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Weekly Updates in Pediatrics

June 2011 - Current Updates in Pediatrics

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Language skills in the very preterm
Language difficulties tend to occur in babies born very preterm. A prospective study of 227 babies born <1250 gms birth weight and gestational age <30 weeks was undertaken at 2 and 5 years to identify biological and environmental factors involved as predictors of language outcomes. Poorer expressive and receptive language skills at 2 years of age were associated with lower maternal education and poorer infant communication skills. These were predictive of poorer language outcomes at 5 years of age.
[J Dev & Behav Ped. 2011;32(3):239-249.]

Clinical features of Children Hospitalized
with Pandemic 2009 A:H1N1 influenza
As compared to seasonal influenza hospitalized patients, children with A:H1N1 influenza tend to be older [6.5 years vs. 1.3 years], black [46% vs. 23%] with an underlying condition [72% vs. 49%] and more often wheeze [57% vs. 16%]. Severity of illness appears to be the same.
[Clin Pediatr. 2011;50(4):348-354.]

Academic outcomes for adolescents with ADHD
and other Behavioral and Learning [BLP] problems
Of a group of 591 schoolchildren 10-11 years of age, 7.3% were diagnosed with ADHD and 15% with BLP. Academic grade achievement at 16 years of age in these children was then compared to a comparable non-affected group. Both ADHD and BLP children underachieved in relation to their optimal cognitive capacity in spite of appropriate IQ levels.
[Acta Paediatr. 2011;100(3):402-406.]

Running-related injuries
Running is a good way for children to be physically active. Little information is available for injuries sustained when children run. Using the National Electronic Injury Surveillance System database, national estimates for running-related injuries were calculated. It appears that 225,344 children 6-18 years of age were treated in USA Emergency Departments between 1994 and 2007 for running injuries, the number of cases increasing over this time period by 34% per year. Fifty percent of injuries occurred at school; most were strains or sprains of the lower extremities and a third involved falling while running.
[Clin Pediatr. 2011;50(6):126-132.]

Cerebral oxygenation following oxygen resuscitation
for episodic preterm desaturations

Desaturations occurring in newborn infants are frequently treated by increasing the inhaled oxygen concentration. [FiO2]. In a small study of stable spontaneously breathing preterm infants during the first 3 days of life, the effects of this on cerebral oxygenation and extraction, were studied and compared to a similar group resuscitated without the increased FiO2.

Results indicated that while arterial oxygen saturations were higher with higher FiO2s, brain oxygen consumption/extraction was not similarly improved. This hyperoxygenation may be potentially harmful, particularly for the sick very preterm infant whose ability to regulate brain circulation and whose antioxidant defenses are limited.
[Neonatol. 2011;99(1):65-72.]

Sucrose as an analgesic for pain
Fifty healthy neonates requiring venepuncture were randomly assigned to either receive 2ml of 30% sucrose, 2 minutes prior to the procedure, or not. A behavioral pain rating scale was used to assess pain, and heart rates, oxygen saturations and “crying times” were noted. Pain scores were significantly better in the treated group, as were heart rates and oxygen saturations.
[J Neo-Peri Med. 2010;3(4):1878-4429.]

Obesity prevention
Though pediatricians are encouraged to guide parents in their efforts to diminish the epidemic of childhood obesity, very little scientific evidence is available which would allow an evidence-based approach to the issue. Some common sense guidelines, however, are discussed in this valuable Editorial. In essence, domains to focus on include:
1. Eating behaviors, particularly portion size appropriateness and diminished intake of sweetened beverages.
2. Increasing energy expenditure through indoor and outdoor interactive play.
3. Early discussion of “screen time”. Enhancing activity and face-to-face interactions may enhance cognitive and social skills.
4. Sleep duration. Short sleep duration appears to be associated with an increased risk of childhood obesity.
5. Parental behavior, emphasizing parental “moderation” and “empowerment” to achieve the above goals.
[Arch Ped Adolesc Med. 2010;164(12):1167-1169.]

Staphylococcus aureus [Staph] nasal colonization

Over a 1-year observation period, the natural history of community-acquired Staph nasal colonization was evaluated. Results indicated that methicillin-susceptible [MSSA] strains tend to be more persistent than methicillin-resistant [MRSA] ones, and many carriers harbor identical strains. Strain substitution tends to usually occur from MRSA to MSSA. MRSA colonization frequently resolves spontaneously with multiple positive cultures identifying those children most likely to remain colonized.
[Ped Infect Dis J. 2011;30(4):349-351.]

Periodontal maternal infection and infant neurological outcome
Periodontitis results in frequent bacteremia and increased inflammatory mediators. Infants of pregnant women treated medically for periodontitis before 21 weeks gestation show no cognitive, motor or language developmental  abnormalities subsequently.
[Pediatr. 2011;127(5):e1212-e1220.]

Risk factors associated with having older friends
3,709 ethnically diverse 8th-grade students [mean age 14.2 years] were categorized according to: a. socio-demographic characteristics, b. behavior factors c. intrapersonal factors d. socio-environmental factors.
Adolescent girls and older 8th-graders and teens with behavior, intrapersonal and socio-environmental problems who smoke cigarettes/marijuana and drink alcohol are more likely to be associated with older friends [>16 years].
[J Adolesc Health. 2011;(48(5):467-472.]

Obesity/neck circumference [NC] and perioperative respiratory events
A prospective study of children 6-18 years of age undergoing elective non-cardiac surgery was undertaken to identify associations between NC and perioperative respiratory difficulties. Increased NC correlated with other measures of obesity and was associated with a history of loud snoring, asthma, hypertension and Type 2 diabetes. Perioperative adverse respiratory events occurs more frequently in children with a large neck circumference.
[Pediatr. 2011;127(5):e1198-e1205.]

Chronic lung disease and Congenital Diaphragmatic Hernia [CDH]
The prevalence of bronchopulmonary dysplasia [BPD] in 30-day survivors of CDH appears to be approximately 41%. A chromosomal abnormality, prenatal diagnosis, lower gestational age and 5-minute apgar score, initial high-frequency oscillatory ventilation, a right-sided defect and an associated cardiac anomaly are all associated with  increased BPD development.
[Neonatol. 2010;98(4):370-380.]

Procedural sedation, pediatric specialties and outcomes
Examination of complications associated with procedural sedation outside the operating room in a large sedation consortium of mixed pediatric subspecialties indicates few major complications actually occurring, and no significant differences in complication rates between anesthesiologists, Emergency medicine physicians, intensivists or general pediatricians.
[Pediatr. 2011;127(5):e1154-e1160.]

Vaccination and children with Urea Cycle Disorders [UCD]
Children with UCDs may have hyperammonemic episodes [HAEs] after infection, fever or other stress situation. A retrospective analysis of 169 UCD children, 7 or 21 days after any immunization supports the safety of immunization in this group of children by finding no statistically significant association between HAEs and immunization.
[Pediatr. 2011;127(5):e1147-e1153.]

A Group A Streptococcal Pharyngitis [GAS] treatment protocol
A prospective study of an Emergency Department protocol designed to limit the use of inappropriate antibiotics in children with suspected GAS, by giving preprinted prescriptions to parents pending pharyngeal swab results was undertaken on 309 children. 100 [32.4%] swabs were positive. Overall, 80.2% adhered to the protocol using, or not using antibiotics appropriately when swabs were either positive or negative, respectively. Parents of younger children [2-5 years] were more compliant.
[Pediatr Emerg Care. 2011;27(5):374-378.]

Evidence-based decision support and blood transfusion rate
A large study of pre-transfusion hemoglobin levels and subsequent transfusion rates of red blood cells [RBCs] with and without an evidence-based computerized decision-support alert system for RBC transfusion, indicated that the alert system significantly reduced transfusion rates. This strategy of providing treatment associated evidence-based decision support alerts might be useful in many other clinical situations. 
[Pediatr. 2011;127(5):e1112-e1119.]

Health-related Quality of life [HRQL], Sickle cell disease [SCD] and Hydroxyurea
Hydroxyurea is safe, efficacious and frequently used in the management of children with SCD. A retrospective HRQL analysis of SCD children treated with and without hydroxyurea therapy self-reported improved physical functioning scores with its use, independent of disease severity.
[J Pediatr Hem Onc. 2011;33(4):251-254.]

Autism spectrum disorders [ASDs] and Early intervention
A systematic review of 10 years of information from a variety of online resources on the results of behavioral and developmental interventions in children ≤12 years of age with ASD indicates:
1. The majority of reports studied are of poor quality.
2. The strength of evidence overall ranges from insufficient to low.
While some reports indicate gains in language and cognitive skills in some children with parent-training improving short-term language function, conclusions are limited by poor study methodologies. Further, while many ASD children are treated medically, little evidence exists to support their use.
[Pediatr. 2011;127(5):e1303-e1311.]
[Pediatr. 2011;127(5):e1312-1321.]

Clinical features of children with
Primary Immunodeficiency Diseases [PID]

While 10 warning signs have been promoted to predict the presence of PID in children, it appears that just 3: a family history of immunodeficiency diseases, the use of intravenous antibiotics for sepsis [for neutrophil PID] and failure to thrive [with T-lymphocyte PID] identifies 89%-96% of such patients.
[Pediatr. 2011;127(5):810-816.]

Physical activity of Hispanic parents and their pre-school children
Self-defined Hispanic parents with children 3-5 years of age were assigned to either a weekly “healthy lifestyle group” [intervention group] or a “monthly school readiness group” [control], for 3 months. Strong correlations were found between the amount of time spent in sedentary behavior and mild/moderate activity for parents and children [no parent undertook vigorous activity!]. Neither child’s age nor gender correlated with the amount of exercise undertaken. Parents’ physical activity levels play a central role in how active their young children are.
[Pediatr. 2011;127(5):888-895.]

Klinefelter Syndrome
In 1942 Henry Klinefelter et al published a report on 9 men with enlarged breasts, sparse facial and body hair and whose chromosomal pattern was XXY. [not all XXY men have the symptoms of Klinefelter’s] The XXY condition appears to be one of the most common chromosomal abnormalities found, occurring in perhaps 1 in every 500 males [how many have symptoms in unknown.]

In general, it appears that individuals diagnosed prenatally have phenotypes less severe. Three main domains of development are affected:
i. Physical development
Babies may have weaker muscles and reduced strength and may sit up, crawl and walk later than normal. As they grow, they tend to be taller, less muscular, have less facial and body hair and as teens have reduced testicular size, testosterone levels, larger breasts and weaker bones. As adults they appear normal, other than being rather tall, however, tend to have more autoimmune disease, breast cancer, vascular disease and osteoporosis. Approximately 95% of XX males are infertile, though they can have normal sex lives.
ii. 25%-plus have language development abnormalities and learning difficulties.
iii. Socially, XXY children tend to be quiet and shy, less confident and struggle in sports. As adults, their lives do not appear to be different from others. There is a 50% increase in mortality risk and 70% increased risk of being admitted to a hospital.
[Acta Paediatr. 2011;100(6):807-813.]
[Acta Paediatr. 2011;100(6):917-922.]
[Acta Paediatr. 2011;100(6):819-823.]
[Acta Paediatr. 2011;100(6):814-818.]

Social environment, suicide and sexual orientation
Lesbian, gay and bisexual youth are more likely to attempt suicide than heterosexual adolescents [21.5% vs. 4.2%]. A positive social environment as defined by: [a.] Proportion of same-sex couples, [b.] proportion of registered Democrats, [c.] presence of gay-straight alliances at school and [d.] non-discrimination and anti-bullying policies that protect such students are all significantly associated with fewer suicide attempts. [controlling for multiple other risk factors]
[Pediatr. 2011;127(5):896-903.]

Subcutaneous Protein C replacement therapy
In a single-case description, a 2-day-old neonate with purpura fulminans and DIC was treated with rTPA, fresh-frozen plasma and unfractionated heparin. He was subsequently diagnosed with severe Protein C deficiency and initially treated with intravenous Protein C concentrate. Because of increasing difficulties with venous access after 6 weeks of treatment, the Protein C was given subcutaneously with good results. [though trough levels were less than recommended.]
[Pediatr. 2011;127(5):e1338-e1342.]

Should pre-adolescent children be present
during physician/parental discussions

In-depth qualitative interview analysis of 53 parents of children receiving treatment for leukemia indicated that while most parents thought there were benefits to their child being fully informed regarding prognosis, adverse events and likely procedures, parents felt that such discussions should be undertaken first with them alone, separately. They were of the opinion that this way, they would have the opportunity to absorb and discuss the information with their physician prior to them talking to their child at an appropriate time and in a reassuring manner.
[Pediatr. 2011;127(5):e1230-e1238.]