Pediatrics Update Vol. 2, No.

1, 2019
Neonatal Brachial Plexus Injuries: An Integrated Approach
By Alexander Y. Shin, M.D.

The brachial plexus injuries experienced by newborns can range from a few stretched nerves to
the tearing or rupturing of all nerves in the brachial plexus network. A multidisciplinary approach is
beneficial to achieving optimal outcomes. The brachial plexus clinic at Mayo Clinic, which manages care for
children and adults, is one of the highest-volume brachial plexus clinics in the country. The treatment team
includes two orthopedic hand and microsurgeons, as well as a pediatric orthopedic surgeon and a
neurosurgeon specializing in peripheral nerve surgery. Subspecialized radiologists and anesthesiologists
with experience in diagnostic and surgical procedures for these young patients also are available.
Appointments for patients with these injuries are generally made within a week or two of referral.
Ideally, the required nerve surgery should be performed early, to avoid muscle degeneration due to the
lack of nerve signals. “We know that if you wait too long for that initial surgery — just observing for the
baby’s first year — you can lose the ability to do primary nerve surgery. Typically, the nerves need to be
operated on in the first six months of life,” says Alexander Y. Shin, M.D., an orthopedic hand and
microsurgeon specializing in brachial plexus injuries at Mayo Clinic Children’s Center in Rochester,
Minnesota. The benefits of an integrated approach can be seen throughout the process of managing
neonatal brachial plexus injuries. Diagnosis generally involves MRI and nerve tests. At Mayo Clinic, pediatric
neurologists, radiologists and anesthesiologists coordinate to perform testing in one setting. “Otherwise, a
baby might end up having two or three major anesthesia procedures. We try to minimize anesthesia to one
when possible,” Dr. Shin says. Having a multidisciplinary team allows for surgical reconstruction that is
tailored to the individual patient’s needs — nerve surgery, tendon transfers and shoulder-to-hand
reconstruction — when necessary. Dr. Shin notes that brachial plexus nerve surgery can restore 70 to 80
percent of shoulder and elbow function in certain types of injury. However, imbalances in growth from
nerve injury around the shoulder can lead to secondary sequelae: typically, internal retraction contracture
and the inability to externally rotate the shoulder. “If those sequelae aren’t addressed before about 2 years
of age, the child might experience long-term problems, especially with the shoulder,” Dr. Shin says. About
70 to 80 percent of patients who need secondary surgery have good outcomes. “A baby having a brachial
plexus injury can understandingly be an emotional experience for parents,” Dr. Shin says. “Our brachial
plexus team works together so that parents and baby can move forward with the best possible care.”

Reaction:
For many years there has been a growing movement to improve the quality and delivery of
healthcare. The pediatrics update introduced by the Alexander Y. Shin, M.D. about the benefits of the
integrated approach in managing neonatal brachial plexus injury could change a child's developmental path
and improve outcomes for children and families. Not only children but families could benefit from early
intervention as well by being able to better meet their children's needs from an early age and throughout
their lives.
The relationship between breastfeeding and reported respiratory and gastrointestinal infection rates in
young children
BMC Pediatrics — Frank NM, Lynch KF, Uusitalo U, et al. | September 24, 2019

Experts sought to investigate whether exclusive longer-term breastfeeding will have a greater impact on
future rates of acute respiratory and gastrointestinal illness during childhood than exclusive shorter-term
breastfeeding. For this investigation, they examined exclusive and non-exclusive breastfeeding in relation
to the 3-month odds of respiratory or gastrointestinal infection for 6,861 children aged 3–18 months and
5,666 children aged 4 years. Breastfeeding was found to be inversely linked to the odds of respiratory
infections with fever, otitis media, and infective gastroenteritis at 3–6 months of age, although the inverse
connection with respiratory illnesses was observed only for girls during the winter months. Between the
ages of 6 and 18 months, breastfeeding within any 3 month period continued to be inversely linked to the
odds of ear infection and infective gastroenteritis, as well as odds of conjunctivitis, and laryngitis and
tracheitis, over the same period of 3 months within this age range. In this group, however, breastfeeding
has been associated with increased common cold reports. Findings suggested that breastfeeding can be
protective against various respiratory and gastrointestinal acute illnesses in few children up to at least
6 months of age, with the duration of exclusive breastfeeding being somewhat protective of otitis media
even after breastfeeding has stopped.

Reflection:

Breastfeeding is very recommended to use for a infants instead and using baby bottle fed formulas during
early stages of life. The DOH recommended here in the Philippines the strictly use of breastfeeding. It is
healthy that infants and toddlers should drink the breastfeed milk because it is a natural formula that is rich
in nutrition than in bottle formulas that mixed with chemicals that may harm the child that can cause
allergies and other problems that may lead to respiratory and gastrointestinal infection. So it is a must that
as a student nurse, I should promote breastfeeding to mothers and help mothers how to properly
breastfeed their child and health educate those who have problem in lactating. As what they said
prevention is better than cure. Why buy expensive milk formulas when you have breast milk where it is free
and natural you can save money and time. In this time, we should be practical regarding with money and
health.
 World Health Organisation update their recommendations for children under five

The World Health Organisation has updated some of their recommendations for children under five. What’s
curious is how the updated guidelines have been reported by the popular press. For instance BBC News
lead with “No sedentary screen time for babies, WHO says”, Nursery World state “Guidance recommends
no screen time for under-twos” and The Sun sensationalizes the report with the warning that “Kids under
two should never be allowed to watch ANY screens – or they’ll get fat, WHO warns”. Yet recommendations
about children’s screen time only made up a small part of the WHO’s updated 36-page guidance, which
altogether focuses on physical activity, sedentary behaviour and sleep for children aged under five. For
children in three age categories (under one, one-two years old and three-four years old) the World Health
Organisation gives guidance on how much time children should be spending on three areas such as physical
activity, sedentary screen time and good quality sleep. They state that their guidelines are for all healthy
children “irrespective of gender, cultural background or socio-economic status of families and are relevant
for children of all abilities” (2019; viii). Many pieces of research have been taken into account when devising
the guidelines, although some people have criticised the recommendations because there are still gaps in
research about children’s physical activity, which the WHO themselves acknowledge.

Parents and practitioners may now be questioning how to ensure they are following the updated
guidelines. In some cases, they may find the guidance useful, as it is does give exact amounts of time that
children should be devoting to activities. For instance, the report states that children under one should
engage in at least 30 minutes of tummy time per day, whereas NHS guidance on tummy time is slightly
more woolly. However, the advice that children under five should not be restrained for more than an hour
at a time (whether that be in prams, car seats or baby carriers) might be daunting for those with
circumstances where that is unfeasible, for instance because of long work commutes.

Reaction
The update for children under five is I think right to be implemented at this moment because in this
generation technology is what we live for. In today’s world, managing screen time is an ongoing challenge.
Limiting, and in some cases eliminating, screen time for children under the age of 5 will result in healthier
adults. Taking away iPads and other electronic devices is only part of the solution of World Health
Organization. Children under 5 should also get more exercise and sleep in order to develop better habits
that will stave off obesity and diseases in adolescence and adulthood.

Albuterol for children undergoing tonsillectomy (July 2019)

Perioperative respiratory complications are common in children undergoing tonsillectomy. A

randomized placebo-controlled trial in almost 480 children demonstrated that pretreatment with

albuterol reduced the frequency of respiratory adverse events, including laryngospasm, coughing,

and oxygen desaturation, with the greatest benefit seen in children with moderate to severe

obstructive sleep apnea (OSA) [3]. Albuterol did not reduce time in the post-anesthesia care unit,

suggesting that most respiratory complications were likely mild.

Additional data are needed before albuterol pretreatment can be routinely recommended for all

children undergoing tonsillectomy. However, these findings support a single dose of albuterol as

a reasonable intervention for children who are at risk for perioperative respiratory difficulties (eg,

individuals with moderate to severe OSA, recent upper respiratory tract infection, or recent

asthma symptoms)

Reflection

According to the findings of this trial, premedication with albuterol prior to undergoing anesthesia

for tonsillectomy significantly reduced perioperative respiratory adverse events. Based on this

data, the authors suggest that, “anesthetists should consider the use of albuterol in routine

practice, particularly in children with moderate to severe OSA.”

Antimicrobial coating ‘new tool’ to fight hospital infections

A new antimicrobial coating for steel surfaces could be the key to fighting hospital-acquired infections,
according to scientists who today published the results of a “successful” clinical trial.
The coating, which was created by scientists at the University of Birmingham and has been named NitroPep,
has proven to “rapidly” kill bacteria that causes some of the most common hospital-acquired infections.
“Our successful clinical study shows that our non-toxic coating could be used on regularly handled steel
surfaces”
Felicity de Cogan
Those behind the study described the coating as a potential “new tool” in the battle against the spread of
infection.
The clinical trial, which was conducted in collaboration with the Royal Centre for Defence Medicine and the
Royal Navy, saw NitroPep coated on steel surfaces on-board a Royal Fleet Auxiliary ship. It was put on door
handles, an operating theatre and part of a communal toilet.
To compare results, researchers also had a series of “control” surfaces that were not treated with the
coating.
Under the trial, both surfaces were subject to standard daily cleaning regimes while the ship was at sea for
an 11-month period.
The surfaces were swabbed on a weekly basis and results were then analysed at a laboratory at the
university.
Findings from the trial showed that the coating was effective against five different bacteria that are
responsible for hospital-acquired infections – Staphylococcus aureus, Staphylococcus epidermidis,
Enterococcus, Pseudomonas aeruginosa and Escherichia coli.
In addition, the study found that the coating killed bacteria within 45 minutes. According to the researchers,
this was “far more rapidly” than other technologies which are currently available, which they said do not
have a significant effect on bacteria until up to 24 hours.
“Despite increased sterilisation and education campaigns, hospital-acquired infections have not been
eradicated"
Felicity de Cogan
Dr Felicity de Cogan, Royal Academy of Engineering enterprise fellow at the University of Birmingham and
chief scientific officer of a new company created to put the product on the market, also called NitroPep,
said: “One of the biggest public health issues across the world continues to be the spread of infection and
contamination from bacterial, viral and insect-borne diseases.
“Despite increased sterilisation and education campaigns, hospital-acquired infections have not been
eradicated and the accumulation of bacteria on frequently touched surfaces is key in the transmission of
infection.”
She said it therefore must be a priority to “research, develop and implement safe and effective prevention
techniques and technologies”.
“Our successful clinical study shows that our non-toxic coating could be used on regularly handled steel
surfaces, such as toilet flush handles, bed rails and metal medical equipment, across healthcare, education
and other industrial and leisure settings helping to create safer and healthier environments,” Dr de Cogan
added.
Managing director of NitroPep, Graeme Forster, said there was a "clear and urgent" need to prevent the
transmission and spread of infection in the built environment globally and he believed NitroPep could be
part of the solution.
The study, published in Materials Science and Engineering C: Materials for Biological Applications , was
carried out by scientists at the University of Birmingham’s institute of microbiology and infection and school
of chemistry; the Royal Centre for Defence Medicine; the University of Nottingham; and Queen Elizabeth
Hospital Birmingham.