Choosing the Right IV Fluids

As noted in previous posts, I tend to favor isotonic IV fluids due to risk of hyponatremia with hypotonic fluids. A new study (below) indicates that some isotonic fluids are associated with an increased risk of electrolyte disturbances. Thanks to Ben Gold for this reference.

In this unblinded, randomized clinical trial with 614 children, participants were randomized to receive commercially available plasmalike isotonic fluid therapy (140 mmol/L of sodium and 5 mmol/L potassium in 5% dextrose) or moderately hypotonic fluid therapy (80 mmol/L sodium and 20 mmol/L potassium in 5% dextrose).

Key findings:

  • Clinically significant electrolyte disorder was more common in children receiving plasmalike isotonic fluid therapy:
    • Hypokalemia developed in 57 patients (19%) and hypernatremia developed in 4 patients (1.3%) receiving isotonic fluids; in total, this group had 61 of 308 patients [20%]) with electrolyte disturbance, compared with 9 of 306 patients [2.9%] of those receiving hypotonic fluid therapy (P < .001)
    • “Severe” hypokalemia (<3.0 mmol/L) was significantly more common in patients receiving isotonic fluid therapy 8 of 308 patients (2.6%) compared with 1 of 306 patients ( 0.3%) patients receiving hypotonic fluid therapy

My take: In the U.S., this suggests that fluids like lactated ringer’s which also has a low amount of potassium should not be routinely used. When choosing an isotonic fluid in children, D5 Normal Saline (0.9%) with added potassium may be more suitable..

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

Poorly-Conceived Allergy Testing Can Lead to Unnecessary Diet Restrictions and Complications

As noted in previous blog posts (see below), allergy testing can lead to unnecessary food restrictions which can in turn lead to numerous subsequent problems. Case in point: YV Virkud et al (NEJM 2020; 383: 2462-2470) report on A 29-Month-Old Boy with Seizure and Hypocalcemia

This boy presented with severe hypocalcemia, rickets, and seizures one year after allergy testing led to additional dietary restrictions. Also, his mother was a vegetarian. At time of allergy testing, IgE testing suggested allergies to milk, cashews, pistachios, egg whites, almonds, soybeans, chickpeas, green peas, lentils, peanuts, and sesame seeds. Many of these foods caused no symptoms with food challenges.

Besides working through the potential reasons for hypocalcemia, the authors make several key points:

  • Nutritional rickets is NOT a historical relic. Vitamin D deficiency appears to be increasing in high-income countries despite food-fortification strategies.
  • There are frequent misdiagnosis of food allergies. “Clinical and laboratory testing is severely limited by poor specificity…approximately 20 to 25% of children have positive IgE blood tests to specific food allergens, even though the true prevalence of IgE-mediated food allergy is likely closer to 6 to 8%.”
  • Avoid indiscriminate use of IgE blood testing. Allergen panels are “particularly problematic, because they often uncover false positives and lead to unnecessary food avoidance.” Individual IgE testing can be used to help confirm a diagnosis after an allergic reaction to a food trigger.
  • The most accurate diagnostic tool is an oral food challenge.
  • In children with food allergies, supplements are often needed to avoid micronutrient deficiencies and a low threshold is needed for involvement of dieticians.
  • Early introduction of foods can reduce incidence of allergies and periodic reassessment is needed to determine if a child has outgrown an allergy.
Xrays show generalized demineralization. The metaphyses show flaring (dashed arrow) and cupping (arrowbead). The physes are radiolucent and widened (asterisks).

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

Best Studies from Pediatrics

Pediatrics has provided free full publication access to what they consider their best 10 articles and 5 influential COVID-19 publications: Pediatrics2020 Best Articles Link

Here are direct links to 3 of the articles:

O Nafiu et al. Race, Postoperative Complications, and Death in Apparently Healthy Children (Video Abstact available on link) Key finding:

  • Among 172 549 apparently healthy children from a retrospective database, the incidence of 30-day mortality, postoperative complications, and serious adverse events were 0.02%, 13.9%, and 5.7%, respectively. Compared with their white peers, AA children had 3.43 times the odds of dying within 30 days after surgery (odds ratio: 3.43; 95% CI: 1.73–6.79)

K Lycett et al. Body Mass Index From Early to Late Childhood and Cardiometabolic Measurements at 11 to 12 Years. The authors followed 5107 infants from birth. Key findings:

  • At age 6 to 7 years, compared with those with a healthy weight, children with overweight had higher metabolic syndrome risk scores by 0.23 SD units (95% confidence interval 0.05 to 0.41) and with obesity by 0.76 SD units (0.51–1.01), with associations almost doubling by age 10 to 11 years. Thus, overweight and obesity from early childhood onward were strongly associated with higher cardiometabolic risk at 11 to 12 years of age.
  • In addition, obesity but not overweight had slightly higher outcome carotid intima-media thickness (0.20–0.30 SD units) at all ages

A Kempe et al. Parental Hesitancy About Routine Childhood and Influenza Vaccinations: A National Survey Key finding:

  • Hesitancy prevalence was 6.1% for routine childhood and 25.8% for influenza vaccines in this online sample of 2176 parents

Colchicine and Leukopenia

A recent study (E Sag et al. J Pediatr 2020; 224: 166-70) provided some useful information about the development of leukopenia in children receiving colchicine.

This study included 213 patients receiving colchicine at doses between 0.5 mg adn 2 mg/day.  Routine labs were obtained 2 weeks after starting treatment, at 3 months, and then every 6 months.  If leukopenia was identified, f/u labs were obtained 1 week later. Colchicine doses were decreased in patients with persistent leukopenia.

Key findings:

  • 23 (10.8%) developed reversible leukopenia.  No cases of leukopenia were severe and there was not an increased rate of infections.

Related blog posts:

Diagnostic Strategy For Children with Diarrhea and Abdominal Pain

A recent study (E Van de Vijver et al. Pediatrics 2020; 146: e20192235) shows a logical approach for testing children with diarrhea and abdominal pain.

Abstract and video abstract link: Test Strategies to Predict Inflammatory Bowel Disease Among Children With Nonbloody Diarrhea

Methods:

  • Prospective cohort study: n=193, 6 to 18 years who underwent a standardized diagnostic workup.
  • Patients with rectal bleeding or perianal disease were excluded because the presence of these findings prompted endoscopy regardless of their biomarkers.
  • In addition to symptoms, objective measures included C-reactive protein (>10 mg/L), hemoglobin (<−2 SD for age and sex), and fecal calprotectin (≥250 μg/g).

Key findings:

  • Twenty-two of 193 (11%) children had IBD
  • “Triaging with a strategy that involves symptoms, blood markers, and calprotectin will result in 14 of 100 patients being exposed to endoscopy. Three of them will not have IBD, and no IBD-affected child will be missed.

My take: The approach advocated by the authors of reserving a diagnostic endoscopy for children at high risk for IBD based on stool tests/blood tests in addition to symptoms has merit.  I would add a couple caveats:

  1. In this population, I would recommend checking for celiac disease (eg. tissue tranglutaminase IgA antibody, serum IgA level)
  2. I think in individuals with ‘borderline’ elevations of calprotectin (50-250 μg/g), followup testing is needed and if remains persistently elevated, then ileocolonoscopy is likely warranted.  (Calprotectin values in younger children tend to be higher -so this approach is best suited in children >5 years of age)

Related blog posts:

COVID-19 Toll on U.S. Children

From AAP News: AAP Report: 513,415 children diagnosed with COVID-19

  • The latest report shows a rate of 680 COVID-19 cases per 100,000 children.
  • Children make up 9.8% of the total cases and about 1.7% of all COVID-19 hospitalizations, up from 0.8% of hospitalizations in late May.
  • Roughly 1.9% of children diagnosed with COVID-19 have been hospitalized, according to data from the 23 states and New York City that are publicly reporting hospitalization data.
  • There also have been at least 103 pediatric deaths in 42 states and New York City, making up about 0.07% of all COVID-19 deaths. Roughly 0.02% of children who have contracted known cases of COVID-19 have died.
  • There have been 792 confirmed cases of multisystem inflammatory syndrome in children in 42 states, New York City and Washington, D.C., and 16 death

“The Truth About Allergies and Food Sensitivity Tests”

This is a link to a 20 minute video regarding “The Truth About Allergies and Food Sensitivity Tests” with Dr. Dave Stutkus and Dr. Mike Varshavski. (If trouble with link, then can find with quick search on YouTube.)

A couple of clarifications:

The video (~at the 3 minute mark) does not provide much nuance on “non-celiac gluten sensitivity” (see related blog posts below)

Some other points:

  • Don’t perform Food IgG testing -this is a memory antibody and does not reflect food allergy or sensitivity
  • So-called food sensitivity IgG tests do not have standardized normal values
  • Don’t perform broad-based IgE testing; there are many false-positives and false negative

Dr. Stutkus decided to undergone ‘food sensitivity’ tests and was reportedly sensitive to nearly 80 foods.

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

NY Times: Vitamin K for Newborns is a No-Brainer

One of the most difficult clinical situations I helped manage involved a newborn who had a devastating intracranial hemorrhage after the parents had refused the routine  administration of vitamin K.  At that time, I did not ask the parents what they were thinking.  I presumed that they were well-intentioned.  Nevertheless, they allowed their child to suffer permanent neurologic injury.

A recent editorial highlights this growing problem: NY Times: Vitamin K for Newborns is a No-Brainer Here’s an except:

Parents are increasingly questioning, and declining, vitamin K, which protects newborns from serious bleeding…

Accounts of healthy babies developing serious, even fatal bleeding in the days and weeks following birth can be found going back centuries

Since the early 1960s, it has been standard-of-care for newborns to receive an intramuscular injection of vitamin K shortly after delivery. Nearly six decades’ worth of data demonstrate that this intervention virtually eliminates vitamin K deficiency bleeding and carries no compelling risk of serious side effects…

Many of the reasons my patients’ parents decline vitamin K are similar to the reasons they decline vaccines: They worry about interventions they perceive as “unnatural” or unnecessary, about whether the doses and ingredients are “toxic” and whether there may be serious complications that doctors are not aware of or that are even being purposefully obscured by doctors, public health officials and pharmaceutical companies…

Parents continue to ask me whether vitamin K might cause childhood cancer, though this suggested association has been debunked….Others simply prefer to spare their newborn the pain of an injection…

Each year in the United States, if no vitamin K were administered, more than 70,000 infants would most likely be affected…

The seeds of mistrust — along with skepticism of science and intellectualism, the allure of the “natural” and the development of social-media-fueled communities founded on these values — run deep, and they’re threatening the health of our youngest and most vulnerable.

My take: Just like seat belts, the approach to this problem should be policy-based.  In my view, if an infant suffers from vitamin K-refusal bleeding, reports should be made public health departments.

Related blog post: Educated or Misinformed –Leading to Hemorrhagic Disease of the Newborn

What Are The Limits of (Preterm) Viability?

A retrospective recent study (PL Watkins et al. J Pediatr 2020; 217: 52-8) provides data that suggests that preterm infants at 22-23 weeks gestation can have good outcomes.

Cohort:

  • n=70 for 22-23 weeks (22 weeks, n=20, 23 weeks, n=50)
  • n=178 for 24-25 weeks (24 weeks, n=79, 25 weeks, n=99)

Key findings:

  • Survival to hospital discharge: 78% for 22-23 week cohort, 89% for 24-25 week cohort
  • No or mild neurodevelopmental impairment 64% or 22-23 week cohort, 76% for 24-25 week cohort. This was based on prospectively collected data at 18-22 months with Bayley Scales (BSID-III) (≥85) and being free from vision and hearing impairment

These survival and neurodevelopmental outcomes far exceed previous reports.  The study and the associated editorial (pg 9) identify several treatment characteristics that could have helped optimize outcomes: antenatal steroids, high-frequency ventilation, and a specialized environment.  Also, the authors did not include infants who were outborn, stillborn or died in the delivery room.

My take: This article’s data needs to be replicated elsewhere; in the meanwhile, it is going to challenge the notion of nihilism for infants born at 22-23 weeks gestation.

Related article: AH Jobe. J Pediatr 2020; 217: 184-8.  This commentary discusses the potential lifetime consequences of antenatal steroids, which may affect neurodevelopment and cardiovascular outcomes. “Antenatal corticosteroids are frequently used to disrupt normal development in rodent models”

Related blog posts:

St Thomas Harbor

AAP Behind the Scenes 2020 (Part 2): AAP Agenda, Safe Sleep, Encouraging Physician Diversity, APEX Mental Health

More from our recent AAP Board Meeting –more highlights:

Dr Sally Goza, AAP National President reviewed some of the AAP’s initiatives:

  • Healthcare coverage & Change in ‘public charge’
  • Gun violence
  • Climate Change
  • Early Childhood Programs
  • Suicide Prevention
  • E-cigarettes
  • Social Media.  She noted that Pinterest and Google have made efforts to curb harmful inaccurate posts, especially with regard to immunization information, whereas Facebook has not been cooperative.

2020 Georgia Blueprint for Children:

Dr. Sarah Lazarus, a terrific ED physician and an advocate for safe sleep, described updates and obstacles related to reducing sudden unexpected death infant death.

Key points:

  • NASPGHAN 2018 GERD recommendations (33 page PDF) with regard to positioning:  “The working group recommends not to use positional therapy (ie, head elevation, lateral and prone positioning) to treat symptoms of GERD in sleeping infants”
  • CPSC has removed many inclined sleepers.  Commentary from Dr. Lazarus from WebMD (November 2019): Sleeping on an Incline Not Safe for Baby

The Consumer Product Safety Commission is warning parents not let a baby sleep in rockers, pillows, car seats, or any other product that holds an infant at an incline — with their head higher than their feet.

“I do think it should have happened a while ago when we saw there were deaths from them, but I’m glad they did it now,” says Sarah Lazarus, DO, a pediatric emergency medicine physician at Children’s Healthcare of Atlanta. Dr. Lazarus is also an injury prevention researcher at Emory University and reviews infant deaths for the state of Georgia.  And what about putting the crib mattress at an incline to help with reflux?

Lazarus says she knows pediatricians used to recommend that, but she says new studies show that it doesn’t really help and may be unsafe. “We do not recommend any sort of wedging or propping or positioning at this point,” she says. In addition to avoiding inclined surfaces, the commission is reminding parents that babies can suffocate if they sleep with blankets, pillows, or other items. The safest way for a baby to sleep is flat on their back, in a bare crib, and on a flat, firm surface.Related blog posts:

Dr. Heval Kelli introduced a program called young physician initiative.  “Getting into medical school can be a long process and difficult to navigate particularly for students from underserved communities due to the lack of access to medical mentorship and network.  The Young Physicians Initiative provides early and interactive guidance to underserved middle school, high school and college students. We inspire students to pursue careers in medicine and pursue pipeline’s opportunities by Being Present in their communities.”

Here are links to his website and to one of the articles covering this project:

My take: This is a terrific program, though there are many other challenges that need to be addressed to encourage applicants from a wide range of socioeconomic groups.

Related blog post: Hidden Costs of Medical Schools

The final speaker, Dante McKay, discussed the APEX program which is a school-based program to address mental health issues in children.