PedSPAM July 2002

Welcome to the PedSPAM archive for July. Here are the month's daily SPAMlets from my update reading that you might have missed:

In the News

Monday, July 1: This study finds that magnesium sulfate, in use since the 1970's, is "not safe" when given to women in preterm labor to stop labor. The researchers found that pre-term babies whose mothers received magnesium sulfate solely to stop the progression of labor had significantly worse outcomes than babies whose mothers did not receive the medication. The researchers did remind that several good studies have shown that magnesium sulfate is safe when given to prevent seizures in mothers with preeclampsia (toxemia of pregnancy). American Journal of Obstetrics and Gynecology 2002;186:1111-1118.
Tuesday, July 2: This report from the UK finds that low birth weight babies have a very much higher rate of strabismus than normal birth-weight children. The investigators wrote that this finding "highlights the importance of screening for strabismus in low-birth-weight children." Archives of Ophthalmology 2002;120:767-773.
Wednesday, July 3: A year-long study finds that mild asthmatics already receiving the inhaled steroid budesonide (Pulmicort®) do better if a long-acting beta-agonist bronchial dilator (formoterol, Foradil®) is added. The intiation of inhaled steroid treatment in mild asthmatics reduced the risk of severe attacks by 60%. Adding the long acting bronchodilator reduced the risk of severe attacks by another 40%, and was more effective than doubling the steroid dose. The researchers conclude that if optimal control is not obtained with an inhaled steroid alone, additional treatment with formoterol should be considered. American Journal of Respiratory and Criticial Care Medicine 2001;164:1392-1397.
Thursday, July 4: Italian researchers report that two children with a rare form of immune deficiency have been cured by gene replacement therapy and now live normal lives in their native countries. Both children, one from Israel and one from Colombia, had adenosine deaminase (ADA) gene deficiency, which causes severe combined immunodeficiency (SCID). Bone marrow stem cells were removed, a good copy of the defective gene was inserted in the cells, and the repaired stem cells were injected into the childrens' bloodstream to re-colonize the bone marrow with healthy stem cells. This procedure has been done before, but the number of corrected stem cells in previous cases was not enough to cure the disease. Science 2002;296:2410-2413.
Friday, July 5: The emergence of increasing numbers of drug-resistant bacteria has led to a parallel increase in the need for surgery to treat complications of ear infections such as mastoiditis. So find doctors in the pediatric Ear Nose and Throat clinic at the University of Texas Southwestern Medical Center in Dallas. Increases in the rate of resistant Streptococcus pneumoniae causing otitis media were paralleled by increased need for surgical operation for serious mastoid infections. Archives of Otolaryngology and Head and Neck Surgery 2002;128:660-663.
Monday, July 8: Children successfully treated for acute lymphoblastic leukemia (ALL) have a low incidence of second cancers. Now that cure of childhood ALL is so routine, researchers are focussing more on any potential treatment-related complications, such as second cancers, which might be caused as long term side effects of chemotherapy and radiation treatments. Data for almost 9,000 ALL survivors were studied, and the results showed that the cumulative risk of any second cancer was 1.18% at 10 years and 2.08% at 15 years. Risk was most related to radiation of the brain and spine, and if the child relapsed and needed another course of treatment. Blood 2002;99:4255,4257-4264.
Tuesday, July 9: While tonsillectomy has been shown to benefit children who have severe recurrent throat infections, whether the benefits outweigh the risks for tonsillectomy in less severely affected children has not been as well documented. This study found that while there was some benefit from tonsillectomy in less severe cases of recurrent sore throat, the risk and cost did not really justify choosing the surgical option. Removal of the adenoids along with the tonsils adenoidectomy was of no added benefit. The overall surgical complication risk for tonsillectomy was 8% - not inconsiderable. Pediatrics 2002;110:7-15.
Wednesday, July 10: The long-chain polyunsaturated fatty acids (LC-PUFA) arachidonic acid (ARA or AA) and docosahexonoic acid (DHA) are now being added to infant formulas in America. These fatty acids are present in small concentrations in human milk, but previously were not present in infant formulas. The rationale for this supplementation is that these fatty acids are present in large amounts in neural tissue. Two such fatty acids important in infant nutrition — arachidonic acid (ARA or AA) and docosahexonoic acid (DHA) - are major fatty acids in neural tissue. DHA also is an important component of the photoreceptor of the retina. It has been hypothesized that the addition of DHA to infant formula will improve infant visual function, and that the addition of both DHA and ARA will improve babies' mental development. However, to date, the relatively few studies testing these hypotheses have yielded variable results. This study found no significant benefit to developmental status at 9 and 18 months in babies given formula fortified with these fatty acids. Pediatrics 2002;110:73-82.
Thursday, July 11: Phenylketonuria is a serious disease that results from an inborn error of processing of the amino acid phenylalanine in the body. It is treated by dietary restriction of phenylalanine. Researchers in the UK find that most older children and adolescents with phenylketonuria (PKU) do not comply with recommended dietary restrictions. Compliance with diet restrictions for children under 10 in the study was better than 70%, but fell to 50% in the 10-14 year age group, and further to 20% for the 15-19 year age group. Blood level monitoring was 80% of the recommended rate among younger children (0 to 9 years of age), but was less than 50% among children 15 to 19 years of age. These findings mean that adolescents and young adults "generally do not comply with recommendations for the monitoring and control of phenylalanine concentrations... If phenylketonuria is proven to be dangerous in adults as it is in infants, maintenance of good dietary control beyond childhood will become increasingly important, and more acceptable modes of treatment than available will need to be developed. Even in young patients, maintenance of good biochemical control can be difficult." Lancet 2002;360:55-57.
Friday, July 12: Airway remodeling in asthma refers to permanent structural damage with irreversible loss of function in the lungs caused by chronic inflammation. This phenomenon is marked by increasing difficulty with forced expiration and loss of the ability of the lungs to redilate when bronchodilator medications such as albuterol are administered. These researchers found that asthma, reduced lung function in early childhood, airway hyperreactivity and male sex are factors associated with the presence of airway remodeling in young adults. American Journal of Respiratory and Critical Care Medicine 2002;165:1467-1468,1480-1488.
Monday, July 15: A report from Singapore says that twisting together of hairs on either side of a scalp laceration is an acceptable method of closure that may actually be superior to standard suture techniques. After the wound is thoroughly cleaned, hairs on either side of the laceration are twisted together to approximate the skin edges. The twisted hairs are then secured with a single drop of tissue glue. The wounds repaired this way showed significantly less scarring, fewer overall complications, lower pain scores (no injections are required), better wound healing, less wound breakdown and, and shorter procedure times compared to standard sutures or staples. Annals of Emergency Medicine 2002;40:19-29.
I have not used this technique but I recall a pediatrician I knew once who did it all the time. The addition of cyanoacrylate glue to secure the twisted hair sounds great.

Tuesday, July 16: Researchers in Ireland and the UK have found that patients with acute asthma attacks may benefit from airway rehydration, meaning humidified air. They discovered that drying of the airways triggers exercise-induced bronchial spasm in "virtually all" patients with active asthma. This has implications not only for treatment of attacks, but for environmental control issues such as air conditioning. Chest 2002;121:1806-1811.
I find this interesting. We have always assumed that exercise triggered asthma stemmed from cooling of the airways. Perhaps the real reason is drying by increased air flow.

Wednesday, July 17: In this study, adults with asthma were given the bacille Calmette-Guérin (BCG) vaccination, and their lung function improved and they needed significantly less medication to control their asthma as well. The researchers think this is due to suppression of certain immune responses by the vaccination, and theorize that this finding could eventually be useful in the treatment of asthmatics. Annals of Allergy Asthma and Immunology 2002;88:584-591.
This would be a long way from clinical use, especially in children, but I will not be surprised to see other immune modulators such as tacrolimus used in the treatment of asthma.

Thursday, July 18: Desipramine is a drug in the class of tricyclic antidepressants. This study is the first to find it effective for children with concomitant chronic tic disorder and attention-deficit hyperactivity disorder (ADHD). In a placebo-controlled study, the drug not only significantly improved ADHD symptoms, but led to improvement in tics in over half the children tested. The drug was well tolerated, with no medicine-related problems noted during the course of the study. The authors state, "Our results suggest that desipramine may offer an effective alternative for the treatment of patients with chronic tics and ADHD... Additionally, desipramine offers some advantages over stimulants, including a longer duration of action obviating the need to administer medication during school hours, absence of abuse potential, and putative positive effects on mood and anxiety, and sleep." Archives of General Psychiatry 2002;59:649-656.
Friday, July 19: Children with type 1 ("juvenile onset") diabetes should be screened annually for early markers of microvascular disease starting around age 10, according to this paper. The British researchers say that this screening should include retinal examination, blood pressure checks, and measurement of urinary protein excretion. The reason for early screening has to do with the influence of puberty on the risk for microvascular disease. "Microalbuminuria (protein in the urine from kidney damage) is not rare and may progress within the first 5 years after the diagnosis of type 1 diabetes mellitus in pubertal subjects," they say. Archives of Disease in Childhood 2002;87:10-12.
Monday, July 22: A total of 17 infants, all under 4 months old, died in the year 2000 in the US after contracting whooping cough, according to researchers from the US Centers for Disease Control and Prevention in Atlanta. The authors highlight the deaths of two infants, one aged 3 months in Colorado and another, aged 3 weeks, in Texas. "The two cases described in this report illustrate that pertussis can be fatal despite broad-spectrum antimicrobial therapy, specific therapy for pertussis, and supportive interventions," the CDC writes. "Caregivers should minimize exposure of vulnerable infants to any persons with respiratory illness," the report stresses. In the two reported cases, family members reported "a cough illness" several weeks before the infants demonstrated respiratory symptoms. While the number of pertussis cases has tended to be more stable among children old enough to be vaccinated, the CDC reports that between 1980 and 1998 "the average annual incidence of reported pertussis cases and deaths among US infants increased 50%." Mortality and Morbidity Weekly Report 2002;51:616-618.
Babies who catch whooping cough do so from an older sibling or an adult. Children must be vaccinated to prevent the spread of the disease from them to younger siblings, and adults with respiratory illness should stay away from young infants who have not been fully immunized. Even two whooping cough shots are not protective - the complete series of three vaccinations has to be completed to give full protection.

Tuesday, July 23: Routine childhood vaccinations -- diphtheria, tetanus and whole cell pertussis (DTP), oral polio vaccine, and measles, mumps, and rubella (MMR) -- are not associated with the risk of developing asthma. Dr. Frank Destefano, of the Centers for Disease Control and Prevention, in Atlanta, Georgia, and colleagues with the Vaccine Safety Datalink research group, examined the association between childhood vaccinations and the risk of asthma. They conducted a cohort study including 167,240 children who were followed from birth to at least 18 months of age and up to a maximum of 6 years of age. Pediatric Infectious Disease Journal 2002;21:498-504.
Wednesday, July 24: Changes in stricter US welfare laws have led to more limited access to nutritious food and an increased likelihood of hospitalization, as reported in this study. About 70% of the nearly 7 million people who left welfare since stricter standards for cash welfare payments were passed in 1996 have been children. Children living in homes where welfare benefits had been reduced or eliminated were about 1.5 times more likely to lack access to nutritious food, were also 2 to 3 times as likely to be admitted to the hospital the day of a visit to a hospital emergency department or clinic regardless of health insurance. Investigators also found that if families continued to receive food stamps after losing their cash welfare benefits there was no change in the outcome: children were just as likely to lack access to nutritious food or to be hospitalized. Archives of Pediatric and Adolescent Medicine 2002;156:678-684.
Thursday, July 25: Children who use nasal steroids for allergies even at doses thought to be safe can manifest adrenal gland suppression and growth delay. Children with dysmorphic syndromes such as Down syndrome seem to be at particular risk. In these children, poor growth may be mistakenly attributed to the syndrome itself, and the signs of adrenal suppression missed. These children should be carefully monitored for growth, excessive hairiness -- especially of the lower back -- and other signs of adrenal gland suppression. Archives of Disease in Childhood 2002;87:45-48.
Friday, July 26: Autism is somehow linked to rapid brain growth in early childhood. Several studies in this review examined brain growth in autistic versus normal children by MRI examination and head circumference measurements, and found that children with autism had significantly larger heads than normal controls. This difference held true until adolescence, when head sizes of the two groups are more equal. Neurology 2002;59:158-159,175-192.
Researchers are still groping to find avenues for research into the cause or causes of autism. It seems to be related to rapid, disordered brain cell growth early in development; it especially affects the areas of the brain that are involved in language.

Monday, July 29: Children suffering from craniosynostosis - premature fusion of the joints of the skull - can soon benefit from a new procedure done by endoscopic means. Standard surgical techniques often last 7-8 hours, and routinely require transfusions to replace the expected extensive blood loss; average hospital stay with the standard procedure is a week. The new procedure takes less than an hour on average and average blood loss was less than an ounce. The procedure can be done much earlier in infancy as well, and average stay is a day after surgery. Pediatrics 2002;110:97-104.
Tuesday, July 30: Thousands of infants a year could be saved from fatal complications of posterior urethral valves, according to a German physician. Posterior urethral valves are flaps of mucous membrane within the fetal urethra that should disappear early in the development of the urinary tract. If these obstructions do not disappear normally, urine outflow is blocked. The resulting lack of amniotic fluid causes the lungs not to form, a fatal malformation. The German physician has developed a procedure for in utero stenting - placing a tube through the constricted area to ensure normal urine flow. The tube is left in place until the baby is delivered. He has performed the procedure on a male fetus at 26 weeks, and the baby was delivered having normal kidney and lung function. Reuters Health
Wednesday, July 31: A 6 year longitudinal study in Australia finds that breastfeeding for at least 4 months reduces the chance infants will develop asthma. This finding is independent of whether or not the mother has a history of asthma. The researchers also confirmed that children of mothers with asthma were more likely to have the condition than those children whose mothers had no history of asthma. Positive skin tests for allergy at 6 years of age were also associated with increased risk of asthma in the children. The protective effect of breastfeeding was found to be independent of the other two factors in the study. Journal of Allergy and Clinical Immunology 2002;110:65-67.

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