AAP Critical Care News: Mar 97

Critical Care News
Volume 4, Number 2
January, 1997

The Newsletter of the Section on Critical Care of the American Academy of Pediatrics.

Questions or comments should be addressed to the editorial staff

IN THIS ISSUE:

Update: Pulmonary Hemorrhage/Hemosiderosis Among Infants--Cleveland, Ohio
The Medical Home Program for Children with Special Needs
AAP Fall Meeting Dates
10th Annual Pediatric Critical Care Colloquium Dates

From the Centers for Disease Control and Prevention:
Update: Pulmonary Hemorrhage/Hemosiderosis Among Infants--Cleveland, Ohio

In November 1994, physicians and public health officials in Cleveland, Ohio, reported a cluster of eight cases of acute pulmonary hemorrhage/hemosiderosis that had occurred during January 1993-November 1994 among infants in one area of the city (1). Two additional cases were identified in December 1994. All 10 infants lived within seven contiguous postal tracts in eastern metropolitan Cleveland. Pulmonary hemorrhages recurred in five of the infants after they returned to their homes shortly after hospital discharge; one infant died as a result of pulmonary hemorrhage. This report summarizes the findings of the follow-up investigation, including a case-control study and an assessment by the county coroner of cases of infant death. These findings documented an association between acute pulmonary hemorrhage/hemosiderosis in this cluster of cases and mold growth in their water-damaged homes.
Case-Control Study of Risk Factors for Pulmonary Hemorrhage
To determine risk factors for acute pulmonary hemorrhage among the infants in the cluster, a case-control study was conducted. The study compared 10 case-infants with 30 age-matched control infants from the same area in Cleveland (2).
The 10 case-infants were more likely than the controls to reside in homes where major water damage (as a result of chronic plumbing leaks or flooding) had occurred (95% CI=2.6 - infinity). The latter finding prompted a visual inspection and quantitative air sampling for and microscopic identification of fungi in the study homes. The quantity of fungi, including the toxigenic fungus Stachybotrys atra, was higher in the homes of case-infants than in those of controls.
Active surveillance by the RBCH identified an additional 11 cases of acute pulmonary hemorrhage/hemosiderosis among infants in the Cleveland area during January 1995 December 1996. Of these 11 infants, two had died as a result of acute pulmonary hemorrhage. The demographic characteristics and clinical presentation of these 11 cases was consistent with the initial cluster of cases.
Based on the findings of the case-control study, health authorities in Cleveland recommended prompt clean-up and disposal of all moldy materials in the water-damaged homes and have designed a prevention program focusing on water-damaged homes.
Coroner's Investigation of Infant Deaths
The county coroner re-examined all infant deaths in Cuyahoga County during January 1993-December 1995 to determine whether cases of pulmonary hemorrhage had been misclassified. Post-mortem examinations were reviewed for all 172 infants who died in the county during that period, including 117 deaths attributed to SIDS; premature infants who died in a hospital were excluded. Pathologic lung specimens were sectioned, stained with Prussian blue, and screened for the presence of hemosiderin.
Extensive hemosiderin-laden macrophages were present in lung tissue of nine (5%) infants, a finding indicating major pulmonary hemorrhage preceding death. Of these nine deaths, two resulted from homicide, and one had a recent history of child abuse. No apparent etiologies for pulmonary hemorrhage/hemosiderosis were identified for the other six infants presumed to have died from SIDS, all of whom had lived in the same postal tracts as the initial cluster.
The findings of the investigation described in this report suggest that, in Cleveland, the infants with pulmonary hemorrhage were more likely than controls to reside in homes that had been affected by major water damage. The water damage may have promoted the growth of fungi, including S. atra. Because S. atra requires water-saturated cellulose-based materials for growth in buildings, it is considered uncommon in homes. Although S. atra has been associated with gastrointestinal hemorrhaging in animals that had consumed moldy grain (3), the fungus previously has not been associated with disease in infants.
SIDS is diagnosed only after exclusion of other known causes of death. The review by the Cuyahoga County coroner indicated that some infant deaths initially attributed to SIDS actually resulted from pulmonary hemorrhage. Agonal alveolar hemorrhage may occur in approximately two thirds of infant autopsies (4); however, the presence of extensive hemosiderosin-laden macrophages within the alveoli indicates major predeath pathologic processes, which precludes the diagnosis of SIDS. Macrophages require approximately 48 hours to convert the iron of the ingested erythrocytes into hemosiderin; therefore, the presence of hemosiderin-laden macrophages in alveoli indicates alveolar bleeding for at least 2 days preceding death (5). Causes of such bleeding and pulmonary hemosiderosis may include cardiac lesions associated with increased left atrial pressure, trauma, pneumonia, and perhaps suffocation.
Further efforts are needed to clarify the association between pulmonary hemorrhage in infants and exposure to water-damaged building materials and to evaluate pathologic methods to identify and quantify pulmonary hemorrhage and hemosiderosis.
References
1. CDC. Acute pulmonary hemorrhage/ hemosiderosis among infants--Cleveland, January 1993-November 1994. MMWR 1994;43:881-3. (overview and Adobe PDF document)
2. Montana E, Etzel RA, Allan T, Horgan TE, Dearborn DG. Environmental risk factors associated with pediatric idiopathic pulmonary hemorrhage and hemosiderosis in a Cleveland community. Pediatrics 1997;99:e5. World-Wide Web site http://www.pediatrics.org/cgi/content/full/99/1/e5
3. Hintikka E-L. Stachybotryotoxicosis as a veterinary problem. In: Rodricks JV, Hesseltine CW, Mehlman MA, eds. Mycotoxins in human and animal health. Park Forest South, Illinois: Patho-tox Publishers, 1977:277-84.
4. Valdes-Depena M. The postmortem examination. Pediatr Ann 1995;24:365-72.
5. Stewart S, Fawcett J, Jacobson W. Interstitial haemosiderin in the lungs of sudden infant death syndrome: a histological hallmark of 'near-miss' episodes? J Pathol 1995;145:53-8.
Our thanks go to Dr. Ruth Etzel, MD, Ph.D. for allowing us to publish this article before it is released to the lay press. Dr. Etzel is Chairperson of the Committee on Environmental Health of the AAP. Please report new cases of idiopathic pulmonary hemorrhage / hemosiderosis to her at Centers for Disease Control and Prevention, 770 Buford Highway NE (Mail Stop F-39) Atlanta, Georgia 30341-3724. Phone 770-488-7320.
PedsCCM ed note: see here for more information and a report form.

FROM THE AAP: The Medical Home Program for Children with Special Needs

The advent of managed care presents both opportunities and obstacles to providing quality pediatric services to children with special health care needs. To help pediatricians benefit from the opportunities and overcome the obstacles presented by managed care, the American Academy of Pediatrics (AAP) has set up the Medical Home Program for Children with Special Needs (MHPCSN). The MHPCSN supports primary and subspecialty pediatricians who care for children with special needs by providing educational materials, technical assistance, training programs, and advocacy. Initiated in 1994, the MHPCSN is funded by a grant from the federal Maternal and Child Health Bureau.
The MHPCSN concept stems from the Academy's position that all children should have a "medical home" where health care services are accessible, family-centered, continuous, comprehensive, coordinated, and compassionate. More specifically, the MHPCSN focuses on ensuring that children with special needs have medical homes where the services provided are also cost-effective. Under the MHPCSN approach, pediatricians serve a leadership role in providing office and community-based services. This role includes identifying and making appropriate referrals to any community, state, and federally-funded resources that will benefit children with special needs and their families.
The goals of the program are to increase pediatricians' awareness of the importance of providing a medical home to children with special needs and to help pediatricians overcome any barriers they may face in providing such care. One method of assistance is the provision of educational and training materials. Some of the materials that have been developed under the MHPCSN thus far include a handbook that describes Part H services and the pediatrician's role in implementing the Individualized Family Service Plan titled, The Medical Home and Early Intervention: Linking services for Children With Special Needs; a topical report titled, "Managed Care and Children with Special Health Care Needs: Creating a Medical Home;" and articles that describe model programs nationwide.
Housed in the AAP Department of Community Pediatrics, the MHPCSN is closely linked to the Community Access To Child Health (CATCH) Program, a grassroots effort to mobilize pediatric primary care providers to enhance the delivery of services and improve access to health care for all children. Through the CATCH Program, which includes a network of over 11,000 pediatricians and health care providers, the MHPCSN increases the awareness of the needs of, and services, available to children with special needs.
Collaboration with other organizations, agencies, and private businesses locally and nationally is essential to the effectiveness of program activities. Currently, MHPCSN staff are networking with national hospital organizations, clearinghouses for resources on disabilities, parent advocacy groups, organizations that promote family-centered care, and insurance providers to promote the goals of the program. The MHPCSN staff welcome contact from any organizations and/or individuals who are involved in activities that promote the principles of a medical home. In addition, the MHPCSN staff are seeking to gather information about: (1) any pediatric health care programs that are focused on improving access to care for children with special needs in a managed care environment; and (2) any educational materials and/or training programs that focus on the provision of services to children with special needs in a managed care environment.
If you are aware of any relevant programs or materials, or if you would like to be added to the MHPCSN mailing list, please contact Liz Osterhus, Program Manager at: 847/981-7621.

We Need Your Submissions to Critical Care News

The success of Critical Care News depends on you. We encourage members of the Critical Care Section to submit articles and announcements. Priority will go to concise articles of current interest to pediatric critical care practitioners. We hope to run announcements for openings for critical care staff positions in future issues. The deadline for the Summer '97 issue is April 15. Please mail submissions to Otwell Timmons. Please direct comments or suggestions regarding this issue to the editorial staff. Thank you.

AAP FALL MEETING

October 31 through November 5, 1997
New Orleans Hilton Riverside & The Ernest Morial Convention Center
New Orleans, Louisiana.
Abstract Deadline: April 15
Please mail abstract submissions to Brahm Goldstein at the address listed in the Editorial Staff section.

PedsCCM Ed note: Additional information on this meeting is here.

10th Annual PEDIATRIC CRITICAL CARE COLLOQUIUM

Celebrating a Decade of Dialogue
September 17-21, 1997
The Arlington Hotel
Hot Springs National Park, Arkansas

Abstract deadline: May 15, 1997

Sponsored by The University of Arkansas for Medical Sciences and Arkansas Children's Hospital

Course Directors:
Michele Moss, M.D
Steve Schexnayder, M.D.

Scientific Committee Chairman:
Al Torres, M.D.

For further information, contact :
Division of Pediatric Critical Care
Arkansas Children's Hospital
800 Marshall Street, Slot 900
Little Rock, Arkansas 72202
Phone (501) 320-1845
Fax (501) 320-3188
Email: pccc@exchange.uams.edu
Web site: http://pediatrics.ach.uams.edu/announce/pccc.htm

See the Hot Springs National Park Web Site at http://www.hsnp.com/

Critical Care News Editorial Staff

Timothy Yeh, M.D. (Section Chairperson)
Pediatric ICU
Children's Hospital Medical Center of Northern California
747 Fifty Second Street
Oakland, CA 94609 510-428-3714
Fax 510-601-3923 timbobyeh@aol.com

Brahm Goldstein, M.D. (Co-Editor)
Chief, Division Pediatric Critical Care
OHSU 3181 S.W. Sam Jackson Park Road
Portland, OR 97201 503-494-8194
Fax 503-494-4953 goldsteb@ohsu.edu

Otwell Timmons, M.D. (Co-Editor)
Carolinas Medical Center
P.O. Box 32861
Charlotte, NC 28232 704-355-7815
Fax 704-355-1221 otimmons@carolinas.org