Tuesday, September 24, 2013

MMRV - Mumps Measles Rubella Varicella vaccine

ACIP Issues New Guidelines for Use of Combination Measles, Mumps, Rubella, Varicella Vaccine

Laurie Barclay, MD
May 11, 2010
Specific Recommendations for Use
Specific recommendations for use of the MMRV vaccine are as follows:
  • Routinely recommended ages for MMRV vaccination continue to be ages 12 to 15 months for the first dose and ages 4 to 6 years for the second dose.
  • At ages 12 to 47 months, either measles, mumps, and rubella (MMR) vaccine and varicella vaccine or MMRV vaccine may be used for the first dose of measles, mumps, rubella, and varicella vaccines. Clinicians should inform the parents or caregivers regarding the benefits and risks of both vaccination options. The CDC recommends that MMR vaccine and varicella vaccine be given for the first dose in this age group unless the parent or caregiver expresses a preference for MMRV vaccine.
  • For the second dose of measles, mumps, rubella, and varicella vaccines at any age (15 months - 12 years) and for the first dose at age 48 months or older, the MMRV vaccine is preferred to separate injections of MMR vaccine and varicella vaccine, but provider evaluation, patient preference, and the risk for adverse events should be considered.
  • A precaution for MMRV vaccination is a personal history of seizures of any cause or a family history of seizures in a sibling or parent. These children generally should be vaccinated with MMR vaccine and varicella vaccine.
"Studies have not demonstrated that antipyretics (e.g., acetaminophen or ibuprofen) prevent febrile seizures," the report authors conclude. "Vaccination with either MMR vaccine or MMRV vaccine can cause fever and, rarely, febrile seizures. Most fevers and febrile seizures after administration of a measles-containing vaccine occur 5–12 days after vaccination with the first dose."
MMWR Morb Mortal Wkly Rep. 2010;59(RR-3):1-12.

Friday, September 20, 2013

Dexamethasone May Help Atopic Infants With Bronchiolitis

Laurie Barclay, MD
Sep 16, 2013
Oral dexamethasone for 5 days reduced hospital stay for infants with bronchiolitis and eczema or a family history of asthma, according to results from a placebo-controlled trialpublished online September 16 in Pediatrics.
"Because steroid use is known to decrease admission rate and length of emergency stay in children with asthma but failed to do so in bronchiolitis, identifying asthmatic or preasthmatic patients and targeting them with steroid treatment early might improve symptoms and hasten recovery," write Khalid Alansari, MD, FRCPC, from the Division of Pediatric Emergency Medicine, Hamad Medical Corporation in Doha, Qatar, and colleagues. "A shorter stay and possibly a lower chance of needing return visits or subsequent hospitalization are desirable goals of better bronchiolitis therapy."
Therefore, the researchers designed a study to test the addition of dexamethasone to salbutamol in infants at risk for asthma, based on eczema or a family history of asthma in a first-degree relative. They enrolled 200 previously healthy infants, median age 3.5 months, with a diagnosis of bronchiolitis and asthma risk., All were treated with inhaled salbutamol and randomly assigned 1:1 to receive either dexamethasone, 1 mg/kg and then 0.6 mg/kg for 4 more days, or placebo.
Shorter Hospital Stay With Dexamethasone
Infants treated with salbutamol plus dexamethasone had a mean time to readiness for discharge of 18.6 hours (95% confidence interval [CI], 14.9 - 23.1 hours) compared with 27.1 hours (95% CI, 21.8 - 33.8 hours) for infants treated with salbutamol plus placebo. Dexamethasone was therefore associated with a 31% shortening of hospital stay (P = .015). In addition, during infirmary treatment, 5 infants in the placebo group, but none in the dexamethasone group, had to be admitted to intensive care (P = .02).
In the week after discharge, 22 infants in the dexamethasone group and 19 in the control group were readmitted to the short-stay infirmary (P = .9). During 7 days of monitoring, there were no reported hospitalizations or adverse effects.
"Dexamethasone with salbutamol shortened time to readiness for infirmary discharge during bronchiolitis episodes in patients with eczema or a family history of asthma in a first-degree relative," the study authors write. "Infirmary and clinic visits in the subsequent week occurred similarly for the 2 groups."
Limitations of this study include limited detail in safety reporting and lack of measurement of prevalences of patient eczema or atopy in the first-degree family of the bronchiolitis population.
"We speculate that a somewhat more prolonged dosing regimen may also reduce the need for post-discharge visits," the study authors conclude.
This study was sponsored by Hamad Medical Corporation. The authors have disclosed no relevant financial relationships.
Pediatrics. Published online September 16, 2013. Abstract

Home Birth 10 Times More Likely to Result in Apgar of 0

Jenni Laidman
Sep 18, 2013
Home deliveries were 10 times more likely to result in an Apgar score of 0 than hospital deliveries, according to a studypublished online June 21 in the American Journal of Obstetrics & Gynecology.
Further, the research, which includes data on nearly 14 million singleton, full-term births of infants of normal weight from 2007 to 2010, found a nearly 4-fold greater risk for neonatal seizure or serious neurologic dysfunction among home births.
Amos Gr√ľnebaum, MD, chief of labor and delivery, New York–Presbyterian/Weill Medical College of Cornell University, New York City, and colleagues used data from the National Center for Health Statistics of the Centers for Disease Control and Prevention to assess deliveries by both physicians and midwives in hospitals, freestanding birth centers, and homes. All of the infants in the study were of 37 weeks' gestation or more and weighed at least 2500 g at birth. Five-minute Apgar scores of 0 and neonatal seizures or serious neurologic dysfunction were analyzed according to where the births took place and whether the delivery was performed by a hospital midwife, a freestanding birth center midwife, a home midwife, or a hospital physician.
Researchers found a relative risk (RR) of 10.55 (95% confidence interval [CI], 8.62 - 12.93) for an Apgar score of 0 for midwife-attended home births (98/60,296 births), compared with the risk during hospital physician delivery (1943/12,615,994 births). The RR for midwife-attended deliveries at freestanding birth centers was 3.56 (95% CI, 2.36 - 5.36; 23/42,000 births). The RR for an Apgar of 0 during hospital midwife delivery was 0.55 (95% CI, 0.45 - 0.68; 95/1,115,794 births), suggesting the critical factor is the location of the birth, not the training of the professional involved in delivery, the authors write.
Risks were greatest for home deliveries of nulliparous patients, with an RR of 14.24 (95% CI, 10.16 - 19.96) for a 5-minute Apgar score of 0 (35/14,801 births) compared with nulliparous patients who had a physician-attended hospital delivery (856/5,155,779 births).
In addition, home births attended by midwives resulted in an RR of 3.80 (95% CI, 2.80 - 5.16) for neonatal seizures or serious neurologic disorders (42/49,091 births) compared with hospital delivery by physicians (1823/8,102,337 births). The RR for freestanding birth centers was 1.88 (95% CI, 1.11 - 3.17; 14/33,188 births). For hospital midwifes, the RR was 0.74 (95% CI, 0.62 9 0.89; 121/727,395 births) compared with physicians.
The authors state that risks determined by this study may be underestimates because some of the bad outcomes marked in the hospital column resulted from transfers to the hospital from a home birth.
"The magnitude of risk associated with home delivery is alarming," Dr. Gr√ľnebaum said in a news release from New York–Presbyterian/Weill Cornell Medical Center. The findings, he said, mean caregivers must warn patients of the risks attendant in home birth. "Physicians therefore should not offer and should recommend against birth settings outside the hospital," the authors write.
The key problem is a lack of available resources to deal with emergencies during a home birth, Frank Chervenak, MD, a study coauthor and director of maternal-fetal medicine at New York–Presbyterian/Weill Cornell, said in the release. "[T]here can be unpredictable complications requiring immediate surgical intervention. If an emergency occurs at home that requires hospital transport, it's often difficult to beat the clock to prevent death or neurological issues."
The study contradicts claims that home deliveries have a low risk profile, as a 2012 National Center for Health Statistics Data Brief stated. The data brief based its conclusions on a lower number of preterm births among home deliveries and a lower percentage of low birth-weight infants. It also counted the reduced numbers of teenaged births and reduced deliveries of multiples at home. However, the current study concluded that the risk is higher even after excluding early deliveries, low-birth infants, and multiple deliveries.
The study also contrasts with a Dutch study published in June that looked at maternal morbidity. That research, published in BMJ, involved some 147,000 low-risk women. It found a risk for maternal morbidity of 1 per 1000 among parous women, for an adjusted odds ratio of 0.43. The odds ratio was adjusted for maternal age, gestational age, socioeconomic status, and ethnicity (Dutch or non-Dutch).
The authors have disclosed no relevant financial relationships.
Am J Obstet Gynecol. Published online June 21, 2013. Abstract

Tuesday, September 17, 2013

Managing ADHD: Don't Neglect the Parents

Medscape Psychiatry > Medscape Psychiatry Minute

This comprehensive review examined 55 studies between 1980 and 2011. The interventions that were evaluated in these studies were parent behavior training, combined home and school/day care interventions, and methylphenidate use. Data were extracted using customized software.
The investigators found that more studies of all of these interventions are consistently documenting effectiveness, but parent behavior training interventions had greater evidence of effectiveness than methylphenidate for treatment of preschoolers at risk for ADHD.
As clinicians, we must be careful in our prescribing of stimulants for young children, and we should consider behavioral approaches first. I'm Dr. Peter Yellowlees.