Jon Matthew Farber, MD

Dr Farber is a pediatrician in Woodbridge, Virginia.

Young children who wheeze from time to time (so-called early transient wheezers) are less likely to develop allergy in adolescence than their peers who never or only infrequently wheeze, according to a study conducted in Australia. Children with persistent wheeze, on the other hand, are at increased risk of having other allergic manifestations in later childhood and adolescence, researchers found.

The study was conducted in a longitudinal birth cohort of 620 children from families with a history of allergic disease, who were followed up to the age of 18 years. Researchers identified 5 wheeze patterns these children exhibited from the age of 4 weeks to 7 years: never/infrequent (47%), early transient (26%), early persistent (5%), intermediate onset (19%), and late onset (3%). Investigators collected data about participants’ wheezing 18 times in the first 2 years of life. They also conducted skin prick testing for common allergens at ages 6, 12, and 24 months and 12 and 18 years, measured fractional exhaled nitric oxide (FENO), a determinant of eosinophilic airway inflammation, and collected information about the existence of eczema and hay fever.

Analysis of the collected data, which took into account potential confounders, including sociodemographic factors and parental smoking and asthma, showed that compared with never/infrequent wheezers, early transient wheezers had reduced risks of hay fever and eczema at age 18 years, along with lower FENO levels and lower risk of sensitization. In contrast, both intermediate onset and late onset wheezers were at increased risk of having hay fever at 12 and 18 years of age, compared with never/infrequent wheezers, with youngsters’ having the intermediate onset pattern also at increased risk of sensitization and higher FENO levels. Although early persistent and intermediate onset wheezers were at increased risk of eczema at 12 years, no wheeze pattern was associated with eczema at 18 years. Overall, intermediate onset wheezers represented the most atopic group (

This impressive, very long-term study provides some indirect evidence for the ‘hygiene hypothesis,’ that early exposure (in this case, perhaps to respiratory viruses) helps protect against allergies. It would have been nice to see if early transient wheezers were less likely to have asthma when older.

Articles

An Australian study examines how childhood wheezing can impact the development of allergies.

Childhood wheezing may protect against future allergy

An account of 3 case studies illustrates how preputial skin may be an ideal graft for repairing syndactyly because the tissue is easily accessed and harvested and is hairless and free of subcutaneous fat; the procedure also is associated with low morbidity/mortality. Syndactyly release generally is performed with full thickness skin grafts from the groin region, which can result in growth of unwanted hair and subcutaneous fat.

The 3 patients, referred to urology at the request of the orthopedic surgeon, underwent circumcision at the time of syndactyly repair to provide preputial skin for graft coverage. The infants were 17-, 18- and 20-months-old, respectively, when they underwent the surgery. The skin grafts healed well in all 3 infants, and though the grafts were associated with some increased pigmentation, parents were satisfied with the outcomes. Given these results, the authors recommend “careful assessment for congenital anomalies that may require skin grafting, such as syndactyl, prior to ‘routine’ neonatal circumcision” (

This strikes me as a brilliant concept, another surgical reason, besides hypospadias, for sparing the foreskin. Please remember this, or inform your obstetrical colleagues, before doing a circumcision in a boy with syndactyly.

Three case studies look at the efficacy of using foreskin for syndactyly repair.

Consider the foreskin for syndactyly repair

"Perhaps” might be the best answer to this question, based on a review of the literature on use of botulinum toxin for treating pediatric chronic migraine. Seven studies with from 1 to 30 participants were included in the review: 2 retrospective analyses, 3 case series, a case report, and a single randomized controlled trial with 125 patients. The number of treatments ranged from 1 to 11, and dosing and injection protocols varied. Only the randomized controlled trial had fixed protocols; the other studies combined a fixed protocol with one that “followed the pain.” Dosages ranged from 100 to 215U, with treatment given about every 3 months.

The randomized controlled trial found no benefit to botulinum toxin compared with placebo. The other studies noted clinically significant benefits for headache frequency, migraine intensity, or migraine duration. Two studies found that headache frequency decreased 50% whereas others noted even greater decreases of 74% and 97%. Decrease in migraine intensity ranged from 25% to 100%. The one study that measured migraine duration showed a median decrease from 8 to 0.75 hours. Side effects were minimal in most studies, generally injection site pain and tenderness (

We can add botulinum toxin to the long list of proposed treatments for pediatric migraine that possibly are worth trying but are not yet proven in large enough randomized, controlled trials. Others on this list include antiepileptics, tricyclics, SSRIs, beta-blockers, and antihistamine medications, as well as cognitive behavioral therapy.

A new study examines the efficacy of the toxin for migraine treatment in pediatrics.

Is botulinum toxin effective for treating children’s migraines?

Using only intensive clinical examination for initial identification of early-onset sepsis (EOS) in late preterm and term neonates substantially decreases laboratory testing and antibiotic use with no adverse outcomes. These were the ­findings of investigators who analyzed the effect of such an approach at their California hospital during a 5-year period.

As part of this approach, late preterm and preterm neonates who appeared well at birth remained with their mothers, even when the infants had perinatal risk factors for EOS. Nurses provided all these babies with enhanced clinical monitoring, and a neonatal hospitalist performed the initial clinical assessment of infants born to mothers with chorioamnionitis. Early in the study period, such chorioamnionitis-exposed infants were admitted to the NICU, but later on these babies instead remained with their mothers for the entire hospitalization if they appeared well.

Antibiotic treatment was administered only if the treating physician decided it was appropriate because the neonate was clinically ill at birth or later developed clinical signs of illness that posed a risk of sepsis. In addition, neonates were not routinely screened using sepsis laboratory testing, and when such testing was performed it was only once antibiotic treatment was started. Finally, routine evaluation for EOS did not include lumbar puncture for cerebrospinal fluid studies and culture. These tests generally were performed only in the presence of neurologic signs, such as mental status changes or seizures, at presentation or when the blood culture became positive.

Analysis of outcomes in 20,394 neonates ≥35 weeks’ gestation found that the percentage of neonates exposed to ampicillin decreased from 11.1% in the period before the clinical-examination approach was instituted to 4.1% during the intervention period. In addition, C-reactive protein testing declined from 15.3% to 6.3%. Overall, during an almost 5-year period, implementation of the clinical-examination approach reduced the use of antibiotics by 63% and sepsis laboratory testing by 59% (

Frymoyer A, et al. J Pediatr. 2020. E pub ahead of print

This paper is a potentially seminal article in my view. I was taught that at-risk newborns required work-ups and antibiotics; this is a drastic change. I expect it will take time to become standard; more seasoned physicians will not necessarily adjust their approach based on articles. In time, the next generation of pediatricians can show how it can be done safely.

Examining how an intensive clinical examination can change the approach to early-onset sepsis.

Author | Jon Matthew Farber, MD

Articles

Childhood wheezing may protect against future allergy

Consider the foreskin for syndactyly repair

Is botulinum toxin effective for treating children’s migraines?

New approach to EOS reduces testing and antibiotics