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Weekly Updates in Pediatrics

December 2011 - Current Updates in Pediatrics

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December 2011
1 Recurrent Abdominal Pain (RAP)
RAP is a common complaint in children, rarely associated with organic disease. John Apley, in 1958 defined RAP as that which waxes and wanes, occurs with three episodes within a three month period and is severe enough to affect the child’s activity.
For 2 years all consecutive patients (4-16 years of age) fulfilling Apley criteria had a stepwise treatment program after a full diagnostic workout.
Of 200 children followed (46% with occult constipation, 20% GIT infection, 2.5% food allergy and 6.5% with miscellaneous/uncertain diagnoses) almost all (99%) became pain free during an 18 month follow up period.
Acta Paediatrica, Vol 100 Issue 11, Nov 2011

2 Repetitive suicide attempts (RSA)
Of 967 patients who presented to an Emergency Department after deliberate self-poisoning, 21% presented with repeated suicide attempts.
The only reliable factors associated with RSA appear to be (a) having a psychiatric history, (b) living without a family, (c) being a female and (d) being on antidepressant treatment.
The American Journal of Emergency Medicine, Vol 29 Issue 8, Oct 2011

3 Early IV fluids during diarrhea and nephroprotection
A retrospective analysis of children <18 years of age with diarrhea associated hemolytic uremic syndrome (HUS), revealed that IV fluids given within 4 days of onset of diarrhea, significantly reduced the risk of subsequent oliguric renal failure.
Archives of Pediatrics & Adolescent Medicine, Vol 165, No 10, Oct 2011
4 Introduction of allergenic foods and wheezing/eczema
A study from the Netherlands of 6905 children from fetal life to young adulthood was undertaken in which the timing of cow’s milk, hen’s eggs, peanuts, tree nuts, soy and gluten introduction was collected at 6 and 12 months of age. Information on the presence of wheezing/eczema was obtained from a parental questionnaire.
Wheezing was reported in 31% of patients at age 2 years and in 14% at ages 3 /4 years. Eczema was found in 38%, 20% and 18% of children at 2, 3 and 4 years respectively.
The introduction of the above allergenic foods introduced before 6 months of age does not appear to be significantly associated with wheezing/eczema at any age.
Archives of Pediatrics & Adolescent Medicine, Vol 165, No 10, Oct 2011
5 Adolescent children and Dream Recall
Adult women report a higher frequency of dream recall than men, and increased awakenings seem to increase dream recall. DR may also be associated with personality traits like creativity. To date no large scale comparable information on adolescents exists.
5580 adolescents (mean age 18 years, males and females) participated in an internet-administered questionnaire related to dreaming, sleep, perceived stress and creativity.
Females described themselves as more creative, had greater dream recall, felt more strongly that DR affected their next day and reported suffering more sleep problems and stress.
It appears that as for adults, adolescent DR is associated with female agenda, good mood and creativity. DR is generally associated with health and well being.
Journal of Adolescent Health, Vol 49 Issue 5, Nov 2011
6 NICU outcomes for “open-bay” (OB) versus “single-family” (SF) room care
A variety of outcomes was examined retrospectively in a group of 3143 similar NICU patients over a 5 year period cared for in either OB or SF environment.
No difference in serious outcome was found.
Journal of neonatal-perinatal Medicine, Vol 4, No 3/2011
7 VSL #3 (Probiotic) in the treatment of Ulcerative Colitis (UC)
VSL#3 is a high potency probiotic with 450 billion live bacteria per packet. It is postulated that on oral intake these bacteria colonize the bowl and adhere to its wall protecting the wall from noxious stimuli which may cause inflammation.
Following a systematic review of the literature a simulated model of 10 year old patients with increasingly severe UC could be created which allowed for a comparison between “standard medical therapy” versus “medical therapy plus VSL#3” over a prolonged period of time. This model assumed that patients would require escalating therapies. Primary outcome was cost-effectiveness (“quality-adjusted life-year”)(QALY).
Taking into account increasing severity over time of UC (including surgery), adjunct VSL#3 use for pediatric UC induction and maintenance does not appear to be cost-effective.
Journal of Pediatric Gastroenterology & Nutrition, Vol 53 Issue 5, Nov 2011
8 Salivary tacrolimus levels in renal transplant recipients
Tacrolimus is frequently prescribed in children undergoing allograft transplantation and appropriate blood levels to prevent rejection and nephrotoxicity (plus other adverse events) require frequent blood levels to be measured. While recent advances have made home-based blood sampling possible, discomfort and patient preference has driven the need to find alternative methods.
High-performance liquid chromatography-tandem mass spectrometry used to compare blood and saliva tacrolimus levels indicates both inconsistent results and poor correlation between samples. Saliva tacrolimus cannot be substituted for blood sample measurements.
Pediatric Nephrology, Vol 26 No 1, Nov 2011
9 Bacterial tracheitis (BT)
Four BT patients presenting with varying degrees of upper airway obstruction are described. 2 of 4 were afebrile and non-toxic, half had an elevated white cell count. Cultures grew Staph. aureus, in 2 patients, 1 grew Moraxella catarrhalis and one had mixed organisms. All 4 were successfully treated with antibiotics and bronchoscopic debridement of the membranes.
BT needs a high index of suspicion because of its varied presentation. Severe forms require aggressive management.
Pediatric Emergency Care, Vol 27 issue 10, Oct 2011
10 Effect of pressure applied during casting on temperatures beneath the casts
An upper extremity model was created to measure pressure and temperature underneath three casting materials (fiberglass only, plaster only splint and plaster splint overwrapped with fiberglass) with otherwise standardized management.
Increasing pressure at cast site leads to a statistically significant increase in temperature. A plaster/fiberglass combination causes the greatest increase, though not to the level of a burn.
Plaster casts should be cooled before overwrapping with fiberglass.
Journal of Pediatric Orthopaedics, Vol 31 issue 7, Oct/Nov 2011
11 Rib resection in thoracic Idiopathic Scoliosis
Scoliosis is a complex 3-dimensional deformity affecting the spine and rib cage. Rib cage deformity decreases primary function causing a restrictive pulmonary disorder. Thoracoplasty with surgical correction of scoliosis decreases pulmonary function though it enhances cosmetic results.
Convex short length rib resection in adolescent thoracic idiopathic scoliosis (and thoracic hypokyphosis) patients appears to give better rib hump correction than either conventional thoracoplasty or no thoracoplsty.
Journal of Pediatric Orthopaedics, Vol 31 issue 7, Oct/Nov 2011
12 Urine IL-8 concentrations in Infectious/non-infectious urinary tract pathology
Cytokines modulate the inflammatory process associated with urinary tract infections (UTI) and IL-8 is pro-inflammatory mediator produced in response to UTI.
A large study of urinary IL-8 levels in 1 month-1 year old infants with acute UTI, resolved UTI, vesicoureteral reflux (VUR) without UTI, non-VUR congenital urinary anomalies with recent UTI, isolated antenatal pelvic dilatation and a control normal group, was undertaken to identify differences in urinary IL-8 levels to enhance diagnosis, prognosis and treatment.
Results indicate that urine IL-8 levels cannot be used as a specific biomarker of urinary tract disease as they may be elevated in many of above conditions.
Pediatric Nephrology, Vol 26 No 11, Nov 2011
13 Whole body cooling and hypoxic encephalopathy
Therapeutic whole body cooling to 33.5 degrees C (core temp.) then re-warming slowly has been extensively reviewed.
A study of 95 neonates, 39 weeks gestation, birth weight 3.43kg (mean) who underwent therapeutic hypothermia following CPR at birth was examined. Survival and adverse results at 9 months of age were assessed.
78% of infants survived, 85% were discharged home, 60% fed orally, 20% had a normal brain MRI, (50% of these had a normal neurodevelopmental exam) and 15% were discharged to rehabilitation hospitals.
Therapeutic hypothermia following severe hypoxic perinatal injury appears safe with encouraging mortality and short-term morbidity.
Journal of Neonatal-Perinatal medicine, Vol 4 No 3/2011
14 Occult serious bacterial infection in young infants with Bronchiolitis
A retrospective analysis of a Medline database for febrile infants younger than 90 days with a diagnosis of bronchiolitis/RSV infection where cultures (blood, urine and/or CSF) were undertaken revealed, only 3.3% having positive urine cultures and no infant having bacteremia or meningitis.
Culture screening in young febrile infants diagnosed with bronchiolitis/RSV infection gives a very low yield.
Archives of Pediatrics & Adolescent Medicine, Vol 165 No 10, Oct 2011
15 Analgesic effects of oral morphine versus oral morphine/sublingual midazolam
58 children (5-16 years) with clinically deformed closed long-bone fractures randomly received either oral morphine (0.5mg/kg)/sublingual placebo or morphine (0.5mg/kg)/sublingual midazolam (0.2mg/kg) analgesia with pain being assessed at 0-120 minutes.
The analgesic effects of oral morphine alone vs. morphine/midazolam are similar, however the addition of midazolam increases the frequency of drowsiness.
Acta Paediatrica, Vol 100 Issue 1, Nov 2011
16 Serum bicarbonate (HCO3) levels and venous pH in Diabetic Ketoacidosis (DKA)
A retrospective analysis of 300 pediatric patients who had both venous blood gases and simultaneous metabolic panels drawn, indicated that a good correlation (R=0.89) exists between the two measurements.
A serum HCO3 level of 18.5 or less predicts a pH <7.30, and a HCO3 level of 10.5 or less predicts a pH <7.10. Venous pH measurements may not be necessary for all patients being evaluated for DKA.
Pediatric Emergency Care, Vol 27 Issue 10, oct 2011
17 Mycoplasma pneumonia associated mucositis (MPAM)
MPAM has been labeled as an atypical Stevens-Johnson syndrome (SJS) with minimal or no skin manifestations. While rare (19 pediatric cases) it occurs predominantly in males and generally responds well to antibiotic therapy and supportive care.
In this case report, a previously healthy girl with MPAM did not respond to conventional treatment but improved following intravenous immunoglobulins (0.5g/kg/day) for 4 consecutive days.
Acta Paediatrica, Vol 100 Issue 1, Nov 2011 
18 Perinatal and neonatal risk factors for Autism
While the etiology of autism in unknown (and probably complex), perinatal and neonatal factors have been the focus of research for more than 40 years. The results of a meta-analysis of 40 studies examining 60 perinatal and neonatal factors are as follows.
Factors associated with increased autism risk include: Abnormal presentation, umbilical cord complications, fetal distress, birth injury or trauma, multiple birth, maternal hemorrhage, summer birth, low 5-minute Apgar score, feeding difficulties, meconium aspiration, neonatal anemia, ABO/Rh incompatibility and hyperbilirubinemia.
No single perinatal or neonatal factor appears to play a role in autism etiology, however there is some evidence to suggest that any deficit in perinatal/neonatal health may be implicated.
Pediatrics, Vol 125 No3, Aug 2011
19 Incidence of Traumatic Lumbar Puncture (TLP)
A prospective study (in a single large tertiary care pediatric hospital) of 127 lumbar punctures (performed over one year) during which CSF was obtained showed 26.2% were traumatic (>400 red blood cells) using the “sitting position” and 12.5% using the “lying position”. Only 26% had no RBCs.
It appears that the incidence of TLP is independent of physicians’ experience, sedation use, or time of procedure. TLP increases with increasing LP attempts.
Clinical Pediatrics, Vol 50 No 11, Nov 2011
20 Shyness versus Social Phobia
To determine frequency of shyness and its relationship to social phobia, a face-to-face survey of 10,123 USA adolescents aged 13-18 years was utilized using a version of the World Health Organization Composite International Diagnostic Interview protocol.
Only 12% of adolescents identified themselves as shy and also met criteria for social phobias.
Patients with social phobia had a greater chance of having psychiatric disorders, including disorders of anxiety, mood, behavior and substance abuse.
Normal “shyness” is different to “social phobia” which is an impairing psychiatric disorder.
Pediatrics, Vol 128 No 5, Nov 2011
21 Outcomes of infants with Acute Liver Failure (ALF)
Common etiologies of 148 infants with ALF (aged <90 days) include, “indeterminate” (38%), neonatal hemochromatosis (13.6%) and herpes simplex virus (12.8%).  Spontaneous survival occurs in 60% of the infants while 46% undergo liver transplantation.
Spontaneous survival in young ALF patients appears better than previously thought. Liver transplantation provides another option.
The Journal of Pediatrics, Vol 159 Issue 5, Nov 2011
22. Preschool wheezing-influence of early antibiotic/fish oil introduction
A longitudinal prospective study of 4496 Swedish children whose parents answered questionnaires at 6 months, 12 months and 4.5 years regarding the use of early antibiotic (< 1 week of age), and early introduction of fish oil (< 9 months), correlated the subsequent development of wheezing during their preschool period, with these interventions.
It appears exposing infants during the first week of life to antibiotics increases the risk of subsequent recurrent wheezing, while the early introduction of fish oil reduces the risk.
Acta Paediatrica, Vol 100 Issue 1, Dec 2011
23 “Continuous” versus “Point-of-Care” glucose monitoring in Type I Diabetes
During multiple types of strenuous exercise (soccer, football, golf, and cross-country skiing) performed episodically over a 3-4 day period, “continuous” glucose monitoring identified significantly more episodes of hypo and hyperglycemia than frequent (mean 8.7/day) “point-of-care” blood glucose testing.
While sensor failure occurs “continuous” glucose monitoring provides an additional opportunity during strenuous exercise in children.
Acta Paediatrica, Vol 100 Issue 1, Dec 2011
24 Fecal Incontinence (FI)
It appears that the neurophysiology of children with fecal incontinence (with and without constipation) is significantly different to healthy normal children or those with Attention-Deficit-Hyperactivity disorder.
Children with FI have more intense frontal, central and parietal region brain responses to a number of different picture stimuli which appears to indicate a neurobiological vulnerability to their enteric and central nervous systems.
Acta Paediatrica, Vol 100 Issue 1, Dec 2011
25 Topical anesthetic cream and cutaneous abscess drainage
A retrospective study of 300 children (median age 7.6 years) who presented to 3 academic Emergency Departments during 2007, examined the relationship between the application of a topical analgesic cream and the spontaneous drainage of an abscess.
Use of a topical anesthetic on a cutaneous abscess prior to any other intervention, results in spontaneous abscess drainage in 9.3% of patients of whom 10% no longer require any further intervention. Those that do, require significantly less procedural sedation.
The American Journal of Emergency Medicine, Vol 30 Issue 1 Jan 2012