

It can be difficult to diagnose the etiology of their strokes. It often takes sophisticated imaging studies and studies that are done by very experienced practitioners. It really often does take a team approach to figure out why a child has had a stroke and figure out what is the best way to prevent more strokes in that child."

While stroke is much rarer in children than adults, it is important that parents, caregivers and health care professionals are aware that children can be affected by the condition and take note of the signs and symptoms that may arise.

Not only is May American Stroke Awareness Month, 2nd-8th May is dedicated to World Pediatric Stroke Awareness Week. Set up by the IAPS and not-for-profit organization Brendon's Smile last year, the campaign aims to raise awareness of pediatric stroke around the globe and educate communities about how the condition can impact children's lives.

Visit the IAPS website to find out more about pediatric stroke and how you can help raise awareness of the condition.

Continue to Read more ...