Benefits of Probiotics Reviewed

Laurie Barclay, MD Medscape News

November 6, 2008 — Probiotics are microorganisms that may be helpful for conditions such as antibiotic-associated diarrhea, infectious diarrhea, irritable bowel syndrome, and atopic dermatitis in at-risk infants, according to a review published in the November 1 issue of American Family Physician.

"Probiotics are live microorganisms that benefit the health of the host when administered in adequate amounts," write Benjamin Kligler, MD, MPH, from Albert Einstein College of Medicine of Yeshiva University, and Andreas Cohrssen, MD, from the Beth Israel Residency Program in Urban Family Practice, both in New York, New York. "Several mechanisms have been proposed to explain the actions of probiotics. In most cases, it is likely that more than one mechanism is at work simultaneously."

Because of these multiple mechanisms of action, many different probiotics have potential applications to various diseases. Those in most widespread use, which have undergone the most clinical testing, include Lactobacillus species (such as L acidophilus, L rhamnosus, L bulgaricus, L reuteri, and L casei); Bifidobacterium species; and Saccharomyces boulardii, which is a nonpathogenic yeast.

Efficacy of a probiotic species taken orally requires that it be resistant to acid and bile so that it can pass through the upper gastrointestinal tract without loss of biological potency. However, even the hardiest microorganisms must be administered regularly to maintain colonization and typically can no longer be cultured from stool samples more than 1 to 2 weeks after ingestion of the probiotic.

Probiotics are considered to be both safe and effective for preventing and treating antibiotic-associated diarrhea and infectious diarrhea. The probable mechanism of action may be a combination of direct competition between pathogenic bacteria in the gut and immune modulation and enhancement.

Other specific applications supported to some degree by available studies include relief of gastrointestinal tract symptoms in irritable bowel syndrome and therapy for pediatric atopic dermatitis.

Although probiotics are sometimes used for other conditions, evidence is lacking to support these indications, and they were therefore not discussed in this review. These conditions include vaginal candidiasis, stomach infection with Helicobacter pylori, inflammatory bowel disease, and upper respiratory tract infections.

On the basis of dosages used in clinical studies documenting efficacy, frequently used dosages range from 5 to 10 billion colony-forming units per day for children and from 10 to 20 billion colony-forming units per day for adults, although these vary based on the specific microorganism or combination used. In most studies, the dosages of S boulardii range from 250 to 500 mg/day.

Probiotics have no reported drug interactions. Common adverse effects are mild and self-limited, including flatulence and mild abdominal discomfort. Septicemia and other severe adverse effects may rarely occur, and these have only been reported in severely ill or immunocompromised hosts or in children with short-gut syndrome. Therefore, probiotics should be used only with caution in patients with short-gut syndrome, and they are contraindicated in patients with conditions that severely compromise the immune system.

Available formulations of probiotics include capsules, powder, tablets, liquid, or incorporated into food.

Prevention of Vulvar and Vaginal cancer

Gardasil Approval Expanded to Prevention of HPV-Related Vulvar, Vaginal Cancer

News Author: Laurie Barclay,
CME Author: Yael Waknine

September 18, 2008 — The US Food and Drug Administration (FDA) announced yesterday that approval for the vaccine Gardasil (HPV quadrivalent [types 6, 11, 16, and 18] recombinant vaccine) has been expanded to include the indication of preventing vaginal and vulvar cancer caused by human papillomavirus (HPV) types 16 and 18 in girls and women aged 9 to 26 years.
"There is now strong evidence showing that this vaccine can help prevent vulvar and vaginal cancers due to the same viruses for which it also helps protect against cervical cancer," Jesse L. Goodman, MD, MPH, director of the FDA's Center for Biologics Evaluation and Research, said in a news release. "While vulvar and vaginal cancers are rare, the opportunity to help prevent them is potentially an important additional benefit from immunization against HPV."
In 2006, the original FDA approval for Gardasil was for the prevention of cervical cancer caused by HPV types 16 and 18, which cause 70% of cervical cancers and which are implicated in unknown percentages of vulvar and vaginal cancers. The original approval, which was for girls and women aged 9 to 26 years, was also for the indications of preventing precancerous genital lesions caused by HPV types 6, 11, 16, and 18 and genital warts caused by HPV types 6 and 11.
In the United States, HPV is the most prevalent sexually transmitted disease, with an annual incidence of 6.2 million new infections, according to the US Centers for Disease Control and Prevention.
Merck & Co Inc, the manufacturer of Gardasil, followed up on more than 15,000 participants from the original cervical cancer prevention studies for 2 more years to determine the effects of Gardasil on the risk for vulvar and vaginal cancer compared with control participants who had not received Gardasil.
This follow-up showed that Gardasil was highly effective in preventing HPV-related precancerous vulvar and vaginal lesions in women who tested negative for HPV types 16 or 18 at study enrollment. None of the participants in the Gardasil group developed HPV type 16- or 18-related precancerous lesions compared with control group findings of 10 precancerous vulvar lesions and 9 precancerous vaginal lesions related to HPV types 16 or 18.
Women previously infected with HPV types 16 or 18 before immunization had no evidence of benefit. To optimize the preventive effects of Gardasil, the investigators therefore recommend vaccination before potential exposure to HPV types 16 or 18.
Caveats from the FDA represented in the label are that presently available information is insufficient to support use in women older than age 26 years and that Gardasil does not protect against diseases caused by other HPV types. Because Gardasil does not protect against preexisting HPV infections and because no vaccine is 100% effective, all women should continue to be monitored with Papanicolaou tests, even after vaccination.
Most adverse events of Gardasil reported since FDA approval in 2006 have not been serious. The most frequently reported adverse events have included syncope, injection site pain, headache, nausea, and fever. Observation is recommended after vaccination in case of syncope or severe allergic reactions.
A short- and long-term safety surveillance study is underway of 44,000 individuals in a managed care organization who received Gardasil for all its approved uses.
Source :Gardasil Prescribing Information

Study Highlights
The FDA has approved an expanded indication for a quadrivalent recombinant vaccine, allowing its use for the prophylaxis of vaginal and vulvar cancer caused by HPV types 16 and 18 in girls and women aged 9 to 26 years.
The HPV vaccine is administered as an intramuscular injection at 0, 2, and 6 months.
Previously, the FDA approved use of the vaccine for the prevention of cervical cancer caused by HPV types 16 and 18; precancerous genital lesions caused by HPV types 6, 11, 16, and 18; and genital warts caused by HPV types 6 and 11.
The current approval was based on data from 3 placebo-controlled, randomized studies that followed up on 18,714 participants for a mean of 3 years; approximately 50% had been vaccinated.
Results showed that the vaccine was 100% effective for preventing precancerous high-grade vulval intraepithelial neoplasia and vaginal intraepithelial neoplasia caused by HPV types 16 and 18 in girls and women who tested negative for infection up to 1 month after the last dose.
In the intent-to-treat population, which included all participants, the vaccine was 71% effective against vulvar intraepithelial neoplasia or vaginal intraepithelial neoplasia associated with HPV 16 or 18.
Results also showed the vaccine to be 49% effective against all vulvar intraepithelial neoplasia or vaginal intraepithelial neoplasia irrespective of whether HPV DNA was detected in the lesion.
No evidence of vaccination benefit was observed in girls and women previously infected with the HPV subtypes contained in the vaccine.
There is insufficient evidence to support use of the vaccine in women older than 26 years.
Adverse events most commonly include syncope, pain at the injection site, headache, nausea, and fever. Because of the potential for allergic reactions and syncope, a 15-minute postvaccination observation period is recommended.

Pearls for Practice
The FDA has approved an expanded indication for HPV quadrivalent (types 6, 11, 16, and 18) recombinant vaccine, allowing its use for the prevention of grades 2 and 3 vulvar and vaginal intraepithelial neoplasia caused by HPV types 16 and 18 in girls and women aged 9 to 26 years. Clinical data showed 100% efficacy in women who were infection naive at baseline. Intent-to-treat efficacy was 71%.

No evidence of benefit was observed in girls previously infected with the HPV subtypes contained in the vaccine, and there is insufficient evidence to support its use in women older than 26 years. Because of the potential for allergic reactions and syncope, patients should be observed for 15 minutes after vaccination.

Thermerosal No link with Autism

California Data Do Not Support a Link Between Thimerosal in Vaccines and

Continuing Increases in Autism Reported to California's Developmental Services System: Mercury in Retrograde

Schechter R, Grether JK
Arch Gen Psychiatry. 2008;65:19-24

Summary

This study was a retrospective review of autism spectrum disorder (ASD) cases referred to the California Department of Developmental Services (DDS) from 1995 through 2007. Children enter the DDS system at 3 years old; therefore, this referral represents the prevalence of a diagnosis of ASD in this population at the age of 3 years.

The authors plotted the prevalence of ASD referrals against critical time points in US vaccine history relative to the use of thimerosal. Critical dates relative to thimerosal are:

1991: The addition of vaccines to the recommended schedule produces an increase in the total mercury exposure (via thimerosal) in vaccines; 1999: A recommendation to remove thimerosal from vaccines was made; 2001: Thimerosal is no longer present in vaccines except in trace quantities; 2002: The overall expiration time period of vaccines with anything more than trace amounts of thimerosal is reached.

The authors' hypothesis was that if thimerosal were a contributor to ASD then children born and vaccinated after 2002 should have decreased rates of ASD diagnosis, and this would be reflected in decreased numbers of referrals (ie, decreased prevalence) to California DDS.

The authors did not find a dip in referral rates; their data did not reflect a change in ASD prevalence. In fact, the prevalence of ASD was increasing before 1991 and continued on roughly the same slope throughout the 1990s and 2000s, regardless of age group evaluated.

Only one year's cohort of children was born after thimerosal was largely eliminated from vaccines and were not at risk for receiving old vaccine -- the children born in 2003. These children also had a higher prevalence of ASD than children born in previous years, and the slope was increasing along a very similar trajectory to prior years. The increase over the time period 1993 through 2003 was from 0.3 cases per 1000 births to 1.3 cases per 1000 births.

The authors conclude that the California DDS data do not support a link between thimerosal in childhood vaccines and development of ASD.

Viewpoint

This study was published in January 2008 but only recently came to my attention. The findings here mirror those of a Danish study that demonstrated ongoing increases in ASD diagnosis despite removal of thimerosal from vaccines,^[1] as well as Canadian data demonstrating no decrease in ASD diagnosis for children vaccinated with non-thimerosal-containing vaccines.^[2] The figure from the Canadian study is particularly interesting and is worth viewing separately.

Obese and Overweight Teens at Higher Risk for Chronic Diseases

News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD

June 2, 2008 — Teens who were obese and overweight had a higher risk for chronic diseases such as type 2 diabetes, cardiovascular disease, and fatty liver disease, according to the results of an Australian cross-sectional study reported in the June issue of the Archives of Pediatrics & Adolescent Medicine.

"Several studies have shown that obese children and adolescents have an increased prevalence of metabolic risk factors for cardiovascular disease, type 2 diabetes, and, more recently, fatty liver disease," write Elizabeth Denney-Wilson, PhD, MPH, BN, from the University of Sydney in Sydney, Australia, and colleagues. "Although morbidity could be expected to increase in parallel with the prevalence of obesity, little is known about chronic disease risk factors in the general adolescent population. Most studies of comorbidities either have been conducted in clinic-based groups of severely obese adolescents or have not studied the full range of metabolic complications."

The goal of this study was to evaluate the association between measures of adiposity (body mass index [BMI] and waist circumference) and risk factors for heart disease, type 2 diabetes, and fatty liver disease as well as the clustering of risk factors in middle adolescence.

At secondary schools in Sydney, 496 grade 10 students were categorized as overweight or obese by the International Obesity Task Force cutoff points and the UK waist circumference cutoff points. Mean age was 15.4 ± 0.4 years; 58.4% were boys. Blood samples were tested for high-density lipoprotein (HDL) and low-density lipoprotein (HDL) cholesterol, triglycerides, insulin, glucose, alanine aminotransferase (ALT), gamma-glutamyltransferase (GGT), and high-sensitivity C-reactive protein (CRP) levels. Published guidelines were used to categorize these results as normal or abnormal. Logistic regression helped define associations between overweight and obesity and risk factors, and clustering of risk factors within individuals was also examined.

In adolescent boys, factors significantly associated with overweight and obesity were insulin levels (P <.001), ALT (P <.001), GGT (P = .005), HDL cholesterol levels (P < .001), high-sensitivity CRP levels (P <.001), and blood pressure (P <.001). Factors significantly associated with overweight and obesity in adolescent girls were insulin, HDL cholesterol (P <.001) and high-sensitivity CRP levels (P < .001).

Compared with adolescents who were not overweight, obese adolescent boys and girls were significantly more likely to have 2 or more risk factors (boys: 73.5% vs 7.6%; girls: 44.4% vs 5.4%; P < .001 for both).

"Overweight and obese adolescents, especially boys, are at substantial risk for chronic conditions," the study authors write. "Waist circumference is not a better predictor of metabolic risk factors than is . . . BMI."

Limitations of this study include lack of data on family history of cardiovascular disease and lack of reporting of the consumption of alcohol and other drugs.

"The propensity of adiposity, behaviors, and risk factors to track from adolescence through adulthood would suggest that health care systems can expect a greater burden of disease from obesity-related conditions when today's young people achieve adulthood," the study authors conclude.

Pearls for Practice

• In adolescent boys, overweight and obesity are linked with abnormal values of insulin, ALT, GGT, HDL cholesterol, high sensitivity CRP, and blood pressure. In adolescent girls, overweight and obesity are linked with abnormal values of insulin, HDL cholesterol, and high sensitivity CRP.
• Obese adolescents, especially boys, are more likely to have at least 2 risk factors for heart disease, type 2 diabetes, and fatty liver disease than nonobese adolescents.

The New South Wales Department of Health supported this study. The study authors have disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. 2008;162:566-573.

Sucrose before Vaccination can Reduce pain

How to Stop the Hurt -- Sucrose Prior to Infant Vaccinations:
A Best Evidence Review Medscape CME/CE Posted 06/16/2008

Charles P. Vega, MD

Vaccination is the most common procedure performed in infancy, although parents might have significant concerns regarding the pain associated with routine vaccinations. Moreover, painful experiences very early in life can promote somatization later in life. Oral sucrose has been demonstrated to reduce pain reactions among neonates, and the current study examines this simple intervention prior to administration of routine vaccination at 2 and 4 months of age.

Participants received either a 24% disaccharide solution at a dose of 0.6 mL/kg, or matching placebo. Infants were not swaddled, cuddled, or restrained during vaccination or the ensuing data collection period.

Sucrose has previously been demonstrated to improve outcomes among neonates undergoing painful procedures. In an analysis of 21 randomized controlled trials involving 1616 infants, sucrose at a wide range of doses (0.012 mg to 0.12 mg) improved the rate of crying at 30 and 60 seconds after heel lance.^[8] However, sucrose was not effective in reducing heart rate at 1 and 3 minutes after heel lance.

Some practices employ other analgesic measures to reduce the pain of pediatric vaccinations. The application of the lidocaine-prilocaine patch prior to the first measles-mumps-rubella vaccine among children at least 12 months of age resulted in a significant reduction in Behavior Pain Scale scores vs placebo treatment.^[9] Moreover, rates of irritability after vaccination were 16% in the lidocaine-prilocaine group vs 31% in the placebo group, and the antibody responses in the 2 groups to the vaccine components were similar.

Parents may also pretreat their children with oral analgesic medications prior to appointments for vaccination, and a study of acetaminophen delivered prior to administration of the diphtheria-pertussis-tetanus toxoids-polio vaccine largely supports this practice.^[10] Compared with placebo, acetaminophen reduced the risk for fever greater than 38 degrees Celsius from 44% to 27%. Rates of behavioral changes after vaccination were 0.9% among the acetaminophen group vs 13% with placebo. However, acetaminophen was superior to placebo for primary vaccinations at 2 to 6 months of age but not for booster vaccination at 18 months of age. At the 18-month vaccination, the overall rate of systemic and local reactions was higher in both the acetaminophen and placebo groups. Another study has demonstrated that neither acetaminophen nor ibuprofen was effective in reducing the risk for local reactions such as erythema and swelling following the fifth diphtheria-tetanus toxoids-acellular pertussis vaccination.

Two key questions remain regarding the implementation of sucrose for the prevention of pain in pediatric vaccinations. First, the weight-based dosing algorithm for sucrose in the current study certainly appeared effective, but the dosage range used in different studies has generally been quite wide. Further research should address the issue of the optimal dose of sucrose. In addition, it would be very easy to conceive that using other analgesics such as acetaminophen in addition to sucrose could be synergistic in improving pain and behavior after vaccination. Moreover, the use of antipyretic medications could also reduce the risk for postvaccination fever.

Regarding the practical utility of different methods of analgesia for routine infant vaccinations, lidocaine-prilocaine can be difficult to apply and maintain in place for the 30 minutes required for effective analgesia prior to procedures.

Oral analgesics must also be delivered well before the vaccine is administered to be effective, and they expose infants and children to the remote possibility of significant adverse events.

In contrast, sucrose appears to be a readily available and applicable means to reduce infants' pain with vaccination. It is inexpensive and safe. Sucrose can also help parents to feel actively involved in protecting their infant from pain, and this should help increase acceptance of routine vaccinations. And that outcome should taste just like sugar for clinicians.

Probiotic Relieves Diarrhea in Infants and Toddlers

By Will Boggs, MD

NEW YORK (Reuters Health) Jun 25 - The probiotic Escherichia coli Nissle 1917 is effective in treating diarrhea greater than 4 days' duration in infants and toddlers, according to a report in the June issue of The Pediatric Infectious Disease Journal.

"There is more and more evidence now for the effectiveness and safety of probiotic drugs," Dr. Jobst Henker from University Carl-Gustav-Carus, Dresden, Germany told Reuters Health. "Earlier data for probiotic foods or food supplements show an excellent safety record but sometimes lack firm data on efficacy."

Dr. Henker and colleagues note that the nonpathogenic E. coli strain Nissle 1917 (EcN) has been licensed in Europe for 90 years for treating bowel diseases. They investigated the response rate and time to response using EcN suspension or placebo in 151 infants and toddlers with diarrhea lasting more than 4 days.

More children treated with EcN than with placebo showed a response to treatment on day 7 (78.7% versus 59.2%, respectively), day 14 (93.3% versus 65.8%), and day 21 (98.7% versus 71.1%), the investigators report.

Diarrhea lasted a median 3.3 days less in children treated with EcN, the report indicates, and the number of stools decreased to three or less daily 2 days sooner in the EcN group than in the placebo group.

More children in the placebo group exhibited dehydration at the end of the study, the researchers note, and more children in the EcN group (97.0%) than in the placebo group (62.3%) improved from a "moderate" state of health to a "good" or "very good" state of health in the course of treatment.

There were no serious or severe adverse events, the investigators say, and only four events were judged to be possibly related to study medication. Parents' and investigators' ratings indicated that EcN was well tolerated by the children.

"Since there is one other successful EcN study by our group in acute children's diarrhea, we believe it is best to start probiotic therapy as early as possible," Dr. Henker said.

"We would like to address the subject of inflammatory bowel disease," Dr. Henker added. "Not only do excellent data exist for the use of EcN in ulcerative colitis remission maintenance in an adult population, but we were able to show similar results in children."

Pediatr Infect Dis J 2008;27:494-499.

Secondhand Smoke Decrease Lung function in Child

Children exposed to secondhand smoke (SHS) at home during early infancy have an increased risk for serious infections requiring hospitalization, according to the results of a prospective cohort study reported in the May 27 Online First issue of Tobacco Control.

"Second-hand smoke ... exposure is a modifiable cause of ill health," write M.K. Kwok from the University of Hong Kong in Hong Kong SAR, China, and colleagues.

Previous research by Moshammer and colleagues suggests that passive smoking has a significant deleterious effect on lung function among children. Their study, which was published in the June 1, 2006, issue of the American Journal of Respiratory and Critical Care Medicine, examined more than 20,000 children between the ages of 6 and 12 years.

They found that maternal smoking during pregnancy was associated with a reduced forced expiratory volume in 1 second as well as a lower maximal expiratory flow among children. Passive smoking during childhood also reduced lung function in children though not to the same degree as in utero exposure to smoking.

Medscape News Author: Laurie Barclay, MD

Meningococcal Vaccine Not Routine 2-10yrs Child

MMWR Morbid Mortal Wkly Rep. 2008;57(17):462-465.

Clinical Context

The MCV4 (Menactra; Sanofi-Pasteur) was approved by the US Food and Drug Administration on October 17, 2007, for use in children aged 2 to 10 years, adding to the existing approval for use in persons aged 11 to 55 years. MCV4 licensure was based on clinical trials in which the safety and immunogenicity of MCV4 was compared with the MPSV4 and was found to be safe and noninferior to the MPSV4 for all serogroups.

From June 2007 to February 2008, the ACIP Meningococcal Vaccine Workgroup considered use of MCV4 in children aged 2 to 10 years. They reviewed data on MCV4 immunogenicity and safety in this age group, the epidemiology and burden of meningococcal disease, the cost-effectiveness of different vaccination strategies, and the programmatic implications. Based on this review, the expert opinion of workgroup members, and feedback from partner organizations, the ACIP decided at its February 2008 meeting not to routinely vaccinate children aged 2 to 10 years.

Study Highlights

• ACIP evaluated data and concluded that evidence was insufficient to determine that 1 dose of MCV4 administered at age 2 years would protect against meningococcal disease through late adolescence and college entry.
• Serum bactericidal activity among children aged 2 to 3 years who received MCV4 was lower vs children aged 4 to 10 years.
• ACIP also reviewed the burden of meningococcal disease among children aged 2 to 10 years.
• Between 1998 and 2007 in the United States, overall rates of meningococcal disease were lower in children aged 2 to 10 years vs infants younger than 2 years and adolescents aged 11 to 19 years.
• Of cases in children aged 2 to 10 years, 41% occurred among children aged 2 to 3 years.
• Among cases that occurred in children 2 to 10 years old, 59% were caused by serogroups contained in MCV4 (A, C, Y, and W-135) vs 77% of cases among those 11 to 19 years old.
• A cost-effectiveness analysis determined that vaccinating children aged 2 years was less cost effective than vaccinating children aged 11 years.
• As of February 2008, the ACIP does not recommend routine vaccination of children aged 2 to 10 years against meningococcal disease unless the child is at increased risk.
• ACIP continues to recommend vaccination for children aged 2 to 10 years who are at increased risk for meningococcal disease.
• Risk factors for meningococcal disease include travel to or residence in countries where meningococcal disease is hyperendemic or epidemic, terminal complement deficiencies, and anatomic or functional asplenia.
• Using clinical judgment on a case-by-case basis, clinicians may also decide to vaccinate children aged 2 to 10 years who are infected with HIV.
• MCV4 is preferred to MPSV4 for children aged 2 to 10 years at increased risk, for control of meningococcal disease outbreaks, and when clinicians or parents decide on meningococcal vaccination for other children aged 2 to 10 years.
• Children aged 2 to 10 years who have received MPSV4 and who are still at increased risk for meningococcal disease should be vaccinated with MCV4 3 years after receiving MPSV4.
• Children who last received MPSV4 less than 3 years before and who are still at increased risk for meningococcal disease should receive MCV4 vaccination as soon as possible.
• Recommendations for use of MCV4 in persons aged 11 to 55 years remain unchanged from earlier published guidelines.
• ACIP continues to recommend routine vaccination against meningococcal disease for all persons aged 11 to 18 years.
• ACIP recommends vaccination against meningococcal disease for persons aged 2 to 55 years who are at increased risk for meningococcal disease.
• Children at increased risk for meningococcal disease throughout their lifetime will most likely need subsequent doses of MCV4, with specific recommendations anticipated based on ongoing ACIP monitoring on duration of protection.
• A history of GBS is a precaution to MCV4 vaccination because these individuals might be at increased risk for GBS after MCV4 vaccination.

Pearls for Practice

• As of February 2008, the ACIP does not recommend routine vaccination of children aged 2 to 10 years against meningococcal disease unless the child is at increased risk because of travel to or residence in countries where meningococcal disease is hyperendemic or epidemic, terminal complement deficiencies, or anatomic or functional asplenia.
• Recommendations for use of MCV4 in persons aged 11 to 55 years remain unchanged from earlier published guidelines. ACIP continues to recommend routine vaccination against meningococcal disease for all persons aged 11 to 18 years. ACIP recommends vaccination against meningococcal disease for persons aged 2 to 55 years who are at increased risk for meningococcal disease.

Smoking Increase Death Risks

Vascular Benefits of Stopping Smoking Are Rapid

News Author: Lisa Nainggolan Medscape
CME Author: Charles Vega, MD

Smoking is clearly linked with an increased risk of mortality, and a previous report on the Nurses' Health Study by Kawachi and colleagues, published in the November 15, 1993, issue of Annals of Internal Medicine, described this risk in detail. Researchers demonstrated that the overall risk of mortality among smokers vs never smokers was 1.87, and the risk of former smokers vs never smokers was significantly elevated at 1.29. Participants who initiated smoking before the age of 15 years had the highest risks for total mortality and cardiovascular disease mortality, but these risks were attenuated to levels similar to never smokers after 10 to 14 years of abstinence from smoking.

The current report from the Nurses' Health Study provides greater detail with regard to cancer mortality risks associated with cigarette smoking in women.

Study Highlights

• The Nurses' Health Study began following 121,700 female nurses in the United States in 1976. Subjects have provided health information every 2 years since initiation of the study, including data regarding cigarette use. Women with a prior history of cancer were excluded from the current study.
• In the current study, researchers focused on reports of overall mortality as well as specific cancer, vascular, and respiratory causes of mortality from 1980 forward. Never smokers were used as the reference group, and the risk of study outcomes associated with smoking was adjusted for body mass index as well as disease and lifestyle factors.
• In 1980, 28% of the study cohort reported current smoking, and 26% were former smokers. The mean age at smoking initiation was 19 years.
• Current smokers had lower body mass index values and slightly less hypertension and also exercised less compared with never or former smokers.
• 12,483 deaths occurred in the study group, 28.9% and 35.2% of which occurred among current and former smokers, respectively. Only 8% of subjects alive in 2002 were current smokers.
• Current smokers experienced a HR of 2.81 for total mortality compared with never smokers, and they were also at higher risk for all major cause-specific mortality.
• Current smokers had a higher risk of death associated with all smoking-related cancers vs never smokers. These cancer sites included bladder, cervix, esophagus, lip and mouth, pharynx, pancreas, and stomach. Smokers were also at higher risk of mortality resulting from acute myeloid leukemia.
• Current smokers also had a significant increased risk of mortality resulting from colorectal cancer vs never smokers (HR = 1.63), but the effect of current smoking on the risk of ovarian cancer mortality was not significant. These same trends were evident among former smokers.
• Overall, 64% of deaths among current smokers were attributable to cigarette smoking.
• Earlier initiation of smoking was associated with a higher risk of death, particularly for death related to respiratory disease or cancer.
• The risk of death decreased by 13% within 5 years of quitting cigarettes, and this risk was further attenuated to levels comparable with never smokers at 20 years after quitting.
• The risk of death resulting from vascular disease declined more rapidly compared with other mortality risks following smoking cessation, with 61% of the full potential benefit for coronary heart disease mortality accrued in the first 5 years after quitting.
• Approximately 28% of deaths among former smokers were attributable to cigarette smoking.

Pearls for Practice

• A previous report from the Nurses' Health Study demonstrated that both current and former smokers had an increased risk of mortality compared with never smokers, but this risk was significantly attenuated after 10 to 14 years of abstinence from smoking. Women who began smoking prior to 15 years of age experienced the highest risk of mortality.
• In the current study, smoking increased the risk of death due to cancers of the cervix, colon and rectum, and stomach. However, the risk of ovarian cancer mortality was not significantly increased with smoking.

Guidelines on Strength Training for Children Revised

Pediatrics. 2008;121:835-840.

Clinical Context

Many young people become involved in strength training, also known as resistance training, in the context of sports and physical fitness programs. However, some adolescents use strength training to enhance muscle size and appearance. Free weights, weight machines, elastic tubing, or an athlete's own body weight may all provide resistance required for strength training. The type and amount of resistance used and the frequency of repetitions vary depending on specific program goals.

Because pediatricians are often asked to counsel young people on the safety and efficacy of strength-training programs, the AAP issued this revision of a previous policy statement. These revised guidelines define relevant terminology and provide updated evidence regarding the risks and benefits of strength training for children and adolescents.

Study Highlights

• Muscle strains account for 40% to 70% of all strength-training injuries and usually involve the hand, low back, and upper trunk.
• Appropriate strength-training programs do not appear to adversely affect growth or cardiovascular health.
• Strength-training programs for young people should follow proper resistance techniques and safety precautions.
• Preadolescents and adolescents should avoid power lifting, body building, and maximal lifts until they reach physical and skeletal maturity.
• Athletes should not use performance-enhancing substances or anabolic steroids, and young people involved in strength training should be educated about the risks of using these substances.
• A pediatrician or family clinician should perform a medical evaluation before the young person begins formal strength training.
• Youth with uncontrolled hypertension, seizure disorders, or a history of childhood cancer and chemotherapy should not participate in strength training until they undergo additional treatment or evaluation.
• In some cases, referral to a pediatric or family clinician sports medicine specialist familiar with various strength-training methods as well as risks and benefits may be indicated.
• Before beginning a strength-training program, children with complex congenital cardiac disease (cardiomyopathy, pulmonary artery hypertension, or Marfan's syndrome) should be evaluated by a pediatric cardiologist.
• Aerobic conditioning should be coupled with resistance training to optimize general health.
• Strength-training programs should include 10 to 15 minutes of warm-up and cool-down.
• Adequate fluid intake and proper nutrition are needed to maintain muscle energy stores and improve recovery and performance.
• To master the proper technique, specific strength-training exercises should first be learned with no load (no resistance), with incremental loads and then added with either body weight or other forms of resistance.
• Strength training should include 2 to 3 sets of 8 to 15 repetitions 2 to 3 times weekly and should continue for 8 weeks or longer.
• A general strengthening program should target the core and all major muscle groups, with exercise through the complete range of motion. More sports-specific areas may be addressed subsequently.
• Illness or injury from strength training should be fully evaluated before resumption of the exercise program.
• Instructors or personal trainers for young people should be certified and specifically qualified in pediatric strength training.
• To ensure safety, any strength-training program for young people must include proper technique and strict supervision by a qualified instructor.

Pearls for Practice

• To ensure safety and efficacy, strength-training programs for young people should follow proper resistance techniques and safety precautions. Preadolescents and adolescents should avoid power lifting, body building, and maximal lifts until they reach physical and skeletal maturity.
• A pediatrician or family clinician should perform a medical evaluation before the young person begins formal strength training to identify risk factors for injury and to discuss previous injuries and other possible medical conditions that may prevent a young person from participating in strength-training programs.

Acne Treatment

Active ingredients in acne products

source: http://www.mayoclinic.com/health/acne-products/SN00039 (for full article)

Acne products work in different ways, depending on their active ingredient. Here are common active ingredients found in acne products and how they work to treat acne.

• Benzoyl peroxide. Probably the most effective active ingredient in acne products, benzoyl peroxide kills P. acnes, helps remove excess oils from the skin and removes dead skin cells that clog pores. Available in strengths from 2.5 percent to 10 percent, benzoyl peroxide can cause excessive dryness, scaling, redness and minor swelling. It can also make your skin more sensitive to ultraviolet (UV) exposure.
• Salicylic acid. This ingredient slows shedding of cells inside the hair follicles, which prevents the pores from clogging. It may also break down whiteheads (clogged pores that have no opening) and blackheads (pores that are open and have a dark surface). Salicylic acid can cause mild stinging and skin irritation. OTC acne products are available with 0.5 percent to 2 percent salicylic acid.
• Sulfur and resorcinol. Rarely used alone, sulfur and resorcinol are often found together in acne products. These ingredients remove dead skin cells that clog pores and help remove excess oil. They may also break down whiteheads and blackheads. Sulfur and resorcinol can cause redness and peeling, which may occur several days after using the product.
• Alcohol and acetone. Often available in astringents and other cleansing washes, alcohol and acetone remove dirt and oils from the skin. Acne products that contain these ingredients can cause a mild burning or stinging sensation.

Using acne products for best results

To minimize redness, excessive dryness and other skin problems, start out with lower strength acne products. If needed, gradually increase the strength and frequency of your applications so that your skin can adjust to the treatments.

Acne products are just one step in your skin care regimen. For best control of acne:

• Avoid oily cosmetics, sunscreens and hair products. Instead use products labeled "oil-free" or "noncomedogenic," which means they won't clog pores.
• Wash problem areas twice daily with a nonmedicated soap or mild cleanser. But don't overdo it. Excessive washing and scrubbing can worsen acne.
• Apply just enough acne product to cover the problem areas.
• Use an oil-free, water-based moisturizer to help alleviate dry, peeling skin.
• Don't pick or squeeze blemishes. Infection or scarring may result.

Treating acne with acne products takes time and patience. It may take four to six weeks of daily use of acne products to see results, and acne may look worse before it gets better. If your acne doesn't improve after two months of treatment, you may want to see your doctor or dermatologist for a prescription lotion or medication.

Burns - What U can do

MAJOR RECOMMENDATIONS For Burns Management

source: http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=11509

Definitions for grades of recommendation (A-C and good practice points [GPP]) are provided at the end of the "Major Recommendations" field.

Prevention

Opportunities for Prevention

A - Primary care providers should provide advice on smoke alarms.

C - Primary care providers should support local initiatives in primary prevention, where possible.

GPP - Primary care providers should provide advice on the regulation of hot water temperature and appropriate first aid management.

First Aid

Stopping the Burning Process and Cooling

C - Ensure your own safety.

C - If on fire, 'stop, drop and roll', smother with blanket or douse with water.

C - For electrical burns, disconnect the person from the source of electricity.

C - Remove clothing and jewellery.

C - Cool burns or scalds by immediate immersion in running tap water (8 to 15 degrees C) for at least 20 minutes. Irrigation of chemical burns should continue for one hour.

C - Do not use ice for cooling.

C - Avoid hypothermia: keep the person with the burn as warm as possible, consider turning the temperature of the water up to 15 degrees C (tepid).

C - If there has been a delay in starting cooling, this should still be started up to three hours after injury.

C - Do not attempt to remove tar.

Gel Pads

C - Gel pads can be used as an alternative to running tap water where water is unavailable or not practical.

Initial Coverings

Polyvinyl Chloride Film (Cling Film)

C - Following cooling, polyvinyl chloride (PVC) film may be used as a temporary cover prior to hospital assessment. It should be applied by persons knowledgeable in its use.

C - PVC film should be layered onto the wound and not applied circumferentially around a limb.

C - Topical creams should not be applied as they may interfere with subsequent assessment.

GPP - PVC film should not be used as a substitute for a dressing product.

Burn Assessment

Emergency Management

C - For major burns perform an ABCDEF primary survey* and X-rays, as indicated.

C - Address analgesic requirements.

C - Establish and record the cause of the burn, the exact mechanism and timing of injury, other risk factors and what first aid has been given.

C - Assess burn size and depth.

C - Give tetanus prophylaxis if required.

C - Be alert to the possibility of non-accidental injury.

*ABCDEF primary survey:
Airway maintenance with cervical spine control
Breathing
Circulation with haemorrhage control
Disability: Neurological status
Exposure with environmental control
Fluid resuscitation

Burn Size

Assessment and Recording of Total Body Surface Area Burn (TBSA)

B - Where time allows, use the Lund and Browder chart as the standard assessment tool for estimating the TBSA of the burn.

Burn Depth

C - The depth of a burn injury should be reassessed two to three days after the initial assessment, preferably by the same clinician.

C - Testing for pinprick sensation by using a needle should be avoided.

GPP - The extent and speed of capillary refill can be used as a clinical method of assessing burn depth.

Non-Accidental Injury

C - If non-accidental injury is suspected, refer to a regional burns unit.

C - If non-accidental injury is suspected, examine for other signs of abuse and photograph injuries.

Classification of Burns

C - Avoid use of the terms first-degree/primary, second-degree/secondary and third-degree burns.

C - Distinguish between burns that will probably heal without skin grafting and those that will probably require grafting (deep dermal burns and full thickness burns).

C - Burns that are unlikely to heal within 21 days without grafting should be referred early to secondary care, ideally by day 10 to 14.

GPP - Use the Australian and New Zealand Burn Association (ANZBA) system of burn classification (see Table 3.3 of the original guideline document for the ANZBA classification of burns based on depth with photographs).

Referral

Emergency Referral

C - Health care practitioners should follow the ANZBA referral guidance when deciding the level of care that is appropriate for people with a new burn injury.

C - When seen in primary care, smaller burns that look like they will fail to heal by 14 days should be discussed with a secondary care service for consideration of an acute referral.

Referral Between Services

C - Transfer between services is facilitated by prompt assessment, recognised communication channels and locally developed protocols agreed between centres on whom to transfer and when to transfer.

C - Referrals to National Burn Centre level care should be via the regional burns units.

GPP - Primary care and accident services will generally develop their own systems for referral depending on the distances involved in travel to secondary services or regional burns units. In general, those people who have less severe injuries than in the ANZBA criteria, but who still require inpatient care, should be referred to local secondary services.

Management of Epidermal Burns or Scalds

Dressings and Creams

GPP - A protective dressing or cream product can be used for comfort in epidermal burns and scalds.

GPP - Review epidermal burns or scalds after 48 hours. If the skin is broken, change to a moist wound-healing product (or alternatively double-layer paraffin gauze).

Management of Superficial and Mid Dermal Burns or Scalds

Preventing Infection

GPP - Products with antimicrobial action (such as silver sulphadiazine cream) should be used on all burns for the first 72 hours (three days) after burn injury.

GPP - Burn wounds with signs of mild cellulitis can be treated with topical silver sulphadiazine and/or oral antibiotics.

GPP - Acute referral to secondary care is required for people with burns with signs of serious or systemic infection.

Wound Healing

C - Use dressings that encourage re-epithelialisation by moist wound healing.

B - The prolonged use of silver sulphadiazine cream (more than seven days) should be avoided in non-infected burns.

GPP - Following initial silver sulphadiazine cream or antimicrobial dressing, a technique that promotes moist wound healing (such as a hydrocolloid dressing) is recommended.

GPP - The convenience of a reduced number of dressing changes with hydrocolloid products should be considered where this is important to the person.

GPP - Double-layer paraffin gauze can be used where hydrocolloids are unavailable.

GPP - Moisturisers and non-drying, non-perfumed soap should be used to protect the skin after burn injury and may also be helpful for pruritus.

GPP - Burn wounds require extra care when exposed to sun.

When to Review

GPP - Superficial and mid dermal burns should be reviewed daily for the first three days, then subsequently every three days.

Management of Blisters

GPP - Preferably leave small blisters intact unless likely to burst or interfere with joint movement.

GPP - If necessary, drain fluid by snipping a hole in the blister.

Scarring

C - Any burns that are unlikely to heal within 21 days without grafting should be referred to a burns unit for scar management by day 10 to 14.

GPP - A person presenting with scarring some months after a burn should still be referred for specialist opinion.

Management of Chemical Injury

General Treatment Advice

First Aid

C - Irrigation of chemical burns should continue for one hour.

C - All chemical burns should be referred to a burns unit.

GPP - Acid burns should not be neutralised with an alkali in primary care.

Eye Injury

C - All significant chemical injuries to the eye should be referred acutely to ophthalmology services.

C - Treat all chemical burns to the eye with copious irrigation of water.

Specific Substances

Hydrofluoric Acid

GPP - Anyone exposed to hydrofluoric acid should be promptly referred to a burns unit for definitive treatment after appropriate first aid.

Phosphorus

GPP - Anyone exposed to phosphorus should be promptly referred to a burns unit for definitive treatment after appropriate first aid.

Management of Electrical Injury

C - All electrical injuries should be referred to a burns unit.

Electrocardiogram (ECG) Monitoring

C - Following electrical injuries people should receive a resting 12-lead ECG.

B - If this initial ECG is normal in people with low-voltage injuries, there is no need for a repeat ECG or for continuous monitoring.

Pain Management

Burn Pain Management

C - Immediately after the injury, cooling and covering the burn may provide analgesia.

C - Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to manage background pain.

C - Consider administering opioids for intermittent and procedural pain.

GPP - Refer to secondary care if failing to manage dressing-change pain.

GPP - Consider the use of non-pharmacological approaches as a supplement to pharmacological management of pain.

Plastics Exposure Harmful?

Widely Used Plastics Compound Raises Concerns

A chemical used in the production of polycarbonate plastics, bisphenol A (BPA), is raising concern over its effects in fetuses and children, according to a draft report from the NIH.

The report, from the National Toxicology Program, concludes that BPA presents "some concern" that exposure of fetuses and children "can cause changes in behavior and the brain, prostate gland, mammary gland, and the age at which females attain puberty." The report cites "negligible concern" that BPA exposure leads to birth defects.

Polycarbonate plastics are used in, among other things, bottles for water and infant formula or breast milk. The draft report says that infants and children have the highest intakes of BPA in the population.

The Canadian government may declare the compound toxic as early as this week, an anonymous source told the New York Times.

Physician's First Watch for April 16, 2008
David G. Fairchild, MD, MPH, Editor-in-Chief

National Toxicology Program report (Free PDF)

New York Times story (One-time registration required)

Food Additives cause Hyperactivity

EU Panel: 'Limited Evidence' Food Additives Cause Hyperactivity in Kids

Physician's First Watch for March 17, 2008

An analysis by the European Food Safety Authority downplays the significance of a Lancet study suggesting some synthetic food colors and sodium benzoate preservative cause hyperactivity in children.

The study, published in 2007, concluded that two mixtures of four synthetic colors and sodium benzoate increased hyperactivity in 3-year-olds and 8- to 9-year-olds. The agency said it used "a more justifiable and conventional statistical model" to analyze those results.

The new analysis showed a small and statistically significant effect of the additives on some children's attention and activity. However, the effects were not seen in all ages and were inconsistent for the two mixtures. The panel said there were not enough data on dose-response, nor was there a biologically plausible mechanism for additives to cause hyperactivity.

The agency said the clinical significance "remains unclear," and the findings cannot be used for changing acceptable daily intakes of the additives.

European Food Safety Authority summary (Free PDF)

Milk & Calcium intake in Children

Children's Dairy Intake in the United States: Too Little, Too Fat?

Kranz S, Lin P, Wagstaff DA J Pediatr. 2007;151:642-646; Epub 2007 Jul 24

Kranz and colleagues note that the most bioavailable food form of calcium occurs in dairy products, thus most professional organizations and advisory boards recommend that children obtain their daily calcium goals through dairy intake. However, whole milk contains almost double the amount of calories per unit volume (3.5% milk fat) compared with nonfat milk (less than 0.5% milk fat) without any additional calcium.

This study sought to compare daily calcium intake by US children. The authors used data from the 1999-2002 National Health and Nutrition Examination Survey (NHANES) and compared them against recommendations of the US Department of Agriculture's MyPyramid plan. The authors note that the American Academy of Pediatrics' (AAP) recommendations for dietary calcium exceed those of MyPyramid.

NHANES data were provided by subjects in an interview. The dietary data used in this study involved 24-hour dietary recall. The study included over 7000 children with dietary intake data, along with physical examination parameters. The current USDA dietary goals are 2 cups of dairy per day for children 2-8 years and 3 cups per day for children older than 8.

Only the youngest age group, 2- to 3-year-olds, met the 2-cups-per-day recommendation on the basis of their average intake. Children 4-8 years fell just short of 2 cups per day, while children 9-18 took in under 2 cups per day, far short of the goal of 3 cups per day for children older than 8.

In general, younger children obtained the majority of their dairy intake (approximately two thirds) from milk, but milk intake accounted for only half of dairy intake in the oldest children. When looking at the fat content of milk consumed, it was evident that whole milk and reduced-fat milk (2% milk fat) comprised a large majority of intake: 87% for children 2-3 years and 78% for children 4-8 years.

Even older children took in high proportions, with whole or reduced-fat milk comprising approximately 75% of milk intake for children older than 8 years, although there was a relative decrease in whole-milk consumption relative to reduced-fat milk.

The authors concluded that dietary intake of calcium is insufficient for children 4-18 years in the United States, and that the dairy products consumed are often unnecessarily high in fat.

Viewpoint

It has taken barely a generation for milk to go from a "luxury" item in childhood diets to a potential "villain." Although the AAP recommends whole milk for children under 2 years old, we could clearly advocate that our patients should consume lower-fat varieties at older ages.^[1] The authors also highlight that there has been a decline in dairy intake during adolescence, when dietary calcium needs increase significantly compared with young childhood. In this study, adolescents in the 14- to 18-year range took approximately 38% of recommended calcium.

Among the many topics to discuss at adolescent visits, diet and calcium intake specifically should remain an important one.

Pediatric Deaths From Influenza/MRSA Coinfection Spark CDC Advisory

Yael Waknine (Medscape Medical News)

January 31, 2008 — Healthcare professionals should be alert to the possibility of bacterial coinfection among children hospitalized with influenza and request bacterial cultures for those who are severely ill or suspected of having community-acquired pneumonia, according to a clinician communication sent today from the Centers for Disease Control and Prevention (CDC).

The warning was based on data collected via the Influenza-Associated Pediatric Mortality Surveillance system, showing that 44% of pediatric influenza-related deaths reported from October 1, 2006, through September 30, 2007, occurred in the setting of bacterial coinfection, and the majority of them (22 [73%] of 30) were caused by Staphylococcus aureus.

Although the number of pediatric influenza-associated deaths only increased moderately from the number reported during the 2 previous surveillance years, the number of deaths in which pneumonia or bacteremia resulting from infection by S aureus increased 5-fold, and many cases (15 of 22) were caused by strains of methicillin-resistant S aureus (MRSA) similar to those associated with US outbreaks of MRSA skin infection.

The median age of children with S aureus infection was higher compared with those having other infections (10 vs 5 years; P < .01), and coinfected children were more likely to have pneumonia and acute respiratory distress syndrome.

Healthcare providers are advised to be aware of the prevalence of MRSA in their communities when choosing empiric therapy for patients with suspected influenza-related pneumonia.

The CDC is requesting that all pediatric influenza-associated deaths be reported as soon as possible to local or state health departments, as well as to the CDC via its Web site, http://sdn.cdc.gov. Information concerning bacterial pathogens should be included on the case-report form, and S aureus isolates should be sent to the CDC for further characterization.

Additional information regarding the CDC advisory may be obtained by contacting the Influenza Division, Epidemiology and Prevention Branch, by telephone at 404-639-3747.

Rapid injection less painful

This is the Medscape Medical Minute. I'm Dr. George Lundberg.

We all know that it hurts to get vaccinated with needle injections. Babies cry. Pediatric researchers in Toronto performed a randomized controlled trial to test whether the usual standard of slow needle insertion, aspiration, slow injection, and slow needle withdrawal or rapid needle insertion, injection, and withdrawal without aspiration hurt more. The substance injected was the usual DPTaP-Hib immunization. They measured whether or not crying occurred, and its duration in 113 healthy 4- to 6-month-old infants. The slow technique resulted in 82% of the infants crying vs 43% in the rapid-technique group; the median duration of crying was 14.7 seconds vs 0. Both parent and pediatrician visual analog scales corresponded to these dramatic differences. There were no adverse effects.

The authors conclude that rapid is better than slow for routine intramuscular injections.

This Medscape Medical Minute article^[1] is selected from Medscape Best Evidence.

Childhood obesity: Make weight loss a family affair

Preventing and treating childhood obesity requires the entire family. Here's how you can encourage a healthy weight in your home.

Children can't change their exercise and eating habits by themselves. They need the help and support of their families and other caregivers. This is why successful prevention and treatment of childhood obesity starts at home.

Childhood obesity is usually caused by kids eating too much and exercising too little. So creating new family habits around healthy eating and increased physical activity can help a child lose weight and can also improve the health of other members of the family.

Change family behaviors

Many behaviors contribute to childhood obesity, whether it's the time spent in front of the TV or computer or the types and amounts of food eaten. These behaviors or habits are hard to change within a family, especially if members aren't ready, willing or able to make changes. Small, progressive steps can help. Keep in mind the following helpful hints.

• It's not a race. The first rule of change is to not make changes too quickly. It takes time and dedication to unlearn unhealthy behaviors and to develop new, healthy ones.
• Think small. Small, gradual changes are easiest to follow and incorporate into your daily lives. And small changes can make a big difference over time. Pick a few small changes that seem doable, for example, turning off the TV during dinner, switching from soda pop to milk or water, or taking a walk after dinner once a week.
• Set individual and family goals. Goals need to be achievable and measurable. Set specific goals for each family member, and then determine family goals. For example, your child's goal might be to eat fresh fruits and vegetables for afternoon snacks, and the family's goal might be to eat out at a fast-food restaurant only once a month.

The new changes might take some time getting used to. But stick to the plan as best you can and evaluate your progress. Sometimes goals need to be adjusted if they don't work for the family. It's better to create a new plan than to stick to one that isn't working.

Create a healthy-weight environment

As you work toward healthy habits and behaviors, create a home environment that supports these efforts. For example, make sure healthy foods are readily available. Serve fruits and vegetables with meals and remove high-calorie, high-fat foods from the home, buying them just occasionally.

A healthy-weight environment also means that exercise and physical activity are built into the day's routine. Encouraging the kids to play outside — to ride bike or play a basketball game with friends, for example — is a good way to keep kids active. Organize family outings that involve physical activity, such as walking to the library or playing at a park.

Parents can also set rules for the home that help reinforce the healthy lifestyle. For example, limiting the time spent watching TV or playing video or computer games encourages children to find other more active pastimes.

Other ways to create a healthy-weight environment:

• Remove sugar-sweetened drinks from the home.
• Offer more whole-grain foods with meals and snacks.
• Reduce the number of meals eaten out at fast-food and other restaurants.
• Sit down together for family meals and have that meal last at least 30 minutes.
• Remove TVs and computers from children's bedrooms.
• Include children in active chores, such as washing the car or walking the dog.

As your family establishes healthy behaviors, be sure that all members — including parents — stick to the plan. For example, if you take the TV out of your child's bedroom, make sure to take the TV out of your bedroom as well. Consistency is crucial to creating a healthy-weight home.

Be a positive role model

The best way to get your child on board with the new, active lifestyle is to commit to the changes yourself. Your actions teach your child what to eat, how much to eat and when to eat. You also encourage your child to be physically active every day if you make it a priority yourself.

Here's how you can be a positive role model:

• Eat more healthy, nutritious foods.
• Control your portion sizes.
• Limit the number of treats and high-calorie snacks you eat.
• Be physically active every day.
• Limit the amount of time you spend watching TV or playing computer games.

Reward successful changes

Rewards for successful behavior changes keep your family motivated and more inclined to stick to the plan. Make a list of how your family has succeeded in changing certain eating and activity habits. Then celebrate your success. Rewards should be consistent with the goal and be given regularly, such as on a daily or weekly basis.

Celebrating progress can be as simple as offering your child praise and attention, or it could be more involved. Planning an activity the family likes to do together, such as skating or swimming, is a good option. Don't use food as a reward or punishment, however. You might unintentionally lay the groundwork for food-related power struggles.

A challenge for today's family

Making changes can be challenging, especially when today's families juggle busy schedules, time and money constraints, and other stressors and demands on daily living. But if your family works together and supports each others' efforts, then success is more likely.

Eventually the new changes will be incorporated into your family's everyday life and will be just the way things are done. Once healthy habits become routine, you're well on your way to maintaining a healthy weight and improving your health as a family.

RELATED

• Weight-loss surgery: Safe for kids?
• Childhood obesity

By Mayo Clinic Staff
Jun 30, 2006

WORKING MEMORY TRAINING AND FUTRE SCHOOLS

WORKING MEMORY TRAINING AND SCHOOLS OF THE FUTURE-
DR. ARTHUR LAVIN

SharpBrains 2007

Today we interview Dr. Arthur Lavin, Associate Clinical Professor of Pediatrics at Case Western School of Medicine, pediatrician in private practice, and one of the first providers of Cogmed Working Memory Training in the US (the program whose research we discussed with Dr. Torkel Klingberg and Dr. Bradley Gibson). Dr. Lavin has a long standing interest in technology-as evidenced by Microsoft’s recognition of his paperless office- and in brain research and applications-he trained with esteemed Mel Levine from All Kinds of Minds.

KEY TAKE-AWAYS:
• Schools today are not yet in a position to effectively help kids with cognitive issues deal with increasing cognitive demands.
• Working Memory is a cognitive skill fundamental to planning, sequencing, and executing school-related work.
• Working Memory can be trained, as evidenced by Dr. Lavin’s work, based on Cogmed Working Memory Training, with kids who have attention deficits.

Context on cognitive fitness and schools

AF (Alvaro Fernandez): Dr. Lavin, thanks for being with us. It is not very common for a pediatrician to have such an active interest in brain research and cognitive fitness. Can you explain the source of your interest?

AL (Arthur Lavin): Throughout my life I have been fascinated by how the mind works. Both from the research point of view and the practical one: how can scientists’ increasing knowledge improve kids’ lives? We now live in an truly exciting era in which solid scientific progress in neuroscience is at last creating opportunities to improve people’s actual cognitive function. The progress Cogmed has achieved in creating a program that can make great differences in the lives of children with attention deficits is one of the most exciting recent developments. My colleague Ms. Susan Glaser and I recently published two books: Who’s Boss: Moving Families from Conflict to Collaboration (Collaboration Press, 2006) and Baby & Toddler Sleep Solutions for Dummies (Wiley, 2007), so I not only see myself as a pediatrician but also an educator. I see parents in real need of guidance and support. They usually are both very skeptical, since they have been promised too many things too many times by “experts”, yet open-minded to ideas with good foundations. Many professionals have only the skeptical frame, since they were educated when scientists still believed the brain was pretty rigid and “untrainable”. We need much more brain science-based professional development, and appreciate the great work SharpBrains is doing.

AF: Let’s talk about that “trainability” and schools. Most people still think of “intelligence” as fixed. Now, I recently read a report on how KIPP schools emphasize the training on some basic skills, such as shared attention, as a needed foundation for good academic performance. So, even if limited in scope, it seems some schools are starting to understand their role in cognitive development. In your experience, are schools fulfilling their roles as “brain gyms”, places where young minds get shaped and ready for life?

AL: Good question. I have been a pediatrician working with schools in the Cleveland area since 1985, seen all kinds of diseases. For example, I have witnessed the growing incidence of autism spectrum disorders, such as autism and Asperger’s. I have also observed how school work has increasingly become more cognitively demanding, starting from kindergarden. There is too much pressure today, and a growing number of problems, yet I don’t see that schools are applying the best knowledge of how minds work. Just as doctors offices are centers of applied medical science, taking the latest advances in medical research and applying them to the medical care of people, schools should be the best place for applied neuroscience, taking the latest advances in cognitive research and applying it to the job of educating minds. Yet, they aren’t, and I can’t blame them , given the wide variety of pressures they work under, and the large change in perspective becoming institutes of applied neuroscience would take.

A cognitive gap?

AF: Some readers may be skeptical of the claim that school work is more demanding today than, say, 20 years ago. They may say kids are simply becoming “lazy”. What do you say to that?

AL: I have never met a lazy kid. All people want to succeed, in life if not in school. Most children who struggle at school struggle mightily to get adequate grades. It is true that some are more resilient that others-if they fail, they will try 10 times harder. The ones that are labeled as “lazy” are typically ashamed of their lack of capacity to deal with demands, and resort to an evasive strategy, they try to avoid the whole situation, run away.

AF: You mention a “lack of capacity to deal with demands”. Is that gap growing? The equation has 2 components: capacity and demands. In terms of capacity, let me mention that recently, the French Education Ministry just introduced mental arithmetic as part of the curriculum. I remember, as a kid, spending many hours in the math class where the teacher would require us to perform a progressively complex sequence of mental calculations-which is good training for skills such as working memory. Memory traininIn terms of demands, I can see how complex homework assignments are these days even in 3-4rd grade. Kids need to plan and prepare a whole matrix of tasks that require good organizational work to complete. They need to sequence what they do today, tomorrow, the day after. The major difficulty, for which such young brains may not be fully ready, is to deal with an overwhelming amount of information and demands, and execute.

AL: Great point. For example, years ago we had to memorize long texts, which, no matter what the content was, was a great way to train and build our attention span, working memory, and to devise strategies to learn. Today, there are less opportunities for such training.


Working Memory and Attention Deficits

AF: That seems to imply a higher need for good executive functions than years ago. A kid needs to have good working memory to retain, prioritize and sequence much information into actionable plans, and then execute them, as I had the fortune to discuss with Mark Katz some months ago. From my previous interviews with Dr. Klingberg and Dr. Gibson, we know that a common problem with many kids with diagnosed attention deficits is, indeed, working memory (the ability to hold in mind and manipulate several units of information). Can you explain what you see in your work with schools?

AL: I am afraid that many schools are too quick to diagnose ADD/ ADHD and consider drugs as the only potential intervention. The label itself can be misleading and counterproductive. School psychologists have wonderful expertise in evaluating subject-related problems and describing attentional deficit symptomatology, but are not trained or asked to complete neuropsychological profiles of a child’s cognitive functions. Up to a point, many kids with attention problems would benefit from educational, not medical, interventions to improve cognitive functions such as working memory. I am seeing it first hand, having used Cogmed Working Memory Training (also called RoboMemo) with 15 pre-screened kids: 80% of them presented a substantive improvement. With 50%, the results we have seen have been dramatic.

AF: Please give us some examples, so our readers can better understand what working memory is and its role in academic performance and daily life.

AL: Let me give you 3 vignettes, all 3 with diagnosed attention deficits, who showed clear benefit not only on cognitive functioning but also on AD/HD rating scales.
Patient 1: 11-year-old boy, very impulsive, even on medication. Doesn’t do homework, constantly forgets chores. After the 5-week program, he is able to sit down and listen instructions, engaging in fewer arguments with his parents. He can do better mental math- for the first time in his life able to do so without using his fingers. He finds that following school and doing homework is easier, grades have improved dramatically.
Patient 2: 16-year-old girl with ADD. She has trouble executing homework, often telling parents she had done it when she really hadn’t. Her parents thought she liked to lie. Yet, when I talk to her, she is clearly more ashamed than dishonest. The working memory training program helps her develop a much improved perception of time. For example, she starts to manage her shower time better, being aware of when 5 minutes have passed-instead of spending 30 minutes in the shower, as before. Much improved school work, lying at home has dropped dramatically.

Patient 3: 19-year-old boy in college, who often became paralyzed when he was faced with complex challenges. He had a tough time with the cognitive training program, but after a while he started learning new strategies and developing self-confidence, and showing marked improvement. Now, he can break complex tasks into manageable pieces . His attentional deficits appeared to threaten his opportunities in his family business. Unable to keep track of change at the cash register, lines at the business would grow and customers get angry, leaving him out of consideration for key start-up employment in the business. Now he can manage day-to-day challenges such as these, and the door to being part of the family business is now open. He can sequence tasks and execute then with a clear plan in mind, without being distracted and losing sight of that plan.

AF: Dr. Lavin, this is all very exciting news, that open the way for new interventions, new policies, a new understanding of what “education” and “learning” is and how to “educate” millions of young minds and equip them for life success. Thank you very much for your time.

AL: Thank you. I really appreciate all the work you are doing to bring the latest neuroscience research and applications to professionals like me and to parents at large.

2008 Childhood Vaccination Schedule CDC

CDC Issues 2008 Childhood Vaccination Schedules

The 2008 recommended immunization schedules for children 18 years and younger have been published in MMWR.

Among the changes from 2007:

• The live attenuated influenza vaccine (FluMist) is now recommended for children as young as age 2.
• The meningococcal conjugate vaccine (MCV4) is recommended for high-risk children aged 2 to 10 years and all children 13 to 18 who haven't been previously immunized. (Routine MCV4 vaccination continues to be recommended for normal-risk children aged 11 to 12, as well as children through age 18 at increased risk for meningococcal disease.)
• A new catch-up schedule advises that children aged 7 to 18 who received their first dose of the tetanus and diphtheria toxoids/tetanus and diphtheria toxoids and acelluar pertussis vaccine (Td/Tdap) before age 1 should be given four doses, with 4 or more weeks between the second and third doses.

MMWR article (Free)

CDC press release (Free)

CDC vaccine site (Free)

Urinary Tract Infections Prevention

Prophylaxis Not Associated with Lower Recurrence of UTIs in Children

Physician's First Watch for July 11, 2007

The use of antimicrobial prophylaxis after a first childhood urinary tract infection is not associated with lower rates of recurrence — and in fact is associated with an increased risk for resistant infections, according to a JAMA study.

Researchers followed some 600 children under age 6 with first episodes of UTI for over a year to examine the characteristics that would predict recurrent infections. They found that white race, age 3 to 5 years, and grade 4 to 5 vesicoureteral reflux were all factors associated with increased risk for recurrence. Antimicrobial prophylaxis had no effect on recurrence risk, but among children in whom infection recurred, prophylaxis was associated with an increased risk for resistant infections.

The authors suggest that clinicians "discuss the risks and unclear benefits of prophylaxis with families ... after a first UTI."

JAMA article (Free)

Reduce Atopy Risk in Baby

Revised Guidelines on Early Dietary Intervention for Atopy Prevention

Breast-feeding helps some infants avoid atopy, but limited evidence exists that other nutritional interventions affect the development of atopic disease in children, according to the American Academy of Pediatrics.

The new guidelines, appearing in Pediatrics, replace a policy statement issued in 2000. The academy's committee concludes that:

• infants at high risk for atopy (i.e., those having first-degree relatives with atopic disease) show benefit from exclusive breast-feeding for at least 4 months;
• infants exclusively breast-fed for at least 3 months are at lower risk for asthma;
• maternal dietary restrictions (e.g., avoiding peanuts, cow's milk) during pregnancy and breast-feeding aren't supported by evidence;
• any protection against asthma afforded by early exclusive breast-feeding cannot be shown beyond age 6;
• "modest evidence" exists that if high-risk infants are not exclusively breast-fed, they will have a lower risk for atopic dermatitis if given extensively or partially hydrolyzed formula.
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Pediatrics article (Free)

Physician's First Watch for January 8, 2008