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    What's new in pediatrics
    Elizabeth TePas, MD, MS
    Mary M Torchia, MD
    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.
    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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    What's new in pediatrics
    authors **Author**
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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
    James F Wiley, II, MD, MPH
    Last literature review version 16.2: mayo 200819.1: enero 2011 | This
    last updated: junio 12, 2008 **(More)**
    febrero 17, 2011
    following representrepresents additions to
    four-month cycle.
    2Resistant depression

    Dosing adjustment of inhaled glucocorticoids
    The resultsA meta-analysis of the Treatment of Resistant Depression In Adolescents study support switchingdose response to a different selective serotonin reuptake inhibitor (SSRI)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 adding cognitive behavioral therapy (if it was not already part ofpeak expiratory flow) in increasing the treatment regimen) when adolescents faildose from low to respondmoderate levels (≤200 mcg/day versus 300 to an adequate trial of therapy with an SSRI [1] .400 mcg/day beclomethasone-equivalent) [1]. (See "Psychopharmacological treatment for adolescent depression","Chronic asthma in children younger than 12 years: Controller medications", section on Resistant depression).
    3Scoliosis screening
    'Inhaled glucocorticoids'.)
    — The American Academyuse of Orthopaedic Surgeons, the Scoliosis Research Society, the Pediatric Orthopaedic Society of North America,a spacer or valved holding chamber is recommended for all children in whom proper breath and the American Academy of Pediatrics do not support the United States Preventive Task Force recommendations against scoliosis screening [2,3] . These groups suggest that if screeningactuation coordination is undertaken, the forward bend test should be includeddifficult (particularly those who are younger than five to six years), and that girls be screened at ages 10 and 12whenever an inhaled corticosteroid is being administered via a pressurized metered-dose inhaler (MDI). In a study comparing spacers, children two to seven years and boys atof age 13 or 14 years. Not all children who are referredused spacers without facemasks had inhalation volumes nearly double the expected tidal volumes [2]. Two tidal breaths were sufficient for evaluation asthe smaller volume spacers (149 mL AeroChamber Plus and 225 mL Funhaler) and a result of screening require spinal radiographs.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 "Clinical features; evaluation; and diagnosis"The use of adolescent idiopathic scoliosis",inhaler devices in children", section on Scoliosis screening).
    5Cardiac evaluation
    'Spacer devices'.)
    and ADHD stimulant therapyasthma riskIn May 2008,The Melbourne Atopy Cohort Study examined the American Academy of Pediatricsrelationship between paracetamol use during early childhood and the American Heart Association recommended performing an evaluation comprisedrisk of asthma in 620 children with a cardiovascular-focused patient and family history,history of allergic disease [3]. To reduce the risk of confounding bias, frequent prospective documentation of paracetamol use and physical examination to detect cardiac disease in patients who need to receive stimulant therapyits indications were obtained. After adjustment for their attention deficit hyperactivity disorder (ADHD) [4] . An electrocardiogram is not required before initiating stimulant therapy for patients with ADHD, if the historyfrequency of respiratory infections, no association was found between paracetamol use and examination are not suggestiveparental report of cardiac disease.asthma at age six or seven. (See "Cardiac evaluation of children receiving pharmacotherapy"Risk factors for attention deficit hyperactivity disorder",asthma", section on AHA and AAP joint statement).
    7Elevated intracranial pressure — Although controlled hypothermia has been used to help reduce intracranial pressure
    Latex allergy
    in some patients with refractory intracranial hypertension [5-7] , a prospective, blinded, randomized multicenter trialspina bifida — The rate of 225 childrenlatex sensitization and allergy has decreased significantly, compared with severe brain injury caused by blunt trauma found no benefit and possibly worse outcomes (eg, severe disability, persistent vegetative state, and death)historical controls, in children who were externally cooled to 32 to 33ºC (89.6 to 91.4ºF) for 24 hours within 8 hours of injury [8] (See "Elevated intracranial pressure in children", section on Experimental therapies).
    9Gastroesophageal reflux in children — Functional constipation is frequently associated
    with dyspeptic symptoms, including gastroesophageal reflux, heartburn, and nausea. In many cases,spina bifida since the constipation is unrecognizedimplementation of latex avoidance (55 versus 5 percent for sensitization and the dyspeptic symptoms are the presenting complaint. This probably occurs because the constipation delays gastric emptying via an intraintestinal reflex, termed the "cologastric brake" [9] . Therefore, the child with reflux or dyspeptic symptoms should be carefully evaluated37 versus 0.8 percent for occult or recognized constipation.allergy, respectively) [4]. (See "Clinical manifestations"Latex allergy: Epidemiology, clinical manifestations, and diagnosis of gastroesophageal reflux disease in children and adolescents",diagnosis", section on Evaluation).
    10Gastroesophageal reflux
    'Prevalence in infantspatients receiving multiple surgeries'.)
    New approvals for ADHD therapy
    Acid suppressing and prokineticMedication abuse and/or dependence may be a concern when choosing medications have a limited role infor the treatment of infants with regurgitation [10] . Many infants with symptoms suggestive of gastroesophageal reflux disease will improve with conservative measures alone [11] . (See "Gastroesophageal refluxattention deficit hyperactivity disorder (ADHD) in infants", section on Lifestyle changes).
    12Autism — There is increasing evidence
    children and adolescents. Two approvals from the US Food and Drug Administration provide new options for the rolesuch patients:
    Lisdexamfetamine, a prodrug
    of genetic factorsdextroamphetamine designed to discourage drug abuse, has been approved for use in the etiologychildren 13 through 17 years of autism. Variation in copy number at multiple loci plays a role it at least 2 to 3 percent of cases [12-16] .age (it was previously approved for children 6 through 12 years and adults) [5,6]. (See "Terminology; epidemiology;"Attention deficit hyperactivity disorder in children and pathogenesis of autism spectrum disorders",adolescents: Pharmacotherapy", section on Genetics).
    13Nocturnal enuresis — Although bladder-training exercises are effective in increasing bladder capacity, it is not clear that increasing bladder capacity affects
    Extended-release clonidine, which has no known potential for abuse or dependence, has also been approved for
    the frequencytreatment of nocturnal enuresisADHD or responseas an adjunct to stimulant therapy for the treatment with an enuresis alarm [17,18] . (See "Management of nocturnal enuresisADHD in children",children and adolescents aged 6 to 17 years [7,8]. (See "Attention deficit hyperactivity disorder in children and adolescents: Pharmacotherapy", section on Bladder training).
    Risk of obesity persisting into adulthood
    — The prevalenceseverity of obesity among children and adolescentsduring adolescence is an important predictor of whether the obesity is likely to persist into adulthood. In a large population study in the United States dramatically nearly tripled between the early 1980s and 2000, but then reached a plateau. The most recent statistics reveal that just over 17States, about 75 percent of U.S. children and adolescents arewith severe obesity (defined as a BMI >120 percent of the 95th percentile, which approximates the 99th percentile) remained severely obese as adults (BMI >95th percentile) [19] .>40) [9]. (See "Definition, epidemiology,"Definition; epidemiology; and etiology
    section on Epidemiology).
    16Prader-Willi syndrome
    'Persistence into adulthood'.)
    CDC guidelines for infants born to lead-exposed women
    20New guidelines from the Centers for Disease Control and Prevention are available to 40 percentguide the clinical approach to infants of patientslead-exposed mothers [10]:
    Blood lead screening is recommended for pregnant women
    with Prader-Willi syndrome have clinically significant scoliosis. Several case series have reported unusually high complication ratesimportant risk factors for scoliosis surgery in individualslead exposure. (See "Adult lead poisoning", section on 'Pregnancy and breastfeeding'.)
    Providers for pregnant women
    with PWS. Inelevated blood lead levels (BLL) should ensure that the largest case series, 9maternal lead level is known by the provider managing the newborn infant. Levels of 16 patients experienced severe complications, including severe progressive cervical-thoracic kyphosis aboveboth the fusion, with or without spinal cord injury [20] .mother and infants should be documented in their medical records. (See "Clinical features, diagnosis,"Childhood lead poisoning: Management", section on 'Prenatal exposure' and treatment"Adult lead poisoning", section on 'Pregnancy and breastfeeding'.)
    of Prader-Willi syndrome",mothers with BLL ≥5 mcg/dL should have cord blood samples sent for blood lead testing at the time of delivery or venous BLL measured soon after birth. (See "Childhood lead poisoning: Management", section on Orthopedic problems).
    18Stingray injuries — Stingrays possess whip-like tails
    'Prenatal exposure'.)
    Additional testing is indicated for neonates
    with a furrowed, serrated spine containing secretory venom cellsan initial venous or cord BLL ≥5 mcg/dL. The frequency of repeated testing and sacs. Stingray injury often results when the animal is inadvertently stepped on in shallow water, causing itneed for other interventions varies according to fling the barbed tail upward into the victim's leg where venom is released. Submersiondegree of stingray injuries in hot water (43 to 46ºC)blood lead elevation (table 1 and figure 1). These guidelines apply for 30infants up to 90 minutes may inactivate someage six months. (See "Childhood lead poisoning: Management", section on 'Prenatal exposure'.)
    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 heat-sensitive protein componentsproven benefits of breastfeeding in young infants, the venomCenters for Disease Control and has been promoted as effectivePrevention recommend that breastfeeding should be encouraged for treating pain.all mothers with a venous BLL <40 mcg/dL [10]. In the United States, infants whose mothers have a retrospective series, 65BLL ≥40 mcg/dL should not breastfeed initially. Infant monitoring of 97 patients (67 percent) had complete analgesia with hot water immersion alone [21] .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 "Marine envenomations","Childhood lead poisoning: Management", section on Stingrays).
    20Acute otitis media
    'Breastfeeding' and "Adult lead poisoning", section on 'Pregnancy and breastfeeding'.)
    2010 guidelines for basic and advanced life support
    Double tympanocentesis studies indicate that failure to eradicateBased upon extensive review of clinical and laboratory evidence, the bacterial pathogen withinAmerican Heart Association (AHA) and the first few days of treatmentInternational Liaison Committee on Resuscitation (ILCOR) published updated guidelines for acute otitis media increases the risk of persistent symptomsbasic life support (BLS) and is associated with increased risk of recurrence, evenadvanced life support (ALS) interventions in children with clinical improvement [22,23] . (See "Treatment of acute otitis media", section on Treatment failure).
    21Bacterial meningitis
    Basic life support
    — The administration2010 international resuscitation guidelines emphasize the importance of adjuvant dexamethasone did not affect mortalityhard, 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 a retrospective cohort of 27802005 include (algorithm 1):
    Initiate CPR in infants or
    children with bacterial meningitis who were admitted to 27 hospitals in the United States between 2001are unresponsive and 2006 [24] .not breathing (or only gasping). (See "Dexamethasone"Basic life support in infants and other measures to prevent neurologic complications of bacterial meningitischildren", section on 'Initiate CPR'.)
    If no pulse is definitely identified within 10 seconds, give compressions before performing airway or breathing maneuvers. (See "Basic life support
    in infants and children", section on Survival).
    22Chemoprophylaxis for N. meningitidis — Ciprofloxacin-resistant isolates
    'Initiate CPR'.)
    The use
    of Neisseria meningitidis have been isolatedconventional CPR (compressions with ventilation) rather than compression-only CPR in some areasinfants and children with cardiac arrest is reaffirmed, regardless of whether the United States (Minnesota, North Dakota) and Spain [25,26] . Rifampin, ceftriaxone, and azithromycin arearrest occurs within or outside of the hospital. Compression-only CPR is appropriate alternatives for chemoprophylaxisonly in areas where resistant strains have been identified (show table 1) [27] .adults. (See "Treatment"Basic life support in infants and preventionchildren", section on 'Conventional versus compression-only CPR'.)
    For infants and children <8 years
    of meningococcal infection",age, a manual defibrillator or an AED with a pediatric dose attenuating system should be used whenever possible. However, if a manual defibrillator or an AED with a pediatric dose attenuating system is not available, then use of an AED without a dose attenuator is now acceptable (algorithm 1). (See "Basic life support in infants and children", section on Antibiotic prophylaxis).
    23Community-acquired pneumonia
    'Automated external defibrillator' and "Defibrillation and cardioversion in children (including automated external defibrillation)", section on 'Automated external defibrillator use in infants and children'.)
    Advanced life support
    A meta-analysis found three days of oral antimicrobial therapyThe 2010 international resuscitation guidelines reaffirm the ALS approach to be as effective as five days for nonsevere community-acquired pneumoniaarrhythmias and cardiac arrest in children aged(algorithm 2 to 59 months [28] . However, the involved studies were performedand algorithm 3 and algorithm 4) [12,13,15]. The major changes for pediatric advanced life support from previous guidelines published in developing countries where pneumonia was diagnosed by2005 include:
    the World Health Organization criteria, whichnewborn period, cuffed endotracheal (ET) tubes are based onequally safe as uncuffed tubes and are favored in some clinical findingscircumstances. Monitoring should ensure that cuff pressures do not exceed 20 cm H2O (table 4) (calculator 1). (See "Emergent endotracheal intubation in children", section on 'Cuffed versus uncuffed'.)
    Evidence is insufficient to routinely recommend cricoid pressure (Sellick maneuver) in infants
    and respiratory rate thresholds. Many of the children included in the meta-analysis probably had viral pneumonia, for which antibiotic therapyundergoing endotracheal intubation. If it is not warranted.used, cricoid pressure should be removed if airway obstruction occurs when ventilation is required or if there is difficulty viewing the larynx. (See "Outpatient treatment of community-acquired pneumonia"Emergent endotracheal intubation in children", section on Duration).
    In another meta-analysis,
    'Cricoid pressure'.)
    Etomidate should not be used routinely in
    children with bacterial pneumonia were more likelyseptic shock. Ketamine, if available and not contraindicated, is preferable to have serum C-reactive protein concentrations greater than 35 to 60 mg/L than children with nonbacterial pneumonia (odds ratio 2.6, 95% CI 1.2-5.6) [29] .intubate pediatric patients in septic shock. (See "Clinical features"Septic shock: Initial evaluation and diagnosis of community-acquired pneumoniamanagement in children", section on Blood tests).
    24Influenza resistance — Oseltamivir resistance among influenza H1N1 isolates continues to increase, particularly
    'Airway and breathing' and "Sedation or induction agents for rapid sequence intubation in Europe where the overall resistance duringadults", section on 'Ketamine'.)
    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 2007-2008 influenza season was 20 percent [30] .targets for glycemic control decrease with advancing age (table 5). In North America, approximately 10 percentprevious versions of influenza H1N1 isolates were resistant to oseltamivir [30,31] . The detectionits Standards of resistant isolates in patients who had not been taking oseltamivir suggestsCare, the American Diabetes Association recommended that resistant virus canhemoglobin A1C be transmittedkept between individuals [32,33] . (See "Antiviral drugs for7.5 and 8.5 percent in children younger than six years of age. However, in the preventionnew Standards of Care, the lower limit for A1C is removed [16], and treatmentslightly lower A1C targets are encouraged if these can be achieved without excessive hypoglycemia. (See "Management of influenzatype 1 diabetes mellitus in children",children and adolescents", section on Antiviral resistance'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 see "Antiviral drugs for the treatmentonset of influenzasymptoms of autism in adults",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 Neuraminidase inhibitor resistance).
    25Respiratory syncytial virus
    '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 randomized controlled trial, children <18two-dose primary series two months with bronchiolitis who were treated with nebulized racemic albuterolapart is now recommended in the emergency department wereindividuals with persistent complement component deficiency or functional or anatomic asplenia, as likely to be successfully dischargedwell as those who were treatedfor adolescents with nebulized racemic epinephrine [34] . When adjustedHIV infection. In early 2011, the US Food and Drug Administration approved Menveo® for severityuse in children between 2 and 10 years of illness, patientsage who received racemic albuterol were slightly more likelyhave an indication for vaccination [19]. Menveo® is the second quadrivalent meningococcal conjugate vaccine to be successfully discharged. (See "Treatment; outcome;approved in the US. It had previously been approved only for individuals between the ages of 11 and prevention55 years. The specific meningococcal vaccine formulation and schedule indicated depend upon age, host factors (ie, type of bronchiolitis in infantsimmunodeficiency), and children",prior history of vaccination; recommendations are presented in the table (table 6). (See "Meningococcal vaccines", section on Inhaled bronchodilators).
    27Congenital diaphragmatic hernia
    'United States'.)
    New recommendations for Tdap
    As the survival rate improves in infants with congenital diaphragmatic hernia, there is an increasing needIn response to provide comprehensive care for these patients. Thean 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:
    A recommendation for off-label use of Tdap rather than tetanus toxoid-reduced diphtheria toxoid (Td) vaccine in children 7 to 10 years who are not fully vaccinated against diphtheria, tetanus, and/or pertussis. (see "Diphtheria, tetanus, and pertussis immunization in children 7 through 18 years of age",
    section on Surgery and'7 to 10 years')
    Elimination of
    the Committeeminimum interval between a tetanus- or diphtheria-toxoid-containing vaccine and Tdap when Tdap is otherwise indicated. (see "Diphtheria, tetanus, and pertussis immunization in children 7 through 18 years of age", section on Fetus'Routine schedule')
    Prevention of early-onset group B streptococcal disease — The Centers for Disease Control
    and NewbornPrevention has developedreleased updated guidelines for the prevention of perinatal group B streptococcal disease. The updated guidelines include a follow-up schedule to guide clinicians innew algorithm for the evaluation and management of these infants (show figure 1) [35] .newborns (algorithm 5) [21]. The revised algorithm decreases laboratory evaluation and empiric antibiotics for low-risk infants. (See "Congenital diaphragmatic hernia in"Management of the neonate", sectionsinfant whose mother has received group B streptococcal chemoprophylaxis", section on Complications and Post-discharge management).
    28CPAP and respiratory distress
    'Management approach'.)
    CDC guidelines for the treatment of STD
    Nasal continuous positive airway pressure (CPAP) may be a reasonable alternativeThe 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:
    A single dose of azithromycin (1 gram orally) has been shown
    to routine intubation and ventilation in very preterm infants who require respiratory supportbe clinically effective for treatment of chlamydial infections in the delivery room [36] . This was demonstrated bypregnancy. The previous recommendation for amoxicillin 500 mg orally three times a multicenter trial of 610 very preterm infants (gestational age between 25day for seven days is also recommended and 28 weeks) that reported no differenceis an equally effective, but less convenient, approach. Pregnant women should be retested for chlamydia three weeks after treatment, and women treated in the primary outcomefirst trimester should be retested three months later. (See "Treatment of death or bronchopulmonary dysplasia at 36 weeks corrected gestational age between neonates who received nasal continuous positive airway pressure (CPAP) comparedChlamydia trachomatis infection", section on 'Treatment during pregnancy'.)
    Diagnostic evaluation for cervicitis has been expanded
    to those who were intubatedinclude testing for C. trachomatis and ventilated.N. gonorrhoeae by nucleic acid amplification, and testing for bacterial vaginosis and trichomoniasis. (See "Prevention of respiratory distress syndrome in preterm infants","Cervicitis", section on Mechanical ventilation'Diagnostic evaluation'.)
    Treatment options for bacterial vaginosis have been expanded (table 7). (See "Bacterial vaginosis", section on 'Treatment of nonpregnant women'.)
    Treatment options for genital warts have been expanded
    and CPAP).
    29Long-term effects
    include waiting for spontaneous resolution, podofilox 0.5 percent solution or gel, imiquimod 5 percent cream, or sinecatechins 15 percent ointment (table 8). (See "Treatment of prematurity — A large population-based Norwegian studyvulvar and vaginal warts", section on 'Approach to treatment'.)
    The dose
    of more than 500,000 individuals demonstrated that survivorsceftriaxone for treatment of prematurity comparedgonorrhea has been increased from 125 mg to individuals born full-term had250 mg intramuscularly in a higher mortality rate throughout childhood and a lower reproductive ratesingle injection. (See "Treatment of urogenital gonococcal infections".)
    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 adulthood [37] .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 "Incidence"Evaluation and mortalitymanagement of the premature infant",suspected methicillin-resistant Staphylococcus aureus skin and soft tissue infections in children", section on Long-term mortality'Treatment overview' and see "Complications"Treatment of the premature infant",invasive methicillin-resistant Staphylococcus aureus infection in children", section on Effect on adult health).
    'Treatment approach' and "Treatment of viabilityStaphylococcus aureus bacteremia in children".)
    Treatment of acute otitis media
    Based upon data from severalMeta-analyses have suggested that many children with acute otitis media (AOM) improve without antimicrobial therapy. However, many included studies evaluating the outcome of extremely preterm infants cared for in the late 1990sdid not use stringent diagnostic criteria and early 2000s, the limitdid not include or focus on children <2 years of viability appearsage, a group that is more difficult to be decreasingtreat. Two recent randomized trials comparing amoxicillin-clavulanate and is approaching 22 weeks gestation [38-40] . (See "Incidenceplacebo included only young children (6 to 23 or 35 months), used a strict definition of AOM (a combination of acute signs/symptoms and mortalitymiddle 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 premature infant",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 Limit'Antibiotic therapy versus observation'.)
    of viability).
    31Oxygen monitoring
    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 multicenter study, whichsmall randomized trial compared pulse oximetry hemoglobin saturation (SpO2) valuesthese alternatives in immunocompetent children [26]. Median time to arterial blood gas measurementresolution was approximately nine months for both groups. No recurrences were reported in follow-up of oxygen tension (Pa02), demonstratedat least two years. These findings suggest that SpO2 valuesthere is little benefit from 85 to 93 percent provide a safe target rangeantimicrobial therapy for neonates who receive supplemental oxygen [41] .advanced NTM lymphadenitis. (See "Oxygen monitoring"Diagnostic approach to and therapyinitial treatment of cervical lymphadenitis in the newborn",children", section on Target pulse oximetry saturation).
    32Oxygen therapy during
    'Nontuberculous mycobacteria'.)
    neonatal resuscitation guidelinesOngoing efforts continue to determineBased upon review of clinical and laboratory evidence, the optimal initial oxygen concentrationAmerican Heart Association (AHA) and European Resuscitation Council (ERC), in collaboration with the International Liaison Committee on Resuscitation (ILCOR), published updated guidelines for neonatal resuscitation of preterm infants in the delivery room. Results2010 (algorithm 6) [27,28]. Two major changes from two small clinical trials suggest that initialprevious 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 with room air[27,28]. This recommendation is based on observations that neonates may resultremain cyanotic for several minutes following birth, as oxyhemoglobin saturation normally remains in hypoxia [42] , but resuscitation may be safely initiated using slightly higher concentrations fractionthe 70 to 80 percent range, and skin color is a poor indicator of inspired oxygen (ie, 30 percent) [43] .oxyhemoglobin saturation during the immediate neonatal period. (See "Oxygen therapy"Neonatal resuscitation in neonatal resuscitation",the delivery room", section on oxygen concentration).
    34Vesicoureteral reflux — There is increasing evidence that prophylactic antibiotics may not
    'Pulse oximetry'.) The guidelines specifically recommend pulse oximetry be an effective interventionused in reducing the ratefollowing 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 infection or renal scarringblended oxygen (mixture of room air and oxygen) in childrenconjunction with mildthe use of a pulse oximeter. No specified oxygen concentration was recommended, and the oxygen concentration is to moderate vesicoureteral reflux [44,45] .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 "Management of vesicoureteral reflux","Neonatal resuscitation in the delivery room", section on Intervention versus surveillance).
    36Cystic fibrosis
    'Supplemental oxygen'.)
    Sepsis and white blood cell count
    — The clinical variability among patients carryinguse of a complete blood count (CBC) in the same CFTR mutations is partly explainedevaluation of neonatal sepsis was supported by the presencea large multicenter study of polymorphismsinfants ≥34 weeks’ gestation, in separate genes, which act as gene modifiers [46] . Polymorphisms in transforming growth factor-beta (TGF-beta) or Mannose-binding lectin (MBL) are found in about 20 percentwhom both a blood culture and CBC were performed within the first 24 hours of patients with classic CF and are associatedlife [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 severe lung disease.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 "Genetics"Clinical features and pathogenesisdiagnosis of cystic fibrosis",sepsis in term and late preterm infants", section on Gene modifiers).
    38Septic shock
    'Other blood tests'.)
    Genetic causes of steroid-resistant nephrotic syndrome
    The antidiuretic hormone analogues, vasopressin and terlipressin (not available in United States), haveImmunosuppressive therapy generally has not been used as second-line pressor agentsshown to treat refractory septic shock [47,48] . In an unblinded randomized trial of 58be effective in treating children with catecholamine resistant shock, those who received terlipressin had increased mean arterial pressures, lowered heart rates, and increased arterial oxygenation without improvementsteroid-resistant nephrotic syndrome (SRNS) due to genetic causes. Screening for such mutations should be performed in overall survival relative toall children treated with conventional pressor therapy [47] . (See "Septic shock: Initial evaluationsteroid-resistant disease and management in children", section on Inotropes).
    40Biologic agents and JRA — Several trials demonstrate the increasing promise
    a family history of biologic agents inSRNS, to prevent the treatmentunnecessary administration of severe juvenile rheumatoid arthritis (JRA), which is refractory to conventionaladditional immunosuppressive therapy.
    In one trial, human recombinant anti-interleukin-6 monoclonal antibody (MRA, tocilizumab, atlizumab)
    This approach was more effective than placebosupported in improving symptomsa large case series, in which 43 of 91 patients had an identified genetic cause for their SRNS [30]. Two-thirds of the patients with severe systemic JRA, which was refractorynongenetic SRNS responded to conventional therapy [49] .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 "Management and complications"Treatment of systemic onset juvenile rheumatoid arthritis",idiopathic nephrotic syndrome in children", section on Anti-interleukin-6 antibody).
    In patients with moderate
    'Genetic mutations'.)
    Fetal surgery for myelomeningocele — Fetal surgery for myelomeningocele can arrest leakage of spinal fluid during gestation, and might therefore prevent
    or severe polyarticular JRA,reverse the Foodhydrocephalus and Drug Administration (FDA) approvedChiari 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 userisk of adalimumab, a monoclonal anti-TNF antibody, based upondeath 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 trialmanifestations of myelomeningocele (spina bifida)", section on 'Fetal surgery'.)
    Zinc supplementation in developing countries — Several placebo-controlled studies have suggested
    that demonstrated fewer disease flaresroutine supplementation with zinc in patients who received adalimumab comparedyoung 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 those who received placebo [50] . (See "Managementpregnant women in Peru reduced the risk of polyarticular onset juvenile rheumatoid arthritis",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 Adalimumab).
    41Anti-TNF agents
    'Prevention of diarrhea and malignancies — The FDA is reviewing the safetypneumonia'.)
    Investigational therapies for some types
    of all anti-tumor necrosis factor alpha agents (anti-TNFcystic fibrosis — Investigational therapies or TNF blockers) approved for usecystic fibrosis include some approaches that target specific types of defects in children becausethe transmembrane conductance regulator (CFTR) gene. Two phase 2 trials have yielded promising results in measures of 30 reportsCFTR function:
    Class I mutations
    of malignanciesCFTR, characterized by premature stop codons, are present in childrenabout 5 percent of cases of cystic fibrosis, and young adults who had started treatmenta much higher percentage in those with Ashkenazi Jewish heritage. Ataluren, an orally available drug, causes ribosomes to read through premature stop codons. In a TNF blocker over a 10-year period from 1998phase 2 trial, administration of ataluren to 2008 [51] . Pending the resultspatients with Class I CFTR mutations improved CFTR function, as measured by epithelial chloride transport measurements, in about half of this investigation, the FDA has stated that clinicians, patients, and parents should be awaresubjects [34]. (See "Cystic fibrosis: Investigational therapies", section on 'Class I mutations: Defective protein production'.)
    Class III mutations
    of the possible associationCFTR, which include G551D, are characterized by defective activation of these agents and malignancies, but the potential benefitsCFTR chloride channel. VX-770 is an investigational drug designed to improve activation of these agents outweigh the potential riskschannel. In a phase 2 trial, patients with the G551D mutation who were treated with VX-770 displayed improvements in certain children and young adults having onefunctional measures of the diseases for which the TNF blockers are approved to treat (eg, juvenile rheumatic arthritisCFTR function, including sweat chloride concentration and Crohn's disease).nasal potential difference [35]. (See "Tumor necrosis factor-alpha inhibitors: Risk of malignancy","Cystic fibrosis: Investigational therapies", section on Preliminary indication of cancer risk).
    43Influenza vaccine
    'Class III mutations: Defective regulation'.)
    Mortality associated with secondhand smoke exposure
    The United States CentersMounting evidence suggests that exposure to secondhand smoke (SHS) substantially increases risk for Disease Controlcoronary heart disease in adults, with associated morbidity and Prevention's Advisory Committee on Immunization Practices has recommendedmortality. A new study estimates that the age groupSHS is responsible for influenza immunization be expanded to include allabout 1 percent of mortality worldwide and that 28 percent of the mortality and 61 percent of the morbidity was seen in children between 6 months[36]. Most of the effects of SHS in children were due to lower respiratory infections and 18 yearsasthma, and most of age by the 2009-2010 influenza season [52] .attributable deaths in children were in developing countries. (See "Influenza vaccination"Secondhand smoke exposure: Effects in children", section on Target groups for TIV).
    44Rotavirus vaccine
    'What is secondhand smoke?' and "Secondhand smoke exposure: Effects in children", section on 'Respiratory symptoms and illness'.)
    Gastrointestinal involvement in Henoch-Schönlein purpura
    Post-licensure studies have confirmed the safetyGastrointestinal symptoms occur in about half of the pentavalent human-bovine reassortant rotavirus vaccine (PRV, RotaTeq)children with respectHenoch-Schönlein purpura (HSP) and range from mild (nausea, vomiting, abdominal pain, and transient paralytic ileus) to intussusception [53] .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 "Rotavirus vaccines","Clinical manifestations and diagnosis of Henoch-Schönlein purpura", section on PRV adverse effects).
    A second oral rotavirus vaccine (attenuated human rotavirus vaccine [HRV], Rotarix) has been licensed for use in infants in the United States [54] . HRV
    'Gastrointestinal symptoms'.)
    Clinical course of spondyloarthropathy — Undifferentiated spondyloarthropathy
    is administered in a two-dose series.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 first dose is given between 6number of active joints and 14 weeksentheses at disease onset were higher in the children who developed sacroiliitis. In a retrospective series of age;143 children with spondyloarthritis, hip arthritis was positively associated, and dactylitis negatively associated, with sacroiliitis [39]. These studies highlight the second dose is given at least 4 weeks later, but not after 24 weeksimportance of age [55] .following patients over a long period of time, as many patients with sacroiliitis will develop ankylosing spondylitis within 10 years. (See "Rotavirus vaccines","Spondyloarthropathy in children", section on Attenuated human rotavirus vaccine (HRV, ROTARIX).
    45Varicella — One-quarter
    'Course and prognosis'.)
    Clinical course
    of 148 healthy children immunized against varicella had no detectable varicella zoster virus antibodies four months after vaccination, raising concernsjuvenile fibromyalgia — A prospective study has found that about primary vaccine failure60 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 optimal interval beforenumbers are small, this study suggests that the second dose [56,57] .symptoms of juvenile fibromyalgia are likely to continue into adulthood. (See "Treatment and preventionprognosis of chickenpox").fibromyalgia in children and adolescents", section on 'Prognosis'.)
    Use of
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    2010 neonatal resuscitation guidelines
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    Genetic causes of steroid-resistant nephrotic syndrome
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    Zinc supplementation
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    Investigational therapies for some types of cystic fibrosis
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    Gastrointestinal involvement in Henoch-Schönlein purpura
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    Rotarix®(Rotavirus Vaccine, Live, Oral) Oral Suspension prescribing information. GlaxoSmithKline, Research Triangle Park, NC 2008.
    Michalik, DE, Steinberg, SP, LaRussa PS, et al. Primary vaccine failure after 1 dose
    febrero 17, 2011. The next version of varicella vaccineUpToDate (19.2) will be released in healthy children. J Infect Dis 2008; 197:944.
    Shapiro, ED. Second dose of varicella vaccine
    julio 2011.
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