The Journal of Pediatrics

Distinguishing between orthostatic intolerance, POTS, and vasovagal syncope in children

Stephen R. Daniels — 2012-02-01

Symptoms of dizziness, lightheadedness, syncope, nausea, fatigue, and headaches are quite common in children and adolescents. Pediatricians often face the challenge of using symptoms and more objective findings together to categorize patients. Although some believe this group of symptoms represents a spectrum of disease, there appears to be important differences in both pathophysiology and clinical presentation. Another issue has been the use of adult criteria for heart rate changes during tilt table testing. This may be problematic because of the normal age-related changes seen in heart rate (HR) and HR response throughout the pediatric age range.

Resuscitation of extremely low birth weight infants

Stephen R. Daniels — 2012-02-01

As medical care has advanced, the ability to resuscitate infants with gestational ages of 23-30 weeks and birth weight 400-1000 g has improved. However, outcomes for infants in this category are quite variable. In this issue of The Journal, Wyckoff et al seek to determine whether cardiopulmonary resuscitation (CPR) in the delivery room is associated with morbidity or mortality in extremely low birth weight infants. They found that infants who received CPR had greater overall morbidity and greater mortality by 12 hours and by 120 days of life. Of the infants who survived, those who received CPR had greater neurocognitive impairment. It should be clear that these associations are not causal but represent the fact that it is the sickest newborn infants who require CPR. Nevertheless, this information could be useful in clinical decision-making (only 14% of extremely low birth weight infants who received CPR in the delivery room and had a 5-minute Apgar score <2 survived without neurocognitive impairment), counseling parents, and forming guidelines for follow-up neurocognitive testing.

Pain crises in children with sickle cell anemia

Thomas R. Welch — 2012-02-01

Sickle cell anemia (SCA) illustrates some of the challenges of keeping current with the management of a chronic illness. As improvements in standard care are incorporated into practice, one needs to periodically reexamine the natural history of the condition, which may be modified by the new therapies. Thus, even in a disease studied as well as SCA, there is an ongoing need for continuing well-characterized multicenter studies.

Chest pain: a sign of psychiatric disorder?

Stephen R. Daniels — 2012-02-01

Chest pain is a common and sometimes vexing complaint in children and adolescents. It is well-recognized that most chest pain in the pediatric population is unrelated to heart disease, but does this mean it is unimportant? In this issue of The Journal, Lipsitz et al publish the result of their investigation into whether chest pain might be associated with psychiatric disorders. They compared children 8-17 years old presenting with medically unexplained chest pain with those presenting with an innocent heart murmur. They found that anxiety and depression were more common in the children with chest pain. Chest pain was also associated with diminished quality of life. In this study, cause and effect cannot be determined. Nevertheless, these findings emphasize that when chronic medically unexplained chest pain is present in children and adolescents, primary care physicians should consider the possibility of a comorbid psychiatric disorder.

Reassuring follow up of girls with precocious adrenarche

Sarah S. Long — 2012-02-01

The growth pattern, pubertal course, and adult height are reported for 85 girls born with appropriate size for gestational age who were referred to Schneider Children's Medical Center of Israel between 5 and 8.8 years of age for precocious adrenarche (PA). The clinical course of these girls provides reassurance that although PA had impact on the pre-pubertal growth pattern, it was not associated with early/rapid progression of puberty or reduced adult height. This cohort and outcomes are in contrast to those of girls with PA who were born small for gestational age.

Methylxanthine for apnea of prematurity

Alan H. Jobe — 2012-02-01

Over the years, multiple interventions have been used to treat apnea of prematurity – ranging from increased oxygen exposures to physical stimulation to pharmacologic interventions. The group in Winnipeg have a distinguished record of studies of respiratory control in infants. Recently, they have explored the potential of increased CO2 as a stimulant of respiratory drive. They now report a well-designed randomized and controlled trial of increased inspired CO2 in comparison to theophylline treatments for infants with apnea of prematurity. Both treatments worked, but theophylline was clearly a superior treatment. Given that the trial by Schmidt et al of caffeine demonstrated not only safety, but improved neurodevelopmental outcomes (NEJM 2007;357:1893-1902), and giving a drug is easier than providing a gas containing CO2 to infants, the practical conclusion from this trial is that methylxanthine therapy is the standard of care for infants with enough apnea of prematurity to need treatment. However, the concept that increasing CO2 will increase respiratory drive is physiologically sound and should not be forgotten.

Differentiating PANDAS and non-PANDAS disorders

Sarah S. Long — 2012-02-01

Not unlike autism spectrum disorder (ASD), more cases of obsessive-compulsive disorder (OCD) and/or tic disorders are being diagnosed in prepubertal children. Also, not unlike ASD, the cause of most cases is unclear. Frustrated families seeking answers frequently think we don't care. We care. We just do not have the answers. Much debate has focused on the purported role of group A streptococcus (GAS) in causing or precipitating the so-called Pediatric Autoimmume Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS). Using objective criteria to define at least the most typical clinical constellation could benefit future investigations of etiology, natural history, and management.

2012-02-01

Masthead

2012-02-01

Information for Readers

2012-02-01

Community Health and Advocacy Training in Pediatrics: Using Asset-Based Community Development for Sustainability

2012-02-01

Pediatricians play a critical role in promoting the health of all children, and community health and child advocacy experiences are now a required component of pediatric residency training. Since the 1999 initiation of the University of California Davis pediatric residency program’s Communities and Health Professionals Together (CHPT) partnership, the CHPT’s scope has expanded to include training of residents from the Departments of Family and Community Medicine and Internal Medicine, as well as students from the Schools of Nursing, Medicine, and Public Health.

Use of Fresh Frozen Plasma in Children

Kenneth S. Azarow — 2011-10-10

This issue of The Journal includes two articles that examine the use of fresh frozen plasma (FFP). At first glance, the authors appear to have differing views as to the benefits and overall utilization strategy of FFP use. Hendrickson et al describe how coagulopathy is independently associated with mortality and morbidity in trauma patients who are injured severely enough to require a transfusion within the first 24 hours of admission. The inference is that early use of FFP in this setting may be an effective way to treat the coagulopathy that can be anticipated. The other article, by Puetz et al, reviews an administrative database that demonstrates the use of FFP across the United States, then refers the reader to the literature, where FFP has been shown generally to not improve outcomes in controlled trials. The end result is that one study infers that FFP may be useful as an upfront resuscitative tool to correct coagulopathy and improve morbidity and mortality secondary to traumatic injury, whereas the other study infers that FFP is grossly overused in the United States and suggests more limited use or at least an increase in the monitoring of FFP use. What message is the reader to take away?

Interinstitutional Variability in Home Care Interventions after Neonatal Intensive Care Unit Discharge

Nicole R. Dobson, Carl E. Hunt — 2011-11-03

Home O2 therapy in preterm infants with bronchopulmonary dysplasia (BPD) may facilitate early discharge from the neonatal intensive care unit (NICU), but creates additional stressors for families. No clinical trial has documented the long-term benefits of home O2 therapy in infants with BPD in the current era of widespread antenatal steroid use and early surfactant therapy. Published guidelines from the American Academy of Pediatrics and American Thoracic Society recommend considering home O2 therapy for infants with an O2 saturation <92%-95% in room air, but there is significant variability in home O2 use among neonatologists.

Hip Ultrasounds: Where do We Go from Here?

Junichi Tamai — 2011-11-15

In this issue of The Journal, von Kries et al have addressed one of the more controversial questions in the care of pediatric orthopedic patients. Many have attempted to balance the value of early detection of developmental dysplasia of the hip with the cost of screening and the direct and indirect costs of intervention. Some have questioned the improvement in outcomes from orthopedic interventions for children with developmental dysplasia of the hip. Absence of conclusive evidence that ultrasound screening of newborns is helpful does not translate to evidence of absence of any value for screening newborns for hip dysplasia.

The Last Mile: Taking the Final Steps in Preventing Pediatric Pharmaceutical Poisonings

Daniel S. Budnitz, Maribeth C. Lovegrove — 2011-11-07

The dramatic reduction in pediatric deaths from unintentional poisonings in the last half of the 20th century is a model of the successful application of injury prevention theory and practice. The increases in hospitalizations, emergency department (ED) visits, and persistence of deaths caused by unintentional pediatric pharmaceutical poisonings in the first decade of this century are described by Bond et al in this issue of The Journal and remind us that this effort is not yet complete. Hopefully the findings in this study can help catalyze targeted efforts to reverse the rise in injuries from pediatric pharmaceutical poisonings and push the number of pediatric deaths closer to zero.

Over-Prescription of Acid-Suppressing Medications in Infants: How It Came About, Why It’s Wrong, and What to Do About It

Eric Hassall — 2011-10-24

It has been almost 20 years since proton pump inhibitors (PPIs) were initially shown to be effective, safe, and well-tolerated for the short-term treatment of gastroesophageal reflux disease (GERD) in children over 1 year of age; GERD diagnosed on the basis of symptoms and hard diagnostic evidence of erosive esophagitis seen at endoscopy. In these studies, mostly performed in children 2 to 17 years of age, PPIs were shown to effectively treat symptoms and erosive esophagitis that were refractory to histamine-2-receptor antagonists (H2RA), buffering agents, prokinetics, and in some subjects, antireflux surgery. Subsequent to those studies with omeprazole, other PPIs were found to be similarly effective. Efficacy and safety were also shown for maintenance of remission of chronic, relapsing erosive esophagitis in prospective studies as long as 2 years, and retrospective studies as long as 11 years of use. Approximately 80% of children who require long-term treatment for GERD have underlying disorders that predispose them to GERD, such as neurologic impairment, repaired congenital esophageal anomalies (eg, esophageal atresia), chronic lung disease, hiatal hernia, a strong family history of GERD, Barrett’s esophagus, or esophageal adenocarcinoma, or obesity. In children without these underlying disorders, GERD is usually not chronic or severe, and most commonly follows a presumed upper gastrointestinal infection with post-infectious dysmotility and delayed gastric emptying, which resolves with time. In other words, in most otherwise healthy children, GERD is not chronic. In children in whom it is, the use of PPIs has revolutionized the long-term treatment of GERD, much for the better, including allowing for significantly decreased rates of antireflux surgery in some centers.

50 Years Ago in The Journal of Pediatrics: Serum Amino Acid Nitrogen in Infancy and Childhood

William W. Hay, Laura D. Brown — 2012-02-01

Andrews BF, Bruton OC, de Barre L. J Pediatr 1962;60:201-5 Andrews et al published normal values for total amino acid nitrogen in 57 infants and children and compared these values with data from 52 children with a variety of pathological conditions, including infection, fevers, neurologic abnormalities, hepatic failure, and intoxications, but none with genetic disorders of specific amino acids.

Calciferol Deficiency Mimicking Abusive Fractures in Infants: Is There Any Evidence?

Ann S. Botash, Irene N. Sills, Thomas R. Welch — 2011-10-13

The history of calciferol∗ metabolism and biochemistry is tightly intertwined with that of American pediatrics. Rickets was a widespread affliction of children in urban areas in the 19th and early 20th centuries. Mellanby recognized the anti-rachitic properties of a fat-soluble substance that was incorrectly named “vitamin” D. Shortly thereafter, Eliot undertook a seminal clinical trial in New Haven that demonstrated the ability of cod-liver oil to prevent rickets in infants. Within decades, supplementation of nursing infants became nearly universal, and clinical rickets largely disappeared. In the latter part of the 20th century, lax prescribing of calciferol supplements to nursing children, combined with an increasing number of mothers of darkly pigmented infants choosing to breast feed, led to a resurgence of clinical rickets.

50 Years Ago in The Journal of Pediatrics: A Correlation of Clinical, Electroencephalographic, and Roentgenographic Findings in Children with Epilepsy

Jane MacLean, Paul Graham Fisher — 2012-02-01

Lundervold A, Jabbour JT. J Pediatr 1962;60:220-3 When Lundervold and Jabbour studied childhood epilepsy, there were only a handful of anticonvulsants, some of which have since been abandoned because of inefficacy or toxicity. Despite these limited treatment options, the authors reported seizure remission in 32% of pediatric patients with epilepsy, and seizure reduction in another 51%. Fifty years later, do today’s children fare better?

Coagulopathy is Prevalent and Associated with Adverse Outcomes in Transfused Pediatric Trauma Patients

2011-09-20

Objective: To evaluate coagulopathy in pediatric trauma patients on presentation to the emergency department, and to quantify the relationship with mortality.Study design: Pediatric trauma patients requiring a blood transfusion (red blood cells, fresh frozen plasma, platelets, or cryoprecipitate) within 24 hours of arrival were included. Coagulation values on emergency department arrival were analyzed, as were clinical details and outcome.Results: A total of 102 children (mean age, 6 years; mean injury severity score 22, mean Glascow Coma Scale 7, 80% blunt trauma victims) were studied over a 4 year period. An abnormal prothrombin time was found in 72%, partial thromboplastin time in 38%, fibrinogen in 52%, hemoglobin in 58%, and platelet count in 23%. An abnormal prothrombin time, partial thromboplastin time, and platelet count were strongly associated with mortality (P=.005, .001, and <.0001, respectively) and remained significantly associated in multivariate analysis after adjusting for injury severity score.Conclusions: Coagulopathy is prevalent in pediatric trauma patients ill enough to require a transfusion and is strongly associated with mortality. Studies are needed to determine whether early coagulation factor replacement and the institution of massive transfusion protocols may improve outcomes in these patients.

Widespread Use of Fresh Frozen Plasma in US Children’s Hospitals Despite Limited Evidence Demonstrating a Beneficial Effect

John Puetz, Char Witmer, Yuan-Shung V. Huang, Leslie Raffini — 2011-09-16

Objectives: To determine the pattern, prevalence and potential complications of fresh frozen plasma (FFP) use in US pediatric hospitals from 2002-2009.Study design: Retrospective cohort study using the Pediatric Health Information System (PHIS) administrative database, which was queried for FFP admissions using diagnostic, procedural, and billing codes. Demographic data, daily use, and procedural codes were used to describe the patient population and pattern of FFP use.Results: Of 3 252 149 PHIS-recorded admissions, 2.85% had codes consistent with FFP use. This percentage did not change over the course of the study (P=.10). FFP was most commonly administered to children <1 year of age (54%), critically ill children (70%), and those with heart disease (34%). Fifteen percent of FFP-related admissions involved a thrombotic event. The overall mortality rate was 17% and it decreased during the study (P<.001). There was noteworthy variation in the proportion of FFP admissions among participating institutions.Conclusions: FFP is commonly used in children admitted to PHIS hospitals. Despite recent expert recommendations highlighting the lack of efficacy in many clinical scenarios, the rate of FFP use does not appear to be changing. Randomized, controlled studies are needed to determine appropriate indications for FFP use and evaluate for potential complications.

Health Care Utilization from Prevalent Medical Conditions in Normal-Weight, Overweight, and Obese Children

Sara F.L. Kirk, Stefan Kuhle, Arto Ohinmaa, Ian Colman, Paul J. Veugelers — 2011-09-01

Objective: To explore the commonly recorded diagnoses in overweight and obese children presenting to a clinical care setting compared with their normal-weight peers.Study design: This was a cross-sectional study linking data from 3361 fifth grade students from the 2003 Children’s Lifestyle and School Performance Study with Nova Scotia administrative health data over 6 years.Results: Overweight and obese children were more likely to have had a diagnosis of internalizing disorders, asthma, other respiratory disorders, obesity, otitis media, and chronic adenoid/tonsil disorder. Conversely, normal-weight children were more likely to have a diagnosis of conduct disorder or other mental diseases. Except for internalizing disorders, overweight and obese children also had significantly higher health care costs for these conditions.Conclusion: Overweight and obese children had higher health care utilization across a range of diagnoses, further confirming that health care utilization patterns of overweight and obese children differ from those of their normal-weight peers. Greater attention to the relationship between more common childhood conditions and overweight and obesity is needed, given the greater prevalence in overweight and obese children and the fact that some of the more established obesity-related conditions occur less frequently, particularly in younger children.

50 Years Ago in The Journal of Pediatrics: The Significance of Atypical Mononuclear Leukocytes

Sarah S. Long — 2012-02-01

Vaughan J, Greenberg SD. J Pediatr 1962;60:177-82 This study of the histological characteristics of “atypical lymphocytes” seen in the blood smears of 20 pediatric outpatients, as well as speculation on origin of the cells (thought to be “lymphocytes in the process of maturing to histiocytes or monocytes”) and nature of the stimulus (viral infection), added some specificity to the passing observations of blood smears by clinical pathologists. At the time, “infectious mononucleosis” was thought to be a viral infection, and the presence of serum heterophil antibodies was confirmatory. The absence of heterophil antibody in the infants and toddlers studied (90% of whom were aged <2 years) puzzled the investigators as to the cause of atypical lymphocytosis.

Postural Tachycardia in Children and Adolescents: What is Abnormal?

2011-10-13

Objectives: To evaluate whether the use of adult heart rate (HR) criteria is appropriate for diagnosing orthostatic intolerance (OI) and postural tachycardia syndrome (POTS) in children and adolescents, and to establish normative data and diagnostic criteria for pediatric OI and POTS.Study design: A total of 106 normal controls aged 8-19 years (mean age, 14.5±3.3 years) underwent standardized autonomic testing, including 5 minutes of 70-degree head-up tilt. The orthostatic HR increment and absolute orthostatic HR were assessed and retrospectively compared with values in 654 pediatric patients of similar age (mean age, 15.5±2.3 years) who were referred to our Clinical Autonomic Laboratory with symptoms of OI.Results: The HR increment was mildly higher in patients referred for OI/POTS, but there was considerable overlap between the patient and control groups. Some 42% of the normal controls had an HR increment of ≥30 beats per minute. The 95th percentile for the orthostatic HR increment in the normal controls was 42.9 beats per minute. There was a greater and more consistent difference in absolute orthostatic HR between the 2 groups, although there was still considerable overlap.Conclusion: The diagnostic criteria for OI and POTS in adults are unsuitable for children and adolescents. Based on our normative data, we propose new criteria for the diagnosis of OI and POTS in children and adolescents.

Plasma Hydrogen Sulfide in Differential Diagnosis between Vasovagal Syncope and Postural Orthostatic Tachycardia Syndrome in Children

2011-09-16

Objective: To explore the predictive value of plasma hydrogen sulfide (H2S) in differentiating between vasovagal syncope (VVS) and postural orthostatic tachycardia syndrome (POTS) in children.Study design: Patients were divided between the POTS group (n=60) and VVS group (n=17) by using either the head-up test or head-up tilt test. Twenty-eight healthy children were selected for the control group. Plasma concentrations of H2S were determined for children in all groups (POTS, VVS, and control).Results: Plasma levels of H2S were significantly higher in children with VVS (95.3±3.8 μmol/L) and POTS (100.9±2.1 μmol/L) than in children in the control group (82.6±6.5 μmol/L). Compared with the VVS group, the POTS group had plasma levels of H2S that were significantly increased. The receiver operating characteristic curve for the predictive value of H2S differentiation of VVS from POTS showed a H2S plasma level of 98 μmol/L as the cutoff value for high probability of distinction. Such a level produced both high sensitivity (90%) and specificity (80%) rates of correctly discriminating between patients with VVS and patients with POTS.Conclusion: H2S plasma level has both high sensitivity and specificity rates to predict the probability of correctly differentiating between patients with VVS and patients with POTS.

Clinical Predictors and Institutional Variation in Home Oxygen Use in Preterm Infants

Joanne Lagatta, Reese Clark, Alan Spitzer — 2011-09-29

Objective: To assess home oxygen use in preterm infants, identify risk factors predicting home oxygen use, and quantify the extent of institutional variation in home oxygen use across neonatal intensive care units.Study design: We conducted a retrospective cohort analysis of surviving infants of 23- to 31-week gestational age discharged home in 2009, with de-identified electronic medical record information from the Pediatrix Clinical Data Warehouse. Mixed-effects logistic regression quantified clinical risk factors and institutional variation affecting home oxygen use.Results: A total of 8167 infants were identified. Home oxygen use varied by gestational age, from 59% of infants 23 to 24 weeks gestational age to 7% of infants 29 to 31 weeks gestational age. Other risk factors included small for gestational age, congenital anomalies, mechanical ventilation in the first 72 hours, fraction of inhaled oxygen >0.4 in the first 72 hours, and patent ductus arteriosus. After adjusting for clinical risk factors, there was still a 4- to 5-fold difference in institutions’ odds of home oxygen use.Conclusions: Home oxygen use was common in infants of earlier gestational ages and infants with more severe respiratory illness. Institutional variation accounted for 4- to 5-fold variation in home oxygen use. Families should be counseled about the likelihood of home oxygen use, and prospective research must identify optimal treatment strategies for high-risk infants.

Outcome of Extremely Low Birth Weight Infants Who Received Delivery Room Cardiopulmonary Resuscitation

2011-09-20

Objective: To determine whether delivery room cardiopulmonary resuscitation (DR-CPR) independently predicts morbidities and neurodevelopmental impairment (NDI) in extremely low birth weight infants.Study design: We conducted a cohort study of infants born with birth weight of 401 to 1000 g and gestational age of 23 to 30 weeks. DR-CPR was defined as chest compressions, medications, or both. Logistic regression was used to determine associations among DR-CPR and morbidities, mortality, and NDI at 18 to 24 months of age (Bayley II mental or psychomotor index <70, cerebral palsy, blindness, or deafness). Data are adjusted ORs with 95% CIs.Results: Of 8685 infants, 1333 (15%) received DR-CPR. Infants who received DR-CPR had lower birth weight (708±141 g versus 764±146g, P<.0001) and gestational age (25±2 weeks versus 26±2 weeks, P<.0001). Infants who received DR-CPR had more pneumothoraces (OR, 1.28; 95% CI, 1.48-2.99), grade 3 to 4 intraventricular hemorrhage (OR, 1.47; 95% CI, 1.23-1.74), bronchopulmonary dysplasia (OR, 1.34; 95% CI, 1.13-1.59), death by 12 hours (OR, 3.69; 95% CI, 2.98-4.57), and death by 120 days after birth (OR, 2.22; 95% CI, 1.93-2.57). Rates of NDI in survivors (OR, 1.23; 95% CI, 1.02-1.49) and death or NDI (OR, 1.70; 95% CI, 1.46-1.99) were higher for DR-CPR infants. Only 14% of DR-CPR recipients with 5-minute Apgar score <2 survived without NDI.Conclusions: DR-CPR is a prognostic marker for higher rates of mortality and NDI for extremely low birth weight infants. New DR-CPR strategies are needed for this population.

Inhaled Nitric Oxide Therapy Increases Blood Nitrite, Nitrate, and S-Nitrosohemoglobin Concentrations in Infants with Pulmonary Hypertension

2011-09-12

Objective: To measure the circulating concentrations of nitric oxide (NO) adducts with NO bioactivity after inhaled NO (iNO) therapy in infants with pulmonary hypertension.Study design: In this single center study, 5 sequential blood samples were collected from infants with pulmonary hypertension before, during, and after therapy with iNO (n = 17). Samples were collected from a control group of hospitalized infants without pulmonary hypertension (n = 16) and from healthy adults for comparison (n = 12).Results: After beginning iNO (20 ppm) whole blood nitrite levels increased approximately two-fold within 2 hours (P<.01). Whole blood nitrate levels increased to 4-fold higher than baseline during treatment with 20 ppm iNO (P<.01). S-nitrosohemoglobin increased measurably after beginning iNO (P<.01), whereas iron nitrosyl hemoglobin and total hemoglobin-bound NO-species compounds did not change.Conclusion: Treatment of pulmonary hypertensive infants with iNO results in increases in levels of nitrite, nitrate, and S-nitrosohemoglobin in circulating blood. We speculate that these compounds may be carriers of NO bioactivity throughout the body and account for peripheral effects of iNO in the brain, heart, and other organs.

CO2 Inhalation as a Treatment for Apnea of Prematurity: A Randomized Double-Blind Controlled Trial

2011-09-12

Objective: To compare the effect of prolonged inhalation of a low concentration of CO2 with theophylline for the treatment of apnea of prematurity.Study design: Prospective, randomized, double-blind controlled trial of 87 preterm infants with apnea of prematurity (27-32 weeks’ gestational age) assigned to either theophylline plus 0.5 L/min of room air via nasal prongs or placebo plus 0.5 L/min with CO2 (about 1% inhaled) by nasal prongs for 3 days.Results: Apnea time significantly decreased in the theophylline group from 189±33 s/h (control) to 57±11, 50±9, and 61±13 (days 1-3) (P=.0001) and in the CO2 group from 183±44 (control) to 101±26, 105±29, and 94±26 s/h (days 1-3) (P=.03). Seven infants in the CO2 group but none in the theophylline group failed to complete the study due to severe apneas (P=.003).Conclusions: Because theophylline was more effective in reducing the number and severity of apneas, inhalation of low concentration of CO2, as used in the present study, cannot be considered as an alternative to theophylline in the treatment of apnea of prematurity. The less effectiveness of CO2 treatment may have been related to the variability of the delivery of CO2.

Unbound Bilirubin does not Increase during Ibuprofen Treatment of Patent Ductus Arteriosus in Preterm Infants

2011-08-29

Objective: To determine whether ibuprofen displaces bilirubin from albumin in preterm infants.Study design: A total of 34 preterm neonates (<32 weeks gestation) treated by ibuprofen (10-5-5 mg/kg) were included in this prospective open-label study. Total bilirubin (TB), unbound bilirubin (UB), and ibuprofen concentrations were measured before, 1 hour, and 6 hours after the first dose; before and 1 hour after the second dose; and 72 hours after the beginning of treatment. The infants were screened by auditory brainstem responses and by neurologic examination at term.Results: At baseline, TB, UB, apparent binding affinity of albumin (Ka), and albumin concentrations were 6.0±1.6 mg/dL, 1.9±2.2 μg/dL, 14.1±5.8 L·μmol−1, and 28.7±2.3 g/L, respectively. Ibuprofen treatment had no effect on TB, UB, or Ka values. No correlation between UB or Ka and ibuprofen concentrations was found. No neurologic symptoms or significant modifications of auditory brainstem responses were observed at term.Conclusion: Ibuprofen (10-5-5 mg/kg) did not displace bilirubin in preterm infants with a baseline TB concentration <8.8 mg/dL.

The Growing Impact of Pediatric Pharmaceutical Poisoning

G. Randall Bond, Randall W. Woodward, Mona Ho — 2011-09-16

Objective: To understand which medications, under which circumstances, are responsible for the noted increase in pediatric medication poisonings, resource use, and morbidity.Study design: Patient records from 2001-2008 were obtained from the National Poison Data System of the American Association of Poison Control Centers for children aged ≤5 years evaluated in a health care facility following exposure to a potentially toxic dose of a pharmaceutical agent. Pharmaceutical agents were classified as over-the-counter or prescription and by functional category. Exposures were classified as child self-ingested the medication or as therapeutic error. For the 8-year period, emergency visits, admissions, significant injuries, and trends in these events were calculated for each substance category.Results: We evaluated 453 559 children for ingestion of a single pharmaceutical product. Child self-exposure was responsible for 95% of visits. Child self-exposure to prescription products dominated the health care impact with 248 023 of the visits (55%), 41 847 admissions (76%), and 18 191 significant injuries (71%). The greatest resource use and morbidity followed self-ingestion of prescription products, particularly opioids, sedative-hypnotics, and cardiovascular agents.Conclusions: Prevention efforts have proved to be inadequate in the face of rising availability of prescription medications, particularly more dangerous medications.

General Ultrasound Screening Reduces the Rate of First Operative Procedures for Developmental Dysplasia of the Hip: A Case-Control Study

2011-09-29

Objectives: To assess the effectiveness of general ultrasound screening to prevent first operative procedures of the hip.Study design: We conducted a case-control study in a population in which general ultrasound screening supplementing clinical screening is recommended and offered free of charge for all children. Participation in ultrasound screening before week 7 as recommended in Germany was the exposure of interest. Case ascertainment was based on active surveillance in orthopedic hospitals. The case definition was: first operative procedure for developmental dysplasia of the hip (closed reduction, open reduction, or osteotomy) in children >9 weeks old and <5 years old and born between 1996 and 2001. Control subjects from the same birth cohorts were recruited in telephone surveys.Results: Cases of first operative procedures for developmental dysplasia of the hip (n = 446) were compared with 1173 control subjects for ultrasound screening. Effectiveness of ultrasound screening to prevent first operative procedures for developmental dysplasia of the hip was estimated as 52% (95% CI, 32-67). Effectiveness did not vary substantially for closed and open reductions and osteotomy.Conclusions: General ultrasound screening reduces the rate of operative procedures for developmental dysplasia of the hip; the impact on developmental dysplasia of the hip. Treatment rates and avascular necrosis need further assessment to balance the benefit against potential overtreatment and adverse effects.

Carotid Intima-Media Thickness at 7 Years of Age: Relationship to C-Reactive Protein Rather than Adiposity

2011-08-29

Objective: According to the concept of adipose tissue expandability, the vascular complications of obesity are related less to the amount of stored fat than to the low-grade inflammation that excess fat storage may elicit. We tested this concept in 7-year-old children by assessing whether carotid intima-media thickness (cIMT) is related to obesity measures or to circulating highly sensitive C-reactive protein (hsCRP), as a marker of low-grade inflammation.Study design: The study group comprised 135 asymptomatic Caucasian children (72 girls and 63 boys; mean age, 7.1±1.1 years) with normal height and weight distributions. Relationships were assessed among cIMT, hsCRP, obesity measures (ie, body mass index [BMI], total fat by bioelectric impedance, and visceral fat by ultrasound), insulin resistance (by the homeostasis model assessment for insulin resistance), and fasting serum lipid levels.Results: cIMT was correlated with hsCRP, but not with BMI or body fat; the regression coefficients between cIMT and hsCRP (adjusted for age, sex, BMI, body fat, and serum lipid levels) were fairly similar across all BMI categories (β=0.370-0.411; all P<.001 to<.0001). Serum hsCRP increased with increasing BMI, total fat, and visceral fat (all P<.001).Conclusion: At age 7 years, cIMT is already associated with low-grade inflammation, as measured by hsCRP, but not with BMI or body fat. These findings imply that public health strategies aimed at early prevention of cardiovascular disease may need to target low-grade inflammation rather than only BMI or adiposity.

50 Years Ago in The Journal of Pediatrics: The Central Nervous System Manifestations of Leukemia: A Report of 6 Cases with Meningeal Involvement

Paul Graham Fisher — 2012-02-01

Steffey JM. J Pediatr 1962;60:183-90 The history of childhood acute lymphoblastic leukemia (ALL) therapy is a Cinderella story. Fifty years ago, a child with ALL had a dismal prognosis. In The Journal in 1962, Steffey bemoaned the rate of children experiencing leukemia relapse in the central nervous system (CNS), particularly the meninges. Indeed, as a child, I remember vividly praying in church every Sunday that a boy 2 years older than me would overcome his ALL. He died after approximately 2 years, much like the children Steffey described.

Effects of Chronic Transfusions on Abdominal Sonographic Abnormalities in Children with Sickle Cell Anemia

2011-09-12

Objective: To assess the effects of chronic erythrocyte transfusions on prevalence of sonographic incidence of organ damage in children with sickle cell anemia (SCA).Study design: Children (N=148; mean age, 13.0 years) with SCA, receiving chronic transfusions (average, 7 years), underwent abdominal sonography at 25 institutions. After central imaging review, spleen, liver, and kidney measurements were compared with published normal values. Potential relations between ultrasound, clinical, and laboratory data were explored via analysis of variance, Student t test, and Cochran-Mantel-Haenzel tests of non-zero correlation.Results: Average spleen length was similar to normal children, but over one-third had spleen volumes >300 mL, 15 had previous splenectomy for splenomegaly, and 24 had abnormal splenic echotexture. Two-thirds had hepatobiliary disease; 37 had prior cholecystectomy, 46 had gallstones, and 16 had gallbladder sludge. Gallbladder disease correlated with older age (P=.002), longer liver length (P<.001), longer duration of transfusions (P=.034), and higher total bilirubin (P<.001). Liver (P<.001) and renal lengths (P≤.005) were larger than published norms.Conclusions: In children with SCA, long-term transfusion therapy may not prevent development or progression of abdominal organ dysfunction.

Markers of Severe Vaso-Occlusive Painful Episode Frequency in Children and Adolescents with Sickle Cell Anemia

2011-09-05

Objective: To identify factors associated with frequent severe vaso-occlusive pain crises in a contemporary pediatric cohort of patients with sickle cell anemia (SCA) enrolled in a prospective study of pulmonary hypertension and the hypoxic response in sickle cell disease.Study design: Clinical and laboratory characteristics of children with SCA who had ≥3 severe pain crises requiring health care in the preceding year were compared with those of subjects with <3 such episodes.Results: Seventy-five children (20%) reported ≥3 severe pain episodes in the preceding year, and 232 (61%) had none. Frequent pain episodes were associated with older age (OR, 1.2; 95% CI, 1.1-1.3; P < .0001), α-thalassemia trait (OR 3.5; 1.6-6.7; P = .002), higher median hemoglobin (OR 1.7; 95% CI: 1.2-2.4; P < .003), and lower lactate dehydrogenase concentration (OR 1.82; 95% CI: 1.07-3.11; P = .027). Children with high pain frequency also had an increased iron burden (serum ferritin, 480 vs 198 μg/L; P = .006) and higher median tricuspid regurgitation jet velocity (2.41 vs 2.31 m/s; P = .001). Neither hydroxyurea use nor fetal hemoglobin levels were significantly different according to severe pain history.Conclusions: In our cohort of children with SCA, increasing age was associated with higher frequency of severe pain episodes as were α-thalassemia, iron overload, higher hemoglobin and lower lactate dehydrogenase concentration, and higher tricuspid regurgitation velocity.

Seizures in Acute Childhood Stroke

2011-09-12

Objectives: To describe the risk of seizures in children with acute stroke and identify factors predicting their later risk of epilepsy.Study design: Data for patients >3.5 years of age at a tertiary care children’s hospital with acute stroke were collected and reviewed.Results: Seventy-seven patients were identified (mean age, 8.4 years); 21% had clinical seizures. An additional 10% of patients had a clinical seizure during the acute hospitalization. Status epilepticus was common in infants and patients with cortical strokes. Non-convulsive status epilepticus was captured only in patients with prolonged electroencephalograms and always within 24 hours of monitoring. Six months after their stroke, 24% of our patients had epilepsy, all of whom experienced seizures at initial presentation with stroke.Conclusion: In our series of pediatric patients with stroke, most of the clinical seizures occurred within the first 24 hours of presentation and did not vary in stroke subtype. Status epilepticus was common, especially in infants. Epilepsy had a high likelihood of developing in the next 6 months in children with seizures in the first 24 hours of stroke onset. Prolonged electroencephalogram monitoring was useful in detecting non-convulsive status epilepticus, but not in predicting the risk of epilepsy at 6 months.

Disease Activity, Proteinuria, and Vitamin D Status in Children with Systemic Lupus Erythematosus and Juvenile Dermatomyositis

2011-09-19

Objective: To evaluate relationships among vitamin D, proteinuria, and disease activity in pediatric systemic lupus erythematosus (SLE) and juvenile dermatomyositis (JDM).Study design: Multiple linear regression was used to associate subject-reported race, sunscreen use, and vitamin D intake with physician-assessed disease activity and serum 25-hydroxyvitamin D (25[OH]D) in 58 subjects with pediatric SLE (n=37) or JDM (n=21). Serum 25(OH)D was correlated with urinary vitamin D binding protein/creatinine ratio (DBP/C) and other indicators of proteinuria.Results: Serum 25(OH)D levels in subjects with SLE were inversely associated with the natural log of urinary DBP/C (r=−0.63, P<.001) and urine protein to creatinine ratio (r=−0.60, P<.001), with an adjusted mean 10.9-ng/mL (95% CI, 5.1-16.8) decrease in 25(OH)D for those with proteinuria. Excluding subjects with proteinuria, serum 25(OH)D levels were inversely associated with disease activity in JDM, but not in SLE. Overall, 66% of all subjects were taking concurrent corticosteroids, but this was not associated with 25(OH)D levels.Conclusions: Low serum 25(OH)D in patients with SLE is associated with proteinuria and urinary DBP. Vitamin D deficiency is associated with disease activity in patients with JDM and SLE; this relationship in SLE may be confounded by proteinuria.

Clinical Features and Outcome of Cogan Syndrome

2011-09-16

Objective: To review the clinical features of Cogan syndrome, a rare vasculitis characterized by systemic, ocular, and audiovestibular symptoms.Study design: Clinical records of patients with Cogan syndrome followed at 2 pediatric rheumatology institutions and those from a database search were reviewed. Data included clinical features at onset and during the disease course, treatments, and outcomes.Results: Twenty-three children with Cogan syndrome (15 males; mean age, 11.4 years [range, 4-18 years]) were included in the analysis. Eleven patients (47.8%) exhibited systemic features at disease onset, including fever, arthralgias-arthritis or myalgias, headache, and weight loss. Twenty-one patients (91.3%) had ocular symptoms, due mainly to interstitial keratitis, uveitis, or conjunctivitis/episcleritis. Vestibular symptoms (39.1%) included vertigo, vomiting, and dizziness. Auditory involvement (65.2%) consisted of sensorineural hearing loss, tinnitus, and deafness. Four patients had cardiac valve involvement, and 3 had skin manifestations. After a median 2 years of follow-up, 30.4% of the patients were in clinical remission, but all others had irreversible complications (deafness, 21.7%; sensorineural hearing loss, 13.0%; vestibular dysfunction, 4.3%; ocular complications, 13.0%; cardiac valve damage, 17.4%).Conclusion: Audiovestibular and ocular involvement have a major impact on prognosis in children with Cogan syndrome.

Interrelationship of Extent of Precocious Adrenarche in Appropriate for Gestational Age Girls with Clinical Outcome

2011-09-12

Objective: To assess the interrelationship between extent of adrenarche at presentation in girls with precocious adrenarche (PA) born appropriate for gestational age and their growth pattern, pubertal course and adult height.Study design: We reviewed clinical and laboratory data from medical charts of 85 girls with PA aged 5.0 to 8.8 years at referral, stratified in 3 subgroups according to bone age (BA) minus chronological age (CA) ≤0 years; 0 1 year.Results: Extent of pubarche and dehydroepiandrosterone-sulfate levels were greatest in the BA−CA >1 subgroup (P=.02, P=.008, respectively), who also were taller at diagnosis (P=.002) and during childhood (P=.01). In all subgroups, pubertal onset was within normal range; menarche occurred earlier than in control subjects (P 1 (P<.001).Conclusions: Although a more pronounced adrenarche and BA advancement at diagnosis in girls with PA born appropriate for gestational age had an impact on their pre-pubertal growth pattern, it was not associated with early and rapid progression of puberty or reduced adult height. This reassuring clinical course indicates that PA is a benign condition, irrespective of the extent of adrenarche at presentation. Adult height prediction is unreliable in PA.

Clinical Factors Associated with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections

Tanya K. Murphy, Eric A. Storch, Adam B. Lewin, Paula J. Edge, Wayne K. Goodman — 2011-08-26

Objective: To explore associated clinical factors in children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).Study design: Children with tics, obsessive-compulsive disorder, or both (n=109) were examined with personal and family history, diagnostic interview, physical examination, medical record review, and measurement of baseline levels of streptococcal antibodies.Results: Significant group differences were found on several variables, such that children in whom PANDAS (versus without PANDAS) were more likely to have had dramatic onset, definite remissions, remission of neuropsychiatric symptoms during antibiotic therapy, a history of tonsillectomies/adenoidectomies, evidence of group A streptococcal infection, and clumsiness.Conclusion: The identification of clinical features associated with PANDAS should assist in delineating risks for this subtype of obsessive-compulsive disorder/tics.

Psychiatric Disorders in Youth with Medically Unexplained Chest Pain versus Innocent Heart Murmur

2011-08-25

Objective: To examine the prevalence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition psychiatric disorders in youth with chest pain compared with a control sample with innocent heart murmur.Study design: We assessed youth ages 8 to 17 years who were examined in cardiology settings for medically unexplained chest pain (n=100) or innocent heart murmur (n=80). We conducted semi-structured interviews and assessed medical history, quality of life, and disability.Results: Youth with chest pain had a higher prevalence of psychiatric disorders compared with youth with murmur (74% versus 47%, χ2=13.3; P<.001). Anxiety disorders predominated, although major depression was also more common in the chest pain group (9% versus 0%; Fisher exact tests; P<.01). Onset of psychiatric disorders generally preceded chest pain. Patterns were similar for boys and girls and for children and adolescents. Chest pain was associated with poorer quality of life and with pain-related disability for youth with co-morbid psychiatric disorder.Conclusions: In childhood and adolescence, medically unexplained chest pain is associated with a high prevalence of psychiatric disorders. Systematic mental health screening may improve detection and enhance treatment of these patients.

Low Rates of Controller Medication Initiation and Outpatient Follow-Up after Emergency Department Visits for Asthma

Annie Lintzenich Andrews, Ronald J. Teufel, William T. Basco — 2011-09-01

Objective: To determine what proportion of patients who are seen in an emergency department (ED) for asthma receive inhaled corticosteroids or attend follow-up appointments.Study design: This was a retrospective cohort study of 2007-2009 South Carolina Medicaid data. Enrollees aged 2-18 years who had an ED visit for asthma were included. Patients admitted for asthma or with an inhaled corticosteroid claim in the 2 months before the month of the ED visit were excluded. Covariates were sex, race, age, rural residence, and asthma severity. Outcome measures were a prescription for an inhaled corticosteroid filled within the 2 months after the ED visit and attendance at a follow-up appointment within the 2 months after the ED visit.Results: A total of 3435 patients were included. Out of the study cohort, 57% were male, 76% were of a minority race/ethnicity, 69% lived in an urban areas, 18% had inhaled corticosteroid use, and 12% completed follow-up. Multivariate analyses demonstrated that patients with severe asthma were more likely to receive an inhaled corticosteroid (OR, 2.9; 95% CI, 2.3-3.7) and attend a follow-up appointment (OR, 2.0; 95% CI, 1.5-2.6). Patients aged 2-6 years and those aged >12 years were less likely to attend follow-up (OR, 0.71; 95% CI, 0.56-0.90 and OR, 0.62; 95% CI, 0.47-0.83, respectively) (all models P < .0001).Conclusion: Children with asthma seen in the ED have low rates of inhaled corticosteroid use and outpatient follow-up. This indicates a need for further interventions to increase the use of inhaled corticosteroids in response to ED visits.

Physical and Mental Health Disparities among Young Children of Asian Immigrants

Keng-Yen Huang, Esther Calzada, Sabrina Cheng, Laurie Miller Brotman — 2011-09-12

Objective: To examine physical and mental health functioning among Asian-American children of US-born and immigrant parents.Study design: We used data from the Early Childhood Longitudinal Study-Kindergarten Class of 1998-1999 base-year public data file. The sample was restricted to 7726 Asian and US-born white children. Asian subgroups were created based on parents’ country of birth. Child physical and mental health was assessed based on multiple sources of data and measures. Analyses included multivariate linear and logistic regression.Results: After adjusting for demographic and contextual differences, disparities were found for physical and mental health indicators. Children of foreign-born Asian families (from east, southeast, and south Asia) were at greater risk for poor physical health, internalizing problems, and inadequate interpersonal relationships compared with children of US-born white families.Conclusion: There is little support for the “model minority” myth with regard to physical and mental health. Evidence of physical and mental health disparities among young Asian-American children and differing risk based on region of origin of immigrant parents suggests the need for culturally informed prevention efforts during early childhood.

Dog Bite Prevention: An Assessment of Child Knowledge

2011-09-01

Objectives: To determine what children know about preventing dog bites and to identify parental desires for dog bite prevention education.Study design: This cross-sectional study sampled 5- to 15-year-olds and their parents/guardians presenting to a pediatric emergency department with nonurgent complaints or dog bites. The parent/guardian-child pairs completed surveys and knowledge-based simulated scenario tests developed on the basis of American Academy of Pediatrics and Centers for Disease Control and Prevention dog bite prevention recommendations. Regression analyses modeled knowledge test scores and probability of passing; a passing score was ≥11 of 14 questions.Results: Of 300 parent/guardian-child pairs, 43% of children failed the knowledge test. Older children had higher odds of passing the knowledge test than younger children, as did children with white parents vs those with nonwhite parents. No associations were found between knowledge scores and other sociodemographic or experiential factors. More than 70% of children had never received dog bite prevention education, although 88% of parents desired it.Conclusions: Dog bites are preventable injures that disproportionately affect children. Dog bite prevention knowledge in our sample was poor, particularly among younger children and children with nonwhite parents. Formal dog bite prevention education is warranted and welcomed by a majority of parents.

Proton Magnetic Resonance Spectroscopic Images in Preterm Infants with Bilirubin Encephalopathy

2011-11-03

Two preterm infants with athetoid cerebral palsy due to bilirubin encephalopathy were examined by magnetic resonance spectroscopic imaging at age 3 years. An increased glutamate/glutamine complex/creatine ratio was found in the basal ganglia. Chemical metabolic abnormalities of the basal ganglia were clearly demonstrated by color-coded metabolite images.

50 Years Ago in The Journal of Pediatrics: The Ototoxic Effects of Kanamycin Sulfate in Infants and Children

Barbara J. Stoll — 2012-02-01

Yow M, et al. J Pediatr 1962;60:230-42 This report was published 3 years after kanamycin became available. As noted by the authors, kanamycin had proven to be an effective drug for the treatment of serious infections. However, because of similarities in chemical structure to streptomycin and neomycin, drugs known to be ototoxic and nephrotoxic, the potential for serious side effects was acknowledged. Yow et al performed hearing testing on 30 children who received kanamycin therapy for 5 or more days. None had known risk factors for hearing loss, but all were seriously ill. Dosages of kanamycin varied widely, and 5 infants received other ototoxic drugs. Sensorineural hearing loss was diagnosed in 5 of the 30 infants (17%) treated with kanamycin. All of these infants had potential confounders that might have increased risk of hearing loss; 1 child received other ototoxic drugs, 1 had Haemophilus influenza meningitis and otitis media, 1 was thought to have emboli to cerebral vessels, and 2 were preterm, very low birth weight infants, 1 of whom received very high doses of kanamycin. Three of the 5 children with hearing loss had impaired renal function at the time of therapy. Thirty children without exposure to kanamycin were studied as controls; 3 were found to have hearing loss.

Recombinant Parathyroid Hormone Therapy for Severe Neonatal Hypoparathyroidism

2011-11-03

Hypoparathyroidism-retardation-dysmorphism (HRD) syndrome (OMIM 241410), also known as Sanjad-Sakati syndrome, is a rare autosomal recessive disorder characterized by hypoparathyroidism, growth failure, developmental delay, and characteristic facies. We describe the effective short-term use (tapered over 12 days) of recombinant parathyroid hormone (PTH) (teriparatide) in an unusual genetic condition characterized by hypoparathyroidism.

50 Years Ago in The Journal of Pediatrics: Foreign Body in the Stomach of a Premature Infant

Christiane Sokollik — 2012-02-01

McCollough WE. J Pediatr 1962;60:277-9 This report by McCollough highlights the multifactorial etiology of bezoars in preterm infants. In contrast to swallowed foreign bodies (like coins, pins, and batteries), a bezoar in the gastrointestinal tract forms through the clumping of materials, which in normal circumstances are degraded, digested, absorbed, and easily transported.

Horner’s Syndrome as Complication of Extracorporeal Membrane Oxygenation in a Neonate

Partha S. Ghosh, Shalaka Indulkar — 2011-09-29

A term-born baby girl had a perinatal course complicated by meconium aspiration syndrome, pulmonary hemorrhage, and shock. She was placed on extracorporeal membrane oxygenation (ECMO) on day of life 3 after high-frequency ventilation failed to maintain adequate oxygenation. She was taken off ECMO on day of life 13, and neurology was consulted for facial asymmetry at 3 weeks of age (). She had partial ptosis of the right eye with miosis (right pupil 2 mm less than left, both reactive to light); extraocular movements were normal. Her face appeared symmetric, and she had normal tone, strength, and reflexes.

A Rare Cause of Ear Pain in a Young Boy

Alyce M. Oliver, Elizabeth M. Simpson, Rita S. Jerath — 2011-10-14

A 7-year-old boy presented with a 3-month history of persistent left auricular swelling and pain. He had been previously treated with several rounds of antibiotics with minimal improvement. Subsequently, he developed swelling and pain in his third, fourth, and fifth fingers. Examination revealed a darkly pigmented patch of skin on the left pinna that was tender to palpation (). Flexure deformities and periarticular swelling of the proximal interphalangeal joints of the third, fourth, and fifth digits were noted. A saddle nose deformity was also observed. Biopsy analysis of the auricular lesion revealed perichondritis and chondritis with eroded, focally necrotic cartilage (). Collectively, these findings led to a diagnosis of relapsing polychondritis.

Cardiopulmonary Arrest on Arrival in an Infant due to Ruptured Hepatoblastoma

2011-10-13

Primary tumors of the liver account for approximately 1% of malignancies in children, with an annual incidence of 1.6 cases per million children in the United States. Between 50% and 60% of hepatic tumors in children are malignant, and >65% of these are hepatoblastomas. Hepatoblastoma occurs predominantly in children <3 years of age.

Persistence of Fetal Hemoglobin Expression in an Older Child with Trisomy 13

Vijay G. Sankaran, Mark V. Sapp — 2011-09-01

A delayed fetal-to-adult hemoglobin switch occurs in infants with trisomy 13. The level of fetal hemoglobin (HbF) has been assessed in very few children with trisomy 13 surviving past infancy. A 4-year-old female with trisomy 13 confirmed by karyotype and chromosomal microarray analysis was followed by our complex care service. The patient had developmental delay, a seizure disorder, frequent aspiration requiring gastrostomy tube placement and feedings, and recurrent urinary and respiratory tract infections. She had undergone repair of a cleft palate, umbilical hernia, and polydactyly. She was maintained on a medication regimen of omeprazole, nitrofurantoin, melatonin, and levetiracetam.

Nasopharyngeal Foreign Body following a Blind Finger Sweep

Aaron Vunda, Lynda Vandertuin — 2011-10-19

A healthy 9-month-old girl playing with her father’s cufflink suddenly developed respiratory distress, coughing, and inconsolable crying. The child’s mother attempted to search her mouth using a blind finger sweep. She felt an object and had the impression that the child had swallowed it.

Non–blood group-specific red blood cell transfusions in preterm infants and necrotizing enterocolitis

Conall T. Morgan, Marie Culliton, Roberta McCarthy, Eleanor J. Molloy — 2011-11-15

We were interested in the report by Blau et al on transfusion-related gut injury (TRAGI) as an etiology for necrotizing enterocolitis (NEC). We hypothesized that TRAGI might be an immune-mediated antigenic response to receiving non group-specific red blood cell (RBC) transfusions. RBC alloantibody formation in infants aged <4 months is rare, and thus all neonates receive group O blood. We used a prospective database of confirmed cases of NEC (Bell’s staging ≥2) from 2006-2010 in a level III neonatal intensive care unit. Out of 44 177 births over the 4-year study period, 602 infants (1.3%) were born at a weight of <1500 g, of whom 39 developed NEC. Nine infants with a birth weight (BW) of >1500 g also developed NEC, for a total of 48 cases of NEC.

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Jonathan Blau, Edmund F. La Gamma — 2011-11-11

Like nearly all previous authors, Morgan et al report that patients with transfusion-related acute gut injury (TRAGI) are of lower birth weight and gestational age and develop disease later in life compared with patients without TRAGI. They also report that most cases of necrotizing enterocolitis occur at approximately 31 weeks postconceptual age, a recent age clustering recognition that raises some additional questions about gut maturation and angiogenesis.

Risk factors for medication-induced diabetes mellitus

Molly O. Regelmann, Fenella Greig, Nanda Kerkar, Robert Rapaport — 2012-02-01

Amed et al compared risk factors for children with type 2 diabetes mellitus and medication-induced diabetes mellitus. Their conclusion that “there is no consistent risk profile for children” to develop medication-induced diabetes is not surprising, given the heterogeneity of underlying medical conditions and diabetogenic agents. Children with medication-induced diabetes mellitus have variable underlying medical conditions. Variable risk profiles have been described even in analyses of groups with a single diagnosis, such as liver transplantation. Could Amed et al provide the frequency of primary diagnoses in their survey? Grouping patients by underlying condition may help determine a risk profile.

Reply

Shazhan Amed, Heather Dean, Jill K. Hamilton — 2012-02-01

We thank Regelmann et al for sharing our interest in this subject and posing important clinical research questions related to medication-induced diabetes mellitus. We acknowledge the heterogeneity of our study population, but point out that our central question was whether there is a new profile of children with medication-induced diabetes in the setting of increased prevalence of overweight and obesity in children in the general population. In this group of 58 children, we did not request the primary disease, but we noted that 98% were receiving at least one diabetogenic drug and 95% were receiving a glucocorticoid. Our hypothesis was that obesity has increased the risk of β-cell exhaustion in these children, leading to a change in the age and ethnicity of affected children. We did not collect C-peptide or insulin levels, because the study was designed as a prospective national incidence surveillance study for non–type 1 diabetes mellitus.

The Journal of Pediatrics

Distinguishing between orthostatic intolerance, POTS, and vasovagal syncope in children

Resuscitation of extremely low birth weight infants

Pain crises in children with sickle cell anemia

Chest pain: a sign of psychiatric disorder?

Reassuring follow up of girls with precocious adrenarche

Methylxanthine for apnea of prematurity

Differentiating PANDAS and non-PANDAS disorders

Table of Contents

Masthead

Information for Readers

Community Health and Advocacy Training in Pediatrics: Using Asset-Based Community Development for Sustainability

Use of Fresh Frozen Plasma in Children

Interinstitutional Variability in Home Care Interventions after Neonatal Intensive Care Unit Discharge

Hip Ultrasounds: Where do We Go from Here?

The Last Mile: Taking the Final Steps in Preventing Pediatric Pharmaceutical Poisonings

Over-Prescription of Acid-Suppressing Medications in Infants: How It Came About, Why It’s Wrong, and What to Do About It

50 Years Ago in The Journal of Pediatrics: Serum Amino Acid Nitrogen in Infancy and Childhood

Calciferol Deficiency Mimicking Abusive Fractures in Infants: Is There Any Evidence?

50 Years Ago in The Journal of Pediatrics: A Correlation of Clinical, Electroencephalographic, and Roentgenographic Findings in Children with Epilepsy

Coagulopathy is Prevalent and Associated with Adverse Outcomes in Transfused Pediatric Trauma Patients

Widespread Use of Fresh Frozen Plasma in US Children’s Hospitals Despite Limited Evidence Demonstrating a Beneficial Effect

Health Care Utilization from Prevalent Medical Conditions in Normal-Weight, Overweight, and Obese Children

50 Years Ago in The Journal of Pediatrics: The Significance of Atypical Mononuclear Leukocytes

Postural Tachycardia in Children and Adolescents: What is Abnormal?

Plasma Hydrogen Sulfide in Differential Diagnosis between Vasovagal Syncope and Postural Orthostatic Tachycardia Syndrome in Children

Clinical Predictors and Institutional Variation in Home Oxygen Use in Preterm Infants

Outcome of Extremely Low Birth Weight Infants Who Received Delivery Room Cardiopulmonary Resuscitation

Inhaled Nitric Oxide Therapy Increases Blood Nitrite, Nitrate, and S-Nitrosohemoglobin Concentrations in Infants with Pulmonary Hypertension

CO2 Inhalation as a Treatment for Apnea of Prematurity: A Randomized Double-Blind Controlled Trial

Unbound Bilirubin does not Increase during Ibuprofen Treatment of Patent Ductus Arteriosus in Preterm Infants

The Growing Impact of Pediatric Pharmaceutical Poisoning

General Ultrasound Screening Reduces the Rate of First Operative Procedures for Developmental Dysplasia of the Hip: A Case-Control Study

Carotid Intima-Media Thickness at 7 Years of Age: Relationship to C-Reactive Protein Rather than Adiposity

50 Years Ago in The Journal of Pediatrics: The Central Nervous System Manifestations of Leukemia: A Report of 6 Cases with Meningeal Involvement

Effects of Chronic Transfusions on Abdominal Sonographic Abnormalities in Children with Sickle Cell Anemia

Markers of Severe Vaso-Occlusive Painful Episode Frequency in Children and Adolescents with Sickle Cell Anemia

Seizures in Acute Childhood Stroke

Disease Activity, Proteinuria, and Vitamin D Status in Children with Systemic Lupus Erythematosus and Juvenile Dermatomyositis

Clinical Features and Outcome of Cogan Syndrome

Interrelationship of Extent of Precocious Adrenarche in Appropriate for Gestational Age Girls with Clinical Outcome

Clinical Factors Associated with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections

Psychiatric Disorders in Youth with Medically Unexplained Chest Pain versus Innocent Heart Murmur

Low Rates of Controller Medication Initiation and Outpatient Follow-Up after Emergency Department Visits for Asthma

Physical and Mental Health Disparities among Young Children of Asian Immigrants

Dog Bite Prevention: An Assessment of Child Knowledge

Proton Magnetic Resonance Spectroscopic Images in Preterm Infants with Bilirubin Encephalopathy

50 Years Ago in The Journal of Pediatrics: The Ototoxic Effects of Kanamycin Sulfate in Infants and Children

Recombinant Parathyroid Hormone Therapy for Severe Neonatal Hypoparathyroidism

50 Years Ago in The Journal of Pediatrics: Foreign Body in the Stomach of a Premature Infant

Horner’s Syndrome as Complication of Extracorporeal Membrane Oxygenation in a Neonate

A Rare Cause of Ear Pain in a Young Boy

Cardiopulmonary Arrest on Arrival in an Infant due to Ruptured Hepatoblastoma

Persistence of Fetal Hemoglobin Expression in an Older Child with Trisomy 13

Nasopharyngeal Foreign Body following a Blind Finger Sweep

Non–blood group-specific red blood cell transfusions in preterm infants and necrotizing enterocolitis

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Risk factors for medication-induced diabetes mellitus

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