June 23, 2021 | Volume 12 | Issue 25
Trends identified in food born illnesses from leafy greens
An interesting article reminds us of the large-scale food poisoning hazards associated with eating leafy greens from recent (and not so recent) outbreaks. It appears that:

1.) Escherichia coli (E. Coli) 0157; H7 infection is the organism frequently involved and often results in severe infection (sufficient to result in hospitalization and the development of hemolytic uremic syndrome).

2.) Outbreaks occur every Fall (since 2017) and are associated with eating leafy greens from 2 regions in California (the South Salinas and Santa Maria Valley’s).

3.) Cattle are a persistent source of E. Coli and outbreaks are associated with vegetable farms being in close proximity to grazing cattle or wild life.
Association of maternal influenza (flu) vaccination during pregnancy with early childhood outcomes
Influenza is likely to cause severe illness in pregnant and post-partum women, and receiving a flu shot (DO NOT ADMINISTER THE LIVE ATTENUATED VACCINE – LAIV, OR THE NASAL SPRAY) protects both the mother (40%-50%) and baby (by transplacental antibody transfer). The Center for Disease Control (CDC) and the Advisory Committee on Immunization Practices (ACIP) both recommend that pregnant women get vaccinated “during any trimester of pregnancy.”

A retrospective cohort study of 28,255 children ( >37 weeks gestation) born to women who received seasonal influenza vaccination during pregnancy examined childhood outcomes at 3.6 years (e.g., asthma, infections, non-immune disorders and urgent/in-patient healthcare utilization).

“Seasonal influenza vaccination in pregnancy is not significantly associated with adverse childhood health outcomes among offspring.”


See related video HERE and below:
Flu vaccines for pregnant women and children.
Association of intravenous radio contrast with kidney function
Hospitalized children frequently undergo computed tomography (CT) using iodinated contrast material to visualize blood vessels and/or organs. Acute kidney injury (AKI) has long been thought of as an associated risk, though recent data questions this relationship. (Iodinated contrast media can be divided into 2 groups – “Ionic” and “nonionic” based on their water solubility, and both “high osmolar” and “low-osmolar” forms exist. Non-ionic low-osmolar agents are usually utilized in children).

A study of 156,028 adult individuals which examined the association of intravenous radio-contrast and nephrotoxicity indicates that intravenous contrast does not appear to be associated with significant long-term (6 months follow-up) kidney injury.

Bacterial meningitis in the absence of pleocytosis in children
Pleocytosis (an increased cell count) in cerebrospinal fluid (CSF) is a “main” feature of bacterial meningitis in infants and children. When however children present with symptoms of meningitis early in the disease process, there is the possibility that the meninges may not have the time to be sufficiently inflamed to raise the white blood cell count in the CSF.

A systematic review of 26 studies (describing 62 children – 18 neonates) with culture or polymerase chain reaction (PCR) proven bacterial meningitis in the absence of pleocytosis describes some of the features found. These include:

  1. 80% have fever in the 24 hours prior to lumbar puncture (LP)
  2. Approximately 80% have a normal CSF glucose
  3. 44% of neonates and 80% of older infants/children have a normal CSF protein level
  4. 83% have a negative CSF gram stain
  5. 28% of neonates and 68% of older infants/children have a positive blood culture
  6. ALL CHILDREN WHO HAVE A SECOND LP HAVE AN ABNORMAL CSF


See related video below:
One year follow-up of adolescents with Internalizing problems utilizing the Pediatric Symptom Checklist (PSC)
“Screening for adolescent depression is a quality indicator of pediatric care…”

The PSC-17 is a general health screening instrument amenable to being a simple tablet-device, parent-completed tool for use in Primary care settings to assess behavioral disorders in adolescents with internalizing and/or externalizing symptoms and/or attention deficits. The PSC-17P-INT subscale has been validated as a screening implement to assess for adolescent depression.

A study of 1,068 adolescents (12-17 years of age) seen at a well-child visit (WCV) in 2017 and 637 of them who completed a second PSC questionnaire in 2018, assessed the feasibility of PSC-17P-INT adolescent screening for depression in Primary practice (and the prevalence of risk and rate of behavioral health (BH) services used before and after screening).

The PSC -17P-INT can be used in Primary care to track adolescents at risk for depression; most youth who initially screen positive (11.6%) remain at risk 1 year later. This data supports the quality guidelines which call for annual depression screening and follow-up for adolescent depression.
Postural orthostatic tachycardia syndrome (POTS) and disordered eating
POTS is a clinical syndrome characterized by autonomic dysfunction resulting in blood volume shifts which give rise to an increase in heart rate (>40 beats per minute) postural dizziness, light headedness, visual changes, near/syncope, headaches, chest and/or musculoskeletal pain/discomfort, brain “fog,” gastrointestinal symptoms, fatigue and poor sleep in adolescents 12-19 years of age (1%) when moving from a laying down state to a standing position. It occurs more often in girls (75%) is frequently triggered by an acute viral illness and is usually self-limiting with improvement in symptoms occurring by 19-21 years of age. Many risk factors and symptoms of POTS overlap with those of youths with Disordered eating.

A retrospective chart review of 96 adolescents and young adults diagnosed with POTS who had participated in a 3-week intensive interdisciplinary pain rehabilitation program examined a variety of issues and abstracted information about eating and weight concerns.

75% of youth with POTS engage in abnormal eating behaviors (e.g., restrictive eating) and 50% experience weight loss. Many experience food allergies and Celiac disease. 25% require invasive procedures (e.g., feeding tubes) to correct nutritional imbalances. All adolescents diagnosed with POTS require extensive screening for eating disorders.


See related video below:
Postural Orthostatic Tachycardia Syndrome
Living with POTS
Bridging the gap between Intensivists and Primary Care Clinicians in Extra-corporeal Membrane Oxygenation (ECMO) for respiratory failure in children
ECMO is a complex, resource intensive form of acute life support (similar to a “heart/lung bypass machine” but utilized for days to weeks), for a variety of critical respiratory/cardiac disorders. It has significant short and long-term complications (primarily from brain bleeding/blood clots in the machine) which include intracranial hemorrhage, ischemic stroke, seizures and subtle neurodevelopmental impairments. These conditions require to be identified early and treated to optimize long-term outcomes.

All primary care pediatric clinicians should be aware of not only the potential benefits but also of the complications of ECMO treatment. All survivors need effective neurological/
neurodevelopmental screening assessment, support, treatment and long-term follow-up.
  • Are mRNA COVID-19 vaccines safe for pregnant women?
  • Can you describe the potential adverse consequences associated with long-term use of oral corticosteroids?
  • What is the incidence rate of clavicular fractures in children?

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Featured Video
Michael's Story
Nicklaus Children's Hospital via YouTube

Michael is a very active athlete who enjoys competitive windsurfing, surfing, basketball, working out, yoga and meditation. Last year, he began feeling lethargic and tired, so his mother took him to the doctor's office for testing.
Mayo Clinic's COVID-19 Vaccine Tracker
Click HERE to view.
Dear Reader

I am sure many of you, like I, are feeling great relief at the improving outcomes following the various public health measures and SARS-CoV-2 immunization programs being undertaken in the USA to date. It seems that while there are many unanswered questions remaining, and firm answers not yet available on many interesting aspects, at present there is significant optimism that the mRNA vaccines will provide not only substantial (but not total) protection against the worst results of COVID-19 but will also minimize spread while appearing to be effective against the variants circulating.

Nevertheless I would urge all to remember that there are places and situations that place us at increased risk for infection, like hospitals, nursing homes, prisons and homeless shelters or while traveling. Some immunocompromised people will remain vulnerable to COVID-19. Continue to take care, wear a mask when appropriate, in addition wash hands or use a sanitizer when in risky situations, continue to cough or sneeze into ones elbow and be aware and cautious in balancing risks and benefits.
 
Best of luck.

Jack Wolfsdorf, MD, Editor
Staff NCH
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