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Weekly Updates in Pediatrics

March 2011 - Current Updates in Pediatrics

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Wheezing in childhood
Asthma includes many phenotypes and a wide range of clinical presentations and prognoses. In a study of 6963, 9-11-year-old currently wheezing children analyzed and classified for the presence of wheezing plus either rhinitis [22.4%] rhinoconjunctivites [67.3%], atopy [45.9%], non-atopic [20.5%] and frequency [79.5%] [≥4 episodes per year], current wheezing was most associated with a history of parental asthma/allergic rhinitis, other allergies, mold and dampness in the home during the first year of life and maternal smoking during pregnancy. Frequency of wheezing, and concurrence of wheezing and atopy/rhinoconjunctivites was most associated with the number of recent household members, prematurity or a longer period of breastfeeding.
[Pediatr Pulmonol. 2011;46(2):166-174.]

Acute Otitis Media [AOM] and
upper respiratory tract infections [URI]
The otoscopic spectrum of tympanic membrane [TM] position, color, translucency and mobility was prospectively evaluated in 294 healthy children 6 months to 3 years of age during an URI. Myringitis [inflammation, no fluid] was diagnosed in 7%, non-bulging [19%], mild bulging [45%], bulging [29%] or perforation [6%] was found. Inflammation varied from mild [6%] to severe [35%] and was bilateral in 54% of AOM episodes.
[Ped Infect J. 2011;30(2):95-99.]

Group child care and infection
It appears that children develop more infections when they start attending group child care, however, those children placed prior to 2½ years of age have fewer and milder infections later during elementary school.
[Arch Pediatr Adolesc Med. 2010;164(12):1179.]

Intraperitoneal microdialysis
for necrotizing enterocolitis [NEC]
In a small pilot study of preterm infants operated upon for NEC, post-operative microdialysis was undertaken through a peritoneal catheter and four hourly samples collected [for 122 hours] for measurements of glucose, lactate/pyruvate and glycerol levels. From results obtained, it appears that peritoneal microdialysis is a safe procedure and with the measurements obtained, patients with and without post-operative metabolic and inflammatory changes can be differentiated.
[J Ped Surg. 2011;46(2):352-356.]

Prematurity, cognitive outcome and brain structure
While previous studies have indicated an association between preterm birth/low birth weight and neurocognitive deficits and structural brain abnormalities in childhood, no long-term follow-up to adulthood has apparently been described. In a Finnish study of such children examined at 31-35 years of age, slightly lower school ratings, lower educational levels and worse verbal learning scores were found. No overall change in brain morphology was evident.
[Pediatr Neurol. 2011;44(1):12-20.]

Early oral fat supplementation
in short-bowel syndrome
Long-term IV Intralipid is a major risk factor for the development of cholestasis in infants with short-bowel syndrome. It appears that early oral supplementation with Microlipid® and fish oil may enable IV feedings to be discontinued with appropriate weight gain and without adverse reactions.
[Neonatology. 2010;98(4):348-353.]

Total sleep duration [TSD], socioeconomic status [SES]
and behavioral problems in schoolchildren

A cross-sectional study of 2,669 male and female Turkish children [mean age 8.2 years] was undertaken to determine total sleep duration [mean 10.20 hours] and bedtime [21.57 hours] and to relate them to SES. Boys went to bed later and slept less than girls. TSD decreased significantly with higher SES scores in both boys and girls.
[Acta Paediatr. 2010;100(3):420-424.]

Complications following restorative proctocolectomy [RPC]
RPC appears to be the procedure of choice in the surgical management of ulcerative colitis, enabling diseased colon to be removed while maintaining transanal fecal continence. In a retrospective analysis of 60 children [median age 13.5 years] who underwent RPC, the only risk factors for complications appeared to be severe acute colitis, and patients operated upon because of failure to achieve remission. As opposed to adult patients so treated, complications were unrelated to steroid use, or hand-sutured anastomoses.
[J Ped Surg. 2011;46(2):336-341.]

Augmentin Duo 400/57 in the treatment
of Blepharokeratoconjuctivitis [BKC]
Diagnostic criteria for BKC are wide and varied. In a retrospective study of 7 children [6-14 years of age] with BKC who received Augmentin Duo 400/57 for a month, 6 had no recurrences for a mean follow-up of 6 months. It appears from this small study that this drug may be at least as effective as systemic erythromycin or doxycycline with fewer side effects.
[J Pediatr Opthalmol Strabismus. 2010;47(6):356-360.]

Unusual presentation of an ectopic testis
Spegelian, or lateral ventral abdominal hernias, are rare and frequently small, and lie between the muscles of the abdominal wall. In a post-operative case report, a diagnosed left lateral infraumbilical spegelian hernia was found to be an abdominal ectopic testis.
[J Ped Surg. 2011;46(2):415-416.]

Outcomes after Neonatal Seizures
One hundred twenty term infants who experienced neonatal seizures were evaluated to identify prognostic factors for the development of cerebral palsy, global developmental delay and epilepsy.
- 45% of infants had no neurodevelopmental abnormality.
- 31% developed cerebral palsy – at least 2 of the following abnormalities were independent predictors of its development: (i) Seizure type, (ii) onset, (iii) EEG background findings, (iv) 5-minute Apgar score.

Predictors for global developmental delay [43%] included: (i) method of delivery, (ii) seizure onset (iii) EEG background findings (iv) etiology.

For epilepsy, [32%] predictors included: i) seizure type, 2) administration of second anti-seizure drug.
[Ped Neurol. 2011;44(2):88-96.]

Bilirubin levels, breast-milk feedings
and retinopathy of prematurity [ROP]
It appears that for infants <32 weeks gestation or birth weight <1500 gms, a modest rise in serum bilirubin [mean 7.2 mg/dl] may be protective for the development of ROP. There appears to be no association between breast-milk feeding and ROP.
[Acta Paediatr. 2010;100(3):347-351.]

An emergency department [ED]-based
educational intervention program [EIP] for gastroenteritis
In a concurrent control, prospective, single-blind trial, children and caregivers were assigned to receive an ED-based EIP, a home nursing education visit, or neither. At 1 and 6 months, a “knowledge” questionnaire was administered. At 1 month post-intervention, scores of the intervention groups were significantly better than the controls, however this difference disappeared by 6 months. At neither 1 nor 6 months were ED visits decreased in the intervention groups.
[Am J Emerg Med. 2011;29(3):271-277.]

Bronchoalveolar lavage [BAL]
in children with Cystic Fibrosis [CF]
Recently, the recommendation for BAL has been changed to include taking specimens from two lobes vs. one. In a retrospective review of 31 patients with CF, one-lobe BAL would have missed 26 positive cultures in 35% of patients. Two-lobe BAL would have equally undetected 12 positive cultures in 23% of patients. It appears that specimens taken from two lobes is superior to one, however a number of infections may still be missed.
[Arch Dis Child. 2011;96:215-217.]

Poor performance in physical education [PE] and bullying
Children with poor social skills [autism spectrum disorders, attention deficit hyperactivity disorder] and clumsy children are at increased risk for being bullied. In 69 healthy university students who reported on PE performance and bully victimization in childhood, strong correlations between poor performance PE and high frequency and long duration of bullying were found. Clumsy children with poor motor skills need to be identified, protected and empowered.
[Acta Paediatr. 2010;100(3):413-419.]

Thermostatic mixing valves [TMV]
to prevent hot-water tap burns

The most common cause of burns in infants and children appears to be skin scalding associated with hot water baths, steam and “tipped over” hot liquids or food. In an attempt to reduce bath water temperature to minimize burns and to assess acceptability of TMVs, 125 families [divided into 2 groups with and without TMVs] were given educational material before and during TMV fitting. At 3 and 12 months follow-up bathwater temperature, acceptability and satisfaction of water temperature was assessed. Bath water temperatures in the intervention group were significantly lower, families were happier and had fewer complaints. Only 15% of families reported problems with their TMVs.
[Arch Dis Child. 2011;96:232-239.]

“Top-down” [TD] vs. “Step-up” [SU] infliximab
treatment for Crohn’s disease [CD]

Infliximab [Remicade] is a monoclonal antibody against tumor necrosis factor alpha [TNFa] a chemical messenger [cytokine] and a key component of the inflammatory autoimmune reaction. Crohn’s disease in an inflammatory disease affecting any part of the bowel from mouth to anus. A 1-year follow-up of 29 CD patients treated for 8 weeks, either with a “TD” or “SU” regiment was analyzed for treatment efficacy. At 8 weeks, 27% of “SU” patients and 89% in the “TD” group achieved remission, which was maintained for the year in 45% and 83% of the “SU” and “TD” groups respectively. The “top-down” protocol appears better than a “step-up” strategy.
[Acta Paediatr. 2010;100(3):451-455.]

Genital gonorrhea [GG] in children

In a small study of potential contacts of 10 prepubertal children with GG sexual abuse can be determined in at least 40% of patients. In no case could non-sexual transmission be found.
[Arch Dis Child. 2011;96:247-251.]

Late-presenting Congenital Diaphragmatic Hernia [CDH]
Fifteen children [mean age 1.5 years] with late-presenting CDH were characterized. Seventy-three percent were left-sided, 40% presented with respiratory symptoms, 40% with gastrointestinal symptoms and 22% with both. 33% of patients had “failure to thrive” and 40% were diagnosed by chest X-ray. Overall survival was 100%.
[Acta Paediatr. 2010;100(3):451-455.]

Hypertropic pyloric stenosis [HPS] –
changing clinical presentations

At a single tertiary care Pediatric hospital, clinical laboratory data from 118 patients with HPS was examined. In contrast to older studies, only 13.6% had a palpable “olive”, and hypochloremia [23%] and alkalosis [14.4%] were similarly less frequently found. The frequent use of abdominal ultrasound may be the cause for the changes.
[Clin Pediatr. 2011;50(3):192-195.]

Growth in patients with Mucopolysacharidosis [MPS]
MPS’s are a group of metabolic disorders caused by an abnormality of one of 11 enzymes required to break down glycosaminoglycans. Seven distinct clinical types have been identified. 28 patients [0.5 years-21 years] with Hunters Syndrome [MPSII] were evaluated in a longitudinal study to identify growth pattern deviations. It appears that during the first 3 years of life, most anthropometric features grow faster than normal, followed by a slowing of growth [including an earlier and decreased velocity pubertal growth spurt] in subsequent years.
[Acta Paediatr. 2010;100(3):456-460.]

Brown recluse spider bites – outcomes
Brown recluse spider bites may cause significant local and systemic problems. In a retrospective study of 26 patients, 85% had a local inflammatory response, while systemic problems included hemolytic anemia [50%], rhabdomyolysis [27%] and acute renal failure [12%]. Sixty-five percent of children had major morbidity with no deaths. Careful monitoring of these patients is essential.
[Clin Pediatr. 2011;50(3):252-258.]

Oral desensitization or avoidance
therapy for IgE-mediated food allergy
Randomized control trials were utilized to examine whether specific oral intolerance induction could be utilized in children 0-18 years of age who had IgE-mediated food allergy, vs. avoidance. While only 3 studies met inclusion criteria, no reduction in end-point allergy could be demonstrated. More research is needed.
[Arch Dis Child. 2011;96:259-264.]

Severe iron-deficiency anemia [IDA] and stroke
Prevalence of IDA peaks at ages 1-3 years and is associated with a variety of abnormalities developmental delay, lethargy, irritability and cognitive problems. A report of 4 children 14-48 months of age with stroke and without other risk factors underlines the potential severity of complications associated with IDA.
[Arch Dis Child. 2011;96:276-279.]

Community treatment for
observed intimate partner abuse
In a randomized controlled trial using “blinded” evaluators, 124 referred 7-14-year-old children seen diagnosed with post-traumatic stress disorder [PTSD] following observed abuse, were evaluated using a wide variety of tests to assess the efficacy of “community-provided” trauma-focused behavior therapy vs. “usual child-centered” therapy. “Community-provided” care significantly increased remission rates with fewer serious adverse events.
[Arch Pediatr Adolesc Med. 2011;165(1):16-21.]