The Journal of Pediatrics (June 2005, Vol. 146, No. 6)

Bone Densitometry in Pediatric Patients – A group from Los Angels compared bone density as measured by DXA (dual energy x-ray absorptiometry) with CT measurements in 400 children to determine weather osteoporosis is over diagnosed using the DXA method. DXA is widely used because it is accessible, low cost, simple to use and is associated with minimal radiation exposure. It is however, unlike CT, influenced by body and skeletal size. Far more subjects were classified as having low bone density measurements using DXA (76 out 400) than by CT (25 out 400) and this was particularly problematic in children whose heights and /or weights were below the 5^th percentile. This study supports the notion that DXA bone studies frequently underestimate bone density in children. Given that osteoporosis is a particularly “hot topic”, a greater understanding of DXA methodology in children and methods to correct for size are certainly needed.

Neurophysiologic and Psychosocial Function in Children with Snoring or Behavioral Sleep Problems – A group from Australia study 11 children with snoring, 13 children with behavioral sleep problems, 9 children with snoring and behavioral sleep problems and 31 controls and compared neurophysiologic and psychosocial functioning. Children underwent a variety of validated cognitive and behavioral assessments. Children with snoring, with or without behavioral sleep problems showed lower intelligence and attention scores. Children who were classified as snorers and behavioral sleep problem patients reported more difficulties with social confidence, more behavioral problems and reduced memory scores. The highest risk patients were those who manifest snoring and behavioral sleep problems. This study adds to the growing volume of literature which defines the substantial liabilities associated with disruption of normal sleep. Snoring in the absence of symptoms suggesting obstructive sleep apnea (i.e., auditable pauses in ventilation) was thought for many years to represent a benign manifestation. Increasingly, that does not appear to be the case – snoring with or without obvious pauses in respiration should be considered a “red flag”.

Diagnosis of Hirschprung’s (HD): Accuracy of Common Tests – A group from the Netherlands studied 111 consecutive patients with suspected HD to compare the diagnostic accuracy of barium enema, anorectal manometry and rectal suction biopsy. 28 of the 111 patients ultimately were found to have HD. Biopsies have the highest sensitivity (92%) and specificity (100%). However there was no statistically significant difference in the sensitivity and specificity as compared with barium enema and manometry. Inconclusive test results occurred most commonly in manometry studies followed by barium enema but very in frequently in the case of biopsy (less than 2%). Rectal suction biopsy remains the most accurate diagnostic study for HD and has a very low “inconclusive” result profile.

Frequency of Abnormal Carbohydrate Metabolism and Diabetes in Adolescents – A group from Cincinnati sought to determine the frequency of glucose intolerance and diabetes in a population of primarily minority adolescent youth by performing fasting and two hour post glucose load blood sugar assessments. The study involved about 25,000 youngsters. 8% of subjects were shown to have glucose intolerance, 0.3% were classified “near diabetes” and 0.36% had diabetes. No surprise, body mass index proved an important risk variable for having carbohydrate intolerance. Clearly, as more adolescents develop obesity, the problem of early onset type II diabetes will continue to grow.

Pediatrics (June, 2005 Vol. 115 No. 6)

Non Severe Acute Otitis Media (AOM): Watchful Waiting (WW) Verses Immediate Antibiotic Treatment – A group from Texas sought to evaluate the safety, efficacy, applicability and cost of a non-antibiotic intervention for children with AOM classified as “non-severe”. The study involved over 200 children between the ages of 6 months to 12 years. A standardized evaluation led to a classification of “non-severe”. Patients were randomized to immediate antibiotic therapy or WW. Patients were followed for a period of 30 days. Parent’s satisfaction did not differ among the groups. Symptom scores resolved faster in children treated with antibiotics and fewer abnormal tympanic membranes on examination and tympanograms were noted by day 12 in the treatment group. Treatment failures were less in the antibiotic treated group. Among the children assigned to the WW group, about 2/3rds completed the study without needing antibiotic treatment. Strep pneumoniae strains cultured at 12 days of age were more likely to show multidrug resistance in the antibiotic treated group. Adverse effects of therapy were (obviously) noted more frequently in the antibiotic treated patients. There was no difference in the rate of office or emergency room visits, phone calls or days of missed school / work among the groups. Cost of therapy was 4 times higher in the immediate antibiotic group. This study points out that WW may well be an acceptable alternative to immediate antibiotic therapy for children with non-severe AOM, substantially reducing the need for antibiotic treatment in this population of patients.

Compliance with Guidelines for Medical Care for first Urinary Tract Infections (UTI) – Using Medicaid data, a group from Seattle conducted a retrospective review to describe the medical care of children with UTI during the first year of life. Current recommendations include imaging studies (including an assessment for reflux) and prophylactic antibiotic therapy for children with reflux. Less then half of children received care which met the American Academy of Pediatrics standards. Children who were hospitalized were more likely to undergo appropriate imaging studies. This study points out that, in the population studied, infants with UTI are often not undergoing the optimal evaluations as defined by the AAP.

School Daily Schedule and Adolescent Sleep – Sleep problems are common in adolescents and it is well appreciated that circadian rhythms and biologic sleep patterns are different than in younger children and adults. 60 incoming high school seniors maintained diaries to help investigators understand the impact of school starting time on adolescent sleep, to compare weekday and weekend sleep patterns and to attempt to normalize the timing of circadice sleep / wake cycle by the administration of bright light in the morning. Adolescents enrolled in the study lost as much as 2 hours of sleep per night during the week after beginning school and weekend sleep time was longer. There were no differences found between weekday sleep during the summer and weekend sleep during the school year. Early morning light treatments did not modify studies of vigilance testing, mood or total minutes of sleep per night. All students performed better in the afternoon rather than in the morning. Students in early morning classes reported being “wearier”, less alert and having to spend greater effort. Clearly, adolescent sleep patterns are often inconsistent with school schedules and early morning bright light therapy does not appear to alter the problems encountered by teens in the early morning hours.

Primary Operative Verses Non- Operative Therapy for Pediatric Empyema – Empyema is noted in 1 in 150 hospitalized children with pneumonia and its management remains controversial. A group from Seattle performed a meta-analysis to compare result for non-operative verses primary operative therapy. Over 50 studies described over 35,000 children treated non-operatively and 25 studies reported over 350 children treated with a primary operative approach. Many outcomes were better in the primary operative group including in-hospital mortality, re-intervention rate, length of stay, and duration of antibiotic therapy. Clearly, there can be no simple “cook book” approach of the treatment of empyema but it is clear that aggressive intervention to identify and treat this serious complication of pneumonia are a priority. Increasingly, surgical intervention is being utilized earlier.

Archives of Pediatrics and Adolescent Medicine (June, 2005 Vol. 159, No. 6)

Urgency of Evaluation and Outcome of Acute Ovarian Torsion (AOT) in Children - A group from Chicago performed a retrospective view from 1987 to 2002 and identified 22 children with a diagnosis of AOT. The mean age was 10 years. In about 25% of patients, the ovary was, in fact, salvaged. Interestingly, prolonged duration of symptoms was not associated with ovarian necrosis. The meantime of symptoms prior to care was rather lengthily – 67 hours with a range of 7 to 159 hours. Almost all patients underwent imaging including ultrasound and CT. Both methods of imaging were highly likely to suggest the diagnosis. 10 of 22 patients had ovaries that contained cyst, teratomas or other masses. This study suggests that ovarian torsion in pediatrics is associated with a better rate of ovary salvage than had been previously appreciated and that prolonged symptoms do not preclude the potential of ovarian liability.

Unit Dose Packaging of Iron Supplements - A group from Canada sought to determine weather a 1997 requirement for unit dose packaging of iron supplements decreased the occurrence of iron ingestion and death among their children. In fact the number of iron ingestion calls per thousand to call centers decreased from 2.99 to 1.91. Strikingly, the number of deaths decreased from 29 to 1 during a 10 year period prior to the institutions unit dose packaging and the 5 year period after. Unit dose packaging is a highly effective intervention for decreasing morbidity and mortality associated with the ingestion of prescription medication.