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Weekly Updates in Pediatrics

February 2012 - Current Updates in Pediatrics

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February 2012 

1 IV Infusion of 3% saline 
IV 3% saline is utilized to rapidly increase intravascular volumes in the management of a variety of clinical situations, by mobilizing fluid from the intracellular space. This not only increases overall plasma volume up to 4-fold that of an infused crystalloid, but also prolongs the duration of the increased plasma volume and has beneficial immunomodulatory effect. A study of 101 children (mean age: 5.9 years) requiring critical care transport was undertaken using IV 3% saline to assess its safety and efficacy.
Significant reductions in serum BUN and anion levels occur with significant increases in serum sodium. No adverse events noted.
2 Diagnostic imaging in cryptorchidism
Undescended testis is the most common genitourinary abnormality found in boys. 
Ultrasound, computed tomography and magnetic resonance imaging have been utilized to localize the undescended testis. While routine diagnostic imaging does not appear necessary, ultrasound evaluation may be of value in children with undescended testis and ambiguous genitalia or hypospadias.
Journal of Pediatric Surgery Dec 2011

3 Safety of High-Concentration Nitrous Oxide (N2O) for procedural sedation
Nitrous Oxide is a gas with no color or smell and which doesn’t irritate the mucose on inhalation. Usually is given briefly for sedation as a 30% N2O/70% oxygen mix.  A 5.5 year study investigating the use of higher doses (up to 70%) N2O given by nasal mask on 7,802 occasions indicated no adverse events for 95.7% of cases. Nine patients had potentially serious complications which resolved without incident.
N2O in a N2O/O2 mix appears to be safe at all pediatric ages administered at up to a 70% concentration by nasal mask, particularly for short periods (less than 15 minutes).

4 Teeth sealants to protect enamel from acid demineralization
Utilizing extracted molars, a variety of sealants were studied to assess their protective effects from immersion in a lactic acid gel for 20 days.
While resin-based sealants containing fluoride or amorphous calcium phosphate provide greater protection than conventional non-flouride sealants, a glass inomer sealant appears most effective.
5 Maternal polyhydramnios and short term outcome for term/near-term singleton babies
A retrospective study of 788 term/near-infants born of mothers with polyhydramnios (and compared to a control group) revealed a greater prevelance of major (2.3% vs 0.13%) and minor congenital anomalies, that they are more likely to be born of diabetic mothers, be delivered by cesarean section and be at increased risk for mild post natal respiratory distress, delayed closure of the ductus arteriosus and hypoglycemia.
Infants born following maternal polyhydramnios without major congenital malformations have minimal clinical problems which do not generally increase the length of their hospital stay.
Neonatology Vol 1010 No 1 Jan 2012

6 Allergic rhinitis 
Allergic rhinitis is a very common problem of all ages, peaking during adolescence. While a variety of drugs have been used in its management, only environmental assessment and control, individually targeted allergen immunotherapy and intranasal steroids appear to be of benefit. 1 in 5 treated patients remained symptomatic.
7 Ritalin usage and cardiovascular events
A study examined the association of Ritalin usage in young ADHD children (6-21 years of age) and the occurrence of cardiac events (angina pectoris, dysrhymias, or transient cerebral ischemia) or cardiac symptoms.
Only rare instances of either events or symptoms were found.
(This does not imply that with abuse side-effects are uncommon. Ed)
8 Vibration and Cold for venipuncture pain
A coolant spray is frequently used to reduce pain during venipuncture in children. In a randomized control trial of 81, 4-18 year olds, this tool was compared to a reusable devise combining cold and vibration. Pain was measured via a self- and parent-report (plus videotape) using the 0-10 Faces Pain Scale. 
Venipuncture success and significantly less pain is associated with a cold/vibration device.

9 Abnormal laboratory findings after a first seizure
Age, sex, the presence of fever, gastrointestinal symptoms, duration and pattern of first seizure and whether it was still ongoing when the patient presented to the Emergency Department was related in 240 children to a variety of serum electrolytes. Though electrolyte abnormalities associated with a first seizure are quite common (for sodium: 34.8%, potassium: 6.7%, calcium: 6.2% and glucose: 52.3%) no statistically significant associations are found.
Pediatric Emergency Care Vol 27 Issue 12 Dec 2011

10 Procalcitonin levels in Late-onset Neonatal Bacterial infections (NBI) 170 pre-term and term infants were prospectively, from day 4 of life, clinically examined and procalcitonin, C-reactive protein and interleukin-6 levels simultaneously measured at the first suspicion of NBI. 34% of patients were diagnosed with late-onset NBI (verified by a positive blood culture or chest x ray plus elevated inflammatory markers). 
Arterial hypertension, feeding intolerance and particularly prolonged capillary refill time are extremely sensitive indicators of NBI. Measuring inflammatory mediators is of value with procalcitonin measurements enhancing sensitivity
Acta Paediatrica Vol 101 Issue 1 Jan 2012
11 Prevention of dental plaque accumulation/Streptococcus mutans (SM) counts
Plaque can be defined as a complex microbial community with as many as 400 distinct bacteria subtypes (with SM being a primary colonizer) plus epithelial cells leucocytes and macrophages, contained in a matrix of bacterial products and saliva. A study of 2-5 year old children examined the value of a 1% chlorhexodine varnish with and without a 40% xylitol solution, xylitol on its own or a 0.05% sodium fluoride application over a 6 month period, to reduce plaque and SM counts.
All applications reduced plaque and decreased SM counts no one material proved statistically better than any other.
Pediatric Dentistry Vol 33 No 7 Nov/Dec 2011

12 Treatment of acute osteomyelitis
A retrospective study of 20 children (9mths-17 years) with acute osteomyelitis (of which 5 were Community-acquired methicillin-resistant (Staphylococcus aureus-CA-MRSA), was undertaken to assess the viability of using trimethoprim-sulphamethoxazole (TMP-SMX) as either primary therapy, or as an alternate to clindamycin. TMP-SMX has an excellent oral bioavailability, susceptibility profile and cost. Patients were treated for 26-59 days.
All osteomyelitis patients treated with orally administered TMP-SMX appeared cured, with only mild adverse events noted. (a larger study would be valuable. Ed)
13 SIDS in the first month of life
The results of a retrospective forensic study done in New Zealand, of 24 SIDS patients who died within 28 days of life indicated an association between SIDS and bed sharing (87.5%), 20% of infants were growth-restricted, and 10% were preterm.
White matter gliosis indicating a possible previous prenatal insult was found in 62.5% of infants studied.

14 Weight and wheezing
Birth weight greater than 4,000gm appears associated with the occurrence, and weight > 110% at age 1.5 months with recurrence, of post-bronchiolitis wheezing.

Acta Paediatrica Vol 101 Issue 1 Jan 2012

15 Helium-oxygen treatment of bronchiolitis 
A clinical trial was undertaken to compare nebulized racemic epinephrine delivered by face mask 70% helium/30% oxygen, to 100% oxygen followed by helium-oxygen inhalation via high flow nasal canula (HFNC) or oxygen alone (via HFNC) in infants (2-12 months of age) with significant clinical acute asthma. All infants initially received nebulized albuterol with 100% oxygen.
It appears that in asthmatic infants nebulized racemic epinephrine delivered by face mask helium/oxygen, followed by helium/oxygen inhalation via HFNC produces the greatest clinical benefit. 
16 Pharyngitis in school age/adolescent children
Viruses are the most common cause of pharyngitis and it may be difficult to distinguish them from bacterial disease. Group A beta-hemolytic Streptococcus (S.pyogenes-GAS) and fusiform necrophorum (FN: anaerobic bacteria) are the commonest bacteria isolated.
FN is both part of the normal flora of the pharynx as well as being a pathogen and should be suspected in patients who have been treated with antibiotics for 48-72 hours without improvement or whose condition has worsened. (abscess formation, mononucleosis and acute HIV may cause a similar clinical picture)

17 Anorexia Nervosa (AN) and refeeding protocols
Starvation-induced cognitive deficits (besides the danger of serious medical complications or death) in AN require effective body weight restoration prior to psychological treatment. Currently the refeeding practice of “start low” “start slow” is largely based on experience and consensus rather than on published data.  An interesting study utilizing 37 hospitalized AN patients (mean age 16.2 years) whose calorie intake was increased every other day (over 16.7 days) from 1205k cal/day to 2668k cal/day indicated that patients fed “low and slow” initially lost weight, and gained weight more slowly staying longer in hospital, than those on a “larger and faster” refeeding protocol. No subjects had refeeding syndrome
A more aggressive feeding strategy in hospitalized adolescent AN patients appears to be warranted.

The Journal of Adolescent Health Vol 50 issue 1 Jan 2012

18 Infant night waking and maternal attachment
Night waking data using daily sleep diaries for the first 6 months of life and for 2 weeks at 12 months of age, was collected on 193 infants and their mothers. Infant-mother attachment was assessed using a standard methodology at 12 months of age, classifying the infants as “secure” or “insecure” (avoidantly, resistantly, or disorganized.)  Infants with an insecure-resistant attachment at 12 months of age woke more during the first 6 months of life as compared to the other infants, with insecure-avoidant waking the least.
Infant-maternal attachment at 12 months of age is related to infant night-waking patterns during the first 6 months of age.

19 Predictive factors in delayed union of pediatric forearm fractures  A case-controlled study of 441 pediatric shaft forearm fractures (non-pathogenic) was utilized to assess factors associated with delayed union (3.2%)
On multivariate analysis, the strongest predictor of delayed forearm union appears to be open reduction. For those patients requiring surgery the recommendation seems to favor closed reduction and internal fixation. 

20 Experimental treatment of unconjugated hyperbilirubinemia  There are a variety of ways of treating indirect hyperbilirubinemia, mostly without enhancing gastrointestinal transit times. 
A study using Gunn rats demonstrated that oral polyethylene glycol (PEG) given as a co-treatment (e.g. with phototherapy) significantly lowers unconjugated bilirubin levels by accelerating gastrointestinal transit. (We await a clinical trial. Ed)

21 Vasoactive peptides as markers of infection
Measurements of precursors of vasoactive peptides, pro-adrenomedulin, C-terminal proendothelin-1 and pro-atrial natriuretic peptide may be of value in differentiating severe, mild and non-infected neonatal patients.
Acta Paediatrica Vol 101 Issue 3 March 2012

22 Bacteremia in well-appearing febrile children
The incidence of bacteremia in well-appearing children age 3 to 36 months who present with fever without source (and where pneumococcal vaccine has been widely distributed) appears to be < 0.5%, and those infants should probably be closely watched without extensive laboratory testing. 
Infants 1-3 months of age have a much higher rate of bacteremia (2%) and require further investigation.
Acta Paediatrica Vol 101 Issue 3 March 2012

23 Risk factors for death in Hemophagocytic syndrome (HLA).
HLA is an uncommon but life-threatening disorder of immunoregulation. It frequently manifests as fever, lymphadenopathy, hepatosplenomegaly, elevated ferritin levels, abnormal liver function tests and jaundice with a skin rash and lymphocytosis, histeocytosis and pancytopenia. Hemophagocytosis is found pathologically.  Primary (familial-at least 5 genetic types-autosomal recessive) and Acquired (or secondary to systemic infection, malignancy etc) forms with differing disease severity exist.
Early death is associated with hyperbilirubinemia, CSF pleocytosis at diagnosis, hyper-ferritinemia and thrombocytopenia. Non-responsive fever and anemia also carry a negative impact.
Acta Paediatrica Vol 101 Issue 3 March 2012

24 Psychosomatic illness in children experiencing child abuse
A cross-sectional study of 2771 children in grades 4, 6 and 9 found a strong association between reported physical abuse and multiple (3 or more) psychosomatic symptoms, particularly when the symptoms cannot be explained by other causes. Healthcare professionals need to be vigilant.