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Weekly Updates in Pediatrics

January 2012 - Current Updates in Pediatrics

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January 2012
1.Olive oil vs silver sulphadiazine (SSD) in the treatment of burns
Burns are wide spread throughout the world and most burn patients suffer from partial thickness burns that are treated conservatively. As the ideal dressing has not been identified and many are expensive and not university available, a randomized control experiment utilizing anesthetized pigs was undertaken. Protocols included every other day treatments of partial thickness burns with SSD cream, purified olive oil or no topical therapy (controls).
Burns Treated with SSD healed faster than controls. Olive oil treated burns did not heal any faster than the SSD or control treated areas.
The American Journal of Emergency Medicine, Vol 30, Issue 1, January 12

2. Parent worry and Children’s Social-Emotional (SE) functioning
Behavioral problems may occur in as many as 24% of children younger than 4 years of age. The Brief Infant-Toddler Social-Emotional Assessment was utilized on 378 Spanish and English speaking mothers of young children (12 mths.- 48 mths. of age) before a well-child visit. Each mother rated the degree of social-emotional problems exhibited by their children and had their worry level assessed.
42% of children had either “clinically significant” or “at-risk” levels of SE problems. While almost 20% of parents expressed worry though having rated the children’s behavior in the normal range, over all worry was significantly associated with SE dysfunction in their offspring.
Parent worry well identifies children who fall into the “clinically significant “ group with SE problems. Parent worry does not clearly identify those children with lesser degrees of SE issues.
Journal of Developmental & behavioral Pediatrics, Vol 32, Issue 9, Dec 11
3. Transient tachypnea of the newborn (TTN)/fluid intake
TTN is a relatively common problem of late preterm or term birth and is probably due to delayed fluid clearance from the air spaces and interstitial tissue of the lung. Treatment usually consists of “time” and a little oxygen therapy. Some infants have severe enough lung abnormality to require mechanical ventilatory support.
Normal term infants receive an average of 15ml/kg of breast milk/day for the first two days of life.
Reducing fluid intake to 40ml/kg per day (term) and 60ml/kg per day (preterm) during the same time frame appears to result in significant improvement in these more severe TTN patients.
The Journal of Pediatrics, Vol 160, Issue, 1, Jan 12
4. Patent ductus arteriosus (PDA) closure with Acetaminophen
Pharmacologic closure of the PDA usually involves the administration of 1 of 2 cyclooxygenase inhibitors (indomethacin or ibuprofen).
5 preterm infants (gestational age: 26-32 weeks) with large PDAs who failed, or had contraindications to ibuprofen therapy were given off-label oral Tylenol (15mg/kg/dose every six hours). Ductal closure occurred in all treated infants within 48 hours. No toxicity was observed.
Pediatrics, Vol 128, Issue 6 Dec 12
5. Porcine vs bovine Surfactants for preterm infants
From five randomized control trials involving 529 preterm infants, efficacy outcomes data for rescue treatment compared porcine surfactant (poractant alfa) to bovine surfactant (beracteant and calfactant) in infants with Respiratory Distress Syndrome. The primary outcome measured was oxygen therapy at a post menstrual age of 36 weeks.
The incidence of oxygen dependence was similar for poractanat alfa and beractant. High dose (200mg/kg) poractant alfa appeared to significantly improve death rates and the need for redosing.
Pediatrics, Vol 128, Issue 6 Dec 12
6.  Adverse events (AEs) and Acupuncture
Acupuncture appears to be increasingly used in children. A systematic review of databases for adverse events associated with needle acupuncture was undertaken.
While a total of 279 AEs out of 37 reports were identified (25 serious), most (253) were mild, and appeared to be due to substandard practice.
Pediatrics, Vol 128, Issue 6, Dec 12
7.  Asthma prevalence and acetaminophen use
An epidemiologic association between asthma prevalence, severity and acetaminophen use has been found in both children and adults, perhaps mediated by glutathione depletion in airway mucosa.
Children with asthma or at risk for asthma should probably avoid the use acetaminophen
Pediatrics, Vol 128, Issue 6, Dec 12
8. Association between weight and risk of crash-related injuries in restrained children
A cross-sectional study of forward facing children (650, 1-5 year olds.. weight 20-65 lbs) (and 344, 3-8 year olds.. 30-100 lbs) who were in age/weight appropriate child restraint systems (adjusting for seating position, type of vehicle, direction of impact, crash severity and model year) found no association absolute weight and clinically significant injuries.
Parents should continue to restrain children in cars according to the current recommendations of American Academy of Pediatrics and the National Highway Traffic Safety Administration
Pediatrics, Vol 128, Issue 6, Dec 12
9.  Infant sleep after immunization and acetaminophen usage
A prospective randomized control trial compared two groups of infant’s monitored for sleep duration and fever during the 24 hours prior to and after their first immunization series at approximately 2 months of age. One group was managed with routine care while the other was given a dose of acetaminophen 30 minutes before immunization and every four hours thereafter for a total of five doses.
Sleep duration was increased following immunization, particularly interestingly, for those infants immunized after 1:30 pm and for those who developed a fever, regardless of whether they were routinely managed or received acetaminophen.
Afternoon immunizations appear to facilitate sleep duration.
Pediatrics, Vol 128, Issue 6, Dec 12
10. Epilepsy and Health Related Quality of Life (HRQoL)
A prospective study of newly diagnosed childhood epilepsy patients, assessed 8-9 years later by child and parent-proxy versions of the Child Health Questionnaire indicated significant comorbidities—26% had a psychiatric diagnosis, 39% neurodevelopmental spectrum disorder, 24% chronic medical illness and 15% migraine.
A psychiatric diagnosis in newly diagnosed epilepsy patients is significantly associated with both child and parent proxy HRQoL issues, even when seizures remit.
Pediatrics, Vol 128, Issue 6, Dec 12
11. Early diagnosis Biliary Atresia (BA)
The records of term infants from a single institution were examined retrospectively from 2007-2010. 61 new born babies’ whose direct/conjugated bilirubin (DB/CB) levels were measured shortly after birth and who were subsequently diagnosed with BA were compared  to a normal control group.
56% of infants diagnosed with BA had elevated DB/CB levels which rose over time, 24-48 hours after birth, with levels being significantly higher than those of controls. 79% of BA patients had a normal DB: Total bilirubin ratio ≤ 0.2
Patients with BA have elevated DB/CB levels shortly after birth. To improve early diagnosis perhaps all (not only jaundiced) babies should have their DB/CB levels measured within 24-48 hours.
Pediatrics, Vol 128, Issue 6, Dec 12
12. Bone grafts and Bone graft substitutes in pediatric orthopedics
Bone graft substitutes are heavily marketed and are increasingly being used.
This article outlines the current status regarding autograft and allograft healing, donor selection and tissue processing, outlining a number of specific products (demineralized bone matrix, specific growth factors, ceramic grafts and platelet rich plasma). For those interested in this area this paper well describes the current status of bone graft substitutes.
Journal of Pediatric Orthopaedics, Vol 32, Issue 1, Jan 12
13. Nystagmus in infancy
Nystagmus is an involuntary eye movement due to ocular motor dysfunction. Two major forms exist (physiological and pathological) with many variations within each type. Etiologies include congenital disorders, acquired or central nervous system disorders, toxicity, or drugs.
Idiopathic Infantile Nystagmus Syndrome (INS) is characterized by early onset of alternating series of slow and rapid eye movements.
A novel functional MRI (fMRI) has been used to identify in four subjects the neural circuitry for INS. It appears to demonstrate that the declive of the cerebellum is a significant site involved in this abnormality.
Journal of Pediatric Ophthalmology & Strabismus, Vol, 48, Issue 6, Nov/Dec 11
14. Resilience in children with Duchenne Muscular Dystrophy (DMD)
DMD is a recessive x-linked form of muscular dystrophy caused by a mutation in the dystrophin gene (Xp21) which results in progressive difficulty in walking, respiratory function and finally death. Symptoms frequently appear in boys younger than 5 years of age starting with proximal leg muscle weakness which eventually spreads to all other muscle groups. The average life expectancy is around 25 years with wide individual variability.
A study of 146 boys with DMD demonstrated resilience and good child adjustment to the disease was associated with decreased parent stress levels and exposure to a wide variety of social interactions and support from other children. Illness severity plays a lesser role.
Journal of Developmental & Behavioral Pediatrics, Vol, 32, Issue 9, Nov/Dec 11
15. Bradyarrythmias in low birth weight infants
It appears that small premature infants (mean: 1030gms, 28.2 weeks gestation) once weaned to supplemental oxygen (nasal cannula) or room air, frequently (mean: 1.25/hr) have bradycardias with some having Bradyarrythmias. These decrease over time (approx. 6 weeks).
Most Bradyarrythmias are either non-sinus atrial or junctional rhythms.
Journal of Neonatal-Perinatal Medicine, Vol 4, Number 4,  2011
16. Masturbation among USA adolescents
A Nationally representative sample of 14-17 year old males and females demonstrated that both sexes masturbate (males 73.8%, females 48.1%). Masturbation increases with age (males: 62.6% at age 14 years—80% at 17 years. Females: 43% at 14 years—58% at 17 years) and that masturbation occurs with numerous partnered sexual behaviors in both males and females.
Sexual development is an important and dynamic process throughout adolescence and masturbation is an enduring part of that normal process. Pediatricians should be comfortable and confident discussing this topic with adolescents.
Archives of Pediatrics & Adolescent Medicine, Vol 165, Number 12, Dec 11
17. Indications for growth hormone (GH) therapy in children
GH has now been available for over 50 years, all now being biosynthetically produced.
Currently, indications for GH use include:
1. Grow hormone deficiency
2. Turner syndrome
3. Small for gestational age
4. Prader-Willi-syndrome (to improve body composition)
5. Chronic renal insufficiency
6. Short stature due to SHOX deficiency (short stature homeobox gene deficiency)
Archives of Disease in Childhood, Volume 97, Issue 1, Jan 12
18. Tinnitus and hearing in 7 year old children
Tinnitus in children may occur with noise exposure (noise-induced tinnitus: NIT) or not, (spontaneous tinnitus: ST) and may be associated with permanent hearing loss or a temporary hearing threshold shift (TTS: a decrease in the ears sensitivity on exposure to noise) which may be temporary, chronic, or permanent.
Of 756 children examined during a standard audiometric screening, 41% reported either NIT or ST on several occasions. 17% reported recurrent TTS.  Spontaneous tinnitus occurs with TTS and/or hearing loss but also in children with normal hearing. Stress may play a role in its occurrence.
Archives of Disease in Childhood, Volume 97, Issue 1, Jan 12
19. Morbidity in Singleton late preterm infants (LPI)
A retrospective, multicenter study of 533 late preterm (34-36 weeks gestation) and 1,686 full term babies evaluated and compared their short term morbidity. LPI had significantly high respiratory distress (34.7% vs 4.6%), hyperbilirubinemia (47.7% vs 3.4%), hypoglycemia (14.3% vs 0.6%), hypothermia (2.5% vs 0.6%), and duration of hospitalization (mean: 9.9 days vs 5.2 days). Complications in the preterm infant was 7.6 times higher overall.
Singleton late preterm infants are at considerable risk for complications and prolonged hospital stays.
Acta Paediatrica, Vol 101, Issue 1, Jan 12
20. Rehospitalization following preterm birth
During the first and second year following preterm (before 32 week gestation) birth, 40.1% and 24.7% respectively, of infants are readmitted to the hospital, with respiratory disorders accounting for a substantial percentage of the readmissions.
Acta Paediatrica, Vol 101, Issue 1, Jan 12
21. Food plating preferences of pre-teen children
In a small interesting study 23 pre-teen and 46 adults were individually shown full-size photos of 48 different combinations of plated foods. The photos differed according to 7 dimensions eg. number of items, placement of entre, organization of the food, etc. Children differed significantly in their food preferences and color tending to prefer a more diverse range (7 different items and 6 different colors) compared to the adults (3 different items and 3 different colors.
Childhood nutrition may be improved by focusing on child preferences in content and color of food presented.
Acta Paediatrica, Vol 101, Issue 1, Jan 12
22. Home monitoring in the prevention of Sudden Infant Death Syndrome (SIDS)
A systematic review of the literature pertaining to home monitoring for the prevention of SIDS, identified only one study deemed level I evidence.
There is no high-level evidence that home monitoring may be beneficial in the prevention of SIDS.
Acta Paediatrica, Vol 101, Issue 1, Jan 12
23. Mortality in Cystic Fibrosis (CF) with Tobramycin inhalations
Tobramycin inhalations have been used for over 10 years to improve lung function and reduce exacerbations in patients with CF infected with Psuedomonas aeruginosa (Pa).
12,740 CF patients treated with Tobramycin inhalations were followed for a median of 6 years. A 21% reduction in subsequent year mortality was associated with its use, with subsequent years continuing the trend. Increased mortality was associated with underweight for age, CF-related Diabetes, female gender, worse lung function and positive cultures for Pa and Burkholderia cepacia complex.
Pediatric Pulmonology, Vol 47, Issue 1, Jan 12
24. Treatment of allergic rhinitis to prevent exercise induced asthma (EIB)
A double blind, randomized, placebo-control parallel group study of children with mild/moderate asthma and intermittent allergic rhinitis was undertaken to assess the efficacy of intranasal fluticasone furoate in preventing EIB.
Intranasal fluticasone significantly increased lung function during EIB and improved patients’ overall ability to be physically active.
Pediatric Pulmonology, Vol 47, Issue 1, Jan 12
25. Safety and efficacy of Milk and Molasses enemas (MME)
MMEs have apparently been around for over 100 years and were used frequently when expensive enemas were unavailable or when patients were particularly constipated. Results (anecdotally!!) appear to be quite impressive! (with lots of cramps, wind and free flowing feces!)
A recent study comparing MME to sodium phosphate enemas in constipated children indicated no significant differences in treatment effect (with perhaps fewer MME treatment failures). Both treatments were found to be equally safe.
Pediatric Emergency Care, Vol 27 - Issue 12, Dec 11