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Weekly Updates in Pediatrics

April 2012 Current Updates in Pediatrics

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April 2012

1. Diagnostic Tests for Celiac Disease (CD)
An analysis of Medline and Embase sources found 16% of 2510 articles on 3110 patients (with and without CD) which allowed for a meta-analysis assessment of the accuracy (compared to a histology standard) of IgA and IgG antigliadin (AGA), endomysial (EmA), antitransglutaminase-2 (TG2) and anti-deaminated gliatin peptides (DGP) antibodies, to accurately diagnose CD.
IgA-EmA and IgA-anti TG2 tests appear highly accurate to diagnose CD. (IgA-AGA and IgA-DPG tests are inferior tests for CD)
2. Second course oral ibuprofen in Patent ductus arteriosus (PDA) closure
A small study of 100 preterm infants < 34 weeks gestation, mean birth weight 1350gms, who had a clinically significant PDA (by echocardiography) after a course of ibuprofen were given a second course to assess its efficacy, side-effects and cost.
47.5% of infants closed their PDAs following their second course with improvement in respiratory function and oxygenation. One patient had an intraventricular hemorrhage and the increase in cost was negligible.
3. Octreotide for congenital idiopathic chylothorax (CIC)
Octreotide is an octapeptide that mimics but is more powerful than somatostatin pharmacologically. It has been used, off label, to treat a variety of diseases including chylothorax, where the data concerning efficacy in adults is mixed.
A small (though amongst the largest described) study of 6 full term CIC patients requiring a chest drain from day 1 and given octreotide from 13.5 days of age for 20 days reports resolution in 5 of 6 patients. No patient has side effects of the drug.
4. Adenotonsillectony (TA) and Obstructive Sleep Apnea Syndrome (OSAS). Cognitive and behavioral function.
45 OSAS children whose apnea/hypopnea index, cognitive and behavioral functions and quality of life was assessed were compared to a matched normal group of healthy children. OSAS patients demonstrated significant impairment in executive functions (planning and fluency), attention and receptive vocabulary and exhibited significantly more behavioral problems. Quality of life was demonstrably worse.
OSAS effects begin early in childhood. Following TA significant improvement in cognitive and behavioral modalities can be observed and measured.
5. Growth hormone treatment in Cystic Fibrosis (CF)
A study of 36 prepubertal CF children, < 14 years old had their growth, lean body mass (LBM), pulmonary function and exercise tolerance measured following daily recombinant human growth hormone (rhGH) treatment for 12 months, followed by a further 6 month observation period and compared to a comparable control group. Height, weight, LBM, forced vital capacity and FEV1  all improved significantly compared to the control group, however exercise tolerance was unchanged.
Treatment of prepubertal CF children with rhGH enhances growth and pulmonary function with an acceptable safety profile.
6. Exhaled breath temperature (EBT) as a measure of airway inflammation/modeling in asthmatic children
Significant EBT differences before and after a standardized exercise test in asthmatic children indicates that increasing EBT correlates with a decreasing FEV1. 
7. Toxicity associated with the treatment of Infantile colic with Star Anise.
Chinese Star Anise (a liquorice-flavored spice) contains ingredients that appear to have activity against bacteria, yeast and fungi and has been used for a variety of conditions, especially flu as it contains a compound similar to Tamiflu. Many believe (mostly without evidence. Ed) that it is useful in respiratory and gastrointestinal disorders.
A report of Star Anise tea use to treat colic in babies (there is an FDA advisory against using such teas) outlines the severe toxicity that can occur-neurological abnormalities (including tetany, hypotonia and seizure-like activity) and gastrointestinal disturbances.
Chinese Star Anise should not be used for the treatment of infantile colic.

8. Brushing teeth and plaque removal
68 children, 4-7 years of age with significant teeth plaque were randomized to have their teeth brushed by a dental hygienist for 1 and 2 minutes using a Phillips Sonicare for children (SFK) at 2 amplitude settings or, the Oral-B stage 3 toothbrush (appropriate for age). 
In 4-7 year old children the Phillips SFK toothbrush (at both amplitudes) removes significantly more plaque than the Oral-B.
9. Febrile Seizures and diphtheria-tetanus-acellular pertussis-inactivated polio virus-hemophilus influenza type b (DTaP-IPV-Hib) vaccine.
Vaccination with whole-cell pertussis carries an increased risk of febrile seizures.
DTaP-IPV-Hib vaccination causes a small absolute increase in risk for seizures on the day of vaccination, without an increase in the incidence of epilepsy.
10.  In-utero opiate (OP)/benzodiazepine (BZ) exposure, and eye abnormalities
A retrospective analysis of 24 children exposed in-utero to either/both OP/BZ was conducted to assess the time of onset and the length of persistence of eye abnormalities (nystagmus and visual acuity)
Nystagmus following OP/BZ in-utero exposure usually appears before 6 months of age and is, in most children, still present at 4 years of age. Visual acuity improves over time but remains impaired.
11. Which premature baby fails nasal CPAP
Premature infants (<30 weeks gestation) frequently require early (within 2 hours of birth) respiratory support. In a study of 182 such infants, 34% failed early nasal CPAP.
Males, with a birth weight < 800gms, who required oxygen concentrations > 25% at 1 and 2 hours of age are at greatest risk for nasal CPAP failure.
12.  Emergency Department (ED) boarding of hospital-admitted children
A retrospective study of 1792 pediatric inpatient records examined the relationship between length of ED stay (LOS) following admission note, vs subsequent inpatient LOS, readmission rate, mortality and overall cost. A variety of covariates were examined. 
Mean ED boarding time was 5.1 hours. This was statistically associated with greater inpatient LOS among low-acuity medical patients, readmission rate for surgical patients and cost. Mortality rate was unaffected.
13. “Oral piercing” injuries and Emergency Department (ED) visits
Over a 7 year period, 24459 oral piercing injuries presented to USA ED’s. 14-23 year olds accounted for 78% of visits and the male:female ratio was 1:2.6.
46% of patients had injuries to the lips, 42% tongue and 10% teeth. Infections were common (42%) and many injuries were due to the patients’ inability to remove the oral piercings overgrown by tissue. Hospitalization was rare.
Teenagers and young adults with oral piercings frequently present to USA ED’s. Physicians/dentists need to be aware of the complications and be prepared to manage these patients.
14. Burn care has greatly improved survival following a severe burn injury. A large retrospective study of 952 severely burned (>30% total body surface area-TBSA) comparably managed pediatric patients was undertaken to identify the burn size most associated with increasing morbidity and mortality.
In a modern burn care setting, a burn size of 60% TBSA is the critical threshold above which morbidity and mortality increases.
15. Prevention of tracheostomy-related pressure ulcers (TRPU) in children
An research intervention model was subsequently incorporated into a TRPU prevention program which included education of staff, ongoing assessment of skin integrity and the use of tracheostomy-skin interface devices.
TRPU rate may be decreased from 8.1% utilizing a standard protocol to 0.3% using education, skin assessment and extended tracheostomy tubes.
16.  “Gender confusion” – a new issue for pediatricians
Apparently 2-4% of boys and 5-10% of girls between the ages of 4-18 years behave as the opposite sex occasionally. 5-13% of teenage boys and 20-26% of teenage girls report cross-gender behavior. Some 2-16% of mothers report that their children wish to be of the opposite sex.
97 patients <21 years of age who had long-standing cross-gender behaviors were seen and analyzed in a Multidisciplinary Gender Management Service. Age of presentation was 14.8 years and males and females were equally represented. 44.3% of patients had a significant psychiatric history including self-mutilation (20.6%) and suicide attempts (9.3%).
In addition childhood gender nonconformity appears to be associated with poorer child/parent relationships and places these children at greater risk for abuse and post-traumatic stress disorder (PTSD).
Gender non-conformity in childhood/adolescence is apparently an under identified problem. A multidisciplinary team may be required to manage these complex patients.
17. Gene polymorphism and Sudden Infant Death Syndrome (SIDS)
It appears that at least seratonergic and noradrenergic neurons (probably with other brain stem neuronal systems) play a role in SIDS. The X-chromosomal monoamine oxide A (MAOA) gene is functionally important in both systems.
A study of 156 white SIDS cases (and matched controls) in which the expression of a functional MAOA promotor length polymorphism was examined, indicated a significant relationship between MAOA genotype, particularly in male infants who died between 46-154 days of age.
This report is the first X-chromosomal locus found associated with SIDS.
18. Fetal growth, cardiovascular risk and Omega-3 supplementation
Impaired fetal growth is a risk factor for subsequent cardiovascular disease and is associated with thickening of arterial walls.
616 growth retarded term babies were randomized at 6 months of age (or start of bottle feeding) to receive either a fish oil, Omega-3 or sunflower seed oil (control) daily supplement until 5 years of age. Carotid intima –media thickness (IMT) (an indicator of subclinical atherosclerosis) was measured at age 8 years. 
Arterial wall thickening associated with impaired fetal growth appears to be preventable by feeding an Omega-3 fatty acid supplement over the first 5 years of life.
19. Fibular periosteal graft-a new way to enhance bone union
The periosteum in children is strongly osteogenic, thick, and can be easily utilized as a vascularized “free” or “pedicled” flap.
12 children had 13 vascularized fibular periosteal grafts used to either prevent or to treat bone non union.
Vascularized periosteal fibular flaps appear to be an effective and valuable treatment option to enhance bone union.
20. Thrombotic microangiopathy associated with Anti-phospholipid syndrome (APS)
APS is rare in childhood and when it occurs it is usually as a complication of Systemic Lupus Erythematosis (SLE)
In this first report, a child with TMA due to APS and a newly discovered Lupus anticoagulant, anti-phosphotidylserine-prothrombin complex IgG antibody (aPS/PT) is described.
21. Incontinence and enuresis in children 6-12 years of age
The prevalence of lower urinary tract symptoms in Brazilian children was assessed using a version of the Dysfunction Voiding Scoring System in which an abnormality of voiding is defined by children being >6 years of age for girls and >9 years of age for boys.
Lower urinary tract symptoms (diurnal urinary incontinence, holding maneuvers and urinary urgency) is detected in 21.8% of school age children (more frequently in girls than boys) in Brazil and is associated with lower social levels and constipation.
22. Investigation of urinary tract infections (UTI) in young (<36 months) children
Recent guidelines have stressed the need for fewer invasive procedures to diagnose UTI in young children. In a retrospective review of 406 children <36 months of age at their first UTI, all underwent initial renal ultrasonography (RUS). Children with an abnormal RUS and those with recurrences had a voiding cystourethrogram (VCUG) and dimercaptosuccinic acid (DMSA) renal scan.
23. Perceptions of Masculinity and HIV risk
Young black men who have sex with men age 15 to 22 (YBMSM) have the highest rate of HIV infection in the USA, 5 times higher than comparable white men. The rate of unprotected anal intercourse however occurs equally across men of other racial/ethnic backgrounds.
An analysis of semi-structured interviews of YBMSM identifies factors that influence their partner selection, risk-assessment and decision making with regard to condom usage. 
Partner perceived masculinity appears to play a significant role in increasing HIV risk in these individuals.

24. Pertussis and retinal hemorrhages
In a small study, 35 children aged 15 days to 2 years with pertussis infection underwent opthomological examination within 72 hours of admission. If retinal hemorrhages were detected further investigation was to be undertaken.
No retinal hemorrhages were found in any child diagnosed with pertussis.
25. Diabetic children treated with continuous subcutaneous insulin infusions (CSII)
Charts of 67 diabetic children aged 1-16 years treated with CSII over a 4 year period were analyzed retrospectively. Significant improvement in measured HbA1c levels, insulin doses, with a trend towards reduced BMI was found.