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Weekly Updates in Pediatrics

May 2012 - Current Updates in Pediatrics

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May 2012

1) Bronco -pulmonary dyspasia/ medicine non-adherence & morbidity.
194 caregivers of premature infants with chronic lung disease completed questionnaires to identify medicine adherence raters and to relate these to respiratory outcomes and quality of life.
Medication non-adherence is common in premature infants with chronic lung disease and this appears to be associated with an increase in respiratory morbidities and Emergency Department visits.
Pediatric Pulmonology March 2012
2) In-utero exposure to antiviral ( AVA ) agents.
Of 1112 live newborn infants exposed during the first trimester to AVA’s, 5.5% had congenital abnormalities, with cardiovascular anomalies occurring most frequently.
No statistically significant association between in utero exposure to AVA’s and congenital anomalies appears to be present, EXCEPT for those inutero infants exposed to EFAVIRENZ.
3) Neurological outcomes following uni- vs bi- lateral intraventricular hemorrhage.( IVH ).
166 ELBW (birth weight <1000gms) with head ultrasound evidence of Grade I-IV were developmentally assessed at 18-22 months corrected age.
Neurodevelopmentally, infants with Grade IV bilateral IVH are significantly worse off than those with equivalent unilateral bleeds. ELBW with Grades I, II, and III IVH bilaterally are indistinguishable neurodevelopmentally at 18-22 months from those with similar grade unilateral IVH.
4) Best Resident " Hand-over " procedures . "Mnemonic"
The process of transmission of information between Residents “handing over” patients requires significant improvements, as Resident information errors appear to contribute to a number of subsequent sentinel events. While focused training in communication and standardized templates or computerized documentation are equally important the “verbal” process maybe enhanced by the utilization of a mnemonic aide.
While there appear to be many Resident communication aides available, most have not been rigorously tested. I-PASS (Illness severity, Patient history etc, Action-“to-do list” Situation awareness and contingency planning, Synthesis-summary) is a novel multi-site pilot study the results of which may well be worth following.
5) Diet in Attention Deficit/ Hyperactivity Disorder ( ADHD ).
The role of diet and dietary supplements in the treatment of ADHD remains controversial but persistent.
ADHD patients whose pharmaco-therapy is unacceptable or unsatisfactory have been offered additive-free (Finegold diet), oligo antigenic/elimination diets, iron and zinc supplements, omega-3 additives and the “avoidance” of a Western type diet. Though many claims of effectiveness remain uncertain, this extensive article is well worth reading by those interested in the field. ED
6) Iron fortified vs low iron infant formulae.
Iron deficiency in infancy is sufficiently common to have led many countries to routinely fortify infant formulae with iron. A randomized control study of 473 healthy full term infants indicated:
Infants fed iron-fortified formulae (12.7mg/L) with high hemoglobin levels may be neurologically adversely affected. The optimal amount of iron for infant formulae requires further investigation.
7) Prepuberty ,obesity, C-reactive protein (CRP ) & atherosclerosis.
It seems that the atherosclerotic vascular complications (measured by carotid intima-media thickness; CIMT) seen associated with obesity, are due to the lipids causing a low-grade inflammatory response which in turn maybe measured by high sensitivity CRP (hsCRP)
A study of 135 prepubertal boys and girls studied to assess the relationship between body weight (BMI), body fat, hsCRP and CIMT, indicates:
Early prevention of cardiovascular disease may need to focus on life-style strategies to decrease low-grade inflammation rather than on BMI or obesity prevention.
The Journal of Pediatrics February 2012
8) Unbound bilirubin does not increase during Ibuprofen treatment.
Previously (April 2012) we published data which indicated the value of a repeat dose of Ibuprofen to close the ductus arteriosis in premature babies.
A prospective study of 34 pre-term jaundiced (total bilirubin level 2.9-8.8mg/dl) neonates (<32 weeks gestation) treated with 3 doses (10mg-5mg-5mg) of Ibuprofen during the first week of life indicates no deleterious effects on Total/unbound bilirubin or albumen binding affinity.
The Journal of Pediatrics February 2012
9) Neurodevelopemental outcomes following delivery room CPR.(DR-CPR).
A large study of 1333 extremely low birth weight (ELBW) infants who received DR-CPR indicates that these babies have more pneumothoroces, Grade III/IV intraventicular hemorrhage, bronchopulmoary dysplasia and death by 12-120 days after birth. Only 14% of DR-CPR recipients with 5 minute Apgar score <2 survive without neurodevelopmental impairment.
10) Diagnosis of Intussusception.
It appears that all young children (<3 years of age) with a combination of a highly suggestive abdominal x-ray, right upper quadrant pain, vomiting and lethargy have intussusception on barium enema or surgery. This combination appears as specific for intussusception as abdominal ultrasound.
11) Renal stones & Ceftriaxone administration.
Treatment with ceftriaxone is known to be associated with biliary pseudolithiasis.
In a first study of 83 matched children (3 mths - 8.9 years) either treated with ceftriaxone or ampicillin for bacterial pneumonia, serum and urinary calcium levels were measured prior to an after treatment.
Children treated with ceftriaxone appear to excrete significantly greater amounts of urinary calcium, which may be linked to the development of urinary sludge or renal stones.
12) Should children Scuba dive?
Cerebral arterial gas embolism (CAGE) is a well-known complication of using a closed breathing system for scuba diving. This is characterized by air/gas bubbles in the blood stream which obstruct blood flow to organs depending on their size and location, causing a variety of severe complications. The usual reason for CAGE is rapid ascent in the water while breath holding. (Leads to overexpansion of alveoli). Pulmonary and neurologic symptoms occur in 20-50% of patients.
An interesting uncommon case report of cerebral arterial gas embolism occurring in a 10 year old boy scuba diving in a pool, reminds us that children not old enough to understand the physics of diving, should not scuba dive.
13) Hypoglycemia following decreased oral intake.
A study of capillary blood glucose levels of 145 children, 1 mth – 5 years of age who presented to a Emergency Department with a history of at least 2 vomiting episodes, >50% decrease in oral fluid intake over a 24-hour period and history of irritability was undertaken to estimate the prevalence of hypoglycemia.
Hypoglycemia appears to be a rare occurrence (<2%) in children <5 years of age who present with vomiting, decreased oral intake or even irritability.
14) Long term effects of dog bites.
The long term psychological consequences of being bitten by a dog include post-traumatic stress or the more severe post-traumatic stress disorder (PTSD). If unrecognized impairment in brain development, and cognitive, behavioral and social skills may result.
Following a dog bite:
85% of parents believe additional support services are needed.
75%, that their families would benefit from education regarding dog bite prevention.
70% note at least 1 new behavioral problem in their child. (Many report concerns about their own reactions)
50% believe the children need interventions to cope with their fears.
15) Rotavirus vaccine & Intussusception.
A 4 year study of a National database for children <1 year of age admitted to a hospital with discharge diagnosis of intussusception prior to, and 1 year after, the introduction of the Rotavirus vaccine indicates that the vaccine has NOT resulted in an increase in hospital patients diagnosed with intussusception. Archives of Pediatric & Adolescent Medicine April 2012
16) Brachial plexus birth palsy. (BPBP)
75% of babies with BPBP have Erbs Palsy (C5-C7 nerve root damage).
A retrospective study of 51841 newborns over 15 years indicates that children with C5-C6/C5-C6-C7 injuries completely recover in 86% and 38% of cases respectively. Global injuries (C5-Th1) almost always result in permanent disability.
Multiparous mothers, rapid late gestation fetal weight and a heavy baby appear to have the greatest influence on the development of BPBP.
17) Educational/Vocational achievements in Twins.
A large study of individuals born (over a 17 year period) and raised as twins (and compared to a matched singleton group) and followed to 27-35 years of age indicates:
Being raised as a twin has neither beneficial nor deleterious effects on employment rates, or mean income with educational/vocation achievements appearing marginally better.
18) Magnetic Resonance enterography (MRE ) in Crohn's Disease.
Crohn’s Disease is chronic inflammatory disorder of the bowel that frequently presents during childhood. These children undergo repetitive radiological examinations, and there is concern over the potential harm of cumulative radiation exposure.
MRE is a new modality that allows for detailed examination of the GI tract without radiation.
A study of 45 children with Crohn’s Disease indicates that MRE examination compares favorably to ileocolonoscopy or macroscopic examination of resected bowel material.
Acta Paediatrica June 2012
19) Growth Hormone (GH) treatment in Prada-Willi Syndrome.(PWS).
16 consecutive PWS patients had cardiovascular and pulmonary function measurements undertaken prior to and 6 months following GH treatment.
GH treatment in PWS improves arterial oxygenation and cardiovascular function during sleep.
20) First rib fractures -a sign of Abuse.
Rib fractures are the most common injury sustained after blunt chest trauma. First rib fractures are rare and are usually associated with a violent force.  In infants these fractures are difficult to diagnose on skeletal survey.
This report describes 4 first rib fractures in infants highlighting the difficulty in detection and emphasizing that a first rib fracture in a healthy infant strongly suggests child abuse.
Clinical Pediatrics May 2012
21) Chronic Nonalcoholic Fatty Liver.(NAFLD). NAFLD is common, (most common cause of chronic liver disease in children in the USA) and for most people causes no symptoms, signs or complications. Occasionally the fat causes an inflammatory process (steatohepatitis) that results in cirrhosis and occasionally liver failure. Typically it occurs in overweight children >3 yrs of age with increased waist circumference.
NAFLD should be suspected in all overweight children and an abdominal ultrasound and liver function tests should be undertaken. Normal results require repeating over time due to poor sensitivity of a single assessment. It appears that the lipin 1 r s13412852 C>T single nucleotide polymorphism may be associated with liver damage and progression of the disease.
Journal of Pediatric Gastroenterology & Nutrition May 2012

Journal of Pediatric Gastroenterology & Nutrition May 2012
22) Serum Ferritin level- a marker of Hemophagocytic Lymphohistiocytosis (HLH)
HLH is an uncommon hematological disorder that usually presents with fever, jaundice, rash, lymphadenopathy and hepatosplenomegaly. Laboratory finding include lymphocytosis, histiocytosis, pancytopenia, abnormal liver function tests with a high serum ferritin level. Pathologically hemophagocytosis is found. It may be “familial” (5 genetic subtypes) or “secondary” to a variety of infectious agents, autoimmune, or metabolic diseases. (Lymphoma too!)
High serum ferritin levels are so strongly associated with HLH, so accessible and cost-effective that it may be the single most valuable tool in diagnosing HLH.
Journal of Pediatric Hematology/Oncology April 2012
23) Traumatic open Globe injuries.
A retrospective chart review of children, average age 9.7 years with open Globe injuries and assessed for a variety of parameters indicates that the most common causes of trauma are:
Accidents (79%), violence (10%) and motor vehicle accidents (9%). 54% are penetrating and blunt rupture is most common.
Visual acuity prognosis following open Globe injury in children is poor, and can be predicted by the Ocular Trauma Score.
Journal of Pediatric Ophthalmology and Strabismus March/April 2012
24) Risk factors for Sudden Infant Death Syndrome (SIDS) after "Back-To -Sleep". (BTS)
Following the campaign initiation of the BTS program for infants, SIDS babies found prone decreased from 84% to 48.5% and were associated with significantly less symptoms of upper respiratory tract infection.
Since infants in the BTS era are now more frequently associated with bed-sharing and prematurity. Variation in risk factors, both intrinsic and extrinsic continue to play a role. The avoidance of multiple risk factors is important in the prevention of SIDS.
25) Breast milk/ Glucose or Sucrose for neonatal pain relief.
In 2 studies, the Premature Infant Pain Profile (PIPP) was used to measure pain, duration and intensity in infants undergoing heel lancing when given either breast milk, 25% glucose or oral sucrose.
25% glucose (compared to breast milk) given orally to premature babies undergoing heel lancing appears to result in little or no pain with a lower incidence and duration of crying. Oral sucrose appears to have no additional beneficial effect when compared to breast milk.
Pediatrics April 2012