Updates in Pediatrics from Nicklaus Children's Hospital: July 14 issue

July 14, 2021 | Volume 12 | Issue 28

Sudden death in the young: Information for the Primary Care Provider

“There are multiple conditions that can make children prone to having sudden cardiac arrest (SCA) or sudden cardiac death (SCD).” This article is an update of the prevention of SCA and SCD, with a comprehensive review of conditions that should prompt more attention and cardiology evaluation, on the role of screening, how to handle post-SCA/SCD situations and concludes with a discussion about genetic testing. (A long article on an important topic worth reading and keeping. Ed.)

Pediatrics

Effect of 2 inactivated SARS-CoV-2 Vaccines on symptomatic COVID-19 infections in adults

“To vaccinate the entire global population more vaccine are urgently needed”. At present 280 candidate vaccines are in development worldwide with 23 already in phase 3 trials using different platforms. Among these are inactivated vaccines (inactivated or killed virus, virus particle, bacteria etc.) which have been extensively studied, are generally safe and widely used against other respiratory infections (e.g. influenza). “Inactivated vaccines have the advantage of being easily stored and shipped at 2°C to 8°C.”

In a double blind, randomized phase 3 trial of 40,382 adults (>18 years of age) participants received one of 2 inactivated vaccines or an aluminum hydroxide (alum) control. Incidence of symptomatic COVID-19 was assessed >14 days after the second injection.

In this pre-specified interim analysis of treatment of adults with 2 inactivated SARS-CoV-2 vaccines, results indicate significantly reduced symptomatic COVID-19 (and severe adverse events) compared to an aluminum hydroxide-only control.

JAMA Network

Return to play after COVID-19 infection in children

3-4 million children in the USA have been diagnosed with COVID-19 since the pandemic began. During SARS-CoV-2 infection children may experience fever, cough, respiratory difficulties, muscle aches, headache, diarrhea, and other symptoms/signs while others may be asymptomatic. Following infection children are at risk for developing Multisystem Inflammatory Syndrome (MIS-C) or becoming “long-haulers” with a variety of symptoms which may continue for many weeks/months.

This article outlines the approach parents/pediatricians might consider prior to allowing children (particularly teens) to resume normal activities post-COVID-19. While most children will be able to safely return to normal activities others might require a slower more gradual approach. Any unexpected difficulties encountered (e.g. fever, shortness of breath, dizziness, swelling of hands/feet or fatigue) once activity is resumed will require prompt medical attention.

JAMA Pediatrics

See related video HERE & HERE.

Association between childhood consumption of ultra-processed food and adiposity

Ultra-processed foods (UPFs) are defined by the NOVA classification system (groups of foods which undergo minimal to ultra-processing by physical, biological or chemical techniques after foods are separated from nature and before they are consumed or made into dishes/meals). These commonly consumed processed foods (‘fast foods”) and drinks (“soft drinks”) are more energy dense/nutritionally poorer and have been implicated in obesity and various chronic non-communicable diseases (e.g. type 2 diabetes, cardiovascular disease and cancer). “Currently, UPFs represent 65.4% and 66.2% of daily calorie intake among United Kingdom and USA school children respectively.”

This study investigated prospectively from a birth cohort of 9,025 children 7-24 years of age and followed for 10 years (median) whether consumption of UPF in childhood is associated with worse adiposity trajectories into early adulthood.

On all parameters measured, higher UPF consumption is associated with greater increases in adiposity from childhood to early adulthood. Public health measures (and parent/pediatrician: Ed.) should urgently and robustly discourage UPF consumption among children.

JAMA Pediatrics

See related video HERE and below:

Classifying ultra-processed foods to improve health outcomes worldwide

Cambridge University Press

Association of demographic factors and infantile hemangioma (IH) characteristics with risk of PHACE syndrome

Infantile hemangiomas are birthmarks of the skin of face, scalp, chest and back made up of abnormal blood vessels which often appear as a rubbery , bright red nodule, or patches/bluish lumps which may be present at birth or appear in the first months of life. The cause is unknown (familial/genetic and multifactorial) and they to occur more often in the preterm, girls and in multiple births.

PHACE syndrome is the association of a hemangioma with posterior fossa malformations, arterial anomalies, cardiac defects and eye changes which tend to occur in 31% of children with familial infantile hemangioma (>22 cm2).

A cohort study of 238 infants (mean age 2.96 months; 77.3% female) investigated the association between IH characteristic and the risk of PHACE syndrome.

Large infantile hemangiomas (>25 cm2 surface area) involving 3 or more locations are associated with higher PHACE risk (parotid gland involvement lowers risk. Race and ethnicity may play a role – more studies required).

JAMA Dermatology

Randomized trial of fetal surgery for severe left diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) occurs in 1 in 2,000 newborns and in spite of advances in surgical and post-natal treatment continues to carry a significant mortality and short/long term morbidities. With the advent of minimally invasive fetal surgery (in selected infants) prognosis has improved particularly with the recognition of a syndrome called “congenital high airway obstruction syndrome – CHADS” in which fetuses whose airways are occluded (for whatever reason) develop oversized lungs. Following experimental data (and observational studies which have demonstrated the feasibility and effectiveness of minimally invasive fetal balloon tracheal occlusion (FETO), intrauterine tracheal occlusion continues only as an “investigational therapy.”

An open-label, randomized assigned, multicenter (with experience in FETO and other types of prenatal minimally invasive surgery) study of 80 (plus 11) women carrying a singleton fetus with severe pulmonary hypoplasia/isolated CDH on the left side investigated the use/outcomes of FETO at 27-29 weeks gestation vs. standardized neonatal intensive care unit expectant care.

In fetuses with isolated left congenital diagrammatic hernia and severe hypoplasia of the lung, FETO performed at 27-29 weeks gestation results in 40% of treated infants surviving to discharge (vs. 15% with expectant care) with no change at 6-7 years of life (FETO increases risk of preterm, pre-labor rupture of membranes and preterm birth).

The New England Journal of Medicine

See related video HERE, HERE and below:

CDH Part 1: What is Congenital Diaphragmatic Hernia?

Congenital Diaphragmatic Hernia, or CDH, is a birth defect with complications that can be difficult to understand. The hernia ultimately inhibits lung growth, causing breathing or other problems after birth.

Sperm parameters before and after COVID-19 mRNA vaccination

“One of the reasons for vaccine hesitancy is the potential negative effect on fertility.”

As reproductive toxicity was not evaluated in the early mRNA vaccine clinical trials, and SARS-CoV-2 infection has been associated with decreases in sperm parameters, a single-center prospective study of 45 healthy 18-50 year old volunteers scheduled for mRNA vaccine evaluated semen (after 2-7 days of abstinence) prior to and 70 days after the second vaccine dose. Semen analysis included volume, sperm concentration, motility and total motile sperm count.

mRNA vaccines against COVID-19 does not appear to decrease any sperm parameter measured in healthy men.

JAMA Network

Mayo Clinic's COVID-19 Vaccine Tracker

Click HERE to view.

From the Editor

It appears to me that we in the USA have entered a new phase in the ongoing Covid-19 pandemic. While some states appear to have the case/hospitalization and death rates under control, a number continue to report spread with children & young adults being the predominant groups requiring hospitalization (fortunately deaths remain relatively few).

While vaccination against SARS-Cov-2 certainly appears to be of great value in preventing spread and protecting the population, recent data from Israel suggests that it’s efficacy is significantly less than previously thought (~ 64% vs 95%). In addition, and equally concerning, the Delta (and Delta Plus) mutation, now the predominant variant in the USA, and a new spike protein mutation labeled Lambda by the WHO, presently circulating in South America, are all believed to be not only significantly more infectious but also more successful in evading vaccine immunity. A booster vaccine dose requirement now seems quite likely.

A recent interesting modeling article looks at what has been a very successful system in minimizing the pandemic. In Taiwan the focus on containing the pandemic has been primarily on public health measures (vs. vaccination) e.g. face masks, social distancing and hand sanitation, with great benefit to all. (The CDC still recommends the wearing of face masks!)

It appears that success against SARS-Cov-2 infection is possible and we’ve known how to achieve it for some time! It’s a combination of vaccination, with distances between us, in our hands (pardon the pun!) and on our faces!

Vaccinate and take care.

Jack Wolfsdorf, MD

Editor in Chief