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Weekly Updates in Pediatrics

August 2011 - Current Updates in Pediatrics

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Infant/toddler sun protection
It is important to remember that the infants’ skin [at least during the first 2 years of life] is not only an immature physical barrier but probably more sensitive to the deleterious effects of solar ultraviolet radiation [UVR]. While UVR exposure of the adult skin results in immunosuppression and cutanenous tumorigenesis, little is known about the accumulating toddler skin damage, which may begin during the first summer exposure.

Sun protection from an early age is essential.
[Pediatr. 2011;128(1):92-102.]

Survival from Hypoplastic Left Heart syndrome [HLHS]
HLHS babies who have chromosomal abnormalities are born premature [<37 weeks gestation], have low birth weight [<2.5kg], are from poor families living in poor neighborhoods, and have an approximately 2-3 times greater risk of dying in the first year of life than those who do not suffer from those handicaps.
[J Pediatr. 2011;159(1):57-63.]

Childhood food allergy
From a cross-sectional survey, data from 38,480 children indicated an 8.0% prevalence of food allergy with 30.4% of them having multiple allergies. 38.7% had a history of severe reactions. Allergy to peanuts, milk and shellfish were most common. Variations in prevalence occurred between different ages, racial groups, income and geographic areas.

Disparities exist in diagnosing food allergy, which might account for the higher prevalence noted in this study.
[Pediatr. 2011;128(1):e9-e17.]

Inhaled hypertonic saline [HS]
for children with Cystic Fibrosis [CF]

Inhaled hypertonic saline in patients with CF improves mucoliary clearance and could be a useful agent in improving lung toilet over a protracted period.

Seven percent HS administered via face mask twice daily for 14 days in 20 children 12-30 months of age with CF, following a test dose for intolerance, appears to have been well tolerated with a good adherence rate.
[Pediatr Pulmonol. 2011;46(7):666-671.]

Asthma: promoting best-care practices
Community Health Centers continue to see substantial numbers of poorly controlled asthmatic children. Guidelines to treatment are available; however, patient adherence remains problematic.

A data-driven continuous quality-improvement process with asthma coordinators providing patient education as part of the management team demonstrated fewer emergency department visits, hospitalizations, daytime symptoms and missed school days. Impressive changes in healthcare outcomes was noted.
[Pediatr. 2011;128(1):20-28.]

Pilonidal Disease management in adolescents
Pilonidal [“nest of hairs”] disease occurs predominantly in 26 years of age, affects boys more frequently than girls, and while usually described as appearing in the buttock cleft, it may occur in other areas. Treatment required usually involves surgery.

A retrospective survey of all patients treated with pilonidal disease in a single pediatric hospital, two forms of surgical management [“wide excision” “cleft lift”] were compared. 97.4% of cleft lift patients healed completely, compared to 73.5% of the excision group.

The cleft left “procedure appears to result in better primary healing, lower chance of recurrent disease and simplified wound care.
[J Pediatr Surg. 2011;46(6):1256-1259.]

Media use and child sleep
Data was collected by “media diaries” on amount of TV time, content title [coded for ratings, violence, scariness and pacing], adult co-use, video games and computer usage in children 3 to 4 years. Nested linear regression models were built to examine these effects on a “sleep problem score.”

On average, children consumed 72.9 minutes of screen time per day with 14.1 minutes occurring after 7 p.m. Eighteen percent of parents reported at least one sleep problem.

Children with a bedroom television, increasing evening media use and violent content are most frequently affected.
[Pediatr. 2011;128(1):29-35.]

Chest pain in children
Pain may be the result of conditions, in any of the structures of the chest, normally referred sources outside of the chest [e.g. abdomen]. “Most chest pain is caused by benign health-limiting illnesses”. Some common causes include costochondritis, injury to chest wall structures, acid reflux and stress or anxiety. Chest pain from cardiac causes in children are rare; however, they do occur [e.g. pericarditis]

In this case-report, a 6.5-year-old previously healthy little girl presents with fever and chest pain. During an extensive evaluation, she died of an aortic rupture due to a rare instance of Infectious Aortitis.
[Pediatr Emerg Care. 2011;27(7):654-656.]

Early weight loss and a weight management program
Following a 20-week family-based behavioral weight loss treatment program, improvement in weight of overweight 7-12-year-old children as well as their parents was noted.

Early weight loss was a good predictor of weight loss at 2-year follow-up.
[Pediatr. 2011;128(1):e33-e39.]

Deformational Plagiocephaly [DP] and developmental delay
Deformational Plagiocephaly or DP [positional, asymmetrical head] primarily occurs in premature infants whose heads maintained this position for a prolonged period of time [though other causes exist]. This results in flattening of the skull. A study of 227 DP children assessed at 7 and 18 months and compared to a matched group of infants indicated lower scores [developmental delays] on all the scales of the Bayley Scales of Infant and Toddler Development.

While a causal relationship could not established, ongoing surveillance of DP infants seems warranted.
[Arch Pediatr Adolesc Med. 2011;165(7):653-658.]

Parents’ experience with Expanded Newborn Screening Evaluations
Thirty families completed 48 open-ended interviews before and/or after parents received confirmatory positive diagnostic results of a rare metabolic disease in their newborn baby. Initially, shock and urgent and frequently frustrated searches for information dominated: parental confusion and information inaccuracies were frequent in spite of counseling and teaching. In spite of all the difficulties, most parents still felt that newborn screening was an important part of infant health.

The evaluation of a newborn for an abnormal screening result is highly stressful for parents and it is critical to ensure appropriate, frequent, patient communication and education [recognizing different cultural and educational backgrounds] by all clinical services involved.
[Pediatr. 2011;128(1):53-61.]

TV exposure and food commercials
A study of 281 English 6- 13-year-old children exposed to repetitive food and toy television commercials indicated that following habitual viewing of both, all children selected fat-rich and carbohydrate-rich items from food preference checklists compared to no changes in food choice following toy commercials.

Children with high television exposure are at increased risk for consumption of calorie-rich food items.
[Pediatr. 2011.128;(1):e93-e100.]

Heliox in the management of Neonatal Meconium Aspiration [MAS]
In a small study of ventilated newborns with MAS, 1-hour heliox ventilation allowed for a significant decrease in inhaled oxygen concentrations with improved ventilation/perfusion matching. Other parameters of respiratory function [e.g. Tidal Volume] improved nonsignificantly. Babies remained clinically unchanged during the heliox treatment.
[Neonatal. 2011;100:265-270.]

Infant allergy and maternal folic acid ingestion
Data on eczema and wheeze was collected on a large cohort of infants at 3, 7, 12, and 24 months, 4 to 5 years and 6 to 7 years after delivery. Atopic dermatitis and total and specific immunoglobulin E levels were measured at 2 years, and a history of asthma determined with lung functions measured at 6 to 7 years. Blood intracellular folic acid [ICF] levels were used as an indicator of folic acid ingestion during pregnancy [ascertained at approximately 35 weeks gestation] and correlated to eczema/wheeze data.

Maternal folic acid ingestion during pregnancy appears NOT to be associated with an increase in atopic disease in infancy.
[Pediatr. 2011; 128:(1):e135-e144.]

CPR training – how to maintain skills!
Retention of skills required for effective CPR is mandatory though difficult to achieve when usage is infrequent. A study investigating the benefits of brief [1-2 minutes] multiple booster bedside cardiopulmonary resuscitation [CPR] training was undertaken utilizing simulated arrests after staff had achieved Basic Life Support Certification [0, 1, 3, and 6 months after training] during 1 of 4 study arms [instructor-only training; automated defibrillator feedback only; instructor training plus automatic feedback and a control group with no structured training].

Retention of CPR skills was 2.3 times more likely after two trainings and 2.9 times after three trainings. Automated defibrillator feedback had the lowest retention rates when compared to the instructor-only training group.
[Pediatr. 2011; 128(1):e145-e151.]

Poor outcomes following traumatic arrest
Of 118 traumatic arrests [pulseless and apneic] in children <13 years of age to which emergency medical services responded, only 5% survive. All survivors were severely neurologically impaired.

In this study, no subset of patients could be identified for whom regressive resuscitation appeared warranted.
[Pediatr Emerg Care. 2011;27(7):616-621.]

Acute Tc-99m DMSA Scan for demonstrating vesicouteral reflux
There is still ongoing debate regarding the type and/or sequence of imaging studies needed during the first febrile urinary tract infection [UTI] in young children. Some suggest a normal DMSA-scan in this setting makes a voiding cystourethrogram [VCUG] unnecessary.

A study which evaluated the accuracy of acute-phase DMSA scanning in identifying dilating [grades III through V] vesicouteral reflux in acute UTIs in comparison to the VCUG, indicated that:

The VCUG is the more accurate investigation in this clinical setting. 
[Pediatr. 2011;128(1):e169-e179.]

Methodone-induced pulmonary adema and ECMO
Extracorporeal membrane oxygenation [ECMO] has been successfully utilized in the management of opiod-induced pulmonary edema.

This is the first clinical report of ECMO being utilized as a rescue therapy in two children with methodone overdose, pulmonary edema, acute respiratory distress syndrome and circulatory failure.
[Pediatr Emerg Care. 2011;27(7):633-634.]
 
Sustained lung inflation [SI] and oxygenation in newborns
Twenty-four preterm babies [28 weeks gestation] who required respiratory support immediately after birth were resuscitated, during which three different SIs 25cm and 30cm water pressure for a 15-minute duration was administered. This was followed by nasal CPAP as a first-line support. Seventy-five percent of infants required more than one SI.

During the last SI, a rapid increase in infants’ heart rate and cerebral tissue oxygen saturation was noted followed, after a short delay, by an increase in arterial oxygen saturation.
[Pediatr Research. 2011;70(2):176-180.]

Inhaled nitric oxide [iNo]/BPD and death
Bronchopulmonary dysplasia [BPD] is a multifactorial disease with many different abnormalities occurring in multiple cell types.

While it appears that iNo use in ventilated preterm infants at 7-21 days may decrease the subsequent development of BPD and death, this meta-analysis is suspect because of design concerns.
[Donohue PK, Gilmore MM, Christofalo E, et al. Pediatr. 2011;127(2):e414-e422.]
[Pediatr. 2011;128(1):e255-e256.]

Marfan syndrome and neurovascular complications
Maran syndrome is a genetic autosomal dominant [though 30% of cases have no family history] connective tissue disorder which causes abnormalities in the elastic tissue of medium-sized arteries. While cardiovascular, skeletal, eye and skin abnormalities are frequent, this case presentation demonstrates their complication neurovascular disaster involving a spontaneous intracranial cerebral artery dissection in an adolescent with a concomitant ischemic stroke.
[Pediatr Neurol. 2011;45(1):39-41.]

Personal belief exemption from Immunization –
Pediatric Infectious Diseases Society [IDS] Position Statement

Through a “progressive national immunization for diseases [smallpox, polio, measles and rubella] have been eliminated from the USA, and others significantly reduced.

The IDS is opposed to any regulation that would exempt children from mandatory immunizations, and in this “must-read” article, outlines the provisions it deems essential to ensure that regulations or legislation be promulgated on this topic.
[Pediatr Infect Dis J. 2011;(30)7:606-607.]

Cerebralspinal fluid [CFS] protein
and traumatic lumbar puncture
For every 1,000 cell increase in CFS red blood cells [per mm3], CFS protein increases by approximately 1mg/dl.
[J Pediatr. 2011;159(1):158-159.]

Vascular anomalies of the male genitalia
Over a 15-year period, approximately 3% [117 patients] of children presenting to a major pediatric teaching center’s surgical department with male genitalia lesions had a  vascular anomaly. Ten percent had tumors; the rest vascular malformations.

Tumors presented with ulceration [33%] and ambiguous genitalia [25%]. Malformations frequently manifested with swelling [40%], fluid leakage [16%] and pain [16%].
[J Pediatr Surg. 2011;46(6):1214-1221.]

Breastfeeding and Sudden Infant Death Syndrome [SIDS]
The benefits of breastfeeding [particularly exclusively for 6 months] are manifold. In an analysis of 24 original case-control studies, 2 teams of 2 reviewers evaluated the study quality.

Breast milk-fed infants at 2 months of age or older who received any amount of breast milk for any duration had significantly reduced risk of SIDS. This effect is strongest when breastfeeding is exclusive.
[Pediatr. 2011;128(1):103-110.]