Tuesday, April 26, 2011

BMI in Teens Linked to Later Coronary Disease

From Heartwire CME
News Author: Shelley Wood
CME Author: Charles Vega, MD

april 15, 2011 — A large, prospective study tracking young men from age 17 well into their 30s, 40s, and beyond has found that body-mass index (BMI) in their teens was a significant predictor of both coronary artery disease and diabetes in later life [1]. Strikingly, say the authors, BMI became predictive of later disease even at levels that would be considered normal or even low-normal by current cutoffs.

Speaking with heartwire , Dr Iris Shai (Ben-Gurion University of the Negev, Beer-Sheva, Israel), who with Dr Amir Tirosh (Brigham and Women's Hospital, Boston, MA) was a lead author on the study, highlighted just how unique their series was. The cohort consisted of Israeli army personnel, who had their height and weight measured when they entered the army, and, if they remained in the armed forces, again every three to five years. The data have been collected as part of the Metabolic, Lifestyle, and Nutrition Assessment in Young Adults (MELANY) study. For their study, Tirosh, Shai, and colleagues followed 37 674 army career personnel (all men) until their first diagnosis of CAD (by angiography) or diabetes or until they retired from military service (until December 31, 2007).

In all, 1173 men developed diabetes and 327 men developed CAD within 650 000 person-years of follow-up (mean of 17.4 years). Baseline BMIs ranged from about 17 to 28, and elevated BMIs were a significant predictor of both CAD and diabetes. When baseline BMIs were organized by deciles, however, a surprising picture emerged: according to researchers, the risk of diabetes, after adjustment for other risk factors, became statistically significant in the eighth decile, which included BMI levels ranging from 22.4 to 23.4. For CAD, the risk became statistically significant at even lower BMIs, those in the third decile, ranging from 19.01 to 19.69.

To heartwire , Shai acknowledged that a BMI of 19 falls below what is considered a normal, healthy weight in adults, but she stressed that this was in 17-year-old boys, who were not yet fully grown.

The notion that BMI in childhood or young adulthood can lead to heart disease and diabetes later in life is not new, Shai acknowledged. "What is new here is we found that once we had the second measurement of BMI, around the age of 30, the most dominant predictor of diabetes was the BMI at age 30--in other words, close to the incidence of disease." In contrast, she said, "the incidence of CHD is predicted by both age 17 and 30. This suggests that history counts--even when you are 17 years old--and most of these were young and healthy recruits to the army, so most had a BMI lower than 25."

The finding that higher BMI at an older age, but not at a younger age, was the better predictor of near-term diabetes, whereas high BMI mattered at both younger and older ages in terms of coronary disease, points to a difference in how BMI relates to later diseases, Shai said. BMI seems to exert a more "acute effect" on diabetes risk in later life, whereas excess weight at younger ages seems to set in motion the development of coronary heart disease. "If you are now in your 30s, but you were heavier when you were 17, but you lose weight, that could dramatically reduce your risk of diabetes" but does not protect against developing coronary disease.

The study findings "highlight the critical importance of considering BMI history when assessing the risk of coronary heart disease vs the risk of diabetes in overweight or obese young adults," the authors write. They also underscore the need for age-specific diabetes-prevention programs as something distinct from coronary-disease-prevention tactics.

Finally, Shai told heartwire , the study may help redefine "normal" BMIs in male adolescents. While she stopped short of saying their study warranted shifting the cutoffs for normal lower on the BMI continuum, she said that she believed their study would be useful for ongoing efforts to refine definitions of optimal BMI in young people.


1. Tirosh A, Shai I, Afek A, et al. Adolescent BMI trajectory and risk of diabetes versus coronary disease. N Engl J Med 2011; 364:1315-1325. Abstract

Clinical Context

Physicians and the general public are paying increasing attention to the problem of obesity during adolescence. Not only has the rate of obesity among this age group increased significantly in the last 2 decades, but also obese teenagers are at increased risk for multiple negative health outcomes as adults. A study by Must and colleagues, which was published in the November 5, 1992, issue of The New England Journal of Medicine, described these outcomes. Overweight during adolescence predicted a higher risk for overall and CHD mortality among men, but not women. Men with a history of overweight during adolescence were also more likely to have incident colorectal cancer and gout, and overweight female teenagers were more likely to go on to have arthritis.

The current study uses a large patient cohort with a long duration of follow-up to further elucidate the risks of teenage overweight and obesity.

More Evidence Secondhand Smoke Bad for Kids' Mental Health

From Medscape Education Clinical Briefs

News Author: Deborah Brauser
CME Author: Désirée Lie, MD, MSEd

April 14, 2011 — Children and adolescents in the United States exposed to secondhand smoke (SHS) are at risk of developing major depressive disorder (MDD), generalized anxiety disorder (GAD), attention-deficit/hyperactivity disorder (ADHD), and conduct disorder, new research suggests.

In a national survey study of more than 2000 nonsmokers between the ages of 8 and 15 years, investigators found that serum cotinine levels, signifying SHS exposure, were positively associated with symptoms of all these disorders — and were especially correlated for boys.

"Our results have important public health implications," write Frank C. Bandiera, MPH, from the Department of Epidemiology and Public Health, Miller School of Medicine at the University of Miami, Florida, and colleagues.

"Given the critical developmental period of childhood and adolescence, the effects of policy to reduce or ban smoking in public places and in the home may help prevent or reduce the progression of illness in at-risk individuals and alleviate the heavy burden...attributable not only to tobacco use but also to mental disorders," they write.

Although the findings are in line with previous research showing a link between mental health outcomes and SHS exposure, the investigators note that this study did not "establish the biological or psychological mechanisms of association."

Still, the investigators note that this new research does provide "critical and much-needed data."

The study is published in the April issue of Archives of Pediatrics and Adolescent Medicine.

High Rate of Exposure

According to the researchers, 66% of all children between the ages of 3 and 11 years have been exposed to SHS.

"Because many mental disorders have an onset in youth at a time when SHS exposure is high, it is critical to consider how SHS may be affecting the mental health of children and adolescents so that appropriate preventive measures can be implemented," they write.

In a recent study reported by Medscape Medical News, investigators from the United Kingdom found that a higher level of salivary cotinine was significantly associated with hyperactivity and conduct disorder in adolescents participating in the Scottish Health Survey. That study, which was published online first December 6 in Archives of Pediatrics and Adolescent Medicine, is also published in the journal's current print issue.

For this study, investigators evaluated data on 2901 nonsmoking US adolescents (51% male; 61.9% non-Hispanic white; 14.8% non-Hispanic black; 12.2% Mexican American; 11.1 other races/ethnicities) who participated in the National Health and Nutrition Examination Survey between 2001 and 2004.

Symptoms of MDD, GAD, panic disorder, ADHD, and conduct disorder were assessed during 12 months using the National Institute of Mental Health's Diagnostic Interview Schedule for Children Version IV.

Results showed that the participants had a mean of 4.93 MDD symptoms, 3.94 ADHD symptoms, 2.86 GAD symptoms, 1.34 conduct disorder symptoms, and 0.29 panic disorder symptoms.

When looking at associations among all participants, investigators found that serum cotinine levels were significantly correlated with symptoms of MDD, GAD, ADHD, and conduct disorder — but not with panic disorder.

"After adjusting for all covariates, serum cotinine level was most strongly associated with ADHD symptoms," report the researchers. Although not quite as strong, the association remained significant for symptoms of MDD, conduct disorder, and GAD after adjustment.

Although there was a significant association in males between cotinine level and MDD, GAD, ADHD, and conduct disorder symptoms, the association for females was only significant with symptoms of GAD.

Finally, a significant association between SHS and MDD, GAD, and ADHD was found for white participants, but only with conduct disorder for the Mexican American group. There were no statistically significant associations with any of the disorders in black participants.

Need to Butt Out

The investigators note that only 26 states currently ban smoking in all public places.

"Efforts to ban smoking in places where children and adolescents are present, including all child care settings and schools, should continue, as well as increased efforts to develop interventions targeted directly at parents and designed to prevent SHS exposure in the homes of children and adolescents," they write.

"To date, there has been little parallel research; thus, the findings of this new study cannot be placed into a larger body of literature to gauge consistency," writes Jonathan M. Samet, MD, from the Department of Preventive Medicine in the Keck School of Medicine, Institute for Global Health, at the University of Southern California, Los Angeles, in an accompanying editorial.

"Consequently, the provocative findings of Bandiera and colleagues need replication and an expanded foundation of mechanistic understanding. Further research on exposure to SHS might also provide insights into neurodevelopmental effects of inhaled pollutants, a topic of rising interest," adds Dr. Samet.

He notes that longitudinal data are needed "to bolster arguments for potential causality, to separately assess maternal smoking during pregnancy and SHS exposure after pregnancy, and to characterize the relationship between exposure at various ages and risk."

With that said, Dr. Samet writes that there is now sufficient evidence of an association with poor health outcomes to "mandate reduction" of SHS exposure in public places.

However, because these bans do not cover homes, clinicians "should motivate parents to protect their children, beginning with prenatal care and continuing during childhood," he opines.

"Pediatricians and other healthcare providers can help eliminate exposure of infants and children to SHS, even while the evidence on mental health continues to evolve," concludes Dr. Samet.

The study was funded in part by the National Institute of Mental Health Intramural Research Program. The study authors and Dr. Samet have disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. 2011;165:332-338, 370-372. Abstract Excerpt

Related Link
The Environmental Protection Agency (EPA) offers a number of resources about the Health Effects of Exposure to Secondhand Smoke, including information on creating and supporting smoke-free homes. Additionally, there are related brochures, offered in both English and Spanish, which are available for download and can be used to support community programs.
Clinical Context

There is no risk-free level of tobacco exposure, and 66% of children aged 3 to 11 years are exposed to SHS. SHS exposure is associated with chronic diseases such as respiratory illness and anxiety and depression among adults. It is not known if SHS exposure in children is associated with mental health conditions.

This is a cohort study of the National Health and Nutrition Examination Survey data to examine the association between SHS exposure as determined by cotinine levels and the risk for mental health conditions in children and adolescents.

Wednesday, April 20, 2011

FDA Warns Again of Lymphoma Risk With TNF Blockers in Teens

From Medscape Medical News

Emma Hitt, PhD

April 14, 2011 — The US Food and Drug Administration (FDA) continues to receive reports of hepatosplenic T-cell lymphoma (HSTCL) in adolescents and young adults treated with tumor necrosis factor (TNF) blockers, azathioprine, and/or mercaptopurine, the agency said today.

HSTCL has been reported in patients taking immunosuppressive drugs for Crohn's disease, ulcerative colitis, psoriasis, and rheumatoid arthritis, according to an alert sent today from MedWatch, the FDA's safety information and adverse event reporting program.

Drugs associated with increased risk include the TNF blockers, a class of drugs that includes infliximab (Remicade, Centocor), etanercept (Enbrel, Amgen and Pfizer), adalimumab (Humira, Abbott Laboratories), certolizumab pegol (Cimzia, UCB), and golimumab (Simponi, Centocor Ortho Biotech Inc). The immunosuppressive drigs azathioprine and mercaptopurine may also be associated with increased risk.

"Although most reported cases of HSTCL occurred in patients treated with a combination of medicines known to suppress the immune system, including the TNF blockers, azathioprine, and/or mercaptopurine, there have been cases reported in patients receiving azathioprine or mercaptopurine alone," the FDA notes.

The FDA first warned of the increased risk for childhood and adolescent cancers associated with TNF blockers in 2008, and warnings were added to the product labels of these drugs in 2009. Warnings about HSTCL have now been added to the product labels for infliximab and adalimumab, and the product labels for azathioprine and mercaptopurine are being updated.

Healthcare professionals are advised to evaluate the potential risks and benefits of therapy carefully and discuss them with patients and caregivers.

The FDA advises clinicians to monitor patients for symptoms of HSTCL, which include splenomegaly, hepatomegaly, abdominal pain, persistent fever, night sweats and weight loss. Patients should also be made aware of these symptoms.

A higher incidence of lymphomas is associated with rheumatoid arthritis, Crohn's disease, ankylosing spondylitis, psoriatic arthritis, and plaque psoriasis, even in the absence of immunosuppressive drugs.

The FDA will continue to monitor the number of reported cases of HSTCL associated with these drugs and to communicate new safety information.

HSTCL is an aggressive cancer and is usually fatal.

More information is available at the FDA Web site.

Wednesday, April 6, 2011

AAP Child Passenger Safety Policy 2011 mPolicy Statement

AAP Child Passenger Safety Policy
Policy Statement

Frequently Asked Questions

March 2011
This information is not for reproduction or distribution

What are the most important messages for parents?
1) The most important message is that children should ride properly restrained on every trip in every type of transportation, on the road or in the air.

2) Infants and toddlers under 2 should ride facing the rear of the vehicle, children should ride in forward-facing seats after outgrowing the rear-facing limits, and older children should ride in a belt-positioning booster seat after outgrowing the forward-facing limits. All passengers of any age should ride in a lap and shoulder seat belt once they have grown big enough for the seat belt to fit properly. All children should ride in the back seat until they are 13 years old.

3) Parents often look forward to transitioning from one stage to the next, but these transitions should generally be delayed until they’re necessary, when the child outgrows the limits for their current stage. Riding rear-facing protects children better than riding forward-facing, riding in a forward-facing seat with a harness protects them better than riding in a booster seat as long as they fit within the stated limits, and riding in a booster seat protects them better than a seat belt alone until the seat belt fits correctly.

How big of a problem are motor vehicle crashes?
While the rate of deaths in motor vehicle crashes in kids under 16 has decreased substantially – 45% between 1997 and 2009 – it is still the leading cause of death for children ages 4 and above. Counting children and teens up to age 21, there are more than 5000 deaths each year. Furthermore, for each fatality there are an additional 400 children and youth who are injured seriously enough to require medical treatment.

What prompted the policy revision?
Over time, large, well-designed research efforts have yielded a great deal of scientific evidence that wasn’t available when the previous policy was published in 2002. We know much more now about how effective safety restraints are in reducing deaths and injuries. Additionally, there have been major changes in the design of vehicles and car safety seats and many states have strengthened their laws around protection of children and youth in motor vehicles.

What is the biggest change in the new policy?
The most significant change is the new recommendation that children under 2 years should ride rear-facing as long as they have not outgrown the weight or height limit for their seat. The previous recommendation advised that it is safest to ride rear-facing to the limits of the seat, but also cited age 12 months and 20 pounds as a minimum. The change reflects recent evidence about the benefits of rear-facing, and also is intended to simplify the message for parents. Additionally, the change is reflected in an algorithm that is intended to provide decision support for pediatricians, both on paper and as part of electronic tools, that will help pediatricians give more accurate, consistent advice to families.

Does the rear-facing recommendation apply to every child?
The recommendation to ride rear-facing until age 2 is meant to apply to the vast majority of children, but there are some situations in which a child should turn forward-facing earlier or later. For example, children who are small for age, particularly those who were born preterm, or who have special health care needs might benefit from riding rear-facing for more than 2 years. Other children might reach the weight or height limit before age 2, in which case they should use a forward-facing seat with a harness. The “age 2” recommendation is not a deadline, but rather a guideline to help parents make a decision about when to make the transition.

Why is rear-facing safer than forward-facing?
A 2007 study1 showed that children under 2 years old are 75% less likely to die or be severely injured in a crash if they are riding rear-facing. For children in the second year of life, it found that the risk of death or serious injury was 5 times lower when riding rear-facing. When a child rides rear-facing, the head, neck, and spine are all supported by the hard shell of the car safety seat and all move together, with little relative movement between body parts. When children ride forward-facing, their bodies are restrained by the harness straps, but their heads – which for toddlers are disproportionately large and heavy – are thrown forward, possibly resulting in spine and head injuries.

Won’t children be uncomfortable riding rear-facing for so long? Are they at risk for foot or leg injuries if their legs touch the vehicle seat?
This is a very common concern, but one that is not supported by any evidence. There are no known detrimental effects of riding rear-facing longer than a year, but the benefits of doing so have been observed for many years in Sweden and more recently in the United States. Children have many ways of making themselves comfortable when facing the rear and can ride safely that way as long as they have not reached the weight or height limit for rear-facing in their seat. For many kids, this could be well past 24 months.

What are the rear-facing limits?
These vary according to the particular seat; for infant seats, the limits are generally between 22 and 35 pounds. Convertible seats are larger and have higher limits, generally at least 35 pounds and some up to 40 or 45 pounds. Height limits vary also. The limits for each particular seat are listed on a label on the side of the seat and in the instruction manual. Convertible seats will also give limits for forward-facing use, so parents should be sure they are observing the right limits for how their child is riding.

How should children ride after they outgrow the limits for rear-facing?
Children should ride in a forward-facing seat with a 5-point harness for as long as possible, until they reach the height or weight limit for forward facing. After that, they should ride in a belt-positioning booster seat until the seat belt fits correctly.

Why are booster seats important?
Because vehicle seat belts were designed for adults. The lap and shoulder portions of the seat belt generally will not fit young children properly. If the shoulder belt lies close to the neck, it will be uncomfortable for the child, who might then put the shoulder belt under his arm or behind his back where it cannot provide upper-body protection in a crash. If the lap belt sits high over the child’s abdomen, the child could sustain severe injuries to abdominal organs. The booster seat keeps the lap and shoulder belts over strong bones where they were designed to be, instead of the soft abdomen or neck.

How do you know when the seat belt fits correctly?
The seat belt fits correctly when the shoulder belt lies across the middle of the chest and shoulder, not near the neck or face; the lap belt is low and snug on the hips and upper thighs, not across the belly; and the child can sit all the way back against the vehicle seat with knees bent without slouching, and can stay that way comfortably for the whole trip. This is usually around 4 feet 9 inches in height, and between 8 and 12 years of age. Although most state booster seat laws only cover children up to age 6 or 8, the vast majority of kids do not yet fit correctly in seat belts at those ages. Parents should not assume that their child is safe to ride in the seat belt alone because he has reached the age required by their state law, but should keep their child in the booster seat until the seat belt fits correctly without it.

Where in the vehicle should children ride?
Children should ride in the rear seat until they reach age 13. Data show that children riding in the front seat are at 40% to 70% increased risk of injury. Riding in the back seat reduces the risk of injury in both frontal and side-impact crashes, and also reduces the severity of injury. If possible, it may be best for children to ride in the middle of the back seat; however, if it is not possible to install a car safety seat tightly or no lap and shoulder belt is available in the middle, then either side of the back seat is a good choice.

Is it safe for children younger than 2 to ride on a parent’s lap on an airplane?
Although the Federal Aviation Administration permits children under age 2 to ride on an adult’s lap, they are best protected by riding in an age- and size-appropriate car seat. If parents do not wish to purchase a separate seat for their young child, they may be able to use an empty seat at no charge if one is available. Parents who do purchase a separate seat for their child can use a car safety seat onboard as long as it bears a label stating that it is approved for use on aircraft. In any case, parents should ensure that an appropriate car safety seat is available for their child’s use when they reach their destination.

Information for Child Passenger Safety Technicians and Advocates

Why is policy development such a long process?
The policy development process is comprised of numerous steps, starting with obtaining approval from the AAP Board of Directors to develop the policy. Once approval is given, the authoring group (in this case, the Committee on Injury, Violence, and Poison Prevention) embarks upon analyzing new information, writing, and revising. For this policy, the committee also collaborated with the Partnership for Policy Implementation to ensure that the language was clear, specific, and suitable for integration with electronic health record tools. Next, the policy in progress is circulated to other AAP groups for internal peer review, followed by a period of addressing the reviewers’ comments with further revisions. This process is intended to identify and resolve any potential medico-legal problems or challenges related to feasibility of integration in pediatric practices. Finally, policies must be reviewed and approved by the Board of Directors; this process may involve multiple revisions as well. All of the internal processes are aimed at producing a policy that is scientifically sound and sensitive to the needs and situations of its audiences.

How can I get connected with pediatricians in my community?
The new policy specifically advises that pediatricians familiarize themselves with resources in their communities, ie, Child Passenger Safety Technicians, who can support them in providing accurate information and handling more complex situations related to the safe transportation of children with special needs or other considerations. You can help by reaching out to the pediatricians in your community. If you are unsure about how to get started establishing these relationships, start with the AAP Chapter in your state; you can find contact information for the chapter’s executive director on the AAP Web site.

Additionally, the AAP plans to undertake a Child Passenger Safety Training Project, which would train pediatricians and the staff in their offices on best practice recommendations. This project will involve participation from Child Passenger Safety Technicians who are interested in taking an active role in providing education and resources to pediatricians. If you are interested in participating in this project, please contact Bonnie Kozial.

1. Henary B, Sherwood C, Crandall J, et al. Car safety seats for children: rear facing for best protection. Inj Prev. 2007;13(6): 398 – 402

Neglected Infections of Poverty - Toxocariasis

From Centers for Disease Control and Prevention (CDC): Expert Commentary

LCDR Paul T. Cantey, MD

I'm Paul Cantey, a Medical Epidemiologist with CDC's Division of Parasitic Diseases and Malaria. Today, I'm here to speak with you as part of the CDC Expert Video Commentary Series on Medscape. I'll be talking about one of the neglected infections of poverty, which are infections that disproportionately affect minorities, women, and disadvantaged groups in the United States.
Often clinicians do not receive sufficient training in the diagnosis and treatment of these infections, which include, but are not limited to, Chagas disease, congenital cytomegalovirus infection, cysticercosis, toxocariasis, toxoplasmosis, and trichomoniasis.

Today, we'll discuss the clinical aspects of just 1 of these infections -- toxocariasis.
Toxocariasis is a human disease caused by infection with the larval stages of the dog or cat roundworm.
Humans become infected by ingesting embryonated eggs in soil or food or encysted larvae in raw tissues from cows, sheep, or chickens.
The seroprevalence of infection with Toxocara is 14% in the United States, and the highest prevalence is in the southern United States.
Risk factors include poverty, low education levels, and dog ownership.
Soil contamination is common; areas of particular concern are sandboxes and places in yards and public parks where animals defecate.

There are 3 clinical forms of Toxocara infection.
The first is called mild toxocariasis. Although it may be asymptomatic, children may present with fever, headache, behavioral and sleep disturbances, cough, anorexia, abdominal pain, hepatomegaly, nausea, and vomiting. Peripheral eosinophilia may also be present.
In adults, mild toxocariasis can be associated with chronic dyspnea, weakness, rash, pruritus, and abdominal pain. Eosinophilia is much more likely to be present in adults.
Mild toxocariasis is often undiagnosed because the patient is not sick enough to seek medical attention.

The 2 more severe forms of the disease are visceral toxocariasis, also known as visceral larva migrans, and ocular toxocariasis, known as ocular larva migrans. Visceral toxocariasis typically occurs in children, although it can infect persons of any age.
Signs and symptoms include fever, lower respiratory symptoms, hepatomegaly, abdominal pain, and anorexia. The skin, heart, kidney, or central nervous system can also be affected. Symptoms are usually severe enough for the patient to seek medical attention. Eosinophils are usually markedly elevated.

Ocular toxocariasis typically occurs in 5- to 10-year-olds, but up to 20% of cases occur in people over the age of 16. Usually only 1 eye is affected, and manifestations can include strabismus, unilateral decreased vision, and leukorrhea. Eye exam may show peripheral posterior polar retinal granuloma and endophthalmitis, with a vitreous band on ultrasound. Eosinophils are often not elevated.

Diagnosis of mild and visceral toxocariasis is made using an enzyme-linked immunosorbent assay (ELISA).
Ocular disease is diagnosed on the basis of clinical criteria because many patients do not develop an antibody response.
Diagnosis cannot be made with stool ova and parasite testing because Toxocara does not reproduce in humans.

Treatment of toxocariasis varies depending on the type of infection.
Mild toxocariasis may not need to be treated.
Visceral toxocariasis is treated with a 5-day course of albendazole.
Ocular toxocariasis requires a 2- to 4-week course of treatment with albendazole, along with corticosteroids to control inflammation. Surgery may also be needed.

For more information on toxocariasis, please see the resources listed on this page. Thank you.

AAP Issues New Guidelines for Management of Iron Deficiency

From Medscape Medical News

Jim Kling

October 14, 2010 — Correction: The original text of this article described the daily iron dose for infants 6 to 12 months as 11 mg/kg. This is incorrect. The dose should be 11 mg/day.

October 5, 2010 (San Francisco, California) — Iron deficiency is one of the most common, yet undetected, problems among children. Here at the American Academy of Pediatrics (AAP) 2010 National Conference and Exhibition, the American Association of Pediatrics released a clinical report, with guidelines for iron intake in infants and children and to improve screening methods.

The clinical report, entitled Diagnosis and Prevention of Iron Deficiency and Iron Deficiency Anemia in Infants and Young Children (0–3 Years of Age), was published online October 5 in Pediatrics. It is a revision of a 1999 policy statement.

Iron deficiency can have long-term irreversible effects on a child's cognitive and behavioral development. By the time a child develops iron-deficiency anemia, it might be too late to prevent future problems.
"The body has a preferential tracking of iron. Red blood cells take precedence over the iron requirements of the brain.
By the time you get iron-deficiency anemia, you've been iron-deficient for a long time," said Frank Greer, MD, professor of pediatrics at the University of Wisconsin School of Medicine and Public Health in Madison, and a coauthor of the report.

The 1999 guidelines call for children to have their hemoglobin checked sometime between 9 and 12 months of age, and again between 15 and 18 months of age.
However, the existing test misses many children with iron deficiency and iron-deficiency anemia. Even those found to be iron deficient frequently receive no follow-up testing or treatment, according to Dr. Greer.

Although supplementing all children with iron would reduce iron deficiency, such a program does not have widespread support in the medical community at this point. That's partly because toddlers, who are the most widely affected group, have a wide range of diets and it is unclear what foods to fortify.

Liquid iron supplements or vitamins could be used, but there is a risk for iron overload in some populations, according to Michael K. Georgieff, MD, professor of pediatrics and child psychology and director of the Center for Neurobehavioral Development at the University of Minnesota in Minneapolis. Dr. Georgieff was on the AAP's committee on nutrition from 1993 to 1999 and played a key role in the 1999 guidelines.

"Iron supplementation and awareness of iron nutrition has probably been one of the most successful public health programs in the United States. In the 1960s, iron deficiency was probably 30% to 40%. Today, it may be under 10%. But in trying to eliminate that last 10%, you have to consider it in terms of exposing kids to [too much] iron," said Dr. Georgieff.

No single screening test is available that will accurately characterize the iron status of a child, he noted. In the report, the AAP recommends 4 protocols for screening for iron deficiency and iron-deficiency anemia, including combinations of several tests and follow-up protocols. "It's burdensome," Dr. Greer admitted.

"Since we're not going to do universal supplementation, we need to identify kids who are at risk for iron deficiency and start targeting them," said Dr. Georgieff, who studies the neurodevelopmental effects of iron deficiency in children.

The AAP report identified several factors associated with iron deficiency and iron-deficiency anemia, including prematurity or low birth-weight, lead exposure, exclusive breastfeeding past 4 months of age without iron supplements, and weaning to foods that don't include iron-fortified cereals or iron-rich foods. Infants with special healthcare needs might also be at risk. Children of low economic status, particularly those of Mexican American descent, are also of concern, according to the report, which recommends selective screening for these individuals.

The guidelines also address means to prevent iron deficiency through a diet of foods naturally rich in iron, such as meat, shellfish, legumes, iron-rich fruits and vegetables, and iron-fortified cereals. Fruits rich in vitamin C help iron absorption. Some children might require liquid iron supplements or chewable vitamins to get sufficient iron.

The AAP recommends varying amounts of iron based on a child's age:

* Term, healthy infants have sufficient iron for the first 4 months of life. Because human breast milk contains very little iron, breastfed infants should be supplemented with 1 mg/kg per day of oral iron from 4 months of age until iron-rich foods (such as iron-fortified cereals) are introduced.
* Formula-fed infants will receive adequate iron from formula and complementary foods. Whole milk should not be used before 12 months.
* Infants 6 to 12 months of age need 11 mg/day of iron a day. When infants are given complementary foods, red meat and vegetables with high iron content should be introduced early. Liquid iron supplements can be used if iron needs are not met by formula and complementary foods.
* Toddlers 1 to 3 years of age need 7 mg per day of iron. It is best if this comes from foods such as red meats, iron-rich vegetables, and fruits with vitamin C, which enhance iron absorption. Liquid supplements and chewable multivitamins can also be used.
* All preterm infants should have at least 2 mg/kg of iron per day until 12 months of age, which is the amount of iron in iron-fortified formulas. Preterm infants fed human milk should receive an iron supplement of 2 mg/kg per day by 1 month of age; this should be continued until the infant is weaned to iron-fortified formula or begins eating foods that supply the required 2 mg/kg of iron.

American Academy of Pediatrics (AAP) 2010 National Conference and Exhibition. Presented October 5, 2010.

Clinical Practice Guideline: Tonsillectomy in Children

From Medscape Pediatrics
An Expert Interview With Ellen E. Wald, MD
by Laurie Scudder, DNP, NP

Editor's Note: The American Academy of Otolaryngology -- Head and Neck Surgery recently issued Clinical Practice Guideline: Tonsillectomy in Children .
The new guideline, which is intended for all providers who care for children 1-18 years old in whom tonsillectomy is being considered, offers evidence-based recommendations on identifying children who are the best candidates for tonsillectomy, operative care, and management.
Laurie Scudder, Clinical Editor, Medscape, recently discussed the guideline with Ellen Wald, MD, a member of the guideline committee and Professor and Chair, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, to expand on the significance of the document for pediatric primary care providers.

Medscape: One of the most relevant recommendations in the guideline for primary care providers is the first statement, which recommends watchful waiting for recurrent throat infections if there have been fewer than 7 episodes in the previous 12 months or fewer than 5 episodes per year in the previous 2 years or fewer than 3 episodes per year in the past 3 years.
So bottom line, children should be observed for at least 1 year before a referral to a surgeon to consider tonsillectomy.
Is this number of episodes irrespective of the severity of the episodes?
Is the intent that these episodes will have all been of sufficient intensity to warrant a visit to a healthcare provider?

Dr. Wald: To put this in perspective, and this is stated clearly in the document, the purpose of the guideline is to avoid unnecessary intervention in children who have recurrent throat infection who are very likely to have a favorable natural history and improve on their own and therefore will be benefited by avoiding surgery. There may be exceptions occasionally on the basis of either very severe or very complicated infections. But in general, I think this is a good outline and the idea is that, yes, these episodes would have been seen by a clinician and the infection would be adequately documented.
A lot of this work dates back to a study that was done by Jack Paradise in the late 1970s. His research used very stringent criteria that described what were termed "counting episodes."
A child was considered to have had a counting episode that contributed to the number of episodes if they had, in addition to their sore throat, at least 1 of the following 4 criteria:

* A fever > 38.3° Celsius;
* Cervical adenopathy, which was defined as a lymph node in the neck that measured > 1 cm and was tender;
* Tonsillar exudates; or
* A positive test for group A streptococci.

Medscape: In a concluding discussion of implementation considerations, the guideline emphasizes the importance of appropriate documentation to support treatment decisions.

Dr. Wald: Absolutely. I think that is one of the important messages for the practitioner. When evaluating a child with sore throat, it is important to specifically note the presence or absence of fever, the presence or absence of swollen lymph nodes, and the appearance of the throat including any swelling of the tonsils, size of the tonsils, and presence or absence of exudates. When group A strep is suspected, there should be an attempt at microbiologic confirmation in the form of a rapid streptococcal antigen detection test or a positive culture for group A strep.
In addition to documenting the specific characteristics of the episode of sore throat, it is also important to specifically ask about absences from school and quality-of-life issues like being able to pay attention and being in a good frame of mind for learning. Growth, also, should always be monitored and documented.

Medscape: Even for those children who meet these stringent criteria over a period of 1-2 years, the guideline indicates that monitoring without surgery is still an option.
Can you discuss some of the children who might reasonably be monitored for a longer period in whom you would expect a spontaneous reduction in episodes?

Dr. Wald: One of the reasons for continued observation is again based on the Paradise studies. Children who met the criteria described earlier were randomly assigned to receive tonsillectomy or continued observation. For the group that was observed, the mean number of episodes of sore throat in the next year prospectively was about 1.
Even children who have a very compelling previous history of sore throat will often improve and would not in subsequent years qualify for surgery. And of course you would rather not do a tonsillectomy in a child who wasn't going to have a lot more trouble.
Another factor that influences a decision about management is the severity of the infection. For example, a child with 5 mild infections in a year might be followed a little bit longer. On the other hand, severe episodes, especially if they involve something like a peritonsillar abscess, might be considered for tonsillectomy a little bit earlier.
Another potential modifying factor is the presence of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA). There is some indication that children with PFAPA who do not fit those very stringent criteria may benefit from tonsillectomy.
This tends to be a self-limiting syndrome, usually lasting several years, and so the degree of morbidity a child is experiencing should be considered before recommending surgery.

The availability of medical care for a given child should also be considered. Does the child live in an urban area where the healthcare provider is down the street or within a short car ride, or does he or she live in a rural area where the ability to get medical care for severe sore throat may be much more difficult? Another important issue is the impact of missing school due to multiple infections. The good student with a mild infection who misses school for a day might reasonably continue to be observed.

In sum, the things that should be considered are the severity of the individual episodes, the proximity of good medical care, and the impact on school performance for any given child. Always keep in mind that even a child who has had a bad season of recurrent streptococcal infections very often will not have that same experience the following year.

Medscape: The guideline does not make a distinction based on a child's age.
A child of 5 years or 15 years should be observed until the criteria described are met. Is that correct?
Are there modifying factors that should be considered in children of varying ages?

Dr. Wald: Age really is not, in general, an important variable, recognizing that sore throat is not a common problem until children are at least 4 or 5 years of age. The peak age for strep pharyngitis as well as other viral causes of pharyngitis or sore throat is usually between 5 and 15 years of age. Precise age isn't important.

Medscape: The guideline strongly supports the consideration of tonsillectomy for sleep disordered breathing (SDB), a diagnosis that may be made clinically.
The guideline clearly notes the range of comorbid conditions that may occur in the child with SDB but does not appear to weight any particular factor more strongly than others.
Can you provide some guidance for primary care providers in determining children with SDB who should more seriously be considered for tonsillectomy?

Dr. Wald: SDB is characterized by recurrent partial or complete upper airway obstruction during sleep that results in disruption of the normal breathing and sleep pattern.
The diagnosis is usually based on history and physical exam, though sometimes more sophisticated testing is necessary. Tonsillar and adenoid hypertrophy is the most common cause of SDB.
While a lot of kids have this problem, there are accompanying factors that persuade us that we want to do something about it.
One issue is growth retardation.
Others include poor school performance or behavioral problems. Behavior seems to be related to poor sleep, and things like aggression, hyperactivity, or depression may be associated with disordered breathing.
Another issue that, interestingly, has some association with SDB is enuresis or bed wetting.
A parent's report of a history in their child of noisy respirations at night associated with a brief cessation of breathing and a very noisy restart of respirations should prompt additional questioning.
You would inquire specifically about their growth, school performance, bed wetting, and any associated behavioral problems. If that history suggests ongoing issues, you might be more interested in referring them for a tonsillectomy.

Medscape: Dr. Wald, any concluding recommendations for primary care providers?

Dr. Wald: I think the bottom line is that while these are very good guidelines and will serve the best interests of children most of the time, we should individualize our approach to patients. It is important to look at each patient, consider these criteria, and then ask the question of benefit vs risk. There are very rare complications of tonsillectomy, including anesthetic accidents and hemorrhage post-tonsillectomy. Accordingly, there should be pretty good indications to justify the risk, even though the risk is small.

Few Effective Treatment Options for Autism

From Medscape Medical News > Psychiatry
'Critical Need' for Additional Research Into Behavioral Interventions

Deborah Brauser

April 6, 2011 — Few medical, behavioral, or developmental treatments show strong evidence of substantial benefit for children with autism spectrum disorders (ASDs), conclude 3 new review studies published online April 4 in Pediatrics.

In the first review, which looked specifically at medication trials in ASDs, investigators found that most were lacking. However, the antipsychotics risperidone and aripiprazole had "the strongest evidence to support their use" specifically for challenging and repetitive behaviors, although each of these drugs was also associated with significant adverse effects.

In a second review, investigators found clear evidence that the gastrointestinal polypeptide secretin is not at all effective for treating ASDs.

Improvements in several areas, including cognitive performance and language skills, were found for some children with ASDs after undergoing intensive behavioral and developmental interventions, according to the third review.

However, the researchers note that "few research studies were rated of good quality and the existing evidence did not provide strong evidence in favor of any single early intervention approach."

"I think what surprised us most was the paucity of research that we found. Additional work is critically needed," the report's senior author Melissa L. McPheeters, PhD, MPH, codirector at the Vanderbilt Evidence-Based Practice Center at the Vanderbilt University Medical Center in Nashville, Tennessee, told Medscape Medical News.

'Strikingly Little Evidence'

Although as many as 1 in every 110 children in the United States has an ASD, "there is currently no consensus regarding which interventions are most effective," write the researchers.
Dr. Melissa L. McPheeters

"When looking across the different studies, certain children showed very positive improvements, especially with behavioral treatment, but others did not and remained very impaired. And there's a real lack of information about how we might go about identifying the children who are most likely to have a positive response," said Dr. McPheeters.

"If we could get more research in that area, that might lead to better targeting of these many possible interventions so we could get the right treatment to the right child."

When looking across the different studies, certain children showed very positive improvements, especially with behavioral treatment, but others did not and remained very impaired.

For the Agency for Healthcare Research and Quality (AHRQ) report, the investigators examined ASD intervention trials from MEDLINE, PsychInfo, and Education Resources Information Center databases that were published between 2000 and 2010 and included children 12 years and younger.

In the medication-specific review, "strikingly little evidence" of significant benefit was found for most ASD-treating medications, report the researchers.

However, at least 2 randomized controlled trials found parent-reported improvements in repetitive and challenging behavior for either risperidone or aripiprazole. Still, significant adverse effects associated with both drug treatments included weight gain, sedation, and risk for extrapyramidal symptoms.

"These 2 medications had the most research and are the only ones actually indicated by the FDA [US Food and Drug Administration] for autism treatment. And they are specifically indicated for the treatment of irritability," said Dr. McPheeters.

Some of the strongest study results to support [medication or device] use have been funded by pharmaceutical companies or device manufacturers that profit from the treatment.

"They did have positive results, but the flip side is that both come with potentially substantial side effects. This means we should probably limit their use to patients who are severely impaired or who are at risk of injury," she added.

The potential benefits and adverse effects of other medications, including selective serotonin reuptake inhibitors and stimulants, could not be judged due to "insufficient strength of evidence."

The investigators note that although the National Institutes of Health has funded 2 large studies assessing medical interventions for ASDs, "some of the strongest study results to support [medication or device] use have been funded by pharmaceutical companies or device manufacturers that profit from the treatment."

Final Word on Secretin

Used to treat peptic ulcers, secretin's additional possible use as a treatment for ASDs appears to stem from some animal studies and a small nonblinded case series of 3 children that reported some symptom improvements.

However, after evaluating 7 randomized controlled trials, the investigative team found no significant efficacy for secretin in treating language and communication impairment and cognitive and social skill deficits compared with placebo.

Because these studies "uniformly point to a lack of significant impact" from secretin, the investigators write that this ASD treatment approach "warrants no further study."

Dr. McPheeters added that she hopes "this is the final word" on the possibility of any useful benefits coming from this medication.

After reviewing 34 trials assessing early intensive interventions, the investigators found significant improvements in cognitive, language, and adaptive behavior skills in some of the children included.

The successful interventions emphasized specific behaviors, such as those found with the University of California, Los Angeles/Lovaas approach, or developmental principles, such as those found in the Early Start Denver Model. However,there were too few studies to be able to find strong evidence for 1 specific approach.

"We judged the literature to be low to insufficient in really establishing effectiveness at this time. Although there were individual studies with positive outcomes, we have a real need for replication because we don't have enough information to say for sure that we know that these are effective," said Dr. McPheeters.

In addition, only one of the studies evaluated was judged to be of good quality, 10 were of fair quality, and 23 were of poor quality.

Overall, the researchers write that several early intervention approaches "have significant potential," but more research is needed to determine which ones may be of most benefit to specific subgroups of children with ASDs.

Part of a Larger Report

It is important to note, said Dr. McPheeters, that the 3 reviews are part of a larger report initiated by the AHRQ, which is available on the AHRQ's Effective Healthcare Web site.

The overall report includes the 3 review studies published in Pediatrics, as well as findings about additional interventions and details of the methods.

"It's very important that clinicians, parents, educators, and caregivers of children with autism have the opportunity to look at all the evidence, which is why we tried to pull as much information together as we possibly could in the full report. We wanted to make sure it was all available so that important decisions could be made on a child-by-child basis."

In addition, recommendation guides for clinicians and for families of children with autism are currently in development by AHRQ and will be posted on the agency's Web site soon.

Although it's not new news to the professionals who serve people with autism, it is a nice compilation of existing studies in a journal that's easily assessable.

"The 3 papers are methodologically sound and were commissioned by the government to bring together what is already known," Susan L. Hyman, MD, associate professor of pediatrics at the University of Rochester Medical Center in New York and the division chief of the Neurodevelopmental and Behavioral Pediatrics Department at Golisano Children's Hospital, told Medscape Medical News.

"Although it's not new news to the professionals who serve people with autism, it is a nice compilation of existing studies in a journal that's easily assessable to pediatricians. It's important to let people know why they know things and that's what AHRQ does," she added.

Dr. Hyman, who is also chair of the autism subcommittee for the American Academy of Pediatrics, noted that the reviews are not telling clinicians to not use specific medications. Instead, the reviews are pointing out "in nonjudgmental ways" the strengths of evidence that guide practice.

The Art of Medicine

"When you're prescribing medicine without evidence, what you're calling upon is the art of medicine rather than the science. And you just need to know that."

She added that the review on secretin, especially, was not surprising. "The secretin summary basically closes the door on this treatment, that there is no indication for it for autism."

Regarding the interventions review, Dr. Hyman said that "there certainly are" other summary documents that have reached different conclusions.

"In the National Standards Project, [investigators] reviewed the literature and said that the evidence strongly supports applied behavior analysis and intervention for autism," she reported.

"I would also reach a slightly different conclusion than the authors of this new paper. They were very careful with their review of the literature, but there are a lot of intangibles when it comes to early intervention.

"And there are outcome variables beyond the core symptoms of autism that these studies measured. So they reported on what the studies reported and not on literature that looked at qualitative improvement and what families get from early intervention."

She noted that the investigators did not include studies of interventions that target isolated features of autism.

"When you look at the big picture analysis, the data is not that strong...You can lose the benefits that are measurable in other types of studies."

That said, Dr. Hyman believes the reviews are helpful and that "they're very important for clinicians to read and discuss with others."

Pediatrics. Published online April 4, 2011. First Abstract, Second Abstract, Third Abstract

Surgery for Amblyopia Improves Behavior, Quality of Life

From Medscape Medical News

Norra MacReady

April 5, 2011 (San Diego, California) — Children with developmental disorders and severe ametropia and amblyopia show objective improvements in behavior and development after photorefractive keratectomy (PRK), Evelyn Paysse, MD, reported in an oral presentation here at the American Society of Pediatric Ophthalmology and Strabismus (AAPOS) 37th Annual Meeting.

Most children with these conditions wear corrective lenses, explained Dr. Paysse, who is associate professor of ophthalmology at Baylor College of Medicine in Houston, Texas.
However, there is a subset of patients who will not wear them, such as children who were born prematurely, autistic patients, and children with cerebral palsy, genetic disorders, and craniofacial abnormalities.

Often these children find glasses inconvenient or uncomfortable. For example, neck hypotonia makes it difficult for a patient to keep her head up, so her glasses will be continually sliding off her nose, Dr. Paysse noted. Children with seizure disorders might fear losing or breaking their glasses during an episode, and children with cognitive or behavioral conditions might find glasses frightening or anxiety-provoking.

Using a term coined by Lawrence Tychsen, MD, from Washington University School of Medicine in St. Louis, Missouri, Dr. Paysse said these children have a kind of "visual autism. They live in a world of blur and isolation, where visual stimuli might be experienced as noxious or averse because they are not seen until they are very close to the face. . . . This increases the stress in these already severely impaired children."

There are about 60 published cases of refractive surgery in this patient population, Dr. Paysse said. The procedure has been associated with improved vision and quality of life, as reported in parent questionnaires, but these findings have been criticized on the grounds of "possible bias because the parents are highly motivated to see an improvement."

Dr. Paysse and her colleagues decided to measure outcomes objectively by subjecting the patients to a well-validated battery of developmental tests just before and 6 months after undergoing PRK.

The patients were 14 children, ranging in age from 4 to 11 years (average age, 5.5 years), with high bilateral ametropia and amblyopia. They had a variety of neurodevelopmental conditions such as autism, Down's syndrome, severe attention deficit hyperactivity disorder, and cerebral palsy. Minimum refractive errors were bilateral myopia of at least 6 diopters (D), bilateral hyperopia of at least 4 D, and bilateral astigmatism of at least 3 D. All of the children refused to wear glasses and were unable to wear contact lenses. With PRK, they were corrected for a maximum treatment dose of –10.43 D for myopia or +5.43 D for hyperopia. Mean postoperative cycloplegic refraction was –1.86 ± 1.85 D for the myopic group and +0.49 ± 1.34 D for the hyperopic group.

Depending on their age and level of function, the children underwent the Vineland Adaptive Behavior Scales, Second Edition (Vineland II); the Beery Burktenica Developmental Test of Visual-Motor Integration, Fifth Edition (Beery VMI); or the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley). These tests evaluated the patients' communication, socialization, motor, and adaptive abilities, as well as their daily living skills, both before and 6 months after undergoing PRK.

The primary outcome measure was a change in the developmental quotient (DQ) in the subdomains, measured as mental age in months/biological age in months multiplied by 100. "The DQ is a very well-used metric in developmental pediatrics," Dr. Paysse said.
Unlike normal children in whom mental age increases with biological age, mental age eventually reaches a plateau in many children with developmental disabilities as their biological age advances, leading to a gradual worsening of the DQ.

In the communication domain, as measured by the Vineland II, the children in this study had a mean preoperative receptive DQ of 23.8 and a postoperative DQ of 31.7 (P = .04), and a mean preoperative communicative DQ of 25.7 and a postoperative communicative DQ of 31.0 (P = .02). In the socialization domain, preoperative and postoperative interpretive DQs were 24.0 and 28.2, respectively (P = .04), and preoperative and postoperative coping DQs were 20.3 and 28.1, respectively (P = .02). Dr. Paysse called these improvements "remarkable." Scores in the other subdomains remained the same, which means that the patients did not show the expected worsening in DQ that comes with time, "and this may be remarkable as well."

"I definitely appreciated Dr. Paysse's use of formal behavioral tests in these children," said Sandra Brown, MD, a pediatric ophthalmologist in private practice in Concord, North Carolina. "I compliment her on this study."

These findings suggest that PRK can improve vision and refractive error in children with neurobehavioral disorders and high isoametropic amblyopia, and there is an associated improvement in the developmental functions of communication and socialization, Dr. Paysse concluded. "This translates into an improved quality of life."

Dr. Paysse and Dr. Brown have disclosed no relevant financial relationships.

American Society of Pediatric Ophthalmology and Strabismus (AAPOS) 37th Annual Meeting: Paper 17. Presented March 31, 2011.