Few Adverse Events Linked to Vaccines, IOM Panel Says

From Medscape Medical News Robert Lowes August 25, 2011 — Only a small number of adverse events are caused by or clearly linked to a group of 8 vaccines, and scientific evidence favors rejecting a causal relationship between the vaccine for measles, mumps, and rubella (MMR) and autism, according to a report issued today by an expert committee of the Institute of Medicine (IOM). "The findings should be reassuring to parents that few health problems are clearly connected to immunizations, and these effects occur relatively rarely," said committee chair Ellen Wright Clayton, MD, JD, a professor of pediatrics and law at Vanderbilt University in Nashville, Tennessee, in a press release. "And repeated study has made clear that some health problems are not caused by vaccines." Analyzing more than 1000 research articles, the IOM committee weighed epidemiological, clinical, and biological evidence for adverse events associated with the 8 vaccines. In addition to the MMR vaccine, the vaccines examined are the varicella zoster vaccine, influenza vaccines (other than the 2009 H1N1 influenza vaccine), hepatitis B vaccine, human papillomavirus (HPV) vaccine, tetanus toxoid-containing vaccines other than those containing the whole-cell pertussis component, hepatitis A vaccine, and meningococcal vaccines. All 8 vaccines are covered by the National Vaccine Injury Compensation Program, and the IOM expects that the committee findings will provide the program with scientific guidance as it adjudicates injury claims. The committee reached 158 conclusions about a cause-and-effect relationship between each of the vaccines and a plethora of adverse events. In the vast majority of cases, the group decided that the evidence is inadequate to accept or reject a causal relationship. No one should construe such a determination to mean that a vaccine is either safe or unsafe, according to the committee, which noted that it never intended to make judgments on vaccine safety per se. "Policy determining vaccine use requires a balancing of risks and benefits," the report stated. "That is outside the bounds of this committee's assignment." MMR Vaccine/Autism Review Included Retracted Article by Andrew Wakefield Three other sets of conclusions about causality offer more guidance. The group decided that the evidence "convincingly" supports a link between anaphylaxis and MMR, varicella, influenza, hepatitis B, meningococcal, and tetanus toxoid vaccines; febrile seizures and MMR vaccine (such seizures almost always have no long-term consequences); syncope and the injection of any vaccine; deltoid bursitis and the injection of any vaccine; disseminated Oka-strain varicella zoster virus, along with Oka-strain varicella zoster virus viral reactivation (both with and without other organ involvement) and varicella vaccine; and measles inclusion body encephalitis and MMR vaccine in individuals with severe immune system deficiencies. According to another set of committee conclusions with a lower certainty level, scientific evidence favors accepting a causal relationship between anaphylaxis and HPV vaccine, transient arthralgia in adult women and MMR vaccine, transient arthralgia in children and MMR vaccine, and a mild and temporary oculorespiratory syndrome and certain trivalent influenza vaccines in Canada. Conversely, the committee stated that the evidence favors rejecting a causal relationship between type 1 diabetes and MMR vaccine; type 1 diabetes and diphtheria, tetanus, and pertussis vaccine; Bell's palsy and inactivated influenza vaccine; asthma exacerbation or reactive airway disease episodes and inactivated influenza vaccine; and autism and MMR vaccine. In its deliberation on MMR vaccine and autism, the committee stated that it reviewed 22 studies for epidemiologic evidence but relied only on 5 that, unlike the others, were "reasonably valid" overall. Each of the 5 studies asserted that there is no causal relationship between the vaccine and autism. The committee also reviewed 4 articles and weighed evidence for the biological mechanisms by which MMR vaccine could possibly trigger autism. Its report noted that one of those articles, authored by the controversial Andrew Wakefield, was retracted last year by its publisher, The Lancet. Earlier this year, a series of articles and editorials in the British Medical Journal called Wakefield's article an "elaborate fraud." "The committee assesses the mechanistic evidence regarding an association between MMR vaccine and autism as lacking," the report stated.

Steroids May Alleviate Acute Pyelonephritis in Children

From Medscape Medical News Laurie Barclay, MD August 22, 2011 — Adjunctive treatment with oral methylprednisolone may lower the occurrence and/or severity of renal scarring in children hospitalized for acute pyelonephritis, according to the results of a randomized controlled trial reported online in the August 15 issue of Pediatrics. "Renal scarring after acute pyelonephritis is associated with long-term sequelae," write Ya-Yun Huang, MD, from the Department of Pediatrics, National Cheng Kung University Medical College and Hospital in Tainan, Taiwan, and colleagues. "Preventing scarring after acute pyelonephritis depends not only on early diagnosis and rapid treatment to eradicate the bacteria but also ameliorating the destructive inflammatory response." The goal of the study was to examine whether glucocorticoids could prevent formation of renal scars after a first episode of acute pyelonephritis in pediatric patients younger than 16 years at high risk for renal scar formation. Inclusion criteria were an inflammatory volume of at least 4.6 mL on technetium-99m–labeled dimercaptosuccinic acid scan (DMSA) or abnormal renal ultrasonography findings. A total of 84 participants were enrolled and were randomly selected to receive either antibiotics plus methylprednisolone sodium phosphate (1.6 mg/kg/day; n = 19) or antibiotics plus placebo (n = 65) every 6 hours for 3 days. The main study endpoint was renal scarring seen on DMSA performed 6 months after treatment. At baseline, both groups had similar patient characteristics, acute inflammatory parameters, and DMSA findings. At 6 months after treatment, 33.3% of children who received methylprednisolone had renal scarring on DMSA, as did 60.0% of those who received placebo (P < .05), with median cortical defect volumes of 0.0 mL (range, 0 - 4.5 mL) and 1.5 mL (range, 0 - 14.8 mL), respectively (P < .01). Compared with the placebo group, patients in the methylprednisolone group also had faster defervescence after treatment. "Adjunctive oral [methylprednisolone] therapy reduced the occurrence and/or severity of renal scarring after acute pyelonephritis in these hospitalized children who had a high risk of renal scar formation," the study authors write. Limitations of this study include setting in a single tertiary referral center with a pioneer and small-scale design, small numbers of patients in some of the subgroup analyses, and inconsistency of the method used to identify patients at high risk for renal scarring. "Nevertheless, the results are promising, and additional studies with larger populations should be designed to validate these effects and determine the optimum dosage of [glucocorticoids] and the age of patients most likely to benefit from them," the study authors conclude. "Adjunctive oral [methylprednisolone] with adequate antibiotics merits further consideration as a potential treatment regimen to alleviate permanent tissue injury in admitted children with serious [acute pyelonephritis]." The National Cheng Kung University Hospital (Tainan) and the National Science Council (Taipei, Taiwan) supported this study. The study authors have disclosed no relevant financial relationships. Pediatrics. Published online August 15, 2011.

Exercise & Prevention of HTN in Children & Adolescents

Obesity, Salt, Exercise and Blood Pressure in Children : Exercise & Prevention of HTN in Children & Adolescents http://www.medscape.com/viewarticle/746947_5 Regular physical activity reduces the risk of cardiovascular disease morbidity and mortality, but also lowers BP and prevents the development of HTN. In a population-based prospective cohort study over an 11-year follow-up period, the incidence of HTN was reduced by 28% in men and 35% in women who engaged in high levels of physical activity. An immediate reduction in BP occurs after an aerobic exercise session (postexcercise hypotension). Several studies using ABPM demonstrated that the BP-lowering effects of exercise are most pronounced in people with HTN who engage in endurance exercise, with 24-h daytime BP decreasing by 5–7 mmHg after an isolated exercise session (acute) or following aerobic exercise training (chronic). BP remains lower for the rest of 24-h period after each 30-min period of moderate exercise (50% of maximal O2 uptake) with greater BP reductions for vigorous exercise (75% of maximal O2 uptake). The mechanisms involved in the postexercise hypotension may involve the reduced activity of sympathetic nervous and renin–angiotensin–aldosterone systems. Brownley et al. reported that 65% of the postexercise mean BP response difference could be accounted for by changes in sympathetic factors, with change in norepinephrine and pre-ejection period elongation being the single best predictors. Restoration of balance in functions of the autonomic nervous system was proposed to serve as a possible exercise-dependent mechanism of BP reduction in obese children.Moderate-intensity aerobic exercise has also been shown to augment endothelium-dependent vasodilation in humans through the increased production of nitric oxide. Data from a subset of the 1998–2002 NHANES survey, including 3110 healthy adolescents (aged 12–19 years) and 2205 adults (aged 20–49 years), revealed that cardiorespiratory fitness, estimated by the duration of a maximal treadmill exercise test, was inversely associated with the risk of developing HTN in both adolescents and adults. Low fitness was identified in 33.6% of adolescents and 13.9% of adults. Lobelo et al. also found an excess cluster of cardiovascular risk factors including SBP in both overweight and normal weight adolescents with lowest quintile of cardiovascular fitness distribution. SBP measured during exercise at the age of 9 years predicted resting SBP 6 years later in adolescent in healthy Danish children. Decline in duration and intensity of physical activity was associated with higher SBP in 12-year-old adolescents followed longitudinally for 5 years. A decline of one session of moderate to vigorous exercise session per week each year of age was reported to result in 0.40 and 0.18 mmHg higher SBP in boys and girls, respectively, at the end of the follow-up period. Intervention studies showed that aerobic exercise training at an intensity of 70–80% of maximal fitness, 5 days per week, reduced SBP in hypertensive and obese adolescents. However, a meta-analysis of 12 randomized controlled trials by Kelley et al. reported that exercise led to small, but not statistically significant, reductions in resting BP in children and adolescents. The lack of statistical significance was attributed to the fact that the majority of the subjects were normotensive, as well as to the lack of strictly defined sedentary control group in most of the included studies. More recent data provide increasing evidence for the positive influence of regular aerobic exercise in resting and 24-h SBP in obese and hypertensive children and adolescents.Apart from the positive effects on BP and HTN rate, Meyer et al. demonstrated that regular exercise, three-times per week, 60–90 min per day, over 6 months, improved early vascular changes as measured by flow-mediated dilation and carotid intima-media thickness. In a similar study by Maggio et al. the beneficial effects on BP, BMI and arterial stiffness remained 2 years after the cessation of training in obese children, in a recently published follow-up study.The majority of the subjects maintained physical activity with further improvements of BP and arterial function. Dietary supervision should be combined with regular physical activity, aiming to control BP, reduce extra weight, improve insulin sensitivity and establish a new lifestyle for children prone to developing HTN and cardiovascular disease. Children of parents with relatively high physical activity have been reported to be 5.8-times more likely to be active themselves than children of two inactive parents The main correlates of physical activity in a group of Singaporean adolescents were self-efficacy, enjoyment of physical activity, parental support and participation in sport teams. Current recommendations for exercise in healthy children and adolescents include 30–60 min per day of moderate-to-vigorous physical activity at least three-times per week.Moderate-to-vigorous-intensity exercise equals to 5–8 metabolic equivalents. This intensity should be maintained for a long duration of time to lower BP values in children with mild essential HTN (five-times per week for 30–60 min). Ideal levels of physical activity should be calculated for each individual separately, in connection with the expected cardiovascular benefit from a greater oxygen consumption. Moreover, children should be encouraged to reduce time spent in sedentary activities, such as playing video games or watching television to less than 2 h per day.

Obesity, Salt, Exercise and Blood Pressure in Children : Dietary Salt Intake & BP in Childhood

Stella Stabouli†1,2, Sofia Papakatsika2, and Vasilios Kotsis2 http://www.medscape.com/viewarticle/746947_4 Dietary Salt Intake & BP in Childhood The International Study of Salt and Blood Pressure (INTERSALT) has provided strong evidence for the association between dietary sodium and elevated BP in adults, especially in Western societies. Yanomamo Indians in the Amazon, who have a low-salt intake, present with a low average BP, no HTN and no positive slope of BP with age. There is also substantial evidence that a reduction in salt intake lowers BP and can prevent HTN and adverse cardiovascular outcomes. Most studies in children show that the average daily salt intake exceeds nutritional needs. As dietary habits create nutritional patterns for the young population, contamination of foods rich in salt increases over time in modern societies, emerging the need for prevention strategies that will reduce sodium exposure in the young through dietary modification. The effect of salt intake may begin early in life. A randomized trial, conducted among 476 Dutch newborn infants, studied the effect of low or normal sodium diets on BP. Infants fed with a low sodium diet had 2.1 mmHg lower SBP than those under a normal sodium diet at the age of 6 months. A subset of these populations was re-examined 15 years later. SBP and DBP at adolescence were 3.6 and 2.2 mmHg lower, respectively, in subjects assigned to the low sodium compared with the control group. Most observational epidemiological studies on salt and BP in children showed a significant positive association between dietary sodium and BP. However, in a study among Spanish school children, urinary excretion of sodium did not correlate with BP, whereas bodyweight correlated directly with BP and salt intake. The investigators assumed that the BP-raising effect of increased dietary sodium might not be seen until a certain age. Moreover, Howe et al. reported that dietary short-term sodium interventions, consisting of a 4-week high-salt diet following 4 weeks low-salt administration, had no significant alterations on BP levels in adolescents. A more reliable estimation of the sodium effects on BP could possibly be seen after a longer time period of sodium restriction. Sinaiko et al. enrolled 13-year-old adolescents in a study of 3-year period sodium interventions. Adolescent girls receiving a low-salt diet, presented a decrease in urinary sodium excretion and a slight decrease in BP levels. A recent meta-analysis of 13 controlled trials on salt reduction in children demonstrated that even a modest reduction in sodium intake causes immediate decreases in BP, and suggested that it may well lessen the subsequent rise in BP with age. The changes in salt intake were assessed by 24-h urinary sodium in four trials, overnight urinary sodium in three trials, spot urinary sodium/creatinine ratio in two trials, spot urinary sodium in two trials, food diary in one trial and random 24-h urinary sodium in one trial. Among the 13 trials, ten were in children and adolescents and three were in infants. The median reduction in salt intake was 42% (interquartile range: 7–58%) in children and adolescents and 54% (interquartile range: 51–79%) in infants. Individual variations in response to high or low sodium intake impact on BP define salt sensitivity or resistance. Children genetically predisposed to develop HTN, such as African–Americans, as well as those with a family history of HTN, more likely exhibit increased salt sensitivity. Simonetti et al. described the highest prevalence of salt sensitivity in children with intrauterine fetal growth retardation, born small for gestational age. In this study, salt sensitivity was defined if mean 24-h BP increased by 3 mmHg on a high-salt diet and was present in 37% of the low birthweight children. Kidney volume and length measured by ultrasound were reduced in low birthweight children and correlated with increased salt sensitivity, suggesting that a deficit of the normal nephron function in children with low birthweight, may lead to increased salt sensitivity and HTN. A similar relation of birthweight to salt sensitivity has been reported in adults. Several investigators examined the impact of salt sensitivity on the circadian variation of BP. Nondipping status, which is considered an early predictor of cardiovascular and renal complications, has been associated with increased salt sensitivity in hypertensive adults. It is assumed that in individuals with high-salt sensitivity, sodium retention and diminished excretory capability leads to elevation in nighttime BP values. This nocturnal HTN compensates for diminished natriuresis during the daytime and enhances pressure natriuresis during the night. Studies with regard to nondipping pattern and salt sensitivity in children and adolescents are controversial. Salt sensitivity has been associated with nondipping status in salt sensitive normotensive black adolescents. However, in a study conducted by Simonetti et al. normotensive children and young adults maintained normal nocturnal BP dipping independently of salt intake and sensitivity.In the same study, a steeper downward slope of BP from daytime to nighttime was observed in salt-sensitive as compared with salt-resistant children and in both groups of adults. The findings of this study may show that a time interval is needed for blunted dipping to develop, as in children the excretory sodium capacity seemed less affected than in young adults with longer exposure to salt. Salt sensitivity has been reported to involve endogenous ouabain, a modulator of the sodium pump in humans. In prehypertensive and hypertensive individuals, circulating levels of endogenous ouabain are not properly regulated in relation to sodium balance. The main mechanism of endogenous ouabain action, which has been described in animal models, may be an elevation in total peripheral resistance.In normotensive rats, acute elevations in salt intake lead to impairment of the muscular arteriolar response to vasodilator agonists in 3 days.The same effect was reported in normotensive and in reduced renal mass hypertensive rats receiving a high-salt diet for 4 weeks. In normotensive rats, impairment of the vascular function was proportionate to the remodeling of the microvessel wall, so that the sodium sensitivity remained unchanged. In reduced renal mass hypertensive rats the effects on the structure of microvessels was greater and resulted in increased sodium sensitivity and HTN. Despite the major role that sodium plays in the development of HTN in children and adolescents, salt sensitivity should be characterized as one component of the whole spectrum of cardiovascular risk factors. Sensitivity to sodium or high-salt intake alone may not directly cause a hypertensive profile, but could be interrelated to other factors, such as family history of HTN, race and obesity, which altogether contribute to the development of HTN and an adverse cardiovascular profile

Risks and Benefits of Second-Generation Rotavirus Vaccines

From Medscape Pediatrics > Viewpoints William T. Basco, Jr., MD Posted: 08/17/2011 Intussusception Risk and Health Benefits of Rotavirus Vaccination in Mexico and Brazil Patel MM, López-Collada VR, Bulhöes MM, et al N Engl J Med. 2011;364:2283-2292 Study Summary The 1999 rotavirus vaccine was associated with an increased risk for intussusceptions, with the highest risk at 3-7 days after the first dose, believed to be associated with the peak viral replication occurring during this period. This resulted in 1 case of vaccine-induced intussusception per 10,000 children who received the vaccine. Studies of the 2 new rotavirus preparations, conducted in more than 120,000 children, do not reveal an increased risk for intussusception. In 2006 and 2007, Brazil and Mexico began administering the new rotavirus vaccines, allowing for an extensive postmarketing evaluation of the potential effects of these new vaccines. Patel and colleagues used 2 statistical approaches to evaluate the data: a case-series approach (resulting in a rate ratio) and a case-control approach (resulting in an odds ratio). Data were collected from 2008 to 2010 in multiple locations in both countries. In general, children were immunized at 2 months (dose 1) and 4 months (dose 2) of age. Surveillance identified potential cases, and then investigators conducted reviews of medical records to verify and obtain additional clinical data. A verified case was any infant who had intussusception documented at surgery, by contrast enema, by ultrasound, or at autopsy. All cases were between 6 and 35 weeks old at the time of intussusception and all affected children were born after the new rotavirus vaccines were introduced into their respective countries. The investigators considered the period of 1-7 days after vaccination to be the time of principal risk. They adjusted for the background incidence of intussusception in each country in 2-week intervals. They also conducted a comparison of benefit and risk and estimated how many deaths might have occurred in each country without the rotavirus vaccine. They then compared this with the number of intussusceptions and deaths from intussusceptions. The study cohort included 615 case infants (with intussusception) and 2050 control infants (without intussusception). In the intussusception group, 19 children (3.1%) died. In Mexico, 91% of infants with intussusception were diagnosed after the first dose, compared with 44% in Brazil. In Mexican infants, a significant increase in intussusception occurred in the 1- to 7-day period after the first vaccination. In Brazil, a significant increase in intussusception occurred in the 1- to 7-day period after the second vaccination. Age of receipt of the first dose of vaccine did not appear to be related to rate of intussusception in either country. The investigators comment that in Brazil, the first dose of rotavirus vaccine is given along with oral polio vaccine, whereas in Mexico, the rotavirus vaccine is given with the inactivated polio vaccine. Other existing data suggest that coadministration of these 2 live virus vaccines reduces immune response to the first rotavirus vaccine. When applied to a hypothetical cohort of children in Mexico or Brazil, the rotavirus vaccine would avert 663 rotavirus deaths in Mexico and 640 rotavirus deaths in Brazil, compared with an estimated 2 deaths in Mexico and 3 deaths in Brazil caused by the vaccine-induced intussusception. Patel and colleagues concluded that receipt of rotavirus vaccine is associated with a short-term increase in risk for intussusception, but the overall risk-benefit ratio suggests that the benefits of reduced rotavirus deaths and hospitalization in the first 5 years of life far exceed the small number of excess deaths potentially caused by the vaccine. Viewpoint In an accompanying editorial, Greenberg points out that the rotavirus vaccine has reduced hospitalization and deaths in both developed nations and in nations in transition. Clearly, some increased risk for intussusception after vaccination exists with the newer vaccines, although this risk was not demonstrated in the US trials. Whether this risk is the same in fully developed nations as in developing nations is also difficult to determine and cannot be answered directly with these data. I am most interested in the modeling part of the study, which might be the most helpful data for clinicians in the United States. The assumptions would be different if the same study were conducted in the United States, and the findings would probably be biased toward a reduced benefit of the vaccine compared with that demonstrated in Mexico and Brazil. Nonetheless, with such huge benefit-risk ratio (eg, 663 deaths averted compared with 2 vaccine-associated deaths in Mexico), the risk-benefit ratio in the United States would still be great even if the benefit was halved. References

Visual Problems in Infancy After the NICU

From CHOP Expert Commentary Monte D. Mills, MD Posted: 08/15/2011 Hi, I'm Monte Mills. I'm the Director of Ophthalmology at the Children's Hospital of Philadelphia (CHOP). I'd like to talk about eye and vision problems in babies after they've been discharged from the neonatal intensive care unit (NICU) for prematurity. This is a very relevant problem. Eye and vision problems are common in the former preemie following discharge from the NICU. We know that you, as primary care providers, provide most of the care for these children as they get older and have been discharged from the hospital. Early recognition of these problems can make a difference in long-term outcome. How common are these problems in former premature infants? They're quite common. Approximately 50% of kids will need glasses due to strabismus, amblyopia, or other vision problems after they're discharged from the NICU, even after their retinopathy of prematurity (ROP) has been taken care of. The risk of having problems is related not only to the severity of their ROP, but also to their degree of prematurity. Infants who weight less than 1500 g at birth or are less than 32 weeks' gestational age at birth have the highest risk for eye problems later in life. Ocular abnormalities caused by ROP or CNS injury from prematurity are also highly associated with cerebral palsy and other manifestations of CNS injury. One of the principles of looking at these kids is that their visual development has to be compared with that of children at their same post-conceptual age. That is, their age should be adjusted for the degree of prematurity and not their actual postnatal age. These infants need to be observed for eye and vision problems even after their retinas have become mature and they have either been treated for ROP or their retinas have matured without treatment, and they've been discharged for close follow-up from the pediatric ophthalmology service that has provided their care in the NICU. What examinations do you perform in the office? There are 4 components of office primary care screening for eyes and vision. First, look at the ocular structures and external eye examination. Second, test for visual fixation and visual development. Third, eye alignment and eye movements. Finally, the ophthalmoscopic examination. First, the eye appearance and structures would be just the observations. Are the eyelids opening and closing normally? Do the corneas and visible external and internal surfaces of the eyes appear to be normal? If not, referral needs to be made. Second, visual fixation. The best tool for visual fixation is the examiner's face. Does the child fixate and follow on the face of the mother or the face of the examiner? Horizontal following and fixation occurs earliest and subsequently vertical following. By 2-3 months of adjusted age, the child should have good horizontal fixation and following. Third, eye alignment. Do the eyes align well? Is there nystagmus or rhythmic eye movement? We know that this is very common early on, but if the child is past 3-4 months adjusted age, the child should be referred. Finally, how does the pupil and red reflex look with the ophthalmoscope? Is there a good red reflex, is it symmetric and bright in both eyes? If not, if there's a shadow or an abnormality, the patient should be referred. Look for other common problems in infancy such as tearing disorders, obstruction of a nasal lacrimal duct, or capillary hemangiomas. They may not be specifically related to prematurity, but may occur frequently in these kids. Refer these children appropriately. An early referral and early treatment for amblyopia, strabismus, and refractive errors can result in better outcomes in our infants. Thank you.

ADHD Rates Continue to Rise in the United States

From Medscape Medical News > Psychiatry Megan Brooks August 22, 2011 — Rates of attention-deficit/hyperactivity disorder (ADHD) in US children continue to trend upward, report health officials from the Centers for Disease Control and Prevention's National Center for Health Statistics. According to Lara J. Akinbami, MD, and colleagues, the percentage of American children diagnosed as having ADHD increased from 6.9% in 1998-2000 to 9.0% in 2007 to 2009. From 1998 through 2009, ADHD prevalence was higher among boys than girls. For boys, ADHD prevalence increased from 9.9% in 1998-2000 to 12.3% in 2007-2009 and for girls from 3.6% to 5.5% during the same period. ADHD prevalence varied by race and ethnicity, but differences between most groups narrowed from 1998 through 2009, the study authors note. For non-Hispanic white children, ADHD prevalence increased from 8.2% in 1998-2000 to 10.6% in 2007-2009 and from 5.1% to 9.5% for non-Hispanic black children. Mexican children had consistently lower ADHD prevalence than other racial or ethnic groups. From 1998 through 2009, ADHD prevalence increased to roughly 10% among children with family income less than 100% of the poverty level and to 11% for those with family income between 100% and 199% of the poverty level. The report also shows regional differences in ADHD prevalence. In the Midwest, ADHD prevalence rose from 7.1% in 1998-2000 to 10.2% in 2007-2009. In the South, rates rose from 8.1% to 10.3% for the 2 periods. In 1998-2000, ADHD prevalence was higher in the South region than in all other regions. In 2007-2009, ADHD prevalence was similar in the South and Midwest regions; prevalence in these 2 regions was higher than in the Northeast and West regions, the report indicates. Dr. Akinbami and colleagues note that these prevalence estimates "are based on parental report of the child ever receiving a diagnosis and thus may be affected by the accuracy of parental memory (including recall bias), by differential access to healthcare between groups (diagnostic bias), or by willingness to report an ADHD diagnosis." They also point out that it was not possible to discern whether rising prevalence of ADHD "indicates a true change in prevalence or increased detection and diagnosis of ADHD." Nevertheless, the societal costs of ADHD — including those associated with medical, educational, and criminal justice resources — are large, they write. ADHD is one of the most common mental health disorders of childhood. Hallmark symptoms, including difficulty staying focused and controlling behavior, begin in childhood and often persist into adulthood, leading to functional impairment in academic, family, and social settings. The causes and risk factors are unknown, but genetic factors likely play a role. National Center for Health Statistics Brief. 2011:70. Text

Moms May Think Softer Is Safer for Sleeping Babies

From Reuters Health Information By Genevra Pittman NEW YORK (Reuters Health) Aug 23 - Lots of African American moms put soft bedding such as pillows and blankets where babies sleep, despite warnings that the cushioning increases the risk of infant death, according to a new study. That's because many parents are under the impression that a soft sleeping environment means the baby will be more comfortable or will be protected from injuries, said Dr. Rachel Moon. "There's this impression that soft is safe," said Dr. Moon, one of the authors of the new study from Children's National Medical Center in Washington, D.C. "But when it comes to babies' sleep environment, soft is not safe, it's actually dangerous." Researchers know that black babies are at least twice as likely as white, Latino, and Asian babies to die of accidental suffocation, strangulation or sudden infant death syndrome (SIDS). While some of that higher incidence may be related to genetics, much of it is probably due to parents unknowingly putting infants in a dangerous sleeping place or position, Dr. Moon said. To find out whether black families know about the risks, Dr. Moon and her colleagues conducted one-on-one interviews and small group discussions with 83 black mothers in D.C. and Maryland with a new baby at home. The researchers asked women if they used soft bedding and bumper pads in their baby's crib or other sleeping location -- and why or why not. More than of half of the moms reported using soft bedding for their baby, according to findings published August 22nd in Pediatrics. They told researchers they wanted to make sure the babies were comfortable and warm, or that they used pillows as a barricade on beds and sofas, or to prop babies up. "We were surprised that people use (soft bedding) because they think it's going to make their baby safer," Dr. Moon told Reuters Health. "We weren't that surprised that people use it to make the babies comfortable." Some mothers thought doctors' recommendations to use a "firm sleep surface" included a bed where a sheet was tucked tightly over pillows -- but that's still a dangerous sleep situation, the researchers warned. Moms also used bumper pads on cribs if they worried that a baby would hit its head on the railings or get an arm or leg stuck. Some, the researchers found, also thought the bumper pads were cute. But just like with pillows and blankets, bumper pads pose a suffocation risk to babies, Dr. Moon said. "There really isn't any need for bumper pads," especially for very young babies, she added. Dr. Fern Hauck, a SIDS researcher at the University of Virginia in Charlottesville, said she understood the desire to make babies comfortable with soft bedding in hopes that they'll sleep better and longer. But, "babies can pretty much sleep anywhere," she told Reuters Health. "If you get them used to a firm crib mattress, they're going to sleep fine on a firm crib mattress." She said that pediatricians have to talk to new parents about all SIDS and suffocation risks, and "really get a little more of a dialogue going" about the safest way for a baby to sleep. Grandparents, friends, and anyone else who would be taking care of the baby also need to have that conversation, Dr. Hauck added. And it's important to know that although the interviews were only done with black mothers, parents of all races may misinterpret a pediatrician's recommendations or what constitutes a safe sleeping environment, said Dr. Debra Weese-Mayer, a pediatrician at Northwestern University Feinberg School of Medicine in Chicago. The study "is a very humbling lesson that even though we think we're giving a very clear message (about sleep surfaces), if the parent and the caretaker are interpreting it in a way different from what we intended, we're not doing a very good job," Dr. Weese-Mayer said. "If it can save some babies because we do a better job of translating our recommendations, that's wonderfully important." SOURCE: http://bit.ly/oqyquw Pediatrics 2011.

Thousands of US Kids Injured Each Year in Window Falls

From Reuters Health Information By Frederik Joelving NEW YORK (Reuters Health) Aug 22 - Every year in the U.S., more than 5,100 kids go to emergency rooms after falling from windows, and a quarter of them need to be admitted, according to the first nationwide study of the problem. Over 19 years, researchers found, the rate has dropped only slightly. "It really is nothing to take comfort in," said Dr. Gary Smith, who heads the Center for Injury Research and Policy at the Nationwide Children's Hospital in Columbus, Ohio. "We continue to see this problem, especially in younger kids, despite the fact that we know how to prevent it," added Dr. Smith, who led the new work. Between 1990 and 2008, an estimated 98,415 kids under 18 were treated at hospitals for injuries they had sustained in a fall from a window. That's about 7.3 injuries per 100,000 children, Dr. Smith and his colleagues reported in a paper scheduled for publication online today in Pediatrics. Toddlers accounted for two-thirds of all cases. According to Dr. Smith, that's because they're curious, don't understand danger, and have a high center of gravity. "As they lean over, their high center of gravity will make them topple," he said. "They almost invariably land head-first." Nearly half the children had damages to their heads or faces, but only two in 1,000 cases were fatal. Most of the falls happened from the second floor. "We need to look beyond the major cities," Dr. Smith said. "Most children don't live in high-rise apartments, they live in homes." The way to prevent falls, he added, is to ensure that kids don't have access to a window, for instance by removing furniture they can climb to get there. Another good idea is to install window guards or stops, which some cities have already mandated. In New York, for instance, the Health Code requires apartment buildings to install guards on all windows in households with kids under 11. "Parents need to remember that window screens simply won't be enough," said Dr. Smith. The findings are based on data from the National Electronic Injury Surveillance System. Tips and statistics from the study are available at http://injuryresearch.net/windowfallswhatsnew.aspx. SOURCE: http://bit.ly/cxXOG Pediatrics 2011.

Kids' Packed Lunches Too Warm to Be Safe: Study

From Reuters Health Information

By Frederik Joelving

NEW YORK (Reuters Health) Aug 08 2011 - A Texas study that tested more than 700 preschoolers' lunch packs found less than 2% of the meats, vegetables and dairy products were in the safe temperature zone.
"It was a shock when we discovered that more than 90% of the perishable items in these packed lunches were kept at unsafe temperatures," said Fawaz Almansour, a doctoral student at the University of Texas in Austin.
His study, released online today in Pediatrics, is the first to check how the food that kids' bring to school is doing about an hour and a half before lunchtime.
According to the U.S. Centers for Disease Control and Prevention, perishable foods kept between 40 degrees and 140 degrees Fahrenheit (4 to 60 degrees Celsius) for more than two hours are no longer safe to eat.
Although 45% of the packed lunches included an ice pack and 12% were kept in refrigerators, nearly all of the perishable foods were in the danger zone.
According to the CDC, one in six Americans gets food poisoning every year, but it is unclear how many cases are caused by lukewarm sack lunches.
"This study is an eye-opener more than anything else," Almansour told Reuters Health. "It shows there is a problem."
His recommendation? Pack the lunch with lots of icepacks, and have kids take it out of the container at school and put it in the fridge.
SOURCE: http://bit.ly/rdSUsH Pediatrics 2011.

Teething an Unlikely Cause of Serious Symptoms

From Reuters Health Information

By Amy Norton

NEW YORK (Reuters Health) Aug 09 2011-
High fevers and other potentially serious symptoms in infants should not be written off as normal signs of teething, according to a new study.
The study, which followed 47 infants over eight months, found that teething typically caused fairly mild problems -- including irritability, drooling, a day or so of diarrhea and poor sleep.
But it was not linked to any serious symptoms, like high fevers or prolonged bouts of diarrhea.
The findings, reported online August 8 in Pediatrics, are in line with other studies that have failed to connect teething to severe signs and symptoms.
"We should look for other causes for the signs and symptoms, before attributing them to the eruption of primary teeth," lead researcher Dr. Joana Ramos-Jorge told Reuters Health in an email.
On days when babies had a tooth erupt, they typically had a slight increase in temperature, explained Dr. Ramos-Jorge, a pediatric dentist at the Federal University of Minas Gerais in Brazil.
But they did not have outright fevers.
The findings are based on 47 Brazilian infants between the ages of 5 and 15 months. Over eight months, researchers visited their homes daily to take the babies' temperature, check for tooth eruptions and interview mothers about any symptoms.
Overall, the study found, the babies were more likely to be fussy or have diarrhea, sleep problems or a poor appetite on the day a tooth emerged, or the day after. But the symptoms weren't severe or prolonged.

SOURCE: http://bit.ly/nzb2mq  Pediatrics 2011.

ACIP Updates Guidelines for Meningococcal Conjugate Vaccine

From Medscape Medical News

Laurie Barclay, MD

August 5, 2011 — An Advisory Committee on Immunization Practices (ACIP) report in the August 5 issue of the Morbidity and Mortality Weekly Report reviews data underlying the extended age indication for quadrivalent meningococcal conjugate vaccine and the interchangeability of both licensed meningococcal vaccines. The report describes licensure of a meningococcal conjugate vaccine for children aged 2 through 10 years and updated booster dose guidance for adolescents as well as for other persons at greater risk for meningococcal disease.

As previously reported by Medscape in January 2011, the US Food and Drug Administration (FDA) approved an extended, lower age range for the quadrivalent meningococcal conjugate vaccine MenACWY-CRM (Menveo, Novartis Vaccines and Diagnostics) to include persons 2 through 55 years of age. The FDA first approved MenACWY-CRM in February 2010 for the prevention of invasive disease caused by Neisseria meningitides serogroups A, C, Y, and W-135 in persons 11 to 55 years of age.
The other FDA-approved quadrivalent meningococcal conjugate vaccine is MenACWY-D (Menactra, Sanofi Pasteur). Like MenACWY-CRM, MenACWY-D is intended to prevent meningococcal disease caused by serogroups A, C, Y, and W-135 among people 2 through 55 years of age.
In addition, MenACWY-D is FDA-approved as a 2-dose series for children 9 months through 23 months of age.
"The [ACIP] recommends that persons aged 2 through 55 years at increased risk for meningococcal disease and all adolescents aged 11 through 18 years be immunized with meningococcal conjugate vaccine," the report states. "
ACIP further recommended, in January 2011, that all adolescents receive a booster dose of quadrivalent meningococcal conjugate vaccine at age 16 years. This report summarizes data supporting the extended age indication for MenACWY-CRM and the interchangeability of the two licensed meningococcal conjugate vaccines."
A multicenter, randomized, controlled trial assessed the safety and immunogenicity of MenACWY-CRM in children 2 through 10 years of age. Seroresponses to groups C, Y, and W-135 after a single MenACWY-CRM dose in children aged 2 through 5 years and 6 through 10 years were noninferior to responses after a single MenACWY-D dose, measured using a human complement serum bactericidal assay (hSBA) . The proportions of children aged 2 through 10 years with hSBA titers 8 or higher after receiving MenACWY-CRM and MenACWY-D were, respectively, 75% and 80% for serogroup A, 72% and 68% for serogroup C, 90% and 79% for serogroup W-135, and 77% and 60% for serogroup Y.
In that trial, headache and irritability were the most common systemic adverse effects with MenACWY-CRM, and rates of adverse effects were similar to those seen after MenACWY-D vaccination. Pain was the most common injection-site reaction, reported within 7 days after vaccination; erythema and induration were also frequently reported. Less than 1% of persons receiving MenACWY-CRM had serious adverse events, and the vaccine was not thought to be responsible for any of these.
The ACIP now recommends that either meningococcal conjugate vaccine can be used in children 2 through 10 years of age who are at increased risk for meningococcal disease. This recommendation supersedes the previous recommendation that children in this age group should receive only MenACWY-D when meningococcal vaccination is indicated. Either meningococcal conjugate vaccine is preferred over quadrivalent meningococcal polysaccharide vaccine.
Children with terminal complement deficiencies or anatomic or functional asplenia should receive a 2-dose primary series, whereas children with increased risk for disease because they are travelers to or residents of countries in which meningococcal disease is hyperendemic or epidemic should receive a single primary dose.
In January 2011, ACIP recommended that adolescents given a previous dose of meningococcal conjugate vaccine before 16 years of age should be given a single booster dose. ACIP now also recommends a booster dose for persons 2 through 55 years of age who continue to be at increased risk for meningococcal disease, including laboratory workers who work with N. meningitides.
Either meningococcal conjugate vaccine is suitable for revaccination, based on a postlicensure study assessing persistence of hSBA antibodies and the safety and immunogenicity of MenACWY-CRM vaccination 3 years after receipt of a single dose of MenACWY-CRM or MenACWY-D. For all serogroups, the percentage of participants with hSBA titers 8 or higher was similar at 36 months after receipt of a single dose of MenACWY-CRM or MenACWY-D at ages 11 through 18 years. After receiving the booster dose of MenACWY-CRM, more than 99% of persons previously given MenACWY-CRM or MenACWY-D had hSBA titers 8 or higher.
Rates of injection-site reactions and systemic adverse events reported after revaccination were similar to those rates reported after the first vaccination. There are currently no available data on the safety or immunogenicity of booster vaccination with MenACWY-D after primary vaccination with MenACWY-CRM.
"Health-care providers should use every opportunity to provide the booster dose when indicated, regardless of the vaccine brand used for the previous dose or doses," the report authors conclude.
MMWR Morb Mortal Wkly Rep. 2011;60:1018-1019. Full text.

Assessment and Management of ADHD: Areas of Agreement and Difference

From Agency for Healthcare Research and Quality (AHRQ) > News and Numbers from AHRQ Agency for Healthcare Research and Quality (AHRQ) Posted: 03/23/2011

• Assessment and Management of Attention-Deficit/Hyperactivity Disorder (ADHD)
• Areas of Agreement and Difference
• Screening and Assessment AACAP
• Screening and Assessment - SIGN
• Initial Management - AACAP
• Initial Management - SIGN
• Pharmacological Intervention - AACAP
• Pharmacological Intervention - SIGN
• Unlicensed Medications
• Psychological Interventions
• Monitoring/Follow-up
• Strength of Evidence
• Methodology
• Source of Funding
• Abbreviations
• Status

Areas of Agreement and Difference

Areas of Agreement

A direct comparison of recommendations presented in the above guidelines for the assessment and management of attention deficit hyperactivity disorder (ADHD) is provided below.

Assessment. The groups agree that comprehensive assessment of the child with suspected ADHD should include clinical interviews with the parent/carer as well as the patient. Focusing on diagnostic criteria for ADHD and associated, potentially comorbid disorders, there is agreement that during the parent interview clinicians should inquire about the patient's: symptoms (frequency, duration, severity, situational variation, age of onset, settings in which impairment occurs); academic functioning; medical history; mental health history (including any treatment received in the past); obstetric and perinatal history; developmental history/acquisition of developmental milestones; family history, including a history of ADHD (due to its heritability) and any other significant mental disorders/psychiatric illnesses; and family functioning. As children and young people may not always be reliable in reporting externalizing behavior, the groups agree that the primary purpose of the patient interview is not to confirm or refute the diagnosis, but rather to aid identification of internalizing signs or symptoms inconsistent with ADHD or suggestive of comorbid conditions (e.g., anxiety, depression).
Given that many children with ADHD experience academic difficulties, the groups agree that, in addition to inquiring about academic performance during the parent interview, a psychoeducational assessment should also be performed. The American Academy of Child and Adolescent Psychiatry (AACAP) notes that the psychoeducational assessment is an opportunity for the clinician to review the patient's academic/intellectual progress and look for symptoms of learning disorders. According to the Scottish Intercollegiate Guidelines Network (SIGN), assessment of the child's presentation in their educational placement is important for confirming diagnosis and identifying educational underachievement. They add that psychoeducational assessment involves testing the child's level of attainment in basic skill areas such as reading, spelling and number work, and evaluating whether the child is achieving appropriately in terms of age and ability. Both groups recommend contacting the child's teacher(s)/school for details about academic performance as well as behavior during the school day to inform diagnosis and plan a management strategy.
The groups agree that laboratory or neurological testing is not indicated in the majority of patients with suspected ADHD. AACAP recommends considering measurement of thyroid levels and TSH only if symptoms of hyperthyroidism other than increased activity level are present, and measurement of serum lead levels only if a patient has been raised in an environment where exposure to lead paint or plumbing is probable. According to AACAP, unless there is strong evidence of certain risk factors in the medical history, neurological studies (EEG, MRI, SPECT, or PET) are not indicated for the evaluation of ADHD. SIGN similarly notes that neuroradiological, neurophysiological, neurochemical and chromosomal investigations are as yet unproven in the diagnosis of ADHD/HKD. They recommend certain physical investigations be carried out when thought to be important in the determination of an underlying medical problem, and might include: blood analyses (lead, chromosomes, Fragile X); electrophysiological studies (EEG); and CT (MRI for neurological disorders/ space occupying lesions).
With regard to psychological testing, AACAP states that psychological and neuropsychological tests are not mandatory for the diagnosis for ADHD, but should be performed if the patient's history suggests low general cognitive ability or low achievement in language or mathematics relative to the patient's intellectual ability. AACAP adds that neuropsychological testing, speech-language assessments, and computerized testing of attention or inhibitory control are not required as part of a routine assessment for ADHD, but may be indicated by the findings of the standard psychological assessment. SIGN similarly states that laboratory assessment measures and psychological tests should not be regarded as a routine part of the diagnostic process, but rather used on the basis of a specific hypothesis in a specific case.
Psychostimulants and atomoxetine. AACAP recommends the initial pharmacological treatment of ADHD be a trial with an agent approved by the FDA for this purpose. U.S. FDA-approved agents include: the psychostimulants dextroamphetamine and methylphenidate; mixed salts amphetamine (e.g., Adderall); and atomoxetine. The same medications, with the exception of mixed salts amphetamine, are also licensed in the UK for the treatment of ADHD/HKD. While Adderall is not licensed in the UK, SIGN notes that a review of four studies found that Adderall showed a small advantage over immediate release methylphenidate and placebo when treatment response was measured by clinician and parent ratings/outcomes.
SIGN recommends psychostimulants as the first choice medication for the core symptoms of ADHD/HKD in children without known (or where there is no family history of) cardiac abnormalities. According to AACAP, the American Academy of Pediatrics, an international consensus statement, and the Texas Children's Medication Project have also recommended stimulants as the first line of treatment for ADHD, particularly when no comorbidity is present. They add that direct comparisons of the efficacy of atomoxetine with that of psychostimulants have shown a greater treatment effect of the stimulants.
With regard to medication use in preschoolers, SIGN provides no recommendations around the use of medications in children of preschool age. SIGN notes that in Scotland most clinicians would seldom confirm a diagnosis of ADHD/HKD in this age group. According to AACAP, stimulants have been widely prescribed by clinicians for preschoolers, although the number of published controlled trials is limited. They do not provide specific recommendations, but cite research findings which suggest that that the dose of MPH (or any stimulant) should be titrated more conservatively in preschoolers than in school-age patients, and that lower mean doses may be effective.
The groups agree that the noradrenergic reuptake inhibitor atomoxetine is superior to placebo, but inferior to stimulants, in treating core symptoms of ADHD. SIGN recommends atomoxetine in children where psychostimulant medication is not appropriate, not tolerated, or is ineffective. AACAP similarly states that atomoxetine may be considered as the first medication for ADHD in individuals with an active substance abuse problem, comorbid anxiety, or who experience severe side effects of stimulants such as mood lability or tics. The groups agree that patients taking atomoxetine should be monitored for suicidal ideation, clinical worsening of mood, and unusual changes in behavior.
Unlicensed medications. The groups agree that, in children who have not responded to licensed medications, unlicensed medications may be appropriate in selected circumstances. Both groups address the alpha agonists clonidine and guanfacine. Concerning clonidine, AACAP states it is effective for impulsivity and hyperactivity; modulating mood level; tics worsening from stimulants; and sleep disturbances, and that clinical consensus has led to its use as adjunctive therapy to treat tics or stimulant-induced insomnia rather than as a primary treatment for ADHD. SIGN recommends consideration of clonidine in children unresponsive to or unable to tolerate psychostimulants or atomoxetine on an individual case basis. The groups agree that clinicians should periodically assess pulse and blood pressure, and monitor for cardiac symptoms and over-sedation in patients prescribed clonidine. There is also agreement that clonidine may be used alone or in combination with another ADHD medication (SIGN specifies methylphenidate on an individual case basis). Concerning guanfacine, SIGN found insufficient evidence on which to base a recommendation. AACAP cites a small double-blind trial that showed its superiority over placebo in the treatment of children with ADHD and comorbid tics, and recommends reviewing personal and family cardiovascular history before prescribing. The groups agree that alpha-agonist discontinuation should be carried out gradually to avoid rebound hypertension.
With regard to tricyclic antidepressants (TCAs), AACAP states that they are the most studied of the non-FDA-approved medications for the treatment of ADHD, and that imipramine and nortriptyline have been most commonly used in recent years. They add that desipramine should be used only if other TCAs have not proven effective or have caused the patient to suffer excessive side effects, and should be used with extreme caution in children and adolescents due to reports of sudden death. According to SIGN, the TCAs are more effective in addressing the behavioral symptoms than attention/concentration deficits. The groups agree that for TCAs, caution is warranted in patients with a history of cardiac problems, and that electrocardiographic monitoring should be performed at baseline and during treatment.
With regard to antidepressants other than TCAs, SIGN did not identify any contemporary evidence on the use of bupropion in ADHD/HKD, but cites an older study which suggested symptom reduction comparable with methylphenidate using several measures. AACAP states that bupropion showed modest efficacy in the treatment of ADHD in one double-blind, placebo-controlled trial, and is contraindicated in patients with a current seizure disorder. SIGN also addresses reboxetine and selegiline, for which they found insufficient evidence on which to base a recommendation.
Psychological interventions. While there is overall agreement that, generally speaking, pharmacological intervention for ADHD is more effective than psychological intervention, the groups agree that behavior therapy is appropriate in certain situations, one of which is as initial treatment for mild ADHD. Circumstances also cited by AACAP include when the diagnosis of ADHD is uncertain, parents reject medication treatment, or there is marked disagreement about the diagnosis between parents or between parents and teachers.
According to AACAP, if a patient has a robust response to medication and subsequently shows normative functioning in academic, family, and social settings, then pharmacological treatment alone is satisfactory. If, however, a patient with ADHD has a less than optimal response to medication, has a comorbid disorder, or experiences stressors in family life, then psychosocial treatment in conjunction with pharmacologic treatment is often beneficial.
Both groups address behavioral parent training, the short-term effectiveness of which has been demonstrated in a number of controlled studies according to AACAP. SIGN recommends behavioral parent training for parents of pre-school children with symptoms of ADHD/HKD. In pre-adolescent children with ADHD/HKD and symptoms of comorbid generalized anxiety, ODD, or aggressive behavior, SIGN recommends behavioral programs to treat the comorbid problems (in conjunction with medication to treat the core symptoms). SIGN found insufficient evidence to make a recommendation for psychological interventions for adolescents. SIGN also addresses school-based interventions, recommending an individualized school intervention program including behavioral and educational interventions for children with ADHD/HKD.

Areas of Difference

Atomoxetine. Recommendations differ slightly with regards to dosing of atomoxetine. Both groups agree that children who weigh <70 kg should be initiated at 0.5 mg/kg/day. SIGN recommends maintaining this dose for at least 7 days before being increased to a maintenance dose of 1.2 mg/kg/day. AACAP, in contrast, recommends maintaining the initial dosage for four days, followed by 1 mg/kg/day for four days, then increasing to 1.2 mg/kg/day. Both groups note that the manufacturer does not recommend the opening of capsules.

Low-Carb Diets May Improve Acne

 

From WebMD Health News

Denise Mann

August 8, 2011 —
Low-carb eating plans may do more than promote weight loss. These diets may also improve acne.
Although the few studies conducted on this topic have yielded mixed results, “theoretically, people with acne may have hyperinsulinemia and foods that are low in the glycemic index (GI) may contribute to the hormonal control of acne,” says Alan R. Shalita, MD, thedistinguished teaching professor and chairman of the department of dermatology at SUNY Downstate Medical Center in New York.
Hyperinsulinemia is characterized by excess levels of the hormone insulin in the blood, and foods with a low glycemic index that are favored by low-carb eating plans can help control blood sugar (glucose) levels.
“I would encourage patients with acne to moderate the amount of carbs that they eat and not to overdo dairy,” he says. There is some suggestion that dairy products may contribute to acne, he says.
Shalita spoke on the relationship between diet and acne at the American Academy of Dermatology Summer meeting in New York.
Much of the information circulating about how certain foods cause or cure break-outs are myths, he says.
For example, there is no evidence that chocolate causes acne, he says. “One study that compared Hershey chocolate bars with carob bars found no difference in acne risk,” Shalita says. “There is sugar and fat in both, so for people that do react to chocolate, it has more to do with the sugar than the cocoa.”
 
Acne Treatment Update
The good news on the acne front has to do with treatments; Shalita says. Over-the-counter (OTC) products are the best place to start for mild-to-moderate acne. Shalita suggests a salicylic acid cleanser followed by a benzoyl peroxide leave-on product to help dry the skin for people with mild-to-moderate acne.
“If you don’t respond, see a dermatologist,” he says.
For severe, scarring acne, the gold standard is still isotretinoin, a form of vitamin A. This drug was formerly known by the brand name Accutane. It can cause severe birth defects and can have other side effects, including depression, hallucinations, and suicidal behavior.
So now people are looking for alternative acne treatments, says Amy Forman Taub, MD, the medical director of Advanced Dermatology and an assistant clinical professor of dermatology at Northwestern University Medical School both in Chicago.
Certain laser treatments can help with acne and acne scars, and for teenagers and people with severe acne, blue light Levulan photodynamic therapy can be an option, she says.
Levulan is a liquid that is applied to the skin and absorbed by the oil glands; blue light treatment activates the medicine in the glands and shrinks them. This treatment also kills acne-causing bacteria, she says.
Other acne treatment options include certain oral contraceptives and oral or topical antibiotics.
“If you have mild acne and can get away with using OTC salicylic acid cleansers and benzoyl peroxide, these are still very viable treatments,” Taub says. But “if your acne is severe, don’t mess with this as a first step as you may be flirting with acne scars."
SOURCES:

Changing Incidence of Bacterial Meningitis

From Medscape Pediatrics > Viewpoints

William T. Basco, Jr., MD

Posted: 08/04/2011

Bacterial Meningitis in the United States, 1998-2007

Thigpen MC, Whitney CG, Messonnier NE, et al; for the Emerging Infections Programs Network
N Engl J Med. 2011;364:2016-2025

Study Summary

Data for this study were obtained from a US Centers for Disease Control and Prevention-sponsored surveillance network. Data were collected between 1998 and 2007. For the purpose of this study, bacterial meningitis was defined as the presence of Streptococcus pneumoniae, Neisseria meningitidis, or Group B Streptococcus in a sample of cerebrospinal fluid. A patient was also considered to have meningitis if any of those bacteria were isolated from another sterile site when diagnosed with meningitis clinically by a healthcare provider. Cases of Listeria monocytogenes, obtained from a different surveillance network, were also included.
The surveillance networks identified 3188 cases of bacterial meningitis caused by the 4 pathogens. Over the time of the study, the incidence of bacterial meningitis declined by 31% (from 2.0 to 1.38 cases per 100,000 population). Age-related differences in the declining meningitis incidence were seen. No change in the incidence of bacterial meningitis was seen in children younger than 2 months of age. However, in all other pediatric age groups (2-23 months, 2-10 years, and 11-17 years of age) the incidence of bacterial meningitis dropped by 51%-64%.
The case-fatality rate for bacterial meningitis did not change significantly over the time period studied: from a rate of 17.9% in the first year of surveillance to 14.7% in the final year, a difference that did not reach statistical significance.
With the exception of Group B Streptococcus meningitis, the incidence of meningitis caused by all other pathogens declined over the study period. The incidence of bacterial meningitis due to S pneumoniae decreased by 26%, with the largest decline (92%) in S pneumoniae serotypes included in the 7-valent conjugate vaccine. Cases caused by nonvaccine pneumococci increased by 61% over the study period.
Qualitatively, Group B Streptococcus caused the overwhelming majority of bacterial meningitis cases in infants younger than 2 months of age. For all groups of older children, S pneumoniae comprised 45%-50% of cases of bacterial meningitis. This was followed by N meningitidis and a small but persistent proportion of cases caused by Haemophilus influenzae across the age ranges.
The investigators concluded that the incidence of bacterial meningitis caused by the pathogens studied declined in the past decade. The downward trend was primarily related to a decreasing incidence of bacterial meningitis caused by S pneumoniae. The largest reductions in cases of bacterial meningitis were in children, but case-fatality rates did not significantly improve.

Viewpoint

These data offer real encouragement to pediatric providers that we are gradually making progress in reducing the rate of this feared illness.
However, many children still become ill with meningitis.
It is very interesting that the relative contributions of the different pathogens did not change much over the study period.
Group B Streptococcus remains the dominant organism in newborns with meningitis. S pneumoniae remains dominant in toddlers and young children, with almost equal contributions of S pneumoniae and N meningitidis in school-age children. Finally, the changing serotype mixture of S pneumoniae meningitis demonstrates the ability of the 7-valent pneumococcal conjugate vaccine to reduce pneumococcal meningitis. These data also indirectly support the expansion of the number of serotypes in the pneumococcal vaccine to the current 13-valent vaccine.
Abstract

A Growing Concern in US Children

From Medscape Psychiatry > Findling on Psychiatry

Robert L. Findling, MD

Posted: 08/01/2011

 Dr. Robert Findling - director of the Division of Child and Adolescent Psychiatry at University Hospitals Case Medical Center and professor of psychiatry and pediatrics at Case Western Reserve University.

In this posting I would like to talk about a paper that was just published in the journal Pediatrics. Boyle and colleaguesdescribed the results of a study that focused on examining the childhood prevalence of developmental disabilities in the United States.
In my opinion, there are 2 key take-home messages from this paper.

The first is that from 2006 to 2008, about 1 out of 6 youngsters in the United States were reported to have a developmental disability. In addition, the number of youngsters with developmental disabilities reflected a greater prevalence than had previously been noted. This is important because these children require more educational and health-related services than youngsters who are developing typically.

Let's discuss how the authors came to these results. First, they looked at data regarding children between the ages of 3 and 17 years of age, a reasonably broad range. In addition, the authors focused on the years from 1997 to 2008. Diagnosis was based on parent report, which is an important consideration, and no formal diagnostic methodology per se was used.

A key strength to this paper is that the data came from the National Health Interview Survey and were gleaned from about 120,000 children. As far as diagnosis is concerned, the parents were simply asked whether or not a doctor or a healthcare professional had told them that their child had one of several developmentally based conditions. These conditions included ADHD [attention-deficit/hyperactivity disorder], autism, mental retardation, and learning disabilities, but also surveyed were conditions such as seizures, hearing loss, and blindness.

Of note, the overall prevalence of developmental disabilities increased with time during the 12-year period, from approximately 12.8% to 15%. That is a pretty big number.
The increases in prevalence of ADHD and autism were noteworthy. The prevalence of autism grew the most, with ADHD having the second greatest increase in prevalence. This report compliments other data that suggest that the rate at which developmental disabilities are being diagnosed in children is certainly increasing over time. The numbers also suggest that demands on educational systems will grow and already are growing. Similarly, because these youngsters are vulnerable, their greater healthcare needs must also be met.
I am both a pediatrician and a child psychiatrist and I recognize that these children's needs are sometimes split between mental health and pediatric professionals. As the number of children with these developmental disabilities rises, one might surmise that child psychiatrists and pediatric professionals will either collaborate more closely or that psychiatrists who have pediatric training may be particularly well suited to meet these youngster's medical needs. Certainly, this seems to be the case, as the number of these youngsters grows, their service needs also seem to be growing.

The 15-Minute Asthma Visit

From CDC Expert Commentary

David B. Callahan, MD

Posted: 08/01/2011

Hello, I am Dr. David Callahan, with CDC's National Asthma Control Program and a Captain in the US Public Health Service. I am speaking to you as part of the CDC Expert Commentary Series on Medscape. Today I would like to discuss how clinicians can provide evidence-based care for their patients with asthma in a routine 15-minute office visit. Today's discussion is based on the National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma.

The goal for long-term management is to control asthma by reducing impairment and risk.
Reducing impairment involves limiting the impact on the patient's day-to-day life by preventing symptoms, limiting the need for quick-relief medications, and maintaining normal activity levels.
Reducing risk means minimizing the need for emergency department visits and hospitalizations and avoiding adverse effects from medications.

Here are 4 key steps to follow:
1. Schedule regular 15-minute visits. Routine follow-up care -- scheduling office visits at periodic intervals-- is an essential part of caring for patients with asthma.
It allows the clinician to monitor and adjust therapy and reinforce the key components of asthma management over time.
An asthma management flow sheet, updated at each visit, can provide a way to make sure that essential components of asthma care are covered across multiple appointments. These routine follow-up visits can reduce the challenge of providing quality asthma care in a typical 15-minute office visit.
 
2. Assess control, beginning with a standardized questionnaire. Assessing control is part of every routine asthma visit and is the basis for stepwise management of asthma medications. Assessing impairment -- a component of control -- can be done using a questionnaire that the patient completes while awaiting the visit. Standardized questionnaires like the Asthma Control Test™, the Asthma Control Questionnaire, and the Asthma Therapy Assessment Questionnaire and others are informative and easy to use. Risk can also be inferred by asking the patient about unplanned, urgent care visits for asthma exacerbations, in conjunction with an analysis of spirometry results that may have been done at a recent separate visit. Occasional spirometry can also help assess progressive loss of lung function over time, another component of the risk domain.
 
3. Review the patient's written asthma action plan at each visit and discuss asthma triggers. Reviewing the patient's written plan can serve several functions in the routine visit. It offers an opportunity to provide focused self-management education, including use of a peak flow meter or an asthma symptom diary.
Similarly, you can review daily asthma management, including use of long-term controller medications, as you discuss the "green zone" used when the patient is doing well. Discussing the yellow and red zones can help the patient recognize symptoms that call for prompt attention, as well as appropriate use of short-acting beta-agonist quick-relief medications.
The asthma action plan should include information on specific asthma triggers that the patient should avoid. Encouraging a multipronged approach to reduce exposure to asthma triggers can be done over multiple visits and reinforced with written patient education materials.
Two triggers demand special attention: tobacco smoke and air pollution.
If the patient is a smoker, a return visit should be scheduled to specifically address smoking cessation. For all other patients, avoidance of environmental "secondhand" smoke can be recommended at each visit.
Air pollution is a common asthma trigger, and the air quality index (AQI) can provide the day-to-day information your patients need to know in order to determine when to modify their activities. In particular, ground-level ozone, a primary component of smog, can trigger asthma symptoms directly and can also sensitize the patient to other triggers. Particulate-matter air pollution is also an important asthma trigger. When air pollution levels are high -- when the AQI is "code orange" or worse -- patients with asthma should avoid outdoor activities. Informing patients where to find the AQI -- such as the newspaper, weather forecasts, or the Environmental Protection Agency Website -- takes only a moment and can be included on the asthma action plan.
 
4. Review medications. Of course, long-term management depends on optimal use of asthma medications. Inhaled corticosteroids are the most effective medications for long-term management of persistent asthma, and assessing their use in the context of stepwise management of asthma can be done as you review medications and administration techniques. Ensuring that the patient has an adequate supply of controller and rescue medications, and scheduling the next follow-up visit, can wrap up your 15-minute office visit.
Finally, the goal of good asthma care is for your patient to be able to enjoy life with as few symptoms as possible, and partnering with your patient through scheduled follow-up care can achieve that goal.

Breast-Feeding Lowers Risk for Asthma in Childhood

From Medscape Education Clinical Briefs

News Author: Nancy A. Melville
CME Author: Penny Murata, MD

07/26/2011

Clinical Context

Breast-feeding appears to be linked with a decreased risk for childhood asthma-related symptoms, according to Fredriksson and colleagues in the November 28, 2007, issue of BMC Pediatrics. However, the influence of a family history of asthma or allergy is not clear. The link between breast-feeding and the risk for asthma might be mediated by atopy or infection.
The current study by Sonnenschein-van der Voort and colleagues, embedded in the population-based prospective cohort Generation R study, described by Jaddoe and colleagues in the November 2010 issue of the European Journal of Epidemiology, assesses the association of duration and exclusiveness of breast-feeding with the risk for asthma-related symptoms in the first 4 years of life and whether the association is mediated by atopic or infectious conditions.

Study Synopsis and Perspective

Preschool children who were not breast-fed or not exclusively breast-fed for 6 months show increased rates of asthma-related symptoms, such as wheezing, shortness of breath, and dry cough, according to a study published online July 20 in the European Respiratory Journal.
Asthma symptoms in children, known to be a leading cause of morbidity, have been linked in previous studies with lower rates of breast-feeding, but the study from researchers in the Netherlands is said to be the first to demonstrate an association between the length of time a child was breast-fed and the number of wheezing episodes the child experiences.
For the study, the researchers evaluated data on 5368 children that was part of the Generation R study, a population-based prospective cohort study of pregnant women and their children from fetal life on in Rotterdam, the Netherlands.
They gathered information on breast-feeding duration, exclusiveness, and asthma-related symptoms, including wheezing, shortness of breath, dry cough, and persistent phlegm.
The results showed that, compared with children who were breast-fed for at least 6 months, those who were never breast-fed were 1.4 and 1.5 times more likely to develop symptoms of wheezing and persistent phlegm, respectively.
In addition, children who were not exclusively breast-fed during the first 4 months of life and were also fed milk or solids during that period also were at higher risks of wheezing, shortness of breath, dry cough, and persistent phlegm in their first 4 years vs those who were exclusively breast-fed in their first 4 months.
Further adjusted analyses indicated that the associations of breast-feeding with asthma-related symptoms were not explained by eczema but, instead, were partly related to lower respiratory tract infections.

Breast-feeding is widely believed to help reduce the risk for asthma in younger children through a mediating effect on atopy and/or infections, the study authors believe.
"Underlying mechanisms might include IgA [immunoglobulin A], cytokines, especially TGF [transforming growth factor]-beta1, and long-chain fatty acids in breast milk that stimulate the infant's immune system," they explained.
"Also, glycans help the innate immune system to inhibit pathogen binding to the host cell target ligand, and changes in the delicate balance between pro- and anti-inflammatory compounds."

The protective effect of breast-feeding, in particular, appears to be related to gut microflora that is changed with breast-feeding, they added.
"The gut microflora is suggested to be different between breastfed and formula fed infants. Compared to breastfed infants, those who receive formula feeding have a more complex microflora with more facultative anaerobes, bacteroides and clostridia at higher levels and frequencies," the study authors write.
"We speculate that this might decrease with increasing exclusivity of breastfeeding, leading to lower infection risk and less wheezing by influencing the development of the immune system. Due to this putative effect on the development of the immune system, infections and asthma-related symptoms might occur less frequent even years after stopping breastfeeding."

The results are in line with previous research showing up to a 2.22-fold increased risk of recurrent wheezing or asthma at the ages of 2 to 6 years among children who were not breast-fed or not exclusively breast-fed until age 4 months.
These new findings add to the previous research by showing a dose-response relationship between breast-feeding and the number of wheezing episodes, said lead author Agnes Sonnenschein-van der Voort, MSc, in a press release.
"The link of duration and exclusiveness of breastfeeding with asthma-related symptoms during the first four years was independent of infectious and atopic diseases," said Dr. Sonnenschein-van der Voort, a researcher with the Erasmus Medical Center in the Netherlands.
"These results support current health policy strategies that promote exclusive breastfeeding for 6 months in industrialized countries. Further studies are needed to explore the protective effect of breastfeeding on the various types of asthma in later life."
Eur Respir J. Published online July 20, 2011.

Cell Phones Not Linked to Brain Tumors in Children

From Medscape Education Clinical Briefs

News Author: Roxanne Nelson
CME Author: Charles P. Vega, MD

07/29/2011;

Clinical Context

The possibility of a higher risk for brain tumors related to the use of mobile phones is truly frightening, particularly if such a risk applies to children and adolescents as well as to adults.
The current study by Röösli and colleagues provides some background regarding whether an association between mobile phone use and the incidence of brain tumors in young people is possible.
Children's developing nervous systems may indeed be more vulnerable to radiofrequency electromagnetic fields associated with mobile phones.
However, the radiofrequency radiation emitted by mobile phones is insufficient to damage DNA directly, and it is nonionizing.
Animal models have not found mobile phone radiation to be carcinogenic, and epidemiologic research has generally not demonstrated significant trends toward a higher prevalence of brain tumors among children since the introduction of the mobile phone.
Nonetheless, children and parents might remain concerned regarding the potential risks of mobile phone use. The current study evaluates how these devices affect the risk for brain tumors in a cohort including hundreds of children and adolescents.

Study Synopsis and Perspective

A new study has found that children and adolescents who use cell phones do not appear to be at a higher risk for brain cancer, adding to the ongoing debate about the possible association between cell phone use and brain tumors.
The study, conducted by Martin Röösli, PhD, senior investigator at Swiss Tropical and Public Health Institute in Basel, Switzerland, and colleagues, looked at children and adolescents who were diagnosed with a brain tumor. The team found that patients with tumors were not statistically significantly more likely to have been regular cell phone users than control subjects.
This study, published online July 27 in the Journal of The National Cancer Institute, is the first to specifically assess the health impact of cell phone use on children and adolescents.
Even though evidence that children are more sensitive to nonionizing radio waves than adults is lacking, "there is genuine concern for the obvious reasons that children are young, growing, and have many years of life remaining," the authors of an accompanying editorial write.
However, the study is consistent with virtually all studies of adults exposed to radiofrequency waves, and "no convincing evidence was found that children who use cell phones are at higher risk of developing a brain tumor than children who do not regularly use cell phones," note John D. Boice, Jr, ScD, and Robert E. Tarone, PhD, from the International Epidemiology Institute in Rockville, Maryland, and Vanderbilt University in Nashville, Tennessee.
But even though the study has filled a gap in our knowledge by showing that there is no increased risk for brain tumors in children and adolescents who are regular cell phone users, the editorialists point out that "it is impossible to prove a noneffect, and it will be debated whether and at what level additional research funds should be spent in assessing health effects associated with nonionizing radiation, especially in times of limited resources."
Research is ongoing, and includes a prospective study that is recruiting 250,000 cell phone users in 5 European countries, and a case–control study of 2000 young people, between 10 and 24 years of age, who were diagnosed with a brain tumor and 2000 control subjects from 13 countries. In the meantime, Drs. Boice and Tarone concur with the study authors that the incidence rates of brain cancer in the general population should continue to be monitored, and that individuals who are concerned should consider alternatives to holding a cell phone up to their ears (such as an ear piece or the speaker option).
When considering the need for future health research on cell phones, Drs. Boice and Tarone note that "in addition to the negative epidemiological data, there is no known biologically plausible mechanism by which nonionizing radio waves of low energy can disrupt DNA and lead to cancer."
 
Rise in Use and Debate Reignited
Over the past several years, a number of studies have attempted to examine the association between cell phone use and an increased risk for brain tumors. To date, the evidence has been inconclusive, although some countries have begun to take precautionary measures.
The debate was reignited in May, when the World Health Organization announced that radiofrequency electromagnetic fields have been classified as possibly carcinogenic to humans (group 2B) on the basis of an increased risk for glioma that some studies have associated with the use of wireless phones.
There has been a dramatic rise in the use of cell phones by children and adolescents during the past few years, and it has been hypothesized that they might be more vulnerable than adults to the possible detrimental health effects of cell phone exposure.
 
No Increase in Tumors
Dr. Röösli and colleagues, conducted an international case–control study of the relation between cell phone use and the risk of developing brain tumors in children and adolescents. The 352 participants were 7 to 19 years of age, resided in Denmark, Sweden, Norway, or Switzerland, and were diagnosed with a brain tumor from 2004 to 2008. The control group consisted of 646 age-, sex-, and region-matched children.
Of the patients with brain tumors, 162 (46.0%) were diagnosed with an astrocytoma, 21 (6.0%) with ependymoma, 30 (8.5%) with another glioma, 62 (17.6%) with primitive neuroectodermal tumors, 53 (15.1%) with other specified intracranial neoplasms, and 24 (6.8%) with unspecified intracranial neoplasms.
Cell phone use was determined from interviews and phone-network providers, if the information was available.
A similar percentage of subjects in the case and control groups reported having spoken on a cell phone more than 20 times before the case patient was diagnosed (75.3% vs 72.1%). Furthermore, 55% of the case group and 51% of the control group reported regularly using a cell phone.
The authors found that children who had used cell phones for at least 5 years were not at higher risk than those who had never regularly used cell phones (odds ratio [OR], 1.26). There was also no increased risk for brain tumors in the areas of the brain with the highest exposure to radiofrequency, such as the temporal and frontal lobes and the cerebellum. Interestingly, in regular users, the odds ratio for tumors in the parts of the brain with the lowest exposure to radiation was statistically significant (OR, 1.92).
 
Possible Risk?
Information on first subscription activations was available for 35% of case patients and 34% of control subjects. There was a statistically significantly increased risk for the 24 case patients and 25 control subjects who had provider-verified cell-phone subscriptions for more than 2.8 years (OR, 2.15; P _trend < .001).
The relations between brain tumor risk and cumulative duration of subscription, cumulative hours of use, and cumulative number of calls were not statistically significant.
"The lack of an exposure–response relationship, given our finding that risk was related to neither the amount of [cell] phone use nor the location of the tumor, does not support a causal interpretation," the authors write.
However, they add that the possibility that cell phones might confer a small increase in risk cannot be ruled out. Therefore, they emphasize "the importance of future studies with objective exposure assessment or the use of prospectively collected exposure data."


J Natl Cancer Inst. Published online July 27, 2011.

Pediatric Bipolar Disorder: A Valid Condition?

From Medscape Psychiatry

Christoph U. Correll; MD, Marta Hauser, MA

01/04/2011

• Bipolar Disorder in Children and Adolescents: A Valid Condition or an Over-Diagnosed Label?
• Increasing Rates of Bipolar Diagnosis in Youth
• Diagnostic Considerations in Youth With Bipolar Disorder Features
• Enter Severe Mood Dysregulation
• Diagnostic Uncertainties
• DSM-V
• Summary and Conclusions

Bipolar Disorder in Children and Adolescents: A Valid Condition or an Over-Diagnosed Label?

Bipolar (BP) disorder, also referred to as manic depression, is characterized by severe and disabling shifts in mood and energy levels. The symptoms can cause serious impairment in relationships and school/work performance, and are associated with a lifetime risk for completed suicide in 10%-15% of those diagnosed with BP I disorder.
Estimates of lifetime prevalence for adult BP I disorder range from 0.4% to 1.6% and, for BP II disorder, approximately 0.5%
Up until fairly recently, BP disorder was rarely diagnosed in children and adolescents.
According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), the age of onset of BP disorder is 20 (for men and women), and criteria do not distinguish between adults and children or adolescents.
However, the increased rate of children and adolescents diagnosed with BP disorder over the past 15 years has raised concern and fueled a debate regarding the accuracy and consequences of this diagnosis in developing youth.
The assignment of a BP disorder diagnosis can have serious consequences, both when this diagnosis is wrongly assigned and when it is missed.

Summary and Conclusions

In summary, despite growing evidence for the validity of pediatric BP disorder, more and longer-term prospective research is needed to characterize and demarcate the features of the disorder in youth more thoroughly and enable diagnostic consensus.
Practitioners are advised to inquire about:
(a) distinct, spontaneous periods of mood changes;
(b) family history of mania, depression and other mood disorders; and
(c) symptoms of irritability, reckless behavior, or increased energy.
However, they should bear in mind that the latter symptoms in particular might be part of other emerging psychiatric disorders and, thus, might lack specificity for BP disorder.
Furthermore, although the diagnosis of (hypo)mania should follow diagnostic criteria, attention should be given to the fact that the clinical presentation of pediatric BP disorder may differ somewhat from those of adults.
For the diagnosis, both current and past symptoms, treatment and treatment response, psychosocial stressors, biological triggers (eg menstrual period in females, substance use, sleep deprivation) and family history should be considered.
Structured interviews and questionnaires may provide helpful tools for the assessment of these aspects. Caregivers and families need to be included in the evaluation and treatment, and both the risks of overdiagnosis and underdiagnosis need to be considered when assessing and managing youth with challenging and often quite disabling emotional dysfunction.

DSM-V

The criteria for BP I and II disorder in DSM-V^[41] are virtually unchanged to those in DSM-IV. Exceptions include the renaming of mixed episode to mixed features specifier.
Based on the important work by the NIMH intramural pediatric mood disorder program on patients classified with severe mood dysregulation (see above), a new diagnostic entity is being proposed, currently called temper dysregualtion disorder with dysphoria (TDD) (Table 5).
Table 5. Proposed Criteria for Temper Dysregulation Disorder With Dysphoria

A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.

1. The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property. 2. The reaction is grossly out of proportion in intensity or duration to the situation or provocation. 3. The responses are inconsistent with developmental level.

B. Frequency: The temper outbursts occur, on average, 3 or more times per week.

C. Mood between temper outbursts:

1. Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad). 2. The negative mood is observable by others (eg, parents, teachers, peers).

D. Duration: Criteria A-C have been present for at least 12 months. Throughout that time, the person has never been without the symptoms of criteria A-C for more than 3 months at a time.

E. The temper outbursts and/or negative mood are present in at least 2 settings (at home, at school, or with peers) and must be severe in at least 1 setting.

F. Chronological age is at least 6 years (or equivalent developmental level).

G. The onset is before age 10 years.

H. In the past year, there has never been a distinct period lasting more than 1 day during which abnormally elevated or expansive mood was present most of the day for most days, and the abnormally elevated or expansive mood was accompanied by the onset, or worsening, of 3 of the "B" criteria of mania (ie, grandiosity or inflated self-esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal-directed activity, or excessive involvement in activities with a high potential for painful consequences; see pp. XX). Abnormally elevated mood should be differentiated from developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation.

I. The behaviors do not occur exclusively during the course of a psychotic or mood disorder (eg, major depressive disorder, dysthymic disorder, bipolar disorder) and are not better accounted for by another mental disorder (eg, pervasive developmental disorder, post-traumatic stress disorder, separation anxiety disorder). (Note: This diagnosis can coexist with oppositional defiant disorder, attention deficit hyperactivity disorder, conduct disorder, and substance use disorders.) The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.

Adoption of this new diagnostic entity would enable the diagnosis of youth currently labeled under the BP spectrum diagnosis heading who seem to have a different long-term course and who may very well require different treatment. However, field trials will need to confirm the validity and specificity of this newly proposed condition.