Current Pediatric Reviews (v.12, #1)

Meet Our Editor: by Giuseppe Buonocore (1-3).

Preface: by Giuseppe Buonocore (4-4).

Idiopathic scoliosis predominantly afflicts adolescents. Adolescents with mild curvatures do not generally have any symptoms. However spinal fusion is indicated when the deformity exceeds 45°. Treatment is thus necessary to prevent and/or reduce the progression of curvatures to that below which surgery is indicated. Conservative treatment of adolescent idiopathic scoliosis includes observation, scoliosis-specific exercises (SSE) and bracing. There is increasing evidence suggesting that SSE and brace treatment can significantly limit the progression of spinal curvatures. In growing adolescents with curvatures more than 20°, bracing is indicated and should be used in conjunction with SSE. The effectiveness of bracing varies according to the type of brace applied to the patient. In general rigid braces are preferable to soft flexible braces, as the latter falls short of halting curvatures progression. Also, preliminary evidence suggests that asymmetric braces which enable over-correction provide more correction when compared with symmetrical braces. Recently it has also been reported that high quality bracing can also reduce curvatures exceeding 45° in over 70% of growing adolescents. This new knowledge might possibly increase the threshold of surgical indications to beyond 50o or above in the near future.

Postural Re-Education of Scoliosis - State of the Art (Mini-review) by Maksym Borysov, Marc Moramarco, Ng SY, Sang G. Lee (12-16).
A new development of correcting exercises has been derived from the original Schroth program in 2010 and the preliminary results have been published that year. Since then the program has been applied in some centers worldwide.
As the original Schroth program was the only program so far to improve many signs and symptoms of scoliosis besides the angle of curvature (Cobb angle) it was interesting to look for the preliminary results of the recent development of scoliosis pattern specific corrective exercises derived from the original program, to see if similar effects can be achieved with this less complicated method.
Methods: A manual search in Pubmed was conducted, using the key words, Schroth, rehabilitation, and idiopathic scoliosis. Three papers have been found describing the short-term results of this new development today called Schroth Best Practice program (SBP). The papers were reviewed and analyzed with respect to the outcome parameters used.
Results: Outcome parameters were Angle of Trunk Rotation (ATR), Vital Capacity (VC), surface topography, electromyography, stabilometry and Cobb angle before and after a course of treatment. There was a significant improvement of all parameters after the application of this new program in all the three papers in the short- to mid-term.
Conclusions: Scoliosis corrective exercises are supported by two randomized controlled trials (RCT) and should regularly be applied in mild scoliosis at risk for progression. Unspecific exercises such as Yoga, Dobomed cannot be regarded as effective as exercises using a well defined scoliosis pattern specific corrective routine.

The Influence of Short-Term Scoliosis-Specific Exercise Rehabilitation on Pulmonary Function in Patients with AIS by Marc Moramarco, Maja Fadzan, Kathryn Moramarco, Amy Heller, Sonia Righter (17-23).
Objective: To investigate the short-term outcomes of treatment utilizing an outpatient scoliosis- specific back school program in thirty-six patients with adolescent idiopathic scoliosis (AIS). Background: Improved signs and symptoms of AIS have been reported in response to curve-patternspecific exercise therapy programs. Additional outcome studies are needed.
Methods/Materials: Thirty-six patients with adolescent idiopathic scoliosis (AIS), 33 females and 3 males, completed a twenty-hour multimodal exercise program (Schroth Best Practice® - SBP) for five to seven days at Scoliosis 3DCSM. Average age was 13.89 years and average Cobb angles were 36.92° thoracic and 33.92° lumbar. The sample was comprised of patients under treatment from August 2011 to February 2015 who never had scoliosis-related surgery and who were not undergoing brace treatment. SBP program components included physio-logic® exercises, mobilizations, activities of daily living (ADLs), 3-D Made Easy®, and Schroth exercises.
Forced vital capacity (FVC), forced expiratory volume in one second (FEV1), chest expansion (CE), and angle of trunk rotation (ATR) were clinical parameters used to evaluate results of this outpatient scoliosis-specific exercise program. Results: Highly significant improvements were noted in FVC, FEV1, CE and ScoliometerTM readings.
Conclusions: A short-term outpatient SBP program was found to have a positive influence on FVC, FEV1, ATR, and CE. We will present long-term results in a subsequent study.

Idiopathic scoliosis afflicts 2-3% of the population. For mild curvatures, observation is the treatment of choice. Though this passive “wait and see” approach has been used for many years, the practice is inconsistent among different countries. In Anglo-Saxon countries where scoliosis specific exercises are not practised, observation is indicated for curvatures below 25° in growing children and adolescents. In countries, such as France, Germany, Italy and Poland where scoliosis specific corrective exercises are employed, only patients with no signs of maturity and with curvatures below 15° are treated by observation. Patients with curvatures between 15 - 25° are treated by scoliosis specific exercises. In view of the unpredictability of the progression of scoliosis curvatures in immature patients and the lack of knowledge of long term biomechanical repercussions of mild idiopathic scoliosis on lumbar spine and lower extremities, it is proposed that active intervention through scoliosis specific exercises rather than passive observation be employed in the treatment of mild adolescent idiopathic scoliosis.

Background: The aim of this study is to evaluate the effect of a Schroth Best Practice® program in an out-patient regimen on the signs of scoliosis in patients with adolescent idiopathic scoliosis (hereafter referred to as AIS). The second aim is to evaluate in-brace correction with the Gensingen Brace® in the first sample of patients with AIS. Both authors have undergone training in this special approach to scoliosis rehabilitation. The first author has undergone PT (physical therapy) and CAD-CAM (computer-aided design and manufacturing)bracing training, the second author PT training.
Materials and Methods: 23 patients with AIS, 19 girls and 4 boys, with an average age of 13.6 years, average Risser sign of 2.52 and an average Cobb angle of 36.9 degrees (20-88 degrees), underwent an out-patient Schroth Best Practice® program with an intensity of two days a week of 2 x 60 min sessions/day. The angle of trunk rotation (ATR) was measured before and after the course.
Eleven of the patients were fit with Gensingen Braces®. Braces were produced via CAD-CAM. In-brace correction was measured and compared with initial data.
Results: After an out-patient Schroth Best Practice® program ATR was reduced significantly from 9.58 degrees to 7.47 degrees in thoracic and from 8.9 to 6.6 degrees in lumbar. An average in-brace correction of 59% was achieved in CADCAM braces.
Discussion: The results achieved with out-patient rehabilitation in the investigations published previously are repeatable. The deformity of the trunk can be reduced significantly after out-patient rehabilitation according to Schroth Best Practice® standards. In-brace correction comparable with published results on CAD-CAM bracing can be achieved in braces according to Gensingen® standards after appropriate training.
Conclusion: Out-patient rehabilitation following the Schroth Best Practice® standards seems to provide an improvement of signs of scoliosis patients in this study using a pre-/post prospective design. The results of the recent studies on Schroth Best Practice® program seem to be repeatable.
Following appropriate training, the in-brace corrections achieved with the CAD / CAM technology can be compared to the in-brace corrections as published in recent literature. CAD / CAM allows for repeatable results globally.

Bracing Scoliosis - State of the Art (Mini-Review) by Ng SY, Maksym Borysov, Marc Moramarco, Xiao F. Nan, Hans-Rudolf Weiss (36-42).
Spinal bracing is indicated in moderate to severe curves during growth. Brace effectiveness in halting progression of adolescent idiopathic scolisosis has been shown in a Cochrane review and in a randomized controlled trial (RCT). The outcome of brace treatment is dependent on the extent of inbrace correction and compliance. We have reviewed the literature on bracing to determine the types of brace that offer the best in-brace correction.
Materials and Methods: The literature has been searched for papers on bracing with documented inbrace corrections and long-term results.
Results: The in-brace percentage of correction of asymmetric braces is generally higher than that of the symmetric braces. According to the literature found in our search, long-term corrections are possible when starting treatment early, at an immature stage and with asymmetric braces of recent standards.
Conclusions: Bracing today is supported by high quality evidence (Level I). Asymmetric braces have led to better corrections than that described for symmetric braces. An improvement of the average corrective effect has been described due to the latest CAD / CAM development. Long-term corrections are possible when starting brace treatment early, at an immature stage and with asymmetric braces of recent standards.

Congenital Scoliosis (Mini-review) by Hans-Rudolf Weiss, Marc Moramarco (43-47).
Congenital scoliosis is a lateral deformity of the spine with a disturbance of the sagittal profile caused by malformations of vertebra and ribs. Typically, early surgical intervention is the suggested treatment (before three-years-old) for young patients with congenital scoliosis. While a previous study was conducted in 2011 to investigate long-term studies supporting the necessity for this recommendation and no evidence was found, this current review, is an updated search for evidence published from 2011 through March 2015. This also failed to find any prospective or randomized controlled studies to support the hypothesis that spinal fusion surgery in patients with congenital scoliosis should be considered as evidence-based treatment. Contradictory results exist on the safety of hemivertebra resection and segmental fusion using pedicle screw fixation. When using the VEPTR (vertical expandable prosthetic titanium rib) device, studies show a high rate of complications exist.
It is difficult to predict the final outcome for patients with congenital scoliosis. However, it is possible that many patients with congenital scoliosis may be able to avoid spinal surgery with the application of advanced bracing technology. Therefore, it is only prudent to advocate for conservative management first before spinal surgery is considered.

Phenobarbital is an effective and safe anticonvulsant drug introduced in clinical use in 1904. Its mechanism of action is the synaptic inhibition through an action on GABAA. The loading dose of phenobarbital is 20 mg/kg intravenously and the maintenance dose is 3 to 4 mg/kg by mouth. The serum concentration of phenobarbital is up to 40 g/ml. Nonresponders should receive additional doses of 5 to 10 mg/kg until seizures stop. Infants with refractory seizures may have a serum concentration of phenobarbital of 100 g/ml. Phenobarbital is metabolized in the liver by CYP2C9 with minor metabolism by CYP2C19 and CYP2E1. A quarter of the dose of phenobarbital is excreted unchanged in the urine. In adults, the half-life of phenobarbital is 100 hours and in term and preterm infants is 103 and 141 hours, respectively. The half-life of phenobarbital decreases 4.6 hours per day and it is 67 hours in infants 4 week old.

Vitiligo in Children: A Birds Eye View by Meghana M. Phiske (55-66).
Vitiligo in children is a distinct subset of vitiligo and differs from adult vitiligo. Characteristic features include family history of autoimmune or endocrine disease, higher incidence of segmental vitiligo, development of early or premature graying, increased incidence of autoantibodies and poor response to topical PUVA. The exact prevalence of vitiligo in children varies between 0.1-4% of the world population and seems to be higher in India than in other countries and it occurs more frequently in females. Around 12% to 35% of pediatric vitiligo patients have family members with the disease. The most common type of vitiligo in pediatric patients is vitiligo vulgaris, representing 78% of cases. The most commonly associated autoimmune disease is thyroiditis. Phototherapy and topical corticosteroids are the most commonly used treatments for adult vitiligo but are less useful in the pediatric population.

Safe Infant Sleep Interventions: What is the Evidence for Successful Behavior Change? by Rachel Y. Moon, Fern R. Hauck, Eve R. Colson (67-75).
Sudden infant death syndrome (SIDS) and other sleep-related infant deaths, such as accidental suffocation and strangulation in bed and ill-defined deaths, account for >4000 deaths annually in the USA. Evidence-based recommendations for reducing the risk of sleep-related deaths have been published, but some caregivers resist adoption of these recommendations. Multiple interventions to change infant sleep-related practices of parents and professionals have been implemented. In this review, we will discuss illustrative examples of safe infant sleep interventions and evidence of their effectiveness. Facilitators of and barriers to change, as well as the limitations of the data currently available for these interventions, will be considered.