Tuesday, December 4, 2012

Food Allergy Guidelines in Kids

Food Allergies in Kids: Putting the Guideline Into Practice

An Expert Interview With AAAAI

Laurie Scudder, DNP, PNP, Anna Nowak-Wegrzyn, MD
  Nov 27, 2012 Authors & Disclosures
Editor's Note:
In 2010, an expert panel convened by the National Institute of Allergy and Infectious Diseases (NIAID) released Guidelines for the Diagnosis and Management of Food Allergy in the United States[1] This exhaustive summary of current literature and expert opinion provided 43 clinical recommendations for the recognition and management of the growing problem of food allergies. One year later, a second group of pediatric allergy experts provided a summary that described the application of these guidelines in infants, children, and teens. [2] However, the American Academy of Pediatrics (AAP) Section on Allergy and Immunology recognizes that more education and awareness are necessary to insure widespread uptake of the guidelines. To that end, AAP and the American Academy of Allergy, Asthma & Immunology (AAAAI) have developed summary documents for pediatric and family medicine providers. Medscape spoke with Anna Nowak-Wegrzyn, MD, Associate Professor of Pediatrics at Mount Sinai School of Medicine's Jaffe Food Allergy Institute about the AAP/AAAAI efforts, the most relevant guidance for children, and continuing controversies in the area of food allergies.
Medscape: What has been the reaction to the guidelines on the part of pediatric providers?
Dr. Nowak-Wegrzyn: I would say overwhelmingly positive. The guidelines were welcomed because food allergy is very common in pediatric practice and not easy to diagnose and manage. Having a document that provides some benchmarks and concrete advice is very helpful.
Medscape: What are the major differences between the 2010 guidelines and earlier recommendations from AAP?
Dr. Nowak-Wegrzyn: The 2010 guidelines put all the current standards of practice into 1 document. In fact, the guidelines reiterated some of the previous guidelines issued by AAP. For instance, the AAP Section on Allergy and Immunology guidelines on prevention of food allergy through diet [3] have been in agreement with the guidelines. Another recent document on use of allergen-specific IgE testing in children with suspected food allergy [4] is well aligned with the guidelines.
Medscape: Are there specific recommendations that have been more challenging to implement in kids?
Dr. Nowak-Wegrzyn: Defining the role of food allergy in children who have atopic dermatitis remains quite challenging. The guideline states that children who have moderate to severe persistent atopic dermatitis benefit from an evaluation for food allergies; it is definitely a clinically challenging problem to figure out which children are appropriate for this kind of evaluation.
The other area of controversy is food allergy prevention by dietary modification; the question of whether avoidance of certain foods during pregnancy or early life could modify the natural course of allergy or prevent food allergy continues to be investigated. The guideline states that there is really no evidence to recommend any of these interventions and emphasizes that the preferred nutrition for an infant is breastfeeding in the presence of a healthy, unrestricted maternal diet. Solids should be introduced when children are ready for the different textures, which usually happens between 4 and 6 months of age. There is really no evidence that delaying introduction of any highly allergenic foods beyond that point prevents any allergy.
This is, again, aligned with the prior statements that were issued by the AAP Section on Allergy and Immunology regarding that topic.
Medscape: Subsequent to the publication of the NIAID-sponsored guideline, the AAP Section on Allergy and Immunology released a clinical report describing the use of allergen-specific IgE testing in children suspected of food allergy. [4] Can you describe the key elements of this report for primary care pediatric providers? Are they in alignment with the 2010 guidelines?
Dr. Nowak-Wegrzyn: Yes. This report is really a reiteration of the guidelines and emphasizes that IgE food allergy represents a big portion of food allergy disorders. These include anaphylaxis, immediate urticaria, and angioedema, as well as atopic dermatitis in some children. Testing for food-specific IgE, which can be done by measurement of specific IgE in the serum or skin-prick testing, is the currently available mainstay of diagnosis. These 2 methods of testing have similar sensitivity and specificity; however serologic testing has less variability.
Both documents caution about careful interpretation of those test results, because documenting a positive IgE response to food doesn't equate to diagnosis of food allergy. Many children who have positive skin tests and positive detectable IgE levels to specific food can ingest the food without any symptoms; in such situations as this, food challenges might be necessary to provide an accurate diagnosis.
In contrast, the documents advise caution even if the tests are negative. That is, even if the child has an undetectable level of IgE by skin-prick test or blood measurement but he or she has a history of an anaphylactic reaction after ingestion of a certain food, the guidelines say you have to take a step back. You cannot just say, well, this child is no longer allergic to this food and allow him or her to eat it at home. If you have a history of severe reaction, even in the setting of negative testing, you should definitely recommend a supervised oral food challenge by a physician who is familiar with managing anaphylaxis.
On one hand, there are children with positive testing who eat the food without any symptoms and nothing happens. On the other hand, there are children who have negative tests, and yet they have a history of severe reactions. In both situations, you have to be pretty careful in interpreting those results.
The other thing that the guidelines stress, which I think is very important for a pediatric provider to recognize, is not to perform panel testing of large panels of food allergens. Instead, focus on the major food allergens in childhood, which are cow's milk, egg, soy, wheat, fish, and peanut and tree nuts. For example, take the case of a child who has severe atopic dermatitis that is very difficult to control with medical therapy, and you are considering the possibility of a food allergen being responsible for this child's skin symptoms. It is appropriate to test for these most common offenders, in addition to the specific foods that have a clear history of a reaction.
The diagnosis of food allergies is not casual. It changes everything. It changes the child's nutrition and increases the potential for a resultant deficiency of protein, vitamins, and minerals. On the other hand, if you miss the diagnosis there is the risk for a life-threatening reaction. Diagnostic accuracy is extremely important. You really don't want to run a panel of 50 tests and then say to the child and family: You are positive, and you are allergic to those 50 foods -- avoid them, goodbye.
If you have reasons to believe that the child with severe atopic dermatitis that is not well controlled with the optimal medical therapy, including moisturizing skincare and moderate- to high-potency topical steroids or anti-inflammatories (such as tacrolimus or pimecrolimus), has an allergy that is driving the skin inflammation, you should look at milk, egg, soy, wheat, or nuts as the most likely causes of skin disease. You would definitely want to perform food challenges to prove that avoidance is necessary. However, if the test results are within the highly predictive range in a child (eg, peanut IgE level ≥ 15 kIU/L), you have over 95% certainty that this child would react with some kind of a symptom during the food challenge test, so you might delay the feeding (challenge) test.
Although as clinicians, we focus on avoidance in kids with food allergies, it is equally important to ensure that you are also making up for things that you are taking away from them. They should be referred to a nutritionist or a dietician to correct for those deficiencies.
Medscape: Can you speak to the emotional effect of food allergy on a young child ?
Dr. Nowak-Wegrzyn: You bring up a very important point. As a physician, I typically focus on the medical issues, such as risk for anaphylaxis or severe eczema. But this diagnosis, as you well know, affects the entire family.
Food allergies affect quality of life not only for an individual child, but also the entire family. It affects how the parents live and cook, where they shop, and where they go out -- or maybe they stop going out, because they don't want to go to a restaurant and be at risk for a reaction. Some people will not fly. They will not go on vacation to a remote area with a child with this diagnosis.
Food allergy is not a casual diagnosis. It has to be really taken seriously. Overdiagnosing food allergy has multifaceted implications for the child and the family.
Medscape: The expert panel in 2010 concluded that insufficient evidence existed to recommend administering influenza vaccine, either inactivated or live-attenuated, to patients with a history of severe reactions to egg proteins. Subsequent guidance from the Advisory Committee on Immunization Practices (ACIP) notes that persons experiencing severe reactions to egg should be referred to an allergist for further testing, but did not indicate that vaccination was contraindicated. [5] This issue continues to be a concern to practicing clinicians. Can you summarize the current evidence on administration of influenza vaccine to children with suspected egg allergy?
Dr. Nowak-Wegrzyn: The guidelines were based on the evidence that was published before they were issued in 2010. Since then, a number of clinical reports and large studies have reported safe administration of the influenza vaccine to children with egg allergy.
What also happened over that period is that the production standards have changed. The industry recognized that this is an issue for many children and improved methods to lower the content of egg proteins, and most vaccine manufacturers now provide information about the content of ovalbumin.
Medscape: A recent study conducted by researchers at the Mayo Clinic documented a 3-fold increase in the incidence of peanut allergy in children[6] Over three quarters of these cases occurred in children younger than 2 years, and about 70% were boys. Can you speak to some of the potential reasons for this increase?
Dr. Nowak-Wegrzyn: This is the million-dollar question! There are many hypotheses. For one, the phenomenon of peanut allergy epidemics is happening mostly in highly developed countries with a so-called westernized lifestyle. In these countries, peanut is predominantly consumed in dry-roasted form. In the other 2 top producers and consumers of peanut, China and India, peanut is consumed as peanut oil or fried or boiled peanut. Studies have shown that the high temperatures during dry roasting make certain proteins more resistant to digestion and enhance the allergenic properties of peanut.
The timing of the introduction of peanut into the infant's diet may be also important. The peanut epidemics unfolded in countries that adopted delayed introduction of peanut into the diet, beyond the first 2-3 years of life, as a means of preventing peanut allergy in susceptible children. However, when 2 Jewish populations were compared -- one living in London that had high rates of peanut allergy, and the other living in Israel that had very low rates of peanut allergy -- the only difference identified was the timing of introduction peanut to infant diet. [7] In London, peanut introduction was delayed, whereas in Israel, peanut was introduced early -- usually by 6 months of age -- in a form of a corn puff covered with peanut, which is a popular snack in that country. This observation led to a very important study,Learning Early About Peanut Allergy (LEAP), that is currently being conducted in London. In this study, children at risk for peanut allergy are being exposed to peanut early in life. The results are expected in 2013-2014.
These are only 2 examples; other theories include the hygiene hypothesis or an overall change in the diet toward more saturated fatty acids.
Medscape: Can you describe the AAAAI and AAP outreach efforts and point our members to best available clinical resources?
Dr. Nowak-Wegrzyn: Both organizations have been very proactive in exploring every possible means of disseminating the guidelines. We have contacted other professional organizations to feature articles in their journals. There were articles that targeted only some aspects of the guidelines, such as the previously mentioned article by Drs. Sicherer and Wood from the Section on Allergy and Immunology on allergy testing in childhood using allergen-specific IgE tests. [4] The Adverse Reactions to Food Committee of the AAAAI developed brief summaries emphasizing the most important guidelines for pediatric as well as internal and family medicine practitioners. These summaries can be freely accessed at the AAAAI website.
Most important, the complete food allergy guidelines can be accessed free of charge online, as canexecutive summaries for clinicians, patients, and families.
Medscape: Any concluding advice for our members?
Dr. Nowak-Wegrzyn: I urge my colleagues to take advantage of the guidelines to get care for children with food allergy up to speed. Think about food allergy in children, because it is a common disorder, affecting about 6%-8% of children in the United States. Always listen carefully to your patients, but remember that the most common food allergies are to cow's milk, hen's egg, peanut, tree nuts, soy, wheat, and seafood. Therefore, avoid fishing expeditions and testing for large panels of food allergens. The younger the child, the more important is the nutritional evaluation to avoid deficiencies. Finally, in children with a history of food-induced anaphylaxis, multiple food allergies, or reactions from unknown food triggers, consider consulting with an allergist.

Tuesday, September 4, 2012

Consensual Sex or Statutory Rape?

Protect our young girls

IT is distressing for those of us working with child abuse victims to see another child who has been sexually abused (statutory rape) apparently ignored by the courts.

The last two rulings by the court seem to focus more on the perpetrator rather than the victim’s situation.

It is possible that the judges involved have never seen the plight of a young girl who has been taken advantage of, even when it is conveniently called “consensual”.

The law to protect young children from sexual abuse and rape is there for a purpose, and written with reasons.

There are a number of concerns here with these custodial sentences.

Firstly, the age disparity between the perpetrator and the victim clearly shows that the victim was too young to understand or control the situation.

It makes a mockery of the word “consensual”. The older men, both adults at the time, should know better but chose to ignore the rights of the young girls.

Secondly, the ruling ignores the trauma that has happened and will continue to haunt these young girls.

Having worked with childhood survivors of sexual abuse for many years, I can say that the girls involved will face much emotional and psychological pain for years to come.

Again this has been seemingly ignored in the sentencing.

Thirdly, we are giving a clear message to other perpetrators that the courts takes a soft view of the abuse of children when the perpetrator involved is a young adult.

This will embolden more to act without restraint.

Both the Penal Code and the Child Act, based on the UN Convention on the Rights of Children, are clear as to these actions.

They are abusive acts of an adult who should know better.

A child has been taken advantage of and damaged, possibly for life.

It is sad when we have ignored the silent cries of our children for our support and protection.


Friday August 31, 2012  DR ALEX KHOO PENG CHUAN ( Paediatric Neurologist Ipoh ) wrote: (http://thestar.com.my/news/story.asp?file=/2012/8/31/focus/11945217&sec=focus)

A crime is a crime, regardless of how young they are

AFTER 55 five years of independence, we have shown the world that our children are unprotected and open prey for the lustful. The consent or lack of consent is irrelevant in these cases, as they concern a crime of the most violent form: child sexual abuse.

Rape is the worst form of violence and when it happens to a child, innocence is lost forever. The reasons given by the judges concerned wherein the perpetrators got off easy is an injustice, being a slap in the face to all of us who have dedicated our lives and careers to the safety and welfare of children.

These children were not sexually experienced individuals, but gullible children who had put their trust in these men only to be betrayed. The very nature of the age gap between the individuals in the relationships suggests that these were paedophiles and predators.

The two girls were hardly beyond primary school and pre-pubertal! Many 12- and 13-year-olds would not even be menstruating yet. The psychological impact on the victims is well documented and ranges from anxiety to suicidal thoughts and social isolation.

While a national bowler and an electrician get their lives and careers back, their victims are left unnamed, shamed and subject to further abuse.

If we were to remain silent, it would mean that we accept the verdict. I certainly do not!

The Court of Appeal would be the right thing. This is clearly so morally wrong. Even if the laws regarding rape, statutory rape and child abuse are legally distinct, an age gap of six years is significant and ought not to have been a factor in the judge’s final decision.

This can only mean that there is clearly a lack of understanding of child development and child psychology among the judiciary, and I would like to invite any of our respected learned judges to join us as we go about our business in the children’s wards and our clinics attending to our little ones.

Maybe then, when they are on the ground instead of being in a high chair, do they feel the pain that affects us all with their verdict. 

MPA e-Committee
Malaysian Paediatic Association

Child Deaths From Influenza

From CDC Expert Commentary

Laurie Scudder, DNP, PNP; Georgina Peacock, MD, MPH

An Expert Interview With CDC's Georgina Peacock, MD

Posted: 08/29/2012
Editor's Note: 
The 2009 influenza A (H1N1) pandemic disproportionately affected children, resulting in a 5-fold increase in deaths compared with more typical flu seasons. A study just published in the journal Pediatrics provides the first detailed description of the children most affected. The study focused on children with neurologic and neurodevelopmental disorders and found that this population has a disproportionately higher risk of dying from flu-related causes than other children. The Centers for Disease Control and Prevention (CDC) is partnering with the American Academy of Pediatrics (AAP), Families Fighting Flu, and Family Voices to reach out to caregivers -- both clinicians and parents -- of children with neurologic and neurodevelopmental disorders to protect them against flu. Medscape spoke with Georgina Peacock, MD, MPH, one of the authors of this study, about the study findings, the implications for clinicians, and CDC's efforts to increase vaccination rates and the use of antiviral medications in children with neurologic and neurodevelopmental disorders.
Medscape: Dr. Peacock, could you briefly describe the methodology for your recent study?
Dr. Peacock: The CDC has been collecting information on influenza-associated pediatric deaths since 2004. This study gathered information from state and local health departments that submitted data about 2009 H1N1 influenza-related pediatric deaths to CDC. The CDC analyzed patient demographics, date and location of death, and length of hospital stay, as well as laboratory tests, including bacterial culture, and other information from these pediatric death reporting forms.
Medscape: What were the key findings regarding pediatric deaths in children with neurologic disorders? Why are these children more likely to have complications from influenza than other children?
Dr. Peacock: Children with neurologic disorders are at higher risk of dying from flu-related causes than other children. More specifically, we looked at 343 pediatric deaths that were associated with 2009 H1N1 influenza for which we had medical information. Of these, 336 children had an underlying medical condition. And when we looked in more detail, in about two thirds of those children, that underlying medical condition was a neurologic disorder. The most common of the underlying conditions were neurodevelopmental disorders like cerebral palsy, moderate to severe developmental delay (intellectual disability), and hydrocephalus. The second most common underlying condition was epilepsy.
There are different theories about why these children have more complications from influenza. Many of these children have associated medical conditions. When we looked at the children with underlying conditions, about 70% of them had more than 1 high-risk condition. That is telling us that these are children who have complicated medical histories.
There are some studies that speculate that the children with neurologic conditions may have impaired lung function, or they may have more difficultly coughing, and coughing is one way we prevent pneumonia. Some of the children have scoliosis, which again may make it harder to cough and clear your airway. Some of those children also had a reported pulmonary condition on their death reporting form, but not all of them. It leads us to speculate that maybe there is an impairment in their ability to cough or clear their airway. But is that also impairing their ability to fight off the influenza infection?
Less frequently, we saw children with secondary risk factors that included congenital heart disease, chromosomal abnormalities, and metabolic disorders, like mitochondrial disorders.
Medscape: Although the vaccine used prior to the 2009 flu season did not cover H1N1, there were immediate efforts to both develop and distribute an appropriate vaccine. Can you describe the impact of vaccination on morbidity and mortality in your study?
Dr. Peacock: This group of children had a fairly low influenza vaccination rate. When we looked at the death reporting forms, we noted that about 23% of the children had received the seasonal flu vaccine and about 3% had received the H1N1 vaccine. Part of the issue was that a number of these deaths occurred before there was even an H1N1 vaccine available. A limitation in our ability to draw conclusions from the data is that we are reviewing a pediatric death report form, not going back and looking at medical records. It is possible that there was a higher rate of influenza vaccination, but these are the rates we were able to calculate.
Although this study looked at pediatric deaths during the H1N1 pandemic, we know that children with neurologic conditions are also at greater risk for complications and deaths from flu during regular influenza seasons. Influenza vaccination is important and we need to increase this vaccination rate, particularly among children who are at high risk for influenza. I think we have a lot of work to do. Part of what we are doing this fall at the CDC is partnering with the AAP, Families Fighting Flu, and Family Voices to really push and encourage vaccination among this group of children, both by talking with healthcare providers about the importance of vaccination of this high-risk group, as well as talking to parents about the importance of making sure they are protecting their children from influenza, because their children are at high risk.
Medscape: CDC and AAP both recommend that children over the age of 6 months receive an annual influenza vaccine. As you have noted, vaccine uptake is suboptimal. That is also the case for antiviral use. How will CDC's partnership with AAP and flu advocacy groups help address these issues?
Dr. Peacock: With the AAP, our plans are to do some communications with members -- particularly with subspecialists who care for children with neurologic conditions -- through letters that are signed both by the AAP and the CDC to encourage them to talk to the parents of their patients about vaccinations. The issue is that most of these subspecialists are not going to give vaccinations. However, they are important health messengers for this information. If the neurologist or developmentalist is talking to the family about vaccinations, we think that will encourage parents to talk with their pediatric primary care provider about getting vaccinated and put that higher on the list.
We also are doing some continuing education webinars for healthcare providers.
On the parent's side, we've been working with Family Voices to conduct focus groups looking at what parents already know about flu and vaccinations. What we have found is that we have a lot of work to do to educate parents about what influenza is and to emphasize that influenza is different from having a cold. It is really important for parents to understand when we are in flu season that, if their child is exhibiting signs of an influenza-like illness, they need to seek care from their pediatric provider and begin antiviral drug treatment if indicated. We also must continually reinforce the importance of a prevention strategy that includes their child getting vaccinated.
Medscape: Could you speak a bit more about the antiviral component of this campaign? Although you have noted the importance of reaching neurologists and developmentalists to enlist them to encourage families to be vaccinated, will they be part of the campaign's effort to optimize antiviral use? Or is that effort focused on primary care providers?
Dr. Peacock: I think it's important that we are including those medical home providers, those primary care providers, in the discussion about encouraging antiviral use. The subspecialists can back that up and, when they are talking to parents, encourage them to talk to their child's primary care provider if the child is having flu-like symptoms. It is important to get antiviral treatment early. But clearly the pediatricians, the family practitioners, those people on the frontline in the medical home are the ones who are going to be pushing that early antiviral treatment, which is really important in these kids. I think that we have a long way to go in regard to antiviral treatment.
The other important message that came out during the pandemic is that rapid influenza testing does not always identify everybody that has influenza. A negative rapid flu test does not mean the child should not start antiviral treatment if the clinician thinks that they have influenza. That is another message that the CDC has been trying hard to get out to the practitioners.
Medscape: What are the most important take-home messages for clinicians as well as the parents of these high-risk children?
Dr. Peacock: First, children need to be vaccinated every year against influenza. Then, if the child is having flu-like symptoms, they should talk to their primary care clinician and get on antiviral treatment as soon as possible if it is recommended.
Medscape: Can you speak briefly about the current swine flu increase?
Dr. Peacock: We are currently monitoring this new strain of influenza called H3N2v, and the prevention messages around this outbreak are really important. Children with high-risk conditions, like neurologic disorders, need to wash their hands, not eat food in areas where animals are kept, and should avoid exposure to pigs and swine barns. Many of the children who have been infected with H3N2v have spent time in these settings.
It is important to get vaccinated against the seasonal flu. However, the current flu vaccine won't protect against the H3N2v strain, so that's why those preventive methods are really important, and obviously any child who has a neurologic disorder who has been around pigs and is exhibiting signs of flu needs to talk to their pediatric provider as soon as possible. The recommendation right now is that if you have a high-risk condition and are having flu-like symptoms and have had contact with a pig, to be evaluated by your provider and begin antiviral treatment if indicated.

    Thursday, July 12, 2012

    Sexting a Reliable Indicator of Risky Sexual Behavior

    From Medscape Medical News > Psychiatry

    Fran Lowry
    July 5, 2012 — The practice of sending sexually explicit photos or messages electronically, otherwise known as "sexting," is prevalent and may be linked to sexual behaviors of adolescents.
    A study of 7 public high schools conducted by investigators at the University of Texas Medical Branch, in Galveston, showed that 1 in 4 teens sent a nude picture of themselves via electronic means, that about 50% have been asked to send a nude photograph, and that about one third asked for a nude picture to be sent to them.
    "Sexting is fairly prevalent behavior among teens," lead researcher Jeff R. Temple, PhD, told Medscape Medical News. "And teens who engage in sexting behaviors may be more likely to have also had sex. In other words, sexting may be a fairly reliable indicator of sexual behaviors, although it may not necessarily be a cause or a consequence, just an association."
    Lack of Knowledge 
    The study was published online July 2 in Archives of Pediatrics & Adolescent Medicine.
    The study was prompted by of a lack of empirical knowledge of sexting behaviors, said Dr. Temple.
    "Pediatricians, parents, teachers, and policy makers were handicapped by insufficient information about the occurrence and nature of sexting, and I wanted to bring data to the conversation," he said.
    The investigators conducted a longitudinal study that included 948 public high school students, most of whom (55.9%) were female. The study sample was 26.6% black, 30.3% white, 31.7% Hispanic, 3.4% Asian, and 8.0% of mixed or other ethnicities.
    The participants ranged in age from 14 to 19 years and self-reported their history of dating, sexual behaviors, and sexting.
    Boys were more likely to ask for a "sext" (a sexually explicit photo or message), and girls were more likely to have been asked for a sext, Dr. Temple said.
    Specifics of the findings include the following:
    • 28% of boys and girls have sexted a nude picture of themselves
    • 21% of girls and 46% of boys asked another teen for a nude picture to be sent
    • 68% of girls and 42% of boys have been asked to send a nude picture of themselves
    • More than one half of all girls were bothered "a lot" by being asked
    • Boys were less bothered by being asked, but more than one half were bothered at least "a little bit"
    Talk About Sex
    The researchers also conclude that sexting behaviors may be a fairly reliable indicator of offline sexual behaviors. For both boys and girls, teens who sexted were more likely to have begun dating and to have had sex than those who did not sext (P < .001).
    The study also found that white/non-Hispanic and black teens were more likely than the other racial/ethnic groups to have both been asked and to have sent a sext.
    Dr. Temple had some advice for doctors when seeing their teen patients.
    "After acknowledging that sexting is a fairly common behavior among teens, I would suggest talking with the patient about potential legal and social consequences of sexting and ask for their feedback," he said.
    "I would also suggest using this as an opportunity to talk about sex and especially safe sex."
    Dr. Temple hopes "more than anything" that the reporting of this study will encourage parents to talk with their children about sexting, sex, and safe sex.
    "I hope some parents will ask their kids what they think of this study; is this happening with teens they know? Parents can use this as an opportunity to encourage their kids to think about potential consequences before pressing "send," and they can talk to them about how they would respond if someone asked them to send a nude picture.
    "Parents need to be talking with their kids about sex and safe sex, and hopefully this study can act as a springboard to that conversation," he said.
    New Opportunity
    In an accompanying editorial, Megan A. Moreno, MD, from the University of Wisconsin-Madison, and Jennifer M. Whitehill, PhD, from the University of Washington, Seattle, state that pediatricians should view social media as part of the integrated self of the adolescent patient.
    "Pediatricians have new opportunities to ask their patients about social media, including questions about how time is spent in this environment. Discussing social media with patients may provide new ways to identify intentions or engagements in risky health behaviors," they write.
    Dr. Temple says he agrees wholeheartedly with his editorialists.
    "Absolutely. Sexting appears to be an extension of existing offline relationships, and a reflection of adolescents' offline sexual intentions or behaviors. Pediatricians can use a conversation about sexting as an avenue to engage their patient in a conversation about other risky health behaviors."
    Dr. Temple, Dr. Moreno, and Dr. Whitehill have disclosed no relevant financial relationships.
    Arch Pediatr Adolesc Med. Published online July 2, 2012.Full articleEditorial

    Tuesday, July 10, 2012

    Headaches in Kids: Is An Eye Exam Necessary?

    I would like to talk about when primary care practices should refer children with headaches for an eye examination.
    Headaches in children are common. The first stop for these children will be to your office -- to understand the history of the headaches, the severity and nature of the headaches, family history, and to examine the child for common causes of headaches in childhood. But some of these children will be examined by you, that examination will be normal, and no obvious cause of the headaches will be found. It may be appropriate to refer these children for an ophthalmic examination with a pediatric ophthalmologist.
    There are certain types of alarming headaches where it probably is not appropriate to refer them for a routine pediatric eye examination, and the child may need to go directly to an emergency room or to a pediatric neurologist. These would be:
    • Severe headaches;
    • Headaches that are increasing in severity and frequency;
    • Headaches that are interfering with normal activities;
    • Headaches that are associated with nausea and vomiting; and
    • Headaches that occur during the night and awaken the child or occur early in the morning.
    But for other types of headaches, if the general examination is normal and there is no obvious cause from the history, it would be appropriate for a pediatric ophthalmologist to examine these patients for certain eye abnormalities that may be associated with headaches.
    What would we be looking for when these children come to pediatric ophthalmology? First, we will look at their vision and refraction to see whether there may be an uncorrected refractive error causing poor vision and requiring glasses, which may be the cause of the headaches and is easily treated.
    Second, we will be looking at their eye alignment and assessing for the presence of strabismus. There are certain forms of strabismus, particularly convergence insufficiency, that may cause eye strain with reading and headaches and are treatable by an ophthalmologist.
    Next, we will look at the slit-lamp examination under high-powered magnification to look for uveitis, ocular inflammation, glaucoma, and other causes of referred pain that may come from the eye but be felt by the child as headache.
    We will be looking at the dilated fundus examination to see the optic nerve and retina to look for such problems as papilledema, diabetic retinopathy, hypertension, and other changes in the eye that may be related to the cause of the headaches.
    Don't be surprised when many of these examinations come back normal. We expect many of these kids to have benign types of childhood headaches that do not cause eye problems. That should be reassuring to you and to the parents. Don't be surprised if the ophthalmologist feels that other studies may be indicated, including sinus imaging or other imaging studies, and suggests referral to a neurologist for certain types of headaches.