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Weekly Updates in Pediatrics

November 2011 - Current Updates in Pediatrics

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1. Partial exchange transfusion (PET) and brain oxygenation in Polycythemic infants
15 polycythemic newborns (venous hematocrit > 70%) had their cerebral oxygenation and microvascular flows measured before and after PET.

PET appears to improve cerebral oxygenation and microcirculation flows in Polycythemic infants. Whether these results improve clinical outcomes requires further study.
Acta Paediatrica
Volume 100, Issue 11, pages 1432–1436, November 2011
2. Outcomes of pediatric heart transplant patients
A retrospective review of 135 Swedish children (1989-2009), less than 18 years of age who underwent heart transplantation for cardiomyopathy (55%) and congenital heart disease (45%) was undertaken after 5.9 years (median) to assess outcome.

Waiting-list mortality was 31% and actuarial survival at 1, 5, 10, and 15 years was 92%, 82%, 76%, and 58% respectively.

Post transplant complications included rejection (34%), malignancies (12%), renal failure (8%), coronary artery vasculopathy (6%), and re-implantation (5%).

60% of patients died while on a waiting list or from post-transplant attrition. Functional status in survivors is good.

Acta Paediatrica
Volume 100, Issue 11, pages 1442–1447, November 2011

3. Behavioral problems in children with Fetal alcohol syndrome
73 children and adolescents with Fetal alcohol spectrum disorder (FASD) were examined for behavioral problems using the Child Behavior Checklist.
Behavioral risk factors associated with prenatal alcohol exposure includes length of time spent in Residential Care and a low dysmorphology score (less visibly affected). Additional services should be directed to these two groups of at risk children.
4. Triple-A syndrome (Achalasia-addisonianism-alachrimia)
Triple-a syndrome is a rare progressive autosomal recessive congenital condition (chromosome 12q13) discovered in 1978, which usually presents with absence of tears. Clinical presentation is highly variable. Adrenal insufficiency due to ACTH resistance, achalasia and signs of autonomic dysfunction (pupillary abnormalities and hypoglycemia) may take years to develop. Patients may be mentally retarded and may present with neurological abnormalities.

An 11 year old boy with Triple-A syndrome presented with neurologic abnormalities early, before other features of this condition were apparent.

Pediatric Neurology
Volume 45, Issue 5, November 2011, Pages 347-349

5. Septic arthritis and acute varicella
Non-bacterial arthritis is a well-recognized complication of acute varicella in children; frequently being a mono-arthritis of a knee.

In this report a 4 year old little girl presented with synovial fluid DNA proven arthritis of the hip, six days before the appearance of the rash.

Pediatric Infectious Disease Journal:
November 2011 - Volume 30 - Issue 11 - pp 980-982

6. Hand sanitizer use and Influenza
A study utilizing school children in 10 elementary schools (5 “control” and 5 “intervention schools”) was used to study the ability of an alcohol-based hand sanitizer to prevent the spread of Influenza in the schools. The “intervention school children” received training in hand and respiratory hygiene and were provided and encouraged to use the hand sanitizer regularly.

Hand sanitizer use does not appear to prevent Influenza spread amongst school children, however children utilizing the sanitizer had significantly less school days lost and laboratory confirmed Influenza A.

7. Complications of intraosseous line (IO) use
A large retrospective study using data from 450 California hospitals and Emergency Departments, identified 291 children (0-18 years), who had IO lines placed. Most common diagnoses for these children included cardiac arrest (34%), trauma (19%) and respiratory failure (6%).

While potential complications of IO use include fractures, osteomyelitis and compartment syndrome, in this study no complications were found.

8. HPV vaccine against Anal HPV infection/neoplasia
Human papillomavirus (HPV) anal infection is increasing, particularly in men having sex with men. This is resulting in an increase in anal intraepithelial neoplasia and cancer.

It appears (in this study supported by its Manufacturer) that the use of qHPV vaccine in high risk populations decreases the rate of intraepithelial neaplasia (and potentially anal cancer) and has a “favorable safety profile.”

N Engl J Med 2011; 365:1576-1585 October 27, 2011

9. Surfactant deficiency in Transient Tachypnea of the newborn (TTN)
The lamellar body count (LBC) correlates with lecithin/sphingomyelin ratios and phosphotidylcholine values and is used as a valid rapid screening test to determine biochemical fetal lung maturity.
Gastric aspirates were collected within 30 mins. of birth from 42 term newborns (21 patients with TTN and 21 control subjects), delivered via elective cesarean section, and analyzed for LBC and stable microbubble test (SMT).

TTN babies were shown to have significantly lower LBC and SMT compared to control infants and both tests were lower in TTN babies who required oxygen for > (greater or equal) 24 hours compared to those who needed oxygen for less time. Term babies with TTn have decreased surfactant function.

10. Parenteral nutrition (TPN) and liver disease
A retrospective review of all neonates who require TPN (2001-2006) post-abdominal surgery was undertaken to investigate the incidence of cholestasis associated with TPN. Of 176 infants treated for 28 days (mean), 24% developed cholestasis. These infants were born earlier (34 vs 36 wks gestation), required longer TPN duration (76 vs 21 days), had longer in-patient stays (86 vs 29 days) and were more likely to be discharged on  TPN.

TPN induced cholestasis appears to occur early in the course of TPN management, particularly in the premature infant.

11. Single (SL) vs 4-incision laparoscopic cholecystectomy
Forty SL cholecystectomy patients were compared to a matched group treated with a standard 4-incision laparoscopic approach. Retrospectively, demographics, operative time, length of stay, blood loss and intravenous narcotic use was obtained.
It appears that though SL takes longer (79.2 mins vs 63 mins) hospital stay is shorter, narcotic usage is less and the procedure is safe and feasible even in the acute setting.

Journal of Pediatric Surgery
Volume 46, Issue 10, October 2011, Pages 1909-1912

12. Single-dose 5-fluoracil (5FU)therapy in experimental caustic esophageal burns
Accidental ingestion of a caustic substance results in increasing fibrosis of the esophagus with 20% of patients developing strictures. A single dose of 5FU is a long acting and effective inhibitor of fibroblast proliferation.
In an experimental model utilizing control Wistar-albino rat groups and induced distal esophageal burns (by instilling 10% NaOH) in 2 experimental groups (I: single intraperitoneal injection of 5FU, II: local treatment with a single intraesophageal application), histopathologic damage and degree of fibrosis could be quantified.

It appears from this animal experiment that a single intraperitoneal application of 5FU decreases caustic esophageal stricture formation. No benefit occurs from local instillation. Clinical studies are required to verify the use of 5FU in the management of caustic esophageal burns in children.

13. SIDS and other sleep-related infant deaths
Though the incidence of SIDS has decreased substantially since the initial American Academy of Pediatrics (AAP) recommendation in 1992 that infants be placed for sleep in a non-prone position, the incidence of other causes of infant death during sleep has increased (suffocation, asphyxia, entrapment and other poorly-defined entities).

The expanded AAP recommendations now include supine position for infant sleep, use of a firm sleep surface, breastfeeding, room-sharing without bed-sharing, routine immunizations, consideration of using a pacifier and avoidance of soft bedding, overheating and exposure to tobacco smoke, alcohol and illicit drugs.

14. Effects of profanity exposure in media
Adolescent (middle school) exposure to profanity in the media appears to affect beliefs about profanity, use of profanity and engagement in physical and relational aggressive behavior.
15. Hypotonic vs isotonic maintenance fluids post-surgery
258 similar post-operative patients (6mths-16years of age) were randomly assigned to receive either hypotonic (0.45% saline) or isotonic (0.9% saline) fluids as intravenous maintenance fluids.

Maintenance hypotonic saline significantly increases the risk of hyponatremia. Isotonic maintenance fluids does not increase the incidence of hypernatremia.

16. Risk of long-acting B2-adrenergic agonists (LABA) in asthma (look for beta)
The US Food and Drug Administration performed a meta-analysis of controlled clinical trials comparing LABA to non-LABA treated asthmatic patients 4-64 years of age.
The greatest number of serious asthma-related events was observed in the LABA 4-11 year-old treated group. It is still unknown whether inhaled steroids affects the significant increase in adverse events found with LABA use in asthmatic children.
17. Disability after traumatic brain injury (TBI) in children/adolescents
Children <18 years of age treated for TBI were compared to a similar demographic group who presented with a broken arm. Outcome measures at 3, 12 and 24 months after injury were compared for disability in health-related quality of life, adaptive skills and participation in social and community activities.
Moderate or severe TBI patients had diminished levels of activity at 3 months which though improved at 12-24 months were still significantly impaired. Communication and self-care abilities were decreased at 3 months post injury and did not improve by 24 months.
18. Chest pain (CP) in children
The records of 3700 children > 6 years of age (median 13.4 years) who presented to a cardiac clinic with a complaint of chest pain and followed for a median of 4.4 years, were reviewed.
CP with exertion occurred in 33% of patients, 12% of whom had syncope associated with their CP. A cardiac cause was found in only 1% of patients. In the remaining patients the cause was “unknown” in 52%, musculoskeletal in 39%, pulmonary in 6.6%, gastrointestinal 2.9%, anxiety-related 1%, or drug related 0.1%. 18% had previously presented to an Emergency Department.

While chest pain is a common complaint in childhood it is rarely of cardiac origin and usually benign.

19. Cognitive and behavioral outcomes after infant exposure to anesthesia
Millions of young children (< 2 years of age) are annually exposed to anesthetic agents which may potentially adversely affect their neurodevelopment.
A study of 350 infants < 2 years of age who were exposed to anesthesia were tested for learning disabilities, emotion/behavior disorders, cognition and achievement outcomes, and compared to a matched unexposed comparable group.

Exposing infants to multiple (BUT NOT SINGLE) anesthesia/surgery appears to significantly increase the risk of developing learning and cognition difficulties with poor achievement scores. Increased emotional/behavioral educational needs are apparently unnecessary.

Pediatrics Vol. 128 No. 5 November 1, 2011
pp. e1053 -e1061

20. Allergic rhinitis/Intermittent nasal steroids and ocular side effects
A study was undertaken of 150 children with allergic rhinitis (8-15 years of age) who had used intermittent intranasal budesonide (approximately 100ug/day) for > 2 years to assess ocular side effects and compared them to a comparable group who had never been exposed to the intranasal steroids.

No differences between the groups for cataract formation, corneal ectasia, ocular hypertension or glaucoma, as well as “dry eye”, was found.

Journal of Pediatric Ophthalmology & Strabismus
September/October 2011 - Volume 48 • Issue 5: 311-317

21. Telephone-based management of mental illness
Many children with mental health disorders do not receive timely care because of access barriers.
A study of 243 children with oppositional-defiant, attention-deficit/hyperactivity or anxiety disorders were randomly assigned to receive “usual care” or “Strongest families” intervention-a telephone based intervention modality which included a weekly telephone coach session and appropriate handbooks and videos.

At 240 and 365 days after randomization and treatment, fewer children were diagnosed as having disruptive behavior or anxiety disorders.
This promises to be a useful mechanism to increase access and management for this group of patients, particularly during financial constraints (Ed).

Journal of the American Academy of Child & Adolescent Psychiatry
Volume 50, Issue 11 , Pages 1162-1172, November 2011

22. Down syndrome (DS) and wheezing. Is it Asthma?
From a case-control study of 130 children with DS who were compared to their siblings and age/six matched control, both “wheeze ever”, and “wheeze” during the previous 12 months was more commonly reported in DS patients than in either their siblings or the matched controls. 3.1% of DS children were physician diagnosed with asthma while 4.2% and 6.7% of their siblings and control patients respectively were so diagnosed. During a 4 year follow up of 24 DS children no diagnosis of asthma or atopy could be confirmed.

Wheeze is common in children with DS. It does not appear to be asthma.

23. Intergenerational transmission of thinness
4423 English families with 2 parents and 7078 healthy children/adolescents with anthropometric data (from a 5 year population based National survey) were examined to categorize their children using International Obesity Task Force criteria, and to investigate the influence of parent weight on the child’s weight status. 5.7% of the children were categorized as thin, more commonly in 2-5 year olds and ethnic minorities.

Parental weight was the strongest predictor of child/adolescent thinness. The prevalence of childhood thinness was highest when both parents were thin and progressively lower when both parents were in the upper half of weight range, were overweight or obese.
Childhood thinness appears to be genetically mediated.

24. Symptom duration in appendicitis and rate of perforation
In adults it appears that the delay from symptom onset to appendicitis treatment on the prevalence of perforation, is minimal.
In a study of 202 children older than 3 years, undergoing appendectomy the incidence of perforation was 10% if symptoms were present for <18 hours. By 36 hours however, 44% of symptomatic untreated children had appendix perforation.

Children unlike adults, have a greater and substantial risk of appendiceal perforation within 24 hours of onset of symptoms which increases in a linear fashion, the longer the delay.

25. Update Etiology of septic arthritis in children
In the post-Hemophilus influenza type B and post-pneumococcal vaccine age, a retrospective chart review of all children < 13 years of age presenting to a tertiary care pediatric Emergency Department, with a diagnosis of septic arthritis, was undertaken.

The most common joint involved was the hip, followed by the elbow, knee and ankle. Methicillin-sensitive S. aureus, followed by methicillin resistant S. aureus and Strep. pneumonia were the commonest organisms isolated.

American Journal of Emergency Medicine, The Vol. 29, Issue 8, Pages 899-902