Paediatrics and Neonatology - Current Awareness:February 2018

Cochrane Reviews(published January 2018)

Anti‐vascular endothelial growth factor (VEGF) drugs for treatment of retinopathy of prematurity

Mari JeevaSankar, JhumaSankar, Parijat Chandra

Authors' conclusions:Implications for practice: Intravitreal bevacizumab/ranibizumab, when used as monotherapy, reduces the risk of refractive errors during childhood but does not reduce the risk of retinal detachment or recurrence of ROP in infants with type 1 ROP. While the intervention might reduce the risk of recurrence of ROP in infants with zone I ROP, it can potentially result in higher risk of recurrence requiring retreatment in those with zone II ROP. Intravitreal pegaptanib, when used in conjunction with laser therapy, reduces the risk of retinal detachment as well as the recurrence of ROP in infants with type 1 ROP. However, the quality of the evidence was very low to low for most outcomes due to risk of detection bias and other biases. The effects on other critical outcomes and, more importantly, the long-term systemic adverse effects of the drugs are not known. Insufficient data precludes strong conclusions favouring routine use of intravitreal anti-VEGF agents - either as monotherapy or in conjunction with laser therapy - in preterm infants with type 1 ROP.

Implications for research: Further studies are needed to evaluate the effect of anti-VEGF agents on structural and functional outcomes in childhood and delayed systemic effects including adverse neurodevelopmental outcomes.

Probiotics for preventing acute otitis media in children Anna M Scott, Elaine M Beller, Justin Clark, Kristian Roos, Keith Grimwood, Paul Little, Chris B Del Mar

Abstract:This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the effects of probiotics to prevent the occurrence and reduce the severity of acute otitis media in children.

Embolisation for pulmonary arteriovenous malformation Charlie C‐T Hsu, Gigi NC Kwan, Hannah Evans‐Barns, Mieke L van Driel

Authors' conclusions: There is no evidence from randomised controlled trials for embolisation of pulmonary arteriovenous malformations. However, randomised controlled trials are not always feasible on ethical grounds. Accumulated data from observational studies suggest that embolisation is a safe procedure which reduces morbidity and mortality. A standardised approach to reporting with long-term follow-up through registry studies can help to strengthen the evidence for embolisation in the absence of randomised controlled trials.

Drug management for acute tonic‐clonic convulsions including convulsive status epilepticus in children Amy McTague, Timothy Martland, Richard Appleton

Authors' conclusions:We have not identified any new high-quality evidence on the efficacy or safety of an anticonvulsant in stopping an acute tonic-clonic convulsion that would inform clinical practice. There appears to be a very low risk of adverse events, specifically respiratory depression. Intravenous lorazepam and diazepam appear to be associated with similar rates of seizure cessation and respiratory depression. Although intravenous lorazepam and intravenous diazepam lead to more rapid seizure cessation, the time taken to obtain intravenous access may undermine this effect. In the absence of intravenous access, buccal midazolam or rectal diazepam are therefore acceptable first-line anticonvulsants for the treatment of an acute tonic-clonic convulsion that has lasted at least five minutes. There is no evidence provided by this review to support the use of intranasal midazolam or lorazepam as alternatives to buccal midazolam or rectal diazepam.

Research Articles

TRIGR Study Group (2018) “Effect of Hydrolyzed Infant Formula vs Conventional Formula on Risk of Type 1 DiabetesThe TRIGR Randomized Clinical Trial”.JAMA.;319(1):38–48.

Importance Early exposure to complex dietary proteins may increase the risk of type 1 diabetes in children with genetic disease susceptibility. There are no intact proteins in extensively hydrolyzed formulas. Objective To test the hypothesis that weaning to an extensively hydrolyzed formula decreases the cumulative incidence of type 1 diabetes in young children. Design, Setting, and Participants An international double-blind randomized clinical trial of 2159 infants with human leukocyte antigen–conferred disease susceptibility and a first-degree relative with type 1 diabetes recruited from May 2002 to January 2007 in 78 study centers in 15 countries; 1081 were randomized to be weaned to the extensively hydrolyzed casein formula and 1078 to a conventional formula. The follow-up of the participants ended on February 28, 2017. Interventions The participants received either a casein hydrolysate or a conventional adapted cow’s milk formula supplemented with 20% of the casein hydrolysate. The minimum duration of study formula exposure was 60 days by 6 to 8 months of age. Main Outcomes and Measures Primary outcome was type 1 diabetes diagnosed according to World Health Organization criteria. Secondary outcomes included age at diabetes diagnosis and safety (adverse events). Results Among 2159 newborn infants (1021 female [47.3%]) who were randomized, 1744 (80.8%) completed the trial. The participants were observed for a median of 11.5 years (quartile [Q] 1-Q3, 10.2-12.8). The absolute risk of type 1 diabetes was 8.4% among those randomized to the casein hydrolysate (n = 91) vs 7.6% among those randomized to the conventional formula (n = 82) (difference, 0.8% [95% CI, −1.6% to 3.2%]). The hazard ratio for type 1 diabetes adjusted for human leukocyte antigen risk group, duration of breastfeeding, duration of study formula consumption, sex, and region while treating study center as a random effect was 1.1 (95% CI, 0.8 to 1.5; P = .46). The median age at diagnosis of type 1 diabetes was similar in the 2 groups (6.0 years [Q1-Q3, 3.1-8.9] vs 5.8 years [Q1-Q3, 2.6-9.1]; difference, 0.2 years [95% CI, −0.9 to 1.2]). Upper respiratory infections were the most common adverse event reported (frequency, 0.48 events/year in the hydrolysate group and 0.50 events/year in the control group). Conclusions and Relevance Among infants at risk for type 1 diabetes, weaning to a hydrolyzed formula compared with a conventional formula did not reduce the cumulative incidence of type 1 diabetes after median follow-up for 11.5 years. These findings do not support a need to revise the dietary recommendations for infants at risk for type 1 diabetes.

Pölkki, Tarja et al. (2018) “Parents' Use of Nonpharmacologic Methods to Manage Procedural Pain inInfants”, Journal of Obstetric, Gynecologic & Neonatal Nursing , Volume 47 , Issue 1 , 43 - 51

Objective: To describe parents' use of nonpharmacologic methods to manage infant procedural pain in the NICU and determine the demographic factors related to such use. Design: A cross-sectional and descriptive study design. Setting: Level III and Level II NICUs (seven units) of four University Hospitals in Finland. Participants: Parents (N= 178) whose infants were treated in Finnish NICUs.

Methods: Parents were asked to respond to a structured questionnaire during their infants' hospitalizations. We analyzed the data using the nonparametric Kruskal–Wallis one-way analysis of variance and Mann–Whitney U test. Results: Most parents reported that they used physical methods, such as touching, holding, and positioning, nearly always/always (86%, 76%, and 55%, respectively). However, less commonly used strategies included recorded music (2%), breastfeeding (2%), and non-nutritive sucking with oral sucrose (6%). Many characteristics of the infants, such as their gestational ages and their conditions, were significantly related to the implementation of nonpharmacologic methods. Conclusion: There is a clear need to extend parents' use of nonpharmacologic methods to manage their infants' procedural pain in the NICU. Because many methods were not considered as pain-relieving strategies, it is important to increase knowledge about the effectiveness of these interventions among parents and nurses.

Tottman, Anna CatherineAlsweiler, Jane M. et al. (2018) “Long-Term Outcomes of Hyperglycemic Preterm Infants Randomized to Tight Glycemic Control”; The Journal of Pediatrics , Volume 193 , 68 - 75.e1

Objective: To determine whether tight glycemic control of neonatal hyperglycemia changes neurodevelopment, growth, and metabolism at school age. Study design: Children born very low birth weight and randomized as hyperglycemic neonates to a trial of tight vs standard glycemic control were assessed at 7 years corrected age, including Wechsler Intelligence Scale for Children Fourth Edition, Movement Assessment Battery for Children 2, visual and neurologic examinations, growth measures, dual X-ray absorptiometry, and frequently sampled intravenous glucose tolerance test. The primary outcome was survival without neurodevelopmental impairment at age 7 years. Outcomes were compared using linear regression, adjusted for sex, small for gestational age, birth plurality, and the clustering of twins. Data are reported as number (%) or mean (SD). Results: Of the 88 infants randomized, 11 (13%) had died and 57 (74% of eligible children) were assessed at corrected age 7 years. Survival without neurodevelopmental impairment occurred in 25 of 68 children (37%), with no significant difference between tight (14 of 35; 40%) and standard (11 of 33; 33%) glycemic control groups (P = .60). Children in the tight group were shorter than those in the standard group (121.3 [6.3] cm vs 125.1 [5.4] cm; P < .05), but had similar weight and head circumference. Children in the tight group had greater height-adjusted lean mass (18.7 [0.3] vs 17.6 [0.2] kg; P < .01) and lower fasting glucose concentrations (84.6 [6.30] vs 90.0 [5.6] mg⋅dL−1; P < .05), but no other differences in measures of body composition or insulin-glucose metabolism. Conclusion:Tight glycemic control for neonatal hyperglycemia does not change survival without neurodevelopmental impairment, but reduces height, increases height-adjusted lean mass, and reduces fasting blood glucose concentrations at school age.

DynaMed Plus Updates(published January 2018)

Topic / Topic
Management of patients with cerebral palsy / Chronic kidney disease (CKD) in children
Tonsillectomy / Obstructive sleep apnea (OSA) in children
Rehydration therapy in children / Micronutrient supplementation in children in low- and middle-income countries
Prevention of acute diarrhea

New NICE Guidance(published January 2018)

Reference / Guidance / Topic
MIB133 / Next-generation sequencing panel for solid tumour cancers in children / Medtech innovation briefing

Behind the Headlines(published January 2018)

  • Secondhand toys 'may pose toxic threat to children'
  • Statins 'safe' for children with genetic heart condition
  • Over half of 12-24 year olds have side effects from energy drinks, survey reports

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