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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, a pediatrician entering hematology/oncology fellowship at St. Jude Children’s Research Hospital.

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

1. Sleep deficiency during critical developmental stages — as reported at the constantly illuminated processing centers for migrant children along the U.S.-Mexico border — is associated with long-term adverse health outcomes. New England Journal of Medicine June 2018

2. Brain maturation between ages 14 and 17 is significantly modulated by events experienced before age 5. Nature June 2018

3. An Idaho boy who contracted bubonic plague has been successfully treated with antibiotics and is recovering in hospital. Time June 2018

4.  As part of an ongoing study, researchers hypothesize that pediatric patients using virtual reality headsets will report significantly less procedural pain and anticipatory anxiety. WRVO June 2018

5. In a study of 183 young families, children’s bad behavior was linked to parents spending more time on digital devices, which was in turn linked to worsening children’s behavior. Pediatric Research, June 2018

Clinical Quiz

A 26-day-old term male infant is brought to the emergency department by his mother over concerns of lethargy and difficulty nursing. She reports that he needs to be awakened to nurse, and feeds for just a few minutes at a time. Examination reveals jaundice, a large umbilical hernia, and an increase of 3 oz (85 g) from his birth weight. Based on this patient’s probable diagnosis, which of the following clinical features is most likely to also be present?

A. Enlarged anterior fontanel  
B. Tachycardia
C. Palpable olive in the epigastrium
D. Petechiae

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

Editor’s Pearl

“When will my child be ready to toilet train?” is a common question asked in the office setting. Here is a quick table that you can use based on Brazelton’s recommendations, which are the most commonly followed today.

To review the different approaches parents may take regarding toilet training, visit

A. Enlarged anterior fontanel

This infant’s clinical features are highly suggestive of the inadequate production of thyroid hormone that occurs in congenital hypothyroidism. The condition is most commonly caused by abnormal development of the thyroid, but can also be the result of inborn errors of thyroid metabolism. As thyroid hormone plays an important role in the formation and maturation of bone, an abnormally large anterior fontanel can be an early sign of the disorder. While most cases will be identified on newborn screening, others may present with features such as persistent jaundice, poor feeding, constipation, and a hoarse cry within the first few weeks to months of life.

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