PedSPAM March 1999

Welcome to PedSPAM for March. Pretty busy around here, as you might imagine. Here are some more things from my update reading that might interest you.

In the News

An analysis of the cases of 278 children brought to a pediatric emergency department for head injuries found that a somewhat alarming 18& were found to have either skull fracture, internal brain injury, or both. A scalp wound was one indication of more serious trauma. The majority of the children with significant head injuries had neither lost consciousness, vomited nor had seizures, and had not exhibited behavioral change when admitted to the ER. More reassuringly, they did report that their data shows that

children less than 2 years of age
with a normal scalp exam
and lack neurological symptoms

are at low risk of skull fracture or brain injury. This is especially true if they were injured when falling 3 feet or less. Archives of Pediatric and Adolescent Medicine, January 1999.

A working group for the Centers for Disease Control and Prevention in Atlanta, the Drug-Resistant Streptococcus Pneumoniae Therapeutic Working Group, still finds that lowly amoxicillin remains the first-line drug of choice for acute otitis media, the common ear infection. However, the recommended dose is now double the old dose: 80-90 mg per kilogram (about 35-40 mg per pound) per day, divided into three doses. "Despite there being about 15 different drugs actively marketed for otitis media, few have any proven efficacy aside from amoxicillin," a committee member added. If after 3 days symptoms persist or worsen, the panel recommends switching treatment to amoxicillin-clavulanate (Augmentin®, cefuroxime axetil (Ceftin®) or injectable ceftriaxone (Rocephin®). Pediatric Infectious Disease Journal, January 1999.

While on another front, the cephalosporin-class antibiotic Vantin® (cefpodoxime proxetil) now is approved as a five-day treatment alternative for mild to moderate acute otitis media in children. The new daily dosing regimen of cefpodoxime proxetil for children 2 months to 12 years old is 5 mg/kg twice daily for five days. This would be my choice only if there was a compliance problem (Johnny won't take his medicine, or Johnny's parents cannot remember it) or a multiple drug allergy problem.

Kids who have a tonsillectomy and/or adenoidectomy for correction of obstructive sleep apnea often show significant weight and height gain after surgery, as reported in Archives of Pediatric and Adolescent Medicine, January 1999. This held true even for morbidly obese children.

Significant iron deficiency anemia in early childhood is associated with mild to moderate mental retardation at age 10, according to a study reported in the January American Journal of Clinical Nutrition. The researchers admit that the causes of mental retardation are many and varied, and their results are not yet generalizable beyond their low-socioeconomic status study population. However, these results are again not new, and further buttress the case for not giving infants iron-free formula.

I recommend Dr. Judith Harris's discussion of what 'association" really means in her book The Nurture Assumption.

A study in the Lancet found that (surprise) regular use of personal stereos is the major risk factor for hearing loss in young men who had repeated bouts of otitis media in childhood. The findings emphasize the importance of curing childhood otitis media, and of warning young people with repeated episodes that personal stereo use increases their risk of deafness.

The National Institutes of Health (NIH) has opened to the public, via the Internet, a database of accumulated scientific studies on dietary supplements, to give consumers and researchers credible information on vitamins, minerals, and herbal products. The database can be accessed through the Office of Dietary Supplements' web site (direct address: http://dietary-supplements.info.nih.gov and the USDA's website http://www.nal.usda.gov/fnic/IBIDS.

Researchers in Spain remind us that therapy with the common seizure medications valproic acid, carbamazepine and phenobarbital can cause carnitine deficiency in children, a disorder of fatty acid metabolism which is usually a genetic disease. They say that serum carnitine levels should be monitored in children treated with these antiepileptic drugs. Carnitine deficiency is manifested by weakness, lethargy, and poor muscular tone. Since it may be a major cause of potentially fatal valproate liver damage, supplementation with L-carnitine may be indicated.

Premature adrenarchy (development of secondary sex characteristics such as pubic hair) is considered a normal variation of pubertal development, but it may cause significant psychosocial problems. In a study reported recently, 44% of children with premature pubertal development exhibited some symptoms of depression or anxiety. Children with premature adrenarche may need psychological evaluation and follow-up. (Archives of Pediatric and Adolescent Medicine 1999;153:137-146)

A study has confirmed what everybody knew already: the addition of formula to breast feedings significantly improved the response to phototherapy treatment for jaundiced breast fed infants. The reason this works is that bilirubin - the waste product of the breakdown of hemoglobin from worn out red cells - is secreted mainly in the gut and is bound to stool - hence the yellow color of baby poop. Formula, being not as well absorbed as breast milk, makes bulkier stools and hence removes more bilirubin from the body. Importantly, the study confirmed that interruption of breast feeding was not necessary - temporary supplementation of the breast was as effective as pure bottle feeding.

Hey, but a single intramuscular shot of Sn-mesoporphyrin eliminated the need for phototherapy for jaundiced infants, reports a study from the January issue of Pediatrics. The drug is not approved in the US for this indication to my knowledge, but the potential savings from such therapy in dollars and emotional cost to the family will probably lead to studies of the treatment for eventual use in the United States. We will be watching this one closely - I don't think I would be investing in any home phototherapy businesses right now.

Infants born small for gestational age (SGA - below 10th percentile for weight corrected for gestational age) and those born large for gestational age (LGA - above 90th percentile for weight adjusted for gestational age) tend to track along the same relative part of the growth charts. SGA babies tend to remain relatively smaller than average, and LGA babies tend to stay relatively larger than average when measured at 4 years.

Treatment with amoxicillin (the pink bubble gum stuff), three teaspoons once a day for ten days, is just as good for treating streptococcal pharyngitis as the standard treatment of penicillin V three times a day. This should improve patient compliance, always a big concern with strep treatment. From Pediatrics, January 1999, pp. 47-51.

Fruit juice is exonerated! A study (perhaps coincidentally funded by the Gerber corporation) found that there is no evidence that excessive fruit juice intake in childhood either stunts ultimate height growth or leads to obesity. the study questions previous recommendations to limit the intake of 100% fruit juice to less than 12 ounces per day. I still say it is liquid junk food for a lot of kids. In all things, moderation. Pediatrics January 1999, pp. 58-64.

There has been ongoing debate whether exposure of the unborn fetus to cocaine causes significant effects on the infant's nervous system. Researchers in New York carefully paired exposed and unexposed infants identified at birth who were evaluated by neurologists unaware of the exposure status of the infants. They concluded that there were clear adverse effects on babies associated with fetal cocaine exposure, and that these ill effects follow a dose-response relationship: the more cocaine use by the mother, the greater the reduction of fetal head growth and abnormalities of muscle tone, movements, and posture. Pediatrics January 1999, pp. 79-85

Researchers in Israel evaluated 18,000 newborns for hip dysplasia with ultrasound examinations (the current gold standard of diagnosis). They determined (at least for their population) that there was a 5% incidence of abnormal hips on initial ultrasound, but that only 0.5% (one tenth of them) remained abnormal over time. The others all normalised without treatment. Pediatrics, January 1999.

The annual Recommended Childhood Immunization Schedule of the American Academy of Pediatrics (AAP), the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and the American Academy of Family Physicians (AAFP) is issued in January of each year. Several significant changes for the 1999 Schedule have been made since publication of the 1998 Schedule, as follows:

Rotavirus vaccine at 2, 4, and 6 months of age is recommended. Details of the AAP recommendations for rotavirus vaccination were published in the December 1998 issue of Pediatrics. There is still some concern about economic issues - it is an expensive vaccine and may burden public health budgets. This will be of particular interest to parents of children in day care.

Inactivated poliovirus vaccine (IPV) is recommended at 2 and 4 months of age. For the third and fourth doses of poliovirus vaccine, either IPV or oral poliovirus vaccine (OPV) can be administered.

Dosages for the two available hepatitis B vaccines, Recombivax HB (Merck) and Engerix B (SmithKline Beecham) have been standardized and clarified. Either vaccine is OK, and the types can be mixed - one shot of one, another shot of the other - without compromising immunity.

Acellular pertussis vaccines combined with diphtheria and tetanus toxoids (DTaP) are listed on the Schedule as the recommended product for pertussis vaccination. Whole-cell pertussis-containing vaccines (DTP) remain acceptable.

A fourth acellular pertussis-containing vaccine (Certiva [North American Vaccines]) has been approved by the Food and Drug Administration for immunization of infants and children. The four existing approved DTaP products are considered equally acceptable.

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