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3 Top Articles You May Have Missed in August 2022

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AUTHOR:
Scott T. Vergano, MD
Department of Pediatrics, King’s Daughters Children’s Hospital, Norfolk, VA

QUOTE:
Vergano ST. 3 Top Articles You May Have Missed in August 2022. Consultant360. Published online September 21, 2022.


For this month’s column, I focus on carefully reading the latest revision of the American Academy of Pediatrics (AAP) clinical practice guidelines on the management of hyperbilirubinemia. No matter how much you know about neonatal jaundice or how long you’ve been dealing with it, I think you’ll learn something from a careful examination of its contents. In case you don’t have the chance, I’ve shared some of the most interesting gems the committee included in the statement. Additionally, I briefly offer my thoughts on growing pains and the recent polio case in New York. Feel free to share with your colleagues, chat in your offices, and write to [email protected] with your thoughts and opinions.

Management of hyperbilirubinemia in infants born at 35 weeks or more of gestation1

Although the most important aspect of this AAP publication is the slight revision of the thresholds for the initiation of phototherapy in term and late preterm infants, the clinical pearls it contains are worth noting. read. The committee updated the levels at which initiation of phototherapy is recommended. In addition to increasing the levels slightly, they also stratified the characterized levels by week of gestation. A quick look at the phototherapy nomograms will reveal that the values ​​are separated by week of gestation, with different values ​​for a child born at 35 weeks than at 36 weeks and at 38 weeks than at 39 weeks.

Another key feature of the new guideline is the definition of a “care escalation threshold”, which for any newborn is a total serum bilirubin level of less than 2 mg/dL below the exchange transfusion level. These infants should be treated and monitored aggressively to avoid possible kernicterus. Recommendations include emergent intensive phototherapy, hydration of fluids by intravenous therapy, serial bilirubin levels at least every 2 hours, and consultation with a neonatologist to consider transfer to a neonatal intensive care unit capable of initiate an exchange transfusion.

As mentioned, many pearls and shades are included in the guideline, which makes it worthy of your reading. Here are a few:

  1. If the maternal blood group is Rh+ (therefore the mother does not need Rh immunoglobulins), blood grouping of the newborn is an option but is not mandatory if the other guidelines are followed.
  2. All neonates should have at least 1 transcutaneous or serum bilirubin level measured, whether or not they appear to have jaundice.
  3. Serum bilirubin, rather than transcutaneous bilirubin, is recommended at levels above 15 mg/dL or below 3 mg/dL of the phototherapy threshold.
  4. A fractionated bilirubin level is recommended at 2 weeks of age for formula-fed infants and at 3 to 4 weeks of age for breastfed infants who remain jaundiced, to assess direct hyperbilirubinemia.
  5. Repeating an elevated direct bilirubin within a few days is recommended, as 99% of neonates with a single elevated direct bilirubin (>1.0 mg/dL) will not have biliary atresia.
  6. Prolonged indirect hyperbilirubinemia in a breastfed infant, or breastmilk jaundice, can last up to 3 months and is almost always mild.
  7. G6PD deficiency should be suspected in a neonate with atypical hyperbilirubinemia, which includes early, prolonged, or rapidly increasing jaundice, as well as late jaundice, recurrent jaundice, or jaundice in a milk-fed neonate mothered. Additionally, testing for G6PD deficiency should be performed on any infant requiring escalation of care.
  8. The G6PD test may be falsely within the normal range after an acute hemolytic event or after an exchange transfusion and should be repeated 3 months later.
  9. The risk of rebound hyperbilirubinemia is highest in infants with hemolytic disease or who require phototherapy during hospitalization at birth. These infants require testing for rebound bilirubin levels. All others require clinical evaluation 1-2 days after stopping phototherapy but do not necessarily require repeat bilirubin levels.

Defining growing pains2

In order to better define growing pains, the authors of this article from Pediatrics carry out a review of the literature on the somewhat nebulous subject. They searched 8 electronic databases and 6 disease classification systems and included all peer-reviewed English-language articles or diagnostic codes that included growing or growing pains. They looked at each of the 145 studies, along with the ICD-10 and SNOWMED codes, for its definition of the condition.

No characteristic was cited in more than 50% of the definitions. The most consistent features included lower extremity pain (referenced in 50% of definitions), evening or night pain (48%), episodic or recurrent pain (42%), normal examination findings physical (35%) and bilateral pain (31%). %). They conclude that their scoping review provides no consistent characteristics of growing pains and that clinicians and researchers should be careful when drawing conclusions based on what they consider to be the condition.

I believe most GP clinicians have seen what we consider growing pains and the condition is real and common. I have always taught learners that in my definition, 4 criteria are required: (1) the pain must at some point involve both legs (it cannot be localized to just one area or one leg); (2) pain should occur primarily at night; (3) the pain cannot interfere with regular daytime activities; and (4) physical examination should be normal and, in particular, should not involve any swelling or tenderness. Any leg pain that does not meet these criteria requires further investigation. Although much less scientific than this scoping review, my 4 criteria have served me well in my clinical practice.

Public health response to a case of paralytic poliomyelitis in an unvaccinated person and detection of poliovirus in sewage3

This case report published in Morbidity and Mortality Weekly Report provides details of the widely publicized case of paralytic poliomyelitis in an unvaccinated immunocompetent adult in Rockland County, New York. The man, who was transferred to a rehabilitation hospital and is recovering, did not travel abroad during the period of transmission and appears to have contracted the infection from a vaccine-associated strain transmitted by another person in the community who had been vaccinated with live attenuated vaccines. poliomyelitis vaccine. Investigations revealed significant vaccine-associated strains of poliovirus in sewage in Rockland and neighboring Orange Counties, and significantly low polio vaccination coverage (60.3% in children under 2 years of age) in Rockland County.

The last case of wild poliovirus transmission in the United States was in 1979. I remember starting practice at a time when there were 4 to 8 cases of polio infections each year in the United States. vaccine-associated poliomyelitis, leading to elimination of live virus. oral attenuated polio vaccine from the routine immunization schedule in 2000. This case should serve as a warning that if we allow immunization coverage to drop significantly, we will put our unvaccinated children and adults at risk of serious and life-threatening diseases that are now rare but still a threat. We must commit to educating our families and communities to eradicate these vaccine-preventable diseases.

References:

  1. Kemper AR, Newman TB, Slaughter JL, et al. Revised clinical practice guidelines: management of hyperbilirubinemia in neonates 35 weeks or more of gestation. Pediatrics. 2022;150(3):e2022058859. do I:10.1542/peds.2022-058859
  2. O’Keeffe M, Kamper SJ, Montgomery L, et al. Defining growing pains: a scoping review. Pediatrics. 2022;150(2):e2021052578. do I:10.1542/peds.2021-052578
  3. Link-Gelles R, Lutterloh E, Schnabel Ruppert P, et al; United States Poliovirus Response Team 2022. Public health response to a case of paralytic poliomyelitis in an unvaccinated person and detection of poliovirus in sewage – New York, June-August 2022. MMWR Morb Mortal Wkly Rep. 2022;71(33):1065-1068. do I:10.15585/mmwr.mm7133e2