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Weekly Updates in Pediatrics

October 2011 - Current Updates in Pediatrics

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Monoclonal Antibody (Pagibaximab-Pa) to prevent Steaphylococcal (Staph) Sepsis

Pa is a human chimeric monoclonal antibody developed against lipoteichoic acid, which in phase 1 studies appears to be a safe and effective against staph infections.
 A study of 88 patients was utilized to evaluate clinical activity, pharmacokinectics, safety and tolerability of 3-once a week 90mg/kg(I) or 60mg/kg(II) Pa infusions versus a controlled placebo group(III) given to very low birth weight (700-1300gm), 2 to 5 day old neonates.
 Staph sepsis occurred in 0%, 20%, and 13% and non-staph sepsis occurred in 0%, 10% and 15% of patients in groups I, II, and III respectively.
 Three once-a-week infusions of 90mg/kg or 60mg/kg Pa given to very low birth weight, high risk neonates appears to be safe, effective and well-tolerated.
Pediatrics Vol. 128 No. 2 Aug 1, 2011 pp. 271 -279

Vocabulary catch-up among adolescents born prematurely

 322 very preterm (birth weights <1,250gms) and term born children aged 16 years, had cognitive and language testing at ages 8, 12, and 16 years.
 At 16 years very preterm born adolescents have deficits in general cognition and higher-order language skills compared to their term peers.
 Significant catch-up in receptive vocabulary occurs in very low birth weight infants by adolescence. A better socio-economic environment and absence of neurosensory abnormalities are associated with better outcomes.
Pediatrics Vol. 128 No. 2 Aug 1, 2011 pp. 313 -322
Continuous positive airway pressure (CPAP) with and without Heliox in viral bronchiolitis

 A systematic review of trials associated with the use of CPAP with and without Heliox in patients with respiratory distress from bronchiolitis was undertaken.
 After 1-2 hours of treatment significant reductions in Pco2 were noted.
 CPAP however does not appear to reduce the need for endotracheal intubation.
Pediatric Pulmonology, Vol 46, Issue 8, pp 736–746, Aug 2011
Neurologic manifestations of Influenza A H1N1 infections

 240 previously healthy children (4 months to 8 years) who met criteria for a viral-like illness were found, by reverse-transcriptase PCR assay to have H1N1 infections, and were utilized in this study.
 7.08% (17 patients) had neurologic abnormalities, 5 had simple febrile seizures, 7 complex febrile seizures, 3 encephalopathy, and 1 patient each had status epilepticus and a flaccid paralysis.  15 of 17 patients completely recovered.
 In children <5 years of age, Influenza A H1N1 viral infections not infrequently will manifest with neurological symptoms. Most recover.
Pediatric Neurology, Volume 45, Issue 2, pp. A1-A6, 67-140 Aug 2011

Epilepsy development and prognosis in Cerebral Palsy

 Neonatal seizures, family history of epilepsy and mental retardation appear to be important predictors of epilepsy and Cerebral Palsy.
 Neonatal seizures, EEG epileptic activity and polytherapy appear to be predictions of poor epilepsy prognosis.
Complications of Acute Bacterial Sinusitis (ABS)

 5-10% of upper respiratory infections in children, particularly 3-6 years of age, are complicated by ABS, with males being significantly more often affected.
 Complications can be categorizes as extra cranial, intra cranial and those involving the bone of the sinus wall (ostiatis).
 The most common extra cranial complication is inflammatory edema of the orbital septum. Orbital complications include cellulitis, abscess, and optic neuritis.
 Epidural empyema is the most common intra cranial complication.
 “Pott’s puffy tumor” is an osteitis of the frontal sinus which is often associated with subdural and epidural empyemas.
 Acute bacterial sinusitis requires careful observation to ensure early diagnosis of complications.
Pediatric Infectious Disease Journal, Aug 2011, Vol 30, 8, pp 701-702

Foreign body (FB) aspiration

 Sensitivity and specificity of various diagnostic criteria utilized for the diagnosis of FB aspiration include:
 Clinical history (63% and 32%), symptoms of paroxysmal cough/respiratory insufficiency (68% and 53%), physical examination findings (70.5% and 63%), x-ray findings (73% and 68%), and the triad of cough, wheeze and decreased breath sounds (88% and 51%), respectively.
 Although no symptom, sign or combination is specific or sensitive enough to make a clear-cut diagnosis of FB aspiration, a witnessed history of aspiration, early (<24 hrs) admission after onset of symptoms and wheezing appear to be appropriate indications for bronchoscopy.
Pediatric Emergency Care, August 2011, 27(8), pp 723-726

Morbidity and mortality of ECMO in late preterm infants with hypoxic respiratory failure

 Comparing full term gestation (39-426/7 weeks), early term (37-386/7 weeks) and late preterm (34-366/7 weeks) infants who met inclusion criteria for ECMO for hypoxic respiratory failure, late preterm infants with a primary diagnosis of sepsis and persistent pulmonary hypertension had the highest mortality (3x higher than meconium aspiration babies on ECMO) and highest complication rates.
The Journal of Pediatrics, Vol 159, Issue 2, Aug 2011, pp 192-198.e3

Thoroscopic repair of Congenital diaphragmatic hernia (CDH)

Thoroscopic versus open repair of neonates with unilateral CDH were compared in a single institution over a four year period (2006-2010). 74% of attempted thoroscopic repairs were completed.
Comparing thoroscopic to open repair of CDH indicated a higher recurrence rate and a steep learning curve associated with thoroscopic surgery.
Journal of Pediatric Surgery, Vol 46, Issue 7, July 2011, pp 1303-1308

Pectus excavatum repair

 A pectus bar used in the repair of pectus excavatum may have a metallic or absorbable stabilizer. Removal of a bar with a metallic devise maybe difficult as fibrous or a new bone may cover it.
In 30 patients who had their bars removed, half fixed with a metallic and half with an absorbable stabilizer, removal of those with the absorbable stabilizer was simpler, faster and required smaller incisions.
Journal of Pediatric Surgery, Vol 46, Issue 7, July 2011, pp 1338-1341

Management of isolated skull fracture

 A retrospective review of patients (mean age 11 months) admitted to a pediatric trauma center (usually following a fall), with a recent (<24hrs) isolated skull fracture, a Glasgow Coma Score (GCS) of 15, and whose head CT scan indicated no other significant skull or intracranial pathology, revealed that 33% were discharged from the emergency department (ED) after a brief observation period (median 3.3hrs). Those admitted to the hospital stayed 18.2hrs (median).
 It appears that children presenting with an isolated skull fracture and a GCS of 15 can be safely discharged from an ED after a brief observation period if they are asymptomatic and have a reliable social environment.
Journal of Pediatric Surgery, Vol 46, Issue 7, July 2011, pp 1342-1346

Parenteral omega-3 fatty acids and intestinal recovery after ischemia/reperfusion (IR) injury

Fatty acids from fish oil appear to be significant disease-modifying substances.
A rat study, utilizing control animals, animals who had IR injury of the small bowel and a group who received omega-3 fatty acids intraperitoneally, indicated that while a significant decrease in bowel and mucosal weight was observed after untreated injury of the small intestine, treatment resulted in significant increases in bowel and mucosal weight, villus height and crypt depth. Bowel injury was significantly ameliorated.
Journal of Pediatric Surgery, Vol 46, Issue 7, July 2011, pp 1353-1360

Constipation in children

 Constipation is a common problem in children. A number of factors may play a role. These include:
1 ”Withholding stool”
2 Early toilet training
3 Changes in diet (too little fiber or fluids)
4 Changes in routine
5 Medications
6 Cows milk allergy or drinking too much milk
7 Medical conditions
8 Family history
Among the many investigations that may or may not be indicated, nuclear transit studies (NTS) allow for “passage time” through the intestines to be calculated.
 Of 520 children with chronic constipation who underwent NTS, 12% were identified with rapid proximal colonic transit. Many of these children had a family history of allergy and symptoms associated with food allergy/intolerance. Dietary exclusion resolved constipation in 50%.
 The NTS can identify rapid proximal colonic transit time as a cause of chronic constipation in children. These patients frequently exhibit symptoms of food allergy/intolerance which may respond to dietary exclusion.
Journal of Pediatric Surgery, Vol 46, Issue 7, July 2011, 1406-1411

Granulocyte transfusions (GTX) for Febrile neutropenia

 Infections remain the most frequent cause of death in neutropenic (or defective granulocyte function) patients.
 A study of 35 children with high-risk febrile neutropenia or abnormal granulocyte function were given GTX for three consecutive days during infections not responding to antibiotics. The infection-related survival was 82.4% at 30 days.
 GTX appears safe and effective in controlling life-threatening infections in granulocyte dysfunction patients.
Journal of Pediatric Hematology/Oncology, Aug 2011, 33, e220-e225

Alpha-fetoprotein (AFP) negative hepatoblastoma

 Hepatoblastoma while rare, is the most common malignant liver tumor of early childhood. Most cases appear during the first 18 mths. of life and tend to be more frequent in children born very prematurely. AFP blood level is the most important serologic marker for hepatoblastoma and can be used to both diagnose and monitor patients response to treatment.
 This report documents the first infant with a hepatoblastoma and a NEGATIVE AFP.
Journal of Pediatric Hematology/Oncology, Aug 2011, 33, e245-e247

Neostigmine use in the critically ill constipated child

 While neostigmine has been used in ill constipated adults, this report of its continuous intravenous use in 3 critically-ill constipated children is perhaps the first. Two of the 3 children responded well with no adverse effects.
Journal of Pediatric Gastroenterology & Nutrition, Aug '11, 53, e224-e226

Emotional problems in children with congenital heart defects (CHD)

 While children with CHDs may have emotional problems at 6 or 18 months of age, it appears that by 36 months there is no increased risk  of internalizing or externalizing emotional problems.
Journal of Developmental and behavioral Pediatrics, August 2011, 32(6), e461-e464

Young adult outcomes of infants delivered at 23-26 weeks gestation

 316 infants born between 23-26 weeks gestation were analyzed retrospectively at 19.3 years (mean). 88% had graduated from high school and 56% were currently enrolled in post-secondary education. 52% had required some educational assistance.
 The majority of babies born at 23-26 weeks, have the ability to become productive members of society with some assistance.
Journal of Neonatal-Perinatal Medicine, Vol 4, No2/2011, pp 93-99

Puberty in daughters of pre-eclamptic mothers
 A study of 120 daughters born of pre-eclampic mothers investigated breast and pubic hair development and compared them to their peers of normotensive mothers.
 Pubic hair growth (Pubarche) more often preceded breast development (Thelarche) in the offspring of the pre-eclamtic mothers. With increasing severity of pre-eclampsia increasing differences were noted.
Archives of Disease in Childhood, August 2011, 96, pp 740-743

Sleep duration and body mass index (BMI)

A study of 7701 children <7yrs of age was undertaken to ascertain whether any relationships could be found between BMI and sleep duration, and whether sleep duration predicts later BMI and/or BMI predicts later sleep duration.
 Sleep duration did not appear to predict obesity in this population (or vice versus) nor did there appear to be any direct relationship between sleep problems and obesity.
Archives of Disease in Childhood, August 2011, 96, pp 735-739

Long term outcomes of pediatric intensive care unit (PICU) admission for asthma

Data from 410 children admitted to a PICU with a diagnosis of asthma were followed for a period of 10.3 years.
67% of asthmatic children admitted to the PICU required subsequent admission to the hospital for asthma, with 17% being readmitted to the PICU. Risk factors for PICU readmission included recent admission, and a previous requirement for ventilatory support. 1.8% subsequently died from asthma. Risk factors for death included multiple PICU admissions, persistent asthma and ventilator support at admission.
Archives of Disease in Childhood, August 2011, 96, pp 729-734

Symptoms/clinical features of serious respiratory infections in children

A prospective study utilizing parents and triage nurses’ documented symptoms of 535 children (3 months-12 years) with suspected acute infection, was analyzed to identify findings predictive of serious respiratory tract infection.
 Parent-reported symptoms were unreliable discriminators of serious respiratory infection and agreed poorly with nursing assessments. Nurse triage assessment of respiratory distress strongly indicated serious respiratory infection.
Archives of Disease in Childhood, August 2011, 96, 708-714

Severe allergic reactions to measles-mumps-rubella (MMR) vaccine in children allergic to eggs and cows’ milk

Allergies to hens’ eggs and cows’ milk are the most common food allergies throughout childhood. While current guidelines recommend safe administration of MMR vaccine in egg-allergic patients, 3 children described in this article presented in anaphylactic shock.
All children should receive MMR in a setting equipped, and with a person capable of, dealing with an anaphylactic reaction.
Acta Pediatrica, August 2011, Vol 100, Issue 8, pp e94-e96

Sudden Unexpected Death in infancy (SUDI)

In a study of 221 SUDI cases analyzed from New Zealand, 83% were Maori, median age at death was 11 weeks (11% occurred in 7-28 day olds), 64% were bedsharing and 57% were placed in non-supine positions at their last sleep.
Bedsharing and non-supine position in this population are the commonest associations found in SUDI.
Acta Pediatrica, August 2011, Vol 100, Issue 8, pp 1108-1112

Anxiety in chronic illness

 Compared to their normal peers, anxiety levels are high in children with a chronic illness.
Apparently chronic fatigue syndrome, migraine/tension headache, sensory impairment and epilepsy cause the highest levels of anxiety.
 Acta Pediatrica, August 2011, Vol 100, Issue 8, pp 1069-1076