FDA approves meningococcal vaccine for infants

The FDA has approved the use of the meningococcal vaccine for infants. Menactra was approved to prevent N. meningitidis for use in infants. The approval is for a 2 dose series to be administered 3 months apart. It is not yet officially included in the immunization schedule but we are definitely looking forward to its inclusion.

Booster for Meningitis Shot Recommended

The American Academy of Pediatrics and the Centers for Disease Control for 2011 is recommending to give a booster to all teenagers who had the meningococcal vaccine.

Routine recommendation between 11-12 years of age and a booster at 16 years.
Adolescents who receive their first dose between 13-15 years of age should receive a booster between 16 to 18 years old.
If patient is at risk for meningococcal disease and are between 2-54 year of age a 2-dose primary series should be administered at least 2 months apart.

For more information please go to www.cdc.gov/vaccines/recs/provisional/default.htm

Congenital Cystic Adenomatoid Malformation of the Lung

Since the advent of the prenatal ultrasonography we have been able to pick-up a lot of diseases while the baby is in the womb so we can be better prepared to handle them when they are born. CCAM(Congenital Cystic Adenomatoid Malformation) is a rare intrathoracic tumor that is present in the lungs. This occurs in 1 - 25,000 to 35,000 pregnancies. This is usually found during the 20 week gestation and they hare followed closely with repeat ultrasounds. The wonderful thing about this is that 60% resolve at birth. The ones that do not resolve are classified into types. The presenting symptoms at birth depends on the size of the cyst if it is encroaching on the blood vessels or the other organs.
Type I - isolated cyst present in the lungs during the neonatal period
Type II - the cyst in the lung is usually associated with other malformations on the baby
Type III - this is the worse kind because the baby would be born as a fetal hydrops and they do not survive.

If the cyst is significant that baby will be in respiratory distress at birth. The ultimate cure for this is surgical excision. If the baby is asymptomatic and the cyst is small. The pediatric surgeon will follow-up in a few weeks and determine when they are going to operate. Even if the cyst is small this can be a focus of recurrent pneumonia so most surgeons operate on the lesion.

Osteochondroma(Exostosis or Benign Bone tumor)

Osteochondroma is a developmental abnormality where a part of the growth plate forms an outgrowth on the surface of the bone.

2 types of osteochondroma

Solitary-this is the most common tumor which accounts to 35% of all the benign tumors. This grows with a child or adolescent and usually stops at maturity. This is usually diagnosed in patients age 10 to 30 years old, it occurs equally in males and females. We do not know the cause of this and there is no way to prevent this from occurring in some patients.

Multiple Osteochondromatosis-this are multiple osteochondroma(more than 2) which is familial (it usually runs in families). It is 70% inherited and only 30% that occurs randomly. It usually occurs within the first three decades of life. Males are more often affected than females.

Symptoms
This can be affected depending where the lesions are located. A patient may have deformities of the forearms and a short stature. This is caused by abnormal growth from the growth plates.

Symptoms and signs of a tumor becoming cancerous

• Growth of osteochondroma after puberty
• Pain at the sight of an osteochondroma
• A cartilage cap larger than two centimeters

Diagnosis:

x-ray of the affected long bone

if cancer is suspected MRI and CT Scan is indicated.

Treatment:

Nonsurgical treatment-tumors with no signs of cancer and are asymptomatic are just watched carefully

Surgical Treatment-if the tumor causes pain and deformity the portion of the bone need to be removed

This is usually monitored by the Orthopedic surgeon.

American Academy of Osteopathic Surgeons

What is Cholera?

We have not seen this type of gastroenteritis for a long time but when we flip through the news it has been spreading in Haiti. It has caused several deaths because of severe dehydration.
Cholera is characterized by voluminous diarrhea without abdominal cramps or fever. Dehydration and shock can occur within 4-12 hours if fluids losses .are not replaced. Stools are colorless with small flecks of mucus "rice-water". Most infected people have no symptoms and some only have mild to moderate diarrhea lasting 3 to 7 days,fewer than 5% have severe watery stools with dehydration.

Humans are the only documented natural host in ingestion of contaminated water or undercooked/raw shellfish, raw or partially dried fish,moist grains,moist vegetables. Direct person to person contact has not been documented.

Treatment:
Oral or parenteral rehydration to correct dehydration and electrolyte abnormalities,
Oral rehydration solution is preferred unless the patient is obtunded or is in shock. The World Health Organization's oral rehydration solution has been the standard.
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Antimicrobial therapy can eradicate the bacteria more quickly. The drug of choice is oral doxycycline as a single dose or a 3 day dose of tetracycline. This medications are not usually given to children younger than 8 years of age but if the patient has cholera the benefits might outweigh the risks in administering the medication. If strains are resistant to the tetracyclines you can give the ciprofloxacins, ofloxacins and the trimethoprim-sulfamethoxazoles.

Control Measures:

Hygiene - disinfection or boiling of water prevents transmission, appropriate hand washing after defecating is appropriate. Keep food promptly refrigerated.
Treatment of Contacts - administration of antibiotics within 24 hours of identification of cholera may prevent infection among household contacts
Vaccine -there is no vaccine currently available for cholera in the United states but there are 2 vaccines available but this are not proven to be effective at all, no country requires the cholera vaccine for entry

What is the Newborn Screening?

This a program from the State of Arizona that screens all newborns for disorders that if diagnosed early enough can be treated. There are also different programs for the different states with regards to the newborn screeen.This comprise of a blood spot screening which detects 28 disorders and a hearing test. The blood spot specimens are analyzed by the State Laboratory. Most babies are born healthy and the screening can identify ones with problems. Approximately 300 newborns each year in Arizona has been identified to have some type of disorder. They can develop organ damage, developmental deal, mental retardation and even death. The disorders can not be cured but it can be treated to avoid or limit the complications.

The test must be timely. The first bloodspot test should be done between 24 and 36 hours of age or prior to discharge from the hospital. For some disorders, false negative results can occur with later testing. The second screen should be done at the first outpatient visit between 5 and 10 days of age.

The hearing test is done in the hospital and any re-screening should be done within 2 weeks and diagnostic testing should be done as soon as possible following the failed outpatient scree. Completing diagnostic testing before three months of age ensures that testing can be done without anesthesia or sedation.

The Arizona screening panel includes:

• 6 amino acid disorders
• fatty acid oxidation disorders
• 9 organic acid disorders
• Biotinidase deficiency
• Classic galactosemia
• Congenital Hypothyroidism
• Congenital Adrenal Hyperplasia
• 3 hemoglobin diseases
• Cystic Fibrosis
• Hearing loss

The incidence in the population is rare, but the potential devastating results and the high costs of treating undiagnosed infants is thought to justify the mass screening. Hearing loss is the most common approximately 2-4 per 1000 births,

Arizona Newborn Screening Program Guidelines-August 2010

Gastroesophageal Reflux in Infants

This is defined as the passage of gastric contents to the esophagus. Once the food reaches the stomach this will be mixed with acidic enzymes that help break down the food in smaller pieces. If the contents of the stomach goes to the esophagus this may cause problems in some babies, because the lining of the esophagus is not designed to hold acidic substances. Most babies have some kind of gastroesophageal reflux but are not bothered by it, they are what you call "happy spitters". Once the babies show symptoms this is called gastroesophageal reflux disease.
Reflux results from the transient relaxation of the lower esophageal sphincter.

Signs and symptoms of GERD (Gastroesophagel Reflux Disease):

• recurrent vomiting
• poor weight gain
• weight loss
• difficulty swallowing
• abdominal pain
• chest pain
• coughing
• regurgitation
• apnea
• wheezing
• hoarseness
• stridor
• abnormal neck posturing (Sandifer syndrome)
• refusal to eat

Diagnostic Approaches

1. Most of the diagnosis of GERD/GER can be obtained by a careful history and physical examination

2. Upper Gastrointestinal Series (UGIS) this is a series of abdominal x-rays which can rule out any anatomical reason for the symptoms

3. Esophageal pH monitoring-this is a useful, valid and reliable test to see the correlation of reflux with the symptoms. We usually hospitalize the baby and insert a probe close to the lower esophageal sphincter and monitor the heart rate, respiratory rate and oxygenation. This is also used to assess the response to treatment.

4. Endoscopy and Biopsy - this is done by a gastroenterologist, they put a tube down the esophagus and get a tissue sample to check if there is any type of inflammation that has been occurring in the area.

5. Empiric Medical Therapy - A trial of medication can be useful if the GER is causing and specific symptoms

Treatment options:

• there is evidence to support a trial of a hypoallergenic formula for 1-2 weeks may work
• may add 1 tsp of rice cereal to an ounce of formula this will of course will increase the caloric density of the formula
• positioning the infant, elevate the head at a 45 degree angle when sleeping and do nor move the baby too much after feeding
• Acid-Suppressant therapy-this blocks the production of acid which in turn relieves the symptoms
• Prokinetic therapy - this reduces the incidence of regurgitation and vomiting but with the multiple side effects of the medications this has not been readily available in the market
• surgical therapy - this is the last resort which generally results in a favorable outcome