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Weekly Updates in Pediatrics

January 2011 - Current Updates in Pediatrics

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Clustering of disorders in extremely
low birth weight [ELBW] infants

After adjusting for gestational age, infants who have severe necrotizing enterocolitis [NEC] appear to be at increased risk for cerebral white matter damage, retinopathy of prematurity [ROP] and severe bronchopulmonary dysplasia [BPD]. Infants with severe ROP are at increased risk for BPD and bacteremia [early and late].

[Acta Paediatr. 2010; 99(12): 1795-1800.]

doi: 10.1111/j.1651-2227.2010.01973.x

Laryngeal Mask Airway [LMA]
for Surfactant Administration
A random controlled trial using lung injured [surfactant washout] newborn pigs was utilized to evaluate the effectiveness of LMA-administered surfactant vs. surfactant delivery through an endotracheal tube [ETT]. LMA surfactant delivery resulted in similar improvement in oxygenation, and placement requires less time and fewer attempts.

[Pediatr Research. 2010; 68(5): 414-418.]

doi: 10.1203/PDR.0b013e3181ef7619

Botulinum Toxin A therapy
for Intractable Headaches
A small retrospective case study of 10 patients [11-17 years] suffering from daily chronic [medical] intractable headaches and who received a standard 100-unit dose of onabotulinum toxin A [Botox] for an average of 8 therapies, revealed a 60% improvement in intensity and/or frequency. Three patients experienced minor adverse events.

[Pediatr Neurol. 2010; 43(5):316-319.]

doi: 10.1016/j.pediatrneurol.2010.06.001

Chlorhexidine aqueous solution vs.
gel for umbilical stump management
Chlorhexidine cord cleansing may be accomplished by using an aqueous solution or a guar-gum thickened gel applied to the stump. Of stumps examined 24 hours post-application, 4.6% were culture positive in “gel”-applied babies, vs. 10.7% in a comparable “aqueous” group. Acceptability and compliance rate were high for both, while the gel seemed to be preferred by users. [Either seems to have displaced oil-based mixtures.]

[Pediatr Infect Dis J. 2010; 29(11):999-1003.]

doi: 10.1097/INF.0b013e3181e70c59

Bronchiolitis and Bordetella Pertussis
PCR or viral antigen examination of nasopharyngeal aspirates in infants <6 months of age admitted with a clinical diagnosis of bronchiolitis, revealed a B. pertussis co-infection in 8.5%, particularly with RSV infection. Clinically, there appears to be no differences in presentation between B. pertussis co-infection with RSV vs. sole RSV infection. In non-vaccinated infants, pertussis should be considered in all hospitalized patients admitted for lower respiratory tract infections.

[Pediatr Infect Dis J. 2010; 29(11):1013-1015.]

doi: 10.1097/INF.0b013e3181f537c6

Cricoid pressure to prevent gastric aspiration
Rapid sequence intubation [RSI] is frequently used in Emergency Departments [and Intensive Care Units] for a variety of indications. Cricoid pressure is utilized to obstruct the underlying esophagus and thereby prevent gastric content aspiration. Cervical spine/neck CT scans of an equal number of patients younger or older than 8 years [the age at which esophageal anatomic position assumes adult configuration] was undertaken to assess tracheal/esophageal alignment at the level of the cricoid cartilage. Forty-five percent of younger children and 15% of the older ones were found to have lateral displacement of the esophagus, all to the left.

[Pediatr Emerg Care. 2010; 26(10):722-725.]

doi: 10.1097/PEC.0b013e3181f39b74

Ketamine use and laryngospasm
In a large matched case-control analysis of 8282 ketamine sedations [IV or IM], 22 associate occurrences of laryngospasm were documented. No association with age, dose or other clinical factor was found. Laryngospasm appears to be idiosyncratic. Co-administration of anticoallergics appears unnecessary. Physicians using ketamine for sedation need to be aware and prepared.

[Pediatr Emerg Care. 2010; 26(11):798-802.]

doi: 10.1097/PEC.0b013e3181fa8737

Conduct disorders [CD] –
Oppositional/Defiant Disorders [ODD]
From a longitudinal birth cohort, predictors during early childhood of CD/ODD at 14-16 years included maternal smoking during pregnancy, exposure to socioeconomic adversity, parental maladaptive behavior, childhood exposure to abuse and interparental violence, cognitive ability and affiliation with deviant peers in early adolescence. Risk factors were similar for both disorders, and preventive measures/treatment for one may reduce the incidence of both.

[J Am Acad Child & Adolesc Psych. 2010; 49(11):1125-1133.]

doi: 10.1016/j.jaac.2010.08.005

Genes, environment and Cystic Fibrosis [CF]
A large study of monozygous and dizygotic CF twins living under different environments had pulmonary function studies evaluated to assess the contribution of genes/environment to their lung function. Regression modeling revealed that genetic factors account for 50% of lung function variation, unique environmental and random events account for 36%, and shared environmental factors account for 14%. Environmental factors play a large role in pulmonary function outcomes in CF patients and are usually unique and random, rather than shared common exposures.

[J Pediatr. 2010; 157(5):802-807.e3.]

doi: 10.1016/j.jpeds.2010.05.018

Extracorporeal membrane
oxygenation [ECMO] and limb ischemia
To minimize the potential neurologic affects of carotid artery ligation in pediatric patients undergoing ECMO, common femoral artery [CFA] is more frequently being used, though this may obstruct flow to the limb. Though the incidents may be higher in survivors, limb ischemia occurs in more than half the patients. Distal perfusion catheters at the time of cannulation does not appear to be of great benefit. New approaches are needed.

[J Pediatr Surg. 2010; 45(11): 2136-40.]

Laproscopic appendectomy
Laproscopic minimally invasive surgery is commonly used to treat appendicitis. This may be accomplished by an either multiple or single incision laproscopic surgery. In a study of 110 patients [mean age 11 years] comparably matched, single-incision laproscopic appendectomy was found to be safe and effective.

[J Pediatr Surg. 2010; 45(11): 2186-2190.]

doi: 10.1016/j.pedsurg.2010.07.012

Commercial weight loss programs in obesity
In a study of 442 overweight and obese adult women who received free, a well-known commercially available structured weight loss program, weight loss was assessed over a 2-year period. Few normally complete the full program, however, with free counseling and free food, involvement improved. Most weight-loss occurred in the first year and remained fairly stable through the second. Insurance companies currently cover the cost of bariatric surgery but not commercial weight-loss programs. This appears to be an “error of judgment”. [JW]

[JAMA. 2010; 304(16): 1837-1838.]
[JAMA. 2010; 303 (3): 235-241.]

doi: 10.1001/jama.2010.1529

Extracorporeal photophoresis [ECP] for
steroid-refractory Graft Versus Host Disease [GVHD]
Few pediatric centers have experience with ECP for GVHD though encouraging results may be obtained. An “off-line” approach [using a continuous flow separator and an ultraviolent irradiator] in  27 patients with steroid refractory acute and chronic GVHD achieved complete remission in 11 of 21 acute GVHD patients and in another 8 patients partial remission. For the chronic GVHD group, 5 of 8 patients obtained complete or partial remission. It appears that this treatment for this situation is safe and effective, even in small children.

[J Pediatr Hem Onc. 2010; 32(8):589-593.]

doi: 10.1097/MPH.0b013e3181e7942d

High- or low-sugar cereals and
children’s breakfast eating behavior
Children who choose a “high” vs “low” sugar cereal [with milk and fruit available] for breakfast tend to eat more cereal, twice the amount of refined sugar and less fruit, compared to a low-sugar-eating cereal group. While milk and total calories consumed did not differ, the “low” sugar group experienced a superior nutritional meal.

[Pediatr. 2010; 127(1): 71-76.]

doi: 10.1542/peds.2010-0864

Over-the-counter cold and cough products
Withdrawal of over-the-counter cold/cough products for infants less than 2 years of age has decreased Emergency Department admissions for their related adverse events by 50%.

[JAMA. 2010; 304(24): 2686.]

doi: 10.1001/jama.2010.1831

Urinary transforming growth factor
β-1 [TGF- β1] and renal dysfunction
TGF- β1 is a polypeptide of a superfamily of cytokines. Its actions include cell growth, cell proliferation, cell differentiation, apoptosis and it is a marker of fibrosis. Renal disease affects 5%-18% of patients with sickle cell disease [SCD]. In this study, urinary excretion levels of TGF- β1 was assessed in 51 SCD patients and compared to a healthy control group to document whether it would function as a marker of early renal injury. No correlation was found between urinary TGF- β1 and microalbuminuria or estimated glomerular function, however elevated urinary levels appear to indicate early renal injury.

[Pediatr Nephrol. 2010; 26(2): 275-280.]

doi: 10.1007/s00467-010-1677-9

Cystic kidney disease – nephronophthisis [NPHP]
NPHP first described in 1945 in later by Fanconi et al is the commonest genetic childhood disorder causing kidney failure in young children and adolescents. It has an autosomal recessive inheritance pattern and is caused by mutations of 11 different genes. These appear to govern ciliary function and planar cell polarity. Abnormality results in a tubulo-interstitial nephropathy and renal cysts. Clinically, the most frequent form is characterized by polyuria, polydypsia, seconday enuresis, growth retardation and anemia. End-stage renal disease occurs around 13 years of age. Different mutations result in differing severities of the disease.

[Pediatr Nephrol. 2010; 26(2): 181-194.]

doi: 10.1007/s00467-010-1585-z

Functional constipation and lifestyle
Information on the bowel habits of 1,000 Pakistani children [ages 5-8 years] in two matched groups, one each from an urban and rural area was examined to determine time of initiation and completion of toilet training, and fluid/food/fiber intake. Daily calorie, macronutrients, fiber and water intakes were higher in the urban population who initiated and completed toilet training earlier and who reported simultaneously less functional constipation.

[J Pediatr. 2010. Article currently in press; issue unassigned]

doi:10.1016/j.jpeds.2010.11.024

Adverse events following Trivalent
Inactivated Influenza vaccination
Over the years, recommendations for flu vaccine for children have changed to include 6-23 months [2004], 2-4 year-olds [2006] and 5-18 years [2008]. An analysis of Vaccine Adverse Events from 1990-2006 indicated no unexpected adverse events, however, 10% of all reports were “serious”, Guillain-Barre syndrome being prominent among them. [Medication errors were also reported in 10% of patients – most suffered no complications.]

[Pediatr Infect Dis J. 2011; 30(1): 89,93-94.]

doi: 10.1097/INF.0b013e3181ebeade

Growing Rod surgery for early-onset scoliosis
Congenital scoliosis may cause both spinal deformity and a thoracic insufficiency syndrome [TIS]. Conventional fusion treatments in children may shorten the spine, worsening TIS. Utilizing growing rod surgery in young children, a modern alternative treatment for early onset scoliosis, appears effective with a relatively low incidence of complications.

[J Pediatr Ortho. 2011; 31(1):1-5.]

doi: 10.1097/BPO.0b013e318202c1f0

“Single-breath counting” [SBC] –
an alternative to pulmonary function testing

Pulmonary function tests are not always available in the office or in the Emergency Department. The SBC test is one that can generally be performed on children >5 years of age and counts, in cadence to a metronome set at 2 beats/second, how far a child can count in a normal speaking voice after a maximal inhalation. In a prospective study of 67 children seen at a pulmonary clinic, SBC tests correlated well with standard Pulmonary Function testing. This interesting small study requires further investigation.

[Am J Emerg Med. 2011; 29(1): 33-36.]

doi: 10.1016/j.ajem.2009.07.006

Post-discharge secobarbital for migraine
Adult patients seen in an Emergency Department [ED] with a clinical diagnosis of migraine received standard ED treatment following which they were discharged with either 2 tablets of secobarbital or placebo [1 tablet to be taken at home arrival and the second, one hour later, if awake]. Headache pain was substantially decreased in those patients taking the seconal.

[Am J Emerg Med. 2011; 29(1): 86-90]

doi: 10.1016/j.ajem.2009.09.027

Clinical predictors of testicular torsion
Children present to an Emergency Department with acute scrotal pain for a variety of reasons. While acute testicular torsion as a cause of this is uncommon, pain lasting less than 24 hours, nausea and vomiting, high position of the testicle and an abnormal cremasteric reflex are associated with a greater likelihood of testicular torsion being present.

[Am J Emerg Med. 2010; 28(7): 786-789.]

doi:10.1016/j.ajem.2009.03.025

Low 5-minute Apar score and mortality
Twenty-eight-day mortality in neonates, gestational age 24-36 weeks, is associated with low 5-minute Apgar scores. Relative risk of death is higher with scores 0-3 vs 7-10. In very low birth weight infants [VLBW], relative risk of death increases 3.1-fold at 24 weeks gestation and 18.5 times at 28 weeks. Low 5-minute Apgar score in VLBW babies is useful in assessing prognosis.

[Acta Paediatr. 2010; 99(12):1785-9.]

H1N1 virus infection in children
A small study from Korea indicates that even treated [oseltamivir] severely ill children with H1N1 virus infection, particularly those who are high-risk have a high mortality rate [14 of 30 patients]. The most common causes of death in this study were encephalopathy and myocarditits. Secondary strep pneumonia and strep pyogenes bacterial lung infections causing significant pneumonia and empyema may also result in death.

[Pediatr Pulmonol. 2010; 45(10): 1014-1020.]

doi: 10.1002/ppul.21288

Clarithromycin in hypoxia/reoxygenation [HR] induced intestinal injury
Three groups of 1-day-old albino rat pups were utilized in a study to evaluate histopathological injury and evidence of oxidative stress following HR. One group was used as a control [1] and groups 2 and 3 were exposed to hypoxia/reoxygenation. Group 3, however, received 3 days of pretreatment with clarithromycin.  Results indicate that clarithromycin has a protective effect on bowel injury, reduces inflammation and diminishes oxidative injury.

[J Pediatr Surg. 2010; 45(11): 2169-74.]

doi:10.1016/j.jpedsurg.2010.06.024