HOT TOPICS
From Masters of Pediatrics—Contemporary and Future Pediatrics, presented January 25-30, 2006, by the University of
Miami Miller School of Medicine, Miami, FL
| RED BOOK UPDATE —Russell W. Steele, MD, Professor and Vice Chairman of Pediatrics, and Division Head, Infectious
Disease and Immunology, Louisiana State University School of Medicine, New Orleans
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| New terms: hand hygiene (instead of hand washing); adverse events (not adverse reactions); tuberculin skin test (TST; not
tuberculin purified protein derivative [PPD]); health care-associated (not nosocomial); name changes of organisms—
Pneumocystis jiroveci (not Pneumocystis carinii); Pityriasis versicolor (not Tinea versicolor); Norovirus (not Norwalk virus
)
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| Kawasaki disease (KD): diagnosis—presentation mimics that of measles (KD highest in differential diagnosis);
striking features (extremity changes [particularly swelling of hands and feet]; bulbar conjunctivitis); change in guideline
for duration of fever; typical KD—start intravenous (IV) gamma globulin (IV immunoglobulin [IVIG]) after 4 days
of fever; diagnosis made when 4 of 5 criteria met; principle features include cervical lymphadenopathy ≥1.5 cm (least
sensitive; relatively arbitrary); epidemiology—median age 2 yr (>5 yr of age, question diagnosis); KD seen in winter
and spring; boys more commonly affected than girls; in recent study, ≈1 in 50 who had sibling with KD developed KD
within 1 yr (with identical twins, probability 1 in 8); concern is development of coronary artery aneurysm (giant aneurysm
≥8 mm); incomplete KD—only 2 or 3 clinical criteria met; fever ≥5 days; perform baseline echocardiography
(ECHO), then follow up or treat (depends on laboratory information); laboratory criteria (C-reactive protein [CRP]
≥3.0 mg/dL; erythrocyte sedimentation rate [ESR] ≥40 mm/hr); if ≥3 criteria present, treat (<3, perform ECHO);
retreatment—10% of children fail IVIG (2 g/kg over 36 hr); retreat with 2 g/kg of IVIG, or use pulse steroid therapy; if
2 doses of IVIG fail, consider pulse steroid therapy
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| New combination vaccines: diphtheria and tetanus toxoids and acellular pertussis absorbed, hepatitis b (recombinant),
and inactivated poliovirus vaccine combined (Pediarix); diphtheria, tetanus, pertussis, polio and Haemophilus influenzae
type b vaccine combined (Pentacel) now before Food and Drug Administration (FDA); Haemophilus B
conjugate (meningococcal protein conjugate) and hepatitis B (recombinant) vaccine combined (Comvax) another new
product
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| Human papillomavirus vaccine: may be approved July 2006
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| Meningococcal vaccine (MCV-4; Menactra): young children most susceptible (highest incidence <4 yr of age);
quadrivalent conjugate vaccine approved for children ≥11 yr of age (investigated down to 2 yr of age); safe and effective;
concern for freshmen in college dorms (4- or 5-fold increase in overall incidence; still, incidence among freshmen in
dorms only 1 per 20,000); mortality with meningococcal meningitis ≈3%; target groups include freshmen living in dorms
and high-risk individuals (eg, microbiologists); Advisory Committee on Immunization Practices—Menactra should be offered
to any individual who wants to lower risk for meningococcal disease; universal immunization for children 6 to 24
mo of age; other candidates include close contacts of young children; children tend to have milder disease (mortalities in
patients >65 yr of age); children spread virus into household, then parents bring it to workplace
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| Bioterrorism: smallpox—fastidious virus (dies quickly on fomites); large vesicles in same stage of development; centrifugal
rash; long prodrome; symptoms include aching and fever; health care workers and caregivers at home at risk, but not
community (when patients feel terrible, they stay at home); triage in emergency department (ED); cidofovir is antiviral
agent effective in vitro against smallpox vaccine strains; able to control outbreak rapidly (widespread infection in community
unlikely); inhalation anthrax infection—diagnosed rapidly because progress so rapid; on chest x-ray, widened
mediastinum due to pulmonary edema; drug of choice ciprofloxacin; usually, doxycycline added; safe and potentially effective
in pregnant women and immunosuppressed individuals
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| Management of infants born to HIV-positive mothers: diagnosis—perform polymerase chain reaction (PCR)
test at birth, 1 to 2 mo of age, and 4 mo of age; if all negative, child can be treated as if not infected (reassure parents); enzyme-linked
immunosorbent assay (ELISA) test optional at 12 and 24 mo; consider CD4 counts at same time as PCRs (results
obtainable more quickly than PCR); if signs or symptoms suggestive of HIV infection, persistent Candida infection,
or failure to thrive, repeat testing; immunizations—in general, children can be given all immunizations (including measles,
mumps, and rubella [MMR]); varicella zoster vaccine (usually good CD4 counts at ≈1 yr of age; if child does not have severe
immune dysfunction, administer); hepatitis A virus vaccine recommended for all children at 12 mo of age (second
dose 6 mo after first); bacillus Calmette-Guérin (BCG) contraindicated
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| Caesarean delivery to prevent pediatric AIDS: decreases overall risk for vertical transmission of HIV by ≈50%
(efficacy varies, depending on whether mother has been on good treatment, aggressive therapy, or no therapy); maternal
ribonucleic acid (RNA) viral loads <1000 copies/mL—if mother compliant during pregnancy, vertical transmission
1% (risk probably reduced further by caesarean delivery, but no data)
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| Accidental needlesticks in community: adding protease inhibitor to combination zidovudine/3TC; caveat—
protease inhibitors cause more adverse events in normal people than in AIDS patients
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| TOP 10 ARTICLES IN DEVELOPMENT AND BEHAVIORAL PEDIATRICS —Martin T. Stein, MD, Professor of Pediatrics,
University of California, San Diego, School of Medicine
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| Do tympanostomy tubes improve developmental outcomes? (study by Paradise et al): after development
of middle ear effusions, many children have tympanostomy tubes inserted to improve hearing and possibly to improve long-
term developmental outcomes; 395 children <3 yr of age who had persistent bilateral effusions for 90 days or unilateral effusion
for 135 days; insertion of tympanostomy tubes performed promptly (ie, at 3 mo) or up to 9 mo later (depending on
whether effusion persisted); at 6 yr of age, 85% of children in prompt-treatment group received tubes, compared to 41% of
children in delayed group; no differences observed between groups in 29 of 30 measures of cognitive, language, speech, and
psychosocial development; mean verbal IQ 98 in both groups; no differences observed in analysis adjusted for age; results
cannot be generalized to children who are not otherwise healthy or who have effusion accompanied by moderate-to-severe
hearing loss; placement of tympanostomy tubes in children with middle ear effusion and mild-to-moderate hearing loss does
not improve developmental outcome in children ≤6 yr of age
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| Cerebral palsy (CP): new guidelines by American Academy of Neurology endorsed by American Academy of Pediatrics
(AAP) on evaluation of child with CP; neuroimaging—abnormal computed tomography (CT) and magnetic resonance
imaging (MRI) common in children with CP; neuroimaging recommended in children for whom etiology of CP
not established; MRI preferred over CT because it may provide more information about etiology and timing of insult
that led to CP; metabolic and genetic testing—rarely, metabolic disorder (eg, glutaric aciduria) associated with CP; inborn
error of metabolism associated with ataxic CP (not common); consider possibility of glutaric aciduria and screen
using plasma amino acid test; metabolic and genetic screening should be considered if history or clinical examination
consistent with specific syndrome or if clinical history of neuroimaging does not suggest specific structural abnormality;
physical examination may suggest genetic disorder (child smiling frequently and laughing intermittently typical of
Angelman’s syndrome; fluorescent in situ hybridization [FISH] test appropriate to look for chromosome 15 deletion);
coagulopathies—hemiplegic CP often associated with cerebral infarction (testing for coagulopathies appropriate); electroencephalography
(EEG)—half of children with CP develop epilepsy; however, insufficient data to recommend routine
EEG in children without seizures; screen for associated conditions
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| Sudden infant death syndrome (SIDS): rate in United States decreased dramatically by putting infants on backs
for sleep; new AAP recommendations—place infants in supine position (side sleeping no longer considered safe); use
firm mattress (avoid soft objects and loose bedding); universal recommendation to avoid bed-sharing (controversial);
place crib or bassinet in parents’ bedroom; pacifier use at bedtime during first year after birth associated with ≈50% reduction
in SIDS; delay introduction of pacifier in breast-fed babies until 1 mo of age or until nursing well established;
avoid positional plagiocephaly—encourage tummy time during day to prevent pressure in back of head and improve
shoulder strength; vary supine head position; avoid excessive time in car seat carriers and bouncers
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| Pemoline (Cylert) withdrawn from market (FDA alert): central nervous system (CNS) stimulant prescribed
for treatment of attention-deficit/hyperactivity disorder (ADHD); overall risk for liver toxicity outweighs benefits; at
least 12 deaths or liver transplantations associated with pemoline
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| Atomoxetine (Strattera; FDA public health advisory): drug associated with increased risk for suicidal thinking
in children and adolescents; atomoxetine selective norepinephrine reuptake inhibitor; examined in patients on 12 trials;
atomoxetine showed greater risk for suicidal ideation than placebo (in cohort, 4 per 1000 patients experienced suicidal
thoughts, none in placebo group); increased risk should be weighed against clinical need for drug; talk to parents and
patients about diagnosis and potential side effects; monitor carefully for signs of clinical worsening, suicidal thinking
or behaviors, or other significant behavior change (irritability and agitation) when therapy initiated or dose increased
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| Posttraumatic stress disorder (PTSD) in parents due to new diagnosis of type 1 diabetes in child
(study by Landolt): in diabetes, parental psychologic adjustment predicts child’s metabolic control; 52 children 6 to
15 yr of age; study conducted in Switzerland; mean number of hospital days at diagnosis 14.3; prevalence of PTSD in
mothers at 6 wk, 6 mo, and 12 mo was 22%, 16%, and 20%, respectively (in fathers, 14%, 10%, and 8%); rates significantly
higher than in community samples (2.2% for women; 1% for men); as group, metabolic control excellent (however,
poorer control at 6 and 12 mo associated with more parental symptoms of PTSD); best pediatric practice is family
pediatrics where child’s clinician attuned to psychologic adaptation of parents at time of illness; treating parent early
for PTSD may help child
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| ED pediatricians underestimate posttraumatic stress responses in children: acute stress responses (ASRs)
to trauma include fear, helplessness or horror, detached emotional feelings, dazed feeling, and re-experiencing traumatic
events; failure to recognize early ASRs in days and weeks after violent or traumatic event could lead to development
of PTSD in children months or years later; only 7% of ED pediatricians believe current statistic from literature
that 4 of 5 children likely to develop ASRs within 1 mo after motor vehicle injury; 86% of respondents incorrectly believe
that injury severity associated with future risk for development of PTSD; only 11% aware of screening tools for
assessing risk (18% provided verbal guidance; 3% provided written instructions to families about posttraumatic stress)
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| Links between early maturation, neighborhood, and violent behavior in girls (study by Obeidallah):
girls with menarche before 11 yr of age evaluated at 12 and 15 yr of age; violent behaviors assessed; independently,
neither timing of menarche nor neighborhood characteristics affect violent behavior; however, combined early menarche
and disadvantaged neighborhood associated with 3-fold increase in violent acts, compared with early maturation
in less disadvantaged neighborhood; girls with early maturation residing in disadvantaged neighborhoods more likely
to engage in violent behavior; additional education, support, and follow-up indicated for early maturing girls in high-
risk environments
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| Repetitive movements not limited to children with autism: repetitive movements of arms, hands, and other
parts of body or complex motor stereopathies often seen in children with autism and mental retardation; findings—40
typically developing children from 9 mo to 17 yr of age (majority boys); onset of repetitive movements almost always
before 3 yr of age; episodes occurred at least once daily in 90%; triggers included excitement (70%), boredom, fatigue,
tiredness, and stress; movements stop in almost all children in response to cue, eg, calling subject’s name; family history
of stereopathies identified in 25% (ADHD in 10%; mood or anxiety disorder in 38%); >50% had symptoms for >5
yr; treatment limited to associated conditions; movements resolved in 5% of children (improved in one third; unchanged
in 50%; worsened in 13%); repetitive movements sometimes present in typically developing children (not all
repetitive stereotypic movements associated with autism or mental retardation)
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| Evidence-based program to promote reading in well-child visits (study by Needleman): reading aloud
to young children enhances development of literacy; preschool children read to ≥3 times/wk more likely to recognize
all letters of alphabet, count to 20, write own name, and read or pretend to read at school entry; Reach Out and Read
(ROR) program encourages parents to read books to infants beginning as early as 6 mo of age at each well-child visit
until 5 yr of age; volunteers model effective reading strategies; researchers interviewed >1600 parents (primarily from
low-income families) before initiation of program and 1 yr later; significant associations found between exposure to
ROR and reading aloud as favorite parent activity, reading aloud at bedtime, reading aloud 3 times per week, and ownership
of >10 books; comment—ROR program practical primary care intervention with minimal cost and time allocation
in primary care offices and clinics serving low-income families
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Educational Objectives
| The goal of this program is to educate the listener about new pediatric guidelines and recent advances in developmental
pediatrics. After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Use appropriate timing in initiating intravenous immunoglobulin therapy for Kawasaki disease.
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| 2. Determine which vaccines may be safely administered to infants born to HIV-positive mothers.
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| 3. Describe recent recommendations for preventing sudden infant death syndrome.
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| 4. Identify potential side effects of atomoxetine in children and adolescents.
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| 5. Recognize posttraumatic stress disorder in children who have been injured in motor vehicle accidents.
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Discussed on This Program
Atomoxetine HCl [Strattera]
BCG vaccine [TICE BCG]
BCG, intravesical (Bacillus of Calmette and Guérin) [Pacis, TheraCys, TICE BCG]
Cidofovir [Forvade (investigational), Vistide]
Ciprofloxacin [Ciloxan, Cipro, Cipro I.V., Cipro XR, Proquin XR]
Diptheria and tetanus toxoids and acellular pertussis adsorbed, hepatitis B (recombinant), and inactivated poliovirus
vaccine combined [Pediarix]
Doxycycline (several formulations and trade names)
Haemophilus b conjugate vaccine with hepatitis B vaccine [Comvax]
Hepatitis A vaccine, inactivated [Havrix, Vaqta]
Human papillomavirus vaccine (investigational)
Huperzine A
Immune globavenous (IGIV) [Gamunex]
Immune globulin IV (human) 10% [Gammagard]
Lamivudine and zidovudine (3TC/ZDV; 3TC/AZT) [Combivir]
L-tryptophan
Measles, mumps, and rubella virus vaccine, live [M-M-R II]
Meningococcal polysaccharide vaccine [Menomune-A/C/Y/W-135, Menactra]
Pemoline (withdrawn from market 10/28/05)
Tuberculin purified protein derivative (Mantoux; PPD; tuberculin skin test [TST]) [Aplisol, Tubersol]
Varicella virus vaccine [Varivax]
Varicella-zoster immune globulin (human) (VZIG)
Resources
reachoutandread.org
Suggested Reading
[No authors listed]: Menactra: a meningococcal conjugate vaccine. Med Lett Drugs 47:29, 2005; American Academy
of Pediatrics Task Force on Sudden Infant Death Syndrome: The changing concept of sudden infant
death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider
in reducing risk. Pediatrics 116:1245, 2005; Ashwal S et al: Practice parameter: diagnostic assessment of the
child with cerebral palsy: report of the Quality Standards Subcommittee of the American Academy of Neurology and the
Practice Committee of the Child Neurology Society. Neurology 62:851, 2004; Derrick JL, Gomersall CD: Community
needlestick injuries may still be dangerous. Arch Dis Child 90:1204, 2005; Gandhi A, Wilson DG: Incomplete
Kawasaki disease: not to be forgotten. Arch Dis Child 91:276, 2006; Landolt MA et al: Prospective study of posttraumatic
stress disorder in parents of children with newly diagnosed type 1 diabetes. J Am Acad Child Adolesc Psychiatry
44:682, 2005; Mahone EM et al: Repetitive arm and hand movements (complex motor stereotypies) in children. J Pediatr
145:391, 2004; Makwana N, Riordan FA: Prospective study of community needlestick injuries. Arch Dis Child
90:523, 2005; Needleman R et al: Effectiveness of a primary care intervention to support reading aloud: a multicenter
evaluation. Ambul Pediatr 5:209, 2005; Oates-Whitehead RM et al: Intravenous immunoglobulin for the treatment
of Kawasaki disease in children. Cochrane Database Syst Rev 4:CD004000, 2003; Obeidallah D et al: Links between
pubertal timing and neighborhood contexts: implications for girls’ violent behavior. J Am Acad Child Adolesc Psychiatry
43:1460, 2004; Omenaca F et al: Response of preterm newborns to immunization with a hexavalent diphtheria-tetanus-acellular
pertussis-hepatitis B virus-inactivated polio and Haemophilus influenzae type b vaccine: first experiences
and solutions to a serious and sensitive issue. Pediatrics 116:1292, 2005; Veenema TG: Safeguarding our nation’s children:
the diagnosis, management, and containment of smallpox in infants and children. Biol Res Nurs 4:295, 2003; Ziegler
MF et al: Posttraumatic stress responses in children: awareness and practice among a sample of pediatric
emergency care providers. Pediatrics 115:1261, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Drs. Steele and Stein were recorded at Masters of Pediatrics—Contemporary and Future Pediatrics, presented January 25-
30, 2006, in Bal Harbour, FL, by the University of Miami Miller School of Medicine, Department of Pediatrics and Department
of Dermatology and Cutaneous Surgery. The Audio-Digest Foundation thanks the speakers and the sponsor for
their cooperation in the production of this program.
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