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• A revised clinical report from the American Academy of Pediatrics, "The Evaluation of Sexual Abuse in Children," updates information
• NEW! Heading Home With Your Newborn: From Birth to Reality
  This authoritative new book by two pediatricians, who are also mothers themselves, addresses all the issues of caring for a newborn.
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Information for Parents About Meningococcal Disease and Meningococcal Vaccine

• CDC Meningococcal Disease Fact Sheet
• CDC Division of Bacterial & Mycotic Diseases, resources about meningococcal disease and meningitis

• Osteoporosis is considered a pediatric disease with a geriatric outcome.

• The risk of developing osteoporosis increases as a person gets older.

• Menopause, particularly before age 45, is one of the greatest risk factors.

• Osteoporosis is the major cause of bone fractures in post menopausal women.

• 1 in 3 women will suffer a spinal fracture in her lifetime.

• 1 in 6 women will suffer a wrist or hip fracture.

• 50% of people who have a hip fracture will never be able to walk independently again.

• A woman's risk of a hip fracture is equal to the combined risk of developing breast, uterine, and ovarian cancer.

• Most hip fractures occur as a result of a fall.

• 1 in 8 men also suffer from osteoporosis.

Gynecomastia is defined as the visible or palpable development of breast tissue in boys or men. It has been divided into four types: Type I: (pubertal or benign adolescent breast hypertrophy) refers to the common entity seen in pubertal males. Incidence may be as high as 60-70%. It is typically a firm, tender, subareolar mass anywhere from 1-5 cm in diameter. The pubertal adolescent frequently complains of pain in the breasts, particularly when wearing binding clothing. It usually spontaneously resolves within 2 years.

Type II (physiological gynecomastia without evidence of underlying disease, or with evidence of organic disease including the effects of specific drugs) refers to a generalized, nonpainful breast enlargement. It is essential to differentiate between physiologic gynecomastia and breast enlargement due either to a pathologic process or to the use of a specific drug. Careful history taking regarding the time of onset, family history, duration of enlargement, history of systemic illness, weight change, and drug or medication use, is important. Physical examination should include height, weight, blood pressure, breast size, and Tanner staging of both breasts and genitals, in addition to a neurologic assessment.

Type III gynecomastia is general obesity simulating gynecomastia, and Type IV is pectoral muscle hypertrophy.

COMMON CAUSES OF TYPE II GYNECOMASTIA I. Idiopathic

II. Familial causes
a. Associated with anosmia and testicular hypertrophy.
b. Reifenstein’s syndrome (male pseudohermaphroditism 2ry to partial androgen insensitivity)
c. Associated with hypogonadism and small penis

III. Specific illnesses or syndromes
a. Kleinfelter
b. Male pseudohermaphroditism
c. Testicular feminization syndrome
d. Tumors
e. Leukemia
f. Hemophilia
g. Leprosy
h. Chronic glomerulonephritis

IV. Miscellaneous drugs
a. amphetamines
b. anabolic steroids
c. birth control pills
d. cimetidine
e. diazepam
f. corticosteroids
g. digitalis
h. estrogens
j. human chorionic gonadotropin
k. insulin
l. isoniazid and other TB drugs
m. ketoconazole
n. marijuana
o. methadone and other narcotics
p. reserpine
q. tricyclic antidepressants

Ovarian cysts in fetus and infants are usually follicular in nature and less than 2 cm in size. They are commonly diagnosed between the 28th and 39th wk. of gestation by sonography. Hypotheses on etiology are:

(1) Excessive fetal gonadotropic activity,

(2) enzymatic abnormalities of the theca interna, and

(3) abnormal stimulation by the mother HCG. Obstetric management consists on observation and vaginal delivery.

After birth, diagnostic assessment and management will depend on the size and sonographic characteristics of the cyst. Simple anechoic cysts, and those less than 5 cm in size can be observed for spontaneous resolution.

Cyst with fluid debris, clot, septated or solid (complex nature), and larger than 5 cm should undergo surgical excision due to the higher incidence of torsion, perforation and hemorrhage associated to them.

Percutaneous aspiration of large simple cysts with follow-up sonography is a well-accepted therapy, preserving surgery for recurrent or complicated cases.

Surgical therapy is either cystectomy or oophorectomy that can result in loss of normal ovarian tissue.

What entities are associated with absent radii? VATER syndrome (anomalies of vertebrae, anus {imperforate}, tracheosophageal region and radii); Fanconi’s anemia; congenital thrombocytopenia (TAR syndrome); and Holt-Oram syndrome (associated with a secundum ASD).

What is Sprengel’s deformity? Congenital elevation of the scapula is a failure of scapular descent during fetal life, resulting is an elevated, hypoplastic scapula. The affected side of the neck is shorter and fuller and gives the appearance of torticollis. It is associated with congenital scoliosis and renal anomalies.

What is the pathophysiology of Osgood-Schlatter disease? The entity consists of painful swelling of one or both tibial tubercles at the insertion of the patellar tendon. The disease is very common in adolescents, usually beginning between the ages of 11 and 15. Vigorous exercise results in stressful pulling of the patellar tendon. Although the tubercles do enlarge from this repetitive strain, the primary problem appears to be a low-grade tendinitis and subsequent new heterophil bone formation in the distal tendon itself. Ossicles have been found in the tendon separate from the tubercle and their removal provides relief. Fortunately, this entity rarely requires surgery. Restriction of activity for two to three weeks and gradual resumption of activity usually diminishes the symptoms.

What are the osteochondroses? They are a group of disorders in which degeneration and aseptic necrosis of unclear cause involve the ossification or growth centers, recalcification then occurring. The patient usually presents with pain in the affected area. The commonly affected sites include: tarsonavicular bone, capitellum of the elbow, carpal lunate, distal ulnar epiphysis, head of femur, head of second metatarsal, Kohler’s disease, Panner’s disease, Legg-Calvé-Perthes disease, Burn’s disease etc.

What are the pathologic stages in Legg-Calvé-Perthes (LCP) disease? LCP is a condition of aseptic necrosis of the femoral head involving children primarily ages 4-10. The firs phase is the incipient or synovitis stage; lasting 1-3 weeks, this stage is characterized by an increase in hip-joint fluid and a swollen synovium associated with reduced movement. the second stage is avascular necrosis; lasting 6 months to 1 year, the blood supply stops to part (or all) of the head of the femur. That portion of the bone essentially dies, but the contour of the femoral head remains unchanged. The third and longest stage is fragmentation or regeneration and revascularization; lasting 1-3 years, the blood supply returns and causes both resorption of necrotic bone and laying down of new immature bone. Permanent hip deformity can occur in this stage. It is important to note that plain radiographs may lag behind the progression of the disorder by as much as 3-6 months. Radionuclide bone scans are much better because early ischemia and avascular necrosis are depicted as decreased localization's of isotope.

What are the characteristic x-ray changes, clinical findings, and history in a child with an osteoid osteoma? Osteoid osteoma is typically seen in older children and adolescents and exhibits a male predominance. Most children complain of localized pain usually in the femur and tibia; however, arms and vertebrae may also be involved. Radiographs and CT scans demonstrate an “osteolytic area surrounded by densely sclerotic reactive bone”. Bone scans reveal “hot spots”. The site is usually less than 1 cm in diameter and arises at the junction of old and new cortex. Pathologically the lesion is highly vascularized fibrous tissue with an osteoid matrix and poorly calcified bone spicules surrounded by a dense zone of sclerotic bone.

What should be noted on physical examination in a child with a suspected fracture? Assess the “five P’s” in the affected extremity; Pain and point tenderness, Pulse (distal to the fracture), Pallor, Paresthesia (distal to the fracture), and Paralysis (distal to the fracture). The involved extremity should also be carefully examined for deformity, swelling, crepitus, discoloration, and open wounds. A primary concern in any evaluation is a distal neurovascular compromise, which may require immediate surgical intervention.

What are the indications for open reduction of a fracture? An open reduction is an operative reduction in which pins are fixed into the separate fragments to promote proximity for healing. Indications include 1) failed closed reduction (often in children with displaced forearm, tibial, or femoral fractures; 2) displaced intra-articular fractures; 3) displaced Salter-Harris III and IV fractures (to prevent premature growth plate closure) and 4) patients with head trauma.

What is the difference between subluxation and dislocation? Subluxation is an incomplete or partial dislocation.

What is metatarsus adductus? A kidney-shaped foot with the front part of the foot (forefoot) turned inward. It is believed to result from intrauterine constriction. Most cases are mild and flexible, with the foot easily dorsiflexed and the lateral aspect easily straightened by passive stretching. Improvement usually occurs within two months with passive stretching exercises. Rigid, more fixed deformities may require casting.

source : Pediatric Pearls -- Orthopedics

FELBAMATE. Released by Wallace pharmaceuticals in 1993 as Felbatol®, felbamate was the first new AED to be released in the US since the early 1970s. Although it appeared to be an effective, broad range AED, significant untoward side effects (aplastic anemia) became apparent with general release and its use has fallen out of favor. It remains a drug to be considered for use with refractory generalized (specifically Lenox-Gastaut syndrome) or focal seizures. In children dose ranges from 15-45 mg/kg BID or TID, some children tolerating and improving on larger doses. Serum concentration are not correlated with efficacy. Most common side effects include insomnia, anorexia, and weight loss; others include dizziness, nausea, vomiting, diplopia and headache. Two of these, anorexia and insomnia, can be minimized by increasing the dose slowly at 2 weeks intervals and by giving it after meals and at bedtime. The drug has significant interactions with carbamazepine decreasing serum concentration but increasing the epoxide metabolite, leading to clinical toxicity. Felbamate increases the serum concentration of valproate and phenytoin by reducing its clearance. As mentioned, about one year after its release, a number of patients developed aplastic anemia, and hepatic toxicity. As of July 1995, 31 patients were reported, 10 of whom 10 died. At present, it is recommended that children taking this drug be followed up closely with weekly liver function test and complete blood counts.

GABAPENTIN. GBP is produced by Parke-Davis and is released as Neurontin®. It is labeled for adjunctive therapy in the treatment of complex partial seizures with or without generalization in individuals 12 years and older. Little has been published with regard to its use in children. GBP is similar in structure to inhibitory neurotransmitter gamma- aminobutyric acid (GABA) but does not appear to act at the GABA receptor. It is an amino acid that freely crosses the blood brain barrier. It is not protein bound, it is not metabolized by the liver, and is excreted solely by the kidneys. Because of a relative short half-life (5-7 hours) TID dosing is recommended. In children, dosages of 15-30 mg/kg have been used. GBP is a well-tolerated drug with minimal side effects. Commonly reported side effects include somnolence, dizziness, fatigue, and ataxia. Since its general release, other side effects reported include behavioral changes (aggression, hyperactivity) and weight gain. No laboratory abnormalities have been reported. Because it is not metabolized by the liver and because it is not protein bound, it does not interact with other AEDs. Its absorption can be slowed by antacids, and therefore, it is recommended that GBP not be taken with these medications. It has been proved effective as adjunctive treatment of refractory partial seizures and generalized tonic-clonic seizures. Larger dosages appear to be more effective than smaller ones. In addition, it may be effective for benign rolandic epilepsy of childhood. Since the drug is not metabolized by the liver, it may be an effective AED for patients with porphyria. It is not effective against absence seizures in children. There appears to be no correlation between serum concentration and clinical efficacy.

LAMOTRIGINE. LTG is produced by the Burroughs-Wellcome company and is released as Lamictal®. It is approved for adults as adjunctive therapy for refractory focal-onset seizures. Despite this limited labeling by the FDA, LTG appears to have a broad spectrum of activity against multiple seizure types. In addition, some evidence indicates that it is effective as a monotherapeutic agent in adults and children for both partial and generalized epilepsies. Structurally, it is unrelated to other AEDs; its action appears to be through the voltage-sensitive sodium channels, leading to inhibition of excitatory neurotransmitter release (glutamate, aspartate). The plasma half-life is approximately 25 hours, which is halved by enzymatic-inducing AEDs (carbamazepine, phenytoin) and increased twofold by valproate. Because of this interaction careful dosing is required. Since the drug has not been labeled for use in children, no guidelines are provided by the company. Some experts (Goa et al) have provided some guidelines: for children less than 12 years old taking enzyme-inducing drugs a starting dose of 2 mg/kg daily for 2 weeks is recommended followed by 5 mg/kg/day divided BID. A maximum dose of 15 mg/kg not to exceed 600 mg/day is suggested. If the child is taking valproate alone, a starting dose of 0.2 mg/kg/day for 2 weeks followed by 0.5 mg/kg/day for 2 weeks, then 1 mg/kg/day with a maximum dose of 5 mg/kg/d not to exceed 200 mg/day is recommended. Common side effects with this agent include dizziness, ataxia, headache, diplopia, nausea, emesis, somnolence, and rash. Most of the adverse experiences were mild and transient with relatively few patients withdrawing from treatment for these reasons in clinical trials. Rashes occur more frequently in patients receiving concurrent valproate and appear to be hypersensitivity reactions; rashes are dose-dependent and generally resolve with reduction or transient withdrawal of the drug. Various behavioral effects including activation, a sense of “well being” and, more rarely agitation has been reported. There appears to be no effect of lamotrigine on other AEDs, but may increase carbamazepine epoxide concentration leading to toxic symptoms. Despite its approval for adjunctive therapy of partial epilepsy, LTG appears to be effective for a broad range of seizures types including primary generalized epilepsy and the Lenox-Gastaut syndrome. A number of monotherapy studies have demonstrated effectiveness at least equal to that of carbamazepine in the treatment of focal-onset seizures. In children, effectiveness has been demonstrated for the generalized epilepsies, including some of the more refractory types such as myoclonic, akinetic, and tonic seizures. Use in girls with Rett’s syndrome reported not only improved seizure control but also improved function and well-being, although how these were assessed was not clear. The drug is effective at serum concentrations as small as 1-3 µg/ml. The upper level of clinically tolerable levels has not been established.

VIGABATRIN and TOPIRAMATE. These two new AEDs have not been approved yet in the United States. Vigabatrin binds to GABA-transaminase, inhibiting the first step in GABA degradation. It appears to be effective in the treatment of refractory partial seizures and in the treatment of West’s syndrome (infantile spasms) in children. Clinical trials in the the US were delayed initially because of reports of white matter vacuolization in rats; this change did not appear in higher primates and is of uncertain significance. In addition, the drug may have significant behavioral effects. Clinical trials continue. Topiramate is a weak carbonic anhydrase inhibitor with a number of mechanisms of action. Results from clinical trials in children have demonstrated that it is a well-tolerated AED effective for both focal- and generalized-onset seizures. This drug is in the final stages of approval by the FDA. (Taken from: Clinical Pediatrics; Volume 36, Number 9, September 1997)

source: http://home.coqui.net/myrna/aed.htm