Institute Activities and Advances
The NICHD's research portfolio encompasses topics including pediatric critical care, traumatic brain injury (TBI) and TBI rehabilitation, and prevention of pediatric injury.
The NICHD supports research on pediatric critical care. As more medically fragile and disabled children live longer after the onset of illness or injuries, there is increasing need for research to evaluate longer-term outcomes after pediatric critical care. Relevant research activities seek to answer questions about the relationship of pediatric critical care practice to child health and disability. Research studies focus on linking pediatric critical care medicine and science to the epidemiology, prevention, and treatment of childhood disabilities. For instance, choice of ventilator and cardiovascular support techniques, choice of pharmacologic agents in sedation and analgesia, and their longer-term effects on child health and development are all emerging issues within pediatric critical care research. Because the use of resources is such a central issue in most pediatric critical care services, comparisons of nursing hours and other measures of service consumption are of interest in weighing the eventual benefits for children and families.
The Institute also supports research to understand all aspects of TBI and stroke, including their underlying mechanisms, and to develop and assess medical rehabilitation therapies and interventions related to improving function, quality of life, and outcomes for stroke and TBI patients. In addition, the program supports efforts related to secondary conditions of TBI and stroke, such as muscle atrophy, speech and language problems, pain, and psychological and psychosocial effects of these conditions.
In the Division of Intramural Population Health Research, the Health Behavior Branch (HBB) conducts research related to injury prevention. HBB investigators have established a comprehensive program of research on the causes and prevention of motor vehicle crashes. This research includes naturalistic studies with instrumented vehicles, experimental studies using driving simulators and test tracks, and evaluation studies of the effects of the Checkpoints Parental Management Program. In addition, HBB investigators studied the integration of individually tailored health communications in the pediatric primary care setting, which may offer an innovative and effective way to reduce injury in young children. The Pediatric Trauma and Critical Illness Branch in the Division of Extramural Research also supports research in these areas.
Some recent findings from NICHD and NICHD-supported researchers include the following:
- Cardiac Protection for Severely Burned Children
Severe burns over a large portion of a child’s body can speed up normal metabolic processes to alarming levels. This “hypermetabolic” response causes dangerous acceleration in a child’s heart rate and cardiac output, as well as other physiological problems that, unless checked, can interfere with the body’s ability to use oxygen, glucose, and other essential factors. Over time, young patients may experience losses in lean body mass and bone mineral content and density, and nutritional problems that interfere with growth. The drug propranolol has been shown to decrease cardiac stress in children and to lessen other harmful effects of the hypermetabolic response, but little was known about how much of the drug was actually necessary to lower pathological stress in young burn patients. Further, nothing was known about whether or how a child’s distinctive physiology affects drug action within the body. Information about this would help guide dosing recommendations. To establish the correct dosing regimen for this important drug, scientists conducted a controlled clinical trial of propranolol in more than 300 pediatric burn patients. Researchers established how much of the drug was necessary to lower pediatric burn patients’ heart rates by 15%. They determined that the drug acted quickly, achieving effective levels within 30 minutes to one hour. They also found that the dose should be increased significantly over the first 10 days to maintain the benefits of the treatment. (PMID: 20598332)
- Supplemental Nutrition and Infection Rates in Critically Ill Children
Up to 40% of children requiring long-term intensive care develop bloodstream infections, often related to the need for catheters and ventilators. To help prevent such infections, children in pediatric intensive care units often receive supplemental nutrition including zinc, selenium, and protein. However, research studies in some critically ill adults and specific groups of children indicate that additional supplements may also be useful to reduce the risk of infection.
Scientists conducted a randomized clinical trial comparing two different types of supplemental nutrition in pediatric intensive care units. Half of the children received a supplement called ZSGM, which included additional zinc, selenium, glutamine, and metoclopramide, beyond what children would typically receive as part of standard care. The other half of the children received supplements of whey protein, which includes essential amino acids that may help boost the immune system, helping children fight off infection. The researchers compared infection rates across these two approaches for nearly 300 critically ill children. They also compared the results across treatments for the 25 children who had conditions that decreased the effectiveness of their immune systems.
The researchers found that the infection rates were identical in the two groups. However, for the small number of patients with compromised immune systems, the group that received ZSGM had lower infection rates. This result suggests that ZSGM supplements may be helpful in critically ill children with compromised immune systems. (PMID: 22079954)
- Making it Easier to Measure Rehabilitation Progress for Children with Severe Burns
Children who suffer from severe burns often have long-term effects, including a decrease in cardiopulmonary function that lasts up to 2 years after the initial burn. To help these children regain their ability to function, rehabilitation specialists often develop individualized exercise programs tailored to the specific child and then follow the child’s progress closely. Maximal oxygen uptake (VO2 peak) is an indicator used to develop individualized exercise programs and then follow the child’s progress. However, calculating VO2 peak for the individual patient requires expensive equipment and a relatively high technical skill level. Researchers developed a simple mathematical formula for estimating VO2 peak in burned children. Using only a treadmill and easily gathered information, they were able to estimate VO2 in children with burns. This formula can improve rehabilitation specialists’ ability to assess fitness and track progress for children with severe burns, and reduce the need for expensive equipment and testing. (PMID: 21316155)
- Children from Low-Income Families at Risk for Injuries at Home
More than 125,000 children are injured by fires and burns at home each year, according to estimates from the Centers for Disease Control and Prevention. Both fires and burns can sometimes be prevented by simple methods like smoke detectors and safe water heater settings. Using a checklist that identifies common safety hazards, researchers assessed the quality of housing for 100 low-income African American families. This measure of housing quality included items related to heating systems, locks, rodents or bugs, mold, and other damage. Researchers also evaluated the relationships between different aspects of housing quality and the use of preventive measures, including smoke detectors and safe water temperatures.
The researchers found that virtually all the families in the sample were living in housing that failed one or more items on the housing quality checklist. The most common problems were inadequate heat; peeling paint; mold, mildew, or water damage; and rats. Each of these problems puts the children at risk for injury or illness. Unsurprisingly, households with a greater number of other housing problems were also significantly less likely to have injury prevention measures in place, including smoke detectors and safe water heater settings. The lack of these preventive measures increases the children’s risk for fire and burn injury. (PMID: 23147973)
- Steroid Drug Helps Young Burn Patients Regain Muscle Mass and Growth
Oxandrolone, a steroid drug, has been used to help young burn patients. In the short term, the drug helped young burn patients maintain body mass and shortened their stay in the intensive care unit. However, no data were available to assess the long-term effects of the drug.
Researchers conducted a randomized controlled trial of oxandrolone, and followed the patients for 5 years to assess long-term outcomes. Young burn patients were randomly divided into two groups. One group received oxandrolone for 1 year post-burn, and the other group received a placebo. Within each group, some children were randomly chosen to receive an additional exercise program. The researchers found that severely burned children who received oxandrolone had a stronger long-term recovery in height, bone mineral content, and muscle strength compared with children who received the placebo. The children who received both the oxandrolone and the additional exercise program gained even more in muscle strength. These benefits persisted for the full 5 years post-burn without adverse side effects. (PMID: 22463890)
- Many Doctors Don’t Ask Teens About Alcohol
Unhealthy alcohol use is the third-leading preventable cause of death nationwide, and alcohol is the most widely used substance of abuse among youth. Research has shown that asking adult patients about alcohol use and advising them to cut back on risky drinking can have lasting effects, and the same may be true for adolescents. To see if physicians routinely advise young people on alcohol use, scientists studied a nationally representative sample of more than 2,500 students in 10th grade. The students were asked about their alcohol use and whether their doctor discussed drinking at their last medical exam. Researchers reported that 34% of the students said they had used alcohol in the past month. However, of the 82% who had seen a doctor in the past year, 54% said they were asked about drinking and 40% said they were advised about related harms. Of the students who reported past-month problem drinking (frequent alcohol use, binging, or drunkenness), about 25% were advised to reduce or stop drinking. One limitation of the study, the researchers noted, is that the data depend on the conversations students remember having with their physicians. Still, the results strongly suggest that physicians may be missing opportunities to discuss alcohol use and abuse with this at-risk age group. (PMID: 23359580)
- Patterns of Substance Use Among U.S. Teens
According to several national studies, most U.S. adolescents will engage in some form of substance use by the time they graduate from high school. However, more research is needed to identify patterns of substance use and abuse. Scientists used the NEXT study, a nationally representative sample of more than 2,500 U.S. 10th-grade adolescents, to assess patterns of substance use. About 29% of these adolescents reported using any illicit drugs in the past year: 26% used marijuana, 9% misused medication, and 8% used other illicit drugs (e.g., ecstasy, amphetamine, cocaine, anabolic steroids, or glue/solvents). During the past month, 35% of adolescents reported alcohol use, 27% binge drinking, and 19% cigarette smoking.
Four groups of teens were identified from the data.
- Nearly 60% of teens were classified in the “nonuser” group. These teens had very low probabilities of any substance use.
- About 23% of teens were considered predominantly alcohol users. These teens had high probability of drinking and moderately high probability of binge drinking, moderate probabilities of using marijuana and smoking cigarettes, and low probabilities of misusing medication and using other illicit drugs.
- About 10% of teens were considered predominantly marijuana users. These teens had high probabilities of using marijuana, low probabilities of using other substances, and had virtually no use of alcohol or binge drinking.
- The final group, comprising about 7% of teens, were classified as “polysubstance users.” Teens in this group had high probabilities for using each of the substances. The polysubstance group was the only group with high probability for misuse of prescription medication. Moreover, the polysubstance teens were much more likely to experience mental health problems. Teens in the polysubstance group reported higher levels of depressive symptoms and more headaches, stomachaches, and backaches, which often underlie depression. (PMID: 23465320)
- Risky Driving and Crash Risk is Higher Among Novice Teenage Drivers than Among Adult Drivers
In an instrumented vehicle study, NICHD researchers found the following:
- Novice teenage drivers had crash risk about 4 times higher than their parents; crash risk declined over time, but after 18 months of licensure, it remained significantly higher than parents’.
- Novice teenagers drove in a more risky manner, with frequent hard stops, sharp turns, and over-corrections. The resulting elevated gravitational force event rates, assessed by accelerometers, were 4 to 5 times higher for teens than for their parents.
- Teenagers also exceeded the speed limit frequently.
- Social norms were the best predictors of teenage risky driving. Teenage drivers who perceived that their friends drove in a risky manner also drove in a risky manner.
- In a randomized trial, teenagers who were provided feedback about their risky driving did not change their kinematic risky driving behavior, but those whose parents also received feedback about elevated gravitational force events significantly reduced their risky driving.
- Parents matter
In research on the Checkpoints Program, which includes persuasive communications and a novel Parent-Teen Driving Agreement, researchers found the following:
- Parental limits on teenage drivers were not very strict and did not last very long.
- Teenagers whose parents set stricter limits reported less risky driving and fewer citations and crashes.
- Families who participated in the Checkpoints Program, compared to the control group, established stricter limits and teens reported less risky driving and fewer citations.
Other Activities and Advances
The NICHD supports a number of research and training networks, which include:
- The Collaborative Pediatric Critical Care Research Network (CPCCRN). This network serves as a national resource for studying the scientific bases of pediatric critical care medicine. The CPCCRN provides the infrastructure needed to pursue rigorous clinical trials and descriptive studies in pediatric critical care medicine. The Network aims to reduce morbidity and mortality from pediatric critical illness and injury by enhancing knowledge of the scientific bases of pediatric critical care practice. The Network currently includes eight collaborative clinical sites with large pediatric intensive care units. A Data Coordinating Center at the University of Utah Health Sciences Center supports the Network by using cutting-edge informatics to manage the complexities of the emerging collaborative research.
- The Medical Rehabilitation Research Infrastructure Network. This network, funded through the National Center for Medical Rehabilitation Research with additional support from the National Institute of Neurological Disorders and Stroke and the National Institute of Biomedical Imaging and Bioengineering, builds research infrastructure in medical rehabilitation by providing investigators with access to expertise, courses and workshops, technologies, and collaborative opportunities from allied disciplines, such as neuroscience, engineering, applied behavior, and the social sciences.
- The NICHD also supports the Pediatric Critical Care Scientist Development Program, a national faculty training and career development program that develops successful pediatric critical care physician scientists who conduct research to enhance the scientific understanding, clinical management, and rehabilitation of pediatric critical illness.