Dr Farber is a pediatrician in Woodbridge, Virginia.

Jon Matthew Farber, MD

A study of a large, multistate primary care group of more than 77,000 children spanning multiple years found a significant association between positional skull deformity (plagiocephaly) and developmental delay. The retrospective analysis relied on electronic medical record data from 45 primary care sites during a 17-year period and included children aged 5 years or younger who were classified as having plagiocephaly if they were diagnosed by 12 months of age.

Of the 77,108 patients seen by 12 months, 2315 (3%) were diagnosed with plagiocephaly (median age of diagnosis, 3 months), with prevalence of the condition increasing over time from 0.1% in 2000 to a maximum of 6.2% in 2016. Patients with plagiocephaly were more likely than their peers to be male, white, have private insurance, have English as a primary language, and have a history of prematurity and abnormal tone and torticollis. Almost 9% of total patients had a developmental delay diagnosis, with 17.5% of the plagiocephaly group having such a diagnosis compared with 8.7% in the group without plagiocephaly. Further, plagiocephaly was independently associated with increased odds for any developmental delay, even after controlling for sociodemographic and clinical factors. As for specific delays, motor, language, social, and general delay—but not cognitive delay—were significantly more likely in the plagiocephaly group. In patients with both plagiocephaly and developmental delay, plagiocephaly generally was diagnosed before developmental delay, at a median age of 3 months and 15 months, respectively (

You may hear about this study from worried parents. I understand why plagiocephaly could be associated with motor delay, but it is harder to account for other delays. I also note that the percentage of children with diagnosed delays seems high. In any case, most children with plagiocephaly will be developmentally normal. Follow them carefully, but you can reassure parents that their child likely will be fine.

Articles

Plagiocephaly has become an increasingly common diagnosis for infants. A study examines whether it could offer a clue about the child's risk of developmental delay.

Plagiocephaly may be an early indicator of developmental delay risk

Practitioners at a health center in Nova Scotia improved the time to antibiotics (TTA) for children with chemotherapy-induced febrile neutropenia (FN) by instituting a quality improvement project that included making many small and easy-to-implement changes to streamline the process.

Multiple potential delays (what the authors of a report on the project call “process wastes”) to TTA included patients’ waiting to be registered or for laboratory technicians, delayed central venous access device (CVAD) access, waiting for the absolute neutrophil count (ANC) to be reported, and delayed antibiotic orders. A multidisciplinary team sought to eliminate these wastes by laying out all stakeholders’ tasks to allow them to be executed in parallel, including nurse-initiated CVAD access and planned antibiotic administration no later than 45 minutes after triage. The authors reviewed how oncology patients who visited the emergency department (ED) with suspected FN were managed under a new streamlined process and compared these results with a baseline audit to evaluate improvements.

After the new process was initiated, 49 FN encounters in 26 patients took place during a 1-year period. The TTA significantly improved to a median of 59 minutes compared with the baseline of 99 minutes for patients with confirmed FN. In addition, the percentage of patients treated within 60 minutes rose from 12% to 47% and those treated within 90 minutes from 39% to 74%. The TTA was significantly shorter if the CVAD was accessed by a nurse to collect blood samples, with a median TTA of 55 minutes compared with 99 minutes when laboratory personnel collected them. The authors also determined that use of a standardized order set was associated with a median TTA of 55 minutes compared with 79.5 minutes without use of standardized order sets. Other positive changes included having families apply topical anesthetic en route to the ED, nurse-initiated steps, information to the electronic medical record, printing important orders with the initial ED package of paperwork, and setting a time limit for ANC returns before administering antibiotics (

Shortening the time to initiating antibiotic therapy in these potentially septic patients is quite important. You do not have to follow all the steps the authors took and can adapt some for your own circumstances, but arranging a protocol at your local hospital should not be that difficult, and could have immense benefits.

A quality improvement sought to shorten the time to antibiotics in pediatric oncology patients who are suspected to have neutropenia.

Shorten time to antibiotics for oncology patients with suspected neutropenia

A 3-minute step test (3MST) is a valid and reliable way to assess the cardiorespiratory and functional capacity of healthy children, according to a comparison of 3MST with the 6-minute walking test (6MWT), a tool often used for this purpose.

Investigators in Brazil recruited 66 public school children aged from 7 to 11 years old for the comparative study. Participants performed the 3MST with a 20 cm-high wooden step, a nonslip surface, and no handrail. They were instructed to go up and down 24 times a minute, keeping pace with a metronome. The 6MWT was performed in a 30m long flat hallway, with the children instructed to walk as far as possible without running.

Comparisons between the 2 tests with regard to performance variables found that the 3MST was a safe and reproducible way to determine exercise tolerance in healthy children in this age group. Further, compared with the 6MWT, the 3MST is short, easy to perform, and requires less physical space (

This test is easy enough to perform, requiring just a metronome and a step. I wish the authors had indicated what an abnormal result might be, so you may want to create your own norms. However, everyone they tested (including those who were obese) was able to complete the task so, at the least, a child who cannot complete the test warrants further evaluation before being cleared for participation in sports.

A 6 minute test is frequently used to test a child's ability to tolerate exercise, but a study investigates if a 3 minute test could work just as well.

How well can a brief step test assess exercise tolerance?

Though physicians sometimes empirically prescribe acid inhibitors for infant distress, nonacid re­flux causes at least as much—and perhaps more—pain and distress in infants than acid re­flux, according to a study in 62 children with persistent unexplained fussiness or distress and a median age of 3.5 months.

The prospective study included all children aged younger than 24 months referred to a European hospital for 24-hour multiple intraluminal impedance-pH (MII-pH) monitoring because of recurrent unexplained inconsolable distress thought to be a symptom of gastroesophageal reflux (GER). In addition to the monitoring, parents filled in a symptom diary and the Face, Legs, Activity, Cry, Consolability (FLACC) scale, a measurement for assessing pain in infants and young children. The scale ranges from 0 to 10 with 0 representing “relaxed and comfortable” and 7-10 “severe discomfort/pain.” Investigators then analyzed the FLACC scores in relation to the presence or absence, duration, chemical composition, and esophageal extension of GER episodes.

During the MII-pH monitoring, 452 episodes of distress were recorded, which parents scored with the FLACC scale. The number of episodes ranged from 1 to 32 per child, with a mean of 7.3. Fewer than half of the episodes (48%) were associated with GER. When associated with symptoms, GER occurred significantly more often before an episode of distress than it did simultaneously or after such an episode.

The median FLACC score did not differ significantly between the distress episodes that were associated with GER and those that did not. Overall, 361 (80%) distress episodes were in patients with an acid reflux index <7% and 91 (20%) in those with a pathologic acid reflux index. Episodes of distress associated with nonacid reflux presented a significantly higher FLACC than those with acid content (FLACC 6 vs 5). In addition, the median FLACC value was significantly lower in the 12 (19%) infants with a pathologic reflux index compared with the 50 infants (81%) with a normal reflux index (

Acid reflux is often blamed, incorrectly, for fussiness in infants. I have commented previously on the risk of anti-reflux medicines (

). I am not advocating for pH probes in fussy children, but rather for innocuous treatments that support parents through the fussy period.

When faced with a fussy infant, it's common to think acid reflux is the cause, but a recent report indicates that it may be time to think of other causes.

Jon Matthew Farber, MD

Articles

Plagiocephaly may be an early indicator of developmental delay risk

Shorten time to antibiotics for oncology patients with suspected neutropenia

How well can a brief step test assess exercise tolerance?

When it comes to infant distress, acid reflux often gets a bum rap!