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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 who recently completed residency training at Children’s National Medical Center.

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

1. Conservative measures to control gastroesophageal reflux in preterm infants, such as left lateral body position, head elevation, and feeding regimen manipulation, have not been shown to reduce clinically assessed signs of the phenomenon. Pediatrics July 2018

2. “Are you planning to rear your infant in a manner similar to or different from the way your parents reared you?” is a recommended question for use in the prenatal visit. Pediatrics July 2018

3. In children with moderate/severe asthma exacerbations, viral detection is not associated with greater severity on presentation; however, the presence of specific pathogens, namely respiratory syncytial virus, influenza, and parainfluenza, identified children with worse outcomes and insufficient response to standardized corticosteroids and bronchodilator treatment. Pediatrics July 2018

4.  Understanding which of the four known physiological pathways is causing a child’s vomiting — mechanical, blood-borne toxins, motion, or emotional response —  will help determine best treatment options, including which antiemetic is most likely to be helpful to mitigate symptoms. Pediatrics in Review July 2018

5. Given the dangers posed by adolescent smartphone use behind the wheel, one preventative strategy may include asking the question “Do you text and drive?” at all physician visits, including health maintenance, acute care, and emergency department visits. In Brief: Pediatrics in Review, July 2018

Clinical Quiz

A 13-year-old boy presents with worsening left knee pain. His mother mentions his pain is typically worse after he plays soccer and is exacerbated by kneeling. Examination reveals swelling and tenderness over the tibial tubercle, and pain with resisted knee extension. No erythema or effusion is present. An X-ray demonstrates the findings seen here. Which of the following is the next best step in the management of this patient?

A. Glucocorticoid injections
B. Ice and NSAIDs as needed
C. Ossicle excision
D. NSAIDs for 14 days, then reassess

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

Editor’s Pearl

Test makers love to ask about normal progression of puberty and precocious puberty. So, when is puberty expected to start and when is puberty early?

Puberty is precocious if it starts:

  • before 8 years of age for girls
  • before 9 years of age for boys

And what is the normal sequence of pubertal changes in girls and boys?

  • Breast budding → peak height velocity → menarche
  • Testicular enlargement → pubic hair → penile growth → peak height velocity

CLINICAL QUIZ ANSWER:
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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