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Updates in Pediatrics
Editor: Jack Wolfsdorf, MD, FAAP
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August 10, 2022 | Volume 13 | Issue 32 |
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Therapy for mild to moderate asthma |
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Asthma is one of the most common non-communicable diseases and is characterized by bronchial inflammation (hyper-responsiveness) and recurring reversible airway obstruction. Most patients (50-75%) have mild or infrequent symptoms which however contribute to 30-40% of exacerbations leading to Emergency Department (ED) use, and even death.
GINA (Global Initiative for Ashma) is a collaboration of the National Institute of Health (NIH), National Heart Lung and Blood Institute (NHLB) and the World health Organization (WHO). Its science committee reviews new literature and assesses its influence on management guidelines.
The 2021 GINA Strategy Report for the treatment of mild/moderate asthma (in children >12 years of age/adults) suggests that:
- Monotherapy with short-acting β-agonists are NO LONGER RECOMMENDED.
- For mild intermittent or persistent asthma, treatment should include inhaled therapy with a corticosteroid (ICS) and Formoterol (a rapid-onset, long-acting β-2-agonist). (If this combination is not possible, a combination of inhaled corticosteroid plus short-acting bronchodilator (SABA) may be utilized).
(For information on the current recommendations for the treatment of moderate/severe asthma please consult reference).
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Read the full article at JAMA Network
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Fecal transplantation in a 2-year-old child with therapy resistant Clostridioides difficile (C. diff) infection (CDI)
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C. diff (formerly clostridium difficile) is a spore-forming bacterium (found is soil, hospital environments, etc.) normally identified in small number in the gut (from person-to-person fecal-oral spread) which, in the face of ingested antibiotics (or antineoplastic agents) may overpopulate the intestine or colon. This may lead (usually 5-10 days after starting the antibiotic course, but may be shorter or longer) to C. diff colitis (many children are asymptomatic) with symptoms (mild/moderate or severe) including diarrhea and cramping (like food poisoning), abdominal tenderness and if left untreated, signs of dehydration, sepsis, etc. Treatment depends on severity, and recurrences may be many.
A case of a 1-year-old female twin with Williams Syndrome and a complex story who was eventually diagnosed at 7+ months (because of post-operative diarrhea) with C. diff infection (organism and toxin isolated from stool) is described. After 2 courses of metronidazole failed to correct the recurrent diarrhea and abdominal pain, she was given vancomycin treatment without success. Fecal microbiota transplantation (FMT) was then the therapy of choice to manage the resistant and recurrent CDI (1 tablespoon of fresh stool/saline from the twin brother rectally administered as an enema under light sedation). 5 Years after 2 fecal transplantations she is free of C. diff infection.
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Prevalence and clustering of congenital heart defects among boys with hypospadias |
In boys the urethra develops during weeks 8-14 of pregnancy and due to a combination of adverse genetic and environmental factors (e.g., mother’s age, weight, fertility treatment, certain hormones, etc.) an abnormality in the positioning of the urethra opening (or hypospadias – which may be sub-coronal, mid-shaft of penoscrotal) may occur.
“Hypospadias and congenital heart defects (CHDs) are 2 of the most prevalent birth defects in the USA”, (1:125 and 1:100 of every live born infant, respectively). “Few studies have evaluated the co-occurrence of hypospadias and CHDs”.
From a retrospective examination of a large multi-state birth defect registry of 1,485 male infants with both hypospadias and CHDs (January 1, 1995, to December 31, 2014) it appears that boys with hypospadias are 5.8 times more likely to have CHDs (5.503% - 7.024% depending on the US State) with hypospadias severity, maternal race (Hispanic) and ethnicity being independently associated with CHD.
It appears prudent for infant boys born with hypospadias to undergo additional CHD screening.
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Time to diagnosis of Autism Spectrum Disorder (ASD) in children with coexisting developmental behavioral disorders (DBDs) |
There are several types of DBDs which include intellectual disability, learning disabilities, attention deficit/hyperactivity disorder and other behavioral disorders.
A study evaluated children (1,049), 6-17 years of age with ASD, developmental delay or intellectual disability to assess whether having a behavioral disorder diagnosis, before ASD is diagnosed, is associated with a delay in ASD diagnosis.
Having an alternate DBD diagnosis before ASD diagnosis is associated with “late” ASD identification. To diagnose ASD early in the face of developmental behavioral disorders requires further study.
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COVID-19 rebound after Paxlovid treatment |
The CDC has recently issued a “Health Alert Network (AHN) Advisory” to update healthcare providers on the potential for recurrence of COVID-19 (“COVID-19 rebound)”) following Paxlovid treatment (which it continues to recommend for early phase treatment of mild/moderate COVID-19 infected persons at high risk for progression to severe disease).
COVID-19 rebound appears to occur between 2-8 days after initial recovery and is characterized by a brief recurrence of mild symptoms/with an increased though diminished risk of transmission, and/or a positive viral test (after being tested negative). No evidence exists that suggests re-treatment with Paxlovid is required and physicians should follow CDC guidelines on isolation.
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Long-term pulmonary outcomes in children mechanically ventilated for severe bronchiolitis |
“Both bronchiolitis and invasive ventilation may cause adverse long-term pulmonary outcomes”.
From a single-center cohort study of 74 children (6-12 years of age) with a history of invasive mechanical ventilation for bronchiolitis (ages <2 years) which investigated (by questionnaire and pulmonary function testing) adverse long-term effects it appears that 26% of children have deleterious pulmonary outcomes, with 19% having previously undetected asthma (which increases with a history of atopic disease in the family, and/or longer duration of mechanical ventilation).
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Disc battery ingestion in pediatric age |
A timely reminder that ingested disc batteries remain a serious health hazard in children, requiring early and qualified medical evaluation and treatment comes from a recent article describing mild to major complications (10.2%) in 118 children referred for disc battery ingestion.
Predictors of a serious outcome include large diameter cells (>20mm), age (<1 year) and symptomatic presentation.
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REGISTER - LEARN - EARN CME CREDIT |
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Fetal MRI for Problem Solving: Case Examples From the Body
At the completion of this activity, participants are expected to:
[1] Understand Florida law on informed consent, [2] Be aware that consent for minors must be in writing and detailed, [3] Learn about Florida’s new regulatory provision specific to pelvic exams.
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Underwriting Opportunities
Advertising in this e-journal in no way implies endorsement of a product by Nicklaus Children's Hospital.
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