Sunday, July 31, 2011

AAP Guidelines: Health Supervision of Down Syndrome Patients

From Medscape Medical News

Nancy A. Melville

July 27, 2011 — New guidelines from the American Academy of Pediatrics (AAP) provide clinicians with the latest recommendations on the health supervision of children with Down syndrome.
The guidelines, published online July 25 in Pediatrics, provide standards of care beginning with the prenatal diagnosis of Down syndrome and extending through age 21 years or older.
"The guidelines are directed to the primary care provider to help meet the needs of the child with Down syndrome in the medical home," lead author Marilyn J. Bull, MD, FAAP, the Morris Green Professor of Pediatrics at Riley Hospital for Children in Indianapolis, Indiana, told Medscape Medical News.
In the guidelines, Dr. Bull and the Committee on Genetics state that children with Down syndrome have an array of unique medical conditions, multiple malformations, and widely varying levels of cognitive impairment, and clinicians are advised to be aware of the various issues that arise because of the presence of extra genetic material from chromosome 21.
As many as 75% of these children have hearing loss, for instance, and as many as 50% have congenital heart disease, Dr. Bull explained.
"It's important for physicians to recognize and manage potentially disabling conditions such as thyroid and cardiology issues as early as possible."
Among key updates to the guidelines are recommendations on monitoring children for cervical spine disabilities. In the past, radiographs of the cervical spine were recommended for children with Down syndrome by approximately age 3 years to detect the risk for instability that can cause spinal compression or spinal cord damage, but Dr. Bull said there is question about the efficacy of the radiographic approach.
"The problem is the radiographs themselves are not a good predictive tool and they don't predict well which child is going to have that increased risk of cervical spine instability," she said.
"So we are placing a different emphasis toward alerting physicians and families of the symptoms that could relate back to the cervical spine and to the prompt intervention that's important should they occur."
The guidelines also now include recommendations that clinicians be on alert for celiac disease, or gluten sensitivity, in children with Down syndrome.
"Celiac disease is somewhat increased in some children with Down syndrome, and since there are potential burdens in evaluating asymptomatic children, we don't recommend every child needs to be evaluated," Dr. Bull said. "But we're recommending that clinicians have a heightened awareness of the symptoms and conduct the proper tests if those symptoms occur."
Sleep apnea is another risk in children with Down syndrome because of anatomic predisposition, and testing is recommended by at least age 4 years or as soon as a child has symptoms, Dr. Bull noted.
The guidelines include an algorithm to help address the various age-specific health issues that can arise throughout growth and development with Down syndrome.
"As children mature, nutrition, behavior and sexuality all become important issues in managing these patients, and health guidance on the issues for families is addressed as well," Dr. Bull said.
Family interaction in health supervision at all ages is heavily emphasized throughout the guidelines, which stress the need to work with parents to help them adjust to the unique challenges of having a child with Down syndrome.
She explained that "Parents are often overwhelmed when they learn their baby has a condition such as Down syndrome, and these guidelines strongly emphasize how important a balanced perspective with accurate information is for families, and how [to] approach families with the appropriate sensitivity, because it certainly is an adjustment."
Although much health supervision of patients with Down syndrome is handled at the primary care level, the guidelines are ultimately designed to inform and benefit the broader array of clinicians that can also be involved in their care.
"Almost every specialty is involved in caring for children with Down syndrome, so it is important for residents and medical students to become familiar with [Down syndrome] because it is highly likely they will encounter a Down syndrome patient in the course of their careers," Dr. Bull said.
Dr. Bull has disclosed no relevant financial relationships.
Pediatrics. 2011;128:393-406.

Breast-Feeding Linked to Lower Asthma Risk in Childhood

From Medscape Medical News

Laurie Barclay, MD

July 26, 2011 — Breast-feeding is linked to lower asthma risk in early childhood, according to the results of a prospective cohort study reported online July 20 in the European Respiratory Journal.
"The link of duration and exclusiveness of breastfeeding with asthma-related symptoms during the first 4 years was independent of infectious and atopic diseases," said lead author Agnes M. M. Sonnenschein-van der Voort, MSc, an investigator at Generation R from the Erasmus Medical Center, Rotterdam, the Netherlands, in a news release. "These results support current health policy strategies that promote exclusive breastfeeding for 6 months in industrialised countries. Further studies are needed to explore the protective effect of breastfeeding on the various types of asthma in later life."
The goals of the study were to evaluate the associations of breast-feeding with the risks for development of asthma-related symptoms at preschool age, and to determine whether atopic or infectious mechanisms could explain these associations.
The study sample consisted of 5368 children who were enrolled in a population-based prospective cohort study. Questionnaires were completed for these children regarding information on breast-feeding duration and exclusiveness, and on asthma-related symptoms including wheezing, shortness of breath, dry cough, and persistent phlegm.
During the first 4 years, children who were never breast-fed had overall greater risks of wheezing, shortness of breath, dry cough, and persistent phlegm than children who were breast-fed for 6 months. Odds ratios (ORs) were 1.44 (95% confidence interval [CI], 1.24 - 1.66), 1.26 (95% CI, 1.07 - 1.48), 1.25 (95% CI, 1.08 - 1.44), and 1.57 (95% CI, 1.29 - 1.91), respectively.
Associations for exclusive breast-feeding were similar, and wheezing at 1 and 2 years had the strongest associations per symptom per year. The associations of breast-feeding with asthma-related symptoms were partly explained by lower respiratory tract infections but not by eczema, on the basis of additionally adjusted analyses.
Limitations of this study include possible residual confounders or effect modifiers or the influence of genetic variances, and reliance on self-report for asthma-related symptoms.
"[O]ur results suggest that a short duration of breastfeeding and non-exclusivity are associated with increased risks of the asthma-related symptoms during the first 4 years of life, with the strongest effect estimates during the first two years," the study authors write. "These associations seem to be partly explained by lower respiratory tract infections but not by atopic mechanisms. Further studies are needed to explore the underlying mechanisms and the protective effect of breastfeeding on the various types of asthma in later life."

Eur Respir J. Published online July 20, 2011.

Childhood Pets Linked to Lower Allergy Risk

From Reuters Health Information

NEW YORK (Reuters Health) Jul 22 - Good news for families that would love to have a furry dog or cat but hesitate for fear the kids might become allergic: Fido or Kitty might actually be good for children's health, scientists say.
They found that children who were exposed to animals at a young age had lower rates of nasal allergies as adolescents.
"Family pets, in particular dogs...need not be removed to prevent allergies, and in fact may protect against them," Melanie Matheson of the University of Melbourne, lead author of the study, told Reuters Health in an email.
Looking at survey responses from nearly 8,500 adults from Europe and Australia, Matheson and colleagues focused on those who grew up around house pets or farm animals, and those who had the troublesome runny noses, itchy eyes, and sore throats that plague nasal allergy sufferers.
Growing up with pets has already been linked to a lower risk of other types of allergies. A 2010 study from the University of Cincinnati showed than owning a dog may decrease the risk of childhood eczema, a skin condition (see Reuters Health story of October 13, 2010). Similarly, a 2011 study from Henry Ford Hospital in Detroit found that growing up with pets cut kids' risk of developing pet allergies by half.
In the new study, published online July 13th in the Journal of Allergy and Clinical Immunology, more than one in four respondents said they had nasal allergies. In most cases, people said their allergies started when they were adolescents.
A number of factors were linked to a higher risk of nasal allergies in the study. Some, like a family history of allergies and the mother smoking while pregnant, are well documented risk factors.
But the research team also found that small children who had lots of exposure to other little kids - because they had young siblings, for instance, or attended day care - had lower risks of nasal allergy. And the more siblings a child had, the lower the odds that the child would have nasal allergies later in life.
The scientists saw a similar pattern among people who grew up on a farm or had pets before age five. Compared to rates in people who didn't have those experiences in early childhood, the odds of having nasal allergies in adolescence were 30% lower in people who grew up on a farm, while having a dog and cat were each associated with a 15% reduction.
Furthermore, people who'd had siblings and animal exposure had lower rates of nasal allergies compared to those who'd had only one or the other experience.
These results were consistent in the 13 countries surveyed, "despite the differences in pet ownership and farming between countries," Matheson told Reuters Health in an email.
The study design cannot prove that exposure to pets or other children are the cause of the lower risk of nasal allergies. Although the authors accounted for several factors, including education and family history of allergies, there may be another cause of the reduced nasal allergy risk that is associated with pets and siblings.
Also, the researchers only had information on exposure to animals before age five, so they don't know whether being around animals at an older age would have any effect on allergy risk.
While the results of the study are promising, it would be premature to suggest that parents buy pets or have more children, said Dr. Jonathan Bernstein, professor of medicine of University of Cincinnati College of Medicine and a co-author of an earlier report on the same topic.
Still, he said, the results provide further evidence that avoiding exposures may not be the best way to protect children against allergies.

J Allergy Clin Immunol 2011.

EU Recommends Restricted Use of GSK's Flu Shot

From Reuters Health Information 

LONDON (Reuters Health) Jul 21 -
European regulators have recommended restricting the use of GlaxoSmithKline's pandemic flu vaccine Pandemrix because of a potential risk of narcolepsy in children or adolescents.
The European Medicines Agency said on Thursday that Pandemrix should only be used in people under 20 years in the absence of seasonal trivalent influenza vaccines, following its link to very rare cases of narcolepsy in young people.
Overall, the vaccine's benefit-risk balance remains positive, the watchdog added.
More than 31 million doses of Pandemrix have been given to people in 47 countries, and GSK said it had been notified of 335 cases of narcolepsy in those vaccinated as of July 6. Two-thirds of the narcolepsy cases were in Finland and Sweden.
Britain's biggest drugmaker said in a statement it had committed to conduct further research into any potential association between Pandemrix and narcolepsy.
Pandemrix was widely used during the 2009-10 outbreak of H1N1 swine flu, although it was not administered in the United States.
Several other drugmakers, including Novartis , Sanofi , CSL and Baxter also made vaccines against H1N1 flu during the pandemic, which was declared over in August last year.
Finnish and Swedish researchers were the first to raise concerns over a possible narcolepsy link to Pandemrix last August after noting cases in children recently given the GSK shot.
One research team earlier this year suggested children given Pandemrix were nine times more likely to suffer from the condition.
Researchers at Finland's National Institute for Health and Welfare said the increase they found in narcolepsy was "most likely" a joint effect of Pandemrix and some other factor or factors.

Sharp Drop in Varicella-Related Deaths Due to Vaccine

From WebMD Health News

Jennifer Warner

July 25, 2011 — Chickenpox deaths in the U.S. have been nearly eliminated thanks to widespread use of the varicella vaccine, according to a new CDC study.
Researchers found chickenpox deaths have dropped by 88% overall and by 97% among children and adolescents since 1995, when the varicella vaccine program began in the U.S. Before the varicella vaccine became available, chickenpox was responsible for about 100 deaths and 11,000 hospitalizations each year.
"The impressive decline in varicella deaths can be directly attributed to successful implementation of the 1-dose vaccination program," write study researcher Mona Marin, MD, of the CDC, and colleagues in Pediatrics. "With the current 2-dose program, there is potential that these most severe outcomes of a vaccine-preventable disease could be eliminated."
A second varicella vaccine dose given at the age of 4 to 6 years was added to national vaccination recommendations in 2006. The first dose is given at the age of 12 to 18 months.
Since 2005, the varicella vaccine has also been available as part of a combination vaccine that offers protection against measles, mumps, rubella, and varicella, known as the MMRV.
Most cases of chickenpox are mild, but it can be life-threatening in rare cases, especially among those with weakened immune systems such as infants and the elderly.
Chickenpox Trends in U.S.
In the study, researchers analyzed national data on deaths for which varicella was listed as an underlying or contributing cause from 2002 to 2007.
Previous studies have reported a 66% overall decline in chickenpox deaths in the first six years of the vaccination program from 1995 to 2001. Researchers say that since then vaccination coverage has increased substantially.
The results show that during the 12 years of the one-dose varicella vaccination program the annual death rate from chickenpox decreased by 88%. The decline was evident in all age groups, but especially among children and adolescents under age 20 (97% decline) and adults under 50 (96% decline).
Researchers say the reduction in chickenpox deaths found in this study is higher than previously estimated and exceeds the cost-effectiveness anticipated by the one-dose program.
"However, this should be interpreted bearing in mind that varicella causes few deaths and that the main benefit of the vaccination program comes from a reduction of lost work and medical care associated with cases and severe complications," write the researchers. "Nevertheless, varicella deaths are a powerful reminder of the importance of vaccination for prevention."

Wednesday, July 27, 2011

A Brief Primer on Antivirals in Children

From Medscape Infectious Diseases > Expert Reviews and Commentary

Treating Influenza and Herpes Viral Infections

Ravi Jhaveri, MD
18th July 2011

A Primer on Antiviral Agents

The world of antiviral drugs is rapidly changing with over 20 antiviral agents and 25 antiretroviral agents currently approved by the US Food and Drug Administration. Key to appropriately utilizing these agents is an understanding of the generic viral life cycle and the places points in that cycle where antivirals can act.
To simplify this, there are 2 major factors that distinguish viruses:
  • DNA vs RNA viruses; and
  • Envelope vs nonenvelope viruses.
Viruses work by hijacking the host cell machinery to manipulate cellular proteins in order to replicate. Viruses bring with them their own replication and packaging, but everything else they borrow from host cells. While not an absolute distinction, most DNA viruses enter the host cell nucleus, whereas RNA viruses stay in cytoplasm.
Figure 1. Viral life cycle.
Figure courtesy of Paul Krogstad, University of California, Los Angeles.
During the viral life cycle, a virus traffics in, binds to its receptor, enters, uncoats, makes its own nucleic acids and proteins, and then reassembles before releasing into the host system. That pretty much applies to all viruses.
Antiviral agents target several places within this process.
Figure 2. Sites of antiviral drug action.
Figure courtesy of Paul Krogstad, University of California, Los Angeles
It is important to emphasize that the viral life cycle results in the ultimate release of new virus. Therefore, a cell that is infected is generating a lot of virions. Virology should be thought of in terms of total numbers of virus. An antiviral agent that is 99.9% effective at reducing virus will leave 0.01% of the infected cells, and these infected cells continue to make new virions. If the original infection caused 1 billion new virions to be produced, 0.01% will continue to produce 1 million new virions, which is enough to generate symptoms in a patient. The best treatment for a viral infection, therefore, is to prevent a cell from being infected. Once a cell is infected and generating new virions, an antiviral must be extremely potent in order to arrest the infection.

Antivirals for Treatment of Influenza in Children

There are 4 antiviral agents currently available for use in both influenza A and B infections. All target a viral neuraminidase that is critical for release of the virus. The agents approved for this indication are:
Amantadine. This agent inhibits viral uncoating, a critical step in viral replication. Administered orally, it is almost 100% bioavailable. It is only effective against influenza A strains. Similar to other agents, it reduces both severity and duration of symptoms if given early in the course of the infection. It is associated with adverse central nervous system (CNS) effects, most notably jitteriness. More severe CNS symptoms may include hallucinations or insomnia.
Rimantadine. Rimantadine, developed later than amantadine, is associated with somewhat less CNS adverse effects.
Unfortunately, over the last 15 years, influenza viruses, including novel H1N1 and H3N2, are both widely resistant to amantadine or rimantadine. Currently, approximately 92% of influenza strains are resistant. The Centers for Disease Control and Prevention (CDC) do not recommend use of either agent in treatment of influenza.[1]
Oseltamivir. This agent is well absorbed and thus readily bioavailable when given orally. The target for this agent is viral neuraminidase, which is critical for viral release. While active against both influenza A and B, it is approximately 10- to 20-fold more active against A than B. Efficacy studies demonstrate that antivirals initiated in the first 2 days of an influenza infection, including oseltamivir, reduce the severity of symptoms as well as duration by approximately 1 day, a reflection of the earlier discussion on the high volume of new virions made during a viral infection.
Zanamivir. Zanamivir is an inhaled powder administered via a Diskhaler. Due to risk for bronchospasm, this agent may not be used in patients with a history of asthma. There is an investigational intravenous formulation in development. Like oseltamivir, this agent targets viral neuraminidase and should be administered within the first 2 days of symptom onset. Recommendations for use of oseltamivir and zanamivir are available from the CDC Website.

Treatment of Herpes in Children

Herpes viruses represent a large family of DNA viruses known for their ability to cause lifelong infection. In aggregate, these viruses are associated with a number of distinct conditions causing significant human morbidity. The most clinically important of these viruses include:
  • Cytomegalovirus (CMV) -- typically, healthy persons infected with CMV are asymptomatic but infection can be life-threatening in the immunocompromised patient.
  • Epstein-Barr virus (EBV) -- most widely recognized as the cause of infectious mononucleosis, EBV is also associated with some forms of cancer, particularly Burkitt lymphoma and nasopharyngeal carcinoma.
  • Herpes simplex virus (HSV) 1-- may cause oral or genital lesions but is primarily associated with orofacial infection.
  • HSV2 -- also may be the cause of either oral or genital lesions, though primarily associated with genital infection.
  • Varicella zoster virus (VZV) -- causes chickenpox as a primary infection and may later reactivate as the cause of shingles.
There are 4 agents or classes of agents indicated for treatment of infections resulting from this family of viruses. They are:
Acyclovir and valacyclovir. These agents are guanosine analogs that dead end DNA replication by competitively inhibiting the viral polymerase. The oral bioavailability of acyclovir is quite low, particularly for pediatric suspensions. Valacyclovir is better absorbed, though bioavailability remains modest at between 55%-70%. Side effects are typically minimal, though renal toxicity occurs in approximately 5% of patients, with a slightly higher incidence in children particularly those with underlying renal insufficiency or who may be taking other nephrotoxic medications. Intravenous preparations may cause local irritation and phlebitis. Neurotoxicity, presenting with symptoms ranging from agitation to frank psychosis, can occur in 1%-4% of patients, primarily in adults. While acyclovir is present in breast milk there is no known teratogenecity.
Ganciclovir and valganciclovir. The mechanism of action of these agents is similar to that seen with acyclovir though the drugs are less efficient at chain termination. Ganciclovir has very poor bioavailability though valganciclovir is approximately 60% bioavailable. Valganciclovir specifically inhibits bone marrow hematapoietic precursor cells, which is the reason that neutropenia, which occurs in 24%-43% of patients, and thrombocytopenia, seen in 5%-15% of recipients, are prominent adverse effects associated with this agent. CNS side effects, ranging from headache to behavior changes, may also be seen with either of these agents. Both agents are teratogenic and classified as Pregnancy Category C and thus are contraindicated during breast feeding. These agents have particular usefulness in the treatment of CMV infection in those patients requiring treatment.
Famciclovir and penciclovir. Penciclovir is a related compound to acyclovir with activity against HSV1 and 2 as well as VZV. It is not orally bioavailable and is used topically. Famciclovir is the oral prodrug of penciclovir and can be used orally for treatment of cutaneous/mucosal manifestations of HSV or VZV.
Foscarnet. This agent is an inorganic pyrophosphate analog that is a noncompetitive inhibitor of the viral polymerase and interferes directly with the enzyme. It has broad activity against herpes viruses and is used primarily in the situation of resistant HSV and CMV infections. It does not have any oral bioavailability and must be given intravenously. The major side effect is renal toxicity; one third of patients will double their serum creatinine by week 2 of treatment. Risk factors for renal toxicity include use of higher doses, rapid infusion, and the presence of other nephrotoxic medications. Because the drug is primarily excreted renally, it requires dose adjustment for patients with renal compromise. Because foscarnet chelates many other agents, it is not compatible with many other infusions. CNS side effects are also common, occurring in approximately 25% of patients and ranging from headache to frank dystonia. It is teratogenic, and it is excreted in breast milk.
Cidofovir. Cidofovir is an acyclic phosphonate nucleotide analog of the deoxycytidine that is a broad inhibitor of many DNA viruses. It has activity in vitro against HSV, CMV, EBV, human herpes virus 6 and 8, and a range of other viruses including some papillomviruses, polyomaviruses, adenoviruses, and poxviruses. It, too, has low oral bioavailability, only about 5%, so it must be administered intravenously.
It is almost entirely excreted unchanged in the urine. Probenecid coadministration prolongs the half life. Nephrotoxicity is a major limiting factor in the use of this drug because it binds to the anti-transporter within the kidney which leads to drug accumulation in the renal cortex. It is mutagenic and teratogenic. It is classified Pregnancy Category C, and it is present in breast milk.

From CDC Expert Commentary

Michele C. Hlavsa, RN, MPH
Posted: 07/18/2011

Hi. I'm Michele Hlavsa, Chief of CDC's Healthy Swimming Program.
RWIs are caused by pathogens transmitted by ingesting, inhaling aerosols from, or having contact with contaminated water in swimming pools and other recreational water venues.
The number of RWI outbreaks reported annually has increased dramatically in recent years. In 2007, 2.4 million US healthcare visits resulted in a diagnosis of acute otitis externa, commonly referred to as swimmer's ear.Annually, ambulatory-care clinicians spend nearly 600,000 hours treating acute otitis externa. In other words, acute otitis externa and other RWIs are common and take up a substantial amount of clinicians' time, but RWIs can be easily prevented.
Studies show that the swimming public believes that chlorine instantly kills all pathogens.
These data also show that swimmers don't think about swimming as a shared water experience.
Unfortunately, these misconceptions lead to risky behaviors, such as swimming during diarrheal illness and swallowing recreational water, which lead to transmission of pathogens that cause RWIs.
As clinicians, it's up to us to educate our patients and dispel misconceptions that lead to illness.

Here are 5 simple prevention messages you can share with your patients to help them proactively protect their health every time they swim.
  1. Don't swim while ill with diarrhea. A person with diarrhea can easily contaminate the water with fecal matter and introduce enteric pathogens into the water. RWI outbreaks caused by enteric pathogens have increased more than 100%, from 37 in 1999-2000 to 81 in 2007-2008. Because of its tough outer shell, the coccidian Cryptosporidium can survive in a well-maintained pool or other chlorinated recreational venue for more than 10 days. Outbreaks of cryptosporidiosis are driving the increase in the number of RWI outbreaks reported annually and can spread into community-wide, and even statewide, outbreaks.
  2. For patients with cryptosporidiosis, don't swim for an additional 2 weeks after diarrhea has resolved. CDC and the American Academy of Pediatrics recommend this step because of the prolonged excretion of Cryptosporidium after cessation of diarrhea, the potential for intermittent diarrhea that might cause infected people to think symptoms have resolved, and the increased transmission potential in chlorinated recreational water venues because of the parasite's high chlorine tolerance.
  3. Don't swallow the water. Pathogens that cause diarrheal illness can be transmitted when swimmers swallow contaminated water. We don't drink the water in our bath tubs; why would we drink the water we swim in?
  4. Keep ears as dry as possible and dry ears thoroughly after swimming. CDC, the American Academy of Otolaryngology, and the American Academy of Pediatrics have recently released updated recommendations to prevent acute otitis externa. Using a bathing cap, ear plugs, or custom-fitted swim molds when swimming can help keep water out of the ears. Pulling the earlobe in different directions while the ear is faced down can help drain water out. If your patient has frequent episodes of acute otitis externa, consider prescribing prophylactic alcohol-based ear drops or a 1:1 mixture of rubbing alcohol and white vinegar. Drops should not be used by persons with tympanostomy tubes or ear tubes, damaged ear drums, outer ear infection, or ear drainage.
  5. Don't swim when you have open wounds. Open wounds can be sites of entry for pathogens, so people with open wounds should refrain from swimming until the wound is healed. Another option is to wear a waterproof occlusive bandage to cover the wound while swimming. Although swimming with open wounds represents a risk for the person with the wound or sore, CDC is not aware of data indicating that this practice puts the health of other swimmers at risk.
We realize that there is little time for patient education in a busy practice. To increase awareness and expedite communication, CDC has created a number of public-targeted prevention materials. To access these materials and more information on healthy swimming, visit our Website. Thanks for tuning in.

Recurrence Risk for Children With First Seizures

Redefining Outcome of First Seizures by Acute Illness

Martin ET, Kerin T, Christakis DA, et al
Pediatrics 2010;126:e1477-1484

Study Summary

Although pediatric providers are familiar with febrile seizures and the generally benign recurrence prognosis they convey, it is less clear what prognosis to offer parents of children with nonfebrile first seizures.
Despite a general sense that nonfebrile first seizures associated with illnesses (eg, afebrile gastroenteritis) have a benign prognosis relative to unprovoked seizures, few sources of data support this belief.

Martin and coworkers enrolled children with a first seizure who presented to a single large, urban, pediatric emergency department. Children were 6 months to 6 years old, had experienced a witnessed event, and were without any of the following potential causes of seizure: trauma, central nervous system infection, toxic ingestion, hypoxia, pseudo-seizures, tumors, or any neurodevelopmental condition that was associated with seizures. The data were collected from 2005 to 2008.
Children were grouped as follows: febrile seizures, nonfebrile illness seizures, and unprovoked seizures (neither illness symptoms nor fever were present). The investigators also collected demographic, health history, developmental, and clinical information from the children's families.
For the children with nonfebrile illness seizures, the investigators grouped them further into gastrointestinal (GI) and nongastrointestinal categories for analyses. Stool and serum samples were obtained from children to identify etiologies of their illnesses. Children were then followed monthly after the index seizure to discern recurrence.
The study enrolled 117 children; 67% had experienced a febrile seizure, 29% a nonfebrile illness seizure, and 4% an unprovoked seizure (5 children). While the mean age of the children was 24 months, this was heavily influenced by whether the seizure was febrile or afebrile, and the mean age of the group with first unprovoked seizure was 54 months.
In bivariate comparisons, children with nonfebrile illness seizures were much more likely to experience a repeat seizure within 24 hours than were the other 2 groups (59% in nonfebrile vs 28% in febrile and 20% in unprovoked seizures). When comparing outcomes by type of illness, children with GI illnesses (compared with non-GI illnesses) had higher rates of recurrent seizures in the first 24 hours (58% vs 27%, P < .001), but they had a lower risk for subsequent seizures after the first 24 hours. Subsequent nonfebrile seizures were most common among children with an unprovoked first seizures (40%), followed by children with nonfebrile illness seizures (14%), with none occurring in children who initially presented with febrile seizures. The investigators concluded that children whose first seizure was associated with a nonfebrile illness have a prognosis similar to those who experience febrile seizures and that GI illnesses in particular appear associated with a very low risk for recurrence.


Martin and colleagues comment that GI illness-associated seizures really do seem to be a different type, and emphasize that 58% of the children with GI illness did not have fever or electrolyte disturbances that accounted for their seizure.
It is reassuring to have a defined group of children with nonfebrile first seizures whose prognosis seems to be more similar to the prognosis of those with febrile rather than unprovoked seizures, so those data have important clinical value.
The investigators emphasize the need for careful reconstruction of the medical history in the week before the seizure to identify potential GI symptoms to ensure that cases associated with GI illness are not missed.

Redefining outcome of first seizures by acute illness.

Pediatrics.  2010; 126(6):e1477-84 (ISSN: 1098-4275)

Martin ET; Kerin T; Christakis DA; Blume HK; Gospe SM; Vinje J; Bowen MD; Gentsch J; Zerr DM
Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA.

Seizures are common in children, but the causes and recurrence risk for children with a nonfebrile first seizure remain poorly understood.
In a prospective longitudinal study of children who presented with a first-time seizure, we investigated the viral etiology of associated infectious illnesses and sought to determine the risk of recurrent seizures stratified by fever and type of illness.
Children (aged 6 months to 6 years) were enrolled at the time of evaluation for their first seizure and followed monthly for up to 5 years. Seizure and illness data were collected through parent interviews and medical-record reviews. Stool, serum, and cerebrospinal fluid collected within 48 hours of the first seizure were evaluated for viral gastrointestinal pathogens.
Of the 117 children enrolled, 78 (67%) had febrile seizures, 34 (29%) had nonfebrile-illness seizures, and 5 (4%) had unprovoked seizures.
Children with nonfebrile-illness seizures were more likely than those with febrile seizures to have acute gastroenteritis (47% and 28%, respectively; P = .05).
No significant differences in seizure recurrence were found between children with or without a fever at first seizure.
Children with acute gastroenteritis at first seizure, regardless of fever, had a lower risk of seizure recurrence compared with children with other acute illnesses (hazard ratio: 0.28; 95% confidence interval: 0.09-0.80).
Our results confirm the role of gastrointestinal illness as a distinguishing feature in childhood seizures.
Children with this distinct presentation have a low rate of seizure recurrence and few neurologic complications.

Risk for Acute Bacterial Meningitis in Children with Complex Febrile Seizure

From Journal Watch > Journal Watch Pediatrics and Adolescent Medicine

Howard Bauchner, MD, and Katherine Bakes, MD
Posted: 09/01/2010;

Abstract and Introduction

Bacterial meningitis is uncommon in children who present with a first complex febrile seizure.


In a retrospective chart review, researchers examined the rate of acute bacterial meningitis (ABM) in 526 otherwise healthy children (age range, 6–60 months) who presented with their first complex febrile seizure (focal seizures, duration >15 minutes, multiple seizures within 24 hours) to a tertiary care pediatric emergency department in Boston between 1995 and 2008.
A total of 156 children (29%) were pretreated with antibiotics. Of 340 patients (65%) who underwent lumbar puncture (LP), 14 (2.7%) had cerebrospinal fluid (CSF) pleocytosis (white blood cell count >7 cells/┬ÁL). Three patients (0.9%) were diagnosed with ABM; two had Streptococcus pneumoniae in CSF culture and one, in whom LP was not successful, had S. pneumoniae in blood culture. One patient with ABM was nonresponsive at presentation, another had a bulging fontanelle and nuchal rigidity, and the third patient had two brief generalized seizures within 24 hours. Two patients with ABM presented before the introduction of the conjugate pneumococcal vaccine. Among the 161 (of 186) children who did not undergo LP and returned for follow-up, none had ABM.


Bacterial meningitis is uncommon in otherwise healthy children with a first complex febrile seizure.
The authors concluded that "LP should be performed on the basis of clinical suspicion and additional signs and symptoms that are suggestive of meningitis." However, they do not provide specific suggestions about when to perform LP.
The prevalence of acute bacterial meningitis in children who present with a first complex febrile seizure and no other signs and symptoms of meningitis is low.
Thus, physicians could consider forgoing LP — after a period of observation — in well-appearing children without overt signs of meningitis whose neurological status returns to baseline.

AAP Practice Guideline Stresses Cause in Children With Febrile Seizure

From Medscape Medical News

Nancy Fowler

February 2, 2010 — Physicians examining infants and young children after simple febrile seizure should contemplate meningitis as a possible cause of fever, according to new American Academy of Pediatrics (AAP) practice guidelines published online January 31 in Pediatrics.

"Meningitis should be considered in the differential diagnosis for any febrile child, and lumbar puncture should be performed if there are clinical signs or symptoms of concern," write Patricia K. Duffner, MD, of the AAP's Subcommittee on Febrile Seizures, 2002-2010, and colleagues.

Febrile seizure occurs in 2% to 5% of all children ages 6 to 60 months.
It is characterized by a fever, or a body temperature of at least 100.4°F or 38°C, taken by any method, in children with no central nervous system infection.
Complex febrile seizure is focal (affecting only specific parts of the body), lasts 15 minutes or longer, and/or recurs within 24 hours.
Simple febrile seizure is generalized, lasts for less than 15 minutes, and does not return within 24 hours
In 1980, the National Institutes of Health designated simple febrile seizure as a benign event, with excellent patient prognosis.

The new guidelines, which replace 1996 practice standards, pertain to patients presenting within 12 hours of simple febrile seizure.
They are not intended for children who have experienced complex febrile seizure or those with prior neurologic insults, abnormalities of the central nervous system, or a history of seizures not related to fever.
Signs and symptoms of meningitis include stiff neck, Kernig's sign (lower back or posterior thigh pain during knee extension while the patient's hip is flexed and he or she is lying supine), and Brudzinski's sign (knee and hip flexion with flexed neck while in supine position).
Lumbar puncture, also known as spinal tap, is used to diagnose meningitis. It involves the removal and examination of cerebrospinal fluid that surrounds the brain and spinal cord.
Updated Guidelines Stem From Comprehensive Review
Before issuing the new guidelines, AAP investigators examined evidence-based literature made available from 1996 to February 2009. They gave preference to population-based studies. However, a dearth of such research necessitated inclusion of information from hospital-based studies and data gathered from various groups of young children with febrile and other illnesses.
The researchers reviewed 372 articles, 169 more than were evaluated for the 1996 guidelines. Key action statements resulting from their investigation, and all pertaining to children presenting with simple febrile seizure, are as follows:
  • Children with meningeal signs, or young patients with a suggestion or history of meningitis or intracranial infection, should undergo lumbar puncture, without exception.
  • Any infant between the ages of 6 and 12 months should have lumbar puncture as an option when Haemophilus influenzae type b or Streptococcus pneumoniae immunizations are not current, or are not known.
  • A child who has been pretreated with antibiotics should have lumbar puncture as an option because antibiotics can mask meningitis.
  • In neurologically healthy children, an electroencephalogram (EEG) should never be performed.
  • In the quest to identify simple febrile seizure cause, diagnosticians should not perform the following tests: serum electrolytes, calcium, phosphorus, magnesium, or blood glucose measurements; or complete blood cell count.
  • Routine evaluation of children with simple febrile seizure should not include neuroimaging.
"In general, a simple febrile seizure does not usually require further evaluation, specifically EEGs, blood studies, or neuroimaging," the authors of the guideline write.
Regarding parental input on the performance of lumbar puncture, the researchers acknowledge that the procedure is invasive, often painful, and frequently costly.
However, they point out that observational data and clinical principles are the foundation of their guidelines and that in the instances that they recommend lumbar puncture, the benefits outweigh possible harm.
"Although parents may not wish to have their child undergo a lumbar puncture, health care providers should explain that if meningitis is not diagnosed and treated, it could be fatal," the guideline authors write.
The guideline authors have disclosed no relevant financial relationships.
Pediatrics. Published online January 31, 2011. Abstract

Monday, July 25, 2011

EU Recommends Restricted Use of GSK's Flu Shot

From Reuters Health Information

LONDON (Reuters Health) Jul 21 - European regulators have recommended restricting the use of GlaxoSmithKline's pandemic flu vaccine Pandemrix because of a potential risk of narcolepsy in children or adolescents.
The European Medicines Agency said on Thursday that Pandemrix should only be used in people under 20 years in the absence of seasonal trivalent influenza vaccines, following its link to very rare cases of narcolepsy in young people.
Overall, the vaccine's benefit-risk balance remains positive, the watchdog added.
More than 31 million doses of Pandemrix have been given to people in 47 countries, and GSK said it had been notified of 335 cases of narcolepsy in those vaccinated as of July 6. Two-thirds of the narcolepsy cases were in Finland and Sweden.
Britain's biggest drugmaker said in a statement it had committed to conduct further research into any potential association between Pandemrix and narcolepsy.
Pandemrix was widely used during the 2009-10 outbreak of H1N1 swine flu, although it was not administered in the United States.
Several other drugmakers, including Novartis , Sanofi , CSL and Baxter also made vaccines against H1N1 flu during the pandemic, which was declared over in August last year.
Finnish and Swedish researchers were the first to raise concerns over a possible narcolepsy link to Pandemrix last August after noting cases in children recently given the GSK shot.
One research team earlier this year suggested children given Pandemrix were nine times more likely to suffer from the condition.
Researchers at Finland's National Institute for Health and Welfare said the increase they found in narcolepsy was "most likely" a joint effect of Pandemrix and some other factor or factors.

Limited Conclusive Data Exist on Perinatal Risk Factors for Autism

From Medscape Education Clinical Briefs

News Author: Deborah Brauser
CME Author: Laurie Barclay, MD

Clinical Context

The cause of autism is not specifically identified and may be multifactorial.
Although the neuropathologic mechanism is nonspecific, studies have shown macroscopic, microscopic, and functional brain abnormalities.
For the past 4 decades, epidemiologic research on risk factors for autism has focused on perinatal and neonatal exposures.
Obstetric and neonatal complications have possibly been linked to autism risk, but specific complications associated with increased risk have not been identified, and the magnitude of effect has been inconsistent across studies. The goal of the study by Gardener and colleagues was to review studies of perinatal and neonatal risk factors for autism and to conduct a meta-analysis as appropriate.

Study Synopsis and Perspective

There is scant conclusive evidence of specific perinatal or neonatal risk factors for autism, according to a new meta-analysis of 40 studies.
The investigators write that although several of the 60 factors evaluated (including abnormal fetus presentation at birth, umbilical cord complications, and low birth weight) were linked to autism risk, "there is insufficient evidence to implicate any 1 factor in autism etiology."
However, the findings suggest that a combination of multiple neonatal complications may indeed increase the risk for autism development.
"Autism has no known cure and can have devastating effects on families, which really underscores the importance of trying to discover risk factors, in particular those that are modifiable and that we may be able to lessen with improved prenatal care, for example," lead author Hannah Gardener, ScD, epidemiologist at the University of Miami, Florida, told Medscape Medical News.

"We did find several significant factors, but whether those are causal or simply markers associated with an increased risk is not perfectly understood," added Dr. Gardener, who was at the Harvard School of Public Health in Boston, Massachusetts, at the time of the study.
She noted that prenatal monitoring is important not only for decreasing risk for autism but for also ensuring the health of the fetus and neonate in many health respects.
"Overall, I think the message to the general public is that it's important to realize that the vast majority of children who experience these complications will not end up having autism. Although we may have found several risk factors, it doesn't mean that a child with any of them is definitely going to have the disorder,"
"The risk is still very low. Each of the factors only increased the risk incrementally, so women should not be overly concerned."
The study was published online July 11 in Pediatrics.
Assessing Specific Complications
"Although many studies support the hypothesis that obstetrical and neonatal complications may increase the risk of autism, the specific complications, magnitude of effect, and overall conclusions of these studies have been inconsistent," write the researchers.
"A lot of these results were inconclusive or contradictory. There were also several limitations to these individual studies, including relatively small sample sizes. Even large studies may not get that many autism cases and so you may miss associations that are there," said Dr. Gardener.
She noted that another problem with examining just 1 study is that an association may be detected "that isn't really there" and is instead due to chance or to "the randomness of nature."
Because of these limitations, the investigators decided to evaluate data from all studies conducted through March 2007 that looked at the association between autism and prenatal, perinatal, and neonatal factors.
The investigators reported their findings on exposures during pregnancy in 2009 (Br J Psychiatry. 2009:195:7-14).

The results from that analysis showed that advanced parental age, maternal medication use, bleeding, gestational diabetes, and having a mother born abroad were the strongest risk factors for the disorder. However, no association was found with previous fetal loss, proteinuria, or maternal hypertension.
For this meta-analysis, they concentrated on 40 studies that examined more than 60 perinatal and neonatal risk factors.
More Research Needed
Results showed that the following were all associated with a significantly increased autism risk:
  • Fetal distress;
  • Birth injury or trauma;
  • Multiple births;
  • Maternal hemorrhaging during labor and delivery;
  • Summer birth;
  • Small for gestational age;
  • Congenital malformation;
  • Low Apgar score;
  • Feeding difficulties;
  • Meconium aspiration; and
  • Neonatal anemia or jaundice.
Factors found not to be significantly associated with autism risk included:
  • Anesthesia use;
  • Assisted vaginal delivery;
  • Post-term birth;
  • High birth weight; and
  • Head circumference.
"The complications identified in the current analysis may be the result of previous prenatal complications and/or may operate in combination with prior prenatal complications to impact autism risk," write the researchers.
"Additional research that considers the joint and independent effects of adverse conditions during these various time periods is required to address these possibilities."
They add that the risk factor associations may also affect only those who are genetically vulnerable.
"However, the correlated occurrence of many of these complications limits the ability to determine which, if any, are independently associated with the disorder."
Dr. Gardener, who called the meta-analysis "important," hopes that it will motivate further studies.
"However, I also hope it doesn't cause a woman to worry that, for example, if she's due to give birth in July that the child will definitely be born with autism. That is absolutely not true. A lot of these risk factors are very common so I hope there isn't undue concern over them."

Pediatrics. Published online July 11, 2011.

Younger Children More Responsive to Amblyopia Treatment

From Medscape Education Clinical Briefs

News Author: Laurie Barclay, MD
CME Author: Hien T. Nghiem, MD
Arch Ophthalmol. 2011;129:960-962.

Study Highlights

  • A meta-analysis of data of 996 children from 4 recently completed randomized amblyopia treatment trials was performed to evaluate the relationship between age and improvement in logMAR amblyopic eye visual acuity.
  • Strabismus, anisometropia, or both caused the amblyopia.
  • The protocols were (1) patching 2 hours per day with near or distance activities for children ages 3 years to younger than 7 years; (2) treatment with atropine with or without a plano lens for children ages 3 years to younger than 7 years; (3) treatment with atropine or patching 2 hours per day for children ages 7 years to younger than 13 years; and (4) use of a Bangerter filter or patching 2 hours per day for children ages 3 years to younger than 10 years.
  • The 4 trials were not designed to determine the maximal treatment effect.
  • Primary outcome was assessed at 17 to 24 weeks after enrollment.
  • Analyses were adjusted for baseline amblyopic eye visual acuity, spherical equivalent refractive error in the amblyopic eye, type of amblyopia, prior amblyopia treatment, study treatment, and protocol.
  • Age was categorized (3 to < 5 years, 5 to < 7 years, and 7 to < 13 years) because there was a nonlinear relationship between age and improvement in amblyopic eye visual acuity.
  • Results demonstrated that children ages 7 years to younger than 13 years were significantly less responsive to treatment than were younger age groups (children 3 to < 5 years old or children 5 to < 7 years old) for moderate and severe amblyopia (P < .04 for all 4 comparisons).
  • There was an association between greater improvement in amblyopic eye visual acuity and a less hyperopic amblyopic eye spherical equivalent (P = .002).
  • There was significant interaction between age group and prior amblyopia treatment (P = .02), indicating less improvement in amblyopic eye visual acuity with a history of amblyopia treatment than without in children ages 3 years to younger than 5 years (P = .02).
  • There was no association between amblyopic visual acuity improvement with amblyopia type (P = .20), amblyopia study treatment (P = .14), and protocol (P = .28).
  • There was no difference in treatment response between children 3 years old to younger than 5 years and children 5 years old to younger than 7 years for moderate amblyopia (P = .67), but there was a suggestion of greater responsiveness in children 3 years old to younger than 5 years vs children 5 years old to younger than 7 years for severe amblyopia (P = .09).

Clinical Implications

  • Possible reasons for a reduced response to amblyopia treatment in older children are there may be declining plasticity of the central nervous system as children age and poorer compliance when older children are treated.
  • There was improvement in visual acuity across all ages in the treatment of amblyopia; however, amblyopia is more responsive to treatment among children younger than 7 years.

CME Test

To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.
A 3-year-old girl presents to your office after being seen by an ophthalmologist. Her mother reports that the patient was diagnosed with amblyopia and will be undergoing treatment. The mother is very concerned that treatment will not be effective because her eldest daughter was diagnosed with amblyopia at age 9 years and has permanent vision loss in the right eye. You explain to her that possible mechanisms that may have led to a poorer response in her eldest daughter include:
Cause from strabismus
Lack of compliance with treatment
Declining plasticity of the central nervous system as children age
Both A and C
Both B and C
According to this study by Holmes and colleague, a child with severe amblyopia may have greater response if treated between which age ranges?
Younger than 3 years
Ages 3 years to younger than 5 years
Ages 5 years to younger than 7 years
Ages 7 years to younger than 9 years

Standardized Management Plan Improves Pediatric Chest Pain Outcomes

From Medscape Education Clinical Briefs

News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD
Pediatrics. Published online July 11, 2011.

Study Highlights

  • The investigators reviewed records for 406 children aged 7 to 21 years seen at a pediatric cardiology outpatient division for chest pain.
  • Diagnosis of chest pain was identified by the International Classification of Diseases, Ninth Revision, billing codes.
  • Exclusion criteria were a history of heart disease or previous evaluation by a pediatric cardiologist.
  • 461 cardiology clinic visits occurred.
  • All patients underwent ECG; 457 ECGs were performed.
  • 175 (43%) underwent echocardiograms.
  • 114 (28%) had an exercise stress test (EST).
  • 40 (10%) had event monitors, and 30 (7%) had Holter monitors.
  • 7 (2%) underwent a cardiac magnetic resonance imaging study.
  • 4 (1%) had a positive history of medical conditions, including systemic lupus erythematosus, juvenile rheumatoid arthritis, carnitine deficiency, and congenital adrenal insufficiency.
  • 4 (1%) had a positive family history of heart disease, including sudden death, cardiac arrest, resuscitated cardiac arrest, and hypertrophic cardiomyopathy in a first-degree relative.
  • 16 (4%) had positive cardiac findings on physical examination, including pathologic murmur, systolic click, friction rub, gallop, and abnormal second heart sound.
  • 25 (6%) had abnormal ECG findings, including increased left ventricular forces, pathologic ST-segment or T-wave abnormalities, axis deviation, frequent premature ventricular contractions, and Wolff-Parkinson-White syndrome.
  • 150 (37%) had exertional chest pain combined with dyspnea in 46 and with dizziness or lightheadedness in 21.
  • 66 (16%) had palpitations.
  • 44 (11%) had positive findings on initial evaluation of medical history, family history, physical examination, or ECG.
  • Cardiac cause was noted in 5 patients (1%): 2 children had pericarditis, 2 had supraventricular tachycardia, and 1 had nonsustained ventricular tachycardia.
  • Noncardiac chest pain diagnoses included musculoskeletal pain, costochondritis, or respiratory or asthma-related conditions.
  • Fewer echocardiograms were ordered by cardiologists with more than 5 years' experience or by cardiologists with higher volumes of annual clinic visits.
  • The number of ESTs was not associated with cardiologists' experience or clinic volume.
  • An algorithm was used to reassess the testing and costs for each patient and included the following:
    • Initial evaluation consisting of medical history, family history, physical examination, and ECG
    • Echocardiogram if any initial evaluation result was abnormal or if normal result on initial evaluation, but chest pain at high level of exertion without alternate explanation
    • No echocardiogram if negative result on initial evaluation plus nonexertional chest pain, plus exertional chest pain and alternative diagnosis suspected, or plus chest pain at low level of exertion without alternate explanation
    • No EST performed
  • The algorithm would decrease use of echocardiography, Holter monitors, and event monitors by approximately 20%, eliminate EST use, and reduce the cost of cardiac evaluation by 21%.
  • Use of a rhythm monitor would be proposed for patients with palpitations and chest pain.
  • Study limitations included use of clinic notes to assess symptoms, history, and examination; retrospective design; possible missed cardiac diagnoses; lack of data on events outside of the study institution; and cost analysis based on 100% compliance with the algorithm.

Clinical Implications

  • In children and adolescents evaluated by a cardiologist for chest pain, 1.2% of chest pain has a cardiac cause, including pericarditis and arrhythmias.
  • In children and adolescents with chest pain, an algorithm that uses pertinent medical or family history, physical examination, and ECG findings to determine additional testing and eliminates EST results in an approximately 20% reduction in echocardiogram and outpatient rhythm monitor use and a 21% reduction in costs.

Friday, July 22, 2011

Many Parents Underestimate Kids' Asthma Symptoms

From Reuters Health Information

By Eric Schultz
NEW YORK (Reuters Health) Jul 13 - Parents of kids with asthma don't always realize when their children's treatment is inadequate, a new drugmaker-funded survey suggests.
While more than 70% of parents interviewed described their child's asthma as "mild" or "intermittent," the disease was adequately treated in only 60% of the kids.
Based on stricter guidelines, the proportion of kids with well controlled symptoms dropped below 20%, according to the new results, published June 23rd in the European Respiratory Journal.
"Parents are only aware of asthma when the child is more severely ill," Dr. Gordon Bloomberg, who was not involved in the study, told Reuters Health.
"Physicians cannot just ask the parent 'how is your child doing?' The physician will get a global answer that doesn't reflect the child's quality of life," said Dr. Bloomberg, of Washington University in St. Louis.
In the survey, more than 40% of parents reported missing work because of their child's asthma, and a similar proportion regularly lost sleep for the same reason.
The research was funded by Nycomed, a Swiss company that makes asthma medications and also helped write the new report.
For the survey, researchers interviewed 1,284 families in Canada, Greece, Hungary, The Netherlands, South Africa, and the UK using a common 25-point questionnaire called the Childhood-Asthma Control Test (C-ACT).
Then they interviewed the children and compared their answers to those of their parents.
One in four children whose parents described their asthma as "mild" or "intermittent" had poorly controlled asthma, defined as a score of 19 or lower on the test.
Using stricter asthma control guidelines, the number of kids whose disease was poorly controlled increased, report Dr. William Carroll of Derbyshire Children's Hospital in Derby, UK, and colleagues.
The study also found children tended to be better than their parents at determining how well their asthma was being treated.
According to Dr. Gregory Sawicki, an asthma expert who wasn't involved in the study, parents need more education about their child's airway problems.
Doctors should "take each opportunity at each visit to assess control, and understand what the parent's perception is...if there is a disconnect, use it as an educational opportunity," Dr. Sawicki, of Children's Hospital Boston, told Reuters Health.
Both Dr. Sawicki and Dr. Bloomberg agreed that kids with asthma should see a physician at least three times a year, to monitor their symptoms and ensure that they and their parents know how to keep symptoms under control.
Dr. Carroll and his colleagues also found kids whose parents worry about medication side effects are more likely to have poorly controlled asthma. They say this suggests parents need more education about asthma medications.
But one expert said more medication is not the be-all and end-all for children. "The idea of total not where we should be putting our energy," Dr. Barbara Yawn from Olmstead Medical Center in Rochester, Minnesota, told Reuters Health in an email.
Instead of just giving children with stubborn breathing problems more medication, she said better communication is needed to determine how children's lives are affected, and what it will take to prevent their symptoms.
Eur Resp J 2011.

Release of Tongue-Tie in Neonates Immediately Improves Breastfeeding

From Reuters Health Information

NEW YORK (Reuters Health) Jul 20 - Frenotomy in newborns with significant ankyloglossia rapidly improves breastfeeding scores and reduces maternal nipple pain, according to the results of a small randomized trial.
The authors say their findings "should now provide compelling evidence for pediatricians, otolaryngologists, oral surgeons, and lactation consultants to seek frenotomy when indicated."
Dr. Melissa Buryk and colleagues at the Naval Medical Center in Portsmouth, Virginia, point out that release of the lingual frenulum is often performed in infants with ankyloglossia who have difficulty breastfeeding, but the practice is controversial and there's been a lack of supporting data.
To investigate, the team enrolled significantly ankyloglossic neonates, whose mothers reported breastfeeding problems or nipple pain, in a randomized study. At a mean age of 6 days, 30 infants had a simple frenotomy and 28 had a sham procedure in which nothing was done, without the mothers being present or made aware of which group their child was in.
Frenotomy produced an immediate improvement in nipple pain and breastfeeding scores, the investigators found. The results are reported in the August issue of Pediatrics.
At 2 weeks' follow-up, maternal nipple pain as measured on the Short-Form McGill Pain Questionnaire (SF-MPQ) had dropped in both groups from pre-intervention levels, but more so in the frenotomy group (p<0.001). Specifically, the score declined from 16.77 to 4.9 and from 19.25 to 13.5 in the frenotomy and sham groups, respectively.
Breastfeeding scores measured by the Infant Breastfeeding Assessment Tool (IBFAT) hardly changed in the sham procedure group, but improved from 9.3 to 11.6 in the frenotomy group, according to the report.
Infants in the sham group were given a frenotomy at or before 2 weeks if the parents wished, and all but one opted to do so. Therefore further comparison between groups was no longer possible, the authors note.
"As in previous studies, we found the procedure to be rapid, simple, and without complications," Dr. Buryk and colleagues comment.
"Additional studies should be done to determine the optimal timing of frenotomy and the ideal screening tool to detect significant ankyloglossia," they suggest.
Pediatrics 2011.

Febrile Urinary Tract Infections in Children

From Medscape Medical News

Laurie Barclay, MD

July 20, 2011 — The management of febrile urinary tract infections in children is changing, according to the results of a clinical review published in the July 21 issue of the New England Journal of Medicine.

"Acute pyelonephritis is the most common serious bacterial infection in childhood; many affected children, particularly infants, have severe symptoms," write Giovanni Montini, MD, from the Department of Pediatrics, Azienda Ospedaliero–Universitaria Sant'Orsola-Malpighi in Bologna, Italy, and colleagues.
"Most cases are readily treated, provided diagnosis is prompt, though in some children fever may take several days to abate.
Approximately 7 to 8% of girls and 2% of boys have a urinary tract infection during the first 8 years of life."

In boys as well as girls, febrile urinary tract infections occur most often during the first year of life, unlike nonfebrile urinary tract infections, which occur mostly in girls older than 3 years.
After infancy, urinary tract infections involving only the bladder usually present with localized symptoms and are easily treated.
When fever accompanies urinary infection, risk is greater for kidney involvement, and underlying nephrourologic abnormalities are more common, resulting in a higher risk for renal scarring and associated substantial long-term morbidity.
The sensitivity of fever to predict renal involvement is 53% to 84%, and specificity is 44% to 92%.

Management approaches for children with proven kidney infections have involved intensive workup and treatment, often including surgery and/or long-term antibiotic prophylaxis.
Because experts have questioned the need for such strategies, various recent or ongoing trials are investigating optimal strategies for the evaluation and treatment of a first febrile urinary tract infection, as well as the best options for subsequent interventions.
In most children, oral and intravenous antibiotics appear to be equally effective in treating febrile urinary tract infections.
Current recommendations of the American Academy of Pediatrics are that parenteral antibiotic therapy and hospitalization be considered for children who appear to be severely ill or dehydrated, or who cannot retain oral intake.
Although antibiotic choice depends on resistance patterns in a given institution or region, cephalosporins and amoxicillin–clavulanic acid are the oral antibiotics most often used, and cephalosporins and aminoglycosides are often recommended for intravenous treatment.
Thanks to advances in prenatal ultrasonography, it is now known that significant renal damage in children is often associated with the presence of hypodysplasia and other urologic abnormalities.
In some children, renal scarring associated with infection results in additional damage to dysplastic kidneys or late effects in kidneys that previously were normal.
"The value of antibiotic prophylaxis has been questioned in recent studies," the review authors write. "Further data are needed to determine which children might benefit from antibiotic prophylaxis. Studies in progress may help to answer these questions."

N Engl J Med. 2011;365:239-250.

Thursday, July 21, 2011

Childhood Obesity is Not Child Abuse

rebecca puhl, Other, 01:54PM Jul 13, 2011

This week, JAMA published a commentary (authored by Lindsey Murtagh and David Ludwig), discussing extreme cases of childhood obesity where state intervention (e.g., child protection services) may be warranted. While the authors wrote that state intervention would not be desirable or ethical for many obese children and that removal from the home does not guarantee improved physical health, they propose that “involvement of state protective services might be considered, including placement into foster care in carefully selected situations”. 

Perhaps not surprisingly, there has been significant media attention to this article. 

This editorial raises a very complex and difficult issue that must be handled sensitively and without unfair bias. We cannot assume that childhood obesity is child abuse, and we need to ensure that the pervasive stigma that exists toward obese individuals does not color the judgments of authority figures who are making decisions about obese children and their families.

Unless there is clear evidence that parents are truly incapable of caring for their child, a child should not be removed from their family on the basis of obesity alone. In making decisions about these families, the same legal standards that are used for parental neglect or abuse in other circumstances (unrelated to body weight) should be used, to ensure that the focus is appropriately on the parents capability of caring for their children – not on the child’s weight per se.

Obesity may indeed be a sign of medical risk, but we need to be careful in our understanding of what role the home environment plays, versus the larger societal environment, the economics of food, and other major societal conditions that have created obesity.

I believe that the intentions of the JAMA article were to discuss how to approach extreme cases of obesity where parental abuse and neglect may be suspected, and the authors were not suggesting that all obese children should be removed from their families. Unfortunately, the media headlines surrounding this story suggest otherwise. Of course, the issue remains very complex even if we limit the discussion to extreme, unlikely cases. 

If anything, this editorial and the resulting media response indicate the need to find effective ways to support parents in their efforts to help their children become healthier. This means we need to make it a priority to change the societal conditions that have created obesity in the first place, such as the fast food industry, widespread marketing practices that target children and families with unhealthy foods, and the economics and pricing of food which make healthier foods more expensive, and unhealthy foods cheap and readily accessible. 

There simply is no magic pill to cure obesity – regardless of whether a child is with or without their parents. We cannot ignore the complexity of this issue, and we must ensure that stigmatization does not play a role in determining the fate of families who are affected by extreme obesity.

Rebecca Puhl, PhD is the Director of Research at the Rudd Center for Food Policy and Obesity at Yale University.

Are Sports Drinks Okay for Kids?

From Medscape Orthopaedics > Viewpoints

Joseph K. Lee, MD

Clinical Report: Sports Drinks and Energy Drinks for Children and Adolescents: Are They Appropriate?

Committee on Nutrition and the Council on Sports Medicine and Fitness
Pediatrics. 2011;127:1182-1189


Sports drinks and energy drinks are now popular beverages in the United States, particularly among children and adolescents. Kids consume sports and energy drinks as a way to stay hydrated during athletics or other activities. However, careful consideration is necessary when selecting a beverage to hydrate before, during, or after exercise to prevent excessive sugar and caloric intake that may encourage dental erosion and obesity.
The Committee on Nutrition and The Council on Sports Medicine and Fitness from the American Academy of Pediatrics (AAP) reviewed literature from 2000-2009 regarding the use of such drinks in the child and adolescent populations and recommended the following:
  • Consumption of sports and energy drinks is not advocated in children and adolescents unless they are participating in prolonged and strenuous physical activities.
  • Instead of sports and energy drinks, increased fluid intake before, during, and after exercise to prevent dehydration with regular water should be recommended.
  • Children and adolescents should avoid exposure to excess sugar, caffeine, carbohydrates, and other stimulants that are contained in many of these drinks due to the potential for a number of deleterious health effects.


The AAP promotes education and counseling of patients, parents, schools, and coaches about fluid intake for children and adolescents. The AAP also continues to advocate the use of water over sports and energy drinks for hydration purposes.
Poor dietary habits have contributed to increased obesity rates in children and adolescents in recent years, and the intake of excess carbohydrates without an appropriate sustained increase in activity level is not recommended given the main requirement of hydration.

Thursday, July 14, 2011

Secondhand Smoke Boosts Neurobehavioral Problems in Kids

From Medscape Medical News > Psychiatry

Fran Lowry

July 13, 2011 — Secondhand smoke exposure in the home is associated with an increased risk for neurobehavioral disorders among children younger than 12 years of age, according to new research.
Zubair Kabir, MD, PhD, from the Tobacco Free Research Institute, Dublin, Ireland, and colleagues reported their findings online July 11 in Pediatrics.

"The results from this study show yet another reason not to smoke around your children," senior author Hillel Alpert, ScM, from Harvard School of Public Health, Boston, Massachusetts, told Medscape Medical News.
"We previously reported the association with otitis media.
A whole range of childhood diseases have been associated with second-hand smoke exposure and smoking in the home, including those reported in Surgeon General reports, so a smoke-free home has major protective advantages against childhood diseases," Dr. Alpert said.
Respiratory problems, an increased risk for sudden infant death syndrome, acute respiratory infections, and more frequent and more severe asthma attacks have been reported in children exposed to secondhand smoke. Yet, write the researchers, in 2007, about 5.5 million of US children lived in households where someone smoked inside the home.

To examine common pediatric neurobehavioral disorders, including attention-deficit/hyperactivity disorder, learning disabilities, and conduct disorders, in children exposed to secondhand smoke in the home, the investigators accessed the National Survey of Children’s Health conducted between April 2007 and July 2008 and analyzed 55,358 children younger than 12 years of age.
The survey asked parents, in English, Spanish, or an Asian language, about diagnoses their children had received and about smoking practices in the household.
The study found that 6% of the children younger than 12 years were exposed to secondhand smoke in the home. "This 6% corresponds to a weighted total of 4.8 million children across the United States," Dr. Alpert commented.
Of these children, 8.2% had learning disabilities, 5.9% had attention-deficit/hyperactivity disorder, and 3.6% had behavioral and conduct disorders.
The odds of a child having 2 or more of these conditions in a household where people were smoking was 50% greater than in households where there was no smoking.
Boys had a significantly higher risk, and older children aged 9 to 11 years and those living in households with the highest poverty levels were at greater risk.
The researchers estimate that 274,000 cases of neurobehavioral disorders might have been prevented, had those households been smoke-free.
"Secondhand smoke is not the only causative factor of neurobehavioral disease in children," Dr. Alpert said. "However, our analysis was able to control statistically for a wide range of other demographic factors, including poverty, pertaining to the children as well as the parents and the type of household."
He added that it is important to highlight that these neurobehavioral disorders are very preventable. "Many of these conditions might be unnecessary if households were smoke-free."
Invited to comment on this study by Medscape Medical News, Karen Wilson, MD, MPH, from the University of Rochester Medical Center, Rochester, New York, said that it confirms what has already been seen in other studies.

"Secondhand smoke is associated with impaired cognitive abilities and neurobiological problems in children, in addition to the expected increase in respiratory diseases," Dr. Wilson, whose research focuses on secondhand smoke exposure among children, said.
"The study underscores the importance of protecting all children against any secondhand smoke exposure," she said.
Pediatrics. Published online July 11, 2011.

Do Family Physicians Take Abdominal Pain Seriously?

From Medscape Medical News

Jim Kling

July 13, 2011 — Complaints of nonspecific abdominal pain (NSAP) in children rarely prompt additional testing or referrals from family physicians, who commonly prescribe medications for the conditions despite a lack of evidence of their effectiveness, according to a study published in the July/August issue of the Annals of Family Medicine.

NSAP, defined as pain for which the physician believes there is no organic pathologic cause, is a common complaint that can lead to school absences and affect a child's well-being.
It is often a complex and time-consuming problem for specialists.

There may be psychological comorbidity or other nonspecific somatic symptoms, and the symptoms can be long-lasting. However, there is a general belief that family physicians consider NSAP to be benign and that parents and children are in need of little more than reassurance.

To better understand the discrepant view between specialists and family physicians regarding NSAP, Marieke J. Gieteling, MD, from the Department of General Practice, Erasmus MC–University Medical Center, Rotterdam, the Netherlands, and colleagues set out to evaluate the primary care view of this condition. Most studies to date on NSAP have been conducted on patients under the care of specialists. Instead, Dr. Gieteling and colleagues used data from the Second Dutch National Survey of General Practice (2001) to calculate incidence and to identify factors associated with childhood NSAP treated in primary care settings. The study focused on children between the ages of 4 and 17 years who had NSAP.

NSAP incidence was 25.0 (95% confidence interval [CI], 23.7 - 26.3) per 1000 person years.
Of children with newly diagnosed NSAP, 92.7% saw their physician once or twice.
Several factors were independently associated with NSAP: female sex (odds ratio [OR], 1.4; 95% CI, 1.3 - 1.5), nongastrointestinal-nonspecific somatic symptoms (OR, 1.3; 95% CI, 1.1 - 1.5), and a higher frequency of healthcare visits (OR, 1.04; 95% CI, 1.03 - 1.05).

The authors determined that on average, family physicians prescribe medication in 45.3% of all healthcare visits; yet, they prescribed medication (laxatives and antispasmodics being the most common) in only 21.3% of visits in which NSAP was diagnosed, which was a significantly lower rate (P < .001).
Three percent of patients with an NSAP diagnosis received referrals to a specialist, and 1% received further testing.
The researchers note that it is quite surprising that patients only visit once or twice for NSAP, because specialists report that NSAP tends to be chronic, and parents and children can be difficult to reassure. It is possible that family physicians are successfully managing NSAP by reassuring parents that there is no underlying disorder and teaching them methods to cope with the problem.
However, it is unknown whether patients who did not revisit the physician continued to experience pain and simply endured it, or were treated with alternative medicine.
The researchers call for further studies into the prognosis of NSAP in family practice settings and the effectiveness of family physician management.
The authors have disclosed no relevant financial relationships.
Ann Fam Med. 2011;9:337-343. Full text