Dilek Dilli

Interventions to Reduce Pain during Vaccination in Infancy

OBJECTIVEnTo investigate interventions that affect pain reduction during vaccination in infants and children attending a well-child unit.nnnSTUDY DESIGNnA consecutive sample of 243 children between age 0 and 48 months receiving their routine vaccinations was randomly assigned to 1 of the study groups. A total of 158 infants under age 6 months were randomly assigned to breast-feeding or no breast-feeding during immunization, and 85 children age 6 to 48 months were randomly assigned to receive 12% sucrose solution, lidocaine-prilocaine cream, or no intervention. All children were evaluated for crying time and pain score by a pediatrician using the Neonatal Infant Pain Scale (NIPS) for those under age 12 months and the Childrens Hospital of Eastern Ontario Pain Scale (CHEOPS) for those over age 12 months.nnnRESULTSnBreast-feeding in infants under age 6 months and use of sucrose or lidocaine-prilocaine in children age 6 to 48 months significantly reduced crying time and pain scores compared with controls. No difference in outcome was seen between the sucrose and lidocaine-prilocaine treatment groups.nnnCONCLUSIONSnHere we expand on previous findings by demonstrating that breast-feeding may have an analgesic effect up to age 6 months and that in older children, both sucrose and lidocaine-prilocaine reduce vaccination pain.

Oral sucrose and non-nutritive sucking goes some way to reducing pain during retinopathy of prematurity eye examinations.

To evaluate the efficacy of oral sucrose combined with non‐nutritive sucking for reducing pain associated with retinopathy of prematurity screening.

Treatment outcomes of infants with cyanotic congenital heart disease treated with synbiotics.

OBJECTIVES: The goal was to investigate the effect of orally administered synbiotics on outcome of infants with cyanotic congenital heart disease (CCHD). METHODS: A prospective, blinded, randomized controlled trial was conducted to evaluate the effect of synbiotics on outcome of infants with CCHD. The infants with CCHD were assigned randomly to 2 groups. Infants in the study group were given synbiotic (Bifidobacterium lactis plus inulin) added to breast milk or mixed feeding until discharge or death. Infants in the placebo group were fed with breast milk or mixed feeding. The outcome measurements were nosocomial sepsis, necrotizing enterocolitis (NEC; Bell stage ≥2), length of NICU stay, and death. RESULTS: A total of 100 infants were enrolled in the trial: 50 in each arm. There were 9 cases of culture-proven sepsis (18%) in the placebo group and 2 cases (4%) in the synbiotic group (P = .03). Length of NICU stay did not differ between the groups (26 [14–36] vs 32 days [20–44], P = .07]. There were 5 cases of NEC (10%) in the placebo group and none in the synbiotic group (P = .03). The incidence of death was lower in synbiotic group (5 [10%] of 50 vs 14 [28.0%] of 50, respectively; P = .04). CONCLUSIONS: Synbiotics administered enterally to infants with CCHD might reduce the incidence of nosocomial sepsis, NEC, and death.

Lidocaine should only be used in neonatal seizures that do not respond to first‐generation AEDs

Sir, We read with great interest the article by Lundqvist et al. (1), which evaluated the efficacy and safety of lidocaine for treating neonatal seizures in infants (gestational age ≥37 week, age ≤28 days) following benzodiazepines, but not preceding phenobarbital treatment. The authors reported that the treatment stopped seizures in 16 of the 30 infants studied. Suspected adverse effects were only seen in one patient, who developed a transient bradycardia. Indeed, several studies indicate that lidocaine is an effective agent for intractable neonatal seizures that do not respond to firstgeneration antiepileptic drugs (AEDs). However, data on the use of lidocaine are limited and it is used off-label in neonates with refractory seizures (2). Phenobarbital, a firstgeneration AED, is still widely used for the treatment of neonatal seizures. It is still preferable because of its efficacy and tolerability. In addition, it is a cost-effective pharmacologic treatment for lowand middle-income countries. There are some disadvantages of lidocaine in clinical practice. For example, the distribution volume and unbound fraction of lidocaine is greater in neonates than in adults who have a low concentration of plasma proteins. In addition, lower glomerular filtration rates reduce renal clearance of lidocaine and its active metabolites, thereby increasing the risk of toxicity in neonates when used for prolonged periods. There is no consensus regarding the dose of lidocaine infusion. Its higher plasma concentrations may cause seizure activity (‘proconvulsant’ effect), and one study highlighted the risk of developing cardiac arrhythmias (bradycardia, tachycardia, prolonged QRS complex and/or irregular heart) (3). For this reason, continuous cardiac and serum monitoring of neonates is indicated. Furthermore, neurotoxic effects of lidocaine in newborns are also reported. Therefore, we think that lidocaine should only be used as an alternative treatment in infants who are not responding to first-generation AEDs. There is an urgent need for prospective, randomised, controlled trials to assess the pharmacokinetic, efficacy and safety of lidocaine in neonates.

Non Benign Neonatal Arrhythmias Observed in a Tertiary Neonatal Intensive Care Unit

ObjectiveTo analyze non benign neonatal arrhythmias (NA) observed in a tertiary neonatal intensive care unit (NICU).MethodsFrom June 2006 through July 2011, newborns admitted to the NICU for NA or diagnosed as NA after hospitalization were evaluated retrospectively. The newborns with non benign NA were included in the study.ResultsDuring the study period, the incidence of non-benign NA was 0.7xa0% (nu2009=u200955/7880). The mean age at diagnosis was 16.7u2009±u20091.8xa0d ranging from 1xa0d to 90xa0d. The most common type was supraventricular arrhythmia (SVT) with an incidence of 0.3xa0%. Univariate analyses showed that there were significant differences between the survived and died infants according types of congenital heart disease (CHD), electrolyte imbalance, and arrhythmias. The mortality rates were higher among infants with obstructive type left-to right shunt and common mixing type CHD. The most dangerous type of electrolyte imbalance was hyperkalemia.ConclusionsMany arrhythmias could not be noticed at neonatal period even in NICU, implying that it is increasingly important for the physician to be aware of the etiology, development, and natural history of these arrhythmias.

Comparison of ketamine plus midazolam versus ketamine for sedation in children during lumbar puncture.

To the Editor: Refractory abdominal pain is a common symptom for which patients seek consultation in pain clinics. The common causes of abdominal pain include pathologies of gastrointestinal, genitourinary, musculoskeletal and nervous systems, as well as other systemic diseases. Takayasu arteritis (TA) is a rare, inflammatory disease of the aorta and its major branches. Stenotic arterial segments can result in variety of ischemic symptoms. Early diagnosis of this large vessel vasculitis has been challenging because of the nonspecific signs and symptoms including fever, fatigue, skin lesions, dizziness, palpitations, hypertension, and abdominal pain. We reported an unusual presentation of chronic, intractable abdominal pain in a 42-year-old, obese African American female. She had more than 20 years’ history of chronic, intermittent mid-lower abdominal pain, and presented to pain clinic after having had an extensive evaluation and negative work-up including upper, lower gastrointestinal endoscopies, and laboratory works for evaluation and treatment recommendation. Her crampy abdominal pain of variable duration and frequency (10 to 12 times a day, last from 15min to 8 h) was associated with nausea and vomiting, and was partly relieved by vomiting. This led to an extensive evaluation involving multiple abdominal surgeries over 20 years without resolution of her abdominal pain. Later on, she had developed some dizziness along with her abdominal pain, primarily postprandial. Discrepancy of her blood pressure was found in bilateral arm: 124/94mm Hg in the right arm and 150/85mm Hg in the left arm, and bruits in her bilateral carotid and subclavian artery. Her magnetic resonance angiography showed diffuse vessel wall thickening of entire thoracic aorta and great vessels off the aortic arch, and mild wall thickening and slight narrowing of the proximal common iliac arteries bilaterally in the presence of patent ascending aorta, renal arteries, celiac artery, and superior and inferior mesenteric arteries. Finally, TA was diagnosed based on the patient’s clinical features and imaging studies in addition to the negative findings of prior endoscopies and exploratory laparotomy, and the typical histologic findings of tissue biopsy, according to ‘‘1990 Criteria of American College of Rheumatology for the Classification of Takayasu Arteritis.’’ The patient was subsequently placed on treatment of prednisone and methotrexate, which resulted in a complete relief of her abdominal pain. Of interest in this case is that there is no visible abnormality of celiac and mesenteric vasculature found by magnetic resonance angiography. The patient’s chronic, intractable abdominal pain is likely secondary to the mesenteric ischemia caused by possible vasospasm of the intestinal vasculature, reduced blood flow in the intestine during eating, and/or referred pain from the surrounding ischemic structures. TA has a varied clinical presentation. The disease may present its atypical form as shown in this patient. The interesting point of this case is the chronic, intractable abdominal pain secondary to TA after the extensive work-up over the past 20 years despite normal imaging of celiac and mesenteric vasculatures. This report emphasizes the importance of ensuring a thorough evaluation in patients who are experiencing abdominal pain with systemic symptoms. Early suspicion of this disease and consultation to the appropriate subspecialty service to facilitate the definite diagnosis of such a condition could reduce the cost of healthcare, and avoid some unnecessary procedures or surgeries.

Do Different Vaccination Regimens for BCG and Hepatitis B Affect the Development of Allergic Disorders in Early Childhood

Aim. To determine whether age at bacilli Calmette-Guérin (BCG) and hepatitis B vaccination has an effect on the development of atopy and allergic disorders in early childhood. Methods. This was a cross-sectional study of 109 children aged between 24 and 36 months with respiratory system diseases. The study population was divided into two groups according to vaccination regimens: group 1, beginning hepatitis B vaccination at birth and receiving BCG vaccine at two months of age; group 2, receiving BCG vaccine at birth and beginning hepatitis B vaccination at two months of age. Atopic status was assessed by skin-prick tests (SPTs). Results. There was no statistically significant difference in atopy between two groups (p = 0.27). However, the prevalence of recurrent wheezing was higher in group 1 (36.4%) than group 2 (16.3%) (p = 0.04). Logistic regression analysis identified receiving BCG vaccine at birth and beginning hepatitis B vaccination at the age of two months were protective for recurrent wheezing (odds ratio 0.5; confidence interval: 0.3–0.8; p = 0.01). Conclusion. We believe that the administration of BCG vaccine at birth and hepatitis B vaccine at two months may be protective against recurrent wheezing but doesnt prevent atopy.

Birth size effect on pulmonary functions and atopic sensitization in preadolescence

Background: The purpose of the present paper was to examine whether low birth size is associated with reduced pulmonary function and increased atopic sensitization in preadolescence.

Fibrinolytic therapy of thrombosis in 27 newborns followed-up in neonatal intensive care unit.

Background and Aim: We aimed to report newborns with thrombosis and needed fibrinolytic treatment. Patients and methods: This was a retrospective study conducted on 27 newborns with thrombosis followed-up in a neonatal intensive care unit between December 2007 and December 2012. The patients were divided into two groups according to treatment protocol; Group 1 (n = 15): recombinant tissue-type plasminogen activator (r-tPA) and Group 2 (n = 12): streptokinase (STK). The groups were compared in terms of the efficacy and complications of the treatments. Results: In Group 1, flow restoration was complete in nine (60%) patients, partial in two (13.3%), and absent in four (26.7%). In Group 2, flow restoration was complete in seven (58.3%) patients, partial in three (25%), and absent in two (16.0%). The incidence of complete/partial recovery was similar in the groups. There was no difference between the two groups with regard to the duration of thrombus resolution. Fibrinolytic treatment was terminated in seven patients (46.7%) in Group 1, while in three patients (25%) in Group 2 due to the complications. The most common complications were minor or major bleedings. There was no statistically significant difference with regard to all bleedings complications between the two groups (P = .08), although the incidence of skin hemorrhages was higher in Group 1 (P = .007). There was no significant difference between the mortality rates. Conclusion: Even though the use of STK is not further recommended because of its potential undesirable side effects in newborns, its efficacy and safety appears to be similar to those of r-tPA.

Cerebral salt wasting in a child with cervicothoracic hematoma.

Although the syndrome of inappropriate antidiuretic hormone secretion (SIADH) is commonly observed in patients with acute or chronic central nervous system (CNS) disorders, cerebral salt wasting (CSW) that results in hyponatremia has rarely been reported in children. Both SIADH and CSW result in increased urinary sodium excretion and hyponatremia. However, the management protocols for these two conditions are quite different; volume restriction is used in treating SIADH, while volume expansion is necessary for the treatment of CSW. We present a case of CSW in a child with cervicothoracic hematoma secondary to head and cervicothoracic trauma, without evidence of brain edema. The child was diagnosed on the basis of high urinary sodium excretion resulting in hyponatremia and low serum osmolarity. Improvements in serum sodium levels after saline hydration confirmed this diagnosis. We believe that potentially dangerous cases of hyponatremia should be carefully evaluated in children with cervicothoracic hematoma secondary to trauma, including situations in which brain edema is absent.