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Updates in Pediatrics
Editor: Jack Wolfsdorf, MD, FAAP
header with photos of various children
September 15, 2021 | Volume 12 | Issue 38
Operative vs nonoperative management of acute pediatric Monteggia injuries
A Monteggia fracture is defined as a proximal 1/3 fracture (or plastic deformity without fracture) of the ulna with an associated radial head dislocation. There are 4 types (I-IV - Bado Classification. Type I = 70-75%) which describe the various positions of the ulna fracture and end-position of the radial head. While fairly uncommon (0.4% of forearm fractures in children) it usually results from a fall on an outstretched hand with hyperextension/hyperpronation of the forearm. Peak incidence; 4-10 years of age.

Symptoms include severe pain, swelling and tenderness and/or range of motion limitation which is not always obvious. Nerve damage occurs in 10-20% of children. Diagnosis is by plain radiography. Treatment (involving a complete fracture of the ulna) remains controversial.

A retrospective analysis of 73 children with Monteggia fractures/complete ulna fracture compared the outcomes (15.2 weeks) of 2 similarly matched groups treated by either immediate operative fixation or a trial of closed reduction and casting.

It appears that even in the presence of complete ulna fracture a trial of nonoperative management with closed reduction and casting may give comparable results to immediate surgery.
First oral blood thinner approved for children

Dabigatran (Pradaxa ®) is a direct, highly selective, reversible and potent thrombin inhibitor type anticoagulant that is now the first FDA approved oral blood thinner available for children 3 months – 11 years of age who have venous thromboembolisms and have received injectable blood thinners for at least 5 days. Peak plasma concentrations occur in 1-2 hours after ingestion and the half-life is 12-14 hours (in older volunteers). The most common adverse effects are digestive symptoms and bleeding

Non-Cystic fibrosis bronchiectasis (NCFB) in children/adolescents: A 10 year follow up
“Non-Cystic fibrosis bronchiectasis is a chronic, progressive respiratory disorder characterized by irreversible and abnormally dilated airways, persistent cough, excessive sputum production and recurrent pulmonary infections”. Etiology varies and includes post-infectious (39%), primary ciliary dyskinesia (30%) airway malformations (8%), primary immune deficiencies (6%), isolated asthma (3%), isolated aspiration (2%) and others. Global prevalence is unknown, but in the USA, it appears to be increasing yearly. Common symptoms are chronic cough (45%), recurrent pneumonia (25%) and recurrent wheezing (11%).

A single tertiary care center study describes the clinical and functional features etc. of 138 children diagnosed with NCFB between 2010-2019.

NCFB presents clinically at 3 years of age (median). Microbiological examination reveals Pseudomonas aeruginosa, Streptococcus aureus and H. Influenza organisms, commonly. Lung function testing demonstrates stability (mostly) of airway obstruction over time.
Is there an association between breast hypoplasia and breastfeeding outcomes?
While insufficient milk supply is apparently the most common reason for premature breastfeeding cessation, and breast hypoplasia (reduction of glandular tissue which may be unrelated to overall breast size) may be one cause of this, a study undertaken to systematically explore the relationship between breast hypoplasia and breast feeding duration, milk supply and lactation onset found (in 42 women – 7 studies) that 95% ceased breastfeeding before 1 month post-partum (the relationship between breast hypoplasia and breastfeeding outcomes requires further study).
Point-of-care ultrasound (POCUS) vs. conventional bladder catheterization for urine sampling in children 0-24 months of age
It can be difficult to obtain urine samples in small infants and while catherization is a common method to obtain it, if the bladder is inadequately filled the process frequently fails requiring unpleasant and potentially hazardous re-catherization. Point-of-Care ultrasonography is often used in the emergency department to assist in invasive procedures.

A prospective cohort study of 110 infants 0-24 months of age divided into 2 groups, one undergoing POCUS bladder catherization, the other conventional catherization only, measured and compared bladder dimension and urine volume collected.

The use of POCUS during bladder catherization in infants is effective and enhances urine sample collection
Impact of infant milk-type and childhood eating behaviors on Functional Constipation in preschool children
An interesting cross-sectional study in Brazil of 1,050 children, 23% of whom had functional constipation (Rome IV criteria) assessed the association between functional constipation, infant feeding in early infancy and eating behavior in preschool children.

Children fed cow’s milk during the first 6 months of life are 15.2 times more likely to have functional constipation (bottle feeding increases the risk 17.02-fold, infant formula 6.35 times and mixed breast feeding 10.83 times). Children with food fussiness increases the likelihood of functional constipation by more than 6-fold.
Buerger’s Disease (thromboangiitis obliterans) in an adolescent male
Buerger’s Disease is a rare, peripheral vascular disorder that mostly affects young/middle age cigarette smoking males which results in narrowing or blockage of veins/arteries of the extremities. While the exact cause is unknown, it has been suggested that genetic factors, the use of tobacco, autoimmune mechanisms and local trauma to the hands and feet contribute to its presentation. In most cases the first symptom is extreme pain of the lower arms and legs while at rest in sudden episodes lasting 1-4 weeks.

Affected individuals may have limb ulcers, numbness and tingling and lack of blood supply to the fingers and/or toes when exposed to cold temperatures (Raynaud’s phenomena). Diagnosis is made on history and characteristic features with confirmation by angiography. Treatment is symptomatic and supportive.

An interesting case-presentation of 16-year-old boy who smoked cigarettes and cannabis for 2 years prior to developing Buerger’s Disease reminds us that this fairly uncommon condition can occur in younger individuals.
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Contact the Editor | jackwolfsdorf@gmail.com