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Weekly Updates in Pediatrics

April 2011 - Current Updates in Pediatrics

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Parental support and outcomes in ELBW babies
Pre-term babies, particularly those who are of extreme low birth weight [ELBW], are at greater risk for the development of medical, neurological and developmental abnormalities. Parents may find managing all the issues involved daunting and frequently will need long-term support. In a Neonatal Intensive Care Unit [NICU], parental support may occur through organized programs [standard care] or via individualized interventions undertaken by the psychosocial services. A retrospective study of similar ELBW [B.W. <1,000 gms] babies whose parents had accepted an individualized parental psychosocial program [PPS] or not, [standard care], were compared.

It appears that improving parental involvement during a critical NICU stay may decrease hospital length of stay, perhaps by enhancing strategies to promote better parent-infant interaction.
[J Matern-Fetal Neo Med. 2011; Early Online, 1-5.]

Gambling on the Internet
2,006 high school student problem gamblers were analyzed and compared to non-Internet gamblers. Problem/at risk Internet gambling was more strongly associated with poor academic performance, heavy alcohol use and non-peer involvement. Both groups suffered equally from dysphoria/depression, tobacco, marijuana and other drug use, carrying weapons and getting into serious fights.
[J Am Acad Child Psy. 2011; (50)2:150-159.]

Age of menarche and psychosocial outcomes
Girls reaching menarche early appear to be at increased risk of early pregnancy and sexually transmitted disease by age 18. Age of menarche appears to be unrelated to mental health, criminal behavior or education/employment.
[J Am Acad Child Psy. 2011;(50)2:132-140.]

New plasma markers for diagnosis of Acute Appendicitis [AA]
Negative appendectomy rates with a diagnosis of AA vary between 5% and 40%, with perforation [perhaps suggestive of late operative intervention] occurring in 5%-30%.

Plasma concentrations of 2 neutrophil proteins indicating early activation, Lactoferrin [LF] and calprotectin [CP], were measured in patients diagnosed with AA and compared to a control group of healthy volunteers. C-reactive [CRP] and white blood count [WBC] concentrations were also measured routinely. In a study of 51 patients, circulating LF and CP levels were significantly elevated in patients with AA. No correlations were found between LF/CP and CRP/WBC.
[Am J Emerg Med. 2011;(29)3:256-260.]

Long-term proton pump inhibitors [PPI] treatment
for gastrointestinal reflux disease [GERD]

GERD develops when stomach contents reflux into the esophagus causing symptoms and/or complications. Erosive reflux disease [ERD] is defined by symptoms plus mucosal damage on endoscopy. Non-erosive reflux disease [NERD] exhibits symptoms without mucosal breaks. A 24-week treatment protocol was utilized to evaluate the effect of three alternative treatment strategies after 8 weeks of PPI [lansoprazole] in 3 groups of ERD and NERD patients.

Group 1: “No treatment”-“symptoms resolved”
Group 2: “On-demand treatment” for an additional 16 weeks in a “symptoms-attenuated group”
Group 3: “Continuous treatment” in a “symptoms-persistent” group.

Results indicated that selection of the alternative management protocols chosen according to the 8-week treatment assessment was useful, effective and well-tolerated in all groups. In general, 16 weeks of therapy was as efficacious as 24 weeks’ treatment.
[Arch Dis Child. 2011;96:9-13.]

Ibuprofen [Ib] suppositories in febrile children
A pre-marketing study of rectal ibuprofen suppositories to evaluate parental satisfaction and possible adverse effects was undertaken on 490 febrile children, each of whom received a 5-10 mg/kg suppository dose. Parent satisfaction was high [4.5 on a 1-5 scale], 1.63% of patients reported adverse events [mostly diarrhea] and 92.2% of parents indicated they would use the medication in the future.
[Clin Pediatr. 2011;50(3):196-199.]

Sub-clinical hypothyroidism [SH] in childhood
SH is defined as an elevated thyroid stimulating hormone [TSH] with a normal total or free thyroxine [T4] or triiodothyronine [T3] level. It appears to be frequently found in both neonates and older children. In general, the majority of children with slightly elevated levels of TSH may have persistent mild elevation and are more likely to normalize without treatment. Neonates with persistent SH may benefit from ultrasound examination of their thyroid to identify morphological abnormalities which may predict the need for supplementation.

Older children developing SH without risk factors should have thyroid peroxidase antibody [TBO] titres evaluated as rising levels are predictive of progression to autoimmune hypothyroidism.

Treatment with thyroxine in children with mild TSH is controversial.
[Arch Dis Child. 2011;96(3):280-284.]

Streptococcus pneumonia vaccination and “carriers”
Since the introduction of vaccination against 7 serotypes of strep pneumonia, virtual extinction of vaccine serotypes has occurred in both disease and asymptomatic carriers. In carriers, those serotypes now appear to have been replaced by 86 distinct non-vaccine sequence types, which in addition may “switch” over time. This could be a concern for both antimicrobial resistance and the prevalence of invasive pneumococcal disease.
[Pediatr Infect Dis J. 2011;30(4):302-308.]

Smoking, alcohol and puberty
Pre-pubertal tobacco and alcohol use in young girls delays and requires longer times for breast development. Girls who drink alcohol before puberty are 4 times more likely to have delayed puberty.
[J Adolescent Health. 2011;48(3):241-246.]

Complications of Home Mechanical Ventilation [HMV]
HMV is increasingly being used for children with chronic respiratory failure. In a retrospective study of patients on HMV with mixed etiology [50% had neuromuscular disease, 30% having had HMV initiated under 1 year of age] severe emergencies occurred infrequently [0.2/patient/year] and those correlated only with age [not diagnosis or mode of ventilation.]
[Clin Pediatr. 2011;50(3):237-243.]

Infants of diabetic mothers-fat mass
and cardiac hypertrophy

While improving glucose control during pregnancy in mothers with Type 1 [TIDM] and gestational diabetes [GM] has improved infant morbidity and mortality, infant skin fold [macrosomia] and cardiac septal thicknesses are unchanged. These abnormalities appear to significantly correlate with cord blood C-peptide and leptin levels.
[Neonatology. 2011;100(2):147-154.]

Measles vaccination and religion
Children from Orthodox Jewish communities in Belgium appear to be at a four-fold greater risk for delayed start, increased temporal spacing, non-completeness or timeliness of measles/mumps/rubella vaccination. This may be related to “belief issues” and difficulty in accessing vaccination programs.
[Pediatr Infect Dis J. 2011;30(4):343-345.]

Pain management during
diagnostic tympanocentesis
Infants/toddlers [6 months-36 months] undergoing tympanocentesis require pain medication. In a randomized control trial using 3 pain reduction interventions [acetaminophen, acetaminophen plus codeine, and ibuprofen plus midazolam], pain and distress measurements taken throughout the procedure indicated that acetaminophen alone appears not to be as effective as the other treatments.
[Clin Pediatr. 2011;50(3):231-236.]

Obesity and Gentimycin serum concentrations
Obese children 2-18 years of age who receive scheduled gentimycin therapy appear to have significantly higher peak and trough concentrations though receiving lower mg/kg of actual body weight doses.
[Pediatr Infect Dis J. 2011;30(4):347-349.]

Subcutaneous [SC] rehydration therapy [SCRT]
For mild-to-moderate dehydration, SCRT [“hypodermoclysis”] augmented at the infusion site with a recombinant human hyaluronidase enzyme [increases SC administration rate five-fold] is less painful and invasive, and appears to make this technique a valuable alternative to failed oral rehydration or when immediate intravenous fluid therapy is difficult.
[Ped Emerg Care. 2011;27(3):230-236.]

Emergency Department physicians’
fear of malpractice and CAT scan use

A study of Board-eligible/certified Emergency Department [ED] physicians utilized their responses to a survey consisting of three clinical scenarios and demographic questions to relate that data to their use of brain CAT scans in children [a proxy for fear of malpractice suits] with minor head trauma. Results indicated that though in only one scenario the fear of malpractice litigation statistically affected the increased usage of brain CAT scans, on average, the greater the fear, the more head CAT scans ordered.
[Ped Emerg Care. 2011;27(3):182-185.]

Azithromycin-induced agitation and choreoathetosis
It is of value, as this drug is so widely utilized, for pediatricians to be aware of this first case describing a child who developed agitation and choreoathetoid movements in association with azithromycin use which resolved on withdrawal of the drug.
[Pediatr Neurol. 2011;44(4):311-313.]

Acute fulminant myocarditis [AFM]
AFM, defined as onset of symptoms ≤ 14 days prior to admission, rapid onset of cardiogenic shock with normal left ventricular size has an 85% survival to hospital discharge. Those children with elevated lactate, creatinine, aminotransferase levels and dysrhymias [50%] require ECMO [70% survival]. 80% of AFM patients will survive without heart transplantation.
[J Pediatr. 2011;158(4):638-643.e1.]

Treatment of community-acquired soft-tissue abscesses
The traditional management of soft-tissue abscesses is open incision and drainage [I/D]. This, however, frequently results in pain from packed dressing changes and requires home nursing care. In a study of 219 patients in two comparable groups [both receiving antibiotics] with soft-tissue abscesses treated with either I/D or subcutaneous drains, 3% of patients treated with I/D developed subsequent recurring abscesses, and one had an incomplete drainage. Patients with subcutaneous drains had no recurrences or
incomplete drainage and wound healing appeared better.
[J Pediatr Surg. 2011;46(3):502-506.]

Hip arthroscopy
Hip arthroscopy appears to be an established procedure for many hip disorders, and while complications of the procedure are well-described in adults, there is little data on children. In a retrospective review of 218 hip arthroscopies undertaken by a single surgeon, the complication rate was 1.8% [similar to that of adults]. No case of proximal femoral physeal separation, osteonecrosis or growth disturbance was noted. The procedure in children appears safe and with a low complication rate.
[J Pediatr Ortho.2011;31(3):227-231.]

Persistence and/or recovery from stuttering
Stuttering history and symptom information was obtained from 216 children who stuttered at age 8 years and who were followed into adolescence. Risk factors assessed for stuttering included head injury, age at stuttering onset, family history of stuttering, handedness, whether a second language was spoken at home, gender, and scores from the Stuttering Severity Instrument Version 3. The only factor to predict persistence or recovery was severity of stuttering at around 8 years of age.
[J Dev Behav Pediatr. 2011;32(3):196-205.]

Oral food challenge with a diagnosis of food allergy
A retrospective chart study of 125 children age 1-19 years evaluated for IgE-mediated food allergy who underwent food challenges indicated that after “food avoidance” and oral food challenge 84%-93% of the avoided foods could be returned to the children’s diet. In the absence of anaphylaxis, serum food specific IgE testing tends to be an unreliable indicator.
[J Pediatr. 2011;158(4):578-683.e1.]

Mathematical learning disabilities [MLD]
Poor mathematical competencies are common in adults and result in employment and day-to-day difficulties. Approximately 7% of children have MLD and another 10% show persistent low achievement in mathematics [unrelated to intelligence]. These children have deficits in understanding and representing numerical magnitude, retrieving arithmetical facts from memory and have a slower ability to utilize mathematical procedures. These specific identifiable cognitive delays and deficits appear amenable to treatment.
[J Dev Behav Pediatr. 2011;32(3):250-263.]

Depression and mental distress in adult
long-term survivors of childhood leukemia
While childhood cancer survivors are thought to be at greater risk of subsequent psychological disorders in adulthood, a recent study examining the prevalence of depressive symptoms and mental well-being in adult long-term Acute Lymphoblastic leukemia survivors [20 years post treatment] found, compared to normal matched controls, less frequent depression and equal mental health well-being.
[J Pediatr Hem Onc. 2011;33(3):194-198.]

Adherence to home automated peritoneal dialysis [APD]
Fifty-one children undergoing home APD, mean age at onset of treatment 11.8 years [57% male], were assessed for treatment adherence of their APD utilizing a number of variables [e.g. sessions/month, duration of each session, number of cycles/session, volume of dialysate/session] over time. Males and African-Americans were more likely to be non-adherent with decreased number of sessions/month and dialysate volume being the most common abnormalities. Overall, 45% of patients exhibited some non-adherence to their home APD program, emphasizing the importance of close monitoring.
[Pediatr Nephrol. 2011;26(5):789-793.]