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Updates in Pediatrics
Editor: Jack Wolfsdorf, MD, FAAP
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December 8, 2021 | Volume 12 | Issue 49 |
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COVID-19 Infections in children – Three reviews |
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1) Risk factors for severe COVID-19 in children
A population-based study in 14 US States (between March 2020 – May 2021) of 2,293 hospitalized children with laboratory-confirmed SARS-CoV-2 infection utilized multivariable generalized estimating equations to generate risk ratios between demographic and medical characteristics to calculate rates of severe COVID-19 among all children.
30% of hospitalized children have severe COVID-19 and 0.5% die during hospitalization.
Severe disease risk is age dependent:
- a. Among children aged <2 years of age, chronic lung disease, neurologic disorders, cardiovascular disease, prematurity and airway abnormality is associated with severe COVID-19.
- b. Among children 2-17 years of age feeding tube dependence, diabetes mellitus and obesity are associated with severe COVID-19.
- c. Overall severe COVID-19 occurs more often in children <18 years if Hispanic or non-Hispanic black.
Pediatrics
2) SARS-CoV-2 antibodies started to decline just four months after COVID-19 infection in a paediatric population
From a single center prospective, cross-sectional cohort study of 1,138 children (mean age 4.4 years) which evaluated the prevalence of SARS-CoV-2 infections of children attending a Pediatric Emergency Department (ED) using antibody testing, it appears that seropositivity increases with age, 41% of positives have no known exposure and antibody levels fall 4 months after initial infection.
Acta Paediatrica
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3) Younger children may have greater risk of transmitting SARS-CoV-2 to caregivers and siblings in the household than older children
Using public health data from the Province of Ontario, Canada investigators identified the transmission of SARS-CoV-2 virus in family clusters in which the apparent primary case was a child (usually older children or teens). Overall, however siblings and parents are at greater risk of infection from younger children.
“Behavior matters” in familial transmission – infant/toddlers demand attention when sick increasing risk of secondary infection in the family as masking and distancing become impractical. Cross infection from older siblings is dependent on mobility and public health measures. Vaccination of all eligible members of the family offers greatest protection for all (as a reminder “masking” decreases infection risk by 53%).
JAMA Network
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Finding the needle in the hay-stack: Population-based study of pre-diagnostic symptomatic interval in children with Central Nervous System (CNS) tumors |
There are a variety of malignant and non-malignant tumors that occur in a child’s brain (or the tissues/structures contiguous to it in the skull) with treatment and prognosis depending on the type of tumor, its location, whether it has spread and the child’s age and health. Many symptoms are non-specific however common ones include headache (typically worse in the morning), sleepiness, irritability, seizures, nausea/vomiting, hearing/vision/speech/personality and memory changes, balance problems or numbness or tingling in the extremities. Both diagnosis and treatment are important in prognosis and long-term survival. Delay in diagnosis is common.
A retrospective chart review study documented and characterized the time to diagnosis of CNS tumors in 148 children (0-17 years of age) over a 16-year period. Results indicate:
- Average age at diagnosis 87.8 months
- Longest time from first symptom to first health care provider visit: 37 days
- 30% diagnosed after a single visit to a healthcare provider, 7.7% after >4 visits
- Median time to diagnosis from first symptom: 62 days
- Tumors in the posterior fossa and children who present with ataxia or weakness are diagnosed earlier
“CNS tumors in children continue to pose a diagnostic challenge with variability in time to diagnosis…”. There is a great need for family education.
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Topical nasal decongestant oxymetazoline (Afrin®); Safety considerations for perioperative Pediatric use |
While this article primarily addresses the concerns of the operative/perioperative use of the nasal decongestant oxymetazoline, it is of great interest as it reminds us that oxymetazoline is a powerful α-adrenergic agonist with great α2 adrenergic receptor activity (resulting in vasoconstriction when administered topically to nasal mucosae) greater and safer than that of phenylephrine, epinephrine or cocaine. It is currently only approved by the US Food and Drug Administration (FDA) for use in children >6 years of age with several reports of cardiac and respiratory complications related to its use in the Pediatric population. If electively used short-term off-label (when potential benefits outweigh risks e.g., during active bleeding, acute respiratory distress from nasal obstruction, acute complicated sinusitis, nasal decongestion for scope examination etc.), avoid excessive administration by using a spray bottle in an upright position with the child upright.
Further studies are needed to understand the systemic absorption and effects in children in both the non-surgical and surgical use of oxymetazoline.
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Sexuality among adolescent with intellectual disability (ID): Balancing autonomy and protection |
ID refers to a significant impairment in intellectual functioning commonly defined as scoring >2 standard deviations below the general population mean on tests of general intelligence (IQ<70).
“Most young people with mild/moderate ID have had sexual intercourse by age 19/20” and more likely to have unsafe sex (>50% of the time compared to their non-ID peers), and are less likely to have had sex issue discussions with family or friends. Families and their pediatricians remain concerned that adolescents with ID may be coerced or manipulated into sexual encounters.
A case presentation of a young adult with moderate ID who was engaged in a sexual relationship without parental knowledge outlines the pediatrician’s dilemma when confronting the tension between supporting patient autonomy and ensuring the safety and minimizing the risks to his/her patient.
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Diagnostic and treatment challenges for Acquired Hemophilia A (AHA) in pediatrics; report of 2 cases |
There are 3 major forms of inherited Hemophilia; Hemophilia A (classical hemophilia/factor VIII deficiency or antihemophilic globulin deficiency), Hemophilia B (Christmas disease or factor IX deficiency) and hemophilia C (factor XI deficiency). Hemophilia A and B are X-linked recessive genetic disorders, Hemophilia C is inherited as an autosomal recessive. Hemophilia may be classified as mild, moderate or severe depending on the percentage of active clotting factor present in the blood (normal 50-150%).
AHA is a rare autoimmune disease (extremely rare in children) mostly occurring in the elderly which results when the immune system produces antibodies which attack blood clotting factors (most often factor VIII). 50% have coexisting disorders including lupus, rheumatoid arthritis, inflammatory bowel disease etc. In severe cases life-threatening bleeding may occur. A diagnosis should be suspected by a clinical picture of spontaneous bleeding – (intracranial bleeding is rare), and an isolated prolongation of the activated partial thromboplastin time (aPTT). Treatment varies (mostly anecdotal due to the rarity of the condition).
An interesting report of 2 adolescent females diagnosed with AHA outlines presentation and difficulties in diagnosis and treatment.
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