Miami, FL
Dec. 6, 2017
Volume VIII |  Issue No. 49

Intoeing ("pigeon toes") in children
Intoeing describes the commonly seen painless inward turning of the feet that is often first noticed by parents when the baby begins walking, or when the child walks or runs. Three conditions in healthy children (generally < 8 years of age) cause in toeing; metatarsus adducts (the foot turns inward), tibial torsion and femoral anteversion. Almost always (95%) intoeing is benign, corrects itself without casts, braces or surgery and can be appropriately evaluated by an experienced Nursing Advanced Pediatric Practitioner (with orthopedic surgical backup).
Management of asymptomatic pediatric umbilical hernias
"Uncomplicated pediatric umbilical hernias are common and most close spontaneously."

A systematic review of 28 manuscripts that addressed optimal timing of repairs, complications when no repair was undertaken and likelihood of spontaneous closure indicates that observation until age 4 to 5 years regardless of the umbilical hernia size is safe and is the Standard of Practice in many pediatric hospitals.

Nitroglycerine (NGT) ointment for pediatric anal fissure
The management of an anal fissure in childhood has increasingly become more conservative with the use of stool softeners and medications to relax the anal sphincter.

An unequal randomized controlled study of 105 children (average age: 2 years) with anal fissure treated with either sitz bath, stool softener and local anesthetic or chemical sphincterotomy with 0.2% NTG ointment indicates that while the ointment treatment is effective, provides rapid symptom relief and good healing, treatment takes longer and recurrence may be a problem.

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Infantile retinal hemorrhages in the absence of brain and bodily injury  
An interesting study of 10 infants (2-9 months of age) with extensive retinal hemorrhage who were admitted to a hospital with one or more of; large heard circumference, alteration of level of consciousness, emesis or irritability; and all of whom had a detailed history, physical examination ( by child abuse pediatrician), ophthalmological examination, blood tests to detect clotting abnormalities, head CT and MRI scans, cervical MRI and skeletal surveys on admission and three weeks later (with normal developmental follow up >3 months later) found NO APPARENT BRAIN INJURY and NO EVIDENCE for a diagnosis of "shaken baby syndrome".

It appears that macrocephaly and chronic subdural hygroma may make an infant more prone to develop significant retinal hemorrhages in the absence of any brain injury (questioning the evidence for the rapid acceleration/deceleration theory for hemorrhages seen in the shaken baby syndrome).

Video Feature
Pigeon toes in children
Pigeon toes in children
Epidemiology and outcomes of hospitalized children with Necrotizing Soft Tissue Infections (NSTIs)
NSTIs include rare necrotizing forms of cellulitis, myositis and fasciitis which are characterized by rapid extensive tissue damage, generalized toxicity, and a high mortality which are usually caused by polymicrobial organisms (anaerobes; e.g. Bacteroides, Clostridium spp or Streptococcus) or a group A streptococcal infection.

A study of demographic and outcome data from 446 children with a diagnosis of NSTI indicates:

1. Median age 10 years.
2. Complications include "compartment syndrome" (4.4%), severe sepsis/septic shock (22.2%) and toxic shock (3.2%).
3. 29.3% require ongoing care after hospital discharge.
4. 72.1% have a bacterial infection.
5. Mortality is 6% (increased in Hispanic children, those with severe sepsis/septic shock and/or mechanically ventilated - surgery is associated with a lower mortality).
Primary spontaneous pneumothorax (PSP) in children
Pneumothoraces in children may be "Primary" (spontaneous) when no cause is found; "Secondary" as a complication of an acute or chronic lung condition or "Iatrogenic" as a result of mechanical ventilation, surgical procedures, etc. A small pneumothorax may be asymptomatic while large ones can be life-threatening.
A population wide study in Taiwan (23 million people) determined the age - stratified incidence, frequency and recurrence rate of PSP.
Adolescents/young adults 15-22 years of age appear to be at highest risk for PSP, with a readmission rate of 17-31%; 8% have more than 3 hospital admissions. Most (96%) recurrent episodes occur within 4 years of the initial attack.
See related video HERE & HERE 
Children who commute to school unaccompanied
From a study of 745 public school children age 6-12 years in Granada (Spain) it appears that older school children 10-12 years are more likely to travel unaccompanied, actively commute by walking or biking, and have a better understanding of safety issues than those who travel accompanied or who are younger in age.

Allowing older children to travel unaccompanied to school supports physical activity and potentially enhances the development of autonomy.

How is congenital heart defect identified prenatally? - Dr. David Drossner explains  
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Does maternal caffeine consumption during pregnancy affect behavioral outcomes in 11 year old offspring?
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What are the bariatric procedures to prevent the secondary deleterious effects of obesity?
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