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Weekly Updates in Pediatrics

May 2011 - Current Updates in Pediatrics

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Cyber Bullying and Depression
Cyber bullying is a relatively new form of bullying. Cyber victims, particularly frequent ones, appear to suffer from higher rates of depression when compared to other forms of bullying.
[J. Adolesc Health. 2011;48(4):415-417.]

Prevalence of asthma/bronchial hyperactivity [BHR]
The prevalence of asthma/BHR appears to be increasing the in the USA population. However, in a pulmonary study of its prevalence in unselected Danish schoolchildren aged 6-17 years of age in 1990-1991 and repeated in 2001 it appears unchanged over the 10-year period.
[Acta Paediatrica. 2011;100(3):385-389.]

Surgical treatment of giant Omphalocoele
It appears that publications that outline the surgical treatment of giant Omphalocoeles may not in fact reflect present practice. In a retrospective study utilizing a questionnaire sent to recently published authors on the topic, 42% had changed or stopped using the technique that they had previously published. Further, there does not appear to be a generally accepted method of management though “staged closure/delayed closure” appear to be most frequently utilized.
[J Pediatr Surg. 2011;46(3):482-488.]

Predicting mortality in Pediatric Trauma
Utilizing factors independently associated with mortality [admission base deficit, International normalized ratio-INR, and Glasgo Coma Scale-GCS] a pediatric “Big” mortality prediction score [base deficit+[2.5×INR]+[15-GCS]] was developed and validated on 1101 trauma-injured children in Iraq and Afghanistan. The score appears to be accurate for both blunt and penetrating-injured patients.
[Pediatr. 2011;127(4):e892-e897.]

Lactose-free, milk protein-based infant formulae
The use of lactose-free infant formulas has increased in the USA, while the information on their impact on growth and gastrointestinal tolerance appears limited. A prospective, blinded randomized trial conducted in healthy normal newborns fed an experimental lactose-free milk protein-based formula vs. a standard lactose-containing milk-based formula for 112 days, indicated that biochemistries, tolerance of feeds, weight, length and head circumference were similar in both groups.
[Clin Pediatr. 2011;50(4):330-337.]

Current treatment preferences for Early Onset Scoliosis [EOS]
19.8% of members of the Pediatric Orthopedic Society of North America responded to a survey which assessed their current treatment choices in the management of EOS. Equal numbers of surgeons were “casting” [62%] and using “growing spine” [64.1%] techniques. 93% would choose non-operative management for the very young [±2 years of age] patient, while 63% would offer surgery as the initial approach to a 5 year old with a progressive large idiopathic curve.
[J Pediatr Ortho. 2011;31(3):326-330.]

Nutrition supplements and complimentary
medicines for Infantile Colic

Five electronic databases were searched to identify randomized clinical trials of complementary and alternative medicines and supplements for the treatment of Infantile Colic. All randomized clinical trials found were flawed, and while some treatments perhaps showed promise, no evidence supported their use.
[Pediatrics. 2011;127(4):720-733.]

Split thyrocricotracheoplasty for subglottic stenosis
Atresia of the larynx, crico-trachea and/or thyroid cartilage is rare and uniformly fatal if untreated. A relatively new operative procedure [slide thyrocricotracheoplasty] after tracheostomy, which may be performed 1-25 months later [where the proximal segment is split anteriorly and the caudal segment posteriorly and then anastomosed] appears to be an efficient treatment option with minimal morbidity.
[J Pediatr Surg. 2010;45(12):2317-2321.]

Brain function in children with Sickle Cell Disease [SCD]
Children diagnosed with SCD are at greater risk for stroke. It appears, however, that SCD children with normal brain MRIs may also have micro-white matter abnormalities which result in deficits in working memory and processing speed [involvement of right frontal lobe and cerebellum].
[J Pediatr Hem/Onc. 2011;33(3):163-171.]

ADHD and food sensitivities
While artificial food colors [AFCs] are not the main cause of attention-deficit hyperactivity disorder [ADHD], a sub-group of such patients appear to improve significantly when placed on an AFC-free diet. Other studies suggest sensitivity to nonsalicylate foods [milk, chocolate, soy, eggs, wheat, corn, legumes] as well as those that are salicylate-containing [grapes, tomatoes, and oranges]. A trial elimination diet in patients unresponsive to conventional therapy may be useful.
[Clin Pediatr. 2011;50(4):279-293.]

Timing of correct parenteral
antibiotic treatment-pneumonia

A retrospective study of 45 children, median age 17 months with severe ventilator treated community acquired pneumonia [CAP], admitted to an intensive care unit was undertaken. Median time to correct antibiotic [MTCA] treatment was defined as the time from emergency department presentation to the initiation of culture appropriate parenteral antibiotic therapy. MTC was 10.3 hours and 71% of children received correct empirical therapy. After adjusting for severity of illness, longer time to “correct antibiotic” was associated with longer duration on mechanical ventilation, intensive care and hospital stay. Delays [even short!] were associated with adverse outcomes.
[Ped Infect Dis J. 2011;30(4):295-301.]

Regression of a Solitary Osteochondroma [SO]
SOs appear to be the most common benign bone tumor, are usually slow growing and are found in skeletally young patients. Significant growth after skeletal maturity is often associated with malignant transformation. While spontaneous regression of a SO is usually unlikely, it appears that 24 cases have now been reported in the literature. As surgical excision carries a complication rate as high as 12.5%, observation and yearly X-rays may be an option, especially in asymptomatic pediatric patients. SOs that resolve appear to do so within 3 years of identification.
[J Pediatr Ortho. 2011;31(3):312-316.]

Glycerin suppositories to enhance
“Time to Full Feeds” in premature babies

In a prospective open randomized controlled trial in which premature babies were divided into 2 gestational age groups [24-27 weeks and 28-31 weeks] both groups being given suppositories from day 1 and compared to a control non-intervention group, no differences on time to full enteral feeding, feed tolerance, incidence of sepsis, necrotizing entercolitis, duration of oxygen requirement, growth or age at discharge, was found.
[Neonatology. 2011;100:169-176.]

Prevention of Retinopathy of Prematurity [ROP]
Arnal Patz discovered the association between ROP and oxygen therapy in the early 1950s and recently many neonatologists have lowered their target oxygen saturations in the neonatal period to 85%-93%, changing levels in small increments. The number of small babies with ROP, however, remains high.

It appears, based on new insights into the pathogenesis of ROP, that in order to reduce the incidence, not only should oxygen therapy be optimized, but other manipulations may be necessary. Depending on the degree of prematurity, hopeful interventions appear to include administration of exogenous erythropoietin, increasing serum IGF-1, optimizing serum glucose levels below 120mg and providing Omega-3 supplements. To prevent the proliferative phase of ROP, increasing hemoglobin levels may be beneficial, while stage III ROP may be responsive to Vitamin E and Omega-3 supplementation. Multiple interventions may be required and much more research is indicated before these treatments become standard clinical practice.
[Neonatology. 2011;100:116-129]

Blood proteins and prediction
of Bronchopulmonary Dysplasia [BPD]

The role of lung and systemic inflammation in the development of BPD was examined in a study of 932 extremely low birth weight newborns [ELBW]. A variety of proinflammatory cytokines, adhesion molecules and proteases were measured in blood samples taken on post-natal days 1-3, 5-8 and 12-15. Elevations of inflammatory proteins associated with BPD occurred early and inflammation increased over subsequent days. Only one elevated chemokine [RANTES] was associated with less BPD. Mechanical ventilation is also associated with an increase in inflammatory proteins, and these may contribute to the development of BPD.
[Pediatr Research. 2011;69(4):347-353.]

Prolonged infant crying and sleep-waking problems
While both of these behaviors are common issues faced by parents and frequently linked together as a general disturbance of infant regulation, they present at different ages and at different times of the day. It appears that infants who cry a lot [peaks at 5-6 weeks] mostly sleep through the night at 12 weeks of age. The two behavior problems have different causes, with sleep-waking issues usually involving “signaling” disturbances.
[Arch Dis Child. 2011;96:340-344.]

Red blood cell transfusions [PRBCs]
and necrotising enterocolitis [NEC]

In a study of 2,311 babies [BW<1500gms], 5.3% developed NEC and 27% of them occurred following [within 48 hours] PRBC transfusion. While an association between PRBC administration and NEC appears to exist, whether this is “temporarily” or “causally” related could not be ascertained.
[Pediatr. 2011;127(4):635-641.]

Child autopsy and parental grief
It is frequently stated that autopsy performed on infants/children who die help bereaved parents. A study of 56 such patients undertaken 3 months after the child’s death found that while 90% of parents valued it as a way of finding out the cause of their child’s death, only 41% felt it helped them live with their loss, and less [30%] found it a comfort. 42% of parents felt it added to their grief.
[Pediatr. 2011;127(4):e1013-e1020.]

Outcomes at school age of very preterm infants
A prospective study over 8 years for mortality and neurological outcomes on 2,846 live births between 24-32 weeks gestation, divided into “small for gestational age” [SGA], “mildly small for gestational age” [M-SGA] and “appropriate for gestational age” [AGA] found a mortality rate of 62% for the SGA group and 38% mortality rate for M-SGA and AGA babies, respectively. Birth weight was not associated with any cognitive, behavioral or motor outcomes at 5 years of age or school performance at 8 years. SGA children born between 29 and 32 weeks gestation had a higher risk of mortality, minor cognitive difficulties, inattention-hyperactivity symptoms and school difficulties compared to AGA children.
[Pediatr. 2011;127(4):e883-e891.]

Maternal feeding restriction and childhood obesity
Some studies suggest parental control over their child’s eating predicts later obesity. A study of 837 mother-infant pairs whose mothers agreed strongly that for their 1-year-old infants “I have to be careful not to feed my children too much” and were followed from their infancy to their third year of life suggested that these parents restricted the food intake of their children because they were already overweight.
[Arch Dis Child. 2011;96:265-269.]

Neurological sequelae after Carbon Monoxide poisoning
Carbon monoxide poisoning is common in adults with a delayed encephalopathy presenting after a lucid period as neuropsychologic abnormalities days or weeks after the acute episode. It appears that the shorter the lucid interval, the older the patient, and the presence of complications are more likely to predict a poorer prognosis. Hyperbaric oxygen treatment seems to be of value in 50% of these patients.
[Am J Emerg Med. 2011;29(3):261-264.]

Periotoneovenous shunts [PVS] for persistent ascites
A retrospective review of a large group of patients median age 34 months [range 1 month-12 years] with persistent ascites who underwent PVS for a variety of pathologies following failed paracenteses, dietary modifications, diuretics and/or TPN, indicated that post-operatively 91% had their ascites resolved. While no intraoperative complications occurred, 36% had post-operative adverse events. It appears that perhaps the procedure should be considered early.
[J Pediatr Surg. 2010;46(2):315-319.]