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Weekly Updates in Pediatrics

September 2011 - Current Updates in Pediatrics

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1. Tongue-Piercing
   Sterile tongue piercing was undertaken using four different materials randomly allocated to 85 subjects. After 2 weeks all patients were examined and microbiological samples were analyzed.
   28.8% of subjects reported lingual recession, and 5% reported chipping of a tooth. In general, bacteria associated with periodontitis were most commonly found in the piercing channels or from the studs. Most (83%) of bacterial species were identified from stainless steel implants. 
Ref. Journal of Adolescent Health, vol. 49, issue 1, July 2011, pp 76-83.
2. Two-day bowel preparation for colonoscopy 
   Polyethylene glycol (PEG) (2gm/kg tablet) with a 5mg tablet of bisocodyl was given daily for two days, to 111 children (mean age 11.9 years) before colonoscopy. Daily stool frequency doubled on day one, and was 3.5 times more frequent than baseline on day two. Colonic preparation was rated at colonoscopy as excellent/good in 92% of patients. Adverse effects included mild nausea (19%), abdominal pain (11%), and vomiting (4%).

   A 2-day bowel preparation with PEG and bisocodyl for children undergoing colonoscopy appears, well accepted, safe and effective.
Ref. Journal of Pediatric Gastroenterology and Nutrition,
vol. 53, issue 1, July 2011, pages 71-74.
3. Safety of Ketorlac in surgical neonates to three months of age. 
   Ketoralac is non-steroidal anti-inflammatory analgesic widely used for pain control in children and adults.  In a retrospective chart review of 57 post-surgical neonates given ketorolac, 17.2% had a bleeding event.
   Bleeding events appear to occur most commonly in infants < 37 weeks corrected gestation age, when Ketoralac is given within 14 days of age, and when renal function is poor.
Ref. Journal of Pediatric Surgery, vol. 46, issue 6, June 2011, pp 1081-1085.

4. Prophylactic antibiotics after laparoscopic pyloromyotomy (LP)
   In a retrospective chart review of 299 patients (half of whom received prophylactic antibiotics) who underwent LP, the rate of wound infection and other wound complications was examined. Wound infection was found in 2.7-3.5% of patients, while other wound complications (granulomas, umbilical hernia, etc.) occurred in 4.5-8.3% of patients.
   The use of prophylactic antibiotics for LP neither improved the rate of wound infection nor wound complication rate.
Ref. Journal of Pediatric Surgery, vol. 46, issue 6, June 2011, pp 1081-1085.
5. Acute Pancreatitis in children
   The Ransom score on admission (age, WBC, blood glucose level, and serum AST/LDH) (mnomic  “GA LAW”), the modified Glasgow criteria (PaO2, age, WBC, serum calcium urea LDH and blood sugar levels) and the Pediatric Acute Pancreatitis Severity Scores (PAPS) were assessed in 211 children with a variety of causes for their pancreatitis, to evaluate prediction capability of major complications. For the PAPS scoring system, only admission WBC (> 18,500), trough calcium (<8.3mg/dl), and BUN (> and 5mg/dl) were independent predictors of severe outcome.
   Commonly used scores are of limited value in predicting severity of pancreatic disease in children.
Ref. Journal of Pediatric Surgery, vol. 46, issue 6, June 2011, pp 1081-1085.

6. Late gestation MRI and Survival in Congenital Diaphragmatic hernia (CDH)
   MRI's can be used to assess lung volume hypoplasia in CDH. 44 patients with an isolated CDH had their prenatal total lung volumes (TVL) evaluated at 32-34 weeks gestation. Non-survivors had significantly lower TLVs (< 20ml) compared to survivors (> 40ml) and much greater need of post-natal ECMO use. 
   Increasing MRI-derived TVL in CDH patients is associated with improved survival, less need for ECMO and shorter length of hospital stay.
Ref. Journal of Pediatric Surgery, vol. 46, issue 6, June 2011, pp 1155-1171.
7. Prevention of Retinopathy of Prematurity (ROP)
   It has been known for over fifty years that oxygen therapy can lead to ROP. This has resulted in many neonatologists lowering their target oxygen saturations to 85-93 %. New insights into the pathogenesis of ROP suggest additional interventions.
   To potentially prevent phase I ROP, increase retinol erythropoietin and serum IGF-1, by administering exogenous rHuEPO, feeding breast milk and/or exogenous IGS-1 maintaining serum glucose levels < 120mg and provide omega-3 supplementation. To potentially decrease proliferative phase II ROP, treat anemia. For the prevention of phase III, vitamin E and Omega 3 supplements may be beneficial.
   As there are multiple factors that cause ROP, the simultaneous administration of multiple interventions require further study before becoming standard therapy.
Ref. Neonatology, 2011 Vol. 100, number 2, pp 116-129.

8. Signaling inflammatory molecules in the lungs of preterm ventilated baboons
 Inflammation plays an important role in the genesis of lung damage in infants undergoing mechanical ventilation. Interleukin (IL)-6 complexed with soluble IL-6 receptor (sIL-6R) appears to be an important modulator of the chemokine expression and leucocyte recruitment, found during inflammation.  Soluble gp130 (sgp130) specifically antagonizes these responses.
   Over a 14 day period, the tracheal fluid from preterm mechanically ventilated baboons was examined for the above mediators and quantified to define the inflammatory changes occurring.
   Expression of sIl-6R and dynamic modulation of sgp130 expression appear to modulate the activity and inflammatory potential of IL-6 during mechanical ventilation of the preterm animal.
Ref. Neonatology, 2011 Vol. 100, number 2, pp 130-138.

9. Genetic and environmental factors in infant sleep patterns
   25-30% of children/adolescents have sleep disorders. A study of 314, 18-month old twins (mono and dizygotic) indicates that shared environmental factors account for 98.3% of the variance in co-sleeping with genetic factors playing a much smaller role.
   Parental behavior interventions play an important role in modifying sleep behavior/disturbances in children.
Ref.  Pediatrics, Vol. 127 No. 5 May 1, 2011 pp. e1296 -e1302.
10. Secretin for children with Autism Spectrum Disorders (ASD)
   Probably one in 110 children in the USA have ASD. Secretin is one of many treatments tried for treating the symptoms.
   In a large well-organized systematic review of a variety of databases looking for Secretin efficacy in ASD, no study was found which indicated significant improvement in language, cognition or autistic symptoms with its use.
Ref.  Pediatrics, Vol. 127 No. 5 May 1, 2011 pp. e1322 -e1325.
11. Interferon Y (IFN- γ) and Non-tuberculous Airway Disease
   A 16 month old infant presented with a 4 month history of clinically severe endobronchial disease. Culture of bronchial washings revealed Mycobacterium avium (M. avium) complex. A history of maternal M. Kansasii osteomyelitis and cutaneous M. avium complex led to genetic testing which confirmed FN-Y-R1 818 del 4 deletion (4 base pare deletion at nucleotide position 818) in both family members.
   Deficiencies of the Interferon- γ pathway are well recognized causes of nontuberculous Mycobacterial infection.
Ref.  Pediatrics, Vol. 127 No. 5 May 1, 2011 pp. e1352 -e1355 

12. Victimization and somatic illnesses. 
   Aggressor-victim interactions are linked to somatic complaints, illness and physical injury in school children.
   A study of 590 school-based children, grades 3 to 5 involved the investigation of these children for a variety of symptoms and variables. Aggression and victimization were independently associated with more visits to the school-nurse for health complaints.
   Aggression and victimization both require early identification and treatment to avoid health problems in school children.
Ref.  Pediatrics, Vol. 127 No. 5 May 1, 2011 pp. e1352 -e1355 

13. Preterm birth and childhood Psychiatric Disorders
   Preterm birth apparently confers a 4-fold increased risk for adverse neurobehavioral outcomes in middle childhood.
   A “preterm behavioral phenotype” characterized by inattention, anxiety and social difficulties has been described, with a marked increase in the prevalence of autism spectrum disorders.
Ref. Pediatric Research, 69, (5 part 2), May 2011, 11R-18R.
14. Pneumatosis Coli. A benign form of necrotizing entrocolitis
   In a study of 65 preterm infants who presented with visible blood in the stool, (VBS) 32 had pneumatosis coli (P coli) (pneumatosis found in the colon only),  and 33, pneumatosis intestinalis (PI) (or classic NEC).
   P coli (an infrequently reported benign form of NEC), tends to occur in late preterm or term (> 34 weeks), well looking babies, (VBS being frequently the only abnormality found which precipitates radiographic evaluation) early (< 7 days of age), and in those babies being fed primarily formula feed. Blood cultures are usually negative, no patients generally required surgery and all babies in this study survived.  
   P. Coli is a  benign form of NEC presenting in well-looking, late preterm/term infants with blood in the stool.
Ref. Journal of Neonatal-Perinatal Medicine vol. 3, number 4, 2010 pp 293-300.

15. Emergency Department (ED) presentation of Acute Pericarditis 
   A retrospective study of 34 children (mean age 12.3 years) who were diagnosed with Pericarditis as the sole diagnosis in the ED was undertaken. 80% were male, 96% presented with chest pain and half had fever . All children had EKG changes and almost half had a normal x-ray chest. Echocardiography diagnosed a pericardial effusion in 82%. 68% were deemed ‘idiopathic’, and all children improved on non-steroidal anti-inflammatory drugs. Recurrences occurred.
   Children presenting to an ED with chest pain require an EKG, which if abnormal necessitates further investigation.
Ref. Pediatric Emergency Care, vol. 27, issue 7, July 2011, pp 582-585.

16. Stool cells and gut pathophysiology in the newborn
   Studies of intestinal cell changes early in neonatal life are not feasible by biopsy. Meconium/stool live colonocytes however are available. In this study, expression of IgA, IgG, CD45 and toll-like receptors-2 and 4 (TLR2 and TLR4) were analyzed by flow cytometry, and PCR utilized to examine the expression of cyto-keratin-19, ribosomal protein-24 and tight junction (Tj) protein zonula occludens-1 (Zo-1).
   IgA expression in colonocytes starts as early as day 2, with IgG expression increasing from low, as infants grow. TLR4 expression is substantial.
   While high levels of IgA in gut cells may provide protection during the neonatal period, increased TLR4 expression may enhance lipopolysaccharide (LPS)-mediated epithelial damage. Stool colonocytes may be a valuable tool in assessing gut pathophysiology in the neonatal period.
Ref. Pediatric Research, 70 (2), August 2011, pp 153-158.

 17. Steroids in Community Acquired Pneumonia (CAP)
   A retrospective analysis of children 1-18 years with CAP was utilized to assess whether systemic steroids improved length of hospital stay (LOS), readmission rates and total hospitalization costs.
   It appears from this study (with multiple limitations), that steroids may only improve outcomes for children who present with ‘wheezing’ and CAP.
Ref.  Pediatrics, Vol. 127 No. 2 February 1, 2011
pp. e255 -e263

18. Oral Erythromycin for feeding intolerance in preterm infants
   Preterm infants frequently present with immaturity of gastro intestinal function which predisposes them to feeding problems. Erythromycin enhances motility by stimulating propulsive contractile activity.
   In a prospective randomized controlled trial of 60 premature infants with feeding intolerance, half were given oral erythromycin ethylsuccinate (50mg/kg/day) for 10 days or until they reached full enteral feeds (the other half were controls). Adverse effects were noted.
   Infants < 32 weeks gestation on erythromycin had greater weight gain per day compared to the control group. Their time to full feeds did not differ.
Ref. Neonatology 2011, Vol. 100, No. 3, pp 290-294.

19. Protein requirements and the critically ill child
In perspective randomized trial of 51 matched critically ill children randomized to receive either a standard or a protein-enriched formula, a positive trend (not statistically significant) in levels of prealbumin, transferrin, retinol-binding protein and total protein was found for the protein-enriched group. No adverse effect of the enriched diet were detected
   A standard diet may not provide sufficient protein for the critically ill child. Enteral protein supplementation appears safe and may enhance some parameters of protein metabolism.
Ref. Journal of Pediatrics, 159, e1, July 2011, pp 127-32.

20. Inferior Vena Cava (IVC) filter use in children
   IVC filters for prophylaxis against pulmonary emboli (PE) is well described in adults. A retrospective analysis of 35 children (mean age 15.5 years) who underwent placement/retrieval of IVC filters and who underwent analysis, indicated 50% underwent placement for (1) contra indication for anticoagulation, (2) high risk of venous thromboembolism (3) recurrent Deep Vein Thrombosis despite anticoagulation and (4) prophylaxis before endovascular thrombolysis. 79% had successful filter retrieval at 42 days. Complications were few.

   IVC filters can apparently be successfully placed and retrieved in children, with an acceptable complication rate. They should be considered before endovascular thrombolysis for lower limb deep vein thrombosis.
Ref. Journal of Pediatric Hematology/Oncology vol. 33, issue 5, July 2011 pp 334-338.

21. Ectopic recurrence of Cranial Pharyngioma
   A 5 year old patient diagnosed with Cranial Pharyngioma and surgically treated presented 17 years later with neck pain and ataxia. 

   This report of a rare, extremely late, relapse of this tumor highlights the importance for a long-term, coordinated multidisciplinary (including neuro-oncologists) approach to these patients.
Ref. Journal of Pediatric Hematology/Oncology vol. 33, issue 5, July 2011 pp 392-397.
22. Leucocytapharesis (LCAP) In pediatric patients with Ulcerative Colitis (UC)
   LCAP is a form of extra-corporeal therapy that removes leucocytes and blood platelets from the peripheral blood via a polyester fabric cloth column through which blood traverses. LCAP has been shown to suppress inflammation. In children the usefulness of LCAP is largely unknown.

   A study of 23, 8-16 year old steroid-resistant, moderate to severe children with UC on standard therapy, and without significant systemic complications, received LCAP once weekly for 5 consecutive weeks; end points were a decrease in stool frequency/hemotochezia and clinical improvement.

   Overall, significant improvement occurred in all measured parameters, and while 61% of patients were noted to have some side effect of treatment, none were serious.
Ref. Journal of Pediatric Gastroenterology and Nutrition vol. 53, issue 1, July 2011 pp 34-39.
23. Exergames: A new exercise!
   Exergames (interactive hand use digital games that feature player movement) are being increasingly used by both adults and children. A study to determine energy expenditure among children (mean age 11.5 years) using six forms of exergaming was undertaken and compared to treadmill walking at 3 mph.
   All games used in this study increased energy expenditure and in general resulted in greater metabolic value than treadmill use. All children enjoyed the games and these may thus be a useful tool to increase energy expenditure in children.
Ref. Archives of Pediatrics and Adolescent Medicine, vol. 165, no 7, July 2011, pp 597-602.
24. Helicobacter Pylori (H pylori) treatment. “Standard treatment” or “Sequential therapy”
   A Prospective random, double blind, control trial of 107 children with H pylori was utilized to assess treatment with either a standard 7 day triple eradication regimen (amoxicillin and clarithromycin plus omeprazole) or a sequential treatment program (amoxicillin and omeprazole) for 5 days, followed by clarithromycin, tinidazole and omeprazole.
   At six to eight weeks after completion of the treatment programs, “sequential therapy” resulted in a higher eradication rate. (though of borderline statistical significance!)
Ref. Journal of Pediatrics Vol. 159, issue 1, July 2011 pp 45-49.
25. Osteochondrosis of the Ischiopubic Synchondrosis (IPS)(Van Neck Disease-VND)
   VND is a benign skeletal abnormality presenting with radiological evidence of hyperostosis of the IPS. It is a relatively little-known entity and frequently presents with groin or buttock pain, mimicking on x-ray ischiopubic osteomyelitis (IPOM).
   IPS can be differentiated from IPOM by the underlying lack of fever, limp, pain on rotation of the hip, elevated ESR, elevated CRP, positive blood culture, and an MRI which shows myositis, abscess and free fluid surrounding the IPS.
Ref. Journal of Pediatric Orthopaedics, vol. 31, issue 5, July/Aug. 2011, pp 520-524.