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Summary: Infantile spasms currently have the diagnostic categories of “idiopathic” and “cryptogenic.” These categories will eventually disappear as more is learned since it is not unreasonable to believe that there is an underlying brain pathology in all children who develop infantile spasms. This article attempts to determine the temporal latency between the underlying cause of the infantile spasms and the onset of the actual spasms. The question about this time interval was explored because of the accusations that vaccinations could be the cause of infantile spasms.  The writers of the article searched for articles that would accurately establish the time interval between a postnatal external brain injury and the clinical onset of infantile spasms.  Nineteen cases were reviewed that included a well-documented encephalopathic event in an otherwise normal infant and the development of subsequent infantile spasms. The time interval between the brain insult and the onset of infantile spasms ranged from 6 weeks to 11 months (mean, 5.1months). Some of the insults mentioned were hypernatremia, sinus thrombosis, meningitis, near-drowning, intracranial hemorrhage, and viral encephalitis. Another set of 14 cases involving perinatal cerebral infarction and the onset of infantile spasms indicates that it was weeks to months before the onset of the spasms, although the exact time of the occurrence of the cerebral infarction was not known.  The results of this study are consistent with many publications in the past about infantile spasms which demonstrate a clear difference in age of onset of infantile spasms based on time and nature of the initial insult. The wide range of latencies suggests that many variables contribute to the underlying pathogenesis of the development of infantile spasms. The type and severity of the brain insult and the postconceptional age at which the injury occurs are definitely factors.  All of the information suggests that there is a latent period of at least several weeks between an event which alters brain function and the onset of clinical infantile spasms. This is evidence against the claims that infantile spasms are a result of vaccinations that occur hours or even days before the onset of clinical infantile spasms. Since the average latency is 5.1 months after postnatal injury, we can continue to be convinced that the close temporal association of vaccination and clinical onset is only coincidental.

Summary: The authors of this study sought to determine clinical and laboratory characteristics that are predictive of pertussis infection among infants due to the increasing incidence of pertussis in the population.  141 infants  were identified who had B. pertussis culture, DFA or PCR testing between January of 2001 and July of 2005.  The investigators performed a retrospective chart review looking at 15 variables to determine which were associated with a positive test result for pertussis.  Of the 141 infants, 13 had a positive test and 123 were negative for pertussis.  The two groups were similar in regards to sex, symptoms of cough, fever, hypoxia, heart rate, ALTEs, post-tussive emesis, and sick contact (with cough) exposure.  The variables that were found to be significant in increasing the likelihood of a positive pertussis test were age (55 days versus 93 days old), time of year (July through October), infants who were less tachypneic, WBC count >12000, percentage of lymphocytes, and an ALC > 9400.  This study can be beneficial to physicians seeking to determine the need to treat for pertussis without waiting for the 14 days of coughing or hearing the whoop that are incorporated in the CDC definition of clinical pertussis.  The study's limitations are that it was a retrospective chart review, and clinical data such as cough duration and quality, immunization status, and other variables may not have been as well documented as laboratory data and vital signs.

Summary: This was a meta-analysis seeking to determine whether CRP could be used to differentiate between bacterial and viral pneumonia.  Fourteen studies met the author's inclusion criteria of patient age between 1 month and 18 years, measurement of CRP as an initial evaluation, cutoff serum CRP of 30-60mg/dl to distinguish bacterial from non-bacterial etiology, having a chest x-ray performed, and including acutely ill children while excluding HIV patients, chronically ill patients, and patients who had received antibiotics within 48 hours.  Eight of the 14 were selected to be included in the analysis, and all but one had a quality score of 2/2.  The ultimate findings were that a serum CRP of 40-60mg/dl "weakly" predicted a bacterial etiology.  However, this study has many limitations. There was significant heterogeneity between studies, and in each study, it was neither clear nor universal between the studies how one determined that patients had bacterial versus viral pneumonia.

Summary: Acute otitis media (AOM) and ear pain are common complaints in children and a major source of health care utilization and antibiotic prescriptions.  This study was planned to evaluate whether structured anticipatory guidance at the 15 month well child check could decrease the use of after-hours and emergency care for ear pain in this age group of children. The authors developed a 5-10 minute power-point presentation delivered by nurses which had 3 goals - how to identify ear pain, how to relieve it safely and how to recognize signs of more serious illness.  Parents were also given prescriptions of antipyrine-benzocaine drops and instructions on dosing of acetaminophen and ibuprofen and other measures to relieve pain.  This education was given to all 15 month olds presenting to well child care at 1/4 primary pediatric sites of a tertiary care center.  The children were then followed for 12 months to determine all hospital, ED, urgent care, and clinic visits for ear pain or related diagnoses.  This group was compared to children from the other sites and retrospectively to children from that site prior to the intervention year.  191 children received 15 month well care at the intervention site. Use of ED for ear pain decreased by 80% for the intervention group (P= 0.009).  Urgent care and primary care visits for ear pain decreased 40.3% and 27.8% respectively, but these were not statistically significant. There was no change in the rate of visits for the non-intervention sites.  Of a subset of intervention parents who were surveyed at the 24 month visit about the intervention, more than 80% of the parents felt the intervention helped them avoid an ED visit.  There were no adverse events in any of the children in the intervention group (mastoiditis, ED, hospitalization for bacteremia, sepsis, etc. due to delayed antibiotics).  Thus, it seems that the intervention of a 10 minutes power-point education plus analgesic ear drops made a significant impact on ED utilization for ear pain in this population.

Summary: This is a prospective randomized, placebo-controlled trial to evaluate the analgesic properties of oral sucrose during routine immunizations.  It was performed at a university-affiliated ambulatory clinic, where 100 infants were identified from a consecutive series of patients who presented for routine immunizations at 2 and 4 months.  They had to be healthy, full term, and without recent illness.  Excluded children were those that were fed 30 minutes before, got acetaminophen that day, started solid foods or did not use a pacifier.  Patients were stratified within the 2 and 4 month group to receive sterile water or sucrose 2 minutes before immunizations.  The principal investigator recorded acute behavior pain response using the UWCH pain scale 5 minutes before administration of the solution and at set intervals after vaccines were given.  Infants were not included if crying was evident before the solution was given.  The infants in the oral sucrose groups displayed reductions in pain scores 2 minutes after solution administration as well as at all assessment intervals.  Thus, oral sucrose is an effective short acting analgesic for routine immunization in otherwise well infants.

Summary: About 1500 Italian children, ages 5-15 years, were recruited from 15 national centers throughout the country that cared for obese children over a several month period.  Controls were obtained from healthy normal-weight children who came to the outpatient clinic for well-child visits.  A third of the population was obese or overweight based on their BMI, using IOTF international BMI cutoffs.  Children with endocrinologic disease, genetic syndromes, psychiatric disorders, chronic disease or chronic medication use were excluded.  Height, weight, and waist circumference were measured by the same investigator at each center.  Triglyceride, HDL, and fasting glucose were measured.  Elevated lab values + waist circumference were used to classify children with metabolic syndrome.  This study found that overweight and obese children with waist circumference >90% were more likely to meet the criteria for metabolic syndrome compared to normal weight children or overweight children with waist circumference <90%. (OR 7 and OR 13.06)  They also showed that 100% of obese children had waist circumference >90%.  This study demonstrates the potential utility of waist circumference in identifying overweight children at risk for metabolic syndrome.  This is an easy measurement to conduct in the office along with BMI.  However, there are no standardized guidelines available for practitioners at this point.  Also, this study bases BMI off of international growth charts which are different that the percentile-based growth/BMI curves used in the US, and the population in this study was only Caucasian children.

Summary: Pediatric gastroenterologists at West Jefferson Medical Center in New Orleans, LA reviewed the charts of 64 infants referred to their clinic for the management of gastroesophageal reflux to evaluate the diagnosis and treatment of infants with regurgitation.  Charts were reviewed over a 3 year period and infants were excluded on the basis of prematurity, underlying illness, neurodevelopmental abnormalities, lower respiratory tract illness, cigarette smoke exposure, or care provided by someone other than the mother. Prior to referral, 90% of infants included had been started on anti-reflux medications and 85% had their formula changed. Only full term infants with symptoms for >2 weeks duration were included and diagnostic tests that were performed before or after referral were radiography, ultrasonography, esophageal pH monitoring, and blood analysis.  Esophageal pH tests were performed only after infants on medication had stopped H2 blockers for at least 5 days and PPIs for 10 days.  Results indicated 89% of infants were gaining weight with appropriate caloric intake prior to study.  Diagnostic tests were abnormal in 20% of infants:  8 had GER, 4 had pyloric stenosis, and one had RTA.  Withdrawal of medications did not result in any change in infant status for 39 infants at follow-up 1 and 4 weeks after evaluation. Six infants had worsening of symptoms and 6 were lost to follow-up.  Overfeeding and under-thickening were noted frequently along with parental exaggeration (5- to 6-fold) of emesis.  Notably, for infants with abnormal pH results, the presenting complaints often included symptoms other than regurgitation, while regurgitation was the sole complaint for those infants with normal pH results.  Poor weight gain was always associated with abnormal pathology.  Parent education and doctor-parent communication are essential tools in the treatment of reflux for babies with persistent regurgitation who are otherwise well. Conservative management should be our first intervention prior to medication.   

Summary: Henoch-Schonlein Purpura (HSP) is the most common vasculitis of childhood.  Although it is typically a self-limited disease, there is a risk of significant complications including gastrointestinal hemorrhage, intussusception, and end-stage renal disease.  In one study, 54% of patients developed renal manifestations within 3 months of diagnosis.  The goal of HSP therapy is to treat symptoms and try to prevent the morbidity associated with renal disease.  Steroids have frequently been used to try to mediate the inflammatory processes that characterize HSP, but the conclusions regarding their effectiveness have always been inconsistent in the literature.  A meta-analysis was performed on a review of literature in the Medline database (1956-2007) and the Cochrane Controlled trials register.  Outcomes for patients with HSP who were treated with corticosteroids at diagnosis were compared with those who were treated with supportive care only.  Odds ratios were calculated for the resolution of abdominal pain, need for surgery, likelihood for recurrence, and the development of transient or persistent renal disease.  Of the 201 articles found, only 15 were included; an article was excluded if it was a review article, used a drug other than corticosteroids, was a case report with fewer than 5 subjects, focused on patients >18 years, did not assess outcomes, or included only patients with nephritis.  Results of the 15 articles showed that corticosteroid treatment did not reduce the median time to resolution of abdominal pain, but did significantly decrease the mean resolution time.  Early corticosteroid treatment also significantly reduced the odds of developing persistent renal disease.  Results also indicated that steroids seemed to reduce the odds of surgical intervention and recurrence but these results were not statistically significant.  Thus, corticosteroids early in the course of illness seem to provide significant benefits in the treatment of HSP.    

Summary: This article is a review of the literature on Clostridium difficile (C. diff) infection in patients with cystic fibrosis (CF) based on a case report.  There are a few case reports on the association of CF and C.diff in the literature.  Children with CF have a higher rate of C.diff carriage compared to normal children (likely from the usage of broad spectrum antibiotics) but infection can vary from being an asymptomatic carrier state to severe disease like pseudomembranous colitis and toxic megacolon.  Patients with CF and neonates are the only populations reported in which C.diff cytotoxin is recovered from asymptomatic individuals.  Patients with CF have a unique intestinal environment secondary to the basic electrolyte transport defect that could affect colonization and growth.  In addition, CF patients have higher rates of colonization with Enterococcus, Lactobacillus, Pseudomonas, and Staphylococcus that have inhibitory effects on C.diff toxin growth.  A genotype link with N1303K mutation in the CF gene has been suggested in cases of fulminant colitis.  C.diff infection should be considered in the differential for the patient with CF who presents with abdominal pain.

Summary: The authors conducted a retrospective chart review at St. Jude's Children's Hospital from 1997 to 2005.  Their two main goals were to describe some epidemiologic characteristics of RSV in an immunocompromised pediatric population and to determine risk factors for more serious disease.  Inclusion criteria included: ages zero to 21 years; underlying diagnosis of neoplasm, hematologic disorder, immune deficiency, or in the critical time before or after stem cell transplant; RSV positive lab results (DFA or culture).  RSV disease was separated into upper respiratory (URTI) and lower respiratory (LRTI) tract infections.  Patients were broken down into 3 main diagnostic categories: 1) acute lymphocytic leukemia 2) solid tumors 3) AML/stem cell transplant/severe combined immune deficiency.  A total of 58 patients met inclusion criteria.  31 patients were RSV culture and DFA positive, 21 were DFA positive and culture negative, and 6 were culture positive and DFA negative.  Much like disease in immune competent pediatric patients, most disease (54 of 58 cases) was diagnosed between October and March of each year of the study.   In univariate analysis, predictors of LRTI were a diagnosis of stem cell transplant/AML/SCID, age less than 2 years, and profound lymphopenia (ALC <100) at time of RSV diagnosis.  In multivariate analysis, age less than 2 years and profound lymphopenia were independent predictors of LRTI.  Age less than 2 years and profound lymphopenia were also associated with a higher risk of death from the RSV infection.  Further, deaths from RSV were seen only in the AML/SCID/stem cell transplant patient group.  RSV is a risk for immune compromised pediatric patients; when these patients are diagnosed with this infection, caretakers should be on high alert for complications.  Also, although immune compromised patients are at higher risk for serious complications from RSV, most of them still present with upper respiratory symptoms, providing a window for early diagnosis and monitoring of these patients.

Summary: The incidence of pertussis in the U.S. is rising, despite widespread immunization with the pertussis vaccine.  The authors of this study sought to identify clinical and laboratory predictors for pertussis in infants.  A chart review was conducted of 141 infants aged 12 months and younger who were evaluated for pertussis.  Demographic, clinical, and laboratory data were collected, including results of confirmatory testing (culture, DFA, or PCR).  13% of patients tested positive for pertussis.  The two groups (pertussis-positive and –negative) were similar in terms of sex, cough symptoms, fever, ALTE, post-tussive vomiting, exposure to others coughing, hypoxia, and heart rate. The statistically significant findings between the two groups that correlated with a positive test include younger age (mean age 55 days vs. 93 days), evaluation between July and October, less tachypnea, higher WBC (20,000 versus 15,000), higher % lymphocytes, and higher absolute lymphocyte counts (ALC).  The ALC was the best predictor of pertussis with a cutoff point of 9400 that maximized sensitivity (89%) and specificity (75%).  The negative predictive value was 97% and positive likelihood ratio was 3.6.  The study, however, was limited, as data, such as WBC count, was not available for all patients.  This may contribute to a selection bias leading to a falsely increased sensitivity of WBC, % lymphocytes and ALC.

Summary: This is a nationally representative, population-based study to examine whether overweight children have (1) more chronic health conditions, (2) poorer health, and (3) greater health care expenditures than healthy-weight children.  It used cross-sectional data from NHANES and MEPS to assess children 6-17 years old.  After adjusting for the confounders of age, gender, race, poverty, and insurance status, overweight children were at increased risk of high cholesterol, high LDL cholesterol, high triglyceride level, and high blood pressure.  There was a trend towards higher glycohemoglobin, which was not significant.  Overweight children did NOT miss more days of school.  In NHANES (but not MEPS), overweight children were more likely to report limitations in walking, running, or playing.  Overweight children reported FEWER healthcare expenditures.  However, after adjusting for socioeconomic status, the expenditures were not different.  The authors conclude that overweight children have more chronic conditions and poorer health than healthy-weight children but have no greater health care expenditures.  The strength of this study is that it used a large, population-based sample.  It confirmed evidence from smaller studies about the relationship of overweight to various markers of health.  Two possible weaknesses are that the MEPS data used parent-reported (rather than measured) weight and BMI, and that parent-reported health status might be related to whether a child is overweight in the first place (i.e., parents reported poorer health status BECAUSE their child was overweight, confounding the results).  Most interesting is the suggestion that overweight children UNDERUTILIZE health care resources, although they have more health problems.

Summary: This article examined perceived barriers to pediatric end-of-life care in health care workers, mainly doctors and nurses.  It is so important to look at this topic because, unfortunately, many children do not receive palliative care early enough.  In this study, self-report questionnaires were sent to staff members at UCSF via campus mail during January through March of 2002.  These questionnaires used Likert-scale responses to identify potential barriers that interfered with end-of-life care in children.  The majority of responses were from physicians and nurses, so the analysis looked at these two groups of medical professionals.  Four of the barriers in the questionnaire were considered to frequently/almost always occur by over half of the participants - uncertain prognosis, family not ready to acknowledge incurable condition, language barriers, and time constraints.  These are in contrast to the most common adult barriers often reported including fear of addiction, fear of hastening death, and fear of legal action.  In addition to differences between adult and pediatric barriers, differences between nurse and physician perceptions on pediatric barriers were also seen.  Physicians more often perceived cultural differences and conflicts among family and staff members about treatment goals as barriers.  Nurses more often than physicians felt that unavailability of ethics committee and lack of palliative care consultation interfered with care. 

Summary: Due to the large number of children exposed to intimate partner violence and its effects on the wellbeing of these children, it is essential for healthcare workers in all settings to be very aware of this issue and assess for partner abuse in the families of their patients.  This study’s purpose was to determine whether previous exposure to partner violence was associated with subsequent ED visits or hospitalizations in the future.  Children included in the study were referred by Child Protective Services, had female caregivers and were cared for in the home.  Caregivers of sampled children were interviewed about health/well-being/home environment including ED/urgent care visits and hospitalizations at the start of the study and then 18 months and 36 months following entry.  Issues considered sensitive were self-administered via computer.  The results of this study showed that children of female caregivers with severe partner violence have significantly higher rates of ED visits.  Unfortunately, this study does not go into any detail about why the patients were seen in the ED or what types of complaints were seen in these children.  In addition, it was found that children exposed to minor partner violence were less likely to be hospitalized.  More research needs to be performed to determine what factors influenced this finding.  Overall, there are many limitations in this study and a great deal of research is required to determine the exact effects of domestic violence on the children exposed to it. 

Summary: Burnout and depression seem to be fairly relevant topics to residents. The point of this study was to explore the effects of depression and burnout on the outcome measure of medication errors made by residents. Using residents at three of our nation’s leading children’s hospitals, 123 residents were given the Harvard national depression screening day scale as well as the Maslach burnout inventory.  Medication errors were recorded and compared among residents using number of errors per month.  According to the criteria, 75% of residents were burned out.  20% of residents met the depression criteria and made 6.2 times more medication errors per resident month as residents who were not depressed.  Burning out residents did not make a difference in medication errors when compared to non-burned-out residents. 

Summary: The point of this study was to try to quantify the number of residents thinking about and deciding to work part-time after residency.  Five-hundred random graduating residents were anonymously polled about their plans after residency in the 2003, 2004, and 2005 AAP Graduating Resident Survey.  About half of those surveyed were continuing with fellowship, thus leaving half (~250 doctors) going into practice.  Almost 40% of those going into practice were seeking part time jobs.  Part time physicians were looking for jobs that required around 23 hours a week of work.  The average annual salary for part time positions was $71,600 compared to $105,600 for full time positions.  Although 40% sought part-time jobs, only 20% accepted part time jobs, mainly because part time employment was harder to find.