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Weekly Updates in Pediatrics

July 2011 - Current Updates in Pediatrics

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Management of blunt splenic trauma in children
Non-operative management of stable pediatric patients following blunt splenic injuries appears to be the standard of care. Most adult centers do repeat imaging at 24-48 hours with embolization of splenic pseudoaneurysms [SAPS]. In a retrospective review of 45 pediatric patients with SAPS, 96% were reported as stable, yet 82% underwent a surgical procedure [splenectomy, splenorrophy or embolization]. While one child had a delayed splenic rupture, no deaths were reported. The issue of whether or not to routinely do follow-up imaging and embolization of children with splenic blunt trauma remains questionable.
[J Pediatr Surg. 2011;46(5):933-937.]

“Growing pains”
To define the family history, clinical features, laboratory findings and outcomes of 30 children, [other clinical signs/symptoms, labs, etc. negative] 3-14 years of age, who presented with a history of growing pains [defined as lower extremity pain for >3 months] a prospective 1-year follow-up was undertaken. Results included: [i] family history present in 20% of patients. [ii] both limbs involved in 80% of cases [iii] pain occurred at night [sufficient to cause awakening] and the afternoon in approximately 50% of children, respectively. [iv] mostly pain occurred weekly [45%], monthly [35%] and every 3 months [15%]. [v] pain was relieved by “massaging” the painful leg [95%]. Reassurance only appears sufficient.
[J Pediatr Ortho. 2011;31(5):606-609.]

following surfactant replacement therapy

Infants successfully extubated following surfactant therapy and never reintubated have a lower mortality rate, rate of bronchopulmonary dysplasia, incidence of air leak, and decreased rates of sepsis, necrotizing enterocolitis, intraventricular hemorrhage and periventricular leukomalacia. Of note, there appears to be differences in reintubation rates between differing surfactant preparations.
[J Neo-Perinatal Med. 2011;4(2):101-109.]

Upper abdominal pain [UAP] and biliary dyskinesia
For children with UAP and aculculous biliary disease, laporoscopic cholecystectomy appears to be an accepted treatment, though with inconsistent results. In a study of 167 children with biliary dyskinesia and who had multiple variables measured, only being thinner [BMI for age <85th percentile] predicted a better symptomatic outcome. Being overweight appears to be a contraindication to cholecystectomy for biliarly dyskinesia.
[J Pediatr Surg. 2011;46(5):879-882.]

Near-infrared [NIR] light
for blood withdrawal in children
A small observational study using a prototype of a NIR vascular imaging system to assist venipuncture in children 0-6 years of age, indicates that the number of venipunctures required and the time taken to successful venipuncture were significantly improved using this promising system.

[In addition, Emergency Department technicians can be successfully trained to place ultrasound-guided peripheral intravenous catheters.]
[Clin Pediatr. 2011;50(6):508-512.]
[Am J Emerg Med;29(5):496-501.]

Endoscopic vs. Open Surgery
for Gluteal Muscle contraction
In a matched retrospective study, endoscopic release of gluteal muscle contractions was found, in degree I and II   patients to be safe, reliable and superior, with less trauma, pain and operative time. It should be used cautiously in degree III patients.
[J Pediatr Ortho. 2011;31(5):e38-e43.]

Glaucoma following Infantile Cataract surgery
A retrospective chart review of all patients who underwent cataract extractions in a children’s hospital over a fixed period of time was undertaken to identify the incidents and risk factors associated with the development of post-microsurgical glaucoma. Infants under three months of age at cataract diagnosis or extraction, and anterior chamber anomalies were the only risk factors found.
[J Pediatr Ophthal & Strabismus. 2011;48(3):142-149.]

Single-incision laporoscopic surgery in children
A retrospective chart review of 142 consecutive patients who underwent a single-site laporoscopic procedure revealed that for 103 non-perforated appendectomies, 24 cholecystectomies, 8 ileocecatomies plus a few other indications were undertaken. The only complication recorded was umbilical surgical site infection [mostly following appendicitis]. Outcomes appear comparable to conventional laporoscopic surgery.
[J Pediatr Surg. 2011;46(5):904-907.]

Occular Fundus examination after Febrile Seizures
In a study of 34 children 3 months-9 years of age, diagnosed with a febrile seizure whose eyes were examined within 24 hours, none were found to have retinal hemorrhages. If retinal hemorrhages are found, other causes need to be considered.
[J Pediatr Ophthal & Strabismus. 2011;48(3):182-186.]

Exercise and pulmonary function
in asthmatic children
Thirty-three children [mean age 12.3. years] with a clinical history of exercise-induced asthma [EIB] undertook submaximal exercise [12 minutes] while ongoing pulmonary function testing was performed. Fifty-seven percent of children showed EIB – 63% of these had bronchoconstriction during exercise, while in the rest, bronchoconstriction occurred between 6 and 10 minutes after exercise.
[Arch Dis Child. 2011;96:664-668.]

Cardiac function in adults of diabetic mothers
An increasing number of women entering pregnancy suffer from Type II diabetes or develop gestational diabetes, resulting in fetal in-utero exposure to hyperglycemia. It appears from a rat experiment [and from other investigations] that adult offspring of hyperglycemic mothers have significant diastolic dysfunction on echocardiography with decreased left ventricular compliance as compared to controls. Adults born of hyperglycemic mothers require ongoing additional cardiac assessments.
[Neonatol. 2011;100:198-205.]

Unilateral enlarged breast mass
in an adolescent boy
Gynaecomastia is the most common cause of breast enlargement in adolescent boys, and while surgical referral is common, surgical treatment is rare. In a single case report, a 14-year-old boy with an enlarging unilateral breast mass was found to have an intraductal papilloma at excision.
[J Pediatr Surg. 2011;46(5):e33-e35.]

Repair of Meniscus tears in young athletes
An arthroscopic inside-out technique, frequently with anterior cruciate ligament [ACL] reconstruction was utilized to repair 49 adolescent knees following athletic injury. “Age at time of injury, time to surgery and the extent, type and location of meniscus tear were noted”. At 27 months [mean] follow-up, excellent outcomes were reported in 43 of 45 patients independent of the variables. Patients with ACL reconstruction required longer times to full activity. Repair of meniscal tears in the immature athlete, independent of time from surgery or area of meniscus appear to have a greater potential to heal.
[J Pediatr Ortho. 2011;31(5):496-500.]

Cerebral blood flow velocity
in VLBW premature babies

When assessing middle cerebral artery, cerebral blood flow velocity [CBFv] [with a normal cranial ultrasound] in very small premature babies, it is important to note the pCO2 at the time of measurement, as cerebral blood flow velocity [in cm/sec] increases substantially when pCO2 increases. [This article provides mean and 95% CI reference curves.]
[J Neo-Perinatal Med. 2011;4(2):127-132.]

Late-school admission and obesity
It appears that girls who have delayed entry into school because of “cut-off” dates, are more likely as adolescents to be obese. Future studies are needed to elucidate the complex mechanisms involved.
[J Adolesc Health. 2011;48(6):644-646.]

Inflammatory response to “clean” surgery
CRP and inflammatory mediators Interleukin [(IL)-1β, IL-6, IL-8, IL-10] and tumor necrosis factor-α (TNF-α) were measured in neonates undergoing thoracic and abdominal surgery in the absence of infection. CRP levels in general remain low [<1.0mg/dl] and peaked on the second post-operative day. Only IL-6 concentrations increased, peaking at post-operative day 1. Serial measurements of indicators of inflammation are more valuable than single estimations.
[J Pediatr. 2011;159(1):121-126.]

Autism and gastrointestinal problems
Children with Autism spectrum disorder [ASD] appear to suffer from more gastrointestinal [GIT] problems than their unaffected siblings. Constipation and chronic diarrhea are most common, and increased autism symptom severity appears to be associated with greater likelihood of GIT issues.
[J Dev & Behav Pediatr. 2011;32(5):351-360.]

Sex partners and risk behaviors
Both young urban men and women who have sex with partners whom they classify as “non-ideal” [lacking either/and emotional support or fidelity] have a higher prevalence of sexually-transmitted infections [and odds of all risk behaviors].
[J Adolesc Health. 2011;48(6):604-609.]

In-utero exposure to maternal anti-epileptic drugs
Babies who have been exposed in-utero to their mothers’ lamotrigine [LTG], sodium valporate [NaV] and carbamazepine [CBZ] were neurodevelopmetally assessed at 9-60 months to identify any neurodevelopmental adverse effects. 39.6% of the babies exposed to NaV, 20.4% of those exposed to CBZ and 2.9% exposed to LTG [compared to 4.5% of a matched control group] had evidence of mild to significant developmental delay. In-utero exposure to LTG does not appear to have a detrimental developmental effect on the fetus. Exposure to NaV and CBZ does.
[Arch Dis Child. 2011;96:643-647.]

Venous thromboembolism [VTE]
in oncology patients

Oncology patients are a growing population in children’s hospitals with admissions having increased by 32% over the past 10 years. Overall, 5.3% of these children will develop VTE, with patients with leukemia and bone/soft tissue sarcomas having the highest risk.
[J Pediatr. 2011;159(1):133-137.]

Adolescent depression and maternal socialization
A study of mono-zygotic twins and subsequent adolescent depression reveals that non-shared environmental variables are important in the genesis of adolescent depression. Maternal disengagement [previously implicated as a causative factor] appears to be in response to, rather than a cause of, adolescent depression.
[J Adolesc Health. 2011;48(6):572-578.]

Predicting language development at 18 months
Data from 42,107 toddlers was analyzed to identify factors associated with delayed language development at 18 months of age. Most variability [95%] remains unexplained; however, a number of factors, including being a boy, low birth weight or gestational age or a multiple pregnancy, and family variables [e.g. maternal distress, low maternal education, etc.] appear to play a role in slower language development.
[J Dev & Behav Pediatr. 2011;32(5):375-383.]

Predictors of hospital admission
for infant bronchiolitis

A study of 449 infants [mean age 23 weeks] presenting with acute bronchiolitis demonstrated that 36% of them were admitted to hospital, and age, respiratory rate, heart rate, oxygen saturations and duration of symptoms are the five best predictors of admission. A simple clinical risk scoring system is described.
[Arch Dis Child. 2011;96:648-652.]

Near drowning in developing communities
It appears that approximately 500,000 people drown each year worldwide. Most [97%] occur in low/middle-income countries. A study from Bangladesh reported 489 childhood deaths in a single city over a 10-year period. 57% were age 1 to 2 years, most drowning occurred in ponds, and in the morning while the mother was doing household chores. Traditional methods of resuscitation [most frequently spinning the child over the head] was utilized in 55% of children. Only 3% of families tried conventional resuscitation. Local risks for drowning need to be identified and community-based resuscitation education is mandatory if this problem is to be solved.
[Arch Dis Child. 2011;96:675-680.]

How much blood can safely
be drawn from a VLBW neonate?

In a post-hoc investigation of a pharmokinetic study, a variety of parameters were measured to assess a safe level of blood removal from these babies. It appears that up to 2.3 ml/kg of blood can be drawn without compromising hemoglobin, hematocrit or hemodynamic variables.
[Neonatol. 2011;100(2):111-115.]

Subsequent primary neoplasms
among survivors of childhood cancer
17,981 5-year survivors of childhood cancer diagnosed at 15 years or younger were followed for a median time of 24.3 years. 7.5% [four times the expected] developed a subsequent primary neoplasm. Organs involved in order of frequency were: Central nervous system, non-melonoma skin cancer, digestive, genitourinary, breast and bone. For those patients over 40 years of age, the greatest risk was for digestive and genitourinary cancers.
[JAMA. 2011;305(22):2311-2319.]