Effect of Nasal Continuous and Biphasic Positive Airway Pressure

on Lung Volume in Preterm Infants

Martijn Miedema, MD, PhD1, Pauline S. van der Burg, MD1, Sabine Beuger, MD1, Frans H. de Jongh, PhD1,
Inez Frerichs, MD, PhD2, and Anton H. van Kaam, MD, PhD1

Objective To monitor regional changes in end-expiratory lung volume (EELV), tidal volumes, and their ventilation
distribution during different levels of nasal continuous positive airway pressure (nCPAP) and nasal biphasic positive
airway pressure (BiPAP) in stable preterm infants.
Study design By using electrical impedance tomography and respiratory inductive plethysmography, we mea-
sured changes in EELV and tidal volumes in 22 preterm infants (gestational age 29.7
1.5 weeks) during 3 nCPAP
levels (2, 4, and 6 cmH2O) and unsynchronized BiPAP (nCPAP = 6 cmH2O; pressure amplitude = 3 cmH2O;
frequency = 50/min; inspiration time = 0.5 seconds) at 10-minute intervals. We assessed the distribution of these
volumes in ventral and dorsal chest regions by using electrical impedance tomography.
Results EELV increased with increasing nCPAP with no difference between the ventral and dorsal lung regions.
Tidal volume also increased, and a decrease in phase angle and respiratory rate was noted by respiratory induction
plethysmography. At the regional level, electrical impedance tomography data showed a more dorsally oriented
ventilation distribution. BiPAP resulted in a small increase in EELV but without changes in tidal volume or its regional
distribution.
Conclusion Increasing nCPAP in the range of 2 to 6 cmH2O results in a homogeneous increase in EELV and an
increase in tidal volume in preterm infants with a more physiologic ventilation distribution. Unsynchronized BiPAP
does not improve tidal volume compared with nCPAP. (J Pediatr 2013;162:691-7).

See editorial, p 670

N
asal continuous positive airway pressure (nCPAP) is one of the most frequently used modes of respiratory support in
preterm infants.1 Its main physiologic effects on the preterm lung are a decrease in airway resistance and a pressure-
dependent increase of the often-compromised end-expiratory lung volume (EELV).2,3 As a result, preterm infants on
nCPAP expend less effort breathing, have less paradoxical breathing, less apnea, and have improved gas exchange.3-8 nCPAP is
also considered a lung-protective mode of respiratory support because it reduces the need for invasive mechanical ventilation,
which can cause secondary lung injury leading to bronchopulmonary dysplasia.9 Regional overdistension and atelectasis caused
by a heterogeneous distribution of aeration and ventilation are considered important pathways in the development of
ventilator-induced lung injury.10,11 However, in recent randomized controlled trials investigators failed to show a clear benefit
of (early) nCPAP over invasive mechanical ventilation in terms of lung injury in preterm infants, which raises the question
whether the increase in EELV during nCPAP is homogeneously distributed across the lung.
Those infants who do not respond to nCPAP are increasingly treated with nasal intermittent positive pressure ventilation
(NIPPV). Studies have shown that, compared with nCPAP, NIPPV is more effective in the treatment of apnea and reduces
extubation failure.12,13 However, the underlying mechanisms of these beneficial effects are not well understood. Studies of tidal
volume during NIPPV have shown conflicting results, with authors reporting increased and no change in tidal volumes.14-18 To
date, in no study have authors investigated the changes in EELV and the distribution of ventilation during NIPPV.
Electrical impedance tomography is a relatively novel, noninvasive, bedside monitoring technique capable of continuously
measuring regional changes in lung impedance in a cross-sectional slice of the chest. These changes are highly correlated with
actual intrathoracic air and ventilation changes.19,20 In the present study, we used electrical impedance tomography to monitor

BiPAP Biphasic positive airway pressure

CPAP Continuous positive airway pressure From the 1Department of Neonatology, Emma Children’s
EELV End-expiratory lung volume Hospital, Academic Medical Center, Amsterdam, The
Netherlands; and 2Department of Anesthesiology and
FiO2 Fraction of inspired oxygen Intensive Care Medicine, University Medical Center
I:E Inspiration-to-expiration time ratio Schleswig-Holstein, Campus Kiel, Germany
nCPAP Nasal continuous positive airway pressure The electrical impedance tomography device was pro-
NIPPV Nasal intermittent positive pressure ventilation vided by CareFusion. The authors declare no conflicts of
interest.
TcPCO2 Transcutaneous partial carbon dioxide pressure
TcPO2 Transcutaneous partial oxygen pressure 0022-3476/$ - see front matter. Copyright ª 2013 Mosby Inc.
All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2012.09.027

691
THE JOURNAL OF PEDIATRICS  www.jpeds.com
regional changes in EELV and ventilation during different
levels of nCPAP and nasal biphasic positive airway pressure
(BiPAP) in stable preterm infants. In addition to electrical
impedance tomography, lung volume changes also were
monitored by respiratory inductance plethysmography,
which provides information on global lung volume changes
and was used in most previous studies on nCPAP and
NIPPV. We hypothesized that increasing nCPAP would
lead to a homogeneous increase in both EELV and ventilation
and that adding BiPAP would not change this finding.
Methods
The study was performed in the neonatal intensive care
unit of the Emma Children’s Hospital, Academic Medical
Center, Amsterdam, The Netherlands. The study was ap-
proved by the central committee on research involving hu-
man subjects, and written informed consent was obtained
from both parents. Infants born at less than 32 weeks of
gestation and who were younger than 7 days of age were
eligible for enrollment if they were treated with nCPAP
and were clinically stable (fraction of inspired oxygen
[FiO2] <0.30 and on average less than one instance of ap-
nea [per 2 hours]). Exclusion criteria were congenital
anomalies of the chest and/or abdomen and fragile skin
condition. The patients were not sedated, and they were
studied in the supine position.
Sixteen hand-trimmed ECG electrodes (Blue Sensor, BRS-
50-K; Ambu, Inc, Linthicum Heights, Maryland) were equi-
distantly placed on the thorax circumference of the newborn
just above the nipple line and connected to the Goettingen
Goe-MF II electrical impedance tomography system (Care-
Fusion, Hoechberg, Germany). Repetitive electrical currents
(5 mArms, 100 kHz) were injected in rotation (scan rate 13
Hz) through adjacent electrodes pairs and voltage changes
were measured by all other passive electrodes pairs. A back-
projection image reconstruction algorithm generated a
32  32 matrix of local relative impedance changes (delta
Z) compared with a reference state. Continuous online
recording of impedance changes and continuous positive air-
way pressure (CPAP) pressures were performed with the use
of Veit software (CareFusion).
Respiratory induction plethysmography bands were se-
cured around the chest and abdomen of the infants and con-
nected to a BiCore II system (Carefusion, Yorba Linda,
California). Volume and pressure changes were continuously
recorded during the study protocol with the use of Polybench
software version 2.5.1 (Applied Biosignals GmbH, Weener,
Germany). Calibration was performed with the previously
described qualitative diagnostic calibration method via the
use of a minimum of 20 consecutive breaths at 2 cmH2O
of nCPAP.21
nCPAP was delivered in all infants with the Infant Flow Si-
PAP system (CareFusion). The protocol consisted of 3 con-
secutive phases. During the first phase, the nCPAP pressure
was set at 2 cmH2O in all patients to standardize lung volume
as much as possible. Next, nCPAP pressure was, in random
692
Vol. 162, No. 4
order, increased to 4 and 6 cmH2O at 10-minute intervals.
At the beginning of the second phase, the CPAP pressure
was set at 6 cmH2O because in daily clinical practice BiPAP
usually is applied during greater nCPAP levels. After a 10-
minute stabilization period, unsynchronized BiPAP was
started with the maximum pressure difference of 3 cmH2O
at a frequency of 50 breaths per minute with an inspiration
time of 0.5 seconds. Patients were kept on BiPAP for 10 min-
utes and were then switched back to nCPAP for another 10
minutes. The third phase was similar to the second one,
but this time BiPAP was synchronized by the use of an ab-
dominal pneumatic capsule (Graseby Medical, Watford,
United Kingdom). If an increase in FiO2 or number of apneas
was observed during the study protocol, the interventions
were stopped and original settings were restored.
Data Acquisition and Analyses
EELV. Electrical impedance tomography data were ana-
lyzed offline with the use of AUSPEX version 1.6 (VUMC,
Amsterdam, The Netherlands). The change in EELV was cal-
culated by selecting a stable 30-second reference period at the
start of each phase of the study protocol. All subsequent im-
pedance recordings in each phase were referenced to this ini-
tial recording. Next, the relative change in EELV was
calculated at CPAP 4 and 6 cmH2O (phase 1) and before,
during and after BiPAP (phases 2 and 3) by averaging the rel-
ative delta Z at the troughs of the spontaneous breaths in
a stable 30-second recording period taken at the end of
each 10-minute interval for each individual patient. This
end-expiratory delta Z was then normalized for body weight.
This analysis was performed for the whole cross section of the
chest and for the ventral and dorsal halves of the scan area.
The calibrated respiratory induction plethysmography
data were analyzed with a custom-built Polybench software
package via the use of a similar approach and the same
time periods as the electrical impedance tomography analy-
sis. Analyses were conducted for the sum, ribcage, and ab-
dominal signals separately.
Tidal Ventilation. To assess the change in tidal volume of
the spontaneous breaths, each selected 30-second electrical
impedance tomography period was then referenced to the av-
erage delta Z in that same period. Next, the delta Z signals
were band pass-filtered in the band of spontaneous breathing
frequency (10/min below the actual breathing frequency and
10/min above its second harmonic). By selecting the peaks
and troughs, we were able to calculate, average, and then nor-
malize the amplitudes for body weight.
To assess the regional distribution of the spontaneous
breaths during each used pressure level of the study protocol,
functional electrical impedance tomography images were
generated by the use of the SD of the impedance time course
of each individual pixel within the 32  32 matrix and nor-
malized in each pixel.20,22 In the anteroposterior ventilation
profile, the impedance change was averaged for each slice
and plotted. Next, the area under the curve for the ventral
(slice 1-16) and dorsal lung region (slice 17-21) was
Miedema et al
April 2013
calculated. In addition, the geometrical center was deter-
mined as previously described.23
The changes in tidal volume also were estimated by use of
the respiratory induction plethysmography data by selection
of the peaks and troughs in the same 30-second periods.
Analyses were conducted for the sum, ribcage, and abdomi-
nal signals separately.
Additional Data. In addition to the changes in lung vol-
ume, the phase angle, or time lag between thoracic and ab-
dominal motion, was determined. If ribcage and abdomen
are synchronous (phase angle 0 ), they will both increase af-
ter the start of inspiration, and during asynchrony (phase
angle 180 ) the ribcage and abdomen will move in opposite
directions. The respiratory induction plethysmography data
also were used to determine the respiration frequency and
the inspiration-to-expiration time ratio (I:E) during the
study protocol.
To monitor the effects of the interventions on oxygenation
and gas exchange, the FiO2, the change in transcutaneous
partial oxygen pressures (TcPO2), and the transcutaneous
partial carbon dioxide pressures (TcPCO2) were recorded
during or between each intervention.
Statistical Analyses
For statistical analysis, we used GraphPad Prism 5.0 (Graph-
Pad Software Inc, San Diego, California) and SPSS version
16.0 (SPSS Inc, Chicago, Illinois). Depending on their distri-
bution, data were expressed as mean
SD or as median with
IQRs. The Pearson correlation coefficient was calculated be-
tween EELV for all patients on the basis of the global electrical
impedance tomography and the sum respiratory induction
plethysmography data.
One-way ANOVA for repeated measures or a Friedman
test were used for comparative analyses among the different
CPAP levels followed by post-hoc testing. Analyses of the
BiPAP data were performed with a paired t test or a Mann-
Whitney test. P < .05 was considered statistically significant.
Results
Twenty-two preterm infants were included and finished the
study protocol without experiencing any complications
(Table I). Despite extensive efforts, we were not able to
establish consistent synchronization via the Graseby capsule
during the BiPAP mode in the third phase of the study.
The limited number of triggered breaths prevented
meaningful analyses; thus, only the data from the phases 1
and 2 are reported.
nCPAP
Increasing pressure steps during nCPAP resulted in a signifi-
cant concomitant increase in EELV measured by electrical
impedance tomography and respiratory induction plethys-
mography (Figure 1), and these changes were highly
correlated (r = .78; P < .01). Regional analyses of the
impedance data showed no difference between the ventral
Effect of Nasal Continuous and Biphasic Positive Airway Pressure on Lung Volume in Preterm Infants
ORIGINAL ARTICLES
Table I. Patient characteristics
Characteristics N = 22
Gestational age, days 29.7
1.5
Age at measurement, days 3.2
1.3
Birth weight, g 1318
312
Five-minute Apgar score 9 (7-9)
Antenatal steroids, n (%) 20 (91)
Rescue surfactant, n (%) 2 (9)
Mechanically ventilated, no (%) 2 (9)
Duration, days 1.5
0.7
nCPAP at start, cmH2O 4.2
0.6
FiO2 at start 0.21
0.00
Data are presented as mean
SD of 22 patients or median (IQR) when stated differently.
versus dorsal lung regions. This was also true for the
ribcage and the abdominal bands of the respiratory
induction plethysmography data (Figure 1, A and B).
The summarized respiratory induction plethysmography
data showed an increase in tidal volume with increasing pres-
sure levels (Figure 1, C). Separate analysis of the ribcage and
abdominal derived tidal volumes showed opposing trends,
with the ribcage data showing an increase and the abdomen
data showing a decrease in tidal volume (Figure 1, D).
These differences in tidal volumes only reached statistical
significance at a pressure level of 6 cmH2O (P < .01). The
phase angle, the breathing frequency, and the I:E decreased
significantly with increasing pressure steps (Table II).
In contrast to the summarized respiratory induction pleth-
ysmography data, tidal impedance volumes decreased at
greater nCPAP levels (Figure 1, C). Regional analysis of the
spontaneous breaths showed a more dorsally oriented
ventilation distribution with increasing pressure levels, as
indicated by the decreasing area under the curve in the
ventral chest region and the greater values of geometrical
centers (Table II). TcPO2 increased significantly with
increasing nCPAP levels, and FiO2 remained unchanged.
TcPCO2, however, did not change throughout this phase of
the study (Table II).
Unsynchronized BiPAP
In 4 infants, the initiation of BiPAP resulted in excessive
movement, making reliable analysis of the respiratory in-
duction plethysmography data not feasible. In the remaining
18 infants, unsynchronized BiPAP resulted in a small in-
crease in mean nCPAP to 7.3
0.2 mmHg and an increase
in EELV on the basis of the global electrical impedance to-
mography and respiratory induction plethysmography
sum data, although only the latter reached statistical signif-
icance (P < .01; Figure 2, A). There were no differences in
regional EELV data or between the ribcage and abdominal
respiratory induction plethysmography data (data not
shown).
During BiPAP, the electrical impedance tomography or re-
spiratory induction plethysmography derived tidal volumes
did not change significantly (Figure 2, B). In line with this
finding, the phase angle and TcPCO2 values remained
unchanged. The mean breathing frequency decreased from
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THE JOURNAL OF PEDIATRICS  www.jpeds.com Vol. 162, No. 4

Figure 1. Changes in EELV and tidal volume (VT) at nCPAP levels of 4 and 6 cmH2O relative to 2 cmH2O. A, Global, ventral, and
dorsal changes in EELV measured by electrical impedance tomography (EELVEIT). B, Sum, ribcage, and abdominal changes in
EELV measured by respiratory inductance plethysmography (EELVRIP). C and D, VT changes at each pressure level. C, VT for the
global electrical impedance tomography data (VTEIT) and the respiratory induction plethysmography sum data (VTRIP). D, Rib-
cage and abdominal respiratory induction plethysmography VT. Data are presented as means with SD. *Significant change in
contrast to nCPAP 2 cmH2O, P < .05; **significant change in contrast to nCPAP 2 cmH2O, P < .01; +significant change in contrast
to nCPAP 4 cmH2O, P < .05; ++significant change in contrast to nCPAP 4 cmH2O, P < .01.

49
14 breaths/min to 43
13 breaths/min during BiPAP
(P < .01), and the I:E ratio increased (Table II). BiPAP had
no impact on the ventilation distribution in the vertical
axis (Table II).
Discussion
We investigated the effect of different nCPAP levels and Bi-
PAP on the regional changes in EELV and ventilation mea-
sured with electrical impedance tomography. Our main
findings are that increasing nCPAP levels result in a homoge-
neous increase in EELV and a more dorsal, physiologic distri-
bution of ventilation. Unsynchronized BiPAP also increased
EELV but did not affect the tidal volume and its distribution.
We simultaneously measured lung volume changes with
respiratory induction plethysmography and electrical imped-
ance tomography, providing information at the global and
regional level, respectively. The 10-minute intervals between
pressure steps were sufficient for stabilization of the volume
tracings in all patients. The stepwise increase in global EELV
with increasing levels of nCPAP is consistent with previous
reports that also used respiratory induction plethysmography
to monitor lung volume changes.2,3,6 The electrical imped-
ance tomography analysis shows that this increase in EELV
is homogeneously distributed across the ventral and dorsal
lung regions, supporting the conclusion that the use of
nCPAP in preterm infants has lung-protective properties.
694
The fact that the respiratory induction plethysmography
and electrical impedance tomography–derived EELVs were
highly correlated confirms the validity of our finding and
suggests that EELV changes measured in a transverse slice
of the lung with electrical impedance tomography represent
global changes in the entire lung in the current setting.
The effect of increasing nCPAP levels and the concomitant
increase in EELV on tidal volumes has been inconclusive with
some studies showing no change and others showing an in-
crease in tidal volume.2-6,24,25 The present study shows that,
on the basis of the respiratory induction plethysmography
data, tidal volumes increase with increasing EELV. The fact
that breathing became more synchronous and less frequent
at greater nCPAP levels strengthens the validity of this find-
ing. TcPO2 showed a small increase with increasing nCPAP
levels, indicating that atelectasis was probably present at the
lower nCPAP levels leading to an increased intrapulmonary
shunt.
At the same time TcPCO2 remained stable at the different
nCPAP levels, which suggests that the greater EELVs did not
result in lung overdistension. To our surprise and in contrast
to the respiratory induction plethysmography data, the elec-
trical impedance tomography–derived tidal volumes showed
a stepwise decrease with increasing EELVs. The reason for
this discrepancy is currently unclear. The fact that previous
studies showed excellent correlations between regional and
global tidal volume changes during mechanical ventilation
Miedema et al
April 2013 ORIGINAL ARTICLES

Table II. Changes in ventilation characteristic during 3 levels of nCPAP and unsynchronized BiPAP
nCPAP level (N = 22) Unsynchronized BiPAP (N = 18)
2 cmH2O 4 cmH2O 6 cmH2O nCPAP before BiPAP nCPAP after
Breathing frequency, breaths/min 58
13 49
12* 46
13* 49
14 43
13† 45
14
Phase angle,  108 (88-133) 60 (35-129)* 37 (27-60)*,z 43 (34-52) 61 (38-74) 47 (35-66)
I:E 0.73
0.17 0.66
0.12 0.59
0.13*,z 0.64
0.16 0.77
0.22† 0.60
0.16x
TcPO2, kPa 7.2
1.7 8.2
1.9* 8.9
2.0*,{ 8.6
1.9 8.9
2.2 8.6
1.9
TcPCO2, kPa 6.4
0.8 6.4
0.8 6.3
0.8 6.3
0.8 6.3
0.7 6.4
0.7
AUCven, % 51.2
8.2 48.8
8.8** 46.8
8.9*,z 46.2
9.3 46.2
8.6 47.2
8.4
Geometric center, % 49.5
3.8 51.0
3.8** 51.9
3.8* 52.1
4.7 52.0
3.8 51.4
3.5

AUCven, area under the curve of the ventral lung region.

Data are presented as mean
SD or median with IQRs if stated differently.
*P < .01 versus 2 cmH2O of nCPAP.
†P < .01 versus nCPAP before.
zP < .05 versus 4 cmH2O of nCPAP.
xP < .01 versus BiPAP.
{P < .01 versus 4 cmH2O of nCPAP.
**P < .05 versus 2 cmH2O of nCPAP.

suggests that the way volume changes are induced (mechan-
ical or spontaneous) might play a role in the validity of ex-
trapolating regional to global volume changes.26-28
The results from this study seem to support this line of rea-
soning. First, increasing nCPAP levels (mechanically) re-
sulted in highly correlated changes in EELV measured by
electrical impedance tomography and respiratory induction
Figure 2. Changes in A, EELV and B, VT before, during, and
after unsynchronized BiPAP. Changes in electrical imped-
ance tomography data and respiratory induction plethysmog-
raphy sum signal are shown. Data are presented as means
with SD. **Significant change in contrast to initial nCPAP 6
cmH2O. P < .01.
Effect of Nasal Continuous and Biphasic Positive Airway Pressure on Lung Volume in Preterm Infants
plethysmography. Second, it was interesting to observe that
the electrical impedance tomography–derived tidal volume
showed a correlated (r = 0.58; P < .01) change with the tidal
volume measured by the abdominal band of the respiratory
induction plethysmography, which might suggest that the
tidal volume changes measured by electrical impedance to-
mography were predominantly influenced by diaphragmatic
excursions resulting in craniocaudal volume changes. Stabili-
zation of the diaphragm with a reduction in asynchronous
breathing at greater nCPAP levels may have resulted in a rel-
ative reduction in regional tidal volume. More research is
needed to unravel this complex relation between spontane-
ous breathing and regional tidal volume changes.
Increasing nCPAP resulted in a shift of ventilation distri-
bution from the ventral to the dorsal lung regions, with a geo-
metric center located at almost 52% of the anteroposterior
chest diameter at 6 cmH2O. To our knowledge, this is the first
report showing that nCPAP in preterm infants can restore
ventilation distribution to normal physiologic values mea-
sured in healthy newborn infants.29,30
In previous studies regarding the effect of NIPPV on tidal
volumes, authors used different interfaces and devices, some
of which are no longer commercially available.14-18 Our study
is the first to use the BiPAP mode on the Infant Flow SiPAP
system. Although this mode was designed originally to apply
2 different levels of nCPAP at a low alternating frequency,
many clinicians use it as a NIPPV mode with greater frequen-
cies and shorter inspiration times. We were able to show that
unsynchronized BiPAP did not change the tidal volume,
a finding consistent with most other studies on NIPPV.16-18
We did find a relatively small increase in EELV during BiPAP,
a finding not previously reported and most likely caused by
the increase in mean airway pressure during BiPAP. Regional
information from the electrical impedance tomography data
showed that there were no changes in the distribution of aer-
ation and ventilation.
Two previous studies have suggested that synchronization
of NIPPV with the patients’ inspiratory effort might improve
the tidal volume.16,18 For this reason we also attempted to in-
vestigate synchronized BiPAP using the Grasby capsule.
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THE JOURNAL OF PEDIATRICS  www.jpeds.com
Unfortunately, we were not able to obtain consistent trigger-
ing in the majority of infants, making meaningful analysis
impossible. Future studies will have to address the effect of
synchronization on tidal volumes.
This study has several limitations that need to be addressed.
First, although not essential, this study does not provide in-
formation on the absolute changes in lung volume. Calibra-
tion of the respiratory induction plethysmography bands by
measuring flow at the airway opening was not performed be-
cause this would mean removal of nCPAP in this vulnerable
preterm population. Second, the patients included in this
study were all clinically stable and younger than 1 week of
age. The results may be different in older or less stable infants
with for instance respiratory distress syndrome or more severe
lung disease. Third, the sample size of this study may have
been too small to pick up small differences in tidal volume
during BiPAP. Finally, the results with BiPAP may differ
when other settings or other modes of NIPPV are used.
In conclusion, this study shows that increasing nCPAP from
2 to 6 cmH2O results in a homogeneous increase in EELV and
an increase in tidal volume with a more homogeneous physio-
logical distribution in preterm infants. Unsynchronized BiPAP
delivered with the Infant Flow SiPAP system does not improve
tidal volume compared with nCPAP. n
Submitted for publication Apr 16, 2012; last revision received Jul 19, 2012;
accepted Sep 17, 2012.
Reprint requests: Martijn Miedema, MD, Department of Neonatology (H3-214),
Emma Children’s Hospital AMC, P.O. Box 22660, 1100 DD Amsterdam, The
Netherlands. E-mail: m.miedema@amc.uva.nl
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851-8.

50 Years Ago in THE JOURNAL OF PEDIATRICS

The Pediatrician and the Young Child Subjected to Repeated Physical Abuse
Woolley PV. J Pediatr 1963;62:4

I n the mid-19th century, French forensic physician Auguste Tardieu recognized patterns of injury in children and
reported nonaccidental trauma as the cause. Unfortunately, his work was ignored by his physician peers.
Nearly a century later, C. Henry Kempe et al described the “Battered Child Syndrome” in the landmark 1962 paper
and called on the medical community to help protect children from physical abuse. In his 1963 editorial, Paul
Woolley recognized these contributions and suggested a “broader attack,” adding social services and law enforcement
to the physician team. He, like Kempe, recognized that ending child abuse would require involvement of the entire
community.
Since the call to action in the early 1960s, identification and protection of child victims has improved. By 1967, most
states had legislation requiring physician reporting of suspected child abuse. Today, every state has laws mandating
reporting of suspected abuse by most professionals who serve children, not just physicians. In 1974, Congress passed
the Child Abuse Prevention and Treatment Act, which served to establish a nationwide network of child protective
services. Children with suspicious injuries can now be removed from the environment of concern and placed in
a safe place before charges have been filed. Technologic advances in radiology and increased recognition of injury
patterns and key historical features have brought about greater awareness in the medical community. Most pediatric
residents receive training in child abuse. The American Board of Pediatrics offered the first Child Abuse Pediatrics
certification examination in 2009, and the first Child Abuse Fellows in fully accredited programs began training in
2010. In many urban areas, there are expert child protection teams drawing from law enforcement, social work,
and health care with the aim of keeping children safe from those who would physically harm them.
Despite this progress, there are still approximately 1500 children per year who die because of maltreatment, and
thousands of others who suffer serious emotional and physical trauma. Fifty years has marked significant improve-
ments in recognizing that this is a serious and complex public health problem and in the ability to recognize and
act on suspected child abuse. But there is still work to be done. We must continue to strive for complete eradication.

Kristine G. Williams, MD
Pediatric Emergency Medicine
Washington University
St. Louis, Missouri

Kristin Stahl, MD
General Pediatrics
Heartland Pediatrics
Collinsville, Illinois
http://dx.doi.org/10.1016/j.jpeds.2012.10.050

Effect of Nasal Continuous and Biphasic Positive Airway Pressure on Lung Volume in Preterm Infants 697