ALLERGY

Formula selection in high-risk infants — A meta-analysis of formula consumption and risk of atopic dermatitis (AD) found that infants who were fed partially hydrolyzed formula (pHF) had a lower risk of AD than those fed cow's milk (CM) formula, particularly those infants at high risk because of family history of atopic disease [1]. An overall reduced risk in any atopic manifestation, which included AD, was also seen in infants fed pHF versus CM formula. (See "Introducing formula and solid foods to infants at risk for allergic disease", section on 'Studies comparing different formulas'.)

Influenza vaccination in individuals with egg allergy — Influenza vaccination now is recommended for all individuals six months of age and older. In addition, the actual ovalbumin content of several brands and lots of the 2009-2010 seasonal and H1N1 influenza vaccines was one or two orders of magnitude lower than the manufacturers' claimed maximum levels in two independent assessments [2,3]. Furthermore, the rate of serious adverse reactions to the vaccine was the same whether or not vaccine skin testing was performed prior to a two-step administration protocol (5 versus 3 percent, respectively) [4].

In light of the recent data, the UpToDate recommendations have changed for the influenza vaccine administration protocols in patients with egg allergy:

• For the patient who is six months of age or older and has known egg allergy of any severity, except severe anaphylaxis, we suggest administration under observation of a vaccine that contains ≤1 mcg ovalbumin per 0.5 mL as a single dose without prior vaccine skin testing.
• If a vaccine that contains ≤1 mcg ovalbumin per 0.5 mL dose is not available, or if the history of anaphylaxis was severe, we suggest administration of the vaccine under observation by a two-step protocol without prior vaccine skin testing.

(See "Influenza vaccination in individuals with egg allergy", section on 'Administration protocols' and "Pandemic H1N1 influenza ('swine influenza') vaccine" and "Seasonal influenza vaccination in adults" and "Seasonal influenza vaccination in children".)

DERMATOLOGY

Head lice — Oral ivermectin is an effective therapy for head lice that is refractory to topical treatment. In a randomized trial, ivermectin was superior to malathion 0.5% lotion for the treatment of head lice in patients who had previously failed therapy with a topical pediculicide [5]. Ivermectin is not recommended for pregnant women or children weighing less than 15 kg, since safety has not been established in these populations. (See "Pediculosis capitis", section on 'Oral agents'.)

Infantile hemangioma — Early evidence suggests that application of topical beta-blockers may be useful for the treatment of infantile hemangiomas. In a pilot study of six patients, treatment with topical timolol 0.5% gel led to a statistically significant reduction in lesion size [6]. (See "Management of infantile hemangiomas", section on 'Topical timolol'.)

ENDOCRINOLOGY

Fasting blood sugar — Even mild elevations in fasting blood sugar values during childhood predict a risk for developing type 2 diabetes mellitus. In the Bogalusa heart study, children with fasting blood sugar values in the upper half of the normal range (between 86 and 99 mg/dL [4.8 to 5.5 mmol/L]) have 2.1 times the risk for developing diabetes during adulthood, and 3.4 times the risk for developing pre-diabetes, independent of the child's weight status [7]. (See "Epidemiology, presentation, and diagnosis of type 2 diabetes mellitus in children and adolescents", section on 'Fasting plasma glucose'.)

GENERAL PEDIATRICS

Autism spectrum disorders — In a cohort of patients with autism spectrum disorders (ASD), chromosomal microarray (CMA) identified significantly more abnormalities than karyotype or fragile X testing (7 percent, 2 percent, and 0.5 percent, respectively) [8]. We suggest that children diagnosed ASD undergo CMA testing in addition to high-resolution karyotype and DNA analysis for fragile X syndrome. (See "Diagnosis of autism spectrum disorders", section on 'Genetic testing'.)

Button battery ingestion — The number of severe and/or fatal button battery ingestions has increased almost sevenfold since 1985 with serious sequelae or death occurring in 2.7 percent of all button battery ingestions [9]. Ingestion of large diameter (≥20 mm) lithium cell batteries is strongly associated with major outcomes (eg, esophageal burn, perforation, or fistula) and death. (See "Button battery ingestion", section on 'Epidemiology'.)

Childhood asthma — A meta-analysis of randomized trials found that children with mild to moderate persistent asthma who were treated with inhaled glucocorticoids had better pulmonary function and asthma control (eg, fewer asthma exacerbations requiring systemic glucocorticoids, less albuterol use, and lower symptom scores) than those treated with montelukast [10]. (See "Chronic asthma in children younger than 12 years: Controller medications", section on 'Compared to inhaled glucocorticoids'.)

Preparticipation sports evaluation — The 2010 consensus guidelines for preparticipation sports physical evaluation endorse the use of a standardized evaluation form that addresses important aspects of the history and examination, particularly the cardiovascular history [11]. The form is available for download at www.ppesportsevaluation.org. (See "The preparticipation sports examination in children and adolescents", section on 'Evaluation forms'.)

GENETICS

Hyperammonemia therapy for NAGS deficiency — Carglumic acid (Carbaglu), previously available outside the United States, was approved by the US Food and Drug Administration in March 2010 for treatment of hyperammonemia due to N-acetylglutamate synthase (NAGS) deficiency [12]. (See "Management of urea cycle disorders", section on 'Carglumic acid'.)

Enzyme replacement therapy for Gaucher disease — Velaglucerase alfa, a recombinant glucocerebrosidase, was approved by the US Food and Drug Administration for the treatment of Gaucher disease [13,14]. Velaglucerase differs from imiglucerase in that the enzyme protein sequence is human [15]. (See "Treatment of Gaucher disease", section on 'Enzyme replacement therapy'.)

Enzyme replacement therapy for late-onset Pompe disease — Intravenous alglucosidase alfa (Lumizyme) was approved by the US Food and Drug Administration (FDA) for use in patients eight years of age and older with late-onset Pompe disease [16]. In a multicenter randomized trial of 90 patients aged 10 to 70 years with late-onset disease, treatment with alglucosidase alfa led to improved walking distance and pulmonary function, whereas these measures declined in the placebo group [17]. (See "Lysosomal acid maltase deficiency (glycogen storage disease II, Pompe disease)", section on 'Therapy'.)

HEPATOLOGY

Hepatitis C — Accumulating evidence supports the use of combination therapy with pegylated interferon and ribavirin to treat chronic hepatitis C infection in children. In a multicenter trial, this combination yielded 93 percent sustained viral response in patients with genotype 2 or 3, and 53 percent in those with genotype 1 [18]. The decision of whether to treat chronic hepatitis C depends on the child's age, genotype, and liver histopathology. (See "Hepatitis C virus infection in children", section on 'Pegylated interferon plus ribavirin'.)

IMMUNIZATIONS

13-valent PCV — The 13-valent pneumococcal conjugate vaccine (PCV13), which was licensed in February, replaces the 7-valent pneumococcal conjugate vaccine (PCV7) in the routine childhood immunization schedule and catch-up schedule [19]. The US Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends a supplemental dose of PCV13 for healthy children aged 14 through 59 months who were fully immunized with PCV7, and for children younger than 71 months with medical conditions that increase the risk of pneumococcal disease (table 1) who were fully immunized with PCV7 and 23-valent pneumococcal polysaccharide vaccine. (See "Pneumococcal (Streptococcus pneumoniae) conjugate vaccines in children", section on 'Supplemental dose'.)

Immunization pain — A meta-analysis of randomized controlled trials that studied the use of sucrose or glucose for control of pain before immunization in infants (1 to 12 months) found significant reductions in the incidence and duration of crying when compared with water or no treatment [20]. (See "Procedural sedation and analgesia in children", section on 'Sucrose'.)

Influenza vaccine — Starting with the 2010 influenza season in the southern hemisphere and the 2010-2011 season in the northern hemisphere, the trivalent influenza vaccine includes antigens from the 2009 pandemic H1N1 influenza A virus, as well as seasonal influenza virus [21,22]. (See "Seasonal influenza vaccination in children", section on 'Composition'.)

Measles, mumps, rubella, and varicella vaccine — The risk of febrile seizures one to two weeks after immunization is increased by approximately twofold in children ages 12 to 23 months who receive the combination measles/mumps/rubella/varicella (MMRV) vaccine compared with children who receive separate injections of MMR and varicella vaccine [23,24]. Although the absolute risk of febrile seizures remains low (approximately 1 per 2300 to 2600 vaccinees), the US Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices suggests separate MMR and varicella vaccine for children ages 12 through 47 months, and combined MMRV vaccine for children ≥48 months if the parents do not have a preference [25]. (See "Standard childhood immunizations", section on 'MMR adverse reactions' and "Standard childhood immunizations", section on 'MMR preparations'.)

Rotavirus vaccine — In March 2010, the US Food and Drug Administration (FDA) temporarily suspended use of the RV1 (Rotarix) rotavirus vaccine, because it was found to contain genetic components of porcine circovirus type 1 (PCV1) [26]. Additional testing revealed that the RV5 (RotaTeq) rotavirus vaccine contained genetic components of PCV1 and porcine circovirus type 2, and that the PCV components had been present in both vaccines since the early stages of vaccine development [26,27]. In May, the FDA lifted the suspension of use of RV1 and recommended continued use of RV5, given that these vaccines have been administered to millions of children with dramatic reduction in the incidence of rotavirus gastroenteritis and without adverse effects related to PCV [27,28]. (See "Rotavirus vaccines", section on 'Porcine circovirus' and "Rotavirus vaccines", section on 'PCV1 contamination'.)

NEONATOLOGY

Respiratory distress syndrome and CPAP — In a trial of extremely preterm infants (gestational age between 24 weeks and 27 weeks), there was no difference in the primary outcomes of mortality and bronchopulmonary dysplasia between infants initially assigned to continuous positive pressure (CPAP) alone and those assigned to CPAP in combination with initial intubation and surfactant therapy [29]. Although the outcomes of this study suggest CPAP alone may be as good or better alternative to initial intubation and surfactant therapy in the initial management of very preterm infants, 83 percent of the CPAP group was subsequently intubated, and two-thirds of these patients received surfactant. In addition, concerns about study design were also cited by an accompanying editorial [30]. Further studies are needed to determine whether CPAP alone is superior to initial intubation and surfactant therapy as initial support for extremely premature infants. (See "Prevention of respiratory distress syndrome in preterm infants", section on Surfactant versus CPAP.)

Probiotics and NEC — A meta-analysis of 11 trials that included 2176 preterm infants demonstrated infants who received probiotics compared with controls without probiotic therapy had a lower mortality rate and were less likely to develop necrotizing enterocolitis (NEC) [31]. Because these clinical trials used different probiotic preparations and varied in study design (eg, timing, duration and dosing of probiotic therapy), the optimal strain(s) and dosing regimen remain uncertain. Despite these reservations, some experts have advocated the use of probiotics in selected settings [32]. However, we recommend limiting the use of probiotics to clinical trials until the most effective regimen for premature infants is identified [33]. (See "Prevention of necrotizing enterocolitis in newborns", section on 'Probiotics'.)

NEPHROLOGY

Maintenance parenteral fluid — Results from a trial that evaluated the effects of four parenteral fluid regimens in surgical pediatric patients suggest that isotonic saline (NS) at a maintenance fluid rate is less likely to result in hyponatremia and hypovolemia compared with other fluid regimens [34]. A two- to fourfold increase in mean antidiuretic hormone concentrations contributed to hyponatremia eight hours after surgery in 30 percent of children who received one-half NS, and 10 percent of those who received NS. In addition, fluid restriction (ie, 50 percent maintenance rate) resulted in hypovolemia in a significant number of patients regardless of fluid tonicity. (See "Maintenance fluid therapy in children", section on 'Hospitalized children'.)

Oral rehydration and ondansetron — A large retrospective study from two pediatric emergency departments showed the use of oral ondansetron to reduce vomiting in children with presumed gastroenteritis does not increase the risk of missing other serious alternate causes of vomiting [35]. Alternate diagnoses included appendicitis, intussusception, bacteremia, pyelonephritis, small bowel obstruction, and intracranial tumor. This study also confirmed previous observations that ondansetron therapy reduced the rate of hospital admissions for gastroenteritis (3.7 versus 6.4 percent) but was associated with an increased likelihood of return to the ED (6.2 versus 4.7 percent). (See "Oral rehydration therapy", section on 'Vomiting and ondansetron'.)

NEUROLOGY

Childhood absence epilepsy — A randomized clinical trial compared ethosuximide, valproate, and lamotrigine in 453 children with childhood absence epilepsy [36]. Ethosuximide and valproic acid were more effective than lamotrigine in eliminating seizures; ethosuximide had a more favorable adverse event profile compared with valproic acid. (See "Epilepsy syndromes in children", section on 'Absence seizures'.)

OBESITY

Fast food — Parents of young children also tend to respond to nutritional information if it is provided on restaurant menus. In a randomized trial, the energy content of the food ordered by parents for their three- to six-year-old children was reduced by an average of 100 kcals when nutrition information was provided on the menu [37]. Providing the nutritional information did not alter the energy content of the meal that the parent ordered for themselves. (See "Fast food for children and adolescents", section on 'Portion size'.)

Weight loss surgery — Adjustable gastric banding (AGB) is one of two established surgical interventions to address severe obesity in adolescents. A randomized trial of 50 adolescents compared AGB with a supervised lifestyle intervention [38]. During the two-year follow-up period, the patients in the AGB group lost an average of 34.6 kg, as compared with 3.0 kg in the lifestyle group. Of note, almost 30 percent of the patients undergoing AGB required revisional procedures. (See "Surgical management of severe obesity in adolescents", section on 'Outcomes'.)

ONCOLOGY

Wilms tumor — In a trial of children less than two years of age with small (<550 g) stage I Wilms tumor with favorable histology, five-year event-free survival was lower in patients treated with surgery alone compared with those treated with surgery followed by adjunctive chemotherapy (84 versus 97 percent) [39]. There was no difference in mortality rate. Continued evaluation of this trial (long-term outcome) and other research efforts are ongoing to determine if there is a group of patients with low-risk Wilms tumor that can be treated with surgery alone. (See "Treatment and prognosis of Wilms tumor", section on 'National Wilms Tumor Study'.)

PULMONOLOGY

Smoking initiation — Nicotine dependence can develop within days to weeks of the onset of occasional cigarette use, and often before the onset of daily smoking [40]. Adolescents with early emergence of symptoms of nicotine dependence are significantly more likely to be smokers two years later, as compared with those who do not report early symptoms [41]. (See "Management of smoking cessation in adolescents", section on 'Nicotine dependence'.)

PSYCHIATRY

Atypical antipsychotics — A clinical trial of 272 children ages 5 to 19 years found that children receiving the atypical antipsychotic medications olanzapine, quetiapine, or risperidone had average weight gains of 18.7, 13.4, and 11.7 pounds, respectively, after 12 weeks of treatment [42]. Participants in an untreated comparison group gained an average of 0.4 pounds. (See "Antipsychotic medications: Treatment efficacy, drug selection, and side effects", section on 'Weight gain'.)

RHEUMATOLOGY

Classification of childhood vasculitis — Classification criteria for Henoch-Schönlein purpura, Takayasu arteritis, polyarteritis nodosa, and Wegener's granulomatosis have been formally validated and finalized by an international consortium of rheumatologic societies [43]. These represent minor changes from previously proposed criteria in 2005. (See "Classification and incidence of childhood vasculitis".)

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