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Weekly Updates in Pediatrics

February 2011 - Current Updates in Pediatrics

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Tissue expanders in abdominal wall defects
Closing large abdominal wall defects can be a challenge for surgeons. A variety of techniques have been used to address this problem. Recently, the successful insertion of either intraperitoneal or abdominal wall expanders have been described to increase the abdominal volume. This allows for subsequent successful definitive reconstruction closure to occur.
[J Pediatr Surg. 2011; 46(2):372-377.]
Doi: 10.1016/j.jpedsurg.2010.11.020

Neuromotor outcomes in infants with
Bronchopulmonary Dysplasia [BPD]
Neuromotor development was assessed using the Hammersmith Infant Neurological Examination in 219 infants ≤ 32 weeks gestation and birth weight ≤1500 gms at 6 months and 12 months of age. At both examination periods, global neurological scores were reduced and the greater the severity of the BPD, the worse the outcomes. Neurological improvement occurred over time.
[Pediatr Neurol. 2011; 44(1):40-46.]
Doi:10.1016/j.pediatrneurol.2010.07.008

Sweat test for Cystic Fibrosis [CF] in Newborns
A positive newborn screening test for CF [by immunoreactive trypsinogen concentrations and at least 1 CF mutation by DNA analysis] is frequently confirmed by a CF sweat test. Preterm infants are 2.4-7.4 times more likely to fail to produce enough sweat. Waiting to test an infant beyond 39 weeks corrected age appears to significantly reduce the problem.
[Pediatr Pulmonol. 2011; 46(1):23-30.]
Doi: 10.1002/ppul.21318

Pre-exposure chemoprophylaxis for HIV prevention
Once daily dosing of 2 oral antiretroviral drugs, emtricitabine and tenofobir disoproxil fumarate [FTC-TDF] given for 1-3 years prophylactically [and taken! JW] to men >18 years of age, who have sex with men, significantly [44%] reduces the incidence of HIV infection, with no substantial increase in adverse events. Long-term use raises issues of the long-term toxic effects of treatment and viral resistance. The challenges remain.
[N Engl J Med. 2010; 363:2587-2599.]
Doi: 10.1056/NEJMoa1011205
[N Engl J Med. 2010; 363:2663-2665.]
Doi: 10.1056/NEJMe1012929

Sports-related injuries in children
A retrospective review of injuries occurring as a result of organized and non-organized play [primarily football and basketball] found, for football organized play carried a higher risk of injury, fractures are common, lacerations more common without helmets and closed-head injuries more prevalent. For basketball, non-organized play had a higher likelihood of injury.
[Clin Pediatr. 2011; 50:17-20.]
doi: 10.1177/0009922810378735

Bladder and intra-abdominal pressure
Abdominal Compartment Syndrome [ACS] is the pathological expression of raised intra-abdominal pressure [IAP], which may be secondary to both intra-abdominal medical and/or surgical processes. A surrogate measure of IAP may be obtained by utilizing an indwelling bladder catheter with a monitoring system attached. In a small study of primarily surgically sick neonates, median and 90th percentile pressure measurements were 8mm Hg and 13mm Hg, respectively. Pressures above the 90th percentile were primarily found postoperatively.
[J Neo Peri Med. 2010; 3(4):301-305.]
Doi: 10.3233/NPM-2010-0129

Pectus Excavatum [PE] and lung volume
377 PE children’s total lung volumes [TLV], constructed by utilizing chest computed tomography [CT], were compared to a similar group of normal children. No significant differences in TLV at any age, for either sex, were found.
[J Ped Surg. 2010; 45(12):2322-2327.]
Doi: 10.1016/j.jpedsurg.2010.08.023

First febrile seizure and meningitis
In a retrospective study of 199 infants in India, 6-18 months of age who presented to an Emergency Department with a first simple febrile seizure, 0.86% had meningitis. Meningitis occurred in 4.86% of infants presenting with their first complex febrile seizure. Duration of seizures longer than 30 minutes, post-ictal drowsiness and neurological deficits were predictors of meningitis.
[Pediatr Neurol. 2011; 44(1):35-39.]
Doi:10.1016/j.pediatrneurol.2010.07.005

Deformational plagiocephally/brachycephaly [DPB]
results at 4 years of age
A longitudinal study was undertaken of infants diagnosed with DPB. Followed to assess age-related normative anatomic and developmental changes at 4 years, 61% had head shape measurements reverting to the normal range. Brachychephaly improved more than plagiocephally. 13% were categorized as “poor improvement”. Developmental delays showed dramatic improvement over time.
[Arch Dis Child. 2011; 96:85-90.]
Doi: 10.1136/adc.2010.190934

Neonatal resuscitation and
neuropsychological function
It appears that infants who receive acute resuscitation after birth but who have no evidence subsequently of encephalopathy, and who remain well afterwards, do not differ at 8 and 11 years of age neuropsychologically, from those not requiring resuscitation.
[Arch Dis Child. 2011; 96:30-37.]
Doi: 10.1136/adc.2009.176065

Male external genitalia growth
Growth and development assessment of external genitalia is an integral part of the health assessment of the adolescent. As wide individual variations exist for penile length and circumference measurements, as well as testicular volumes, this recent large cross-sectional population-based study examining healthy white males 0-19 of age, living in both urban and rural areas, gives growth curves for age of all three parameters. Data indicates continuing earlier development of puberty as well as variations in measurements between urban and rural populations. This is a valuable reference article for general pediatricians and endocrinologists. [JW]
[Arch Pediatr Adolesc Med. 2010; 1152-1157.]
Doi: 10.1001/archpediatrics.2010.223

Drowning and Sudden Cardiac Death
While rates of drowning in developed countries appear to have decreased over the past years, drowning remains a leading cause of death in children <15 years of age. Most drownings occur in swimming pools, with 19% occurring in public pools with lifeguards present. 50% of drownings occur in swimmers who are rated as “moderate swimmers”. While the overall rate of sudden cardiac death is low [secondary to cardiomyopathy or coronary artery abnormality], most sudden cardiac deaths occurs in swimmers who have normal anatomic hearts. Specific inherited channelopathies, while rare, have diagnostic and preventive implications for family members. Molecular autopsies aimed at identifying the genetic disease should be obligatory. ECG screening is controversial.
[Arch Dis Child. 2011; 96(1):5-8.]
Doi: 10.1136/adc.2010.185215

Pelvic Inflammatory Disease [PID]
and adolescent pregnancy
Female adolescents are more likely than adults to have sexually transmitted infection, repeated PIDs and shorter times to unwanted pregnancies.
[Arch Pediatr Adolesc Med. 2011; 165(1):49-54.]
Doi: 10.1001/archpediatrics.2010.256

Intractable seizures and epilepsy surgery
While the benefit of epilepsy surgery for children with intractable seizures is well-known, its effects on cognition are less well documented. 67 patients appropriately referred for epilepsy surgery had pre- and post-operative neuropsychologic evaluations. Verbal, performance, full-scale intelligence quotients and the Child Behavioral Checklist were evaluated and comparisons made between the pre- and post-operative data obtained. No overall significant changes occurred.
[Pediatr Neurol. 2011; 44(2):117-121.]
Doi: 10.1016/j.pediatrneurol.2010.10.011

Rectosigmoid perforation with personal watercraft use
Personal watercraft [jet-skis, wave-runners, etc.] usage has become increasingly popular since the 1970s. While perforation of the rectum by excessive water pressure exerted through the anal canal when falling off backwards from such a craft is rare, this first description of a potentially lethal injury warrants attention. The National Transportation Safety Board recommends wetsuit bottoms for all pediatric operators and passengers of these watercraft.
[J Pediatr Surg. 2011; 46(2):402-404.]
Doi: 10.1016/j.jpedsurg.2010.08.052

H1N1 Influenza A infection and
Neurological complications
A variety of neurologic abnormalities have been associated with an Influenza infection. In a 4-month winter study, 74 children were confirmed with laboratory H1N1 infection, 14 [19%] presented with neurologic complications. Most [71%] presented with seizures [febrile and afebrile] transverse myelitis, myositis, expressive aphasia and syncope.
[Pediatr Neurol. 2011; 44(1):47-51.]
doi:10.1016/j.pediatrneurol.2010.08.011

Resection of pulmonary metastases
improves survival with Ewing Sarcoma [ES]

ES is a malignant round-cell tumor frequently occurring in males and often involving the pelvis, femur, humerus, ribs and clavical. While 5-year survival of localized disease may be 70%-80% with chemotherapy, long-term overall survival [OS] of patients with metastasis has not improved. In a small study of patients with PMs, who had surgical removal of the pulmonary metastases, 5-year overall survival rate was highest compared to either chemotherapy alone or to radiation of the lung.
[J Pediatr Surg. 2011; 46(2):332-335.]
Doi: 10.1016/j.jpedsurg.2010.11.013

Hypothermia for Out-of-hospital Cardiac Arrest
For adult patients, hypothermia [32°C-34°C] treatment for 12-24 hours following successful cardiac resuscitation has been recommended in the 2005 AHA Guidelines for Cardiopulmonary Resuscitation. It appears that morbidity and mortality is unaffected by which temperature is chosen within the temperature range suggested, however, at 32°C, hypotension is significantly increased.
[Am J Emerg Med. 2011; 29(2):148-154.]
doi:10.1016/j.ajem.2009.08.021

Neuro outcomes following Childhood Stroke
Neoromotor and neuropsychologic outcomes in 31 children who had strokes and who were compared to a normal group indicated that 62%-70% had neuromotor impairment and exhibited worse attention, language, memory and sensorimotor functions. Executive functions [self-control, planning, reasoning and abstract thinking] remained intact, and these appear to contribute to the normal range of intelligence quotient found. Neurocognitive deficits require long-term follow-up.
[Pediatr Neurol. 2011; 44(2):101-109.]
Doi: 10.1016/j.pediatrneurol.2010.08.012

RSV infection-early risk
factors for Respiratory Failure

Previously healthy RSV-infected children who exhibit at initial presentation to an Emergency Department with lethargy, grunting and a PaCo2 ≥ 65mm Hg, are at significant risk for requiring subsequent mechanical ventilation.
[Am J Emerg Med. 2011; 29(2):168-173.]
doi:10.1016/j.ajem.2009.08.020

Blood lipids and Lipoprotein
levels from Youth to Adulthood

High-risk blood lipid and lipoprotein levels measured at 9, 12, or 15 years of age, were found when levels were repeated 10 years later, to be substantially improved. These changes were probably related to improved life-style, weight, fitness, saturated fat intake, smoking and socioeconomic position.
[Arch Pediatr Adolesc Med. 2011; 165(1):68-76.]
Doi: 10.1001/archpediatrics.2010.246

Maternal Diabetes and Fetal Esophageal Atresia [EA]
A population-based, matched case-control study utilized to assess the effect of maternal diabetes on the incidence of EA in their offspring, demonstrated the adjusted risk of EA in these infants to be 70% higher than those infants of women without diabetes.
[J Pediatr Surg. 2010; 45(10):2004-2008.]
Doi: 10.1016/j.jpedsurg.2010.06.008

Basal ganglia and thalamic changes,
and depression/anxiety disorders
While studies of adults with depression/anxiety disorders have demonstrated smaller subcortical volumes in structures such as the amygdala, hippocampus, caudate nucleus and thalamus , this cranial ultrasound study of 651 infants’ brains at 6 we`eks of age is apparently the first to find smaller gangliothalamic diameters in children at 18 and 36 months of age who exhibited higher Child Behavior Checklist Internalizing scores. This points to a biological vulnerability associated in the development of Internalizing problems/depression in childhood.
[J Am Acad Child Adolesc Psych. 2010; 49(10):1053-1063.]
Doi:10.1016/j.jaac.2010.07.003

ELBW infants and neurodevelopmental outcomes
A multicenter retrospective analysis of neurodevelopmental outcomes was assessed over two time periods [1990-2001 and 2002-2004] to determine whether survival and adverse outcomes had decreased over time. Both infant survival and neurodevelopmental outcomes were unchanged. Impairment was noted in over 50% of surviving infants.
[Pediatr. 2011; 127(1):62-70.]
Doi: 10.15242/peds.2010-1150