Abstracts from Pediatric Journals                                      Vol. 1, issue 1, Sep 98

A collection of abstracts from various pediatric journals
 

Pediatrics
 

Communicating withthe child is as important as communicating with the parent, in pediatrics.Children's contributions have been, until now, primarily ignored in communication research. Alexandra Maria van Dulmen from the Netherlands Institute of Primary Health Care (NIVEL), Utrecht, the Netherlands examined how children contributed to communication during outpatient pediatric encounters and what factors were associated with children's contributions. Children's contributions to the outpatient encounters were limited to 4%.Pediatricians directed one out of every four statements to the child. Although pediatricians asked children a lot of medical questions (26%), only a small part of the medical information (13%) was directed at the children. Apart from social talk and laughter, the amount of pediatrician-child communication increased with children's age.Pediatricians may need to acquire similar communication skills to discuss medical-technical issues with the children. (Pediatrics 1988;102:563-568) September 1998.
 

Comparative Efficacy of the Lederle/Takeda Acellular Pertussis Component DTP (DTaP) Vaccine and Lederle Whole-Cell Component DTP Vaccine in German Children
Ulrich Heininger during a 3.5-year study period, studied 10 271 infants (DTP or DTaP, n = 8532; DT, n = 1739).They were actively followed along with all household members for cough illnesses. Both vaccines (DTP and DTaP) are better at preventing typical pertussis than mild illness. When case definitions similar to those in other recent trials are used, the Lederle/Takeda vaccine has an efficacy similar to other multicomponent DTaP vaccines. attackUsing similar criteria, the efficacy against typical pertussis (21 days of cough with either paroxysms, whoop, or posttussive vomiting) was 94%  and 86%  for DTP and DTaP, respectively.(Pediatrics 1998;102: 546-553).
 
 Obesity Evaluation and Treatment: Expert Committee Recommendations
 
The Committee recommended that children with a body mass index
(BMI) greater than or equal to the 85th percentile with complications of obesity or
with a BMI greater than or equal to the 95th percentile, with or without
complications, undergo evaluation and possible treatment. Clinicians should be
aware of signs of the rare exogenous causes of obesity, including genetic
syndromes, endocrinologic diseases, and psychologic disorders. They should screen for complications of obesity, including hypertension, dyslipidemias, orthopedic
disorders, sleep disorders, gall bladder disease, and insulin resistance. Conditions
that indicate consultation with a pediatric obesity specialist include pseudotumor
cerebri, obesity-related sleep disorders, orthopedic problems, massive obesity, and
obesity in children younger than 2 years of age. Recommendations for treatment
evaluation included an assessment of patient and family readiness to engage in a
weight-management program and a focused assessment of diet and physical activity habits. The primary goal of obesity therapy should be healthy eating and activity.
The use of weight maintenance versus weight loss to achieve weight goals depends
on each patient's age, baseline BMI percentile, and presence of medical
complications. The Committee recommended treatment that begins early, involves
the family, and institutes permanent changes in a stepwise manner. Parenting skills
are the foundation for successful intervention that puts in place gradual, targeted
increases in activity and targeted reductions in high-fat, high-calorie foods. Ongoing
support for families after the initial weight-management program will help keep obesity in check.(Pediatrics 1998; 102:e29).
 
The journal of Pediatrics
 

Growth Hormone therapy and Behavior

    Many referred children with short stature have problems in behavior, some of
    which ameliorate during treatment.These are the findings from a study from
    the University of North Carolina, State University, Detroit, Michigan; SUNY
    at Buffalo, New York; and Genentech, Inc., South San Francisco, California
    with GH. Seventy-two children in the GHD group and 59 children in
   the ISS group completed 3 years of GH therapy and psychometric
   testing. Mean IQs of the children with short stature were near
   average. IQs and achievement scores did not change with GH
   therapy. Child Behavior Checklist scores for total behavior problems
   were higher (P < .001) in the children with short stature than in the
   normal-statured children. After 3 years of GH therapy these scores
   were improved in patients with GHD (P < .001) and ISS (P < .003).
   (J Pediatr 1998;133:366-73).

Hepatitis B surface antigenemia at birth:

    A long-term follow-up study to investigate the prevalence and outcome
   of hepatitis B surface antigenemia in newborns of  hepatitis B e antigen
   (HBeAg)-positive hepatitis B surface antigen (HBsAg) carrier mothers
   under the current immunoprophylaxis programon was carried out by
   Jen-Ruey Tang, MD .The newborns were tested for HBsAg soon after birth,
   before hepatitis B immune globulin administration.All newborns received
   hepatitis B immune globulin within 24 hours after birth followed by
   hepatitis B vaccination. Sixteen (2.4%) of the 665 subjects were found to
   be seropositive for HBsAg at birth, and all remained HBsAg-positive at
   6 months of age.Twelve of the 16 received long-term follow-up care, and all
   were confirmed to have chronic HBV infection. Of the 12, 2 had HBeAg
   seroconversion. Current immunoprophylaxis strategy does not  protect
   newborns with surface antigenemia, apparently acquired in  utero, from
   becoming HBV carriers.(J Pediatr 1998;133:374-77).

  ITP: Immediate response to therapy and long-term outcome

   A retrospective of 332 children with ITP was carried  out by
   Desiree Medeiros, MD George R. Buchanan, MDfor occurence of major
   hemorrhage and thier response to treatment with IVIg and corticosteroids.
   Of 332 patients with ITP, 58 (17%) had 68 episodes of major
   hemorrhage; 56 of these episodes were treated with  corticosteroids,
   intravenous immunoglobulin, or both. The platelet count rose to
   20,000/mm3 within 24 hours after presentation after only 18% of
   evaluated events, and 28% of patients with major hemorrhage still had
   a platelet count <20,000/mm3 after 7 days. Twenty-seven of 49 patients
   available for evaluation had resolution of ITP within 6 months, 21 had
   chronic ITP, and 1 died of sepsis. Only a minority of these patients had
   an immediate rise in platelet count after receiving intravenous immunoglobulin,
   corticosteroid treatment, or  both. Prospective studies of childhood ITP
   focusing on short-term outcome variables in addition to platelet count should
   be performed   to better define optimal treatment for each affected child.
  (J Pediatr 1998;133:334-9).
 

  Monteleukast in asthma
 
 James P. Kemp, MD, in a study on 27 children between 6 and 14 years
 with exercise induced asthma, has concluded that Monteleukast a leukotrine 
 receptor antagonist attenuates exercise induced bronchoconstriction.Patients
 received montelukast (5-mg chewable tablet) or placebo once daily in the
 evening for 2 days in crossover fashion (at least 4 days between treatment
 periods).Standardized exercise challenges were performed 20 to 24 hours.
 (J Pediatr 1998;133:424-8).

BMJ

Cushings syndrome from intranasal steroids

Although iatrogenic Cushing's syndrome from oral steroids is well
recognised, it is not usually associated with intranasal corticosteroids.
C A Findlay etal from the Royal Hospital for Sick Children, Yorkhill,
Glasgow and Department of Clinical Biochemistry,Glasgow Royal Infirmary, Glasgow  report two cases of this uncommon complication. Both the cases
were given intranasal betamethasone for over one year for allergic rhinitis. Significant systemic absorption of intranasal steroids is not surprising
given their pharmacokinetics. Corticosteroids are generally well absorbed from
sites of local application. The degree of absorption from the intranasal route depends on severalfactors, including the number of drops instilled, the vascularity and surface area of the nasal mucosa, and the time the solution remains in contact with the mucosa. In addition, some of the solution will undoubtedly be swallowed and readily absorbed by the gastrointestinal tract.

       Betamethasone, one of the mainstays of treatment for nasal congestion in children,is a potent corticosteroid which is very water soluble as the sodium phosphate ester and has a long duration of action (half life 36 hours compared with 8-12 hours for hydrocortisone).It may also be difficult to administer the prescribed number of drops accurately.The authors also recommend that  treatment with betamethasone nasal drops should not be prolonged for more than six
weeks and that the potential difficulties with administration and possible
overdose should be considered. The cases described may represent the tip of an iceberg. Many children with milder cases may escape detection, perhaps because they have stopped taking their treatment. Further work is required to establish a safe dose and duration of treatment.(BMJ 1998;317:739-740).
 

Medical and Pediatric Oncology

• Home intravenous antibiotic treatment for febrile episodes in immune-compromised pediatric patients.
• Recombinant human erythropoietin for the treatment of anemia

 E. Shemesh1 etal from Tel Aviv University, Tel Aviv, Israel studied the feasibility
 of home intravenous , antibiotic treatment (HIAT) for febrile episodes in
 immune-compromised  (neutropenic, splenectomized), low-risk pediatric patients.
 Thirty hematology-oncology patients were studied from January 1993 to January
 1995 and who suffered from a febrile episode and were considered at low risk for
 septic complications were immediately discharged on  HIAT. Patients were
 followed for at least 3 weeks after recovery.  Thirteen out of 60 (22%) febrile
 episodes, or eight out of 42 (19%) episodes of  fever and neutropenia eventually
 led to hospitalization. Pseudomonas species  infections were associated with the
 highest rate of unresponsiveness (88%). A  central venous catheter infection
 developed in two cases following HIAT.No other complications were identified.

       The authors recommend that immediate discharge on HIAT for low-risk  pediatric immune-compromised  patients suffering from a febrile episode is
feasible, safe, and well accepted by patients and families. However Patients who are foundto have Pseudomonas infections  should probably be hospitalized.
(Med. Pediatr. Oncol. 30:95-100, 1998).
 

Recombinant human erythropoietin for the treatment
of anemia in children with solid malignant tumors

This study was performed by Pedro León1 *, Miguel Jiménez1, Pascual
Barona1, Luis Sierrasesúmaga1 of Department of Pediatric Oncology, School
of Medicine, University of Navarra,Pamplona, Spain  to assess the efficacy and safety of recombinant erythropoietin (r-HuEPO) therapy for anemia in children with cancer.Twenty-five patients under 18 years of age with solid
 malignant tumors were treated with 150 U/kg/day of r-HuEPO 5 times weekly
 for  12 weeks. Response was defined as an increase of the baseline hemoglobin
 level by at least 2 g/dl. r-HuEPO patients were compared to 25 matched historical
 controls.Response was achieved in 72% of r-HuEPO patients. The authors concluded that r-HuEPO is a safe and effective means of increasing hemoglobin
 level and reducing blood requirements in children with solid malignant tumors
 receiving chemotherapy. (Med. Pediatr. Oncol. 30:110-116, 1998).

Pediatric Pulmonology

  Follow up of young children hospitalised for wheezing

      One year follow-up of young children hospitalized for wheezing and  the
  influence of early anti-inflammatory therapy and risk factors for subsequent
  wheezing and asthma were studied by Tiina M. Reijonen1, Matti Korppi1
  Department of Pediatrics, Kuopio University Hospital, Finland.  In addition,
  the risk factors for recurrent wheezing and asthma were identified.
  Eighty-eight children under 2 years old treated in the hospital for wheezing
  were  followed for 1 year. Nebulized anti-inflammatory therapy was given for
  16 weeks: 31 patients received  budesonide, 29 patients cromolyn sodium, and
  28 control patients received no therapy. The number of subsequent
  physician-diagnosed wheezing episodes was  recorded.

     Four months of anti-inflammatory therapy did not significantly decrease the
 occurrence of asthma 1 year later; 45% of patients in the cromolyn group, 42%
 in the budesonide group, and 61% in the control group had asthma, defined as at
 least two bronchial obstruction episodes during the 1-year period after the original
 hospitalization for wheezing. Young  children requiring hospital admission for
 wheezing during a respiratory tract  infection are at increased risk of having
 subsequent asthma if they have past history of wheeze , atopy or a family
 history of atopy, elevated serum ECP or if they were over 12 months of age
 at the original bronchial obstructive episode, and especially when viral studies
 are negative.(Pediatr Pulmonol. 1998; 26:113-119).

 Prevalence of asthma or respiratory symptoms among
 children attending primary schools in Paris

     This cross-sectional study was carried out in  1994 on a randomized sample
 of 3,756 pupils attending Paris public primary schools by I. Momas1 from
 Département de Pneumologie pédiatrique, Hôpital Armand Trousseau, Paris,
 France. The response rate by parents to an initial standardized self-administered
 questionnaire was 94.8%. This questionnaire identified 601 children (17%) as
 having recurrent respiratory symptoms. The Prevalence of parent-reported doctor-diagnosed asthma was 6.1%. In addition to these 211 children with asthma,
 344 other children had recurrent respiratory  symptoms: 120 children were "wheezers," and the remaining 224 children were "coughers."

    Among "chesty" pupils not identified as asthmatics,  nearly 14% had
 a peak expiratory flow 20% lower than the predicted values for age and height.
 In children identified as asthmatic, 25.3% were not under medical supervision,
 55.5% had never performed lung function tests, 63.7% did not receive any
 prophylactic treatment, and 59.7% were receiving no treatment.
 Bronchodilator prophylactic medication before exercise was used by only 7%
 of asthmatics.The authors concluded that children with asthma and participating
 in this study were  less than optimally investigated, underdiagnosed and
 undertreated, and their  medical management was not optimal. In addition to
 its epidemiologic value, the  study has helped Paris school doctors to advise
 parents to refer their children to their general practitioner when asthma was
 suspected or undertreated.(Pediatr Pulmonol. 1998; 26:106-112).

Teratology

Corticosteroids during pregnancy and oral clefts: A case-control study

 Elvira Rodríguez-Pinilla1 & M. Luisa Martínez-Frías of Facultad de Medicina,
 Universidad Complutense and Departamento de Farmacología, Facultad de
 Medicina, Universidad Complutense, Madrid, Spain  present the results of a
 case-control study on the  relationship of corticosteroids during pregnancy and
 oral clefts in the newborn  infant. Case subjects were 1,184 liveborn infants with
 nonsyndromic oral clefts. The results of the logistic regression analysis, show a
 relationship between exposure to corticosteroids during the first trimester of
 pregnancy and an increased risk of cleft lip (with or without cleft palate) in the
 newborn infants (OR = 6.55; CI = 1.44-29.76; P = 0.015), controlled for potential
 confounder factors, such as maternal smoking, maternal hyperthermia, first-degree
 malformed relatives with cleft lip with or without cleft palate, and maternal
 treatment with antiepileptics, benzodiazepines, metronidazole, or sex hormones
 during the first trimester of pregnancy.The authors recommend that  the use of
 corticosteroids during the first trimester of pregnancy, should be restricted to the
 following situations: for life-threatening situations, for those diseases without any
 other safe therapeutic alternative, or for those cases with replacement therapy.
 (Teratology 58:2-5, 1998).
 

  Compiled by Dr C VidyaShankar