|
-
Do steroids given
during acute bronchiolitis help prevent wheezing later? It has
been postulated that during the acute RSV infection the immune
response may induce long-lasting detrimental effects, thereby
contributing to post-bronchiolitis wheezing (PBW). Therefore,
immune-modulating drugs like corticosteroids, administered in the
acute phase of RSV bronchiolitis, may prevent PBW and asthma. A
randomized double-blind placebo-controlled intervention was
conducted in the acute phase with oral prednisolone 1 mg/kg/day
for 7 days or a placebo in fifty-four patients less than 2 years
of age and hospitalized for RSV bronchiolitis between 1992 and
1995. At the mean age of 5 years, 47 patients had completed their
follow-up but the incidence of wheeze in either group was not
different. So if you are sure its bronchiolitis, no need for
steroids (Pediatr Pulmonol 2000; 30: 92).
-
There is currently
no optimal test to screen for endogenous Cushing’s syndrome (CS)
in children. Traditional 24-hour urine or midnight serum cortisol
values may be difficult to obtain. Sixty-seven children (5-17
years) were enrolled in a study, with a break up of 24 obese
volunteers, 29 non-obese volunteers, and 14 children with CS.
Saliva was obtained at 7.30 a.m., bedtime, and midnight for
measurement of free cortisol by radioimmu-noassay. The diagnostic
accuracies of midnight salivary cortisol and urinary free cortisol
per square meter were the same (93%). Salivery cortisol
measurement at bedtime or midnight rules out CS in nearly all
cases. Night-time salivary cortisol sampling is thus a simple,
accurate way to screen for hypercortisolism in children (J Pediatr
2000; 137: 30).
-
The effectiveness
of intervention measures on the primary prevention of asthma has
not been well studied. To assess the effectiveness of a
multifaceted intervention program in the primary prevention of
asthma in high-risk infants, a prospective, prenatally randomized,
controlled study was conducted with follow-up through the age of 1
year. A total of 545 high-risk infants (at least 1 first-degree
relative with asthma or 2 first-degree relative with other IgE-mediated
allergic diseases) were identified before birth. They were
encouraged inter-ventions in the form of avoidance of house dust
mite and pet allergens and environmental tobacco smoke,
encouragement of breast-feeding, and supplementation with a
partially hydrolyzed formula. There was a modest but significant
(p = 0.04) reduction in the risk of possible or probable asthma
and rhinitis without apparent colds at the age of 12 months in
high-risk infants. The authors do readily concede that a prolonged
follow up is required to confirm the decrease in incidence of
asthma (Arch Pediatr Adolesc Med 2000; 154: 657).
-
Studies assessing
cost effectiveness of newer (and relatively expensive) techniques
are few and far between in any developing country including India.
A study from Hyderabad suggests that CT may be the initial
investigation of choice (and cost effective too) in management of
partial seizures. The etiological spectrum of 558 children (<16
years) with partial seizures seen in a university hospital in
south India, was analyzed. Single CT enhancing lesion (SCTEL;
solitary cysticercal granuloma), single small cerebral calcific CT
lesion (SSCCCTL), and multiple small cerebral calcific CT lesions
together accounted for 51% of patients categorized under
symptomatic localization-related epi- lepsies. They conclude that
in India a child with partial seizures with no obvious causation
has a high probability of harboring one of these three lesions (J
Trop Pediatr 2000; 46: 202).
-
With increasing
survivors from acute leukemia it has become imperative to study
the side effects of some of the drugs used in therapy. The effect
of high dose dexametha-sone therapy in induction phase of ALL on
adrenal function was studied in ten children with early B-cell
lineage acute lymphoblastic leukemia using the corticotropin
stimulation test. High-dose dexamethasone therapy can cause
adrenal insufficiency lasting more than 4 weeks after cessation of
treatment. This problem might be avoided by tapering doses of
glucocorticoids and providing supplemental glucocorticoids during
periods of increased stress (J Pediatr 2000; 137: 21).
-
What are the
predictors of neonatal sepsis? In a hospital based study among
18,299 newborns ³2000 g without major congenital anomalies, 2785
(15.2%) were evaluated for sepsis with a complete blood count
and/or blood culture. A total of 62 (2.2%) met criteria for
proven, probable, or possible bacterial infection. It was
concluded that the risk of bacterial infection in asymptomatic
newborns is low. Evidence-based observation and treatment
protocols could be defined based on a limited set of predictors:
maternal fever, chorioamnionitis, initial neonatal examination,
and absolute neutrophil count. (Pediatrics 2000; 106: 256).
-
Markers for airway
inflammation that can be measured noninvasively in expired air may
be helpful in treating patients with asthma. For example, levels
of nitric oxide are high in the breath of children with asthma
exacerbations and decrease with anti-inflammatory therapy. Expired
nitric oxide testing has now been standardized and may be useful
for children with recurring wheezing that is diagnostically or
therapeutically challenging. However, the results may be
influenced by several bio-chemical and anatomic variables and must
therefore be interpreted with caution (J Pediatr 2000; 137: 14).
-
The recognition,
follow-up, and early treatment of neonatal jaundice has become
more difficult, since the earlier discharge of newborns from
hospitals has become common practice. This prospective study was
under-taken to identify the newborns at risk for developing
significant hyperbilirubinemia by trying to determine the cutoff
critical predictive serum bilirubin value on the first day of
life. A total of 498 healthy term newborns were followed with
daily serum total bilirubin measurements for the first 5 days of
life, and cases with serum bilirubin levels of 17 mg/dL after 24
hours of life were defined to have significant hyperbilirubinemia.
They conclude that a serum bilirubin measurement of 6 mg/dL in the
first 24 hours of life will predict nearly all of the term
newborns who will have significant hyperbilirubinemia and will
deter-mine all those who will require a phototherapy treatment
later during the first days of life. (Pediatrics 2000; 106: e16).
-
Can neonatal MRI
predict later neurodevelopmental outcome? Fifty-two term infants
who presented at birth with a neonatal encephalopathy consistent
with HIE and who had neonatal brain MRI were entered into the
study. Head circumference charts were evaluated retrospectively
and the head growth over the first year of life compared with the
pattern of brain lesions on MRI and with the neurodevelopmental
outcome at 1 year of age. Suboptimal head growth was documented in
53% of the infants with HIE as compared to 3% of the controls.
Suboptimal head growth was significantly associated with the
pattern of brain lesions, in particular involvement of white
matter, basal ganglia and thalamic lesions and was a better
predictor of neurodevelopmental outcome than microcephaly
(Pediatrics 2000; 106: 235).
-
How soon do blood
cultures become positive? Conventional wisdom suggests that
routine techniques would take a minimum of 48-72 hours. However, a
recent study suggests otherwise. During the 47-month study period,
10,200 single bottle blood cultures were obtained, 711 (6.97%) of
which became positive. Of the 258 cultures containing only
pathogens, 14% were positive by 12 hours, 87% by 24 hours, 92% by
36 hours, 95% by 48 hours, 98% by 60 hours, and 99.7% by 72 hours.
Ninety-five per cent of critical pediatric pathogens including Streptococcus
pneumo-niae, Salmonella and other Enterobacteria-ceae, Neisseria
meningitidis, and groups A and B streptococci were detected in
<24 hours. This study can assist emergency department, clinic,
and primary care clinicians when making critical decisions
concerning patients on whom blood cultures were obtained. Use of
short stay (<24 hours) or extended care units requiring less
patient supervision may be easier to justify when a continuously
monitoring blood culture instrument is used in the microbiology
laboratory (Pediatrics 2000; 106: 251).
-
SIDS has long been
a topic of a raging debate. Now there’s another interesting and
complex theory as to its causation that implicates the cerebellum!
Dysfunction in affected brain areas appears to arise prenatally
from a compromised fetal environment, with a nicotinic component
contributing to the deficient mechanism. Physiologic character-istics
of infants who later succumb to SIDS, and cardiovascular events
associated with the fatal scenario suggest a failure of
interaction between somatomotor and autonomic control mechanisms
in infants at risk for the syndrome. A failure of compensatory
motor actions to overcome a profound hypotension, perhaps mediated
by cerebellar mechanisms that regulate blood pressure, may
underlie the fatal event (Pediatr Res 2000; 48: 140).
-
Use of IV
terbutaline has increased in PICU management of severe asthma. To
examine the cardiac toxicity as measured by elevations in serum
cardiac troponin T (cTnT), a prospective cohort study was
conducted. Only 3 (10%) of the 29 patients had elevations in cTnT.
Each underwent mechanical ventilation for >72 hours, which was
the earliest point at which cTnT elevations were identified. Both
mechanical ventilation (p = 0.02) and prolonged administration
(>72 hours) of intravenous terbutaline (p = 0.02) were
significantly associated with elevations in cTnT. The authors
found no clinically significant cardiac toxicity from the use of
intravenous terbutaline for severe asthma as measured by serum
cTnT elevations (J Pediatr 2000; 137: 73).
Gaurav Gupta,
Senior Resident,
Advanced Pediatric Center,
Postgraduate Institute of Medical
Education and Research,
Chandigarh 160 012, India.
E-mail: [email protected]
|
