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What's new in pediatrics
Alison G Hoppin, MD
Melanie S Kim, MD
Elizabeth TePas, MD, MS
Mary M Torchia, MD
Last literature review version 19.1: enero 2011 | This topic last updated: febrero 17, 2011
The following represents additions to UpToDate since the last version that were considered by the authors and editors to be of particular interest. The new material described below represents a small subset of the updating that has been performed, since approximately 40 percent of the topic reviews are updated during each four-month cycle.
Dosing adjustment of inhaled glucocorticoids — A meta-analysis of the dose response to inhaled glucocorticoids in children with mild to moderate persistent asthma suggests that there is little additional benefit (as measured by beta-agonist use, asthma symptom score, forced expiratory volume in one second, and peak expiratory flow) in increasing the dose from low to moderate levels (≤200 mcg/day versus 300 to 400 mcg/day beclomethasone-equivalent) [1]. (See "Chronic asthma in children younger than 12 years: Controller medications", section on 'Inhaled glucocorticoids'.)
Spacers — The use of a spacer or valved holding chamber is recommended for all children in whom proper breath and actuation coordination is difficult (particularly those who are younger than five to six years), and whenever an inhaled corticosteroid is being administered via a pressurized metered-dose inhaler (MDI). In a study comparing spacers, children two to seven years of age who used spacers without facemasks had inhalation volumes nearly double the expected tidal volumes [2]. Two tidal breaths were sufficient for the smaller volume spacers (149 mL AeroChamber Plus and 225 mL Funhaler) and a 500 mL modified plastic soft drink bottle, but three tidal breaths were required for the larger volume spacer (750 mL Volumatic). Additional tidal breaths did not significantly increase drug delivery. Drug delivery was otherwise equivalent between the four devices. (See "The use of inhaler devices in children", section on 'Spacer devices'.)
Acetaminophen and asthma risk — The Melbourne Atopy Cohort Study examined the relationship between paracetamol use during early childhood and the risk of asthma in 620 children with a family history of allergic disease [3]. To reduce the risk of confounding bias, frequent prospective documentation of paracetamol use and its indications were obtained. After adjustment for the frequency of respiratory infections, no association was found between paracetamol use and parental report of asthma at age six or seven. (See "Risk factors for asthma", section on 'Acetaminophen'.)
Latex allergy in patients with spina bifida — The rate of latex sensitization and allergy has decreased significantly, compared with historical controls, in children with spina bifida since the implementation of latex avoidance (55 versus 5 percent for sensitization and 37 versus 0.8 percent for allergy, respectively) [4]. (See "Latex allergy: Epidemiology, clinical manifestations, and diagnosis", section on 'Prevalence in patients receiving multiple surgeries'.)
New approvals for ADHD therapy — Medication abuse and/or dependence may be a concern when choosing medications for the treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents. Two approvals from the US Food and Drug Administration provide new options for such patients:

Risk of obesity persisting into adulthood — The severity of obesity during adolescence is an important predictor of whether the obesity is likely to persist into adulthood. In a large population study in the United States, about 75 percent of adolescents with severe obesity (defined as a BMI >120 percent of the 95th percentile, which approximates the 99th percentile) remained severely obese as adults (BMI >40) [9]. (See "Definition; epidemiology; and etiology of obesity in children and adolescents", section on 'Persistence into adulthood'.)
CDC guidelines for infants born to lead-exposed women — New guidelines from the Centers for Disease Control and Prevention are available to guide the clinical approach to infants of lead-exposed mothers [10]:

CDC guidelines for breastfeeding in lead-exposed women — Based upon estimates of infant blood lead level (BLL) elevation occurring from breast milk ingestion (table 2) and the proven benefits of breastfeeding in young infants, the Centers for Disease Control and Prevention recommend that breastfeeding should be encouraged for all mothers with a venous BLL <40 mcg/dL [10]. In the United States, infants whose mothers have a BLL ≥40 mcg/dL should not breastfeed initially. Infant monitoring of BLL during breastfeeding should proceed according to recommendations for follow-up screening of neonates and infants under six months of age (table 1 and table 3). Continuation of breastfeeding is based upon whether there is evidence that breast milk is contributing to elevated infant BLL on the follow-up maternal and infant screening. (See "Childhood lead poisoning: Management", section on 'Breastfeeding' and "Adult lead poisoning", section on 'Pregnancy and breastfeeding'.)
2010 guidelines for basic and advanced life support — Based upon extensive review of clinical and laboratory evidence, the American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) published updated guidelines for basic life support (BLS) and advanced life support (ALS) interventions in children.
Basic life support — The 2010 international resuscitation guidelines emphasize the importance of hard, fast chest compression, with full chest recoil and minimal interruptions [11-14]. The major changes for basic cardiopulmonary resuscitation (CPR) from previous guidelines published in 2005 include (algorithm 1):

Advanced life support — The 2010 international resuscitation guidelines reaffirm the ALS approach to arrhythmias and cardiac arrest in children (algorithm 2 and algorithm 3 and algorithm 4) [12,13,15]. The major changes for pediatric advanced life support from previous guidelines published in 2005 include:

Age-specific goals for A1C in type 1 diabetes — Young children with type 1 diabetes have a higher risk of hypoglycemic episodes as compared with older children. As a result, the targets for glycemic control decrease with advancing age (table 5). In previous versions of its Standards of Care, the American Diabetes Association recommended that hemoglobin A1C be kept between 7.5 and 8.5 percent in children younger than six years of age. However, in the new Standards of Care, the lower limit for A1C is removed [16], and slightly lower A1C targets are encouraged if these can be achieved without excessive hypoglycemia. (See "Management of type 1 diabetes mellitus in children and adolescents", section on 'Age-specific goals'.)
Alleged association between MMR and autism discredited — The report that suggested a link between recent receipt of measles-mumps-rubella (MMR) vaccine, enterocolitis, and the onset of symptoms of autism in 12 children has been discredited [17]. An investigative reporter compared the case descriptions in the report with the children’s medical records and found multiple discrepancies (eg, three children did not have autism, five had developmental concerns before receiving MMR, colonoscopy findings initially reported as unremarkable were amended to “nonspecific colitis” after “research review”). These revelations refute the hypothesis that there is an association between MMR vaccination and autism. (See "Autism and chronic disease: Little evidence for vaccines as a contributing factor", section on 'Enterocolitis and regression'.)
New recommendations for meningococcal conjugate vaccine — The US Advisory Committee on Immunization Practices (ACIP) has modified guidelines regarding use of the quadrivalent meningococcal conjugate vaccines to recommend that adolescents be vaccinated ideally at age 11 or 12 years, with a booster at age 16 [18]. In addition, a two-dose primary series two months apart is now recommended in individuals with persistent complement component deficiency or functional or anatomic asplenia, as well as for adolescents with HIV infection. In early 2011, the US Food and Drug Administration approved Menveo® for use in children between 2 and 10 years of age who have an indication for vaccination [19]. Menveo® is the second quadrivalent meningococcal conjugate vaccine to be approved in the US. It had previously been approved only for individuals between the ages of 11 and 55 years. The specific meningococcal vaccine formulation and schedule indicated depend upon age, host factors (ie, type of immunodeficiency), and prior history of vaccination; recommendations are presented in the table (table 6). (See "Meningococcal vaccines", section on 'United States'.)
New recommendations for Tdap — In response to an increase in pertussis cases in the US, the Advisory Committee on Immunization Practices and American Academy of Pediatrics have updated recommendations for tetanus toxoid-reduced diphtheria toxoid-acellular pertussis (Tdap) vaccine in children and adults [20]. The updated guidelines include:

Prevention of early-onset group B streptococcal disease — The Centers for Disease Control and Prevention has released updated guidelines for the prevention of perinatal group B streptococcal disease. The updated guidelines include a new algorithm for the evaluation and management of newborns (algorithm 5) [21]. The revised algorithm decreases laboratory evaluation and empiric antibiotics for low-risk infants. (See "Management of the infant whose mother has received group B streptococcal chemoprophylaxis", section on 'Management approach'.)
CDC guidelines for the treatment of STD — The CDC updated guidelines for treatment of sexually transmitted diseases (STDs) [22]. The following recommendations, consistent with recent UpToDate topics, represent some of the revisions from 2006 CDC guidelines:

New MRSA treatment guidelines — The Infectious Diseases Society of America (IDSA) has published guidelines for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in adults and children [23]. These guidelines include the management of various clinical syndromes caused by MRSA, including skin and soft tissue infections, bacteremia, endocarditis, pneumonia, bone and joint infections, and central nervous system infections. (See "Evaluation and management of suspected methicillin-resistant Staphylococcus aureus skin and soft tissue infections in children", section on 'Treatment overview' and "Treatment of invasive methicillin-resistant Staphylococcus aureus infection in children", section on 'Treatment approach' and "Treatment of Staphylococcus aureus bacteremia in children".)
Treatment of acute otitis media — Meta-analyses have suggested that many children with acute otitis media (AOM) improve without antimicrobial therapy. However, many included studies did not use stringent diagnostic criteria and did not include or focus on children <2 years of age, a group that is more difficult to treat. Two recent randomized trials comparing amoxicillin-clavulanate and placebo included only young children (6 to 23 or 35 months), used a strict definition of AOM (a combination of acute signs/symptoms and middle ear effusion), and experienced otoscopists [24,25]. Antibiotic therapy was associated with shorter duration of signs and symptoms, fewer treatment failures, and lower rates of residual middle ear disease, confirming the benefit of antimicrobial therapy for children younger than two years of age with strictly defined AOM. (See "Acute otitis media in children: Treatment", section on 'Antibiotic therapy versus observation'.)
Treatment of nontuberculous mycobacterial lymphadenitis — Complete excision is the preferred treatment for nontuberculous mycobacterial (NTM) cervical lymphadenitis. When complete excision is not possible, nonsurgical approaches include antimycobacterial therapy and observation. A small randomized trial compared these alternatives in immunocompetent children [26]. Median time to resolution was approximately nine months for both groups. No recurrences were reported in follow-up of at least two years. These findings suggest that there is little benefit from antimicrobial therapy for advanced NTM lymphadenitis. (See "Diagnostic approach to and initial treatment of cervical lymphadenitis in children", section on 'Nontuberculous mycobacteria'.)
2010 neonatal resuscitation guidelines — Based upon review of clinical and laboratory evidence, the American Heart Association (AHA) and European Resuscitation Council (ERC), in collaboration with the International Liaison Committee on Resuscitation (ILCOR), published updated guidelines for neonatal resuscitation in 2010 (algorithm 6) [27,28]. Two major changes from previous guidelines include the following:
  • Pulse oximetry — In the 2010 guidelines, the use of pulse oximetry is recommended to determine oxyhemoglobin saturation (SaO2) during neonatal resuscitation in the delivery room [27,28]. This recommendation is based on observations that neonates may remain cyanotic for several minutes following birth, as oxyhemoglobin saturation normally remains in the 70 to 80 percent range, and skin color is a poor indicator of oxyhemoglobin saturation during the immediate neonatal period. (See "Neonatal resuscitation in the delivery room", section on 'Pulse oximetry'.) The guidelines specifically recommend pulse oximetry be used in the following settings:

  • When resuscitation is anticipated
  • When positive-pressure ventilation is used for more than a few breaths
  • Persistent cyanosis
  • When supplementary oxygen is used

  • Oxygen concentration — The 2010 guidelines recommend the initial use of blended oxygen (mixture of room air and oxygen) in conjunction with the use of a pulse oximeter. No specified oxygen concentration was recommended, and the oxygen concentration is to be adjusted to achieve targeted SaO2 levels based on pulse oximetry measurements. If blended oxygen is not available, room air should be used initially for resuscitation. (See "Neonatal resuscitation in the delivery room", section on 'Supplemental oxygen'.)

Sepsis and white blood cell count — The use of a complete blood count (CBC) in the evaluation of neonatal sepsis was supported by a large multicenter study of infants ≥34 weeks’ gestation, in whom both a blood culture and CBC were performed within the first 24 hours of life [29]. An association with blood-culture-proven early-onset disease was found for any of the following parameters:
  • Total white blood cell count <5000/microL
  • Absolute neutropenia: granulocyte count <1000/microL
  • Relative neutropenia: granulocyte count <5000/microL
  • Ratio of immature to total granulocytes (PMNs) ≥0.3

This study also demonstrated a CBC was more helpful as a predictor for sepsis if obtained after four hours of age because the WBC and absolute neutrophil count normally increase rapidly during the first six hours of life. (See "Clinical features and diagnosis of sepsis in term and late preterm infants", section on 'Other blood tests'.)
Genetic causes of steroid-resistant nephrotic syndrome — Immunosuppressive therapy generally has not been shown to be effective in treating children with steroid-resistant nephrotic syndrome (SRNS) due to genetic causes. Screening for such mutations should be performed in all children with steroid-resistant disease and a family history of SRNS, to prevent the unnecessary administration of additional immunosuppressive therapy. This approach was supported in a large case series, in which 43 of 91 patients had an identified genetic cause for their SRNS [30]. Two-thirds of the patients with nongenetic SRNS responded to cyclosporin therapy, most achieving complete remission. In contrast, there were no complete responders among patients with genetic SRNS, with only two having incomplete response. (See "Treatment of idiopathic nephrotic syndrome in children", section on 'Genetic mutations'.)
Fetal surgery for myelomeningocele — Fetal surgery for myelomeningocele can arrest leakage of spinal fluid during gestation, and might therefore prevent or reverse the hydrocephalus and Chiari II malformation that contribute to neurologic dysfunction. In a randomized trial, outcomes of infants undergoing fetal surgery were compared with those for infants undergoing standard myelomeningocele repair shortly after birth [31]. Fetal surgery significantly reduced the risk of death or need for shunt placement during the first year of life, and resulted in improved scores for mental development and motor function at 30 months of age. These benefits occurred despite a higher risk of preterm delivery among infants undergoing fetal surgery. (See "Pathophysiology and clinical manifestations of myelomeningocele (spina bifida)", section on 'Fetal surgery'.)
Zinc supplementation in developing countries — Several placebo-controlled studies have suggested that routine supplementation with zinc in young children in developing countries slightly reduces risk for diarrhea and pneumonia. Although the effect size is small and probably enhanced by publication bias, a new meta-analysis concluded that zinc supplementation reduces the risk of pneumonia by about 20 percent [32]. In addition, zinc supplementation given to pregnant women in Peru reduced the risk of prolonged diarrheal episodes in their infants by 34 percent as compared with controls [33]. (See "Zinc deficiency and supplementation in children and adolescents", section on 'Prevention of diarrhea and pneumonia'.)
Investigational therapies for some types of cystic fibrosis — Investigational therapies for cystic fibrosis include some approaches that target specific types of defects in the transmembrane conductance regulator (CFTR) gene. Two phase 2 trials have yielded promising results in measures of CFTR function:
  • Class I mutations of CFTR, characterized by premature stop codons, are present in about 5 percent of cases of cystic fibrosis, and a much higher percentage in those with Ashkenazi Jewish heritage. Ataluren, an orally available drug, causes ribosomes to read through premature stop codons. In a phase 2 trial, administration of ataluren to patients with Class I CFTR mutations improved CFTR function, as measured by epithelial chloride transport measurements, in about half of the subjects [34]. (See "Cystic fibrosis: Investigational therapies", section on 'Class I mutations: Defective protein production'.)
  • Class III mutations of CFTR, which include G551D, are characterized by defective activation of the CFTR chloride channel. VX-770 is an investigational drug designed to improve activation of the channel. In a phase 2 trial, patients with the G551D mutation who were treated with VX-770 displayed improvements in functional measures of CFTR function, including sweat chloride concentration and nasal potential difference [35]. (See "Cystic fibrosis: Investigational therapies", section on 'Class III mutations: Defective regulation'.)

Mortality associated with secondhand smoke exposure — Mounting evidence suggests that exposure to secondhand smoke (SHS) substantially increases risk for coronary heart disease in adults, with associated morbidity and mortality. A new study estimates that SHS is responsible for about 1 percent of mortality worldwide and that 28 percent of the mortality and 61 percent of the morbidity was seen in children [36]. Most of the effects of SHS in children were due to lower respiratory infections and asthma, and most of the attributable deaths in children were in developing countries. (See "Secondhand smoke exposure: Effects in children", section on 'What is secondhand smoke?' and "Secondhand smoke exposure: Effects in children", section on 'Respiratory symptoms and illness'.)
Gastrointestinal involvement in Henoch-Schönlein purpura — Gastrointestinal symptoms occur in about half of children with Henoch-Schönlein purpura (HSP) and range from mild (nausea, vomiting, abdominal pain, and transient paralytic ileus) to more significant findings (gastrointestinal hemorrhage, bowel ischemia and necrosis, intussusception, and bowel perforation). However, the frequent presence of fecal occult blood, hypoalbuminemia without proteinuria, and positive alpha1-antitrypsin tests even in HSP patients without gastrointestinal symptoms suggests that gastrointestinal involvement and mucosal injury is more common than the clinical history indicates [37]. (See "Clinical manifestations and diagnosis of Henoch-Schönlein purpura", section on 'Gastrointestinal symptoms'.)
Clinical course of spondyloarthropathy — Undifferentiated spondyloarthropathy is a heterogeneous condition with a variable course. In a prospective series of 59 children with enthesitis-related arthritis, 30 percent developed symptoms of inflammatory back pain with sacroiliitis detectable on dynamic magnetic resonance imaging (MRI), but not radiographs, of sacroiliac joints [38]. The number of active joints and entheses at disease onset were higher in the children who developed sacroiliitis. In a retrospective series of 143 children with spondyloarthritis, hip arthritis was positively associated, and dactylitis negatively associated, with sacroiliitis [39]. These studies highlight the importance of following patients over a long period of time, as many patients with sacroiliitis will develop ankylosing spondylitis within 10 years. (See "Spondyloarthropathy in children", section on 'Course and prognosis'.)
Clinical course of juvenile fibromyalgia — A prospective study has found that about 60 percent of 48 young adults diagnosed with juvenile fibromyalgia in childhood or adolescence continued to experience widespread pain, poor sleep, and fatigue after a mean follow-up of 3.67 years [40]. Even though the numbers are small, this study suggests that the symptoms of juvenile fibromyalgia are likely to continue into adulthood. (See "Treatment and prognosis of fibromyalgia in children and adolescents", section on 'Prognosis'.)
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  2. Schultz A, Le Souëf TJ, Venter A, et al. Aerosol inhalation from spacers and valved holding chambers requires few tidal breaths for children. Pediatrics 2010; 126:e1493.
  3. Lowe AJ, Carlin JB, Bennett CM, et al. Paracetamol use in early life and asthma: prospective birth cohort study. BMJ 2010; 341:c4616.
  4. Blumchen K, Bayer P, Buck D, et al. Effects of latex avoidance on latex sensitization, atopy and allergic diseases in patients with spina bifida. Allergy 2010; 65:1585.
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UpToDate performs a continuous review of over 440 journals and other resources. Updates are added as important new information is published. The literature review for version 19.1 is current through enero 2011; this topic was last changed on febrero 17, 2011. The next version of UpToDate (19.2) will be released in julio 2011.
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