Sunday, November 20, 2011

Food Allergy in Kids Not Being Optimally Diagnosed

Medscape Medical News from the:American College of Allergy, Asthma & Immunology (ACAAI) 2011 Annual Scientific Meeting Fran Lowry November 14, 2011 (Boston, Massachusetts) — Oral food challenges are the gold standard for diagnosing food allergies in children, but only a small fraction of kids in the United States are getting them, researchers reported here at the American College of Allergy, Asthma & Immunology 2011 Annual Scientific Meeting. As a result, it is likely that childhood food allergy is seriously underdiagnosed, Ruchi Gupta, MD, from Northwestern University Children's Memorial Hospital in Chicago, Illinois, told Medscape Medical News. "Guidelines just came out in March of this year from the National Institutes of Health NIAID [National Institute of Allergy and Infectious Diseases] stating that oral food challenge is the proper test to diagnose food allergy, along with medical history and positive skin and blood testing," Dr. Gupta said. "Oral food challenge solidifies the fact that the child does indeed have that particular food allergy. It is also a way for us to determine whether they do not or whether they have become tolerant. In our study, just one fifth of the kids had one." Dr. Gupta and her colleagues conducted a randomized cross-sectional survey of American households from June 2009 to February 2010. Respondents were 18 years and older who lived in households with at least 1 child younger than 18 years and who could complete the survey in Spanish or English. The survey involved 40,104 children; of these, investigators identified 3339 children with food allergy. A formal physician diagnosis of food allergy was made in 61.5% of these children. Of these, 47% had a skin test and 40% had a blood test for food allergy. However, an oral food challenge was done in just 15.6% of children; it was done more commonly if the child had a severe food allergy or had multiple food allergies, Dr. Gupta said. Formal diagnoses were most frequently confirmed by oral food challenge for milk allergy (22.4%), soy (19.2%), peanut (16.1%), wheat (15.5%), shellfish (14.4%), tree nut (12.6%), egg (12.4%), sesame (11.2%), and fin fish (9.1%). "Overall, what this tells us is that food allergy is not being diagnosed optimally and oral food challenges are definitely not being done enough," Dr. Gupta said. However, she added, the test can be cumbersome for busy practitioners to do. This might be one reason why oral challenge is not used as often as it should be. "This lack of use is understandable because oral food challenges take a long time for physicians to do. A test can take a couple of hours, and that ties up a room for a long time. Plus, reimbursements are poor, so there are lots of reasons why allergists are not able to do as many as they probably would like to do," Dr. Gupta said. New strategies are needed to promote the appropriate diagnosis of food allergy in accordance with NIAID guidelines, she added. "We need to get the word out, especially to general physicians, to increase their awareness about the current food allergy guidelines, so that they can help getting children accurate diagnoses and getting them to allergists." John Oppenheimer, MD, an allergist in private practice in Cedar Knolls, New Jersey, and chair of the scientific program committee, told Medscape Medical News that this study reinforces the fact that care for individuals with food allergies is suboptimal. "Presently, some overrely on blood or skin testing, but the gold standard is the ability to ingest a full serving of a food," Dr. Oppenheimer said. "Blood and skin tests have a very high false-positive rate. This abstract reminds us that in some patients...oral food challenge can aid in determining a true allergy." "Despite the fact that it is almost 2012, we have no perfect test to determine if a patient is allergic to a specific food," Dr. Oppenheimer continued. "Both the blood and skin tests are solely confirmatory tools, based upon history. They function very poorly as a screening tool. Thus, the allergist is left to rely upon history and to layer these confirmatory tests to determine the best move forward. When it appears reasonable, from the standpoint of risk, they can then perform a food challenge. As noted by Dr. Gupta, these are very time consuming and are not without risk. In light of the complexity of this scenario, I always suggest involving the allergy specialist early in the care of a food-allergic patient. There is no better time to determine the likelihood of food allergy than just after the sentinel reaction," he said. New tests for food allergy are on the horizon, he added. "Peptide microarray immunoassays may help stratify prospective patients undergoing food challenge regarding the likelihood of reaction, as noted in a study by Cerecedo et al" (J Allergy Clin Immunol. 2008;1223:589-594). Dr. Gupta has disclosed no relevant financial relationships. Dr. Oppenheimer reports financial relationships with AstraZeneca, GlaxoSmithKline, Merck, and Novartis. American College of Allergy, Asthma & Immunology (ACAAI) 2011 Annual Scientific Meeting: Abstract 48. Presented November 7, 2011.

Monday, November 14, 2011

Panel Recommends Universal Cholesterol Screening for Kids

Medscape Medical News from American Heart Association (AHA) 2011 Scientific Sessions From Heartwire Michael O'Riordan November 13, 2011 (Orlando, Florida) — An expert panel is recommending that all children, regardless of family history, undergo universal screening for elevated cholesterol levels. The panel recommends that children undergo lipid screening for non fasting non–HDL-cholesterol levels or a fasting lipid panel between the ages of 9 and 11 years followed by another full lipid screening test between 18 and 21 years of age. The guidelines, from the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, appointed by the National Health, Lung, and Blood Institute (NHLBI) and endorsed by the American Academy of Pediatrics (AAP), also recommend measuring fasting glucose levels to test for diabetes in children 10 years of age (or at the onset of puberty) who are overweight with other risk factors, including a family history, for type 2 diabetes mellitus. "The goal of the expert panel was to develop comprehensive evidence-based guidelines that address the known risk factors for cardiovascular disease to assist all primary pediatric care providers in both the promotion of cardiovascular health and the identification and management of specific risk factors from infancy into young adult life," write panel chair Dr Stephen Daniels (University of Colorado School of Medicine, Denver) and colleagues in Pediatrics. The level of evidence supporting the "strongly recommended" cholesterol screening recommendation is graded B, meaning that it is based on consistent evidence from observational studies, genetic natural history studies, or diagnostic studies with minor limitations. However, as some critics have pointed out, there are no randomized, controlled, clinical trials showing that the treatment of elevated cholesterol levels in children has a long-term clinical impact on cardiovascular outcomes, as well as no data showing that the use of lipid-lowering drugs is safe in children this young or when used for decades. In addition to the publication, Daniels and members of the writing committee plan to present their report at the American Heart Association 2011 Scientific Sessions this week. Not Going to Have a Heart Attack Tomorrow Dr Steven Nissen (Cleveland Clinic, OH), who was not part of the writing committee, called the guidelines "irrational," saying pediatricians have pushed widespread cholesterol screening forward in the absence of evidence supporting pharmacologic interventions if children are found to have elevated LDL-cholesterol levels. Nissen told heartwire that while the guidelines stress dietary and lifestyle intervention in kids with elevated cholesterol levels, the temptation to use the drugs in this population will be too high. "Plus, what is the 20-year risk of cardiovascular disease in a patient who is 11 years old?" asked Nissen. "It's zero." What is the 20-year risk of cardiovascular disease in a patient who is 11 years old? It's zero. In their recommendations, the expert panel acknowledged that a focus on cardiovascular risk reduction in children and adolescents is tough, because the likelihood of a clinical end point of manifest cardiovascular disease is remote. Speaking with heartwire , Dr Daphne Hsu (The Children's Hospital at Montefiore, NY) took a different interpretation of the guidelines but acknowledged that pediatricians are forced to infer how risk factors might translate into clinical outcomes 30 to 40 years down the road. Still, she said there are data showing a risk of subclinical atherosclerosis in young patients with elevated cholesterol levels. Moreover, the new recommendations cull together the best data currently available, and based on her assessment of the risks of screening and the potential benefits, the new AAP/NHLBI guidelines make sense. As for the risks, Hsu does not believe that universal screening will lead to an increased use of cholesterol-lowering medications, such as statins. "If we find a patient has elevated cholesterol levels, we know their risk is not very high, and it is not going to be high enough to warrant treatment, but the screening could be enough to spur changes in behavior," said Hsu. "If they have elevated levels, we can then begin to look for why this is the case, and we can look for ways to change their eating habits, change what they eat, and change how often they exercise." Hsu said that it was "highly unlikely" that screening would lead to more children being treated with cholesterol-lowering medications, probably less than 1%. She said the greatest benefit would be to children with major lipid disorders who might have been missed with other screening tools. She said the 2008 AAP document on lipid screening and cardiovascular health provides guidance on treatment with pharmacologic agents. Written also by Daniels and Dr Frank Greer (University of Wisconsin Medical School, Madison), along with the Committee on Nutrition, the document says that treatment should be started if LDL-cholesterol levels are higher than 190 mg/dL [2]. The cutoff point for therapy is 160 mg/dL for children with other risk factors, with targets as low as 130 mg/dL or even 110 mg/dL when there is a strong family history of cardiovascular disease, especially with other risk factors, such as obesity, diabetes, metabolic syndrome, and other higher-risk situations. An Age When They'll Listen to You In her practice, Hsu said she sees firsthand the epidemic of childhood obesity, with many young children having pre-metabolic syndrome. With screening of children aged 9 to 11 years old, she believes they are at a vulnerable age that might be more responsive to recommendations from their family doctor, whereas older children, particularly teenagers, don't like being told what to eat or how much to exercise. She said cholesterol screening can signal potential long-term complications and can serve as an increased wake-up call for families. "We're not telling the kids or families that they're going to have a heart or stroke tomorrow but instead saying that we want them to live until they're 85 years old," said Hsu. "We want to see them live longer than their grandmother or grandfather." Nissen, on the other hand, isn't buying the argument, stating there is no evidence-based data showing that young patients or their families change their behavior when presented with evidence of a bad test result, such as increased cholesterol levels. Proponents of other screening modalities have made similar arguments in the past, suggesting that evidence of calcification or stenosis is a motivating factor to move toward heart-healthy behaviors, but the data do not bear this out. Earlier this year in the Journal of the American Society of Echocardiography, researchers reported that abnormal findings on an office-based carotid ultrasound test changed physician behavior, with doctors changing their use of aspirin and cholesterol-lowering medications, including setting more aggressive lipid and blood-pressure targets. Patients, on the other hand, failed to make changes to their diet or increase physical activity levels and, in some instances, even failed to quit smoking, despite an increased awareness of their cardiovascular-disease risk. "Shouldn't we be counseling children on the benefits of healthy eating and lots of physical exercise even without knowing their LDL-cholesterol levels?" said Nissen. "I don't see how screening changes this at all. We simply have no evidence that patients will change their behavior based on more screening." The expert panel also provides guidance on the assessment of family history of cardiovascular disease, tobacco exposure, nutrition and diet, growth and overweight/obesity assessments, blood pressure, and physical activity.

Sunday, November 13, 2011

Updated AAP Policy: Turn Off the TV and Talk to Your Toddler

From Medscape Medical News Fran Lowry November 10, 2011 (Boston, Massachusetts) — An updated policy statement from the American Academy of Pediatrics (AAP) Council of Communications and Media recommends that media, particularly television, have potentially negative effects on children younger than 2 years, and recommends no media use in this age group. "We said this in 1999, and we're saying it 12 years later, in 2011," Ari Brown, MD, a pediatrician in private practice in Austin, Texas, who headed the council, said here at the AAP 2011 National Conference and Exhibition. "Kids should learn from play, not from a TV screen. This new policy statement reaffirms what we said back then," she told Medscape Medical News. The highlights of the policy statement were unveiled at the meeting. They include the following recommendations: The AAP discourages media use by kids younger than 2 years, and pediatricians should discuss these recommendations with parents. Discuss setting "media limits" before age 2 because many parents are not aware of the AAP recommendations. Pediatricians should explain the importance of unstructured, unplugged play in allowing a child's mind to grow, problem solve, think innovatively, and develop reasoning skills. The importance of parents sitting down to play with their children cannot be overstated. Encourage parents to read to their children to foster cognitive and language development. Don't place a TV in the child's bedroom. Don't watch adult TV when a young child is in the room. Dr. Ari Brown From 40% to 60% of American households with young children report that the TV is either always or often on when no one is watching, Dr. Brown said. "The truth is someone is watching, and that's the child. The effect is distracting; it reduces talk time, which we know is important for language development, and it disrupts the child's play," she said. Since the first policy statement, research has shown just how disruptive that TV can be. A child playing in a room where the TV was on and tuned to a show that was not even geared toward children looked up at the screen 3 times per minute. "So every 20 seconds, the child would actually look up and glance at the TV. They would be less concentrated on their playing, and they would move on to another activity more quickly," Dr. Brown said. "This proves that the TV is distracting the young child from their valuable play time." Parents are encouraged to turn off the TV when their young children are in the room because they tend not to focus as much on them, she added. TV is not educational for such young children; there are better ways to engage young children, she said. "You can't be playing with your child 24 hours a day, we get that.... But your child's time is actually quite valuable. When they are playing independently, they are learning how to problem solve and think creatively — these are important life skills. You are actually doing your child a service by letting them play on their own." There is also a concern that too much television can delay language development, Dr. Brown said. "There is a national children's study that has just started looking at the long-term effects of environmental exposures, including media use. We won't have the results of that study for 20 years, but at least somebody is looking at it now," she said. "We do know about short-term effects, and can see the short-term effects in language delays. Perhaps it's because parents and children are not talking to each other when the television is on; kids really need that." Tanya Altmann, MD, from the University of California at Los Angeles, agrees that studies are showing that when the television is on in the house, parents talk less and interact less with their children. Dr. Altmann, who was invited to comment on the updated policy statement, said that video screens are much more ubiquitous than they were in 1999 when the initial policy statement came out. "It's really hard to raise children today without keeping this in mind. Everywhere you go, parents are on their smart phones, there's TV, computers. Video plays a major role in our lives today," she said. "It's so important to keep in mind that the brains of children under the age of 2 are rapidly developing. The evidence is there that such young children can't learn from screens and there may be some harmful effects. Parents must be aware of this and set limits for their children under age 2. They should even consider not having the television on at all." American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition. Presented October 17, 2011.

Friday, November 11, 2011

Is There an Up Side to Autism?

From Medscape Medical News > Psychiatrists in the News Society's Negative Bias Toward Autism Needs Rethinking, Expert Says "autism is a different way of being, not necessary a disordered way of being, and the difference can give us strengths and abilities that other people may not have." Yael Waknine November 7, 2011 — Autism may be an advantage in some settings and should not be viewed as a defect that needs suppressing, according to a provocative article published online November 2 in Nature. Dr. Laurent Mottron "Recent data and my own personal experience suggest it's time to start thinking of autism as an advantage in some spheres, not a cross to bear," author Laurent Mottron, MD, PhD, from the University of Montreal's Centre for Excellence in Pervasive Development Disorders, told Medscape Medical News. According to the article, the definition of autism itself is biased, being characterized by "a suite of negative characteristics," focusing on deficits that include problems with language and social interactions. However, in certain settings, such as scientific research, people with autism exhibit cognitive strength. "We think that the kind of strengths and cognitive profile that we find in autistics are much more specific than scientists usually acknowledge," said Dr. Mottron. "Unfortunately, there is no gold standard for the diagnosis of autism. Clinical diagnoses are reliable among scientists, but it is just a consensus...everybody may fail." He noted that as a result of a diagnosis, many individuals with autism end up working at repetitive, menial jobs despite their potential to make more significant contributions to society. "After 18 years of age they're not kids anymore, and they're forgotten," he said. "People have a cliché, that if he's autistic you can do nothing with him. That's not true. The fact that you have some terrible autistic life is not representative of autism in general." Advantages Autism should be described and investigated as an accepted variant within human species, not as a defect to be suppressed. Dr. Mottron has 8 individuals with autism people in his research group including 4 assistants, 3 students, and 1 researcher, Michelle Dawson, whom he met almost 10 years ago during a television documentary about autism. Following the show, Ms. Dawson experienced problems in her job as a postal worker and was asked by Dr. Mottron to edit some of his papers. "She gave exceptional feedback, and it was clear that she had read the entire bibliography," Dr. Mottron noted. Her single-minded autistic abilities to discern patterns out of mountains of data and instant recall of correct information made her perfectly suited to a career in science, he said. Though lacking a formal doctorate, Ms Dawson has since coauthored 13 papers and several book chapters. Dr. Mottron said Ms. Dawson and other individuals with autism have convinced him that more than anything, people with autism "need opportunities, [and] frequently support, but rarely treatment." As a result, he believes that "autism should be described and investigated as an accepted variant within human species, not as a defect to be suppressed." Dr. Mottron noted that autistic brains do function differently, relying less on verbal centers and demonstrating stimulation in regions that process both visual information and language. Advantages may include spotting a pattern in a distracting environment, auditory tasks such as discriminating sound pitches, detecting visual structures, and mentally manipulating complex 3-dimensional shapes. Individuals with autism also perform Raven's Matrices at an average of 40% faster than nonautistics, using their analytical skills to complete an ongoing visual pattern. Other benefits of autism include the ability to simultaneously process large amounts of perceptual information as data sets and the presence of instantaneous and correct recall. Because data and facts are of paramount importance to people with autism, they also tend not to get bogged down in career politics or seek popularity via promotional publishing; online essays such as those posted by Ms. Dawson in her blog may instead receive unintentional acclaim. Intellectual Disability Not Intrinsic What we know is that if we reach these individuals at a young age, when their brains are malleable, we can cognitively redirect the transmission of information via the corpus callosum to the speech areas in the left hemisphere of the brain and oftentimes speech and language will kick in. "I no longer believe intellectual disability is intrinsic to autism," Dr. Mottron said, noting that intelligence in people with autism should be measured with nonverbal tests. In his article, Dr. Mottron cites recent data, including an epidemiological study that showed the disorder is 3.5 times more prevalent than common statistics suggest. He noted that the study showed that many of those with autism have "no adaptive problems at all," and can function relatively normally. However, he added, a focus on "normocentrism" prevails in some countries. France, for example, has proposed mandatory interventions aimed at forcing children with autism to adopt "typical" learning and social behaviors, rather than allowing them to make the most of their differently wired brains. Dr. Mottron finds such a concept concerning. "There is no current treatment for autism, just educational strategies that do not put the emphasis on learning abilities for nonsocial information.... [W]e need to take their learning style for what it is and feed it," he said. Joanne Lara Some of these therapies may include engaging children with autism in a music and movement program, said Joanne Lara, MA, founder of Autism Movement Therapy, Inc, in an interview with Medscape Medical News. "What we know is that if we reach these individuals at a young age, when their brains are malleable, we can cognitively redirect the transmission of information via the corpus callosum to the speech areas in the left hemisphere of the brain, and oftentimes speech and language will kick in." She continued: "The audio processing of music in the brain combined with the forward, backward, and side-to-side movements stimulate and activate the dormant areas of the brain that, in autism, do not generally receive transmission of neurons. "Movement and music, when combined with gross motor and visual processing, oftentimes helps the areas of the brain of the individual with autism to work together to allow for a whole-brain processing approach," she added. Counterpoint "I think it's critically important to acknowledge the potential strengths associated with autism, but it's equally important, if not more important, to reiterate the notion of the right to effective treatment," Jonathan Tarbox, PhD, BCBA-D, director of research and development at the Center for Autism and Related Disorders, Tarzana, California, told Medscape Medical News. "If an individual with [autism] is having a difficult time in their life because they don't know how to do something that they want to do, and there is a proven effective method to teach that skill, then we as fellow humans have a moral and ethical responsibility to provide the treatment that addresses it," he said. Behavioral intervention programs, he said, should be used in a supportive environment to treat skill deficits in individuals with autism wanting to learn, similar to those used for literacy and mathematics. He added that autism is no different: People who have skill deficits and want to learn have a right to effective treatment. Dr. Tarbox took exception to Dr. Mottron's contention that individuals with autism need opportunity more than treatment. Environmental support, he said, does create opportunity. In addition, he noted that research shows that early intensive behavioral intervention increases the ability to communicate and function independently. "How can a newly found ability to communicate not be considered an opportunity?" he said. One of Dr. Mottron's main points is that the performance of individuals with autism on visual intelligence tests is often overlooked, showing that the true intelligence of people with autism is higher overall than verbal intelligence tests would indicate. "This is, of course, true, but true intelligence is of little relevance to a person's everyday quality of life. What really matters is one's ability to do what one wants to do in life independently; that is, without having to rely on support from others," said Dr. Tarbox. There are many people, autistic and nonautistic, who have superior intelligence, but still have much difficulty in life and suffer for it. "There are many people, autistic and nonautistic, who have superior intelligence but still have much difficulty in life and suffer for it. Unfortunately, vocal language is the medium with which most humans interact, so deficits in one's ability to vocally communicate are going to create barriers for people." Dr. Mottron also states that no education programs are tailored to the unique ways that people with autism learn. However, Dr. Tarbox noted that there are "many tens of thousands of special education teachers, speech and language pathologists, and applied behavior analysts working to change what they do to help individuals with autism learn." The aim of behavioral interventions, he added, is not to try to teach individuals with autism to adopt typical learning and behavior but, rather, to teach skills that help increase independence. Such programs, he said, "teach skills that open doors for individuals with autism, but they do not dictate which door to take." First-Hand Experience I think what Dr. Mottron was getting to is the idea that autism is a different way of being, not necessary a disordered way of being, and the difference can give us strengths and abilities that other people may not have. "I think what Dr. Mottron was getting to is the idea that autism is a different way of being, not necessary a disordered way of being, and the difference can give us strengths and abilities that other people may not have," said Stephen M. Shore, EdD, assistant professor at Adelphi University in Long Island, New York, in an interview with Medscape Medical News, citing the well-known accomplishments of Temple Grandin, PhD. "At the same time, there are many challenges that come with being on the autistic spectrum, such as sensory issues, communication, interacting with others. These things are challenges, and we do have to address them," Dr. Shore noted. Diagnosed himself with autism at age 2 and a half years, and nonverbal until age 4 years, Dr. Shore was originally recommended for institutionalization. With the help of family and others, he completed a doctoral dissertation at Boston University in Massachusetts that was focused on matching best practice to the needs of people on the autism spectrum. He now spends his time researching, teaching, writing books, and conducting autism workshops around the world. According to Dr. Shore, the best way to address those issues is to find a way to use a person's strengths to overcome their challenges. "There is a point in time when you have to get off the remediation and start moving on to finding a way the person can be successful in communication," he said. Methods may include use of a computer keyboard, rather than a pen, to write, or pointing at pictures to communicate, he said. Adjusting the environment also plays a vital role and often benefits people without autism. "Many autistics have sensory issues and perceive fluorescent lights as most people strobe lights, which will really affect productivity at work and school," Dr. Shore said. "Research shows that everybody's productivity is affected by fluorescent lamps, so everyone benefits by using alternate lighting." With respect to the plethora of methodologies used to address autism in children, Dr. Shore notes that the wide variety of diversity within the autism spectrum disorders necessitates a tailored approach. Parents and educators are encouraged to pick one or more approaches that best suits the child's needs and abilities. This may include use of Applied Behavioral Analysis, Treatment and Education of Autistic and Related Communication-Handicapped Children, Daily Life Therapy, the Miller Method, the Developmental/Individual Difference/Relationship-based method, relationship development intervention, and social communication/emotional regulation. "You can have a right or wrong approach on an individual basis, but not on a generic basis," he said. Nature. Published online November 2, 2011. Full text

Wednesday, November 9, 2011

How to talk with your teen

The teenage years are full of change for both parents and teenagers. Not only are teens growing and changing physically, but they are developing their identity and becoming more independent. The hormones that drive puberty and bring on its physical changes also affect how a teen thinks and feels. At the same time, major changes happen in the adolescent brain, influencing judgment, decision-making, and emotions. Teens test their limits and try very hard to fit into their peer groups. You might even think that your teen’s friends have become more important to him than you and your family. Why is healthy communication important? As your teen moves toward adulthood, it’s normal and natural for her to put distance between herself and family. But it’s more important than ever to keep the lines of communication open. If your teen feels she can talk to you, than she knows you will listen and consider his views, and chances are you have and will continue to have a healthy relationship. By encouraging open and honest conversation, your teen is more likely to come to you for the important stuff—like relationships, school, sex, drugs—rather than turning to friends for help and guidance or feeling alone. Here are some tips to help you communicate with your teen: Talk with your teen about his interests (music, sports, hobbies, plans for the weekend, future goals). Schedule family time. All teens need to feel that they’re a valued member of the family. Part of that will come from setting aside family time to do regular activities together, such as going to the movies, going for a hike or skating. Family meals are an excellent way to connect with each other and talk about the things that happened during the day. Research also shows that having at least one family meal a day can prevent your teen from experimenting with risky health behaviour. Spending time as a family will help you know your teen as he grows and develops. Listen. Teens want their parents to listen to their stories, concerns and feelings with patience, understanding, and acceptance. Your teen needs to believe he can share problems and issues, and know that you will support him. It’s also a good idea to repeat her own words when discussing what your teen tells you so that she knows you understand. Be prepared and willing to discuss the things he wants to talk about. Think about the things your teen might want to talk about (relationships, sex, drugs, alcohol) so that you are ready when he comes to you with difficult questions or ideas. Treat your teen with respect and don’t dismiss his feeling or opinions. Find ways to discuss and acknowledge your differences without judging. Listen to your teen’s point of view with an open mind. Active listening will help your teen feel important, know that you take her concerns seriously, and will strengthen your relationship. Be trustworthy. Don’t make fun of your teen, or share his personal stories with others. Respecting your teen’s desire for privacy is important. If you do, he is more likely to talk about issues like violence, abuse, harassment or severe mood problems. Stay calm, and try not to get frustrated. Your questions and tone of voice might put your teen on the defensive. Offer help, even if your teen doesn’t ask. The challenge is to be involved without intruding and to let your teen know you are always available. Avoid lectures. If your teen’s stories spark a lecture from you, she’ll be less likely to share with you another time. Express your concerns, but know that it’s normal for teens to experiment. Be upfront about the rules and consequences. Keep it short, and to the point. Teens generally won’t stay focused for long conversations. Plan. Set aside regular time to catch up, or talk about issues your teen is facing. Another good place to talk with your teen is while travelling together in the car, when you have a captive audience. Step away. If a conversation becomes emotional or heated, it is probably a good idea to step away and come back to it when everyone has calmed down. Be honest about your feelings. If you are, your teen may be more open with you. When should I call the doctor? Change is normal in the teenage years, but drastic or dramatic changes in your teen’s behaviour or routine may be cause for concern. Here are some warning signs to watch for: extreme weight gain or weight loss, sleep problems, significant irritability or ongoing problems with mood, sudden change in friends, or isolation, trouble at school, either with learning or behaviour, trouble with the law, overuse of electronic media like cell phones or smart phones, or signs of drug or alcohol use. If your teen is showing trouble with any of these things, talk to your doctor. For more information: Social media: What parents should know Your teen’s sexual orientation Reviewed by the CPS Adolescent Health Committee and Public Education Advisory Committee

Tips for limiting screen time at home

“Media” is the term used to describe the many ways we communicate. Electronic media includes television, computers, cell phones, video games and movies. The amount of time we spend using them is sometimes called “screen time”. Children and teens have access to more kinds of electronic media than ever before. You can help your children develop healthy media habits by monitoring screen time and teaching them to use media safely and wisely. How can I set limits on my children’s screen time? Start encouraging good media habits when your children are young. Otherwise, it will get harder to enforce limits and influence their choices as they get older. Consider all electronic media when setting time limits for your family. Television, movies, the Internet (including social media), video games and gaming devices (whether hand-held, or played through a computer or television) all add to your child’s total screen time. Children learn many of their values and ideas from their parents. Be aware of your own media habits and change them if necessary. Limit television watching to less than 1 to 2 hours per day. Avoid making television watching part of your regular daily routine. Keep television, computers and gaming equipment out of your child’s bedroom. Keep them in common areas, where you can watch your children while they use them. Turn off the television or computer when you aren’t using it. Balance screen time with sports, hobbies, creative and outdoor play, both on their own and together as a family. Late-night chatting online, surfing and texting with friends shouldn’t cut into important sleep time. Ask your child or teen to give you their cell phone at a certain time at the end of they day so they aren’t interrupted with phone calls or text messages during family time. Talk about the importance of shutting off cell phones and the value of being unconnected at night. Find out about online protection for your family. Programs that provide parental controls can block websites, enforce time limits, monitor the websites your child visits, and their online conversations. Ask your child or teen where else she uses computers. Talk to teachers and caregivers about where and when your children are using electronic media. How can I help my child develop healthy electronic media habits? Get involved in your child’s media use — watch, play and listen with your child. Talk to her about it, find how what she enjoys and why. Share your own beliefs and values. Preview television shows, music and video games to see if they are okay. Encourage your child to try different media experiences. Help them make good choices. Learn about the Canadian and American ratings systems for television, music, movies and video games. They can help you choose appropriate media with your child. Talk to your child about stereotypes and violent images in the media. Educate him about the strategies that advertisers use to sell products to children. Limit the violent content your child is exposed to. Notice whether there are any changes in how he behaves after watching scary or violent shows, or playing video games. Speak out. If media content strikes you as inappropriate or offensive, tell the media organization. For more information: How to promote good television habits Impact of media use on children and youth: A position statement by the Canadian Paediatric Society. Media Awareness Network My Privacy, My Choice, My Life: A resource for children and teens about online privacy by the Office of the Privacy Commissioner of Canada. Concerned Children’s Advertisers: A website with tools to help children be media-wise. Reviewed by the CPS Community Paediatrics Committee and Public Education Advisory Committee Posted: June 2011 Canadian Paediatric Society

Friday, November 4, 2011

No Imaging Needed for Most Low Back Pain in Teens

Medscape Medical News from the:American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition November 1, 2011 (Boston, Massachusetts) — Most cases of low back pain in children will get better with conservative management and do not need to be diagnosed with radiographic studies, researchers said here at the American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition. Mechanical low back pain is common in the pediatric population, and recent studies have shown that undiagnosable mechanical low back pain accounts for up to 78% of cases in adolescents. The most common pathologic cause of back pain in this age group is spondylolysis and spondylolisthesis, senior author Denis Drummond, MD, from the Children’s Hospital of Philadelphia, Pennsylvania, said. Low back pain can appear very serious when a child presents, and kids can end up getting a big work-up with too many imaging studies, Dr. Drummond told Medscape Medical News.This exposes them to too much radiation, he said. "It’s bad enough to give radiation to an adult, but a child absorbs more and their metabolism is much greater than an adult’s. Radiation is accumulative and kids with low back pain get imaged close to the pelvis, which exposes the ovaries, bladder, and colon to potentially dangerous doses," he added. In the current study, Dr. Drummond and his team retrospectively reviewed the records of 2846 children aged 10 to 19 years who were seen at their institution with low back pain between 2000 and 2008. Most (63%) were female, and the average age was 14 years. In 79% of the patients (n = 2244), the cause of their low back pain went undiagnosed. Over 90% had 3 or fewer office visits. Spondylolysis, which was diagnosed in 272 patients (9.6%), was found by plain radiography in 234 patients (86%), by bone scanning in 34 patients (12.5%), and by computed tomography (CT) in 4 patients (1.5%). Two-view and 4-view radiography was equally sensitive in diagnosing spondylolysis. The sensitivity of 2-view was 78%, and that of 4-view was 72% (P = .39). The researchers also found that bone scans delivered significantly more radiation than both CT and 2- and 4-view radiography. "We didn’t think that bone scans would be associated with so much radiation when we started this study. But it turns out that it was the worst of all the imaging modalities. The dye from the scan sits in the bladder for 24 hours and that is enough to change some cells if done often enough," Dr. Drummond commented. "When we presented this, people said ‘Holy cow! I didn’t know bone scans were associated with so much radiation,’ and they told me they were now going to consider giving up doing them," he said. "Our message is try and treat the low back pain conservatively. If you want, you can do a 2-view x-ray at the first visit or else put them on physical therapy, and be patient. If they are 50% to 60% improved when you see them in 6 weeks, you’re probably on the right track. If the pain is all gone at 3 months, get them ready to go back to sports or usual activities. If there is just as much pain at 6 weeks, go back to the old system of more investigation, but the majority will get better by then," he said. American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition; Abstract #14782. Presented October 14, 2011.

HBA1c Unreliable for Pediatric Screening

From Reuters Health Information By Will Boggs MD NEW YORK (Reuters Health) Oct 26 - Hemoglobin A1c is not a reliable marker of dysglycemia in overweight or obese children and adolescents, researchers say. "Despite the new guidelines recommending the use of hemoglobin A1c for diagnosis of diabetes, it is not as reliable a test for identifying children with diabetes or at high risk for diabetes," lead author Dr. Joyce M. Lee from University of Michigan in Ann Arbor told Reuters Health in an email. She suggests that doctors "consider ordering alternative tests, such as a random glucose or a 1 hour nonfasting glucose tolerance test." Dr. Lee and colleagues compared five nonfasting screening tests in 254 overweight or obese children and adolescents aged 10 to 17 years: HbA1c, urinalysis, fructosamine, a one-hour glucose challenge, and a random blood test. A formal two-hour oral glucose tolerance test showed that 39% of the youngsters had prediabetes and 1.2% had diabetes, according to a report online September 27th in Diabetes Care. Urinalysis had a very low sensitivity (but high specificity) for detecting dysglycemia. On the other tests, higher thresholds provided lower sensitivity and higher specificity, whereas lower thresholds had higher sensitivity but lower specificity. Discrimination was poor for HbA1c and fructosamine levels, as evidenced by relatively low likelihood ratios across test thresholds, as well as by low values for area under the curve (AUC). With random glucose and one-hour glucose challenge tests, however, discrimination was "closer to an acceptable range," the authors said. Both provided substantially higher AUC compared to HbA1c or fructosamine. The researchers say their findings are consistent with other recent studies of HbA1c tests in children. "Either the nonfasting one-hour glucose challenge test or the random glucose represent promising screening tests for use in the pediatric primary care setting, as these are tests that clinicians can easily order the same day of the visit," they conclude. Dr. Lee said she and her colleagues are now trying to learn "whether a clinical risk score based solely on clinical characteristics" would help screen children for diabetes. "This would be a convenient and cost-effective way to identify high-risk children," she said. SOURCE: Diabetes Care 2011.

Wednesday, November 2, 2011

Community-acquired Pneumonia in Children

From Thorax What's New? Anne Thomson; Michael Harris 10/27/2011; Thorax. 2011;66(10):927-928. © 2011 BMJ Publishing Group Ltd & British Thoracic Society Abstract The community-acquired pneumonia in children guidelines have just been updated with new evidence on incidence, aetiology and management. This guidance should improve patient care. Introduction The British Thoracic Society (BTS) guidelines have recently been updated, reflecting 10 years of new evidence.[1] What have we learned in that time? The past decade has brought new diagnostic techniques, the introduction of universal infant pneumococcal vaccination and new information on antibiotic delivery. Community-acquired pneumonia (CAP) is common and most is seen and treated in the community. The guideline confirms that no diagnostic tests are necessary in the community but emphasises the importance of providing families with information, including advice on management, identifying any deterioration and the importance of reassessment. The incidence of children admitted to hospital with CAP (defined as fever, clinical signs and chest radiograph infiltrate) in the prepneumococcal vaccine era was 33/10 000 aged 0–5 years and 14.5/10 000 aged 0–16 years evidenced from remarkably consistent prospective studies in Norway and the UK.[2 3] Infant vaccination with PCV 7 (seven-valent pneumococcal conjugate vaccination) started in the UK in 2007, and a national time trends study has shown a 19% decrease in admission rates between 2006 and 2008.[4] In countries such as the USA where PCV 7 has been available for longer, a decrease in hospital admissions of ~30% is reported. When establishing aetiology, new PCR techniques have improved diagnostic yield so that a pathogen can be detected in 65–86% of cases. This careful work has identified mixed viral–bacterial infection in 23–33% of CAP cases. Streptococcus pneumoniae remains by far the most common bacterial cause and is found in 30–40% of cases as a single or co-pathogen. Group A Streptococcus contributes 1–7% of cases. Mycoplasma and Chlamydia pneumoniae are found with variable frequency and are not uncommon in the preschool child. The common winter viruses respiratory syncytial virus (RSV), parainfluenza and influenza are frequent pathogens, but the newer identified viruses such as human metapneumovirus and human bocavirus are found in 8–12% and ~5%, respectively. Overall viruses account for 30–67% of cases and are most frequent in children <1 year of age.[5 6] In the 2002 guidance, clinicians were encouraged to search for a pathogen in all cases, but this has been revised to more practical guidance that aetiological investigation be restricted to those with either severe or complicated disease. Clinical features of pneumonia are not specific for aetiology, and the evidence is that chest radiograph findings do not help in this respect. The WHO produced a method for standardising the interpretation of chest radiographs in children, but, even using this, the concordance rate between trained reviewers was only 48%.[7] Little wonder that chest radiograph interpretation can create heated discussions on ward rounds! Investigation of the use of acute phase reactants as a means of differentiating aetiology and/or severity of CAP has continued over the past 10 years. There have been many publications and much heat, but no light. The outcome is simply to reinforce the guidance that they are not of clinical utility in distinguishing viral from bacterial infections and should not be a routine test. Oxygen saturation <92% is an indicator of severity and the need for oxygen therapy. No new studies on oxygen delivery were identified. Similarly, there were no new studies on physiotherapy, but good quality evidence already exists that it is not beneficial and should not be performed in children with pneumonia. The BTS paediatric pneumonia audit data from 2010 showed that 15% (of 2209 cases reported) were nevertheless receiving it. So how does this evidence help us decide who should receive antibiotics? We know that viruses are the most common cause of lower respiratory tract infection (LRTI) in young children. In a vaccine probe study, only 6% of children <2 years old with a clinical diagnosis of pneumonia had Pneumococcus identified.[8] With the introduction of PCV 13 the likelihood of bacterial pneumonia in a fully vaccinated child will fall further. Fully vaccinated children <2 years old presenting with mild symptoms of LRTI need not be treated with antibiotics, but should be reviewed if symptoms persist. The evidence is that bacterial and viral pneumonia cannot reliably be distinguished and therefore all other children with a clear clinical diagnosis of pneumonia should receive antibiotics. Which antibiotic should be used? On the basis of the known common bacterial pathogens in children and available randomised controlled trials of different antibiotics, amoxicillin is effective, well tolerated and cheap. In the past some paediatricians have been anxious that Mycoplasma pneumoniae be covered, and have in addition used macrolide antibiotics. However, a Cochrane review did not find enough evidence to indicate that antibiotics improved outcomes in children with M pneumoniae LRTI.[9] Studies using only amoxicillin have had very low failure rates. Macrolide antibiotics should not be first line but can be added at any age if there is no response to first-line empirical therapy. There is important new evidence on how those antibiotics should be given. The PIVOT trial randomised UK children over the age of 6 months to either oral amoxicillin or intravenous penicillin, and the outcomes were equivalent (with a shorter duration of hospital stay in the oral group).[10] Similar results have been reported in the developing world. Oral amoxicillin is therefore the antibiotic of choice both in the community and in hospital. Intravenous antibiotics should be reserved for children unable to absorb oral drugs or those presenting with septicaemia or complicated pneumonia. These recommendations should result in significant changes to practice and be welcomed in these financially challenged times as they should decrease costs with no change in effectiveness of treatment. Junior doctors are creatures of habit and feel (rightly or wrongly) that they are more likely to be criticised for underinvestigation than overinvestigation and usually send laboratory tests when inserting an intravenous line. Now: no intravenous line, no tests, no physiotherapy. Simple oral antibiotics and supportive care will be effective for the majority of children with CAP, who will also escape from hospital faster.

Tuesday, November 1, 2011

Maternal Hypertension Increases Risk for Birth Defects

From Medscape Education Clinical Briefs News Author: Ricki Lewis, PhD CME Author: Désirée Lie, MD, MSEd 10/21/2011 Clinical Context Some studies have suggested an increased risk for fetal malformations with the use of angiotensin-converting enzyme (ACE) inhibitors in the first trimester of pregnancy, but this observation has not been confirmed in other studies. This is a population-based examination of mother–infant pairs recruited between 1995 and 2008 to examine the risk for congenital malformations with use of ACE inhibitors, use of other antihypertensives, and no use of antihypertensives among pregnant women both with and without hypertension. Study Synopsis and Perspective Pregnant women with treated or untreated hypertension are at higher risk of carrying fetuses with congenital anomalies than are normotensive women. The finding points to elevated blood pressure as the teratogen, rather than the drugs used to treat it, according to a report published online October 18 in the British Medical Journal. ACE inhibitors are known to be teratogenic during the second and third trimesters. A 2006 study using data from the Tennessee Medicaid population associated first-trimester ACE inhibitor exposure with neural tube defects and cardiac malformations, but did not find association with other antihypertensives. Two subsequent studies implicated other drugs. The new investigation disentangles the effects of antihypertensive drugs from those of the condition they treat. De-Kun Li, MD, PhD, MPH, and colleagues at the Kaiser Foundation Research Institute in Oakland, California, conducted a population-based retrospective cohort study that evaluated 465,754 mother-infant pairs from northern California in the Kaiser Permanente database, from 1995 to 2008. This included electronic medical records of fetal malformations, maternal drug exposures, and potential confounding factors such as preexisting diabetes and overweight during pregnancy. The researchers compared 4 groups of pregnant women: those with hypertension who took ACE inhibitors during the first trimester, those with hypertension who took other antihypertensives during the first trimester, those with hypertension who took no antihypertensives during the first trimester, and pregnant women who did not have hypertension and did not receive antihypertensives for other indications. The offspring of women taking antihypertensives had elevated rates of cardiac anomalies and birth defects overall, but not of neural tube defects, compared with women not taking the drugs. However, the elevation was not seen when rates were compared with the cohort of women with untreated hypertension, implicating the underlying hypertension. Use of ACE inhibitors in women with hypertension was associated with increased risk for congenital heart defects compared with normal control participants (those with neither hypertension nor use of antihypertensives), at 15 of 381 (3.9%) v 6232 of 400,021 (1.6%) patients, with an odds ratio of 1.54 (95% confidence interval [CI], 0.90 - 2.62). Similar associations were found for other antihypertensives. However, compared with the 2.4% (708/29,735) of pairs with untreated hypertension that had congenital heart defects, the use of ACE inhibitors or other antihypertensives in the first trimester was not associated with increased risk (odds ratios, 1.14 [95% CI, 0.65 - 1.98] and 1.12 [95% CI, 0.76 - 1.64]). "Compared with the hypertension controls, there was no increased risk of malformation associated with use of either ACE inhibitors or other antihypertensive drugs," the investigators conclude. Limitations of the study include not controlling for influences of diet and exposures to other medications and not delineating more specific types of birth defects. In an editorial, Allen Mitchell, MD, from the Slone Epidemiology Center at Boston University, Massachusetts, supports the findings, adding that we still have much more to learn about the precise effects of elevated maternal blood pressure on the fetus. The study was funded by the Agency for Healthcare Research and Quality and the Food and Drug Administration. The authors have disclosed no relevant financial relationships. BMJ. Published online October 18, 2011. Full text