Thursday, July 31, 2014

State-of-the-Art Research in Neonatal Abstinence Syndrome

Associate Editor Dr. Phyllis Dennery offers a preview of a State-of-the-Art Review being early released this week from our August issue.

Photo by ceejayoz via Wikimedia Commons

The State of the Art review by Dr. Kocherlakota (doi: 10.1542/peds.2013-3524) artfully reminds us of the significant changes that have occurred around the problem of neonatal abstinence syndrome. 

What was thought to be an urban problem of female heroin users or users in methadone programs is now a much bigger and growing problem. In many instances, the abused drug is one that was prescribed or obtained through unscrupulous providers or “pill mills”, and the problem is expanding into rural as well as suburban communities with easy access to such drugs. This makes it difficult for practitioners to appropriately treat the infant because it is often not clear if drugs are used in combinations that may modify symptoms and therapeutic approaches. 

In addition, lengths of stay are getting longer because we fear the consequences of rapid weaning. It will be important to adopt management guidelines that allow for judicious use of resources so as to arrive at best outcomes. Perhaps, in the vein of personalized medicine, we will also need to tailor our approaches to the drug(s) abused.

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Outcomes in Multifocal Neuroblastoma as Part of the Neurocristopathy Syndrome

Our Case Report Editor, Dr. Jeffery Malatack shares a case report we early released this month from our upcoming August issue.

By: Jeffrey Malatack, MD

Neuroblastoma rosettes
Photo by Maria Tsokos, US National Cancer Institute
Neuroblastoma has been appreciated for many years to have patient outcomes related to a variety of unique tumor features, including presence of stage 4S subtype, presence of opsoclonus/myoclonus and association with ROHHAD syndrome (Rapid onset Obesity with Hypothalamic dysfunction, Hypoventilation and Autonomic Dysregulation).

In each of these settings the prognosis of the malignancy is improved by what is believed to be an antitumor immune response. Neuroblastoma occurring as part of neurocristopathy syndrome has not previously been considered another special setting with an improved outcome. The neurocristopathy syndrome occurs due to a germline mutation of a neurogenesis regulator gene. The result is abnormal neural crest cell development resulting in congenital central hypoventilation syndrome, Hirschprung’s disease, and neuroblastoma which is often multifocal and disseminated in its presentation. Such widespread neuroblastoma has been considered highly aggressive and treated with either palliative intent or with very intense high dose chemotherapy.

Dr. Williams and colleagues (doi:10.1542/peds.2013-3340) writing from Australia report a patient with neurocristopathy syndrome who had multifocal neuroblastoma associated with the underlying germline mutation. The reported patient was treated conservatively with surgery and low dose chemotherapy. Following treatment he had extensive residual disease that has continued to mature from malignant to nonmalignant neural tumor despite no further treatment.

A literature review also provided in Dr. Williams’ report identified 26 similar patients presenting with multifocal neuroblastoma as part of the neurocristopathy syndrome. In all cases the neuroblastoma behaved in an indolent manner with no deaths from tumor reported where patients received appropriate treatment. These provocative findings suggest neurocristopathy-associated neuroblastoma should be treated conservatively, despite the aggressive appearance of the disease.

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Tuesday, July 29, 2014

A Ray of Hope: Sensitivity of Limited vs. Total Follow-up Skeletal Survey

By: Lewis First, MD, MS; Editor-in-Chief 

Photo by Craig Breil via Flickr
There is no question that a child who has been allegedly abused warrants a follow-up skeletal survey—but do all the bones need to be radiated for a second time or can a more limited  approach be taken that will not miss fractures not appearing on a preliminary survey?

Hansen et al. (doi: 10.1542/peds.2013-4024) have addressed this concern through a retrospective review of medical records from five institutions in children under 2 years of age who had a full skeletal survey when initially suspected for child abuse. They then looked at whether a limited view follow-up skeletal survey, in which the spine and pelvis are spared in the absence of findings on the first survey, was performed instead.

The results, though retrospective, suggest there is value and less radiation in considering a limited view protocol. But to convince yourself, read this study and decide if it will result in less radiation in your patients who require follow-up skeletal views for alleged abuse.

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Monday, July 28, 2014

Wake Up to Two New Studies on Obstructive Sleep Apnea

By: Lewis First, MD, MS; Editor-in-Chief 

Photo by Nnelumba via Flickr
We have published a number of studies over the years on the morbidities associated with obstructive sleep apnea (OSA), but this week we share two new studies that further explore the potential medical complications associated with this disorder.

The first, authored by Rosen et al. (doi: 10.1542/ peds.2013-4223), identifies the prevalence of OSA in children with sickle cell anemia. Given the lower waking oxyhemoglobin saturation associated with OSA, this could be a problem in those whose cells are prone to sickling under hypoxic stress, and this study supports that hypothesis. Have you looked into the role of OSA in your patients with sickle cell disease? If not, you may want to after reading this interesting study.

The other OSA article we are releasing this week looked at anthropometric changes in children during the 7 months following adenotonsillectomy for OSA. The study, performed by Katz et al. (doi: 10.1542/peds.2014-0591) was a randomized controlled trial in which children ages 5 to 9.9 years old either got an early adenotonsillectomy or were monitored with supportive nonoperative care. Changes in weight and growth indices were monitored in each randomized group that involved more than 450 children total.

So what happened? Do you think those with early adenotonsillectomy gained or lost weight compared to those with supportive care? The results you may find difficult to swallow but suggest that an early surgical approach to OSA may not solve the obesity problem and, in fact, may worsen it.

When considering adenotonsillectomy for these patients, you may want to have some good weight monitoring and nutritional counseling ready to go in its aftermath if you want to sustain the gains (but not the weight gains). Read on to learn more.

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Thursday, July 24, 2014

Quality Improvement to Support Food-Insecure Families

Deputy Editor Dr. Alex Kemper offers a preview of a Quality Report being early released this week from our August issue.

By: Alex Kemper, MD, MPH, MS 

Photo by Toshimasa Ishibashi via Flickr
Here are some startling facts from the US Department of Agriculture released in 2013:

  • 17.6 million households (14.5%) had food insecurity at some time during 2012. This is a stable number since 2008.
  • 3.9 million households with children were food insecure at some time during 2012.

There is ample evidence that food insecurity can have a profound impact on the development and wellbeing of children. Although pediatricians cannot solve this major problem alone, we are certainly not helpless. For example, we can advocate for policy to help families either individually or in partnership with the organizations that represent us, like the American Academy of Pediatrics. We can also work to actively identify families with food insecurity and refer them to available resources (e.g., government assistance programs, local food banks).

Today we are releasing a Quality Report by Dr. Andrew Beck and colleagues (doi: 10.1542/peds.2013-3845) demonstrating how a successful collaboration between pediatricians and community partners was developed to help food-insecure families and their infants have better access to infant formula, educational materials, and clinic and community resources.

Read this and be inspired. Do you know who in your practice faces food insecurity? What do you do to address the problem?

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Wednesday, July 23, 2014

HIV & Child Mental Health: A Case-Control Study in Rwanda

Pediatrics Editorial Board Member Joann Schulte, DO, MPH, shares her expert perspective on a new article from our August issue. To learn more about Dr. Schulte and her work in general pediatrics and preventive medicine, check out her bio on our Contributors page.

By: Joann Schulte, DO, MPH
Photo by Julien Harneis via Flickr

Every pediatric practice has such children: She might be an older sister of an ex-preemie who gets short shrift of maternal time because her mother spends much of the week taking the infant to an endless series of medical appointments. Maybe he is the 5-year-old who had a kidney transplant and now seems to do nothing but fight with the younger brother who was once his constant companion.

Chronic medical conditions impact siblings and families. So it is not surprising that the stigma of HIV influences not only the children and adults who are infected with the virus, but also children who are affected by HIV, but not infected themselves.

The topic was explored in a study published in the August issue of Pediatrics and studied children aged 10 to 17 years in Rwanda. Betancourt et al. (doi: 10.1542/ peds.2013-2734) found HIV-affected children were more likely to be depressed, anxious and have conduct problems than their counterparts who were either HIV-infected or HIV-negative.

Researchers enrolled 683 children of whom 218 were HIV-infected, 228 HIV-affected (negative for HIV but with family members infected) and 237 were HIV-unaffected (HIV negative and no family members infected). The study was a collaboration between faculty at the Harvard School of Public Health, the Rwandan Ministry of Health and Partner in Health, a Boston-based NGO.

What does this mean for you? The healthy children in your practice whose siblings have chronic illness have their counterparts in Rwanda. Dealing with mental health is an issue, no matter what chronic illnesses impact children or what language they speak.

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Tuesday, July 22, 2014

Jaundice in Breastfed Infants: How Long Can It Last?

Photo by Cheryl via Flickr
By: Lewis First, MD, MS; Editor-in-Chief 

We certainly see babies coming into offices at 3 and even 4 weeks of age still looking somewhat
yellow, prompting us to check a bilirubin level and finding an unconjugated level still over 5 mg/dL. Is this prolonged level normal? Should we worry and keep checking levels or reassure parents that all is well?

Maisels et al. (doi: 10.1542/peds.2013-4299) looked into this issue of the natural history of hyperbilirubinemia and jaundice in newborns by measuring transcutaneous bilirubin levels in predominantly breastfed infants over 35 weeks gestation.

The results suggest that almost a third of breastfed infants will stay jaundiced for their first month of life. As to whether a particular level of bilirubin correlates with the color or location of the jaundice, the authors looked into this as well. Their findings were interesting confirming the lack of accuracy of predicting bilirubin by distribution of visible jaundice, but reassuring in that the wide range of levels obtained by severity of color do not appear to be high enough to be worrisome.

The brief summary in this post just begins to skin the surface on a nice study well worth reading in its entirety to have a better understanding of when to worry and not to worry about persistent unconjugated jaundice in breastfed infants.

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