June 2, 2021 | Volume 12 | Issue 22
Refracture of both bone forearm fractures: A comparison of casting only (CO) vs. casting and extended functional bracing (CFD)
The preferred non-operative treatment of midshaft pediatric both (radius and ulnar) bone fractures – one of the most common pediatric fractures, is cast immobilization for 6-8 weeks. 4-8% of children however refracture within 6 months.

A retrospective study of 426 children, <15 years of age which examined the efficacy of casting alone vs. casting plus bracing to prevent refracture (3 groups: casting only, casting plus functional brace <8 weeks; and casting plus functional bracing >8 weeks) indicates (and contrary to previous case series) that there appears to be no significant benefit of adding bracing to cast immobilization to reduce refracture rates.

Emergency Department (ED) visits for bicycle related injuries
“Bicycling leads to the highest number of sport and recreation-related ED visits for traumatic brain injury (TBIs) in the US. As bicycling continues to grow in popularity it is important to examine strategies that mitigate the risk for TBI.” While most children who suffered from a TBI recover, some experience ongoing symptoms that have emotional, cognitive, behavioral and academic sequelae.

A study from the US Centers for Disease Control and Prevention (CDC) examined ED visits for bicycle related TBIs during 2009-2018 and found the ED visits decreased by 50% for children/adolescents <17 years of age (and 5.5% among adults). Children and adolescents aged 10-14 years have the highest rates (with adult males).

Expanded implementation of comprehensive bicycle safety interventions (improved compliance with traffic laws, helmet use and bicycling infrastructure plus increased awareness among parents about TBI might be factors involved in decreasing bicycle TBI in children).


See related video HERE and below:
NYU emergency room physician Dr. Reed Caldwell
Recognition, evaluation and management of Pediatric Hereditary Angioedema (HAE)
Hereditary angioedema is a rare, potentially life-threatening inherited autosomal dominant genetic disorder characterized by childhood (mean age 11.2 years) attacks of nonpruritic skin swelling (no hives), upper airway swelling (tongue and pharyngolarynx ) and severe abdominal pain from either a hereditary C1 esterase deficiency (type 1) or mutation (type 2). The defect leads to overproduction of bradykinin (with resultant vasodilation, vascular leakage and transient non-pitting edema usually involving the face, neck, upper airway, abdomen and/or extremities). The edematous episodes do not respond to epinephrine, glucocorticoids or antihistaminics.

A review article on HAE outlines all aspects of this uncommon disorder (estimated 1:50,000 USA population), discussing all areas of interest. (Well worth reading Ed.).
Tympanostomy tubes for medical management of recurrent acute otitis media (AOM)
Tympanostomy-tube placement for recurrent otitis media is the most frequently preformed operation in children after the neonatal period. Previous studies of this treatment have yielded mixed results.

A randomized unblinded trial involving 250 children (6 months-35 months of age) with recurrent otitis media (>3 episodes in 6 months) compared the number of episodes during a 2-year follow-up of tympanostomy-tube placement to treatment with episodic amoxicillin with clavulanate (for 10 days).

For recurrent AOM there appears to be no significant difference in the number of acute otitis media episodes (over 2 years) that occurs following tympanostomy-tube placement or episodic antimicrobial therapy. Severe adverse incidences are similar between the 2 treatment groups.


See related video HERE and below:
Acute otitis media is infection of the middle ear and it is a very common problem in children. The majority of children will be diagnosed with at least one episode of otitis media.
Systematic review of a single-center toxicology study in pediatric poisoning
While there are many types of substances found in the home that can be toxic to children if ingested, inhaled or absorbed through the skin, medications (either prescription or over-the-counter) account for approximately 50%.

A retrospective systematic review from a Brazilian toxicological center which evaluated (from local and multiple databases) medication poisoning in pediatric patients indicates that 93% are accidental and antihistaminics, benzodiazepine, analgesics and antibiotics are the commonest medications involved.
Validation Rule of 7’s for identifying children at low-risk for Lyme Meningitis
Lyme disease is an infection caused by the bacterium Borrelia burgdorferi spread by tick bites (Black-legged deer ticks found in the North East, Mid Atlantic, and North-Central USA, and Western Black legged ticks found on the West Coast of the USA). Not all ticks (which live in wooded areas, low grass lands and yards) carry Lyme disease and a child is more at risk during the spring and summer months. Symptoms usually appear in 3-30 days after a tick bite and there is an early and late-stage disease (which can occur weeks to months after the bite and which includes severe tiredness and weakness, nervous system symptoms, cardiac problems, eye disorders and other symptoms).

The absence of the “Rule of 7’s” (7 days of headache, >70% cerebrospinal fluid mononuclear cells and absence of 7th or any cranial nerve palsy) classifies children at low-risk for Lyme meningitis.

A study of 721 children with meningitis was used to validate the clinical prediction “Rule of 7’s” in children with the potential for Lyme disease meningitis.

“The Rule of 7’s” accurately identifies children with meningitis at low risk for Lyme meningitis with a sensitivity of 98%, specificity of 40% and negative predictive value of 100%.
Thoracoscopy vs. Thoracotomy for congenital lung malformations (CLM)
Congenital lung malformations consist of a broad range of conditions which represent 5-18.7% of all congenital anomalies (fetal lung lesions potentially diagnosed in 1:15,000 live births).

A study of 106 children with CLMs treated by video-assisted Thoracoscopic surgery (VATS) or open Thoracotomy (OT) compared outcomes.

Comparing VATS to OT treatment for congenital lung malformations indicates that VATS management has a shorter hospital length of stay, chest tube duration, antibiotic requirement and is a feasible, effective and safe technique. Complications rates (22.6%) are similar.


See related video HERE.
  • Are mRNA COVID-19 vaccines safe for pregnant women?
  • Can you describe the potential adverse consequences associated with long-term use of oral corticosteroids?
  • What is the incidence rate of clavicular fractures in children?

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Dear Reader:

I am sure many of you, like I, are feeling great relief at the improving outcomes following the various public health measures and SARS-CoV-2 immunization programs being undertaken in the USA to date. It seems that while there are many unanswered questions remaining, and firm answers not yet available on many interesting aspects, at present there is significant optimism that the mRNA vaccines will provide not only substantial (but not total) protection against the worst results of COVID-19 but will also minimize spread while appearing to be effective against the variants circulating.

Nevertheless I would urge all to remember that there are places and situations that place us at increased risk for infection, like hospitals, nursing homes, prisons and homeless shelters or while traveling. Some immunocompromised people will remain vulnerable to COVID-19. Continue to take care, wear a mask when appropriate, in addition wash hands or use a sanitizer when in risky situations, continue to cough or sneeze into ones elbow and be aware and cautious in balancing risks and benefits.
 
Best of luck.

Jack Wolfsdorf, MD, Editor
Staff NCH
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