Weekly Updates in Pediatrics Newsletter

The Updates in Pediatrics weekly newsletter provides concise information about a broad range of current pediatric topics to enhance the education of practicing primary care pediatricians. The scope includes translational research, infectious disease, neonatology, surgery and other relevant topics concerning the health of children. 

Jack Wolfsdorf, MD, FAAPAbout the Editor

Jack Wolfsdorf, MD, FAAP

Director of Critical Care Medicine, Nicklaus Children’s Hospital, Clinical Professor of Pediatrics, (1984-2004). 
Chairman, Bioethics Committee, Nicklaus Children’s Hospital, 2006-present. 
Editor-in-Chief, Updates in Pediatrics, formerly International Pediatrics, Nicklaus  Children’s Hospital, 2004-present. 
Published over 120 articles. 

Childhood hoverboard injuries

Published on: 11/15/2017
Publication source: The Journal of Pediatrics

"Hoverboards pose a significant risk of musculoskeletal injuries to pediatric riders". A prospective study of injuries revealed that most involve the upper (predominantly) or lower extremity (similar to skate board injuries). Injuries in children occur in those who do not wear helmets or protective padding.

Effective of inhaled nitric oxide on survival without bronchopulmonary dysplasia (BPD) in preterm infants

Published on: 11/10/2017
Publication source: JAMA Pediatrics

While inhaled NO administered to at risk infants for 24 days appears safe, it does not improve measured outcomes.

Neurodevelopment with fetal growth restrictions (FGR)

Published on: 11/08/2017
Publication source: Pediatrics

A study which evaluated 889 very preterm (<28 weeks gestation) infants non-growth restricted and compared them to FGR babies indicates that at 10 years of age being growth restricted increases the likelihood of cognitive and behavioral problems, impaired social awareness, social and psychosocial function, phobias, obsessions and compulsions, autistic mannerisms, autistic spectrum disorders and problems with semantic and speech coherence.

Childhood asthma: Mode and type of infant feeding

Published on: 11/07/2017
Publication source: Journal of Pediatrics

At 3 years of age 12% of children are diagnosed with possible or probably asthma. Any mode other than direct breastfeeding (i.e. breast feeding with expressed breast milk, breast milk and formula or formula alone) is associated with an increased risk of asthma.

Comparison of the Nuss vs. Ravitch procedure for Pectus Excavatum (PE) repair

Published on: 10/27/2017
Publication source: Journal of Pediatric Surgery

An analysis from multiple databases comparing Nuss to Ravitch procedures for PE reveals that the Nuss procedure has significantly shorter operative time and less blood loss (though post-operative hospitalization times are similar).

Long-term results after extensive soft tissue release in very severe congenital clubfeet

Published on: 10/23/2017
Publication source: Journal of Pediatric Orthopaedics

92% of post operative patients are satisfied, though no foot has excellent results (only 30% have a fair/good outcome) with female patients being less satisfied because of social constraints due mostly to calf atrophy.

Second hand smoke exposure and preclinical markers of cardiovascular risk in toddlers

Published on: 10/22/2017
Publication source: Journal of Pediatrics

"Second hand smoke exposure in the very young has a detectable relationship with severe markers of cardiovascular risk, long before the emergence of clinical disease."

Predicted value of procalcitonin (PCT) for intestinal ischemia and/or necrosis in adhesive small bowel obstruction (ASBO)

Published on: 10/16/2017
Publication source: Journal of Pediatric Surgery

PCT levels closely correlate to the presence of intestinal ischemia and necrosis in children with ASBO.

Black Toenail sign in MELAS Syndrome (mitochondrial encephalopathy with lactic acidosis and stroke-like episodes)

Published on: 10/11/2017
Publication source: Pediatric Neurology

A database study from two children's hospitals searched through brain magnetic imaging studies for likely MELAS patients. 124 studies from 14 MELAS patients (average age 16 years) were found. These revealed that gyral necrosis (the black toenail sign) is a common imaging feature which correlates with the disease duration.

Dietary intake and relapse rate in early pediatric multiple sclerosis (MS)

Published on: 10/09/2017
Publication source: Journal of Neurosurgery Psychiatry

MS is an autoimmune disease that attacks the central nervous system that is increasingly being identified in children appearing to account for 3-10% of all patient with MS. Environmental exposure to ultraviolet radiation, vitamin D levels, EB infection, passive smoking and obesity have all been identified as risk factors in genetically predisposed children (mostly the histocompatibility complex on chromosome 6). Epigenetic factors probably link the two.

Laparoscopic pediatric inguinal hernia repair

Published on: 10/09/2017
Publication source: Journal of Pediatric Surgery

Laparoscopic inguinal hernia repair by disconnection of the hernial sac at the IIR with peritoneal closure appears feasible, safe and has a lower recurrence rate than when the sac is left intact.

The impact of low-grade (grades I - II) germinal matrix-intraventricular hemorrhage on neurodevelopmental outcome of very low birth weight preterm infants

Published on: 10/03/2017
Publication source: Neonatology

Very low birth weight preterm infants with grades I - II GMH - IVH have similar early neurodevelopmental outcomes compared to matched controls.

Sleep positioners and the risk of suffocation in infants

Published on: 10/03/2017
Publication source: US Food & Drug Administration Consumer Updates

The "ABC" of a safe environment for a young infant to sleep in includes: Alone - on the Back - in a bare Crib. "Positioners" should not be used.

Comparative infant safety and maternal antiretroviral treatment (ART) regimens in HIV infected pregnant women

Published on: 10/02/2017
Publication source: JAMA Pediatrics

A birth observational surveillance study of outcomes among 47,027 pregnant HIV infected women treated with three drugs and 11,932 HIV exposed infants from conception, indicates that adverse birth outcomes are lower when mothers are treated with tenofovir disoproxil fumarate, emtricitabine, and efavirenz (TDF-FTC-EFV) compared to a number of other three drug regimens.

Gene polymorphism and the severity of recurrent viral induced wheeze

Published on: 09/26/2017
Publication source: Pediatric Pulmonology

Of 3 phenotypes described ("Cluster 1: "nonatopic uncontrolled severe viral-induced wheezing"; Cluster 2: "multiple wheezing with multiple atopic allergic comorbidities" and Cluster 3: "mild episodic viral-induced wheeze"), the TT-genotype (homozygous/dominant) of IL-4 rs2070874 (Interkeukin-4 inflammatory cytokine - rs gene variant polymorphism) is the only one significantly associated with the Cluster 1 clinical presentation of non-atopic severe viral-induced wheezing indicating the importance of this group of cytokines in the mediation of the immune system's inflammatory response to viral infections.

Management following measles exposure

Published on: 09/23/2017
Publication source: Clinical Infectious Disease

Following exposure to measles, administration of any post-exposure prophylaxis (MMR or immune globulin) decreases the chance of contracting measles by 92.9%.

Risk of recurrence of adverse events following immunization (AEFI)

Published on: 09/20/2017
Publication source: The American Academy of Pediatrics

A summary of published literature (29 articles) available from three databases which estimated the risk of AEFI recurrence following re-immunization and which included adverse effects (like hypotonic hypo-responsiveness, anaphylaxis or seizures), indicates that adverse events occur in 0-0.8% overall (allergic-like reactions; approximately 5% and fever in 0-84%) of re-immunized infants.

Abstinence-Only-Until-Marriage (AOUM); an update review of its impact

Published on: 09/19/2017
Publication source: Journal of Adolescent Health

An interesting and provocative article argues that AOUM policies and programs are not effective, violate adolescents' rights and reinforce harmful gender stereotypes.

Turning one year of age in a low socioeconomic environment

Published on: 09/17/2017
Publication source: Journal of Developmental & Behavioral Pediatrics

One of only a few studies which have examined multiple environmental factors associated with poverty and its effects on infant development, underscores how infants exposed to a detrimental environment early, results in poorer developmental functioning at one year of age.
"Support for families and children from impoverished circumstances cannot begin too early".

Effect of hospitalization on weight in underweight youth with Restrictive Eating Disorders (RED)

Published on: 09/14/2017
Publication source: Journal of Adolescent Health

Hospitalization of patients with restrictive eating disorders and a BMI <85% significantly improves weight gain on hospitalized children/adolescents at 1 year follow up.

Vitamin D insufficiency and fracture risk in urban children

Published on: 09/14/2017
Publication source: Journal of Pediatric Orthopaedics

After controlling for age and daily sun exposure low 25(OH)D levels are associated with a higher incidence of bone fracture. Hypovitaminosis D should be considered in all children with fractures.

Finger-marker for maintaining the correct compression point during pediatric cardiopulmonary resuscitation (CPR)

Published on: 09/10/2017
Publication source: The American Journal of Emergency Medicine

A cross-over simulation study on a remodeled infant CPR mannequin to examine compression position, rate, depth, and hands-off times undertaken by pediatric emergency room physicians and paramedics indicates that significant improvement in compression positions occurs with sticker placement (though no changes noted in other measured parameters)

Detection of late-onset sepsis (LOS) in preterm infants by fecal volatile organic compound analysis

Published on: 09/09/2017
Publication source: Journal of Pediatric Gastroenterology & Nutrition

Fecal samples from 36 preterm infants with LOS assessed by electronic nose technology (volatile compounds cause the smell of sweat, blood, urine, feces, etc. and are an indicator of the composition and activity of intestinal microbial metabolism) can be differentiated from matched normal controls up to 3 days prior to the clinical onset of the disease. Stool VOC profiling is clinically feasible and is potentially an exciting area for future studies in at risk infants.

Perinatal risk factors and Infantile Hypertrophic Pyloric Stenosis (IHPS)

Published on: 09/09/2017
Publication source: Journal of Pediatric Surgery

A retrospective meta-analysis of 15 studies published in English from a number of databases investigated risk for a number of perinatal factors in infants with IHPS. Data suggests IHPS is associated with:

  1. Being first-born.
  2. Delivered by caesarian section.
  3. Being preterm.
   4. Being bottle-fed (most significant factor).

Minimal or wide excision of pilonidal sinus in children

Published on: 09/05/2017
Publication source: Journal of Pediatric Surgery

A retrospective chart review of two groups of 21 children who underwent surgery for pilonidal sinus (minimal incision or wide excision) indicates that minimal incision surgery results in better postoperative function outcomes fewer sick and days in analgesia with an overall long-term favorable outcome rate of 62% (45% after wide excision).

"Loop drainage" for the treatment of subcutaneous abscesses in children

Published on: 09/04/2017
Publication source: Journal of Pediatric Surgery

A retrospective study of 576 consecutive children who underwent loop drainage (cf. abscess packing) of a subcutaneous abscess indicates that micro-incisions and loop drainage is safe, effective, has shorter time to discharge, lower recurrence rates, less scarring, eliminates the need for repetitive packing and is recommended to be the standard of care for subcutaneous abscess in children.

Physical activity and sedentary behavior on working memory at ages 7 and 14 years

Published on: 09/03/2017
Publication source: The Journal of Pediatrics

It appears from a longitudinal prospective cohort study across four Spanish regions which examined extra-curricular physical activity and sedentary behavior at preschool and primary school age on working memory at primary school age and adolescence that low extra-curricular physical activity levels is associated with poorer working memory performance at primary school age and adolescence respectively. Lack of extra-curricular activity at primary school result in poorer working memory in adolescence.

Sleep duration and telomere length in children

Published on: 08/29/2017
Publication source: Journal of Pediatrics

A preliminary study which assessed the association between sleep duration and telomere length in 1,567 children indicates that children with shorter sleep duration have shorter telomeres than matched controls (unassociated with race, sex, or socioeconomic status).

Optimal duration for breast feeding

Published on: 08/28/2017
Publication source: Journal of Gastroenterology and Nutrition

It appears that infection/hospitalization prevention in fully breast-fed infants occurs primarily during the first 4-6 months of life, and that protection against infection is limited to the first 12 months (optimally, breast-feeding should continue to 12 month of age).

Posterior urethral valve in fetuses; evidence for the role of inflammatory biomarkers

Published on: 08/22/2017
Publication source: Pediatric Nephrology

It appears from a cross-sectional study on urine samples for a wide variety of inflammatory biomarkers from 24 fetuses with posterior urethral valves (PUVs), collected at 22 weeks (+- 4 weeks) gestation and compared to healthy male controls, that at that early age there is already an intense physiopathological inflammatory process (which correlates with negative renal biomarkers) which results in a PUV occurring just after the embryological formation of the urethral membrane.

Lactobacillus reuteri DSM 17938 (L. reuteri) vs. a placebo in the management of functional abdominal pain (FAP) in children

Published on: 08/22/2017
Publication source: Acta Paediatrica

Either L. reuteri or a placebo are equally effective in decreasing abdominal pain in children with FAP.

Celiac disease (CD) and Non-celiac sensitivity

Published on: 08/15/2017
Publication source: JAMA

An excellent review article outlines the current evidence regarding screening, diagnosis and treatment of both CD and non-celiac gluten sensitivity.

Effectiveness of psychological intervention for children with Functional Somatic Symptoms

Published on: 08/12/2017
Publication source: Journal of Pediatrics

An extensive literature search of multiple databases for randomized control trials published in peer reviewed journals on psychological treatment on symptom load and disability in children with functional somatic symptoms revealed that symptom load, disability and school absences are all significantly improved post treatment.

Time to appendectomy and risk of complications

Published on: 08/12/2017
Publication source: JAMA Pediatrics

From a study of 2,429 children in 23 children's hospitals which examined the association between time to appendectomy and risk of complicated appendicitis and postoperative complications, it appears that delaying appendectomy within 24 hours of presentation is not associated with increased risk of complicated appendicitis or adverse outcomes.

Outcomes of preterm infants in elementary and middle school

Published on: 08/06/2017
Publication source: JAMA Pediatrics

It appears that singleton preterm infants (gestational age 23-24 weeks) born near the limits of viability perform at levels comparable to those born at full term in readiness to enter kindergarten, scores on standardized tests in elementary and middle school and on gifted status.

A new approach to the investigation of sudden unexpected death in pediatrics (SUDP)

Published on: 08/03/2017
Publication source: Pediatrics

An interesting article outlines a new approach to SUDP (beyond preventive measures in the child's sleep environment and detection of child abuse) which aims at understanding apparent biological vulnerabilities in a small child (<3 years of age) which may be lethal. These include abnormalities in the hippocampus, advances in the detection of epilepsy, the diagnosis of rare presentations of known diseases, newer approaches to the understanding of unknown mechanisms and genetic variances. Well worth reading for all pediatricians (Ed).

Plantar Fasciitis

Published on: 07/25/2017
Publication source: JAMA Pediatrics

Treatment options include cooling with ice, reducing sport activities, shoe insert supports (or orthotic devices), physical therapy, daily stretching of calf muscles and analgesics. For severe pain foot casting with crutches may be necessary. In rare cases surgery may be considered if conservative therapy is unsuccessful.

Pediatric Sacroiliitis - differences between infants and children

Published on: 07/22/2017
Publication source: The Pediatric Infectious Disease Journal

Infants with PSI are more likely to have an ambiguous onset with refusal to bare weight only, a higher erythrocyte sedimentation rate (ERS) and platelet count with sterile blood and joint fluids (PCR for Kingella kingae and MRI should be considered for early diagnosis and treatment).
Children/adolescents with PSI usually present with a history of limping and buttock/lower back pain and methicillin-susceptible Staphylococcus aureus as the most frequent pathogen.

Inattention and poor eye contact is not all Autism

Published on: 07/18/2017
Publication source: Clinical Pediatrics

Absence seizures may be difficult to diagnose in children with ADS, and are rarely reported. Two case presentations illustrate that stereotypic and inattentive behavior considered to be part of ASD may in fact be absence seizures. An EEG should be routine in all children diagnosed with ASD.

Epilepsy and the adverse effect of the postictal period

Published on: 07/13/2017
Publication source: Pediatric Neurology

A prospective survey-based approach was utilized to analyze postictal symptom data from 208 children seen  in a Children's Hospital Neurology outpatient department.
86% of children report postictal symptoms which include:

  1. Fatigue, sleepiness and/or tiredness - 90%
  2. Weakness and/or being unable to move normally which prevented normal activities - 78%
Postictal clinical phenomena have a significant functional impact on the lives of children with epilepsy.

Another benefit of breast feeding

Published on: 07/12/2017
Publication source: Neurology

It appears form a study of 397 newly diagnosed women with multiple sclerosis (MS) or its precursor "clinically isolated syndrome" (CIS; one of the MS disease courses that "refers to a first episode of neurologic symptoms that last at least 24 hours and is caused by inflammation or demyelination in the central nervous system") and compared to matched controls, that women who breast feed for >15 months have a significantly reduced risk of developing MS/CIS (or of having post-partum relapses).

Two-thumb encircling technique over the head (OTTT) of patients for lone rescuer infant cardiopulmonary resuscitation (CPR)

Published on: 07/11/2017
Publication source: Pediatric Emergency Care

The-over-the-head, two-thumb encircling lone rescuer CPR technique for a young infant results in greater depth and rate of compression and shorter hands off time than the conventional TFT. This may be a suitable technique for cardiac arrest during ambulance transport (or for any other lone infant rescuer CPR situation; Ed).

Increased breast feeding duration and growth, adiposity and blood pressure at 16 years of age

Published on: 07/03/2017
Publication source: JAMA Pediatrics

A secondary analysis of a randomized clinical intervention that increased breast feeding duration indicates that while longer breast feeding times enhances post infancy weight, height and BMI, it has little effect after 8.5 years of age and is NOT associated with a lower risk of obesity or increased blood pressure at age 16 years. 

Oxygen-saturation targets in extremely preterm infants

Published on: 06/28/2017
Publication source: The New England Journal of Medicine

Oxygen-saturations in extremely preterm infants outside appropriate levels may be associated with ROP (retinopathy of prematurity) and BPD (bronchopulmonary dysplasia).

Guidelines on fruit juice intake for children: American Academy of Pediatrics (AAP)

Published on: 06/28/2017
Publication source: American Academy of Pediatrics

Fruit juice is marketed as a healthy, natural source of vitamins and, in some instances, calcium. Because juice tastes good, children readily accept it. Although juice consumption has some benefits, it also has potential detrimental effects. Pediatricians need to be knowledgeable about juice to inform parents and patients on its appropriate uses.

Natural course of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) in adolescents

Published on: 06/28/2017
Publication source: BMJ Journals

CFS/ME is characterized by 6 months of fatigue (that doesn't disappear with sleep or rest) significant enough to interfere with daily activities and 4 or more symptoms which include cognitive problems, sleep problems, sensitivity to light, depression, headaches, joint pains, recurrent flu-like symptoms etc.

Intravenous fluids (IV) for headache treatment

Published on: 06/28/2017
Publication source: oDV1_aWztzg

It appears that the administration of intravenous fluids is often recommended for migraine headaches in the Emergency Department (ED).

Outcomes of bronchiolitis following different therapeutic regimens

Published on: 06/09/2017
Publication source: Acta Paediatrica

A study of 286 infants (<2 years of age) randomly allocated to three different general units in a tertiary pediatric care center with a diagnosis of bronchiolitis, and treated (or not) with 3% nebulized hypertonic saline (with terbutaline), adrenaline, ipratropium and/or budesonide indicates that on analysis treatment with nebulized hypertonic saline and/or adrenaline results in longer times of oxygen saturation <92% and longer hospitalization stays.

Body mass index (BMI) and Vigorous Physical Activity (VPA) in children and adolescents

Published on: 06/06/2017
Publication source: Acta Paediatrica

Reported vigorous physical activity alone does not appear to decrease obesity in children or adolescents (in fact VPA may be associated with a higher BMI). Overweight/obesity is multifactorial in origin and changes in other variables in conjunction with VPA is required to manage the increased BMI seen in children and adolescents.

Vascular endothelial growth factors A (VEGF-A) and congenital renal lesions in children with urinary tract infections

Published on: 05/22/2017
Publication source: Acta Paediatrica

In children with UTIs, the C-allele polymorphism of VEGF-A gene is associated with probable congenital hypodysplastic (small and malformed) kidneys. Differing VEGF genotypes or T alleles do not appear to be associated with urinary reflux or other urinary tract anomalies.

Preterm infants - adult outcomes

Published on: 05/17/2017
Publication source: Acta Paediatrica

As adults those born preterm:

  1. Have different personality types with an increased risk of anxiety/depression, difficulty transitioning from childhood to adolescence and increased borderline behavioral issues.
  2. Significantly higher systolic and diastolic blood pressures and variable risks for coronary heart disease and stroke.
  3. Significantly higher likelihood of irritable airway disease/asthma (particularly in those following bronchopulmonary dysplasia).
  4. A greater prevalence for type II diabetes, abnormal lipid profiles and higher levels of abdominal fat.
  5. 60% of nearly 1 million adult nephrons are formed during the second and third trimester of fetal life. The effect on adult kidney function remains unclear.
"Being preterm needs to be considered a chronic condition."

Small airway function before and after cold dry air challenge in pediatric asthma patients during remission

Published on: 05/09/2017
Publication source: Pediatric Pulmonology

It appears from a study of 43 asthmatic children (mean age 13.7 years) in clinical remission for a year with normal baseline spirometry and body plethysmography that when challenged with an inhalation of cold dry air, a significant number continue to have substantial small airway involvement and hyper-responsiveness amenable to bronchodilator therapy.

Primary ciliary dyskinesia (PCD)

Published on: 05/08/2017
Publication source: Clinical Pediatrics

An interesting case presentation of a 5 year old little girl with PCD outlines a characteristic clinical course and is a useful guide to remind us to remember PCD in children with recurrent pulmonary/upper respiratory tract infections.

Risk factors for mortality before age 18 years in Cystic Fibrosis (CF)

Published on: 04/24/2017
Publication source: Pediatric Pulmonology

Risk of death from CF (median age 13.4 years) identified at 6-8 years of age include: female sex, unknown CFTR genotype, minority race or ethnicity in the USA, low socioeconomic status, pseudomonas aeruginosa positivity (on >2 cultures), and weight <50 percentile.

Voiding cystourethrograms (VCUG) in infants younger than three months with Escherichia coli (E. coli) urinary tract infection (UTI) and normal renal ultrasound

Published on: 04/13/2017
Publication source: Archives of Disease in Childhood

It appears that in infants with first febrile UTI in the presence of a normal US and E.coli bacteria, it is safe to avoid preforming VCUG, saving many unnecessary procedures, limiting radiation exposure with a very low risk (less than 1%) of missing a high-grade VUR.

Propranolol treatment for infantile haemangiomas (IH) in wheezing children

Published on: 03/07/2017
Publication source: Pediatric Pulmonology

A retrospective case-control study at a tertiary pediatric hospital reviewed 680 children (and 1828 clinic visits) followed for IH, of whom 216 were treated with propranolol.
Incidence of respiratory episodes was noted in treatment and control groups.
Propranolol does not appear to exacerbate wheezing episodes in IH infants and children.

A decade of pediatric tracheostomies

Published on: 03/06/2017
Publication source: Pediatric Pulmonology

A retrospective review over a ten year period of 426 children (median age 1.5 years) admitted to a pediatric Intensive Care Unit who underwent a tracheostomy for a variety of reasons indicates:

  1. 23% die (75th percentile survival time 5.9 years).
  2. Patients undergoing tracheotomy for airway obstruction are least likely to die (vs. those with acquired neurologic disease who are most likely to die).
  3. 50% are de-cannulated at 1-2 years.
  4. 62% remain cannulated with children with congenital neurologic disease least likely to be decannulated.
  5. >50% of tracheotomy patients are discharged with a tracheotomy in place on some form of mechanical support.

Wide variability in caloric density of expressed human milk

Published on: 12/01/2016
Publication source: Journal of Human Lactation

The presumption that human breast milk contains 20kcal/oz. may lead to under nutrition in "at risk" infants. Nutritional strategies to optimize caloric intake should be individualized.

Maternal tetanus, diphtheria and acellular pertussis vaccination in preventing pertussis in infants <2 months of age

Published on: 05/09/2016
Publication source: JAMA Pediatrics

On multivariable analysis it appears that when a mother is vaccinated during pregnancy with Tdap it significantly reduces the likelihood of her young infant presenting with pertussis.

Updates in Pediatrics Yearly Archives