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Welcome to The Differential, our weekly pediatrics briefing. Created by physicians for physicians, The Differential is designed to be quick (skim it in just a few minutes) and thorough (all the information you need is in right here). Today’s Differential is edited by Dr. Cherilyn Cecchini.

The Differential for Pediatrics is available as a free weekly email.
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Single-Sentence Summaries

1. Between 1999 and 2014, antibiotics prescription to U.S. adolescents was halved while amphetamine prescriptions for ADHD increased by 30%. JAMA May 2018.

2. The CDC’s reported 0.2% uptick in autism rates is likely due to better screening in minority communities.  AAP News Apr 2018

3. Low  levels of arginine vasopressin in cerebrospinal fluid may be a biomarker for autism. Stanford University School of Medicine News May 2018.

4. The popularity of juuls – sweet, vaporless e-cigarettes about the size of USB drives – has led to an FDA crackdown on their sales to minors. AAP News Apr 2018.

5. Outpatient observation is a cost-effective, value-based alternative to cerebrospinal fluid testing in febrile infants. Hospital Pediatrics April 2018.

Clinical Quiz

A 14-year-old boy is brought to the pediatrician by his mother over concerns of difficulty walking and worsening clumsiness. He reports a gradual loss of night vision, and a long history of chronic diarrhea which is pale and foul-smelling. Examination reveals an ataxic gait, and loss of deep tendon reflexes. Bilateral retinitis pigmentosa is noted on fundoscopy and a peripheral blood smear reveals the findings seen here. Which additional laboratory finding is most likely?

A. Low total cholesterol level
B. Elevated calcium level
C. Low vitamin B12 level
D. Elevated alpha-tocophereol level

Answer at the bottom of this email, or click here to see the full case and discussion on Figure 1.

Editor’s Pearl

Have a new mother in the office who is breastfeeding and wondering about storage recommendations? An easy way to remember is the “rule of 5s,” as in 5 hours at room temperature, 5 days in the fridge, and 5 months in the freezer. Courtesy of the CDC, here are exact guidelines that you can reference here, store for later use, or print for a patient’s parents.

Breast milk storage guidelines

Storage Conditions // Duration
Room temperature // 6-8 hours (3-4 in warm climates)
Refrigerator // 5 days
Freezer compartment // 2 weeks
Freezer drawer (separate door) // 3-6 months
Deep freezer // 6-8 months


Clinical Quiz Answer:

A: Low total cholesterol level

This patient’s presentation and clinical findings are suggestive of abetalipoproteinemia, a form of neuroacanthocytosis. The condition, also known as Bassen-Kornzweig disease, is an autosomal recessive disorder characterized by neurologic impairment and the presence of acanthocytes (spiculated red blood cells) on a peripheral blood smear. Other notable laboratory findings include a low total cholesterol level, with an absence of beta-lipoproteins on electrophoresis. The resultant inability to absorb and transport vitamin E causes the neurologic manifestations associated with the disease.

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