Pediatric News

Meningococcal Vaccine/Booster Dose Guidelines Updated
Neisseria meningitidis remains a significant cause of invasive bacterial infections, and the authors of the current Policy Statement from the American Academy of Pediatrics (AAP) summarize some key points regarding the epidemiology of N meningitidis infection in the United States. Adolescents should be routinely immunized with MCV4 at age 11 or 12 years and receive a booster dose at age 16 years, according to updated guidelines in an AAP policy statement published online November 28 and in the December print issue of Pediatrics.

Causes of Death Among Stillbirths
Stillbirth affects 1 in 160 pregnancies in the United States, equal to the number of infant deaths each year. Rates are higher than those of other developed countries and have stagnated over the past decade. There is significant racial disparity in the rate of stillbirth that is unexplained. This article sought to ascertain the causes of stillbirth in a population that is diverse by race/ethnicity and geography. Overall this systematic evaluation led to a probable or possible cause in the majority of stillbirths. Obstetric conditions and placental abnormalities were the most common causes of stillbirth, although the distribution differed by race/ethnicity.

Corticosteroid administration for patients with coronary artery aneurysms after Kawasaki disease may be associated with impaired regression
Corticosteroid administration in Kawasaki disease (KD) is controversial but accepted as treatment for patients who do not respond to initial treatment. The impact of corticosteroids on evolving coronary artery aneurysms (CAA) and future vascular remodelling is unknown. This study indicated that the use of corticosteroids in the acute phase of KD for patients with evolving CAAs may be associated with worsening involvement and impaired vascular remodelling and warrants further study.

Sunken Chest Demands Prompt Evaluation, Expert Says
Children with sunken chest require prompt evaluation to rule out more serious underlying conditions and to plan corrective surgery if necessary, according to experts. The main reason to perform surgery is to improve heart and lung function, not to improve appearance, Dr. Fizan Abdullah, a pediatric surgeon at Johns Hopkins Children's Center in Baltimore, explained in a Hopkins news release. The ideal time for surgery is between ages 14 and 16, Abdullah said. Doing the surgery at an earlier age when a child's bones are still growing could result in reemergence of the sunken chest. However, earlier surgery would be performed in severe cases that seriously compromise heart and lung function, Abdullah said.

MRSA a major factor in kids’ H1N1 flu deaths, study finds
Many of the pediatric deaths and critical illnesses in the 2009-2010 H1N1 influenza pandemic occurred among children who acquired antibiotic-resistant bacterial infections in addition to being infected with that flu virus, a study in the journal Pediatrics reports Monday morning.

The study looked at 838 cases in which children (under age 21) infected with H1N1 were admitted to 35 pediatric intensive care units (PICUs) across the country. The median age of children who were critically ill with an H1N1 infection was six. Simultaneous infection with methicillin-resistant Staphylococcus aureus (MRSA) bacteria in the lungs increased eightfold the risk that children with no pre-existing conditions would die, the study found. Here’s the frightening part: Most of the children were treated with an antibiotic (vancomycin) aimed at combating those bacteria — but to little apparent benefit.

C-Section Delivery Linked to Respiratory Infections in Infants
Babies born by elective cesarean section are more likely to get a serious respiratory infection in the first year of life, a study found. Babies born by C-section had an 11 percent greater chance of being hospitalized for bronchiolitis, researchers at the Telethon Institute for Child Health Research in Perth, Western Australia found. The study, published in the online edition of the journal Archives of Disease in Childhood, is based on birth data and hospitalization records of 212,068 babies over a 10- year period in Western Australia.

Association Between Sleep Duration and Hypertension
Short sleep duration was reported to be associated with an increased risk of hypertension among adults. The present study aimed to investigate this association in children and adolescents. This was a a cross-sectional study of 4902 children and adolescents age 5 to 18 years. Blood pressure (BP) was measured at the research center and classified using the population-based percentiles. Sleep duration and related information were determined through questionnaires.This study found that short sleep duration (<9 h) is independently associated with hypertension among Chinese boys age 11 to 14 years old.

Folic Acid Supplements in Pregnancy and Severe Language Delay in Children
Prenatal folic acid supplements reduce the risk of neural tube defects and may have beneficial effects on other aspects of neurodevelopment. The authors of this article examined the associations between mothers' use of prenatal folic acid supplements and risk of severe language delay in their children at age 3 years. This was a prospective observational Norwegian Mother and Child Cohort Study recruited pregnant women between 1999 and December 2008. This article found that Among this Norwegian cohort of mothers and children, maternal use of folic acid supplements in early pregnancy was associated with a reduced risk of severe language delay in children at age 3 years.

How Well Does Serum Bicarbonate Concentration Predict the Venous pH in Children Being Evaluated for Diabetic Ketoacidosis?
: The objective of the study was to determine whether serum bicarbonate (HCO3) concentration can accurately predict venous pH in the evaluation of diabetic ketoacidosis (DKA). This was a retrospective review of patients who presented to a children's hospital emergency department and received an International Classification of Diseases, Ninth Revision code related to DKA or diabetes mellitus was performed.The results demonstrated that a HCO3 18.5 or less predicts pH less than 7.3 (area under the curve = 0.97; CI, 0.94-0.99; sensitivity, 93%; specificity, 91%), and a HCO3 10.5 or less predicts pH less than 7.1. The authors conclude that a serum bicarbonate accurately predicts abnormal venous pH in children with DKA. Venous pH determination may not be necessary for all patients being evaluated for DKA.

Children's chest pain rarely signals heart problem
Children and teenagers who complain of chest pain only rarely have a heart problem causing it, a study published Monday suggests. The study, reported in the journal Pediatrics, looked at records for 3,700 children older than six who came to Children's Hospital Boston to have their chest pain evaluated. Just one percent turned out to have an underlying heart condition. The most common were inflammation of the heart muscle or its surrounding sac, which is often the result of an infection; and supraventricular tachycardia, a rapid heartbeat that is rarely life-threatening. No child died of a cardiac cause during the 10-year study period.

Rapid Rehydration in the ED Effective for Children
A 4-hour rehydration technique for children with gastroenteritis worked just as well as a 24-hour inpatient approach, according to a study published online September 26 inPediatrics.

AAP Releases Clinical Guidelines for Urinary Tract Infection Management
Since the introduction of effective vaccines against Haemophilus influenzae type b and Streptococcus pneumoniae,there has been increasing recognition of the urinary tract as the frequent site of occult and serious bacterial infection in febrile infants and children. Because of the nonspecific clinical findings and inability to obtain reliable urine specimens without invasive measure, the diagnosis and treatment of urinary tract infections (UTIs) may be delayed. In 1999, the American Academy of Pediatrics (AAP) developed clinical practice guidelines for the diagnosis and treatment of UTIs in febrile infants and young children. The aim of this study was to report the revisions to the AAP practice parameter regarding the diagnosis and management of initial UTIs in febrile infants and young children.

Parental Smoking and the Risk of Middle Ear Disease in Children
This article was a systematic review and meta-analysis of studies of the association between secondhand tobacco smoke (SHTS) and middle ear disease (MED) in children. The study selection was sixty-one epidemiological studies of children assessing the effect of SHTS on outcomes of MED. Articles were reviewed, and the data were extracted and synthesized by 2 researchers. It was found that exposure to SHTS, particularly to smoking by the mother, significantly increases the risk of MED in childhood; this risk is particularly strong for MED requiring surgery. We have shown that per year 130 200 of child MED episodes in the United Kingdom and 292 950 of child frequent ear infections in the United States are directly attributable to SHTS exposure in the home.

Autism risks for siblings of affected kids are higher than previously thought, new study says
A new study suggests nearly one in five children with an autistic older sibling will develop the disorder too — a rate much higher than previously thought. Researchers followed 664 infants who had at least one older brother or sister with autism. Overall, 132 infants or about 19 percent ended up with an autism diagnosis, too, by their third birthdays. Previous smaller or less diverse studies reported a prevalence of between 3 percent and 14 percent.

Sequential Therapy Compared with Standard Triple Therapy forHelicobacter Pylori Eradication in Children
This study sought to determine the effectiveness of sequential therapy compared with standard triple therapy for Helicobacter pylorieradication in children. In 107 children with H pylori infection confirmed with 2 of 3 tests (13C-urea breath test, histopathology, rapid urease test), we conducted a double-blind, randomized, controlled trial comparing a sequential treatment (amoxicillin and omeprazole for 5 days followed by clarithromycin, tinidazole, and omeprazole for 5 days) to a 7-day standard triple eradication regimen (amoxicillin and clarithromycin plus omeprazole) followed by placebo for 3 days. This study found that In children with H pylori infection, sequential eradication therapy compared with standard triple therapy resulted in a higher eradication rate.

Fluid Boluses for Critically Ill Kids May Be Wrong Course
The risk of death was significantly increased among critically ill African children with impaired perfusion who were given boluses of albumin or saline, researchers reported. In a randomized trial, children who got boluses of either of the fluids were 45% more likely to die within 48 hours than those who were not given fluids, according to Kathryn Maitland, MBBS, PhD, of the Kenya Medical Research Institute – Wellcome Trust Research Programme in Kilifi, Kenya, and colleagues. The trial was halted early because of the excess mortality, Maitland and colleagues reported online in the New England Journal of Medicine

Gastroenteritis in childhood: a retrospective study of 650 hospitalized pediatric patients
Acute diarrhea continues to be an important cause of hospitalization in young children, and deaths still occur as a result. We reviewed a large cohort of hospitalized children affected by gastroenteritis. The hypothesis of our study was that clinical characteristics and a limited set of laboratory data can differentiate between the different causative pathogens of diarrhea. A chart review was performed of 650 patients with pathogen-proven diarrhea treated between April 2005 and May 2008 in the children's hospital of the University of Würzburg. Clinical presentation at the time of admission and during hospital stay, laboratory findings, stool pathogen results, and epidemiological data were collected and compared. A severity score was generated. This article found that gastroenteritis is a common reason for hospital admission in previously healthy children during the first years of life. Rotaviruses were found to be the most common pathogens in our cohort. On the basis of clinical and laboratory parameters it appears possible to distinguish between the different causative agents. This may have implications for hospital hygiene management and for the identification of predictive markers of a severe course.

Clostridium difficile Infection in Hospitalized Children in the United States
This article sought to evaluate the trend in Clostridium difficile infection (CDI) among hospitalized children in the United States and to evaluate the severity of and risk factors associated with these cases of CDI. This was a retrospective cohort study using the triennial Healthcare Cost and Utilization Project Kids' Inpatient Database for the years 1997, 2000, 2003, and 2006. It was found that there was an increasing trend in cases of CDI, from 3565 cases in 1997 to 7779 cases in 2006. Patients with CDI had an increased risk of death , colectomy, a longer length of hospital stay, and higher hospitalization charges. There was no trend in death, colectomy, length of hospital stay, or hospitalization charges during the 4 time periods. The risk of comorbid diagnoses associate with CDI included inflammatory bowel disease, with an OR of 11.42, and other comorbid diagnoses associated with immunosuppression or antibiotic administration. This article showed that there is an increasing trend in CDI among hospitalized children, and this disease is having a significant effect on these children. In contrast to adults, there is no increasing trend in the severity of CDI in children. Children with medical conditions (including inflammatory bowel disease and immunosuppression) or conditions requiring antibiotic administration are at high risk of CDI.

CT scan surge for kids' emergencies raises concern
Soaring numbers of kids are getting CT scans in emergency rooms, a study found, raising concerns some may be exposed to adult-sized radiation doses and potential risks for cancer down the road. 

The number of ER visits nationwide in which children were given CT scans surged from about 330,000 in 1995 to 1.65 million in 2008 -- a five-fold increase. The number of kids' ER visits didn't increase measurably during the study, but the percentage of visits involving CT scans climbed from about 1 percent to almost 6 percent. 

Increases occurred at children's hospitals but also at general hospitals, where most kids are treated, and which raises concerns some may have gotten adult-sized doses of radiation. The study didn't include dose information, but general hospitals may be less likely than pediatric facilities to use special CT protocols with kids to limit their radiation exposure, the study authors said. 

Single-dose extended-release azithromycin versus a 10-day regimen of amoxicillin/clavulanate for the treatment of children with acute otitis media
A randomized, double-blind, double-dummy, multicenter international study was conducted to assess the clinical and bacteriologic response, safety, and compliance of a single 60-mg/kg dose of azithromycin extended-release (ER) versus a 10-day regimen of amoxicillin/clavulanate 90/6.4mg/kg per day in children with acute otitis media at high risk of persistent or recurrent middle ear infection. The primary endpoint, clinical response at the test-of-cure visit in the bacteriologic eligible population, was achieved in 80.5% of children in the azithromycin ER group and 84.5% of children in the amoxicillin/clavulanate group (difference–3.9%; 95% confidence interval–10.4, 2.6). Bacteriologic eradication was 82.6% in the azithromycin ER group and 92% in the amoxicillin/clavulanate group (p=0.050). Children who received amoxicillin/clavulanate had significantly higher rates of dermatitis and diarrhea, a greater burden of adverse events, and a lower rate of compliance to study drug compared to those who received azithromycin ER. A single 60-mg/kg dose of azithromycin ER provides near equivalent effectiveness to a 10-day regimen of amoxicillin/clavulanate 90/6.4mg/kg per day in the treatment of children with acute otitis media.

Interpreting Conjugated Bilirubin Levels in Newborns
This article examined the clinical significance of elevated conjugated bilirubin (CB) levels in newborns. This retrospective study evaluated a birth cohort of 271 186 full-term newborns born within a Northern California hospital network from 1995 to 2004.  The 99th percentile for CB is 0.5 mg/dL, and the 99th percentile for DB is 2.1 mg/dL. CB levels between 0.5 and 1.9 mg/dL can be associated with infection, but most often remain unexplained. Liver and biliary disease become increasingly likely as CB levels increase; for CB ≥5 mg/dL, 47% of newborns have biliary disease and 43% have liver disease. CB and DB levels are not interchangeable. In newborns with CB levels ≥0.5 mg/dL and <2 mg/dL, infection must be ruled out, and the newborn should be observed. In newborns with levels ≥2 mg/dL, a more in-depth assessment of the hepatobiliary system is indicated.

Inhaled corticosteroids for rescue may offer effective step-down treatment in mild asthma
Results from a US study suggest that children with mild persistent asthma may benefit from inhaled corticosteroids (ICSs) as rescue medication with a bronchodilator as an effective step-down strategy from daily corticosteroid use. Such a treatment strategy offers effective protection against exacerbations while reducing the risk for growth retardation associated with daily ISC use, say Fernando Martinez (University of Arizona, Tucson, USA) and team.

Adjunct Corticosteroids in Children Hospitalized With Community-Acquired Pneumonia
The authors sought to determine if systemic corticosteroid therapy is associated with improved outcomes for children hospitalized with community-acquired pneumonia (CAP).  In this multicenter, retrospective cohort study we used data from 36 children's hospitals for children aged 1 to 18 years with CAP. Main outcome measures were length of stay (LOS), readmission, and total hospitalization cost. The primary exposure was the use of adjunct systemic corticosteroids. For children hospitalized with CAP, adjunct corticosteroids were associated with a shorter hospital LOS among patients who received concomitant β-agonist therapy. Among patients who did not receive this therapy, systemic corticosteroids were associated with a longer LOS and a greater odds of readmission. If β-agonist therapy is considered a proxy for wheezing, our findings suggest that among patients admitted to the hospital with a diagnosis of CAP, only those with acute wheezing benefitfrom adjunct systemic corticosteroid therapy.

Some vaccines tied to lower kids' leukemia risk
The findings, published in The Journal of Pediatrics, showed that kids born in counties where most children had been vaccinated for hepatitis B had about 20 percent lower odds of all types of childhood cancers than those born in counties where fewer were vaccinated. Those born in counties with high use both of polio vaccines and of a vaccine series that included hepatitis B and polio, among other diseases, had 30 to 40 percent lower odds of getting acute lymphoblastic leukemia, a cancer that affects the white blood cells.

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