Pediatrician In House

Clarifying Meningococcal Booster Dose Recommendations

2012-01-25T22:01:00.000-08:00

From CDC Expert CommentaryAmanda Cohn, MD01/17/2012Hi, I am Dr. Amanda Cohn, a pediatrician and epidemiologist. Thanks for tuning in to this CDC Expert Video Commentary on Medscape.In January 2011, recommendations were made by the Advisory Committee on Immunization practices (ACIP) for adolescents to receive a booster dose of meningococcal conjugate vaccine. Today I am going to explain the rationale behind this recommendation and answer frequently asked questions about implementation.First, some background. When this vaccine was first recommended for adolescents in 2005, the expectation was that protection would last for 10 years. However, currently available data suggest that immunity wanes much earlier than 10 years. In fact, only about half of adolescents are still protected 5 years after administration of the initial dose. Based on that information, a single dose for all 11- to 18-year-olds, recommended to be given at age 11-12 years, may not offer continued protection through the period when risk for meningococcal infection is highest, 16-21 years of age.Therefore, ACIP voted to recommend a booster dose of meningococcal conjugate vaccine for adolescents. This booster dose is recommended to be given at 16 years of age, following the routine first dose at age 11-12 years. Unfortunately, not all adolescents receive these doses on time, so here are some key points about when to give the booster dose.For adolescents who receive the first dose at age 13-15 years, a 1-time booster dose should be administered, preferably between the ages of 16 and 18 years. There is no need to wait 5 years from the first dose before administering the booster. Rather, give the booster dose any time after the child's 16th birthday. Eight weeks is the minimum interval between doses.If the teen is younger than 16 years of age, but the clinician believes this is a situation where there may not be another opportunity to provide the booster dose, the second dose can be given prior to 16 years of age. The booster dose is not recommended for adolescents who receive their first dose of meningococcal conjugate vaccine after their 16th birthday.What about college requirements? Meningococcal vaccination is required to attend many colleges, but which kids going off to college still need the booster dose? You may have a patient going off to college who requires vaccination. Many colleges will consider any dose given within 5 years prior to matriculation as valid. However, the recommendation for providers is to still follow the new guidelines: Administer a dose (a booster dose or the first dose if the adolescent is unvaccinated) after the 16th birthday and prior to college. Ideally, we want kids to get the booster dose before they reach the age when they are at greatest risk.All college freshmen living in a dormitory are recommended to be fully vaccinated. The booster dose may still be given to college students not living in dorms but is not routinely recommended.Which vaccine should be used? Only the meningococcal conjugate vaccine is recommended for adolescents. However, if the first dose of meningococcal vaccine was administered as polysaccharide vaccine, it is still counted as valid in the adolescent schedule. The booster dose of meningococcal vaccine for adolescents should always be a conjugate vaccine. The 2 licensed products, Menactra® and Menveo®, are interchangeable. If polysaccharide vaccine is inadvertently administered as the booster dose, revaccination with conjugate vaccine is recommended 8 weeks later.We want to protect as many kids as possible from this rare but often devastating disease. For more information on meningococcal disease and vaccine recommendations, visit www.cdc.gov/meningococcal. Thanks for tuning in today.

HPV & Sex

2012-01-25T21:54:00.001-08:00

From Medscape Infectious Diseases HPV & Sexual activity - any relationship?Paul A. Offit, MD 01/17/2012 Hi, my name is Paul Offit. I am talking to you today from the Vaccine Education Center at the Children's Hospital of Philadelphia. What I want to talk about is an article on the human papillomavirus (HPV) vaccine that recently appeared in American Journal of Preventive Medicine. The first HPV vaccine, called Gardasil®, contains serotypes 6, 11, 16, and 18 and came out in 2006. At that time, it was recommended for girls only. This past year, the vaccine was also recommended for boys. When the vaccine came out, there were a number of issues that were of concern to parents. People wondered whether the vaccine was really safe. There were questions about whether it caused blood clots, with consequent strokes and heart attacks. There were questions about whether it caused chronic fatigue syndrome. More recently, in September 2011, during the Republican national debates, Michele Bachmann raised the question of whether the HPV vaccine could cause severe developmental delays, which she referred to as "mental retardation." So, there has been a lot of fear surrounding this vaccine.In fact, none of those concerns are true. A number of studies have shown that the HPV vaccine does not cause chronic fatigue syndrome, blood clots, strokes, or heart attacks. But another issue was raised that really hasn't been addressed until this article was published, and that is the question of whether getting an HPV vaccine increases your desire for sexual activity -- or, said another way, promiscuity.The researchers at the Centers for Disease Control and Prevention, headed by Lauri Markowitz, looked at this. In their article titled "Human Papillomavirus Vaccine and Sexual Behavior Among Adolescent and Young Women," they looked at whether those who got the HPV vaccine were more likely to be promiscuous than those who did not. The answer was, not surprisingly, no. It doesn't make sense that that would have ever been true. First of all, no vaccine is 100% effective. Second, this particular vaccine protects against about 70% of strains that cause cervical cancer and 90% of strains that cause anal and genital warts. So, it's not even 100% effective against all strains of HPV. Obviously, the vaccine does not prevent other sexually transmitted diseases, such as syphilis, gonorrhea, chlamydia, or herpes.The concern never made sense. It's like making an argument that once I get a tetanus-containing vaccine, I can feel comfortable running through a bed of rusty nails. I don't think that is true either. I think we can now feel comfortable about the safety of this vaccine and also the notion of whether it increases sexual activity or promiscuity.The problem with HPV vaccine is that people haven't been very good about getting it. Only about one third of girls and young women for whom this vaccine is recommended get it. Hopefully, we can be better at encouraging vaccine use, and hopefully this study will make people feel more comfortable about the vaccine. Thank you.Related Resource Prevent HPV

Hair Loss and its Management in Children

2012-01-25T21:45:00.000-08:00

From Expert Review of DermatologyVibhu Mendiratta; Masarat Jabeen 01/15/2012; Expert Rev Dermatol. 2011;6(6):581-590. © 2011 Expert Reviews Ltd.AbstractHair loss in children can cause psychological stress to the parent and patient alike. Alopecia can be classified into congenital and acquired. Commonly encountered causes of pediatric alopecia (tinea capitis, alopecia areata, traction alopecia and trichotillomania) are reversible if diagnosed early. Special note should be made of the extent and type of alopecia (scarring or nonscarring), any hair shaft anomalies and signs of inflammation. Diagnostic evaluation includes a bewildering array of age-old simple bedside tests (e.g., potassium hydroxide preparation) to state-of-the art accurate instruments (e.g., trichoscan). Systemic antifungal therapy is required for tinea capitis. Topical and systemic immunomodulators are currently being employed for treating alopecia areata. A holistic approach would include not just therapeutic intervention but also an active search for associated nutritional deficits, underlying psychosocial disturbances and behavioral problems, the latter two requiring counseling and behavior therapy. Children with permanent hair loss can be offered surgical hair transplantation or camouflage devices, such as wigs.IntroductionThough losing hair is not usually health threatening, it can scar a young child's vulnerable self esteem by causing immense psychological and emotional stress; not just to the patient, but also to the concerned parents and siblings. Thus, management of hair disorders can be quite a daunting task for the attending physician and mandates a holistic approach to the patient. Nevertheless, an organized diagnostic and management strategy can turn this challenging task into an interesting and fruitful exercise.To fully understand hair loss in childhood, a basic knowledge of normal hair growth is necessary. The normal hair cycle is divided into four phases: the active growth anagen phase, followed by a brief catagen phase, the resting telogen phase and finally the shedding exogen phase. Typically, 85–95% of hairs are in the anagen phase, which lasts approximately 3 years. Less than 1% of hairs are in catagen, the transitional phase, which lasts from a few days to weeks. The telogen phase (which accounts for 5–15% of hairs and lasts about 3 months) ends when the new anagen hair emerges from the follicle.For the classification of pathological hair loss in children, two major groups should be differentiated: congenital and acquired hair loss. This distinction is the first step in diagnosis (Box 1 & Figure 1). Pathological hair loss, although rare in the first year of life, may be a symptom of an underlying congenital syndrome or clue to an underlying metabolic disorder which may have a bearing on the mental and physical development of a child.Hair loss on the scalp can also be classified as focal or diffuse (Box 2). Focal hair loss is secondary to an underlying disorder that may cause nonscarring or scarring alopecia.Patient's personal and family history, a thorough clinical examination, as well as general and specific diagnostic procedures aid in correct diagnosis and early treatment.The key points in a patient's history are:Age of onset of the patient: congenital or acquired;Onset of hair loss: sudden or insidious;Extent of alopecia: localized or diffuse;Subsequent development of the disease and associated symptoms;Physical and mental development (may be affected as a part of a genotrichosis);Psychological problems of the child;Obvious physical or emotional triggers in the previous 2–5 months, and any accompanying complaints (e.g., fatigue, weight changes, and nail or skin abnormalities);Past medical history including chronic illnesses, surgeries, medication, autoimmune, dermatologic and psychiatric disorders (e.g., anxiety and obsessive–compulsive tendencies);Family history of alopecia, autoimmune disease, dermatologic or psychiatric disorders;Hair grooming practices (chemicals, tight braiding).Examination should have the following components:Sparsing of hair (hypotrichosis) or loss of hair (alopecia);Thorough examination of scalp as well as the other hair-bearing areas of the body, especially loss of axillary and pubic hair, eyelashes, eyebrows and body hair;Type of alopecia: localized or diffuse, scarring or nonscarring;Any hair shaft anomalies, hair quality, color, roughness and tendency to breakage, 'exclamation-point' hairs;Presence of erythema, edema, papules, pustules, scaling, atrophy, telangiectasias, follicular hyperkeratosis, ulceration and scarring;Hair pull test:Approximately 20 hairs are grasped and firmly tugged away from the scalp;The number of extracted hairs is counted;>10% of grasped hairs or two hairs suggests positive pull test and active hair shedding.The skin, nails, oral or genital mucous membranes (e.g., for evidence of associated dermatoses, such as lichen planus);Thorough clinical examination of the entire head and body is necessary in order to evaluate impaired vision, defective hearing, dysmorphic features, clues to autoimmune or metabolic diseases, or ectodermal anomalies.for rest of article go to:http://www.medscape.com/viewarticle/753720?src=mp&spon=9

PPIs Not Helpful in Children With Poor Asthma Control

2012-01-25T18:53:00.000-08:00

From Medscape Medical NewsJennifer GarciaJanuary 24, 2012 — Use of proton pump inhibitors (PPIs) in children with poorly controlled asthma who were using inhaled corticosteroids and who had no symptoms of gastroesophageal reflux (GER) was not found to improve asthma control and was, in fact, associated with an increase in adverse effects, according to results of a study published in the January 25 issue of JAMA.PPIs "are often prescribed for poorly controlled asthma regardless of reflux symptoms, and there have been large increases in the use of PPIs among children between 2000 and 2005.... Hence, it is of clinical importance to determine whether antireflux therapy, the most common of which are PPIs, improves control of asthma in children," write Janet T. Holbrook, MPH, PhD, from the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and colleagues from the Writing Committee for the American Lung Association Asthma Clinical Research Centers.The goal of this placebo-controlled, double-masked, randomized study was to determine whether the PPI lansoprazole was effective in controlling asthma symptoms in children with asthma, but no overt GER. The researchers also investigated whether pH testing would identify children with GER who responded to PPI therapy.Between April 2007 and September 2010, the Study of Acid Reflux in Children With Asthma enrolled 306 children at 19 US academic clinical trial centers. The children had physician-diagnosed asthma that was poorly controlled and were receiving inhaled corticosteroids (≥176 μg/day of fluticasone equivalents) for at least 8 weeks before enrollment. Participants were excluded if they had any symptoms of GER, were receiving any PPI or other reflux medications, or had any history of esophageal disease or other major illness. Participants were evaluated over the course of 24 weeks and ranged in age from 6 to 17 years (mean, 11 years of age).The children were randomly assigned to receive either lansoprazole (15 mg/day for those weighing <30 kg; 30 mg/day for those weighing ≥30 kg; n = 149) or a matching placebo (n = 157). The researchers found that the mean difference in the Asthma Control Questionnaire (ACQ) score between the 2 groups was 0.2 units (95% confidence interval [CI], 0.0 - 0.3 units), which was not statistically significant (P = .12).There also was no significant difference in the forced expiratory volume in the first second (0.0 L; 95% CI, −0.1 to 0.1 L), and no change in the rate of episodes of poor asthma control (relative risk, 1.2; 95% CI, 0.9 - 1.5) or asthma-related quality of life (−0.1; 95% CI, −0.3 to 0.1). In addition, children treated with lansoprazole developed more respiratory infections (relative risk, 1.3; 95% CI, 1.1 - 1.6; P = .02) than those in the placebo group.A subgroup of children in the study (n = 115) underwent esophageal pH studies before randomization; the prevalence of GER among this group was found to be 43%. In those children with a positive pH study, there was no positive treatment effect with lansoprazole vs placebo for any asthma outcome.The researchers evaluated a change in the ACQ score between case and control participants as their primary outcome. The questionnaire was administered at enrollment, and again at the 24-week follow-up visit. Secondary outcomes included the rate of acute episodes of poor asthma control, the Asthma Symptom Utility Index, the Asthma Control Test for adolescents (aged 12 - 17 years)/children (aged 6 - 11 years), asthma-specific quality of life score, methacholine provocative concentration, spirometry, exhaled nitric oxide, gastrointestinal symptoms, and nocturnal awakenings.The authors also required the children to maintain a journal at home to record any asthma exacerbations, rescue treatments, morning peak expiratory flow, nocturnal awakenings, oral corticosteroid use, and unscheduled healthcare visits for asthma symptoms.The most common adverse event reported among both groups was asthma exacerbation. A higher prevalence of upper respiratory tract infections, sore throats, and episodes of bronchitis was noted among patients in the lansoprazole group. The study authors speculate that this may be a result of loss of host defense against bacterial colonization as a result of higher gastric pH levels. Activity-related bone fractures were not statistically different between the 2 groups (6/149 in the lansoprazole group vs 1/157 in the placebo group; P = .06)."The results of this clinical trial are uniformly negative regarding the benefit of acid suppression therapy on symptom relief, lung function, airway reactivity, or quality of life," write the authors. The results also "indicate that PPI therapy for poorly controlled asthma is not warranted."In an accompanying editorial, Fernando Martinez, MD, from the Arizona Respiratory Center, University of Arizona, Tucson, notes that although it is not a statistically significant difference, the increase in activity-related bone fractures in the lansoprazole group also raises concerns. This potential complication has prompted an advisory from the US Food and Drug Administration about the risk for fractures in adults receiving chronic PPI therapy. "In this context, a less conservative test assessing if the odds ratio was significantly greater than 1.0 (not just different from 1 in any direction) might have been more appropriate and may have yielded a statistically significant result," writes Dr. Martinez.Overall, however, Dr. Martinez praises the work of Dr. Holbrook and colleagues and concludes that "[g]iven their potential adverse effects, these medications should thus be used with great restraint for treatment of GER/[gastroesophageal reflux disease] during childhood. The substantial increase in use of PPIs in children during the last decade is worrisome and unwarranted."Support for this study was provided by the American Lung Association Asthma Clinical Research Centers Infrastructure Award and National Institutes of Health/National Heart, Lung, and Blood Institute grants. Dr. Holbrook and colleagues have disclosed no relevant financial relationships. Dr. Martinez has served as a consultant to MedImmune and has presented at an Abbott-sponsored seminar.JAMA. 2012;307:373-381.

Delayed Introduction of Solid Foods

2012-01-25T05:26:00.000-08:00

From Medscape Pediatrics > ViewpointsWilliam T. Basco, Jr., MD01/10/2012The Introduction of Allergenic Foods and the Development of Reported Wheezing and Eczema in Childhood: The Generation R StudyTromp II, Kiefte-de Jong JC, Lebon A, et alArch Pediatr Adolesc Med. 2011;165: 933-938Study SummaryBackground. Parents give many reasons for delaying the introduction of complementary foods to a diet of breast milk or infant formula, including concerns about increased risk for early excessive weight gain, development of allergic sensitivity to the foods, and autoimmune diseases such as diabetes or celiac disease. Pediatric professional organizations generally recommend delaying the introduction of solid foods until the child is at least 4 months of age, with some recommending delaying these foods until the child is 6 months of age. Data about whether the early introduction of solid foods elevates the risk for allergies or other food sensitivities are conflicting.Methods. This study evaluated the results of a generational cohort study from The Netherlands that followed more than 7000 infants and mothers who delivered their infants between 2002 and 2006. The goal was to determine whether the timing of introduction of allergenic foods such as cow's milk, eggs, peanuts, tree nuts, soy, and gluten was associated with eczema and wheezing through the fourth year of life. The investigators also conducted subgroup analysis looking at children with and without a history of allergy to cow's milk demonstrated during the first year of life and subgroup analysis comparing children with and without a parental history of atopic disease. The outcomes were assessed when the children were ages 2, 3, and 4 years, using questionnaires completed by their parents.Approximately two thirds of the cohort parents responded at each of the survey points. Data on food introduction was obtained during visits when the child was between 6 and 12 months old, again collected by parental report on a questionnaire. Parents were asked about the age when they first introduced each of the allergenic foods. When children were between 6 and 12 months of age, parents again completed a short food frequency questionnaire.The analyses controlled for appropriate covariates including gender, gestational age, maternal sociodemographic factors, and family history of allergic diseases. The investigators were also able to control for illnesses experienced by the child. Finally, breastfeeding was divided into 6 different categories ranging from children who were "never" breastfed to children who were "exclusively breastfed" through at least 4 months of age. Data were obtained on whether the child had ever been seen by a physician for cow's milk allergy. The 2 main outcomes of interest were whether the child experienced eczema or wheezing, and the authors created prediction models for children experiencing either of those at age 2, 3, or 4 years.Findings. The investigators stratified analyses by both cow's milk allergy and parental history of allergic disease. There were 6905 children in the analysis cohort. At 2 years of age, 31% of the children had experienced wheezing and 38% had experienced eczema. At 3 years of age, 14% of the children reported wheezing and 20% reported eczema. At 4 years of age, 14% of the children had experienced wheezing and 18% had experienced eczema. Almost half (47%) of the children had a parent with a history of atopic disease. With respect to breastfeeding, 11% of the children had never been breastfed, whereas approximately 24% had been exclusively breastfed to at least 4 months. No respiratory illnesses at 12-24 months of life were reported by 48%. Three quarters of the children were in daycare during the second year of life.When looking at the outcomes of wheezing and eczema, the introduction of allergenic foods at ≤ 6 months of age was not associated with the likelihood of wheezing or experiencing eczema at either 2, 3, or 4 years of life. Wheezing and eczema were both more likely in children who experienced cow's milk allergy or who had a parental history of atopic disease, but introduction of allergenic foods before 6 months of life was not associated with either outcome in the stratified analyses. The investigators concluded that their data do not support delayed introduction of allergenic foods until after 6 months of age for the prevention of either wheezing or eczema.ViewpointThe discussion section of this article reviews additional cohort studies that had very similar findings. It appears that the bulk of evidence suggests that delayed introduction of allergenic foods, even among those felt to be atopic prone, does not provide protection against the development of atopic illness. It will be interesting to see how long it takes for general practice to evolve, but the building data suggest that we should reconsider feeding recommendations, at least as they pertain to allergy.Abstract

Allergy Tests Should Only Verify Diagnosis in Children

2012-01-24T22:02:00.000-08:00

From Medscape Education Clinical BriefsNews Author: Ricki Lewis, PhDCME Author: Désirée Lie, MD, MSEd 01/10/2012Clinical ContextAccording to the current study by Sicherer and Wood, most allergic responses are mediated by immunoglobulin E (IgE) antibodies specific to the trigger allergen, which can be detected with in vitro or skin tests. Quantification of in vitro allergen-specific IgE (sIgE) levels is becoming more common. The 3 detection systems approved by the US Food and Drug Administration have excellent performance characteristics to identify different IgE antibodies but do not measure IgE antibodies with similar efficiencies. Therefore, a test for an allergen in 1 of 3 test systems may not be equivalent to the same allergen test in a different system.This is a review of different tests available for allergen testing in children and indications for use.Study Synopsis and PerspectiveAllergy tests should be used only to confirm a diagnosis that has already been made on the basis of symptoms and medical history, advise 2 leading allergists in an article published in the January issue of Pediatrics.Scott Sicherer, MD, from Mount Sinai Hospital in New York City, and Robert Wood, MD, from the Johns Hopkins Children's Center in Baltimore, Maryland, reviewed the benefits and limitations of blood tests and skin-prick tests in the detection of allergic diseases.For blood tests, enzymatic assays for IgE antibodies (in vitro sIgE) tests have replaced radioallergosorbent tests, but the 3 products approved by the US Food and Drug Administration either detect different antibody populations or do not measure them with comparable efficiencies.Both the skin-prick test (SPT) and sIgE test detect a sensitized state. "However, detection of sensitization to an allergen is not equivalent to a clinical diagnosis. In fact, many children with positive tests have no clinical illness when exposed to the allergen," Dr. Sicherer and Dr. Wood write.They further point out that testing for allergens that do not make sense (because they would never be encountered in the patient's environment or because the patient is obviously not allergic to them) could lead to "detrimental actions of unnecessary allergen avoidance." They also warn against a false-negative on an SPT or sIgE test when a child is obviously allergic to a particular trigger.The allergists identify circumstances in which SPT and sIgE are warranted: to confirm a suspected allergic trigger after observing a child react, to monitor the course of a food allergy to detect when it might be waning or outgrown, to confirm allergy to an insect after an anaphylactic response, and to identify allergies to vaccines (SPT only).SPT and sIgE tests should not be used, Dr. Sicherer and Dr. Wood write, to screen for allergies in nonsymptomatic children or to diagnose food allergies or drug allergies. Food allergies should be assessed with food challenges, they write, and skin and blood tests do not detect antibodies to drugs.The tests might be useful for identifying the trigger of a respiratory allergy (allergic asthma or seasonal or perennial allergic rhinitis) that is ubiquitous but not obvious in the patient's environment: for example, SPT or sIgE can detect allergy to dust mites, animal dander, cockroaches, molds, or pollen.The authors have disclosed no relevant financial relationships.Pediatrics. 2012;129:193-97. Abstract

Antiretroviral Safe in Reducing HIV-1 Transmission via Breast-Feeding

2012-01-24T21:58:00.000-08:00

m Medscape Education Clinical BriefsNews Author: Laurie Barclay, MDCME Author: Hien T. Nghiem, MD01/10/2012 Clinical ContextBreast-feeding in sub-Saharan Africa is an important source of nutrition for infants between birth and age 24 months, leading to improved overall survival duration. However, breast-feeding for infants exposed to HIV can account for 30% to 40% of all mother-to-child transmissions. Strategies for prevention of mother-to-child transmission are needed. Guidelines from the World Health Organization recommend extended breast-feeding for infants exposed to HIV-1 until age 12 months, together with antiretroviral prophylaxis for the mother or infant for the duration of breast-feeding. Nevirapine given once daily for the first 6, 14, or 28 weeks of life to infants exposed to HIV-1 via breast-feeding reduces transmission through this route vs single-dose nevirapine at birth or neonatally.The aim of this study by Coovadia and colleagues was to assess the incremental safety and efficacy of extension of such prophylaxis to 6 months.Study Synopsis and PerspectiveA daily oral dose of nevirapine given to infants up to 6 months of age can safely reduce mother-to-child transmission of HIV-1 via breast-feeding, according to the results of a phase 3, double-blind, randomized, placebo-controlled trial published online December 23 in the Lancet."Nevirapine given once-daily for the first 6, 14, or 28 weeks of life to infants exposed to HIV-1 via breastfeeding reduces transmission through this route compared with single-dose nevirapine at birth or neonatally," write Professor Hoosen M. Coovadia, MD, from the University of Witwatersrand in Johannesburg and the Nelson Mandela School of Medicine at the University of Kwazulu-Natal in Durban, South Africa, and colleagues. "We aimed to assess incremental safety and efficacy of extension of such prophylaxis to 6 months."Within 7 days of birth, breast-feeding infants born to mothers with HIV-1 in 4 African countries were enrolled and given once-daily nevirapine from birth to 6 weeks. Using a computer-generated permuted block algorithm with random block sizes allowing stratification by site and maternal antiretroviral treatment status, 6-week-old infants without HIV infection were assigned to receive extended nevirapine prophylaxis or placebo either until 6 months or until breast-feeding stopped, whichever came first.Kaplan-Meier analyses allowed between-group comparison of the primary efficacy outcome of HIV-1 infection in infants at 6 months. Adverse reactions were also recorded in both groups as safety endpoints.Of 1527 infants randomly assigned between June 19, 2008, and March 12, 2010, 762 were assigned to receive nevirapine, and 765 to receive placebo. Five of these patients were excluded from the primary analyses because they had HIV-1 infection at randomization. HIV-1 infection occurred between 6 weeks and 6 months in 1.1% (95% confidence interval [CI], 0.3% - 1.8%) of infants who received extended nevirapine, and in 2.4% (95% CI, 1.3% - 3.6%) of those who received placebo. Reduction in transmission associated with extended nevirapine was 54% (difference, 1.3%; 95% CI, 0% - 2.6%; P = .049).At 6 months, both groups had similar mortality rates (1.2% with nevirapine vs 1.1% with placebo; P = .81) and combined HIV infection and mortality rates (2.3% vs 3.2%; P = .27). The treatment groups had no significant differences in frequency of adverse events, serious adverse events (16% vs 15%), and deaths.Limitations of this study include a lack of adjustment for multiple statistical tests, which could increase the risk for false-positive findings."After 6 weeks of treatment with once-daily nevirapine, continued use of nevirapine to age 6 months in uninfected infants of breastfeeding mothers with HIV-1 is safe, and results in a greater than 50% reduction in mother-to-child transmission from breastfeeding compared with placebo," the study authors write. "No other study has directly assessed the incremental benefit of extension of nevirapine from age 6 weeks until 6 months to establish whether the extended period is more efficacious and whether there are increased safety issues associated with long-term treatment with nevirapine."The National Institutes of Health supported this study. The study authors have disclosed no relevant financial relationships.Lancet. Published online December 23, 2011. Abstract

Bacterial Bronchitis Frequent in Children With Chronic Wet Cough

2012-01-24T21:49:00.000-08:00

From Medscape Education Clinical BriefsNews Author: Laura Newman, MACME Author: Désirée Lie, MD, MSEd01/11/2012Clinical ContextAccording to the current study by Zgherea and colleagues, chronic wet cough, defined as a wet cough that lasts for 4 weeks or more, is easily recognized by parents and pediatricians. Also, it is a major debilitating finding in children with pulmonary disorders such as cystic fibrosis or ciliary dyskinesia and immunodeficiency disorders. However, the diagnosis of chronic bronchitis is not easily accepted in pediatric practice as in adult practice, and it is uncertain what the prevalence of purulent and nonpurulent bronchitis is among children with wet cough.This retrospective study determines the frequency of bacterial infections among children with wet cough, using medical charts and bronchoscopic findings.Study Synopsis and PerspectivePurulent bronchitis is common among children with chronic wet cough, according to a retrospective study published online January 9, 2012, in Pediatrics.In addition, 56% of the children in the study, all of whom had been referred to a pediatric pulmonary clinic because of an intractable wet cough, had bacterial infections of the lower airway. The investigators, led by Daniela Zgherea, MD, from the Department of Pediatrics, Maimonides Infants and Children's Hospital, Brooklyn, New York, also found that tracheomalacia was identified on bronchoscopy far more frequently in the 0- to 3-year-old children in their study (30.3%) than in the general pediatric population.The authors raise the need to better understand the etiology and best treatments for these lingering coughs (lasting 4 weeks or more)."The diagnosis of 'chronic bacterial bronchitis' is not readily accepted in the pediatric population, however, as many physicians assume that is an 'adult' respiratory illness associated with tobacco smoking," the authors write.In the study, investigators reviewed the charts and bronchoscopy findings of 197 children referred by their primary care physician to a pediatric pulmonary clinic at Maimonides Infants and Children's Hospital because of a persistent chronic wet cough. More than half of the study patients (55%) were aged 0 to 3 years, 36% were aged 3 to 7 years, and 9% were older than 7 years of age.One third of the children in the youngest group had bronchoscopy-confirmed laryngomalacia or tracheomalacia. However, the frequency of laryngomalacia and tracheomalacia did not appear to be associated with purulent or nonpurulent bronchitis.Bacterial cultures were positive in 91 children (46%). Of these, nontypable Haemophilus influenzae accounted for nearly half (49%) of the positive cultures, Streptococcus pneumoniae accounted for 20%, Moraxella catarrhalis accounted for 17%, and Staphylococcus aureus accounted for 12%.Bacterial infections were more frequently associated with purulent bronchitis (84%) than with nonpurulent bronchitis (16%; P < .001). Regarding the 16% of children with purulent bronchitis who had negative cultures, the authors hypothesize these may be false-negatives, in part resulting from the timing of sputum collection relative to antibiotics use."The presence of a relatively large group of children with nonpurulent bronchitis and negative bacterial cultures among our study patients may point out the existing connection between chronic wet cough and asthma, which is also suggested by findings of [bronchoalveolar lavage] eosinophilia seen in some children in our study," the authors write.However, the study was unable to determine whether asthma contributed to the persistent cough. They recommend further prospective studies of the relationship between chronic wet cough, bacterial infections, and asthma in children.The authors have disclosed no relevant financial relationships.Pediatrics. Published online January 9, 2012. Abstract

Acute Macular Degeneration

2012-01-24T21:45:00.000-08:00

From Medscape Education Clinical BriefsFrequent Aspirin Use Linked With Early and Wet Late AMD CME/CEDaniel M. Keller, PhDCME Author: Laurie Barclay, MD01/12/2012Clinical ContextPrevious findings have been inconsistent regarding associations between aspirin use and age-related macular degeneration (AMD). Several studies suggested a harmful effect of aspirin on AMD, whereas other studies showed no evidence of an association, or possibly a nonsignificant benefit.Aspirin use is widespread and is often indicated for its antiplatelet activity as well as for its analgesic effect. The objectives of the European Eye Study by de Jong and colleagues were to estimate the prevalence of AMD across Europe and to investigate possible risk factors, particularly exposure to solar radiation and antioxidant vitamin use. This analysis aimed to study associations between aspirin use and early and late AMD.Study Synopsis and PerspectiveThe risks for early AMD and wet late AMD are associated with frequent aspirin use, and the risk increases with greater aspirin consumption, European researchers reported in an article published in the January 2012 issue of Ophthalmology.The results, from the large, population-based, cross-sectional European Eye Study, suggest caution in recommending aspirin to patients with early or late AMD who may take it for other conditions, such as prevention of cardiovascular disease (CVD).When adjusted for all potential confounders of age, sex, education, smoking, body mass index, diabetes, CVD, angina, cholesterol, and systolic blood pressure, daily aspirin users had a greater than 2-fold increased risk for wet AMD when compared with participants who never consumed aspirin.The research, led by Paulus T.V.M. de Jong, MD, PhD, emeritus professor of ophthalmic epidemiology at the Academic Medical Center and a member of the Netherlands Institute of Neuroscience in Amsterdam involved 4691 participants aged 65 years or older who were chosen by taking a random sampling from population registers in 7 countries.Field workers interviewed the participants about sociodemographic, health, and lifestyle factors. Aspirin use was quantified as never (n = 2760), monthly or less (n = 766), weekly but not daily (n = 326), or daily (n = 839). Digitized color fundus images were recorded at each participating center and sent to Rotterdam, the Netherlands, where 2 staff members graded them according to the International Classification and Grading System for Age-Related Maculopathy and AMD.Grades 1, 2, and 3 corresponded to early AMD, and grade 4 corresponded to late AMD, which was subdivided into dry or wet AMD. Wet AMD was defined as serous or hemorrhagic detachment of the retinal pigment epithelium, a subretinal neovascular membrane, subretinal hemorrhage, or other signs. Participants with grade 0 (macula free of drusen or pigmentary irregularities or with hard drusen) were the control patients. The main outcome measure was the odds ratio (OR) for AMD in aspirin users.Daily aspirin users were older, were less likely to smoke, and had lower blood pressure and cholesterol levels, but more CVD and angina.Among all participants, 36.4% had early AMD, and 3.3% had late AMD, of whom about two thirds had wet and one third dry AMD. More frequent aspirin use was associated with higher grades of AMD. One third of the individuals with wet AMD consumed aspirin daily compared with only 16% of control participants.Similar trends in ORs were seen when investigators adjusted only for age and sex, or for age, sex, and CVD (both P < .001 for the trends). There was no significant association for aspirin with wet AMD according to the presence or absence of CVD or angina (ie, AMD was independent of CVD or angina).For the 42 cases of dry AMD with information on aspirin use and potential confounders, dry AMD was not associated with aspirin use after adjustment for age and sex.Limitations of the study include its cross-sectional and retrospective nature, with the possibility of recall error about aspirin use and possible confounders. In addition, there were no data on the doses of aspirin or the use of other antiplatelet or anticoagulant drugs.Dr. de Jong told Medscape Medical News that "people should be aware that aspirin, often just bought over the counter without prescription, may have adverse effects — apart from major gastrointestinal and other bleeds, also for AMD." He said future randomized trials will be necessary to find out whether there is a critical dose of aspirin in relation to the risk for AMD.On the basis of this study and the body of literature, he said, he would advise people who have early or late AMD not to take aspirin for pain, and if they are taking it for primary prevention of CVD to discuss with their physicians whether it is wise to continue doing so. "For secondary prevention...the benefits of daily aspirin outweigh the risks," Dr. de Jong said.George Williams, MD, chairman of the Department of Ophthalmology and director of the Beaumont Eye Institute at William Beaumont Hospital in Royal Oak, Michigan; clinical professor of ophthalmology and biomedical sciences at Oakland University William Beaumont School of Medicine; and an expert correspondent for the American Academy of Ophthalmology, commented to Medscape Medical News that the study "raises some interesting questions" but "does not provide a definitive answer on the role of aspirin in the development of AMD."There has not been a consistent trend among studies looking at this question, and differing inclusion criteria and definitions of AMD severity make it difficult to compare studies."The strength of this study is that they have photographic documentation of the status of the macular degeneration," Dr. Williams said. "In some of the other studies, we know exactly how much aspirin people were on because they were randomized to aspirin. However, in those studies we are relying upon less robust data to determine the degree of macular degeneration."Another potential confounder is that aspirin is a component of many over-the-counter medications that people do not recognize as containing the drug.Dr. Williams said he is concerned that although the study started with almost 4700 patients, in the end there were only 36 patients in the wet AMD group who had been taking daily aspirin. He said he would want to see larger numbers before becoming more comfortable with an association of aspirin with wet AMD.He noted that the value of prophylactic aspirin for the prevention of CVD is coming under increasing scrutiny. "It's going to require physicians to take the time to talk to their patients about the possibility that there may be an association [of aspirin with the development of AMD]," he said. "So patients who are on aspirin should discuss with their prescribing physician the reasons why they're on aspirin, what the benefits are, and then make a decision as to whether they wish to continue. But at this point I certainly see no definitive reason for people to stop aspirin when it's indicated for their overall health."A disadvantage for primary care physicians is that most will not have a comprehensive knowledge of the status of their patients' macular degeneration, "so it will require communication between primary care providers and ophthalmologists to come up with the best solution for a specific patient," Dr. Williams advised.Dr. de Jong has disclosed no relevant financial relationships. Dr. Williams is a consultant/advisor to Alcon Laboratories, Allergan, Neurotech, OptiMedica, Pfizer, and Thrombogenics. He also has received grant support from Alcon Laboratories, Allergan, Genentech, and Neurotech, is an equity owner of Nu-Vue Technologies, OptiMedica, and Thrombogenics, and has patent/royalty income from Nu-Vue Technologies.Ophthalmology. 2012;119:112-118. Abstract

Most US Teenagers Lack Hepatitis A Immunization

2012-01-24T20:59:00.000-08:00

From Medscape Medical NewsDaniel M. Keller, PhDJanuary 23, 2012 — Most adolescents in the United States lacked immunization for hepatitis A in 2009, leaving them susceptible to hepatitis A infection going into adulthood. In the first study to evaluate hepatitis A vaccine (HepA) coverage in the United States, using data from healthcare providers, researchers from the US Centers for Disease Control and Prevention in Atlanta, Georgia, reported in an article published online January 23 and in the February print issue of Pediatrics that nationally, 1-dose coverage with HepA among adolescents was 42.0%. Of those teenagers who were vaccinated, approximately 70% completed the 2-dose series, which is equivalent to 29.5% of the entire cohort of adolescents surveyed.Using data from the 2009 National Immunization Survey-Teen (N = 20,066) to determine HepA coverage among 13- to 17-year-olds, Christina Dorell, MD, MPH, and coauthors found that among states in which the Advisory Committee on Immunization Practices (ACIP) has recommended universal child vaccination at 2 years since 1999 (group 1), 1-dose coverage was 74.3%. Among states with an ACIP recommendation for consideration for child vaccination at 2 years since 1999 (group 2), the rate was 54.0%, and among states with a recommendation of universal child vaccination at 1 year of age since 2006 (group 3), the rate was 27.8%.The researchers noted that 1 dose of vaccine induces protective levels of antibodies in more than 97% of infants and children, and a second dose is thought to confer long-lasting immunity.Because hepatitis A virus is highly infectious and will probably continue to be introduced to the United States through imported food, international travel, international adoption, and other means, the authors recommend continued vaccination of adolescents to protect them during this period, and as they mature into adults. In this way, the prevalence of significant hepatitis A disease may be minimized, lowering morbidity, hospitalizations, lost work, and the large expense of containment efforts.The authors have disclosed no relevant financial relationships.Pediatrics. 2012;129:213-221. Abstract

Adopting a Healthy Diet May Help ADHD

2012-01-19T06:08:00.000-08:00

From Medscape Medical News > PsychiatryMegan BrooksJanuary 17, 2012 — When drug therapy fails to control attention-deficit/hyperactivity disorder (ADHD) or is unacceptable, adopting a "healthy" diet, eliminating items known to predispose to ADHD, and adding omega-3 fatty acid supplementation may be worth trying, new research suggests."The recent increase of interest in this form of therapy for ADHD, and especially in the use of omega supplements, significance of iron deficiency, and the avoidance of the 'Western pattern' diet, make the discussion timely," the authors write.Many parents and physicians continue to be interested in how diet and dietary changes, particularly parents wanting to find an alternative to stimulant medication or a complementary therapy. Nevertheless, it remains a "controversial" topic, the authors note.For their review, J. Gordon Millichap, MD, and Michelle M. Yee, CPNP, from Children’s Memorial Hospital in Chicago, Illinois, searched PubMed for relevant studies on the role of diet and dietary supplements for the treatment of children with ADHD.They note that their recommendations on diet and dietary supplements are based on a critical review of the data and their own experience in a neurology clinic for children and adolescents with ADHD.The study was published on January 9 in Pediatrics.Elimination Diets Not AdvisablePerhaps the "most promising and practical" complementary or alternative treatment, write Dr. Millichap and Ms. Yee, is adopting a "healthy" dietary pattern, omitting items shown to predispose to ADHD or to make the condition worse. These items include fast foods, red meat, processed meat, potato chips, high-fat dairy foods, and soft drinks.They point to a "provocative" study published last year, which found a link between ADHD in adolescents and a "Western-style" dietary pattern that was high in fat, refined sugars, and sodium and low in fiber, folate, and omega-3 fatty acids (Howard et al, J Atten Disord. 2011;15:403-411). ADHD was not associated with a "healthy" dietary pattern rich in fish, vegetables, fruit, legumes, and whole-grain foods.Adopting a healthy dietary pattern "may offer an alternative method of treatment of ADHD and less reliance on medications," the authors of the current study write.They also note that although many parents report worsening of hyperactivity symptoms after consumption of foods and drinks containing sugar or aspartame — and isolated reports support the parents' observations — most controlled studies have failed to find a significant harmful effect of sugar or aspartame, the authors note.Additionally, they say that the elimination of sugar and aspartame and adapting additive-free diets are complicated, disruptive, and often impractical; such measures are indicated only in select cases.Fatty Acid Supplements May Be HelpfulLow levels of long-chain polyunsaturated fatty acids (PUFA) have been reported in the plasma and red cells of children with ADHD in comparison with their ADHD-free peers, Dr. Millichap and Ms. Yee note. Some studies have demonstrated a reduction in ADHD symptoms with PUFA supplementation, although no definitive conclusions can be drawn.However, the authors note that "on the basis of reports of efficacy and safety, we use doses of 300 to 600 mg/day of omega-3, and 30 to 60 mg/day of omega-6 fatty acids, continued for 2 or 3 months, or longer if indicated.""As initial or add-on therapy, we have occasional reports of improved school grades and lessening of symptoms of ADHD, without occurrence of adverse effects. Most parents are enthusiastic about trying the diet supplements, despite our explanation of only possible benefit and lack of proof of efficacy," they note.They also note that iron and zinc supplementation is advisable when there is a known deficiency in these minerals, and this may "enhance the effectiveness" of stimulant therapy.Dr. Millichap and Ms. Yee have disclosed no relevant financial relationships.Pediatrics. Published online January 9, 2012. Abstract

No Benefit of Additional Foods, Fluids in Breast-Fed Infants

2012-01-02T20:54:00.000-08:00

From Medscape Education Clinical BriefsNews Author: Lara C. Pullen, PhDCME Author: Laurie Barclay, MD12/21/2011Clinical ContextBreast-feeding provides all of the nutritional, immunologic, and psychological requirements needed for a healthy, term infant to thrive, and it also benefits maternal health and well-being. Health organizations throughout the world recommend exclusive breast-feeding for 6 months.However, mothers in many countries and communities supplement breast-feeding with other fluids or foods before the infant is 6 months old, suggesting perceived benefits of early supplementation or lack of awareness of the possible risks. The objective of this Cochrane review by Becker and colleagues was to evaluate the benefits and harms of supplementation for full-term healthy breast-fed infants and to examine the timing and type of supplementation.Study Synopsis and PerspectiveCurrent research supports the World Health Organization's recommendation for exclusive breast feeding for the first 6 months after birth, according to a Cochrane review that was designed to assess the benefits and harms of supplementation for full-term healthy breast-fed infants up to 6 months of age.The systematic literature review included 6 trials (814 infants) and was published online December 7 and in the December issue of the Cochrane Library. The review included randomized or quasi-randomized controlled trials in infants younger than 6 months of age and compared exclusive breast-feeding vs breast-feeding with any additional food or fluids. All of the studies were conducted many years ago (1982 - 1999).There was a significant difference favoring exclusive breast-feeding over fluid supplementation up to and including week 20 (risk ratio, 1.45; 95% confidence interval [CI], 1.05 - 1.99). The review also raised concerns that the addition of glucose water at 70 mL/kg/day might displace nutrients provided by breast milk.Three trials examined infant morbidity and found a statistically, but not clinically, significant difference in temperature at 72 hours (mean difference [MD], 0.10°; 95% CI, 0.01° - 0.19°) in glucose-supplemented infants compared with exclusively breast-fed infants. In addition, serum glucose levels were higher in glucose-supplemented infants at 24 hours, but not at 48 hours (−0.24 mmol/L; 95% CI, −0.51 to 0.03).In addition to finding no benefit from fluid supplementation of newborns or infants (up to age 6 months), the review found possible negative effects on the duration of breast-feeding from the brief use of additional water or glucose water.The studies were independently selected for inclusion in the review by 2 authors, and 3 authors extracted the data and assessed the risk for bias. The review was performed because although the World Health Organization and other organizations recommend exclusive breast-feeding for 6 months, the addition of other fluids or foods is common in many countries and communities. This practice suggests perceived benefits of early supplementation or lack of awareness of the possible risks.Although the review focused on the effects on the infant during the first 6 months of life, the authors noted that supplementation with nonhuman milk may have effects on the developing gastrointestinal, metabolic, and immune systems that persist through childhood and beyond. The review also did not include the effect of an artificial teat on infant sucking skills or its role as a potential source of infection.The review was also limited in that it only looked at effects on the infants and did not include the possible effects of supplementation on the mother. These could include engorgement, mastitis, earlier return to fertility, nutritional status, maternal use of time, and maternal mental health and financial effects.The authors have disclosed no relevant financial relationships.Cochrane Library. Published online December 7, 2011. AbstractRelated Link Information about The Baby-Friendly Hospital Initiative, which discourages infant supplementation, was developed by WHO and UNICEF and is available online.Clinical ImplicationsAccording to a Cochrane review of randomized controlled trials in healthy, breast-fed newborn infants, the benefits or harms of supplementation or the effect of timing and type of supplementation could not be determined. However, brief use of additional water or glucose water had no detectable benefit to newborn infants and possible negative effects on the duration of breast-feeding.For infants 4 to 6 months old, there was no detectable benefit from additional foods nor any detectable risks related to morbidity or weight change. This Cochrane review found no evidence to disagree with international health associations' recommendation for exclusive breast-feeding for healthy infants for the first 6 months.

Infant Acetaminophen Dosage Change May Cause Confusion

2011-12-30T20:24:00.000-08:00

From WebMD Health NewsJennifer WarnerDecember 23, 2011 — Double check the label on liquid acetaminophen before giving it to a child or infant to avoid giving your child the wrong dose.The FDA is urging parents and caregivers to carefully read the label on liquid acetaminophen marketed to infants and children as a new, less concentrated form of the popular pain reliever arrives on store shelves.Acetaminophen products include several over-the-counter brands, including Little Fevers, PediaCare, Triaminic, Tylenol, and store brands or generic versions of the drug.While the new 160 mg per 5 mL concentration is now arriving in drugstores, much of the older, more concentrated 80 mg per 1 mL or 80 mg per 0.8 mL versions may still be in people’s medicine cabinets.“There is still some on store shelves; there is still some in homes; and there is still some in distribution,” Carol Holquist, director of the FDA’s Division of Medical Error Prevention and Analysis, says in a news release. “Be very careful when you’re giving your infant acetaminophen.”Giving too little liquid acetaminophen could cause the drug to be ineffective. Giving too much could possibly lead to death.The drug is used to temporarily reduce fever and relieve minor aches and pains from the common cold, flu, headache, minor sore throat, and toothache.Why the New Version?Until recently, liquid acetaminophen marketed for infants was available only in the stronger 80 mg per 1 mL or 80 mg per 0.8 mL concentrations that don’t require giving infants as much liquid with each dose. Meanwhile, the less concentrated 160 mg per 5 mL version was marketed for children.Earlier this year, a report from the FDA showed that confusion caused by the different concentrations of liquid acetaminophen for infants and children was leading to overdoses that made infants seriously ill, and some died from liver failure.To avoid these dosing errors, some manufacturers voluntarily changed the concentration of liquid acetaminophen for infants to the same concentration as the liquid acetaminophen marketed to children.The new, less concentrated 160 mg per 5 mL liquid acetaminophen for infants has new dosing instructions and may have a new dosing device in the box, such as an oral syringe rather than a dropper.What You Should DoThe FDA advises parents and caregivers to read the “Active ingredient” section of the Drug Facts label on liquid acetaminophen marketed to infants or children to tell the difference between the two products.Other tips for ensuring safe and accurate dosing of liquid acetaminophen include:Do not depend on a banner proclaiming that the product is “new” to determine the drug’s concentration. Some medicines with the old concentration also have this word on their packaging.Use only the dosing device provided with the purchased product in order to correctly measure the right amount of liquid acetaminophen.Consult your pediatrician before giving this medication and make sure you’re talking about the same concentration.If the dosing instructions provided by your health care provider differ from what is on the label, check with a health care professional before administering the medication. Do not rely on dosing information provided from other sources, such as the Internet, old dosing charts, or family members.FDA officials say it is important to note that there is no dosing amount specified for children younger than 2 years of age. If you have an infant or child younger than 2 years old, always check with your health care provider for dosing instructions.

Concussions, Our Patients, and You

2011-12-28T18:52:00.000-08:00

Gregory Lawton, MD, Pediatrics, General, 09:24AM Dec 19, 2011Recently, the New York Times chronicled the life and death of hockey's premier enforcer, Derek Boogaard, who died at the age of 28 in April from an overdose of pain killers. His brain, subjected to hundreds of bare-knuckle fights over from the age of fourteen years, demonstrated pronounced evidence of chronic traumatic encephalopathy (CTE).I was dumbfounded at how matter of fact, even nonchalant, his parents were, as they described their late son's career, and their acceptance of his job, to deliver (and receive) physical punishment. His father was more concerned about the toll of fighting on his hands.Last month, a new study detailed the potential destructive effects on the brain's white matter resulting from the frequent heading of soccer balls.According to the study, adults who actively played soccer and acknowledged heading the ball more than 1,100 times in the previous twelve months had radiological and cognitive evidence of a decline. While the study was on adults, it raises more than a few questions concerning the effects of heading on the developing brains of children and adolescents.Finally, a December National Geographic piece visually quantifies the 537 head shots a college football player sustained during a single season. Two hits resulted in concussions, and interestingly enough, the hits that resulted in concussions were not the hardest of the bunch. This adds to the complexity of concussions and their prevention, with the notion of rotational as well as direct forces.What to do? We are parents, coaches, as well as pediatricians. We go to hockey and football games and pay good money for the tickets. Some measures are within our reach but are quixotic in nature. Others are hopelessly naïve. Let's start small. As parents, just say no to some things. My father forbade me to play football (so I became a baseball catcher instead). Ditto for my son. Is this a bit inconsistent, trading a blitzing linebacker's helmet for a foul ball off the facemask? Probably, but I would like to think that neither myself nor my parents were as "bewildered" by their son's activities as Derek Boogaard's parents. Life and sports are both associated with risks. The only risk-free option is not to play. To choose one sport over another is to exercise our judgment and choose one set of risks over another. As coaches, we have the opportunity to combine personal interest and professional knowledge as it relates to developing athletes. A growing consensus seems to be developing that heading should be discouraged in players under the age of twelve. For older players, teaching chest trapping (especially on punts) may make for better ball control as well as fewer concussions. Keeping an eye out for concussive symptoms such as headaches, dizziness, or nausea in our players should decrease the incidence of second concussion syndrome, regardless of the sport.As pediatricians, we need to continue to educate parents and players about the signs, symptoms, and CONSEQUENCES of concussions. We need to impress upon them that no practice, scrimmage, game, or playoff, is worth the risk of a second concussion.How many kids in our practices have gone on to professional football, lacrosse, or hockey careers? Compare that to the number of future teachers, business owners, or managers we see. The reality is that the vast majority of our patients will make their future mortgage payments not with their athletic prowess, but with their more prosaic communication, organization, decision-making skills. Brain cells are our patients' most precious collateral. We must emphasize this fact with regard to concussions as strenuously as we do with drug and alcohol counseling.Finally, what are we to make of our football season tickets or our interest in a Flyers-Rangers game? Both sports are physical, often violent. Both are also punctuated with moments, indeed entire sequences that are mesmerizing for their grace, speed, and superb athleticism. What is closer to the essence of each sport, the violence or the elegance? Perhaps we should aspire to cheer that which is closer to the essence.Chris Nowinski, of the Center for the Study of Tramatic Encephalopathy at Boston University Medical School, is a former Harvard football player (as well as professional wrestler). He has suffered post-concussion syndrome. He still loves his Bruins; however, he tends to remain seated during the fights. Enforcers in hockey, football players who lead with their helmets and soccer players who take the hard shots out of the air with their heads are doing one thing, according to Nowinski. "They are trading money for brain cells."We don't see professional athletes in our offices. We see student athletes. Let's asked them to be smart, to play tough, but to play fair. Concussions will happen, but we need to be proactive in both prevention and treatment. When we counsel about second concussions, we need to modify the Nowinski's quote. Don't trade brain cells for glory.Look for me on Facebook at A Musing Pediatrician, http://www.facebook.com/profile.php?id=100003267241424

An Infant is not Just a Small Child

2011-12-28T18:39:00.001-08:00

From Expert Review of Clinical PharmacologyClinical Pharmacology in Neonates and Young InfantsThe Benefit of a Population-tailored ApproachJohn van den Anker; Karel AllegaertAuthors and DisclosuresPosted: 12/22/2011; Expert Rev Clin Pharmacol. 2012;5(1):5-8. © 2012 Expert Reviews Ltd. Print This Email this An Infant is not Just a Small ChildTailored Pharmacokinetic Studies in Infancy: Improved Sampling Strategies & Data An Infant is not Just a Small ChildJohn van den Anker; Karel AllegaertPosted: 12/22/2011; Expert Rev Clin Pharmacol. 2012;5(1):5-8. © 2012 Expert Reviews Ltd.The most essential characteristics of childhood are growth and maturation. Both phenomena are most prominent during infancy, making the claim that 'an infant is not just a small child' as relevant as the more commonly used paradigm that 'a child is not just a small adult'. There is already one log size difference in weight (0.5–5 kg) within the neonatal population, quite similar to the log size spectrum (5–50 kg) of childhood.The birth weight increases by 50% in the first 6 weeks of life, and doubles in the first 4 months to be three-times higher at the end of infancy. In this same time interval, there is a fourfold increase in caloric needs. As a consequence, the first year of human life is characterized by a very dynamic biological system where growth, maturation and extensive variability are the key issues.From a clinical pharmacology perspective, the consequence of such a dynamic setting is extensive interindividual variability throughout infancy in both the pharmacokinetics and pharmacodynamics of xenobiotics. Instead of median values for pharmacokinetic estimates or outcome variables, the range and its contributing covariates are crucial. Body composition and compartment sizes change during infancy, and all phase I (e.g., cytochromes) and phase II (e.g., glucuronidation) metabolic processes mature in an iso-enzyme-specific pattern, while renal function (glomerular filtration rate and tubular absorption/excretion) also displays age-dependent capacity. The phenotypic variability in either drug disposition or effects during infancy is further affected by the contribution of other, non-ontogeny-related covariates (e.g., perinatal asphyxia with whole body cooling, comedication, genetic polymorphisms, sepsis or inflammation, and congenital renal impairment).History provides the community with compound-specific observations to illustrate the negative impact of exposure to chloramphenicol (deficient glucuronidation capacity resulting in chloramphenicol accumulation and gray baby syndrome), benzyl alcohol (deficient alcohol dehydrogenase activity resulting in benzyl alcohol accumulation and gasping syndrome) or – much more recently – dexamethasone (specific vulnerability of neonatal cortical and subcortical nervous tissues, resulting in cerebral palsy and blunted brain growth) in neonates. All these anecdotic observations can be considered as illustrations of failure to consider the specific characteristics of this vulnerable population.However, optimism is a moral duty. Implementation of the pediatric regulation in the USA in 1997 has resulted in a rebirth of pediatric product development, including drugs for infants. Subsequent implementation of a similar pediatric legislation initiative in the EU (2007) and in WHO initiatives (e.g., the WHO 'make drugs child size' program, which is an ongoing program of the WHO and resulted in an essential medicines list for children in 2011) further stimulated all stakeholders (industry, academia, governmental and research organizations) to develop focused pediatric research activities. As an illustration, a search for 'newborn/infant' on the clinicaltrials.gov website in early October 2011 resulted in 1318 protocols for interventional studies, of which 899 were initiated (based on the sponsor's location) in the USA and 376 in Europe. Although this is only a snapshot of the ongoing clinical research activities, it suggests that there is growing research activity aiming to further improve pharmacotherapy.In addition to compound-specific observations, such studies also stimulated the development and validation of research tools in the field of pharmacokinetics (e.g., analytical techniques and population pharmacokinetics) and pharmacodynamics (population-specific 'biomarkers') adapted to newborns and infants.

Caffeine Intake May Negatively Affect Children

2011-12-28T03:48:00.000-08:00

From Medscape Medical NewsLaurie Barclay, MDDecember 22, 2010 — Caffeine intake is prevalent in children and may have negative effects on sleep duration, according to the results of a study reported online in the December 16 issue of the Journal of Pediatrics."Caffeine's diuretic properties have encouraged behavioural health practitioners to eliminate caffeine from the diet of children with enuresis," write William Warzak, MD, from the Munroe-Meyer Institute and the Department of Pediatrics, University of Nebraska Medical Center in Omaha, and colleagues. "The Food and Drug Administration has not developed pediatric guidelines for caffeine consumption, but Canadian guidelines recommend that children aged 4 to 6 years old consume no more than 45 mg/d, approximately equivalent to the amount of caffeine found in a 12-ounce can of cola.... The most recent caffeine consumption data for children living in the United States is almost a decade old, and most of this research has been conducted with older children, adolescents, and adults."The study goals were to obtain current data for caffeine intake in children, to evaluate the associations between caffeine, enuresis, and sleep, and to assess cross-cultural differences in caffeine consumption by Spanish- and English-speaking children aged 5 to 12 years.During routine clinical visits at a pediatric clinic in Omaha, parents were surveyed about their child's daily consumption of various types of snacks and beverages. Of 228 young children whose parents were surveyed, about three quarters regularly consumed caffeine. Mean daily caffeine intake was approximately 52 mg in children aged 5 to 7 years and approximately 109 mg in children aged 8 to 12 years. Older children drank more caffeinated beverages than younger children."Some children as young as 5 years old were consuming the equivalent of a can of soda a day," Dr. Warzak said in a news release. "Children between the ages of 8 and 12 years consumed an average of 109 mg a day, the equivalent of almost 3 12-ounce cans of soda."This study authors note that 109 mg caffeine daily is almost twice the amount recommended by Canadian pediatric guidelines and in excess of the amount shown to create physiological effects in adults.Although caffeine intake was significantly negatively correlated with hours slept, caffeine consumption and enuresis were not significantly correlated. Compared with English-speaking parents, Spanish-speaking parents reported fewer events of enuresis in their children."Contrary to popular belief, children were not more likely to wet the bed if they consumed caffeine, despite the fact that caffeine is a diuretic," said coauthor Shelby Evans, PhD, also from the University of Nebraska Medical Center.Children aged 5 to 7 years slept an average of 9.46 hours per night, which is above the minimum 9 hours recommended by the US Centers for Disease Control and Prevention (CDC), but approximately one quarter of these children slept less than 9 hours per night. Children aged 8 to 12 years old slept an average of 8.47 hours per night, which is below the minimum proposed by the CDC.Limitations of this study include the inability to determine causal relationships, potential recall and parental bias, and a modest sample size of Spanish-speaking children. In addition, this study did not address the specific physiological and psychological effects of caffeine consumption on young children."Parents should be aware of the potentially negative influence of caffeine on a child's sleep quality and daily functioning," Dr. Warzak concluded.The study authors have disclosed no relevant financial relationships.J Pediatr. Published online December 16, 2010.

Kids' Leukemia Risk Tied to Dads' Smoking

2011-12-27T19:21:00.000-08:00

From Reuters Health InformationBy Kerry GrensNEW YORK (Reuters Health) Dec 15 - Children whose fathers smoked have at least a 15% higher risk of developing acute lymphoblastic leukemia, a new Australian study finds."Paternal smoking seems to be real" as a risk factor, said Dr. Patricia Buffler, a professor at the University of California, Berkeley, who was not involved in the current analysis."The importance of tobacco exposure and children's cancers has been overlooked until recently," Dr. Buffler told Reuters Health. "So I think this paper is important" in adding to the growing body of evidence.The research team, led by Dr. Elizabeth Milne at the Telethon Institute for Child Health Research in Australia, surveyed the families of nearly 400 children with ALL.Although ALL is the most common childhood cancer, it is still rare, affecting about three to five children out of every 100,000, according to the National Cancer Institute.The survey asked about the smoking habits of both parents.Dr. Milne and her colleagues compared these families to the families of more than 800 children of similar ages who did not have leukemia.They found that the mothers' smoking behavior had no impact on the kids' risk of developing the cancer.The researchers then added their results to those of nine earlier studies.When they did that, they found that kids whose fathers smoked at all around the time of their conception were 15% more likely to develop leukemia. Those whose dads smoked at least 20 cigarettes per day around that time were 44% more likely to be diagnosed with the cancer, according to a report published online December 5 in the American Journal of Epidemiology.Because of the toxins in tobacco smoke, Dr. Buffler said, "it's not unlikely that you'd have damage" in the cells that produce sperm."Sperm containing DNA (damage) can still reach and fertilize an ovum, which may lead to disease in the offspring," Dr. Milne wrote in an email to Reuters Health.The study did not prove that DNA damage in the sperm caused by smoking is responsible for the children's increased risk of cancer."The causes of ALL are likely to be multifactorial, and our findings relate to just one of the possible contributing factors," said Dr. Milne.Several other environmental factors are also tied to a greater chance of developing childhood leukemia, including ionizing radiation and the mother's exposure to paint or pesticides while pregnant.Dr. Milne said that many of the studies regarding these potential causes have been small, and not conclusive.Dr. Buffler is leading an international consortium of researchers tracking thousands of cases of childhood leukemia to determine the influence of environmental, genetic, and other biological factors on developing the disease.SOURCE: http://bit.ly/snq3sL

Lower Asthma Risk in Chubby Tots Who Slim Down

2011-12-27T19:19:00.000-08:00

From Reuters Health InformationBy Amy NortonNEW YORK (Reuters Health) Dec 21 - Overweight preschoolers who don't slim down are at a higher asthma risk at age seven, but the baby fat doesn't seem to matter for kids who lose the extra weight, a new study suggests.Of more than 2,000 Swedish children followed to age eight, those who were overweight or obese at age seven - that is, with a body mass index at or above the 85th percentile -- were more likely to have asthma than their thinner peers -- whether or not they were overweight earlier in life.In contrast, children who were heavy as toddlers or at age four, but not at age seven, were no more prone to asthma than kids who'd always been normal-weight.Children who are chubby early in life often see their weight normalize by school age, according to lead researcher Jessica Ohman Magnusson, of the Karolinska Institute in Stockholm.But if the extra weight persists after age four, she told Reuters Health in an email, parents may need help in managing their child's weight in a healthy way.A number of studies have found that heavy children have a higher risk of asthma, or more severe symptoms. But whether the extra pounds are the cause is not clear. "We don't think we can say that overweight is causally associated with asthma," Magnusson said.That's because early-childhood pounds were not tied to asthma risk in cases where children eventually became normal-weight, she said. It's possible that other factors, and not weight itself, explain why children who remain heavy have an increased asthma risk.As reported online December 19th in Pediatrics, 6% of the total cohort of eight-year-olds had asthma, compared to 10% of the kids who were overweight at age seven.When the researchers accounted for parents' history of allergies, maternal smoking during pregnancy, and other factors, they found that being overweight at age seven was linked to a doubling in the risk of asthma. That was true regardless of whether the kids were normal weight or heavy at age four.Around 300 children in the study were overweight at some point. But fewer were persistently heavy; 122 children remained overweight from the age of one to age seven.So parents should feel reassured, Magnusson said, that those early extra pounds often do not last. And based on these findings, children whose weight normalizes may not have an increased asthma risk.SOURCE: http://bit.ly/tVwsye

Atopic Dermatitis : Diagnosis & Pathogenesis

2011-12-27T19:10:00.000-08:00

Cases in Atopic DermatitisMedscape Pediatrics CME Lawrence F. Eichenfield, MDProfessor of Clinical Pediatrics and Medicine (Dermatology), University of California Pathogenesis and Diagnosis of Atopic DermatitisAtopic dermatitis (AD) is a common inflammatory skin disorder affecting 10%-20% of children during their first decade of life. It is characterized by a pruritic, scaling rash that follows a fluctuating course. In approximately 60% of patients, AD starts in the first year of life. Newborns and infants usually have involvement on the cheeks, chin, and extremities. As the child ages, the rash typically transitions to classic involvement of the flexural antecubital and popliteal fossae. Fortunately, AD frequently resolves when the patient grows older.The pathogenesis of AD is complex and multifactorial. Acute AD is characterized by strong type 2 T-helper (TH2) cell responses with production of interleukin (IL)-4, IL-5, and IgE antibodies, whereas chronic AD has immunologic features more consistent with TH1-mediated responses. Recent evidence also suggests a possible role for TH17 cells.There is a significant barrier defect in people with AD. Many have mutations in the epidermal proteins that result in epidermal barrier dysfunction. The epidermis of skin affected with AD often has decreased levels of filaggrin, a protein responsible for aggregation and adhesion of the cornified envelope; ceramides, the predominant lipids of the cornified envelope; and antimicrobial peptides, such as beta-defensins and cathelicidins, proteins of the innate immune system that resist cutaneous colonization and infection. Further exacerbating the epidermal barrier of people with AD is increased transepidermal water loss. As a result of these barrier defects, allergen absorption and bacterial colonization and infection are enhanced, which further potentiates the immunologic dysfunction present in skin affected by AD.The diagnosis of AD is usually not challenging. However, other diagnoses should be considered if the presentation is atypical. Differential diagnoses include scabies, psoriasis, allergic contact dermatitis, immunodeficiency diseases, metabolic conditions, nutritional disorders, Langerhans cell histiocytosis, and various other disorders as suggested by the patient's presentation.Because AD is part of an atopic triad that includes asthma and allergic rhinitis, it is important to ask patients and parents whether there is a history of any of these in the patient or family. If there is such a history, AD is more likely. A child has a 20% risk for AD if one parent is affected and a 50% risk if both parents are affected. Furthermore, the concordance rate between monozygotic twins is 80%, and the concordance rate between dizygotic twins is 20%.Findings on physical examination that support a diagnosis of AD include typical pruritic eczematous dermatitis, hyperlinear palmar dermatoglyphics (increased fine skin lines), Dennie-Morgan fold (infraorbital line caused by edema), allergic shiners (dark periorbital skin due to sinus congestion and venous congestion), allergic salute (horizontal crease on the dorsal nose secondary to chronic allergies and rubbing), keratosis pilaris (spiny papules on the anterolateral upper arms), and ichthyosis vulgaris (fish-like scales on the skin). The diaper area of infants and toddlers with AD is characteristically spared, partially due to the occlusive hydration effect of diapers. The presence of significant rash in this area should prompt the consideration of other etiologies.There are many proposed diagnostic criteria for AD. Perhaps the most practical, sensitive, and validated for use in epidemiologic studies are the UK Working Party's Diagnostic Criteria for Atopic Dermatitis (Table 1). To meet these criteria, the patient must have pruritus and 3 or more minor criteria.Table 1. UK Working Party's Diagnostic Criteria for Atopic DermatitisA. Required Criterion1. PruritusB. Minor Criteria (≥ 3 of the following must be present)1. Onset < 2 years of age2. History of flexural involvement3. History of asthma or hay fever (or history of these conditions in parent or sibling if patient is < 4 years of age)4. History of general dry skin in the last year5. Visible flexural eczema (or eczema involving the cheeks/forehead and outer limbs in children < 4 years of age)Similarly, the American Academy of Dermatology Consensus Conference stated that AD is best thought of as a syndrome with features classified as "essential," "important," and "associated" (Table 2).Table 2. American Academy of Dermatology Consensus Conference Definition of Atopic DermatitisA. Essential Features (must be present)1. Pruritus2. Eczema (acute, subacute, chronic)a. Typical morphology and age-specific patterns*b. Chronic or relapsing historyB. Important Features (seen in most cases, adding support to the diagnosis)1. Early age at onset2. Atopya. Personal and/or family historyb. IgE reactivity3. XerosisC. Associated Features (helpful in suggesting the diagnosis but too nonspecific for defining or detecting AD for research or epidemiologic studies)1. Atypical vascular responses (eg, facial pallor, white dermographism, delayed blanch response)2. Keratosis pilaris/hyperlinear palms/ichthyosis3. Ocular/periorbital changes4. Other regional findings (eg, perioral changes/periauricular lesions)5. Perifollicular accentuation/lichenification/prurigo lesionsExclusionary ConditionsDiagnosis of AD depends on excluding such conditions as scabies, seborrheic dermatitis, allergic contact dermatitis, ichthyosis, cutaneous lymphoma, psoriasis, and immune deficiency diseases* Patterns include (1) facial, neck, and extensor involvement in infants and children; (2) current or prior flexural lesions in any age group; and (3) sparing of groin and axillary regions.

Parents' Smoking May Cause Vascular Damage in Children

2011-12-27T17:44:00.001-08:00

From Medscape Medical NewsLaurie Barclay, MDDecember 26, 2011 — Parental smoking during pregnancy may cause vascular damage when the children reach 5 years of age, according to the results of a birth cohort study published online December 26 and in the January 2012 print issue of Pediatrics."Smoking during pregnancy has been related to thicker carotid intima media thickness in young adults, and this was also shown in neonates," write Caroline C. Geerts, MD, from the Julius Center for Health Sciences and Primary Care and University Medical Center Utrecht in the Netherlands and colleagues. "The relation between smoke exposure in early life, the prenatal period in particular, and the vascular development of young children is largely unknown."To evaluate the association between parental smoking during pregnancy and subsequent vascular characteristics in their children, the investigators used data from the birth cohort enrolled in the Wheezing Illnesses Study Leidsche Rijn (WHISTLER)-Cardio study. At 5 years of age, 259 participants underwent ultrasonographic measurement of carotid artery intima-media thickness (CIMT) and arterial wall distensibility. Parental smoking data were also updated.After adjustment for the child's age and sex, maternal age, and breast-feeding, children of mothers who had smoked throughout pregnancy had more vascular damage than children of mothers who did not smoke during pregnancy. CIMT was 18.8 μm thicker in the former group (95% confidence interval [CI], 1.1 - 36.5; P = .04), and distensibility was 15% lower (95% CI, −0.3 to −0.02; P = .02).Children of mothers who smoked after pregnancy, but not during pregnancy, did not have these adverse effects on CIMT and distensibility. If both parents smoked during pregnancy, the associations were even stronger than with only maternal smoking: CIMT was 27.7 μm thicker (95% CI, 0.2 - 55.3), and distensibility was 21% lower (95% CI, −0.4 to −0.03)."This study is the first to show that the effect of smoking during pregnancy on the vasculature of children is (still) visible at the age of 5 years," the study authors write. "Pregnancy appears to be the critical period for this damage to occur."Limitations of this study include slightly different profiles in participants than in nonparticipants, lack of cotinine measurements at birth, and reliance on parental self-report of smoking."In view of the early origins of cardiovascular disease, preventive measures against smoking should be specifically directed at the gestational period," the study authors conclude.The Netherlands Organization for Health Research and Development supported the WHISTLER birth cohort. The University Medical Center Utrecht supported WHISTLER-Cardio. The authors have disclosed no relevant financial relationships.Pediatrics. Published online December 26, 2011. Abstract

Food Allergy in Kids Not Being Optimally Diagnosed

2011-11-20T19:45:00.001-08:00

Medscape Medical News from the:American College of Allergy, Asthma & Immunology (ACAAI) 2011 Annual Scientific MeetingFran LowryNovember 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.

Panel Recommends Universal Cholesterol Screening for Kids

2011-11-14T19:01:00.001-08:00

Medscape Medical News from American Heart Association (AHA) 2011 Scientific SessionsFrom HeartwireMichael O'RiordanNovember 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 TomorrowDr 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 YouIn 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.

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

2011-11-13T19:11:00.001-08:00

From Medscape Medical NewsFran LowryNovember 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 BrownFrom 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.

Is There an Up Side to Autism?

2011-11-11T17:55:00.001-08:00

From Medscape Medical News > Psychiatrists in the NewsSociety'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 WaknineNovember 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."AdvantagesAutism 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 IntrinsicWhat 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 LaraSome 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 ExperienceI 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

How to talk with your teen

2011-11-09T22:23:00.001-08:00

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 orientationReviewed by the CPS Adolescent Health Committee and Public Education Advisory Committeehttp://www.caringforkids.cps.ca/teenhealth/TalkWithTeen.htm

Tips for limiting screen time at home

2011-11-09T22:05:00.001-08:00

“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 CommitteePosted: June 2011 Canadian Paediatric Society

No Imaging Needed for Most Low Back Pain in Teens

2011-11-04T19:55:00.000-07:00

Medscape Medical News from the:American Academy of Pediatrics (AAP) 2011 National Conference and ExhibitionNovember 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

2011-11-04T19:53:00.000-07:00

From Reuters Health InformationBy Will Boggs MDNEW 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: http://bit.ly/sL0WJY Diabetes Care 2011.

Community-acquired Pneumonia in Children

2011-11-02T22:19:00.000-07:00

From ThoraxWhat's New?Anne Thomson; Michael Harris10/27/2011; Thorax. 2011;66(10):927-928. © 2011 BMJ Publishing Group Ltd & British Thoracic SocietyAbstractThe community-acquired pneumonia in children guidelines have just been updated with new evidence on incidence, aetiology and management. This guidance should improve patient care.IntroductionThe 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.

Maternal Hypertension Increases Risk for Birth Defects

2011-11-01T22:59:00.000-07:00

From Medscape Education Clinical BriefsNews Author: Ricki Lewis, PhDCME Author: Désirée Lie, MD, MSEd10/21/2011 Clinical ContextSome 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 PerspectivePregnant 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

The Evolution of Bullying

2011-10-26T20:37:00.000-07:00

Gregory Lawton, MD, Pediatrics, Sep 27, 2011During the first recess on the first day in the first year of the first school (approximately 80,000 BC), an impressively hirsute Neanderthal pushed a smaller, more studious Neanderthal to the ground before depositing him into a trash container.The same thing happed on the second day, only before a larger crowd.And thus bullying began.In the year 2011, the basic characteristics of bullying remain the same. It's about one person or group acting in a manner that is intent on hurting, harming, or humiliating another person or group. It's about doing this on a regular basis. It's about doing this because one side is bigger or stronger than the other side. Might makes Right. So what's new? VOLUME.A single bully is a solo singer. There is one (really loud) singer and one speaker. Maybe the bully has a couple of sidekicks. Now it's a trio, but there is still only one speaker.Welcome to 2011. With the near ubiquity of social media (Facebook and Twitter) and smart phones that permit instant access, the number of speakers has multiplied. Throw in texting and the number of speakers multiplies again. Once upon a time, bullying might only take place on the bus, or at lunch, or after practice. Now, it can be a 24/7 event, whether in the car, at the mall, in the kitchen, or even while on a family vacation during the summer in another state. Cyber bullies can post a hateful message on Facebook or a vengeful text message anytime, anywhere. What's more, if it's done via a video upload to YouTube, the number of speakers increases exponentially. The volume can be devastating.This degree of now public (thanks to social media) humiliation can be realized in a number of horrific scenarios. Victims of bullying have taken revenge to heinous extremes at Columbine High School and Virginia Tech. According to the website Bullying Statistics, http://www.bullyingstatistics.org/ other victims, feeling isolated, resort to suicide.As pediatricians, we see bullies every day. They are our patients. The trouble is, they don't wear a sign announcing that they are bullies when they come in for a physical. Perhaps we are more observant of the victims of bullying. They are the kids with belly pain, headaches, slipping grades, or insidious school aversion. What can we do? What should we do?A recent article on Medscape, http://www.medscape.com/viewarticle/749448, offers a wealth of resources on programs to counter bullying. The trick, however, remains in recognizing it in our offices. What can we, as pediatricians do to prevent bullying?1. Remain open to the idea that every child can be a bully, or a victim. Listening for clues when a patient indicates that he doesn't like school or doesn't "fit in" may indicate that could be a potential target. Ask about discipline issues at school. Are detentions for academic reasons or altercations? The answers could lead to insight that the patient may be more likely to bully others. 2. Caution parents about social media and the need to monitor its use in their home. Encourage them to know what is on their child's Facebook page. Look at the text posts periodically. Advise parents to keep computers and smart/cell phones out of the bedrooms at night so as to keep their child's room nominally safe from electronic intrusions, vicious or otherwise.3. Consider speaking with parents separately before or after an appointment. Ask explicitly about school, it's social and academic aspects. Communicate that you are willing to work with the kids, their parents, and the schools as part of a coordinated anti-bullying effort.As with so many aspects of our professional lives, there are no easy answers, nor is there a one size fits all approach. We can make a difference however, as we always do, one patient at a time. By enforcing social media rules in our homes, we decrease the potential for cyber bullying in our personal lives. By listening a bit differently to our patients, we may unearth the real reason for school aversion. The Neanderthal will always be out there. But now he or she has evolved; Facebook and smart phones are the new weapons. Pediatricians can (and for the sake of our patients must) evolve faster.

Parents Can Detect, Contribute to, or be Affected by Critical Events During a Child's Hospitalization

2011-10-26T20:33:00.000-07:00

From ISMP Medication Safety Alert!® Acute Care EditionPosted: 09/23/2011; ISMP Medication Safety Alert © 2011 Institute for Safe Medication PracticesProblemToday, parents are often permitted around-the-clock visiting hours to stay with their hospitalized children, even in neonatal and pediatric intensive care units (ICUs). Many parents take advantage of this option and remain with their children as much as possible. For an ill child, this can be comforting and provides an important emotional benefit. At the same time, parents may be carefully watching and interacting with healthcare professionals, and observing the specialized equipment at their child's bedside, including infusion pumps, IV lines, and drainage systems. A study published by Frey et al. in 2009 suggests that parents who stay with their hospitalized children are inevitably involved in safety issues. In particular, the study showed that parents can help detect critical (harmful or potentially harmful) events precipitated by healthcare professionals. However, the study also showed that parents can contribute to a critical event and are often adversely affected by a critical event.The study was conducted over a 5½ year period in a neonatal-pediatric intensive care unit and a neonatal intermediate care unit in a university children's hospital. During the first 2 years of the study, visiting hours for parents were limited to afternoons and evenings; morning visitations were not allowed and overnight stays were strongly discouraged. Around-the-clock visiting hours were permitted during the last 3½ years of the study.During the span of the study, a total of 2,494 critical events were recorded; 101 of these events directly involved parents. In 18 cases, a parent contributed to the critical event. In 11 cases, a parent detected a critical event. In the remaining 72 cases, a parent was one of the affected individuals. For each event, the actual and potential severity was determined to be minor (requiring no interventions), moderate (requiring routine therapy available outside a critical care unit), or major (requiring therapeutic interventions specific to critical care units, or resulted in death).In the group of critical events that involved parents (n=101), medication events (38%) and line disconnections/reconnections (28%) were most prevalent. In the group of critical events that did not involve parents (n=2,393), events involving medications were again most prevalent (33%), but issues with line disconnections/reconnections (2.7%) were significantly lower. Most events precipitated by parents and subsequently detected by healthcare professionals caused actual harm determined to be of moderate severity, and some events had the potential to cause a high severity of harm. On the other hand, critical events detected by parents did not cause actual harm, although the events had the potential to cause harm of moderate severity. Further details about the study follow.Parents Detecting Safety ProblemsThe most common safety problems detected by parents involved medication errors, tubes or drains that became disconnected, and respiratory distress. Examples include: A mother who realized that a physician had prescribed a five-fold overdose of carvedilol for her child (5 mg BID instead of 1 mg BID) A mother who noticed the wrong weight listed on her child's medical record used for prescribing medications Parents who called attention to their child's respiratory distress or failure.It took parents between 0–70 hours (median 10 hours) to detect a critical event precipitated by a healthcare professional. This suggests that without the parents' interventions, some critical events might have continued without correction. The authors determined the potential harm from continuation of the detected critical events to be severe in 4 cases, moderate in 6 cases, and minor in 1 case. All of the events detected by parents occurred only after around-the-clock visiting hours were made available. This observation suggests that it is easier for parents to detect safety problems if they spend more hours at their child's bedside, observing and participating in their care.Parents Contributing to Safety ProblemsThe most common safety problems precipitated by parents involved the disconnection of tubes and drains, medication errors, and physical trauma. Examples include: A mother accidentally disconnected a central venous line while breast feeding her baby A mother accidentally disconnected a pleural drain while holding her infant A father fell off a chair with his child on his lap.All of the disconnected tubes and drains happened in young infants, from 4 days to 1½ years old. It took healthcare professionals between 0–29 hours (median 0.25 hours) to detect a critical event precipitated by a parent. The authors note that this finding suggests that healthcare professionals are providing appropriate supervision of parents and hospitalized children. Most of these events caused moderate harm (10 cases) before being detected. In all but one event, quick discovery of the problems averted severe harm.Parents Affected by Safety EventsThe most common types of problems affecting parents involved miscommunication and feeding mix-ups. One can expect parents to be emotionally affected by most critical events that involve their children, especially those leading to harm. However, with some critical events, parents were directly affected in ways that were not anticipated. One of the most common examples included mothers who were subjected to viral testing because their breast milk was accidentally fed to another child. Failures such as this increase parental stress during a child's hospitalization.Safe Practice RecommendationsConsider the following recommendations to strengthen the partnership between the treatment team and a hospitalized child's parents, prevent parental contribution to critical events, promote parental detection of errors, and protect the hospitalized child from harm.Educate Parents. Teach parents about the disease/condition, medical tests, and treatment plan for their hospitalized child. Specifically tell parents about all the medications their child is receiving, the prescribed doses (including the fact that it differs from the dose taken at home, if applicable), potential side effects, and when and how they are given. Write down important information for parents to reference as needed. Parents who know what to expect can help recognize when something is not right.Update Parents. Provide parents with timely and comprehensive updates regarding their children in language they understand. Some children's hospitals encourage parents to be part of "family-centered" rounds, allowing them to gain a better understanding of their child's total treatment plan and current status since the entire medical team is available to answer questions and address concerns.Anticipate Involvement. Be aware of increasingly independent parental involvement in the medical care of their children. A 2001 study by Hurst showed that parents continuously analyze hospital procedures and develop an action plan to protect their babies.[2] A fundamental challenge for mothers in this study was to increase their position of authority relative to the medical team, thereby safeguarding their babies. Parents may intervene during the care of their children, which can lead to prevention and detection of a critical event, or contribution to a critical event despite good intentions. Close parental involvement in the child's treatment plan should be encouraged, supervised, and monitored.Encourage Parents to Speak up. Encourage parents to report any concerns or worries they have regarding their child's care. Frey et al. suggests periodically asking parents these two questions: "Are there aspects of your child's care that you find concerning?" and "What do you worry about when you leave your child?" Encourage parents to keep asking questions or voicing concerns until they receive an answer with which they are comfortable and fully understand. Remind parents that they know their child better than anyone on the medical team; thus, communication of their observations is extremely important.Respond to Parents' Queries Appropriately. Parents do not want to be labeled as being "difficult" or "demanding;" they fear no one will want to take care of their child if they are perceived this way.[2] Some may even view basic questions or requests for information about their child's condition as a slight to the medical team's competence. So, when parents do speak up, healthcare professionals should perceive and reflect their actions in a manner that fosters true collaboration and empowerment, and should encourage and reinforce the parents' role in making queries by providing thoughtful and complete answers.Provide Access to a Rapid Response Team. Allow parents to activate a rapid response team if they feel no one is addressing their expressed concerns regarding their child's condition and/or medical treatment. Instruct parents, upon their child's admission, regarding the purpose of the rapid response team and how to activate it.Establish Safe Handling Guidelines. To reduce the risk of tubing disconnections, establish guidelines for safe handling of infants and children with lines and drains, teach these guidelines to parents, and monitor adherence to the guidelines.Teach Parents Not to Reconnect Tubes. Orient parents to the tubes or drains attached to their child. Teach them about the dangers of reconnecting tubes and drains themselves and how to call for immediate help from a healthcare professional if their child's tubes or drains become dislodged or disconnected.

Infant Cataracts: Screening in Primary Care

2011-10-26T20:14:00.000-07:00

From CHOP Expert CommentaryMonte D. Mills, MDPosted: 09/26/2011Director of the Division of Ophthalmology at Children's Hospital of Philadelphia. Infant cataracts are rare. About 1 in 2000 to 1 in 5000 children will have unilateral or bilateral cataracts during infancy. Early detection and treatment are crucial to getting the best visual outcomes for our infants with cataracts.The primary care provider is in the perfect situation to detect and refer these infants for treatment early on during early infant examinations in the hospital and office.The critical and best instrument to detect cataract is the direct ophthalmoscope that you have in your office and in the hospital. You would use it by setting it to the large white spot setting and shining it in a darkened room into the infant's eyes. As you look through the peephole, look at the quality of the red reflex in both eyes simultaneously, examining for symmetry, redness, and brightness of the red reflex. Cataracts would be seen as a dull red reflex or as an asymmetrical red reflex, bright in one side and dull in the other side. It can also be visible as a white pupillary reflex. Children with asymmetry, a dull red reflex, or a white reflex should be referred for evaluation to an ophthalmologist.Infant cataracts should be treated during the first 6 weeks of life to get the best visual outcome. With prompt detection and an early referral and treatment, we can get the best possible outcomes for our patients with infant cataracts. Later in life, infant cataracts might be seen with symptoms including nystagmus, poor visual fixation and following, poor social smile, or strabismus. These children, of course, should also be referred for a full evaluation to an ophthalmologist and potentially for treatment.With early detection using the red reflex test with the direct ophthalmoscope, you'll be able to detect early cataracts. Refer them promptly to achieve the best possible visual outcomes.

New Method of Scoliosis Assessment

2011-10-26T20:06:00.000-07:00

From SpinePreliminary Results Using Computerized PhotogrammetryRozilene Maria Cota Aroeira, MSc; Jefferson Soares Leal, MD; Antônio Eustáquio de Melo Pertence, PhDPosted: 09/26/2011; Spine. 2011;36(19):1584-1591. © 2011 Lippincott Williams & WilkinsStudy Design. A new method for nonradiographic evaluation of scoliosis was independently compared with the Cobb radiographic method, for the quantification of scoliotic curvature.Objective. To develop a protocol for computerized photogrammetry, as a nonradiographic method, for the quantification of scoliosis, and to mathematically relate this proposed method with the Cobb radiographic method.Summary of Background Data. Repeated exposure to radiation of children can be harmful to their health. Nevertheless, no nonradiographic method until now proposed has gained popularity as a routine method for evaluation, mainly due to a low correspondence to the Cobb radiographic method.Methods. Patients undergoing standing posteroanterior full-length spine radiographs, who were willing to participate in this study, were submitted to dorsal digital photography in the orthostatic position with special surface markers over the spinous process, specifically the vertebrae C7 to L5. The radiographic and photographic images were sent separately for independent analysis to two examiners, trained in quantification of scoliosis for the types of images received. The scoliosis curvature angles obtained through computerized photogrammetry (the new method) were compared to those obtained through the Cobb radiographic method.Results. Sixteen individuals were evaluated (14 female and 2 male). All presented idiopathic scoliosis, and were between 21.4 ± 6.1 years of age; 52.9 ± 5.8 kg in weight; 1.63 ± 0.05 m in height, with a body mass index of 19.8 ± 0.2. There was no statistically significant difference between the scoliosis angle measurements obtained in the comparative analysis of both methods, and a mathematical relationship was formulated between both methods.Conclusion. The preliminary results presented demonstrate equivalence between the two methods. More studies are needed to firmly assess the potential of this new method as a coadjuvant tool in the routine following of scoliosis treatment.IntroductionScoliosis has been defined as a lateral curvature of the spinal column superior to 10° Cobb, generally associated to vertebral rotation. Monitoring of this angle has been one of the principal parameters used in defining the type of treatment to be instituted in young patients who are still growing.The most trustworthy method to accompany the evolution of the curvature has been the standing posteroanterior full length spine radiograph, with curvature measurement using the Cobb method.[3] However, over the course of follow-up, this can result in taking more than 25 radiographs.Nearly 15% of patients in one study had undergone 50 or more radiographic examinations, and approximately 17% had received an estimated cumulative radiation dose of 20 cGy or greater.This high number of radiographs can expose patients to relatively high doses of ionizing radiation. Various studies have shown that repeated exposure to radiation in children could be harmful to their health.Many nonradiographic methods of scoliosis accompaniment have been proposed as an alternative to radiographic evaluation.Nevertheless, the majority has not demonstrated a good correlation with the Cobb method.Photogrammetry can be regarded as the science and technology of obtaining spatial measurements, and other geometrically reliable information, derived from photographs.The computerized photogrammetry method proposed in this study can be considered one of many uses of photogrammetry. It has been used in different fields, such as: cartography, architecture, engineering, quality control, and three-dimensional modeling. However, its use in the evaluation of scoliosis has not been well studied. To the authors' knowledge, no data are presently available in the literature that proposes a protocol for photogrammetric measurement of scoliosis, which is applicable to clinical practice.The goals of this investigation were to develop a protocol for computerized photogrammetry method for the quantification of scoliosis curvature as well as to compare the results with those from the Cobb radiographic method in the group of volunteers. Our hypothesis is that both methods yield similar results in obtaining the scoliosis curvature angle.http://www.medscape.com/viewarticle/749301?src=mp&spon=9

Allergic to Antihistamines---really!

2011-10-26T19:39:00.001-07:00

Gary Stadtmauer, MD, Allergy & Clinical Immunology, 08:22AM Oct 17, 2011How many times have we heard patients say they are "allergic" to drugs like antihistamines and corticosteroids? Hypersenstivities to medications used to treat allergic diseases are fortunately uncommon. Both the allergy literature and the dermatology literature describe delayed (and even immediate) hypersensitivity reactions to corticosteroids. Patch testing is the preferred method of detecting Type IV hypersensitivity to corticosteroids since intradermal testing may cause dermal atrophy. Corticosteroids with C16 methylation (such as betamethasone) are less allergenic than other steroids. I have seen a couple of cases of drug exanthema from antihistamines but never immediate hypersensitivity...until now. I recently saw a young woman who has had recurrent urticaria/angioedema of immediate onset due to Benadryl. She had no associated symptoms. Scratch testing to Benadryl 5mg/ml was negative but ID was positive at 0.5 mg/ml (W/F of 4/10) and 5 mg/ml (W/F o 5/10). See image below.One could question whether this is an IgE-mediated event. Perhaps it is or perhaps in the occasional patient the antihistamine acts as an agonist, binding to the receptor instead of blocking it thereby triggering histamine release. Anaphylactic shock caused by a challenge with 12.5 mg oral diphenhydramine has been reported and the authors of this case suggest the mechanism was IgE-mediated.

Low-Dose Intradermal Flu Vaccine Effective as Intramuscular

2011-10-25T19:55:00.000-07:00

From Medscape Medical NewsDaniel M. Keller, PhDOctober 24, 2011 (Boston, Massachusetts) — Injecting a lower dose of 2010/11 trivalent influenza vaccine (TIV) intradermally was more immunogenic than a traditional full-dose intramuscular injection for chronically adults, Ivan Hung, MD, clinical assistant professor in the Department of Medicine at the University of Hong Kong, China, reported here at the Infectious Diseases Society of America (IDSA) 49th Annual Meeting.Dr. Hung and colleagues used 1 of 2 devices to administer intradermal injections using 20% or 60% of the standard dose, and compared the immunogenicity with standard doses delivered intramuscularly in an open-label, prospective, randomized trial.From December 2010 to March 2011, 282 chronically ill adults were randomly assigned to 1 of 4 treatments: TIV containing 3 μg of hemagglutinin antigen per strain, administered with a MicronJet600 device; the same treatment but with 9 μg of hemagglutinin antigen per strain; 9 μg of Intanza9 vaccine, administered with the Soluvia device (Sanofi-Aventis); and 15 μg of TIV administered intramuscularly (control group).Immunogenicity was determined through a hemagglutination inhibition assay at baseline and 21 days after vaccination.Of the 282 subjects enrolled, 262 completed the study — approximately evenly divided among the 4 groups (63 to 68 per group.) Demographically, the groups were similar, with a median age of 73.5 years (range, 68.0 to 78.5 years).At day 21, the seroconversion rates for influenza A/H1N1 for all the intradermal lower-dose groups were higher (approximately 50%) than for the intramuscular full-dose group (approximately 13%; P = .017). Similarly, seroprotection, determined by hemagglutination inhibition assay, was greater for all the intradermal groups than for the intramuscular group (P = .024).In all cases, seroconversion, seroprotection, and geometric mean titer fold increases were at least as good or better for the intradermal groups than for the intramuscular group in terms of response to the A/H1N1, H3N2, and influenza B components of the vaccines."The reason for that is perhaps [because] the intradermal vaccination attracted dendritic cells, and that actually mounted a much better immune response," Dr. Hung said, also noting that no serious adverse effects were detected.He recommends that all elderly and immunocompromised individuals receive intradermal influenza immunizations to compensate for their reduced reactivity to vaccines."Intradermal vaccination actually mounted a much better immune response, and that would offer better protection against influenza and the complications of influenza (for example, pneumonia) in the elderly population and also for those immunocompromised hosts," Dr. Hung told Medscape Medical News. "For the lower dose, you have slightly fewer side effects in terms of swelling, in terms of redness, which is important for elderly people and perhaps has less systemic effects."He explained that intradermal injection is quite easy to give, and suggested that intradermal dose reduction might be an effective way to make vaccine go further in situations of high demand during future pandemics, once the efficacy of dose-sparing vaccination in healthy individuals has been demonstrated.Andrew Pavia, MD, chief of pediatric infectious disease at the University of Utah, Salt Lake City, and chair of the Pandemic Influenza Task Force of the IDSA, who was not involved in the study, told Medscape Medical News that it is worthwhile investigating better ways for influenza immunization."The weakness of flu vaccine is that it doesn't cause as good an antibody response in the elderly. One of the things that we'd like to do is to get a flu vaccine or a way of delivering the old flu vaccine that works just as well in the frail elderly as it does in healthy young and middle-aged adults."Besides the equivalent or better efficacy that Dr. Hung showed, Dr. Pavia sees other advantages of intradermal injections. "There have been reports that with intradermal devices, it hurts much less going in because the needle is a microneedle, which people barely feel, but there may be increased itching or redness at the site, compared to getting a deeper injection with an intramuscular vaccine. Some people may prefer itching to injection pain," he said. "The efficacy studies really haven't been done to show that they're truly equivalent. Cost would be the only other barrier. I think as an alternative, this is very interesting and potentially very useful."He also sees intradermal injection as an advantage for people who are "relatively needle-phobic." "It may be useful when you've got a less-skilled population because this is pretty much an automatic device — you don't have to be skilled in giving an intramuscular injection, and of course, there's less risk of needle sticks," he explained.The study received no commercial funding. Dr. Hung reports a collaboration with and receiving research support from NanoPass Technologies. Dr. Pavia has disclosed no relevant financial relationships.Infectious Diseases Society of America (IDSA) 49th Annual Meeting: Abstract 533. Presented October 21, 2011.

Do Not Give Flu Vaccine by Jet Injection, FDA Says

2011-10-25T19:01:00.001-07:00

From Medscape Medical News > Alerts, Approvals and Safety Changes > Medscape AlertsRobert LowesOctober 24, 2011 — Clinicians should not administer influenza vaccines with needleless "jet injectors" because the vaccines have not been approved for such devices, the US Food and Drug Administration (FDA) has warned.The announcement, issued October 21, follows recent advertisements by major retailers such as Kroger stating that customers can receive such a needleless seasonal flu vaccine instead of the standard injection at their in-store pharmacies. Kroger announced October 21 that it had discontinued the use of this administration technique.A jet injector shoots a high-pressure stream of liquid medication that can penetrate the skin and deliver a dose to tissues underneath.Two manufacturers of jet injectors, PharmaJet and Bioject Medical Technologies, have contested the FDA warning, noting that their products already have received FDA clearance for delivering drugs and vaccines. FDA spokesperson Shelly Burgess told Medscape Medical News that the manufacturers are entirely correct on that point. However, influenza vaccines themselves need to be approved for specific administration methods, regardless of whether the device is approved, Burgess said.So far, the FDA has not cleared any influenza vaccine for jet injection. The agency is advising clinicians to abide by label instructions for administration, whether it is by needle injection or nasal spray.The only vaccine cleared for use with approved jet injectors is for measles, mumps, and rubella (MMR)."Jet injectors represent a different method of delivery that has the potential to change the characteristics of an approved vaccine," the FDA stated in its announcement. "Therefore, each vaccine preparation must be individually evaluated for administration by jet injector, and safety and effectiveness data for that vaccine must be submitted to [the FDA's Center for Biologics Evaluation & Research] for review and approval."The FDA has not received any reports of adverse events associated with jet-injected influenza vaccine, nor is it voicing specific safety concerns, Burgess told Medscape Medical News. "We just haven't studied it yet."When asked whether customers who received influenza vaccine by jet injection should get immunized again during the current influenza season, Burgess referred the matter to a spokesperson for the US Centers for Disease Control and Prevention (CDC). CDC spokesperson Thomas Skinner told Medscape Medical News that "based on current, though limited, information from publications, CDC and FDA believe that it is not necessary for people who got their flu vaccine via jet injector to be re-vaccinated."More information about the FDA announcement is available on the agency's Web site.To report adverse events related to jet injection of an influenza vaccine, contact MedWatch, the FDA's safety information and adverse event reporting program, by telephone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at http://www.fda.gov/medwatch, or by mail to MedWatch, FDA, 5600 Fishers Lane, Rockville, Maryland 20852-9787.

BABIES AND TODDLERS SHOULD LEARN FROM PLAY, NOT SCREENS

2011-10-24T20:26:00.000-07:00

News Release from the American Academy of Pediatrics.BABIES AND TODDLERS SHOULD LEARN FROM PLAY, NOT SCREENSOctober 18BOSTON - The temptation to rely on media screens to entertain babies and toddlers is more appealing than ever, with screens surrounding families at home, in the car, and even at the grocery store. And there is no shortage of media products and programming targeted to little ones. But a new policy statement from the American Academy of Pediatrics (AAP) says there are better ways to help children learn at this critical age.In a recent survey, 90 percent of parents said their children under age 2 watch some form of electronic media. On average, children this age watch televised programs one to two hours per day. By age 3, almost one third of children have a television in their bedroom. Parents who believe that educational television is "very important for healthy development" are twice as likely to keep the television on all or most of the time.The policy statement, "Media Use by Children Younger Than Two Years," will be released Tuesday, Oct. 18, at the AAP National Conference & Exhibition in Boston and will be published in the November 2011 issue of Pediatrics (published online Oct. 18). Ari Brown, MD, FAAP, lead author of the policy, will discuss the recommendations in an embargoed news briefing for reporters at 10 a.m. ET Monday, Oct. 17, at the Boston Convention & Exhibition Center.The AAP first provided guidance on media use for children under age 2 in 1999. This consisted of a recommendation in the Academy's policy statement, "Media Education," which discouraged TV viewing for children in this age group.At the time, there was limited data on the subject, but the AAP believed there were more potential negative effects than positive effects of media exposure for the younger set. Newer data bears this out, and the AAP stands by its recommendation to keep children under age 2 as "screen-free" as possible. More is known today about children's early brain development, the best ways to help them learn, and the effects that various types of stimulation and activities have on this process."The concerns raised in the original policy statement are even more relevant now, which led us to develop a more comprehensive piece of guidance around this age group," said Dr. Brown, a member of the AAP Council on Communications and Media.The report set out to answer two questions: Do video and televised programs have any educational value for children under 2? Is there any harm in children this age watching these programs?The key findings include: Many video programs for infants and toddlers are marketed as "educational," yet evidence does not support this. Quality programs are educational for children only if they understand the content and context of the video. Studies consistently find that children over 2 typically have this understanding. Unstructured play time is more valuable for the developing brain than electronic media. Children learn to think creatively, problem solve, and develop reasoning and motor skills at early ages through unstructured, unplugged play. Free play also teaches them how to entertain themselves. Young children learn best from-and need-interaction with humans, not screens. Parents who watch TV or videos with their child may add to the child's understanding, but children learn more from live presentations than from televised ones. When parents are watching their own programs, this is "background media" for their children. It distracts the parent and decreases parent-child interaction. Its presence may also interfere with a young child's learning from play and activities. Television viewing around bedtime can cause poor sleep habits and irregular sleep schedules, which can adversely affect mood, behavior and learning. Young children with heavy media use are at risk for delays in language development once they start school, but more research is needed as to the reasons.The report recommends that parents and caregivers: Set media limits for their children before age 2, bearing in mind that the AAP discourages media use for this age group. Have a strategy for managing electronic media if they choose to engage their children with it; Instead of screens, opt for supervised independent play for infants and young children during times that a parent cannot sit down and actively engage in play with the child. For example, have the child play with nesting cups on the floor nearby while a parent prepares dinner; Avoid placing a television set in the child's bedroom; and Recognize that their own media use can have a negative effect on children.The report also recommends further research into the long-term effects of early media exposure on children's future physical, mental and social health.According to Dr. Brown, "In today's ‘achievement culture,' the best thing you can do for your young child is to give her a chance to have unstructured play-both with you and independently. Children need this in order to figure out how the world works."

Tdap Vaccine for Pregnant Women

2011-10-24T18:21:00.000-07:00

From Medscape Medical NewsUpdated Recommendations for Tdap Include Pregnant WomenRicki Lewis, PhDOctober 21, 2011 — The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention is taking measures to fill a gap in the protection of infants from pertussis, by vaccinating pregnant women and people in contact with infants younger than 1 year.The tetanus, diphtheria, and pertussis (Tdap) vaccine consists of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine. Vaccinating pregnant women and those in contact with infants will supplement the current practice of "cocooning," in which unvaccinated postpartum mothers and other family members receive Tdap. Although ACIP has recommended cocooning since 2005, compliance has been poor.ACIP also recommends Tdap for people aged 11 through 18 years after they complete the childhood vaccine regimen of diphtheria and tetanus toxoids and pertussis/diphtheria and tetanus toxoids and acellular pertussis, as well as for adults between the ages of 19 and 64 years who have not received Tdap, in addition to people older than 65 years who may be in contact with infants who have not received the vaccine.The reason for the new recommendations is that infants, especially those younger than 2 months, which is when vaccination begins, are particularly vulnerable to developing severe illness and death from pertussis. Vaccinating pregnant women will pass antibodies to the newborn before and during birth. ACIP advises administration after 20 weeks' gestation to minimize the confounding effects of early pregnancy loss in evaluating safety and to maximize the maternal antibodies transmitted to the fetus and infant, given that the half-life of such antibodies is 6 weeks. This new perinatal exposure should provide protection until the infant's first vaccination at 2 months.In the United States each year since 2004, a mean of 3055 infants contract pertussis, with 19 or more deaths, according to the National Notifiable Diseases Surveillance System of the US Centers for Disease Control and Prevention. The total number of cases reported for 2010 was 27,550.Abundant evidence indicates that tetanus and diphtheria vaccines are safe during pregnancy. Although the possible teratogenicity of the vaccine was not initially studied, data from patient registries maintained by the vaccine manufacturers (Sanofi Pasteur and GlaxoSmithKline Biologicals) indicate that Tdap is safe.Further studies will investigate whether exposure to maternal antibodies is indeed protective, or whether it blunts the infant's vaccine response.MMWR Morb Mortal Wkly Rep. 2011;60:1424-1426. Full text

Acne Vulgaris Treatment & Management

2011-10-21T20:48:00.000-07:00

James Fulton Jr, MD, PhD; Chief Editor: Dirk M Elston, MD more...Medical CareTreatment should be directed toward the known pathogenic factors involved in acne. These include follicular hyperproliferation, excess sebum, P acnes, and inflammation. The grade and severity of the acne help in determining which of the following treatments, alone or in combination, is most appropriate. When a topical or systemic antibiotic is used, it should be used in conjunction with benzoyl peroxide to reduce the emergence of resistance.Topical treatmentsTopical retinoids are comedolytic and anti-inflammatory. They normalize follicular hyperproliferation and hyperkeratinization. Topical retinoids reduce the numbers of microcomedones, comedones, and inflammatory lesions. They may be used alone or in combination with other acne medications. The most commonly prescribed topical retinoids for acne vulgaris include adapalene, tazarotene, and tretinoin. These retinoids should be applied once daily to clean, dry skin, but they may need to be applied less frequently if irritation occurs. Skin irritation with peeling and redness may be associated with the early use of topical retinoids. The use of mild, nondrying cleansers and noncomedogenic moisturizers may help reduce this irritation. Alternate-day dosing may be used if irritation persists. Topical retinoids thin the stratum corneum, and they have been associated with sun sensitivity. Instruct patients about sun protection. Also see Sunscreens and Photoprotection.Topical antibiotics are mainly used for their role against Propionibacterium acnes. They may also have anti-inflammatory properties. Topical antibiotics are not comedolytic, and bacterial resistance may develop to any of these agents. The development of resistance is lessened if topical antibiotics are used in combination with benzoyl peroxide.[18] Commonly prescribed topical antibiotics for acne vulgaris include erythromycin and clindamycin alone or in combination with benzoyl peroxide. Clindamycin and erythromycin are available in a variety of topical agents. They may be applied once or twice a day. Gels and solutions may be more irritating than creams or lotions. Clindamycin has maintained better efficacy than erythromycin.Benzoyl peroxide products are also effective against P acnes, and bacterial resistance to benzoyl peroxide has not been reported.[19] Benzoyl peroxide products are available over the counter and by prescription in a variety of topical forms, including soaps, washes, lotions, creams, and gels. Benzoyl peroxide products may be used once or twice a day. These agents may occasionally cause a true allergic contact dermatitis. More often, an irritant contact dermatitis develops, especially if used with tretinoin or when accompanied by aggressive washing methods. If intensive erythema and pruritus develop, a patch test with benzoyl peroxide is indicated to rule out allergic contact dermatitis.Systemic treatmentsSystemic antibiotics are a mainstay in the treatment of acne vulgaris. These agents have anti-inflammatory properties, and they are effective against P acnes. The tetracycline group of antibiotics is commonly prescribed for acne. The more lipophilic antibiotics, such as doxycycline and minocycline, are generally more effective than tetracycline. Greater efficacy may also be due to less P acnes resistance to minocycline. However, P acnes resistance is becoming more common with all classes of antibiotics currently used to treat acne vulgaris.[20]P acnes resistance to erythromycin has greatly reduced its usefulness in the treatment of acne. Subantimicrobial therapy or concurrent treatment with topical benzoyl peroxide may reduce the emergence of resistant strains.Although continued use of systemic tetracycline group antibiotics was believed to result in colonization with tetracycline-resistant Staphylococcus aureus, this does not appear to be true. A study by Fanelli et al found that S aureus remained sensitive to tetracycline even after prolonged use of that antibiotic for acne. This has significant ramifications when considering efforts to control the spread of methicillin-resistant S aureus (MRSA) because tetracycline group antibiotics are currently one of the primary options for outpatient treatment of MRSA.[21]Other antibiotics, including trimethoprim alone or in combination with sulfamethoxazole, and azithromycin, reportedly are helpful.[22, 23]Some hormonal therapies may be effective in the treatment of acne vulgaris. Oral contraceptives increase sex hormone–binding globulin, resulting in an overall decrease in circulating free testosterone. Combination birth control pills have shown efficacy in the treatment of acne vulgaris.[24, 25, 26, 27]Spironolactone may also be used in the treatment of acne vulgaris.[28] Spironolactone binds the androgen receptor and reduces androgen production. Adverse effects include dizziness, breast tenderness, and dysmenorrhea. Dysmenorrhea may be lessened by coadministration with an oral contraceptive. Periodic evaluation of blood pressure and potassium levels is appropriate. Pregnancy must be avoided while taking spironolactone because of the risk of feminization of the male fetus.Isotretinoin is a systemic retinoid that is highly effective in the treatment of severe, recalcitrant acne vulgaris. Isotretinoin causes normalization of epidermal differentiation, depresses sebum excretion by 70%, is anti-inflammatory, and even reduces the presence of P acnes. Isotretinoin therapy should be initiated at a dose of 0.5 mg/kg/d for 4 weeks and increased as tolerated until a cumulative dose of 120-150 mg/kg is achieved. Coadministration with steroids at the onset of therapy may be useful in severe cases to prevent initial worsening. Some patients may respond to doses lower than the standard recommendation dosages. A lower dose (0.25-0.4 mg/kg/d) may be as effective as the higher dose given for the same time period and with greater patient satisfaction. Lower intermittant dosing schedules (1 week out of each month) are not as effective.[29]Isotretinoin is a teratogen, and pregnancy must be avoided. Contraception counseling is mandatory, and 2 negative pregnancy test results are required prior to the initiation of therapy in women of childbearing potential. The baseline laboratory examination should also include cholesterol and triglyceride assessment, hepatic transaminase levels, and a CBC count. Pregnancy tests and laboratory examinations should be repeated monthly during treatment.Acne can be a very depressing situation. It freezes personality development in the adolescent stage and may create hostility, anger, and antisocial behavior. Associated mood changes and depression have also been reported during treatment. Isotretinoin may heighten feelings of depression and suicidal thoughts.[30] Do not administer isotretinoin to a depressed or suicidal teenager. Although a cause-and-effect relationship has not been established, patients should be informed of this potential effect and must sign a consent form acknowledging they are aware of this potential risk.[31, 32]A US Food and Drug Administration–mandated registry is now in place for all individuals prescribing, dispensing, or taking isotretinoin. For more information on this registry, see iPLEDGE. This registry aims to further decrease the risk of pregnancy and other unwanted and potentially dangerous adverse effects during a course of isotretinoin therapy.While using isotretinoin, the patient is considered at high risk for abnormal healing and the development of excessive granulation tissue following procedures. Many dermatologists delay elective procedures, such as dermabrasion or laser resurfacing (eg, with carbon dioxide laser or erbium:YAG laser), for up to 1 year after completion of therapy. Other procedures to be avoided during therapy include tattoos, piercings, leg waxing, and other epilation procedures. Note the images below.Acne with reactive hyperpigmentation; before treatAcne with reactive hyperpigmentation; before treatment. Acne with reactive hyperpigmentation; after treatmAcne with reactive hyperpigmentation; after treatment.A summary of the American Academy of Dermatology treatment guidelines, Guidelines of care for acne vulgaris management, may be of interest.[33] Also see the Medscape Acne Resource Center.

Kids' Urinary Infections Usually Not a Kidney Risk

2011-10-21T20:33:00.001-07:00

From Reuters Health InformationBy Amy NortonNEW YORK (Reuters Health) Oct 12 - Most children with recurrent urinary tract infections (UTIs) are not at increased risk of chronic kidney disease later in life, a new meta-analysis suggests."If there is no structural abnormalities in the kidney ultrasound after the first UTI, the parents should not be worried at all" about the risk of chronic kidney disease, said lead researcher Dr. Jarmo Salo of the University of Oulu in Finland.Recurrent UTIs in young children have been seen as a possible risk factor for chronic kidney disease later in life, especially in cases with vesicoureteral reflux (VUR).But the idea that repeat UTIs and VUR are risk factors for chronic kidney disease is not universally accepted -- nor is the practice of testing children for VUR when they have a urinary tract infection.For the new study, reported October 10th in Pediatrics, researchers pooled data from 10 studies, with 1,576 patients, that either looked at the history of childhood UTIs in people with chronic kidney disease, or that followed children with UTIs to monitor their renal function.They also reviewed the records of all 366 patients who were treated for chronic kidney disease at their hospital over one year.The 10 studies showed no evidence that childhood UTIs -- even along with VUR -- were the main cause of chronic kidney disease, according to the researchers.And of the kidney disease patients who did have a history of childhood UTIs, all also had structural abnormalities in their kidneys. Similarly, of the 366 patients at their center, the researchers found that only three had repeat childhood UTIs that might have contributed to their chronic kidney disease -- and all had structural abnormalities in the kidneys that would be detectable on ultrasound.Dr. Salo told Reuters Health in an email that doctors in Finland no longer "actively" look for VUR because there's evidence that it is a "normal phenomenon," and that treating it does not prevent long-term kidney damage."We suggest that the (x-ray) imaging studies are not necessary if the child has structurally normal kidneys in ultrasound," Dr. Salo said.But a pediatric urologist not involved in the study cautioned against making a "sweeping" recommendation against VUR testing."The good news for parents is yes, the chances of your child developing kidney disease will be very low," said Dr. Hiep T. Nguyen of Children's Hospital Boston.However, he told Reuters Health, repeat UTIs in young children (generally younger than 5) are not the same as those in older kids or adults. And some of those children are at increased risk for kidney damage -- particularly if they have more-severe, high-grade VUR.What's more, Dr. Nguyen said, there is evidence that finding and treating high-grade VUR with low-dose antibiotics and period testing to see whether reflux has resolved may prevent kidney damage.Nguyen said that a young child with a UTI should have an ultrasound "at a minimum" to look for structural abnormalities in the kidneys.Dr. Salo agreed.But the area of controversy is in testing for VUR. Essentially, Dr. Nguyen said, pediatricians are increasingly moving away from recommending VUR testing for children with urinary tract infections.Pediatricians, he noted, see a lot of children with UTIs, and most of those kids will have no long-term kidney disease as a result. But urology specialists see the people with chronic kidney disease, and they are apt to see the value in testing for VUR so that kids with reflux can be treated."We are looking from two different viewpoints," Dr. Nguyen said.VUR has a strong genetic component, and researchers are working on gene tests -- where a child will just have to "spit in a cup," Dr. Nguyen said -- that could help pinpoint the kids with UTIs who would be the best candidates for VUR testing.For now, the decision to do VUR testing is basically case-by-case.Dr. John Gearhart, director of pediatric urology at Johns Hopkins Children's Center in Baltimore, said the current findings "should reassure mothers and fathers."But he agreed that there are cases where testing for VUR is appropriate: if there's a family history of the condition, for example, or if a young child has more than one urinary infection that includes fever.Testing for VUR does involve radiation, albeit as low a dose as possible, Dr. Gearhart noted in an interview. So limiting the number of children who have it is important.There can also be side effects from the low-dose antibiotics given to children with VUR -- such as stomach upset, diarrhea and yeast infections.There is an ongoing North American clinical trial looking at whether giving antibiotics to young children with mild to moderate VUR prevents kidney scarring, which could eventually lead to chronic kidney disease.That, according to Dr. Gearhart, should give more insights into whether it is helpful to give all children with VUR preventive antibiotics.SOURCE: http://bit.ly/oY8CodPediatrics 2011.

Easy 2-Step Screening Tool Detects Underage Drinking

2011-10-21T20:31:00.000-07:00

From Medscape Medical News > PsychiatryYael WaknineOctober 14, 2011 — A new tool to screen children and teenagers for alcohol was introduced today by the National Institutes of Health National Institute on Alcohol Abuse and Alcoholism."Routine screening and intervention for alcohol use in young people is critical to preventing the constellation of problems associated with adolescent drinking," said Howard Koh, MD, MPH, in a National Institutes of Health news release. The new screening tool offers "an opportunity to engage young patients before it is too late."Dr. Koh is assistant secretary for health at the US Department of Health and Human Services.The screening tool was developed in collaboration with the American Academy of Pediatrics Committee on Substance Abuse, clinical researchers, and health practitioners.A simple, fast, and effective early-detection test that is easily managed by busy practitioners, the tool consists of 2 basic questions: one to quantify a patient's use of alcohol in the past year, and the other to inquire about friends' consumption of alcohol as a predictor of future use."People who start drinking before the age of 15 are much more likely to have alcohol problems later in life than those who begin drinking at age 21 or older," noted Pamela S. Hyde, administrator of the Department of Health and Human Services' Substance Abuse and Mental Health Services Administration. "By helping clinicians identify underage drinking early, this simple and straightforward tool will help young people avoid behaviors that prevent them from achieving their full potential."In addition to the 2-question screen, the guide includes a chart to determine the risk for adverse consequences based on age and the level of alcohol consumption. Options for follow-up range from a motivational discussion regarding the medical implications of alcohol abuse to referrals for additional treatment."Clinicians who care for young people are well aware of the many harms caused by underage drinking," said Sharon Levy, MD, MPH. "The guide takes much of the mystery out of intervening with young patients who are drinking, allowing clinicians to proceed within a clinical framework of low, moderate, or high risk. It will enable pediatricians and other clinicians who care for young people to easily incorporate alcohol screening across the care spectrum, from annual visits to urgent care."Dr. Levi serves as chair of the American Academy of Pediatrics' Committee on Substance Abuse and assistant professor of pediatrics at Harvard Medical School in Boston, Massachusetts.

Most Shy Children Do Not Suffer From Social Phobia

2011-10-21T20:14:00.000-07:00

From Medscape Medical News > PsychiatryFran LowryOctober 19, 2011 — Many children describe themselves as being shy, but only 1 in 10 may actually have social phobia, a disabling psychiatric disorder that goes beyond normal human shyness, new research shows.Debate has recently surfaced over whether the diagnostic term social phobia "medicalizes" normal human shyness, resulting in unnecessary treatment, especially in youth, senior author Kathleen R. Merikangas, PhD, from the National Institute of Mental Health, Bethesda, Maryland, told Medscape Medical News."We wanted to examine the prevalence of shyness and social phobia, and the only way we really get to know about the scope of these problems is by going after the general population," she said.The study was published online October 17 in Pediatrics.Disabling DisorderDr. Merikangas and colleagues collected household and school data from across the United States to garner a nationally representative sample of adolescents aged 13 to 18 years and create the National Comorbidity Survey–Adolescent Supplement, a face-to-face survey. The data in the survey included 10,123 adolescents and 6000 parents.Participants were asked about a variety of mental disorders, including social phobia."Social phobia is a very disabling psychiatric disorder. It interferes with a person's social life, their educational activities and success in school, and limits outside activities. Those affected feel uncomfortable to the point where they avoid contact with others or speaking out in class, and this is where we draw the threshold between a normal trait and disorder," said Dr. Merikangas.The researchers found that almost half of the adolescents (46.7%) rated themselves as shy, and that about 62.4% of parents reported that their teenagers were shy."It's almost like a normative trait to describe yourself, or for the parents to describe their kids, as being shy. It's just like saying someone has blue eyes or brown eyes, or they are extroverted or introverted. Shyness is one of those, and it's a normal human trait," Dr. Merikangas said.Increases With AgeThe study also found that of the children who report themselves as shy, 12% had social phobia, or substantial impairment from their shyness.In addition, the rate of social phobia increased with the age of the children. For 13-year-olds, the rate was 6.3%; for 15- to 16-year-olds, it was 9.6%; and at age 17 to 18 years, it was 10.4%.Social phobia is treatable, Dr. Merikangas emphasized."Parents of children who have social phobia can modify their child's environment; help them to have gradual exposure to the things that exacerbate their social phobia. Behavioral and exposure therapy, similar to fear-of-flying programs that some of the airlines put on, can help," she said.The education system could also help these children, she added."If the education system were to recognize it, more teachers may be less harsh in grading kids who don't raise their hand in class, or who don't talk in class. If they are aware of social phobia, they may help them, rather than punish them."Gateway DisorderCommenting on the study for Medscape Medical News, Anne Marie Albano, PhD, from Columbia University and the New York State Psychiatric Institute, New York City, said: "I think it's a critical study. It has quantified and clarified what we have known in psychiatry, which is that shyness is a normally distributed trait that is not a clinical syndrome, and it is distinct from social phobia or social anxiety disorder, which is disabling."Dr. Albano agreed that there is much that can be done for kids with social phobia."There are highly effective treatments in cognitive behavioral therapy that teach them skills for managing the anxiety and making their way into the social world they need to live in," she said.For those who develop more impairment in functioning, the combination of medication and psychotherapy is effective, she added."One of the big things about social phobia that we know is it's a gateway disorder. It usually occurs first, and it's a gateway to depression and substance abuse, so it's critical that we get kids help for this and not dismiss it as a normal personality trait," she said.This study was supported by the Intramural Research Program of the National Institute of Mental Health. Dr. Merikangas and Dr. Albano have reported no relevant financial relationships.Pediatrics. Published online October 17, 2011. Abstract

Cell Phones and Brain Tumors: No Link, But Is Study Flawed?

2011-10-21T18:55:00.000-07:00

From Medscape Medical News > OncologyRoxanne NelsonOctober 21, 2011 — The latest study on cancer and cell phones — the largest to date — has found no evidence of an overall increase in brain tumors or any cancers over an 18-year period. However, a group of experts says that the study is seriously flawed, and declares that it should be "condemned as misleading spin."The study was published online October 20 in BMJ, and the fierce rebuttal comes from ElectromagneticHealth.org.Updated ResultsThe study is an update of a nationwide Danish study that compared the cancer risk for all 420,095 Danish cell-phone subscribers with that for nonusers from 1982 to 1995, with follow-up to 1996 (J Natl Cancer Inst. 2001;93:203-207) and then 2002 (J Natl Cancer Inst. 2006;98:1707-1713). This study has found no evidence of any increased risk for brain or central nervous system (CNS) tumors or any cancer among cell-phone subscribers, and the latest results — which now span a period of 18 years — confirm this finding of no evidence.The researchers, led by Patrizia Frei, PhD, a postdoctoral research fellow from the Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, extended the follow-up of the Danish cohort to 2007, and focused on CNS tumors in 358,403 cell-phone subscribers.Overall, 10,729 CNS tumors occurred from 1990 to 2007 in 5111 men and 5618 women. The incidence rate ratio for CNS tumors was consistently close to 1 in women and men, both overall and when stratified.However, when analyzed by morphologic subtype of intracranial CNS tumor, there was a slight but nonsignificantly elevated incidence rate ratio of glioma in men (1.08; 95% confidence interval [CI], 0.96 to 1.22). The ratio was highest in the shortest-term users (1 to 4 years); after 5 years of use, the numbers were only slightly elevated.For other and unspecified types intracranial tumors of the CNS, incidence rate ratios were nonsignificantly higher in both men (1.12; 95% CI, 0.95 to 1.33) and women (1.19; 95% CI, 0.85 to 1.67), but the authors did not see a "clear indication of a dose–response effect."The authors note that this "extended follow-up allowed us to investigate effects in people who had used [cell] phones for 10 years or more, and this long-term use was not associated with higher risks of cancer."However, they point out that because "a small to moderate increase in risk for subgroups of heavy users or after even longer induction periods than 10 to 15 years cannot be ruled out, further studies with large study populations, where the potential for misclassification of exposure and selection bias is minimized, are warranted."More Research Needed?The study has 2 important methodologic advantages over most other studies, write Anders Ahlbom, PhD, and Maria Feychting, MD, PhD, both from the Karolinska Institute in Stockholm, Sweden, in an accompanying editorial.First, "it was based on a computerized cohort that was followed passively in registries, so it avoided the need to contact people," they point out. Thus, the problems of nonresponse and selection bias, which have been an issue in other studies, were eliminated.Second, the researchers used digitized subscriber data that were obtained from the operators, rather than from retrospective questionnaires or interviews with users. "This circumvented the recall bias that is present in other studies," the editorialists write, although they point out that "having a [cell] phone subscription is not equivalent to using a [cell] phone and, conversely, some users will be nonsubscribers."Although the study used a Danish cohort, the editorialists point out that in Sweden, where handheld cell phones were introduced almost 25 years ago, the incidence rates for glioma have not risen since 1970. The use of cell phones has spread quickly, and 87% of people 16 to 75 years of age were using them in 2002. The proportion that has been using them for 10 or even 15 years must have been substantial, note Drs. Ahlbom and Feychting. Thus, "the absence of a trend in the incidence of brain tumors in national statistics is reassuring."The research that has been conducted evaluating the safety of cell phones is now extensive, and "the question is how much more research is needed," they write. "Continued monitoring of health registers and prospective cohorts is warranted, but more case–control or other studies with built in selection and recall bias are not needed," the editorialists conclude.Fierce RebuttalHowever, a group of experts from several countries have joined together and issued a fierce rebuttal of this study in a document posted on ElectromagneticHealth.org, a health education and advocacy group based in the United States."This seriously flawed study misleads the public and decision makers about the safety of [cell] phone use. I consider that their claims are worthless," Denis L. Henshaw, PhD, emeritus professor of human radiation effects, University of Bristol, United Kingdom, states in the document."From the way it was set up originally, this deeply flawed study was designed to fail to find an increased risk of brain tumors tied [to] cell phone use. In order for any study of a relatively rare disease like brain tumors to find a change in risk, millions must be followed for decades. By extending an earlier analysis on the same group of cell phone users, this new report provides unsurprising, biased, and misleading conclusions," explains Devra Davis, PhD, MPH, cancer epidemiologist and president of Environmental Health Trust, in the document.A serious concern about this study is the choice of individuals in the control group, the group of experts asserts. The Danish researchers compared the rates of brain tumors that occurred from 1990 to 2007 in those who began using cell phones after 1987 with the rates in those who were nonsubscribers when the study started. "This understates risk, because most of those who began as 'nonsubscribers' to cell phone service (i.e., the 'controls' at the time the cohort was collected) became cell phone users later on, and accumulated almost as many years (on average per person) as the 'exposed' subscribers. Hence, the comparison to the population not contained in the subscriber sample is a comparison between 2 exposed groups. When Michael Kundi and colleagues from the Medical University of Vienna mathematically corrected for this concern in an earlier report from this Danish study, they found a significantly increased risk for brain tumors," the group writes.This concern about the control group is raised in the editorial, which describes it as a "weakness" of the study. The misclassification of subscribers and nonsubscribers "would dilute any association between [cell-]phone use and cancer risk, and this is important for a negative study like the current one," they note. "However, for long-term users, this misclassification would have only a small effect: long-term users who did not hold personal subscriptions would make up a small proportion of the reference population," they assert.In their rebuttal, the experts declare that this updated Danish study "in fact did find increased risk, even though the study is currently being promoted to the media as if it did not.""Statistical significance tests are tools used in science to help understand the chance that a finding is real. In fact, the article reports a significant increased risk of a very rare form of glioma of the cerebral ventricle based on 8 cases (2.58; 95% CI,1.08 to 6.10), but the authors chose to make no mention of this significant finding. In this instance, despite the small number, the finding is significant," they write."The authors reject all other findings of borderline significance completely. In a study of relatively rare diseases, such as brain tumors, the failure to obtain statistical significance should not be confused with a lack of public health importance. In fact, most of the reported numbers of brain tumors in this article give estimated risks where the result goes from below 1 (a negative result meaning no increased risk), to above 1 (a positive result indicating in some instances a doubled or greater risk)," they add."All of the few well-designed case–control studies of this issue have found significantly increased risk. Thus, these borderline findings of increased risk may well signal an important association," they add.In the document, Alasdair Philips, an expert in electromagnetic health from Powerwatch in the United Kingdom, says: "This study only looks at 7% of the Danish population who had a personal cell-phone subscription for at least 1 year during the period 1987 to 1995. It ignores corporate subscribers (the heaviest users then), and the researchers have no data at all on cell-phone use since 1995, so the extra 86% of the population who started to use a cell phone since 1996 were left in the 'nonsubscriber' part of the population. This study uses seriously flawed data to make a flawed analysis and should be condemned as misleading spin."A Mixed BagPrevious studies on the link between cell phones and cancer have come to various conclusions.Approximately 30 epidemiologic studies have attempted to evaluate a possible association between cell-phone use and the risk for brain and salivary gland tumors. There have also been a number of experimental studies involving cell cultures and animal models.One meta-analysis found evidence linking cell-phone use to an increased risk for tumors, whereas another study showed that cell-phone use for as little as 50 minutes at a time appears to affect brain glucose metabolism in the region closest to the phone's antenna. Yet another study pointed to evidence that exposure to cell phones prenatally and early in life increases a child's risk of developing behavioral problems.Conversely, a recent study reported that children and adolescents who use cell phones do not appear to be at a higher risk for brain cancer. In 2009, a Scandinavian study failed to find substantial changes in brain tumor incidence among adults 5 to 10 years after the use of cell phones sharply increased. Results from the 13-country INTERPHONE project, the largest study ever conducted on cell-phone use and cancer risk, reported no increase in risk for glioma or meningioma with the use of cell phones. However, there were suggestions of an increased risk for glioma in people with the highest levels of exposure.Some countries have begun to take measures to limit cell-phone exposure in children. In June, the World Health Organization's International Agency for Research on Cancer announced that radiofrequency electromagnetic fields have been classified as possibly carcinogenic to humans (group 2B) on the basis of an increased risk for glioma that some studies have associated with the use of wireless phones.This study was funded by the Danish Strategic Research Council to cover costs for data linkage. The authors and editorialists have disclosed no relevant financial relationships.BMJ. Published online October 20, 2011. Abstract, Editorial

Contrasting Views on Treatment of Children Dying From Cancer

2011-10-19T21:59:00.000-07:00

From Medscape Medical News > OncologyRoxanne NelsonOctober 19, 2011 — Despite significant improvements in cure rates, childhood cancer can follow an unpredictable course. In some cases, the disease will progress or recur and ultimately lead to death. A new study has found that parents and healthcare professionals might not always see eye to eye when it comes to end-of-life care for a child.A study published online October 17 in CMAJ found that, compared with healthcare providers, parents strongly favored aggressive treatment in the palliative phase of care. Parents also ranked hope as a more important factor when making treatment-related decisions.Hope and the child's quality of life tied for the highest ranking in importance for parents; these were followed by increased survival time. Healthcare professionals, however, ranked quality of life as the most important factor, followed by increased survival time.The researchers observed that parents favored the use of chemotherapy more than healthcare professionals (54.5% vs 15.6%; P < .0001)."Information about the quality of life and length of life is important, but we don't know a lot about these parameters in real life," said lead author Lillian Sung, MD, PhD, a pediatric oncologist at the Hospital for Sick Children in Toronto, Ontario, Canada. "These should be research parameters."For example, in some cases, chemotherapy can improve quality of life, she explained in an interview.Healthcare professionals also need to speak more explicitly with parents about end-of-life care and explain what the choices are and what can be expected, she continued. "We need more communication and more honest dialogue."Hope is a good coping mechanism."We also need to let parents know that we appreciate where they're coming from, and that we don't want to take away hope," said Dr. Sung. "Hope is a good coping mechanism, but the nature of that hope may change in the trajectory of illness."At the outset, a parent's hope might be for a cure, but as the illness progresses, that hope changes to wanting more time and a better quality of time; finally, it might evolve to hoping for a peaceful death, she explained."We need to work with parents and provide guidance," Dr. Sung explained. "We also shouldn't assume that just because parents are hopeful that they don't understand what's going on."Child's InputIn a commentary accompanying the study, Caprice Knapp, PhD, and Kelly Komatz, MD, both from the University of Florida, Gainesville, note that this study is important because it highlights "the incongruity between the preferences of parents and those of healthcare workers.""It may be that this incongruity masks a greater concern: miscommunication or unrealistic expectations," they write, pointing out that a key finding of research recently published by the Center to Advance Palliative Care was that most physicians do not understand the scope of palliative care."If there is a basic misunderstanding of terminology, definitions, and messages associated with end-of-life care, then incongruity of preferences might be expected," the editorialists note.The researchers highlight the importance of hope in the pediatric palliative setting and the difficulty in balancing "hope for a cure with hope for the comfort and dignity of the child."This study is important because of its design and rigor, the editorialists explain. Even though only 77 interviews were completed, that is "an impressive number that should be acknowledged," they write, adding that evidence in pediatric palliative care is limited by small sample sizes, and that the authors should be "commended for consistently doing their study over 4 years."However, an important limitation of the study is that the children's preferences were not obtained, Drs. Knapp and Komatz write. Not including that information "fails to recognize that decision-making is triadic, not dyadic.""Without this information, it is unclear whether families or healthcare workers drive incongruity," they note.Dr. Sung agrees that the child's input is very important, and notes that parents did rate their child's opinion as being very important in making this type of decision. Depending on the child's maturity and cognitive ability, it is important to include them in these discussions.It is very rare that clinicians speak to the children, said Dr. Sung. "By talking to them, it may facilitate their comfort and allow them to express their own feelings. There is great value in what the children have to say."Chemotherapy and Importance of HopeChoosing between palliative chemotherapy and supportive care alone is one of the most important and difficult decisions in pediatric oncology. The goal of this study was to compare the strength of preference between parents and healthcare professionals for supportive care alone and palliative chemotherapy, the researchers explain.Prior to beginning the study, Dr. Sung and colleagues held a focus group with 12 parents of children who had died of cancer. From this, they identified the range of factors that parents consider important when choosing between supportive care and palliative chemotherapy.The focus group also tested the visual aids and the interview scripts that were going to be used in the study to help ensure that the potential for causing additional distress to the participants would be minimized.A total of 77 parents of children whose cancer had no reasonable chance of being cured and 128 healthcare professionals in pediatric oncology were involved in the study. Interviews were conducted with both parents and providers, and visual analogue scales were used to help respondents illustrate the anticipated level of the child's quality of life, the expected duration of survival, and the probability of cure (for healthcare personnel only). The participants were then asked about their preference for treatment options, given these baseline attributes, reported which factors might affect this decision, and ranked all identified factors in order of importance.Overall, parents and healthcare professionals had similar viewpoints when making end-of-life decisions, although parents focused more on the importance of hope. In addition, as a group, healthcare providers tended to regard supportive care alone more positively than parents. This indicates, the authors note, that parents and healthcare professionals generally have different underlying attitudes about end-of-life care.These differences might, in part, "contribute to the apparent conflict between professionals and parents when tensions emerge during the palliative phase of care," they write.Despite the importance that parents placed on the child's quality of life, they still reported that they would accept chemotherapy if it reduced both quality of life and survival time. This finding, the authors note, shows the complexity of decision-making, and that it is "possible that hope for a cure is such an important factor that it may override considerations of the child's quality of life and survival time."The study was supported by the Canadian Cancer Society. Dr. Sung is supported by the Canadian Institutes of Health Research through a New Investigator Award. The other authors and the editorialists have disclosed no relevant financial relationships.CMAJ. Published online October 17, 2011. Abstract, Abstract

Kids and Heat: Making Exercise Safe

2011-10-18T22:07:00.000-07:00

From Medscape PediatricsAn Expert Interview With Michael F. Bergeron, PhDLaurie Scudder, DNP, NP; Michael F. Bergeron, PhDEditor's Note:The American Academy of Pediatrics (AAP) Council on Sports Medicine and Fitness and the Council on School Health recently issued a policy statement titled "Climatic Heat Stress and Exercising Children and Adolescents". In a revision of a previous statement issued in 2000, this new policy statement relies on recent evidence to provide guidance to support clinicians in providing advice to children, teens, parents, coaches, and others that allows for safe participation in outdoor sports and exercise in a range of adverse climatic conditions including high heat and humidity. Laurie Scudder, DNP, NP, spoke with Michael F. Bergeron PhD, lead author of the policy statement; Director, National Institute for Athletic Health & Performance at Sanford Health ; and Professor, Department of Pediatrics at The University of South Dakota, about this policy and implications for clinicians.Medscape: Dr. Bergeron, the AAP policy statement is supported by a number of recent studies that compared body temperature regulation, exercise tolerance, and cardiovascular responses between similarly fit children and adults exposed to equally intensive exercise and environmental conditions and concluded that, assuming appropriate preventive measures are undertaken, children and adults tolerate these conditions equally well. Could you expand briefly on some of these key studies and findings?Dr. Bergeron: The earlier policy on this topic was based on physiologic and anatomic characteristics of children that had been thought to impair thermoregulatory ability, particularly during exercise in the heat. One of these factors was a reported low exercise economy; that is, there has been a concern that kids expend a much higher amount of energy during physical activity and consequently would produce more heat for a given level of exercise. However, at the same relative exercise intensity (commensurate with body size), there are no differences between children and adults.Second, children up to about 13 years of age have a much higher ratio of body surface area to their mass. That was thought to put them at a temperature regulation disadvantage, suggesting that they potentially could gain more heat from the sun and such. And children do have a lower sweating capacity up until the later teenage years. Some of the early evidence also suggested that their cardiovascular capacities including cardiac output were lower than adults.Collectively, all of that set the stage for a perspective that kids would be at a much higher risk for poorer physical performance and heat-related illness during physical activities in hot climates. However, more recent research, both my own and that of a number of others, does not support this notion. The more current research has done a better job in more directly comparing identical relative exercise intensities in the same environments with equal levels of hydration in adults and kids. Also, these studies do not support the contention that there is a maturational disadvantage during exercise in the heat.Therefore, the AAP Council on Sports Medicine and Fitness and the Council on School Health wanted to make the point in the new policy statement that the evidence does not suggest or support that children and adolescents are at any kind of thermoregulatory or cardiovascular disadvantage. Kids were also thought to not be able to adapt to the heat as well as adults. Again, more recent research does not support that. Of note, most of the research conducted in this area has been done with children 8 years of age and older. There is not a lot of research on temperature regulation with children younger than 8 years. Accordingly, there may be some differences in those earlier ages. However, when we're talking about sports and exertional heat illness, it is usually children and adolescents in the later elementary school into middle and high school years who are typically participating in these activities.Again, are there temperature regulatory differences in younger children? There may be, but that is not the population in the policy statement toward whom we're really directing the attention.The new policy focuses on the factors that do indeed put kids at risk. Although children are not at a maturational disadvantage for increased risk from exercise in the heat, there are a host of modifiable factors that do lead to higher risk when exercising in the heat.Medscape: As you noted, the new policy stresses that heat-related illnesses such as heat cramps, exhaustion, and stroke are caused by known, preventable risk factors. What are the biggest risk factors for incurring heat illnesses during sports?Dr. Bergeron: There are certainly a number of things that can increase risk. The environment itself, being hot, causes body temperature to go up even if you're not doing anything. When you exercise, your body produces a lot of heat. Normally there are a number of ways that the body gets rid of that heat, the primary mechanism being sweating. Additionally, a breeze can very effectively contribute to a convective heat loss.The hotter it is, the more heat that your body will be producing, especially during intense exercise. The more humid it is, the more that you're going to sweat and the less effective that sweat is in releasing the energy or heat from the body because, in order for sweat to be effective in regulating temperature, it needs to evaporate. The more water in the air, the less evaporation, and you see that as sweat beads up on your skin or just rolls off to the ground. Hot and humid conditions that include intense solar radiation and a lack of a breeze are the worst conditions. Hazy, hot, humid, and still days are common, even in the late summer and early fall in some regions.When you look at what primarily causes kids to have problems, it usually comes down to doing too much for too long in too hot of an environment. Sometimes this occurs before a child or adolescent is acclimated to the heat. However, if you work young athletes hard enough and long enough in an extreme environment, even those who are used to these summer conditions are going to have problems.Also, kids typically do not tend to be well hydrated before, during, and after activities in the heat, especially with multiple same-day practice sessions or competitions and tournament scenarios. Insufficient recovery time and recovery nutrition are often important contributing problems, too.There are a host of other factors. Preseason practice starts in the late summer. Kids may have spent a lot of time indoors and are not used to the outdoor weather. They may also not be well rested, and are often not fit enough and prepared for the intensity, duration, and type of activities that they jump right into.This sets up a "perfect storm" for all the kids who are not acclimated and well prepared physically, nutritionally, restwise, or fitnesswise. Then you place this very motivated group of kids on a team with a motivated coach. This enthusiasm and sense of urgency to get these kids ready in a short amount of time, when they are not as prepared to tolerate the practices as coaches and parents think they are, readily prompts a number of risks and problems. Of course, you also have kids who don't want to quit or show "weakness".There are certainly a lot of factors. However, it usually boils down to doing too much, too long, too hard, in too hot of an environment.Medscape: The statement indicates that although most children can indeed exercise safely in the heat if the right precautions are taken and modifications are made, certain ones should be, at least temporarily, restricted from exercise in excessive heat including those with recent illnesses, diabetes insipidus, type 2 diabetes, obesity, cystic fibrosis, hyperthyroid conditions, or any acute or chronic condition that affects water-electrolyte balance or thermoregulation. All of these make intuitive sense. The document also noted that kids with sickle cell trait merit specific concern because exertional sickling may contribute to heat intolerance and related clinical problems. Can you discuss this a bit more? What specific recommendations would you make for this group of children?Dr. Bergeron: Sickle cell trait, of course, is different from sickle cell disease because most of the hemoglobin for those with sickle cell trait is normal, with anywhere from 30% to 40% having the sickle characteristic. By and large, routine physical activity, whether it's sports or playing, is not associated with any notable signs or symptoms. Accordingly, there are no restrictions for these children and adolescents, and these kids may not ever be aware that they potentially might have a problem.However, more and more, epidemiologic studies, case studies, and other research has found that exercise that is high enough in intensity and conducted in sufficient thermal stress can cause an effect similar to what might happen at altitude. A certain amount of measurable red blood cell sickling can cause potential occlusion at the small microvessels. This would also prompt a widespread immune system response that begins an entire cascade of events in the blood and vessels, via cell adhesion molecule activity and other changes that create the potential for localized vascular dysfunction prompting full blockage or restricted blood flow and consequent problems. It is not totally clear whether the exertional rhabdomyolysis often associated with sickle cell trait and intense, repeated exercise is the result of the activity level being too high or whether sickle cell trait was the primary independent contributing factor.The National Collegiate Athletic Association is now considering a proposal to require screening of all of their athletes, although this is still a contentious issue. The current thinking is that those with sickle cell trait should more deliberately build up their training; self-pace; and avoid high-intensity, repeated activities, especially at the end of a practice. If those athletes with sickle cell trait exhibit a problem, then they should indeed promptly stop and get assessed.Sickle cell trait warrants concern, particularly when these kids are exercising hard and repeatedly in a hot environment. Otherwise, most activities are going to be just fine.Medscape: Can you speak to other risk factors that may put kids at risk for excessive heat retention or poor thermoregulation, such as uniforms?Dr. Bergeron: Uniforms and protective equipment are barriers to heat dissipation, whether it's a helmet, shoulder or leg pads, sleeves, or pants. All prevent heat from being dissipated and create a heavier metabolic and thermal load. It is harder work just to carry all that extra padding and the uniform, so metabolically, there is a greater demand.There are many other factors that are worth talking about. As the new policy statement from the AAP makes clear, you really need to look at everything including education, awareness, and preparation. It is the responsibility of coaches, parents, and the athletes themselves to be sure that they're ready and that they understand the risks and the signs and symptoms of a heat-related problem.It really comes down to monitoring and paying attention. We must recognize when children are having difficulty and get them off the field and promptly and properly attended to. It should also be appreciated that people with developing heat-related illness are often the worst ones to judge if they are having serious problems. Affected kids need to stop when they often don't want to because they don't want to be seen as weaker. However, these kids are also often not even capable of assessing themselves. It is incumbent on all involved, including the other players, to recognize and respond to developing problems. Of course, the adults involved need to ensure that sufficient preparatory steps are taken and emergency procedures are in place and practiced in order to reduce the risk for catastrophic outcomes.There is a lot of attention on hydration, as there should be. Hydration is integral to safety and performance in any athletic activity, especially in the heat. However, you can be pretty well hydrated and still get into trouble. So hydration is not the only answer. There is also concern about the high-caffeine energy drinks that kids have been using with more frequency recently. These may cause an increase in fluid loss or even mask fatigue and allow kids to push themselves too hard.I am often asked, "When is it unsafe to exercise, that is, at what temperature should kids not go out there?" It is really a sliding scale, with risk increasing as the number of risk factors increases. Then the urgency for some kind of offsetting action becomes greater. However, it is not the same for everybody and not the same for all conditions. It is important to assess both the athletes and the conditions with which you are dealing and appropriately and sufficiently accommodate for that. The main point of the AAP statement is to recognize that you can do a lot out in the heat and in a lot of environmental circumstances, as long as you make the appropriate adjustments.Medscape: That is a good segue to my next question. The AAP statement emphasizes the importance of preconditioning, suggesting that this process of acclimatization include graduated exposure over 10-14 days to increasing environmental temperatures as well as increased intensity and duration of physical activity. In your experience, is this time frame generally provided? Are there more specific guidelines available to describe this process?Dr. Bergeron: As I indicated earlier, preseason sports activities often focus on accomplishing a lot in a short amount of time with a high level of enthusiasm and motivation. Coaches and players often have a sense of urgency that they only have 2 weeks or so to prepare for the season and therefore must push.In the case of football, exertional heatstroke deaths most often occur in the first few days. Again, it goes back to doing too much, too long, too hard, and too soon. What coaches, parents, and the kids themselves need to realize is that they are not professional athletes and are typically not conditioning year-round. The kids are probably not as conditioned as they think they are, and coaches want them to be.Even those who live in a warm environment may be spending a lot of time indoors. They begin the season likely not used to exercising in hot conditions with high intensity and long duration, especially in a uniform. It really makes a lot of sense to give kids a chance to adapt, not only to the environment, but to the intensity, duration, and uniforms. If you give kids a chance to progressively adapt, they not only will be safer, but these young athletes will perform better too!In someone fully unacclimatized to the heat, it can take 10 days to 2 weeks for the body to adapt by increasing blood volume, so that exercise causes less cardiac stress and increasing sweating ability. With exercise-heat acclimatization, the body also conserves electrolytes, primarily sodium and chloride, to improve fluid retention. These are adaptations that happen over a period of time. Although 2 weeks is ideal, progressing through those first few days more sensibly can really make a big difference.Medscape: The statement does not specifically address parents. What recommendations should a healthcare professional provide to parents and teens about readiness for hot weather sports?Dr. Bergeron: Preconditioning is important and something that needs to be done over a long period of time. When you look at the preseason period, whether it's football or soccer, the notion is that there are 2-3 weeks to get athletes in shape. The body does not adapt that quickly. Conditioning and fitness cannot be changed in a very short amount of time.However, an athlete can get fatigued and be seriously hurt in a very short amount of time. True changes, ie, measurable changes in fitness and conditioning, take a long period of time. Parents, kids, and coaches need to recognize that you are not going to make substantial gains in fitness and athletic capacity in 2-3 weeks. If you try to, you're just going to put these kids at risk for some kind of injury or maybe worse.Being rested, well fed, and well hydrated places athletes in a better state to tolerate the heat. Some research also has shown that being sleep deprived increases vulnerability to the heat. Kids can't be staying up late and ignoring meals.The discussion really needs to be that: If you're going to play sports, you need to have some kind of plan so that you're not just sitting idly and waiting for the season and then you go. It needs to be a balanced, multifaceted, long-term physical activity conditioning and recovery plan that helps prepare for that.However, it is also important to realize that these kids are playing sports primarily for fun, the socialization, and, hopefully, health. They are not professional athletes. If you work them like professional athletes, there will be consequences. They are primarily students and sports are a part-time activity. Unfortunately, a lot of parents, coaches, and sports academies have taken on more of a professional development model, which overlooks sufficient progressive adaptation, rest, and recovery -- and the fact that these kids are student athletes!Athletes, coaches, administrators, and parents must understand the real and more realistic objective.Medscape: The policy includes specific hydration recommendations, suggesting that 9- to 12-year-old children consume 100-250 mL every 20 minutes and that teens drink up to 1.0-1.5 L/hr during physical activity in the heat. Although water is usually sufficient, exercise of longer duration -- more than an hour or so or repeated same-day sessions -- may warrant use of electrolyte solutions. Is this true for children of all ages? What about younger kids? Are beverages containing carbohydrates warranted in some situations?Dr. Bergeron: It's difficult to give a hard-and-fast answer to that. If you're not going to be exercising very long and you're just going to be exercising once a day and you're having normal meals, then drinking water as you feel you need it during those activities and more if it's hotter is going to be just fine for even older kids.However, for the longer you go, the harder you go, and the hotter it is, the proportional value of something else besides water is going to increase. In other words, you're going to be expending more energy, whether it's because of high intensity, long duration, repeated bouts, or because the heat itself is causing you to use carbohydrates at a greater rate. Maybe then you're not going to get enough energy and electrolytes from meals alone. This happens with a lot of kids in tournament scenarios who are playing multiple times each day during a weekend event. They don't have time for sufficient meals between competitions. In these kinds of situations, there is likely an advantage of having some kind of carbohydrate-electrolyte drink.What does a child or adolescent need during physical activity from a nutrition perspective? They certainly need water. As they go longer and harder, they need some kind of carbohydrate, whether they're taking that in as a food snack or in a sport drink. As you get older, the volume of sweat is greater and the amount of electrolytes, primarily sodium and chloride, lost from sweat become greater too.I would say that replacing electrolytes from sweating is not generally of primary importance in somebody up to about 12-13 years of age. However, by 14-15 years of age, when the sweat rate is higher and the concentration of electrolytes is greater, salt loss is a larger issue. Parents will often note that their kids never had a problem with electrolyte deficits and muscle cramping at a younger age but do experience more problems at 14 or 15 years of age. Accordingly, they need to pay a little bit more attention to water and sodium loss through sweating, especially the more times they play and the more times they're exercising for longer durations.Again, it depends on the situation: the recovery time and meal opportunities; the duration of the activity; and how many times you're doing it on the same day. You need to get your nutrition in there one way or the other. If you can't do it with meals, you need to be thinking about something else.Medscape: The statement also emphasizes the importance of trained personnel and facilities capable of treating heat illness being readily available. This may not always be the case in lower-resource communities. Can you expand on this? What specific types of facilities should be available? An emergency action plan with clearly written protocols is also recommended. Are there resources to assist schools and communities with development of these plans?Dr. Bergeron: Part of the effectiveness of cooling is early recognition. So the first step is to recognize that there's a problem and promptly respond. If an athlete is believed to be overheated, then he or she should be immediately stopped and taken out of the sun and heat. If there is an opportunity for getting indoors into air-conditioning or in the shade, that should be done. Rehydrate if possible.If it appears that athlete children or adolescents have crossed the threshold to exertional heatstroke because their body temperature is elevated, this is an emergency. Although checking body temperature is not always feasible, if the affected youth is showing central nervous system changes or collapses, then having something like a wading pool or tub filled with water and ice available can save a life. Promptly submerging most of the body in cold water or rotating cold wet towels and fanning are not expensive solutions. This just requires forethought and having and promptly implementing a plan. That is what is spelled out in the policy statement: You need to have an emergency action plan in place. It doesn't have to be extensive. It would be nice if you had an athletic trainer on-site. Unfortunately, a lot of schools don't have that luxury. However, you at least need to have people learn the signs and symptoms of heat illness and have a sense of urgency when they see evolving heat illness; it's a lot easier to catch it early.You can always put athletes back in a game, but once they collapse with exertional heatstroke, there's no do over. Now you're dealing with a medical emergency. Again, having the education and awareness to recognize an emergency and the forethought to have on-site some kind of simple, rapid cooling system available, such as a wading pool and some water and ice, can save a life.Medscape: Are there resources available for schools and communities that don't have a trainer available and wish to develop emergency action plans?Dr. Bergeron: There are a number of resources. The American College of Sports Medicine (ACSM) has a 2007 position statement on Exertional Heat Illness During Training and Competition. It includes a lot of information about the physiology and recognition of problems with heat. They outline suggested equipment and supplies for treating heat-related illnesses, what should be on hand, and how to treat athletes should they have problems.The National Athletic Trainers' Association has a number of guidelines, too. A 2010 paper outlined the prevention, recognition, and treatment of a number of problems and describes simply the equipment that should be on hand.[1]Medscape: You also served as lead author for the ACSM's 2005 consensus statement on heat stress and injury risk in youth football players. Are there any notable differences between these 2 recommendations?Dr. Bergeron: There are not many differences. The ACSM youth statement was specific to youth and high school football. Therefore, the recommendations are very specific to the football preseason period. That is one of the only, if not the only, sports-specific guidelines for reducing risk in the heat of which I'm aware.However, as we said in the AAP policy statement, you can apply those guidelines as a template for other sports. The whole idea is that the foundation of what we recommended with the ACSM in 2005 is the same foundation in the AAP statement. You need to be educated and prepared. Athletes need to acclimate and progress slowly. Adults need to monitor and respond.The bottom line is very similar.Medscape: Are there any other key elements of this new statement that you would like to emphasize?Dr. Bergeron: Although these guidelines provide more latitude, they are not intended to downplay the challenge or the health threat of environmental heat stress and exercise in the heat. The main point is worth reiterating: Risk can be substantially reduced if modifiable factors are appreciated and appropriately addressed.If the workload is adjusted and these recommendations followed, most, if not all, exertional heat-related problems would be averted. The statement should provide some degree of comfort that sports and exercise can be fun and safe even in the summertime. Again, it's not that you don't recognize that there can be challenges and problems, but we don't always have to shut everything down.Kids never play themselves to death. It's really the scenarios and circumstances that adults create and inflict on them that cause problems.References

Pediatric UTI: Putting the Guidelines Into Practice

2011-10-18T20:43:00.000-07:00

From Medscape PediatricsAn Expert Interview With S. Maria Finnell, MDLaurie Scudder, DNP, PNP; S. Maria Finnell, MD, MS10/05/2011Editor's Note:The American Academy of Pediatrics (AAP) has recently published an updated Clinical Practice Guideline and technical report addressing the diagnosis and management of an initial urinary tract infection (UTI) in febrile infants and young children. This document updates the previous guidelines published in 1999 and makes several new recommendations based on more recent research. Laurie Scudder, DNP, PNP, spoke with S. Maria E. Finnell, MD, MS, who coauthored the Technical Report. Dr. Finnell is an assistant professor in the School of Medicine at Indiana University and a physician with the Pediatric Infectious Disease Division at the Riley Hospital for Children.Medscape: The new guideline recommends selective urine testing in febrile infants between 2 and 24 months of age based on the prior probability of UTI in that child. Several factors that increase risk are identified and the guideline makes different recommendations for low-risk and high-risk infants. Could you expand on this?S. Maria Finnell, MD: There are certain clinical findings that can help clinicians identify children at very low risk for UTI. The benefit of identifying these very low-risk children is that these children can be observed and do not need initial testing.High-risk children are identified based on the number of risk factors, and these factors differ somewhat between boys and girls. How many risk factors a particular child has is the important point here.In the original studies, some risk factors were identified as being stronger than others. For boys, circumcision status definitely matters the most. Uncircumcised boys have a greater risk for UTI than circumcised boys. For girls, non-black race appears to be the risk factor that carries the most weight.Probability of UTI among febrile infant girls and infant boys according to number of findings present. A probability of UTI exceeds 1% even with no risk factors other than being uncircumcised. From Subcommittee on Urinary Tract Infection and Steering Committee on Quality Improvement and Management. Urinary tract infection. Pediatrics. 2011; 28:595-610.Medscape: The guideline emphasizes the importance of collecting an acceptable urine sample for urinalysis and culture prior to initiating antimicrobial therapy. The risk for suprapubic aspiration is also discussed, although it is noted that in some circumstances, such as boys with severe phimosis, this may be the only option for obtaining a urine specimen. Is there any role for noninvasive collection strategies such as use of a bag applied to the perineum?Dr. Finnell: Yes. It is important to point out that bag specimens are acceptable if they are going to be used for urinalysis. However, a bag specimen cannot be used to culture the urine because contamination from skin, the vagina in girls, or the prepuce in uncircumcised boys leads to false positive results too often.If the urinalysis from a bag specimen is positive, then the culture needs to be obtained by catheterization. So you can use bag specimens, but only for the urinalysis. To obtain a urine culture from the child and confirm the diagnosis of UTI, that specimen needs to be from a catheterization. When it is not possible to catheterize the child, as in the example that you mentioned, then we recommend suprapubic aspiration.Medscape: The guideline notes that a diagnosis of UTI requires the presence of both a quantitative urine culture and evidence of pyuria. Pyuria is defined as the presence of white blood cells noted by means of microscopic analysis. However, use of a leukocyte esterase test is also discussed. Is leukocyte esterase testing an acceptable alternative to microscopic analysis?Dr. Finnell: Yes. Leukocyte esterase on a dipstick is an acceptable surrogate marker for pyuria. It is not, as described in the technical report, as specific as either bacteria or white blood cells found on microscopy, but together, a positive urine culture and a positive leukocyte esterase is an acceptable way of diagnosing UTI.Medscape: Would the reverse -- a negative leukocyte esterase test in a child -- be an acceptable reason not to proceed to culture?Dr. Finnell: On a dipstick, if either leukocyte esterase or nitrite is positive, a culture should be obtained. If neither is positive, the clinician can follow the clinical course. For a urinalysis, either presence of white cells above the threshold of normal for the test used or the presence of bacteria should motivate a culture. If neither is present, the clinician can choose to follow the clinical course.It is important to point out that the specimen must be fresh (< 1 hour after voiding in room temperature, < 4 hours after voiding if stored in a refrigerator) to be able to make these decisions based on these tests. If the initial testing is negative (urinalysis or dipstick), the clinician should follow the child's clinical course and reevaluate if fever persists. These recommendations are well illustrated in the algorithm that accompanies the guideline (Figure 2).Medscape: The guideline recommends that regional variation in antimicrobial susceptibility patterns dictate the choice of initial treatment. In situations where this information may not be readily available, are there other considerations that should dictate the choice of therapy, including the route of administration?Dr. Finnell: The guideline does list the antibiotic options for initial treatment of UTI. As always, that treatment decision has to be tailored to the patient in front of the clinician. So, for example, allergies, dosing frequency, and how adherent the parents are anticipated to be are going to be important when choosing both the initial antibiotic treatment as well as the route of administration of the antibiotic.I think it is worthwhile to point out that recent studies have found that oral therapy is as effective as parenteral therapy. However, children who are too ill to take medication orally or who cannot tolerate medication by mouth for any other reason should be treated with antibiotics parenterally.Medscape: Renal and bladder ultrasonography (RBUS) is recommended as the initial imaging test, although the guideline notes the potential for misleading results if RBUS is obtained too early in the acute infection. If not in the acute course, when should this type of imaging be performed?Dr. Finnell: Ultrasonography is ideally performed after full recovery and completion of the antibiotic course. That means a minimum of 2 weeks after diagnosis, and sometimes longer.There are, though, some exceptions to consider. First, RBUS is an excellent tool to identify renal abscesses in children who do not respond to therapy as expected. In those cases, the ultrasound would be done earlier in the course. Secondly, RBUS may also need to be performed earlier if there are concerns that the parents may not return with the child for imaging once the child has improved.Medscape: One of the most notable differences from the 1999 guideline is the recommendation that a voiding cystourethrogram (VCUG) should not be routinely performed after a first febrile UTI. Can you explain the basis for this change of recommendation?Dr. Finnell: The 1999 guideline recommended the VCUG after first UTI for children who were between 2 and 24 months of age. The rationale for that recommendation was that it was thought that children with vesicoureteral reflux (VUR) could be treated with prophylactic antibiotics to reduce further episodes of UTI.However, since the 1999 guideline was published, there have been 6 published randomized controlled trials that have examined the effects of antibiotic prophylaxis in preventing recurrent UTIs. Meta-analyses of these results performed for the technical report that accompanies this guideline do not support the contention that antibiotic prophylaxis prevents febrile UTI when VUR is found through VCUG. Because it wouldn't change the treatment, it can no longer be justified to put all children through a VCUG after a first episode of UTI.Medscape: There is no longer a recommendation for use of prophylactic antibiotics to prevent UTI recurrences because, as you just discussed, the meta-analyses have revealed no significant reduction in symptomatic UTI with prophylaxis, even for those infants with grade 3 or 4 VUR. Are there any situations where prophylaxis should be considered?Dr. Finnell: I think it is important to note that we know now that the vast majority of young children with the first UTI will not benefit from prophylactic antibiotics. However, there may be a few children who have recurrent UTI or really high-grade VUR who may benefit. Those potential benefits to these children have not been tested in the clinical trials we have seen to date. There were very few children with really high-grade reflux enrolled, so these situations are unusual and have not been well studied. When there are no good studies, we are going to have to rely on our best clinical judgment on a case-by-case basis. Providers are going to have to make their call on what to do for these children.Medscape: Is there a comparable role for clinical judgment in making the decision to test children for subsequent UTIs? For example, consider the case of a toddler who has a documented UTI and 2 months later, when both older siblings have febrile upper respiratory tract infections, presents with a fever. Should that child still be tested for recurrent UTI even though the clinical suspicion is that the fever is more likely to be the result of a cold than a second UTI?Dr. Finnell: In general, the clinician should always be more suspicious of UTI in a child who has already had one documented UTI. Saying that, you have to take the clinical picture into consideration. If there is another source for the fever, the risk for UTI is going to go way down. We do not recommend automatic testing every time this child has a fever, but we do recommend contact with medical care and an evaluation. The importance of this needs to be communicated to the parents of children with documented UTI.Medscape: How long should that elevated level of suspicion persist. Is it important to test more often until the child is 4 or 5 years of age and able to provide a history of what hurts?Dr. Finnell: One reason why UTI is such a tricky diagnosis in very young children is that they can't express their concerns. As the child grows older, you can take your guard down a little bit. However, an elevated level of suspicion for UTI and a low threshold for evaluation should persist throughout childhood.Medscape: Dr. Finnell, are there other key recommendations or important points in this new guideline that you would like to emphasize?Dr. Finnell: Yes. There are some data to suggest that early treatment of UTI may decrease the risk for renal damage. Therefore we recommend early evaluation, within 24 to 48 hours, in the case of fever in children who have previously been diagnosed with a UTI. When these children have the next fever, they should be seen early, evaluated and, if indicated, tested for UTI with the goal of preventing future renal damage.I would also like to point out that these 2 AAP publications in Pediatrics offer the most current and comprehensive evidence available on the topic of UTI in children 2-24 months of age. These AAP recommendations are going to influence care not only in the United States, but around the world.

Infants Likelier to Get HIV If Mother Infected Through Sex

2011-10-18T20:14:00.000-07:00

From Medscape Medical NewsDaniel M. Keller, PhDOctober 18, 2011 (Belgrade, Serbia) — In a retrospective study of HIV-infected women giving birth in a hospital in Romania, the rate of transmission of the virus from mother to infant was "strikingly higher" if the mothers acquired the infection through sexual contact (SI) than if they were infected by the parenteral route (PI), especially if the mothers were young at the time of infection, Cristiana Oprea, MD, PhD, from the Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases in Bucharest, reported here at the 13th European AIDS Conference of the European AIDS Clinical Society.The AIDS epidemic in Romania is characterized in part by a homogeneous, large cohort of youth and adolescents infected with the F-1 strain of HIV by the parenteral route in the late 1980s. Several studies around the world have characterized pregnancy outcomes for mothers who were vertically infected, but few publications have reported on mothers who acquired HIV through the parenteral route.Demographics and Treatment CharacteristicsPI mothers were younger than SI mothers at the time of delivery (median, 19 vs 26 years) and were more likely to be coinfected with hepatitis B, but their rate of mother-to-child transmission (MTCT) of HIV was much lower, probably because they had been followed and were receiving treatment for an extended time.The PI mothers were diagnosed with HIV at a median age of 9 years (range, 1 to 18 years), and 93% knew their HIV serostatus before becoming pregnant; in contrast, SI mothers were diagnosed at a median age of 25 years (range, 14 to 38 years), and only 42% were aware of their serostatus before becoming pregnant (PI vs SI mothers for age at delivery, age at diagnosis, and knowledge of serostatus, P < .001 for all).The median maternal CD4 counts did not differ significantly at the time of delivery between the PI and SI mothers (460 vs 497 cells/mm3; P = .599). However, the SI mothers had a higher viral load than the PI mothers (4.7 vs 3.6 log10 viral copies/mL; P = .015). Viral RNA was undetectable in 81.2% of the PI group and in 40.0% of the SI group (P < .001).Fifty-five percent of PI mothers received antiretroviral therapy (ART) before pregnancy, compared with 3% in the SI mothers (P < .001). PI mothers had a mean exposure to ART of 26.4 weeks during pregnancy, compared with 8.5 weeks for the SI mothers (P < .001).Results Show Importance of Maternal TreatmentThe investigators found no perinatal transmission of HIV, in either the SI or PI mother–child pairs, when there was complete prophylaxis. They said that the number of pregnancies of PI women has been increasing as they reach child-bearing age and start families. Most of the PI mothers were unemployed, unmarried, and part of a serodiscordant couple.SI mothers have tended to be diagnosed and treated for HIV later than the PI mothers, especially in the first years of the study, but mandatory testing for HIV in pregnancy "dramatically reduced" late diagnoses and improved pregnancy outcomes, Dr. Oprea reported.In this retrospective, parallel, single-center study, 108 PI and SI HIV-infected mothers gave birth to 119 infants from January 2000 to January 2011. Infants were considered HIV-negative if 3 tests for HIV viral load were negative and 1 of the tests was performed after the age of 3 months, or if an HIV antibody test was negative after 18 months.Forty-seven PI mothers gave birth to 53 infants, only 1 of whom was infected with HIV. Sixty-one SI mothers gave birth to 66 infants, 17 of whom were infected."There is a statistically significant difference in the MTCT rate between these groups — 1.8% in the PI group and more than 25% in the SI group. So the overall MTCT rate was very high — 15% — due to late diagnosis in the SI group," Dr. Oprea reported (P < .001).Treating mothers with highly active antiretroviral therapy (HAART) appears to be safe for the offspring and effective in reducing MTCT. "There were between 3 and 8 HAART regimens used before pregnancy. We have all HIV-uninfected children born to these women, and we didn't record any congenital abnormality," Dr. Oprea said. "In 68 mother–child pairs with only ART prophylaxis and no breastfeeding, the mother-to-child transmission rate was 0, [regardless of] the mode of delivery or the mode of HIV transmission in the mothers."Over the years of the study, the number of PI mothers having babies has increased as they have reached child bearing age. The number of SI mothers has remained relatively constant. Over this same 10-year period, the number of HIV-infected newborns has decreased because HIV testing of all pregnant women has been implemented in Romania. The number of infected newborns in 2009 and 2010 was 0 in each year, but there have been 2 cases in 2011 born to SI mothers.A limitation of the study is that it was retrospective for the first 5 years, and some data were missing, especially for SI mothers. It was also a single-center study and should be confirmed elsewhere, Dr. Oprea advised.Session cochair Karina Butler, MB, consultant in pediatric infectious diseases and head of the multidisciplinary infectious disease/immunology service at Our Lady's Hospital for Sick Children in Dublin, Ireland, told Medscape Medical News that the study reinforces the message that young women who know their diagnosis and are receiving treatment, particularly before conception, "have a much, much lower risk of transmission." She said French cohort studies have shown the same thing."It highlights the problem we have of young women who are newly acquiring infection, and also those who are being newly diagnosed with infection, even in the late stages of pregnancy, and not getting on treatment in time to prevent mother-to-infant transmission," Dr. Butler noted.She said she does not think there is a biologic difference in the infection once it has been acquired, so the differences between the findings for the PI and SI women relate more to their knowing their HIV status and receiving treatment. Since PI women are receiving ongoing care, they are more likely to be referred to antenatal care early."The problem with the SI women was they presented very late to treatment," Dr. Butler said.She explained that in the absence of any treatment, there is about a 30% chance of in utero transmission of HIV. "So if you have someone presenting late, they may have already transmitted [the virus] in utero, particularly if it's a new infection. The woman who seroconverts in pregnancy or gets a new infection in pregnancy — she's the one who's at highest risk of early in utero transmission," she said. If an infant is not infected in utero, treating the mother in the peripartum period is very effective in preventing transmission during delivery. "But we want to have women on treatment and stably suppressed," Dr. Butler said. "In Romania, the overall transmission rate was 5%, so they still have a way to go."The study did not have any commercial funding. Dr. Butler has disclosed no relevant financial relationships.13th European AIDS Conference of the European AIDS Clinical Society (EACS): Abstract PS4/1. Presented October 13, 2011.

CDC: National HPV Vaccine Programs Yet to Spread in Americas

2011-10-17T20:09:00.000-07:00

From Medscape Medical NewsEmma Hitt, PhDOctober 14, 2011 — Human papillomavirus (HPV) vaccine is being used as part of national or regional immunization programs in only 4 of 35 countries in the Americas — the United States, Canada, Panama, and Mexico — according to a new report.The report was published by researchers with the Pan-American Health Organization in collaboration with the US Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, in the October 14 issue of the CDC's Morbidity and Mortality Weekly Report.Elissa Meites, MD, from the CDC's Division of Sexually Transmitted Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, and colleagues note that HPV vaccines are "among the most expensive vaccines available, and current prices in high-income countries are not affordable for low- and middle-income countries.""These data show that HPV vaccination programs are being implemented in more countries throughout the Americas, but we still have a long way to go," Dr. Meites told Medscape Medical News."In many countries, the high cost of the vaccine is a barrier to implementing vaccination programs, since public health funds are stretched thin," she said. "Even in the United States, where the CDC recommends routine vaccination against HPV and most insurance covers HPV vaccine for adolescents, only 32% of 13- to 17-year-old girls have been fully vaccinated with 3 doses of HPV vaccine."In the United States, the authors report, coverage rates for HPV vaccine have increased since its introduction in 2006, although only a third of girls aged 13 to 17 years have received all 3 shots. Vaccine administration occurs mainly through primary care providers, but Vaccines for Children also provides the vaccine at no charge for eligible participants.In Canada, school-based HPV vaccination and other public programs beginning in 2007 have enabled from 51% to 85% of coverage (all 3 HPV vaccination doses), although rates vary by jurisdiction.In Panama, the Ministry of Health added bivalent HPV vaccine to the national immunization program in 2008; it is delivered in both clinics and schools for girls aged 10 years and older. "In 2009, 1-dose coverage among girls aged 10 years was 89%, and 3-dose coverage was 46%," the authors note. "In 2010, 3-dose coverage was 67%."In Mexico, the immunization program expanded nationally in September 2011 to include school-based vaccination for all girls aged 9 years. The most recent data of coverage in 182 municipalities (representing <10% of the population) in 2009 indicate that 1-dose coverage was 85%, and 2-dose coverage was 67%. Three-dose coverage at 60 months had yet to be measured.According to the authors, some countries are using an extended 3-dose schedule, but the Pan-American Health Organization, the World Health Organization, and the CDC "recommend a 3-dose schedule administered over 6 months." They add that "[a]dditional strategies are needed to overcome challenges to increasing HPV vaccine introduction, especially in regions with a disproportionate burden of cervical cancers.""These vaccines are safe and effective, and provide an opportunity to prevent cancer and save lives," Dr. Meites said.Morb Mort Wkly Rep. 2011;60:1382-1384. Full text

New ADHD Guidelines Updated to Include Broader Age Range

2011-10-17T19:11:00.000-07:00

From Medscape Medical News > PsychiatryFran LowryOctober 17, 2011 (Boston, Massachusetts) — For the first time in a decade, the American Academy of Pediatrics has issued an updated set of guidelines for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) that now include younger, preschool children and adolescents.The guidelines, "ADHD: Clinical Practice Guidelines for the Diagnosis, Evaluation and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder," were released here at the American Academy of Pediatrics National Conference & Exhibition and simultaneously published online October 16 in Pediatrics."We wrote the original guidelines in 2000 to 2001, and they were written for children between the ages of 6 and 12 because that's where most of the available evidence was at the time," Mark Wolraich, MD, CMRI/Shaun Walters professor of pediatrics and chief of the Section of Developmental and Behavioral Pediatrics at the University of Oklahoma Health Sciences Center, Oklahoma City, told Medscape Medical News."Over the years, we have heard about the concern for preschool children and adolescents and what should be done with them. We've expanded the age group to include children aged 4 to 18 because there's certainly new evidence to support recommendations for the broader age group," said Dr. Wolraich, lead author of the guidelines.Increase in Approved MedicationsThe last 10 years have also seen an increase in the number of medications that have been approved by the US Food and Drug Administration for the treatment of ADHD, and the new guidelines reflect this. They also emphasize the chronic nature of the disorder"We had pushed for the idea that ADHD was a chronic illness in the initial guidelines, and that clinicians needed to use chronic illness principles in treating it, and this has been further emphasized," Dr. Wolraich said.Other key recommendations include: assessing children for other conditions that might coexist with ADHD, such as oppositional defiant and conduct disorders, anxiety, and depression; making sure that Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, criteria have been met; obtaining information primarily from reports from parents or guardians, teachers, and other school and mental health clinicians involved in the child's care; first line of treatment for preschool-aged children 4 to 5 years old should be evidence-based parent- or teacher-administered behavior therapy; titrating medication doses to achieve the maximum benefit with the least adverse effects; and for adolescents, the primary care clinician should prescribe FDA-approved ADHD medications with their consent."The challenge in adolescents is you no longer have individual teachers as good reporters of their behavior, because they are going from class to class, and no one has them for a long period of time. It tends to be hard to get good information," Dr. Wolraich said.He added that it is important to start treating children at a young age."When we can identify them earlier and provide appropriate treatment, we can increase their chance of succeeding in school. With our greater awareness now about ADHD and better ways of diagnosing and treating this disorder, more children are being helped."Clinical Judgment Not EnoughPeter Jensen, MD, codirector of the Division of Child Psychiatry and Psychology at the Mayo Clinic, Rochester, Minnesota, told Medscape Medical News that the updated guidelines give more detailed instructions to help primary care physicians manage these patients.Dr. Peter Jensen"What's wonderful about the updated guidelines is they provide additional guidance and specificity over the guidelines that were published back in 2000 to 2001," Dr. Jensen said."Some of these kids have very complex problems; many also have anxiety and depression. The guidelines take note of this, and they also emphasize the use of rating scales from teachers and parents. They take us a step further," he added.Providing more detailed guidance on the diagnosis and treatment of children with ADHD is important, he said."Many doctors treat ADHD by the seat of their pants," he said. "They are well intentioned, but when we are in the midst of a busy office day and frantic parents, and understaffed, our clinical judgment isn't enough, and we are prone to miss things. If the mom smiles we think all is well. But that is not as accurate as looking at the rating scale from the parents, from the teacher, and talking with Johnnie."Clinical judgment is not enough to replace these kinds of tools, and the guidelines add more of that kind of detail and will be more likely to help us keep from making errors of omission and commission."Dr. Jensen said he suspected that ADHD may be increasing because so many demands for sustained attention are being placed on today's children."We expect our kids to learn more, do more, we expect them not just to go to college but to have 3 or 4 hobbies and activities they do in the afternoon and quickly get that homework done, and then we expose them to many different stimuli."They have the TV going, and the Game Boy going. All those things are competitors for attention. If you had a society where homework was not important, almost by definition you'd have fewer parents complaining about their child's inattention," said Dr. Jensen.Dr. Wolraich disclosed that he is a past consultant to Shire, Lilly, Shinogi and Nextwave all of which produce medications for ADHD. Dr. Jensen has disclosed no relevant financial relationships.Pediatrics. Published online October 16, 2011. Full text

Food Allergies in Kids More Common Than Thought

2011-10-16T20:36:00.000-07:00

From WebMD Health NewsBrenda GoodmanJune 20, 2011 — The largest study ever to track childhood food allergies in the U.S. shows that they may be more common and more dangerous than previously recognized.The study, a detailed survey of families with at least one child younger than 18, shows that 8% of kids under age 18 are allergic to at least one food. Surveys for about 38, 000 children were completed.Previous studies, including a government survey published in 2009, had pegged that number at around 4%.Allergies to peanuts were the most commonly reported, affecting 2% of kids. Milk and shellfish allergies ranked second and third. Tree nuts, egg, fin fish, strawberry, wheat, and soy rounded out the top nine food triggers."This study shows that there's a very high, and higher than we thought, prevalence of food allergy in the U.S." says Susan Schuval, MD, pediatric allergist at Cohen Children's Medical Center in New Hyde Park, N.Y., who was not involved in the study."We see this in our clinic," Schuval says, "tons and tons of food allergies."Severe Reactions Are CommonMany food allergies in children are mild and fade over time. But in other cases, reactions to food can be dangerous and even deadly.The new study offers one of the first estimates of these severe reactions in children, showing that 40% of kids with food allergies experience severe symptoms such as wheezing and anaphylaxis, which is characterized by difficulty breathing and a sudden drop in blood pressure."I don't think people quite understand food allergy," says study researcher Ruchi S. Gupta, MD, MPH, an assistant professor of pediatrics at Northwestern University's Feinberg School of Medicine in Chicago. "It could be something that's life-threatening. It could cause death."The study found that food allergies were highest in preschoolers, peaking between 3 to 5 years of age.Teenagers, however, particularly boys, were most likely to experience severe, life-threatening reactions."More fatalities occur in teenagers and older children," Gupta says. "They're going out with their friends and they don't want to feel different. They may not ask the ingredients in everything, you know, at a restaurant, in front of people."Independent experts praised the scope of the new study, which is published in the journal Pediatrics."This is a very significant study since accurate data on the prevalence of food allergy are lacking," says Robert Wood, MD, director of pediatric allergic and immunology at Johns Hopkins University School of Medicine, in Baltimore, in an email to WebMD.Tracking Food Allergies in KidsBecause the study was so large, researchers weren't able to use clinical measures, like blood tests or medical records to count allergy cases.Instead, they relied on parents to report either a doctor's diagnosis or classic symptoms.The survey, which randomly sampled parents across the country, was designed by a panel of allergy expert. The panel agreed on what symptoms to include as allergic reactions.When symptoms reported by parents didn't match, researchers discounted the reports. For example, reports of bloating after drinking milk, which may be more indicative of lactose intolerance than a true milk allergy, were dropped.Still, experts said, because the study didn't include objective measures, the numbers may have been skewed."The overall prevalence estimate of 8% seems on the high side compared to most of the prior estimates," says Scott H. Sicherer, MD, a professor of pediatrics at the Jaffe Food Allergy Institute at Mount Sinai Medical School in New York City.Previous studies, however, were smaller and had other significant limitations. For example, one survey relied on a single question to tally allergies. Other studies only looked at allergies from a select trigger, like peanuts.And because the current study didn't track reports of allergies over time, it's impossible to say whether the new number represents an increase in food allergies in kids."This is a unique study because it was large, evaluated many different foods, and gives some insights on severity and risk of food allergies in children," says Sicherer, who has reviewed other estimates of food allergies in children but was not involved in the current research.Experts say study is also important because it hints at some of the misery that is visited on children with food allergies."Children who are peanut allergic are relegated to the peanut-free table at school, which kind of makes them feel like outcasts," says Schuval. "Plus there's a fear of having an allergic reaction after eating certain foods or going to a restaurant. It really can affect your whole life."

Rotavirus Vaccine Tied to Short-Term Risk for Intussusception

2011-10-16T20:31:00.001-07:00

From Medscape Medical NewsMegan BrooksJune 17, 2011 — The monovalent rotavirus vaccine (RV1; Rotarix, GlaxoSmithKline) carries a short-term risk for bowel intussusception in roughly 1 of every 51,000 to 68,000 vaccinated infants, a new study indicates. However, the benefits of the vaccine far outweigh the risks, the study team emphasizes.The study appears in the June 16 issue of the New England Journal of Medicine.In 1999, a rotavirus vaccine (RotaShield, Wyeth Laboratories) was withdrawn from the US market after postlicensure surveillance showed it caused intussusception in 1 of every 10,000 infant recipients.This prompted Manish M. Patel, MD, from the Centers for Disease Control and Prevention in Atlanta, Georgia, and colleagues to assess the association of the new monovalent RV1 vaccine with intussusception in Brazil and Mexico. Brazil added RV1 to their national childhood immunization programs in March 2006, and Mexico followed in May 2007.A total of 615 infants with intussusception (285 in Mexico and 330 in Brazil) and 2050 control infants (739 in Mexico and 1311 in Brazil) were enrolled in the study. Of these, 594 patients with intussusception (97%) and 2033 control patients (99%) had a history of vaccination.Among infants from Mexico, there was roughly a 5-fold increased risk for intussusception 1 to 7 days after the first dose of RV1. Using a case-series method, the incidence ratio was 5.2 (95% confidence interval [CI], 3.0 - 9.3). Using a case-control method, the odds ratio was 5.8 (95% CI, 2.6 - 13.0).Among infants in Brazil, no significant risk for intussusception was found after the first dose. However, a small but significantly increased risk was seen 1 to 7 days after the second dose in both the case-series analysis (incidence ratio, 2.6; 95% CI, 1.3 - 5.2) and the case-control series (odds ratio, 1.9; 95% CI, 1.1 - 3.4).Benefits Clearly Outweigh RisksThe authors point out that the first week after dosing corresponds to the period of peak intestinal virus replication, during which a local inflammatory response in the lymphatic tissue or intestines may occur, "a response that has been implicated in the pathogenesis of intussusception."They emphasize, however, that the increased risks uncovered from their analysis translated into an annual excess of 96 hospitalizations for intussusception, and 5 deaths in the 2 countries combined.These figures, they say, "are outweighed by the real-world benefits of RV1 vaccination, which has annually prevented more than 80,000 hospitalizations and 1300 deaths in Mexico and Brazil."They further point out that these "emerging" data on RV1 have been reviewed by the World Health Organization, as well as by regulatory agencies and immunization advisory committees in Brazil, Mexico, and the United States. All of these organizations have unanimously favored continuing the recommendation that rotavirus vaccination be administered to infants to prevent severe and potentially fatal rotavirus disease.The study was supported in part by the Global Alliance for Vaccines and Immunization and the US Department of Health and Human Services. The authors have disclosed no relevant financial relationships.N Engl J Med. 2011;364:2283-2292. Full text

Toys - Safety tips

2011-10-11T19:57:00.001-07:00

ToysSelect only toys suitable for the child's age group, and make sure to read and follow all warnings, safety messages, and instructions that come with the toy.Child with a toy box Always supervise children at play and teach them how to use toys safely. Keep small toys, small balls, or small loose toy parts out of the sight and reach of children under 3 years of age or older children who still put toys in their mouth. The small items are choking hazards. Repair or throw away weak or broken toys - check often for hazards like loose parts, broken pieces, or sharp edges. Check that toys like rattles and teethers have handles or parts that are large enough so they will not get stuck in an infant's throat and block their airway. Keep all toys, especially plush and soft toys, away from heat sources like stoves, fireplaces, and heaters. Avoid toys with cords, especially stretchy cords that are long enough to wrap around a child's neck. Avoid loud toys as loud noise can damage a child's hearing. A toy that is loud for an adult is likely too loud for a child.Two grandkids with their grandfather and a toy boxToy Boxes Use a toy box without a lid, or use a toy box with a lightweight lid, sturdy supportive hinges, and air holes. Heavy lids can fall on children's heads and necks causing death. Children should not have access to airtight storage bins, trunks, or boxes. Access to these types of storage products could lead to suffocation if a child climbs inside.Ride-On Toys Choose a ride-on toy that suits the child's age, size, and abilities. Check that the ride-on toy will not tip when the child is using it. Be aware that a child on a wheeled ride-on toy can move very quickly: Use a ride-on toy far away from stairs, traffic, swimming pools, and other dangerous areas. Use a ride-on toy away from hazards such as lamps, cords, decorations, or appliances that could be knocked or pulled down onto a childLatex BalloonsLatex balloons have caused a number of deaths. Deaths have occurred in children as old as 9 years. Balloons or broken balloon pieces can be inhaled and as a result, block a child's airway. Latex balloons are best used for decoration, not for play. Always keep inflated and uninflated latex balloons, and pieces of broken balloons, out of the reach of children. Adults should always inflate balloons. Supervise children when balloons are around.Toys With Batteries Only adults should install batteries. Improper installation, or mixing different battery types, can cause batteries to leak or overheat, which coul injure a child. Make sure batteries in toys are not accessible to the child. A child should not take battery-operated toys to bed. Burns or other injuries could result from batteries leaking or overheating. Call your doctor or poison control centre right away if a child swallows a battery. Batteries can be poisonous.TrampolinesTrampolines should not be considered as toys; there is a serious risk of injury to children using them. Most trampoline-related injuries happen at private homes, usually in backyards on full-size trampolines.The hazards that result in injuries and deaths include: colliding with another person on the trampoline, landing improperly while jumping or doing stunts on the trampoline, falling or jumping off the trampoline, and falling onto the trampoline's springs or frame.Always supervise children when they are using a trampoline. Do not allow children under 6 years of age to use a trampoline, even when supervised. Allow only one person on the trampoline at a time. Do not allow children to perform somersaults and other stunts.http://www.hc-sc.gc.ca/cps-spc/pubs/cons/child-enfant/index-eng.php#Pacifiers

Baby Strollers - safety tips

2011-10-11T19:56:00.000-07:00

When choosing or using a stroller keep these points in mind: Always supervise children when they are in the stroller. Choose a sturdy stroller and follow the manufacturer's instructions for the child's weight and height. Always use the safety harness and lap belts, and make sure that the child is seated properly in the stroller. Use the brakes when stopped, and when placing the child in or removing the child from the stroller. Make sure that the child's hands and feet are not in the way before making adjustments to the stroller. Check the stroller regularly for signs of damage and to make sure the wheels are securely attached. Do not use pillows or blankets as padding, as they pose a suffocation risk. Do not carry additional children, items, or accessories in or on the stroller except as recommended in the manufacturer's instructions. Do not use a stroller on an escalator.

play safety

2011-10-11T19:54:00.001-07:00

PlaygroundsChildren have died when their clothing or drawstrings got caught on playground equipment or on fences. Other children have died when they became entangled on ropes or skipping ropes attached to playground equipment. Always supervise children and teach them to use the equipment safely. Remove cords and drawstrings from children's hoods, hats, and jackets. Tuck in all clothing, such as a scarf, that can get caught on playground equipment. Take off bicycle helmets before using playground equipment. Bicycle helmets can get caught on equipment and strangle a child. Check playground equipment for ropes. Do not let children tie ropes or skipping ropes to playground equipment.PlaypensA playpen should be a place where a baby is safe. Make sure the playpen is a newer model with small holes in the mesh.Playpens Never leave a baby in a playpen with the side down; the baby can roll into the space between the mattress and the mesh side and suffocate. Avoid playpens that have sharp edges or hinges that can pinch, scrape, or cut fingers. Make sure side latches are in their fully closed position when setting up a playpen. Never put scarves, necklaces, or cords in the playpen or around a baby's neck. These items can catch on the playpen and strangle a baby. Remove mobiles and toy bars when the baby begins to push up on their hands and knees. Check for tears in vinyl rails or in the mattress pad of the playpen. A baby can bite off small pieces and choke. If a change table or bassinet is provided as an insert for the playpen, never place a baby in the playpen while the change table or bassinet insert is still in place.http://www.hc-sc.gc.ca/cps-spc/pubs/cons/child-enfant/index-eng.php#Pacifiers

Pacifiers

2011-10-11T19:53:00.001-07:00

Never tie or hang a pacifier or any other object around the neck of a baby or a young child. This can result in strangulation. Pacifiers should be replaced at least every two months rather than waiting for signs of breakdown. Inspect pacifiers daily. Check the nipple for changes in texture, tears, or holes. These can appear with age or exposure to heat, certain foods, or sunlight. Check that the nipple and any ring or handle remains firmly attached when it is pulled upon forcefully. Any pacifier displaying signs of breakdown should be thrown out right away because the broken or loose pieces are choking hazards. A teething ring is a safer alternative for a baby who is chewing on a pacifier.http://www.hc-sc.gc.ca/cps-spc/pubs/cons/child-enfant/index-eng.php#Pacifiers

Children's Clothing

2011-10-11T19:52:00.000-07:00

Cotton and cotton-blend fabrics catch fire and burn more quickly than most synthetic materials. Nylon and polyester are more difficult to catch fire and burn more slowly.Loose-fitting cotton and cotton-blend sleepwear for children do not meet flammability requirements. If you prefer cotton and cotton-blends make sure the sleepwear is a snug-fitting style, such as polo pyjamas or sleepers.Snug-fitting clothing is less likely to catch fire than clothing with flowing skirts, wide sleeves, or large ruffles.Other safety considerations for children's clothing: Dress children in actual sleepwear when putting them to bed rather than T-shirts or other day clothes. Most day clothes do not meet the flammability requirements for sleepwear. Drawstrings or cords on children's clothing should be removed. Children can strangle on drawstrings and cords that get caught around their neck or on other objects. Belts, ties, or sashes on children's robes should be stitched firmly to the centre back of these products. Young children are at risk of strangulaion from any type of cord that can be detached from the clothing. Check for loose buttons or other small parts as they could become a choking hazard. Check blankets and sleepers regularly for loose threads and fix them immediately, as threads can wrap around a baby's finger or neck and cause injury.from Is your child safe brochure : Health Canada

Baby Slings & Baby Carriers

2011-10-11T19:45:00.001-07:00

source: Health Canada www.hc-sc.gc.caThe use of baby slings and baby carriers (worn by the caregiver) has led to serious injuries, and in some cases, the death of babies in Canada. Slings that use knots or rings to hold the two ends of fabric together pose a potential safety risk because knots can come loose and fabric can slip through the ring, causing the baby to fall. It is important to choose the right sling or carrier for you and the baby. When choosing a baby sling or baby carrier, look for a model that: is appropriate for the age and size of the baby and that it can accommodate the growth of the baby. is the appropriate size for the adult carrying the baby. comes with detailed and easy to understand instructions. Follow them carefully and keep for future use. will not allow the baby to slip through the leg openings or fall over the side of the product. comes with safety straps. Make sure that they are always securely fastened. Before each use, check for ripped seams and other signs of wear that may make the product unsafe. Take caution when bending over, hold onto the baby with one hand and bend at the knees, to prevent the baby from slipping out of the sling or carrier.Baby WalkersBaby walkers are banned in Canada. It is a criminal offence to sell, advertise, or import new or used baby walkers, even for your own use. It is also a criminal offence to give them away.Blind and Curtain CordsThere is a possible strangulation or entanglement hazard for babies and young children who have access to looped or long blind and curtain cords. There are steps you can take to reduce the risk of this type of tragedy from happening in your home.Whether your blinds or curtains are new or old, do not leave cords hanging. Keep the cords high and out of the reach of children. Cut the cords short when blinds are fully down or when curtains are fully closed. Tie the cords out of the reach of children, whether the blind is up or down, make sure children cannot reach the cords. Never put a crib, bed, high chair or playpen near a window or a patio door where a child can reach a blind or curtain cord.Use a clip, clothes pin, or big twist tie to keep the cord high and out of reach of childrenUse a clip, clothes pin, or a big twist tie to keep the cord high and out of the reach of children.Wrap the cord around a cleat or two nails or screws that you have attached to the wall near the top of the blinds or curtains, high and out of the reach of children.Wrap the cord around a cleat or two nails or screws that you have attached to the wall near the top of the blinds or curtains, high and out of the reach of children.Remove the loop in the cord by cutting the cord in half.Remove the loop in the cord by cutting the cord in half. Then, put plastic tassels or a break-away device at the end of the cords.Install tie-downs for vertical blinds.Install tie-downs for vertical blinds. You can buy these devices at hardware or department stores. When installing tie-downs, follow the manufacturer's instructions that come with the product. Make sure that the tie-down device is securely attached to the wall beside the window. Do not put sofas, chairs, tables, shelves or bookcases near windows. This will prevent children from climbing up to reach the blind or curtain cord.Bunk BedsChildren under 6 years of age should never use the upper bunk of bunk beds.Since 1985, a number of deaths were reported in Canada when children under 6 years of age were placed in the upper bunk. Typically, the children suffocated when their bodies slipped between the guard rail and the mattress. Check regularly to make sure the frame of the bed is sturdy and in good condition. Make sure the upper bunk has guard rails on all sides even if the bed is placed against a wall. Make sure the spaces in the guard rail are small enough so that a child cannot slip through. Mattresses should fit snugly on all sides leaving no gaps between the mattress and the sides of the bed. See also Safe Sleep.Health Canada recommends the use of bunk beds that meet the requirements of the current ASTM International bunk bed standards. Know before you buy; check the label, visit the manufacturer's Web site, or ask your retailer, to find out if the bunk bed you have selected meets these standards.

Water safety for young children

2011-10-11T19:37:00.001-07:00

Drowning is the second most common cause of death for children under 5 years of age. Children can drown in as little as 2.5 cm (1 inch) of water. Many of these tragedies happen in backyard pools, and almost always in pools without 4-side pool fencing and self-closing, self-latching safety gates.Take the following essential precautions to help protect your children: Babies who cannot sit without support and are too young to wear a portable flotation device (PFD) should be held by an adult at all times. Toddlers should always be within arm’s reach of an adult when they are in or around water. This includes pools, bathtubs, and beaches, and other water sources. Swimming lessons are a great opportunity for families to participate in fun activities that contribute to a healthy lifestyle.But on their own, they will not protect or prevent a child from drowning. All children should be supervised by an adult when they are in or around water and should never be left alone in a pool or bathtub, even for a moment. The Lifesaving Society recommends a supervision ratio of at least 1 adult for every 2 young children, and 1 adult for every baby.Should I use a life jacket or a personal flotation device (PFD) for my child? Life jackets are different from PFDs. A life jacket can turn the person over from face-down to face-up. A PFD will keep a person floating, but not necessarily face-up. It is lighter and less bulky than a lifejacket. PFDs also keep people warmer in the water because the foam in the vest is spread more evenly around the body.You can use either a lifejacket or a PFD for your child, as long as it is designed for children.In Canada, approved life jackets and PFDs are not available for infants who weigh less than 9 kg (20 lb). There is no safety standard for smaller infants. PFDs or life jackets should be worn by all infants who weigh at least 9 kg (20 lb) and by toddlers who are swimming or playing near or in the water. Check the label to be sure that your child’s PFD or life jacket meets current national safety standards. It should be approved by at least one of the following: Transport Canada, Canadian Coast Guard or Fisheries and Oceans Canada. It should be the right size for your child’s weight. Make sure it stays buckled up. Keep all safety straps fastened, including the crotch strap. Remember that water wings, bathing suits with flotation devices in them, inflatable wings and other swim toys ARE NOT safety devices.What should we do if we have a swimming pool at home? Swimming pools—whether in- or above-ground—should be fenced on four sides. That means NOT having direct access to a pool from a deck, patio or back door (the house doesn’t count as a “side”). The fence should be climbing-resistant and at least 1.2 m (4 ft.) high. Any gate to the pool area should be self-closing and self-latching. Make sure that hot tubs and spas not contained within the fenced pool area have a locking hard cover or are located in an area that can be closed and locked. Empty toddler and other portable backyard pools after use (at least once daily if you are using them every day). By not having standing water, you also help reduce the risk of West Nile Virus. Parents and pool owners should learn how to swim and how to rescue a drowning victim. They should also maintain certification in first aid and cardiopulmonary resuscitation (CPR). Pool owners should have an emergency action plan, rescue equipment, and a telephone on the deck or poolside. Slide or play equipment should be designed specifically for pool use.What are some other water safety tips? Use diapers designed for use in water. They don’t get as heavy as regular diapers and are less likely to cause your child to lose his balance in a wading pool. Empty buckets and pails, ice chests with melted ice, or bathtubs as soon as you are done with them. Do not keep a container filled with water (such as a rain barrel) around your home. When your children are playing under a sprinkler, watch for pools of water collecting on the ground. They can be slippery. Move the sprinkler often, or take a break until the water has drained. Use sprinklers on grassy surfaces only, and make sure the play area is free of toys or other obstacles. A backyard water slide should be used with caution. Set it up on a soft, grassy slope, free of bumps, and well away from trees or shrubs. Teach children to slide in a sitting position. Keep children away from ponds and streams at any time of year, unless you are with them.When can my child take swimming lessons?There is not a lot of research about the exact age when young children are ready to learn how to swim. Several studies show that children do not have the skills to swim on their own until they are 4 years old, even if they start lessons at a younger age. If your child is younger than 4 years old, look for swimming programs that focus on building water confidence and that teach parents about water safety. This is a great way to have fun and be active with your children.Teach your children these important pool rules and follow them at all times: No swimming without an adult. No running or pushing. No food or drinks. No riding toys.Source: Well Beings: A Guide to Health in Child Care (3rd edition)For more information: Swimming lessons for infants and toddlers, a statement of the Canadian Paediatric Society Lifejackets & PFDs, Transport Canada Lifejackets & personal flotation devices, Safe Kids CanadaReviewed by the CPS Injury Prevention Committee Last updated: April 2011Canadian Paediatric Society, 2305 St. Laurent Blvd., Ottawa, Ont. K1G 4J8Phone: 613-526-9397, fax: 613-526-3332

Your preschooler and safety:

2011-10-11T19:36:00.000-07:00

How to prevent injuries at homeSafety begins at home. You probably spent a lot of time and effort making your home safe for your baby. Did you know there are still more things you can do as your child grows older?Here are some basics to keep in mind: Be prepared for new skills: Your child’s risk of injury depends, in part, on his physical development and thinking and remembering skills. For example, does he enjoy climbing? Can he pull a chair over to a counter or stove? Can he open the door by himself to go outside or into the bathroom? Think ahead and prepare before a situation becomes dangerous. Actively supervise: Be aware of where your child is and what he is doing. Monitor the spaces your child lives and plays in: What aspects of your home might pose a risk to your child? Look at your living spaces from your child’s perspective. This will help you take steps to make her safer. Keep cords wound up and put away, electrical outlets covered with safety caps and drawers closed and latched when you aren’t using them. Prevent access to certain areas that are more dangerous—such as a backyard pool or a home workshop that has tools in it—until your child is old enough to use them safely. Keep hot liquids away from the edge of the counter, and off tables with a tablecloth or runner so your child can’t accidentally pull them down. Sharp objects such as knives and razors should always be stored out of reach. Your preschooler is becoming more coordinated and independent. She's also gaining a better understanding of her own safety. You can talk to her about things that are safe or unsafe, and about family rules that she can understand and see everyone following.When it comes to safety, your preschooler can: learn basic rules and recognize when they aren’t being followed. learn safe or unsafe behaviours from other children. use “imaginative logic.” That means he might not look both ways before crossing the street at a crosswalk if he's heard that a crosswalk is “safe.” tell you when he’s afraid for himself or others.But he still cannot: understand or recognize a new or unknown risk. always remember rules when excited, or in a situation that requires him to process many pieces of information, or caught up in active play. judge the distance or speed of objects. These skills develop later. always control himself when he hears “no” or is asked to slow down. always make the connection between action and result.Learning rules is importantIntroducing basic rules for safety, following them yourself, and helping your children understand them is important.A good safety rule: is simple, clear and age-appropriate, so that your child understands. is consistent. If a rule isn’t applied in the same way over and over, your child will think it has no meaning and will be less likely to follow it. is reasonable. A random rule—which can’t be easily explained or doesn’t seem to have a cause or effect/consequence—is easy to forget and may not matter much. is reinforced. When your child behaves safely without prompting, offer praise (“Great job picking up these toys,” or “Thanks for looking out for your little sister by picking up your toys.”). is shared. Everyone in the family knows the rule, follows it and helps others follow it too. is positive. Say, “We walk when we’re at the wading pool,” rather than “No running.” If a child hears “no” more than “yes” when you set safety rules, he’ll be more tempted to test them. Also, it’s helpful to tell children what they should do, rather than just what they should not do. is not scary. A child shouldn’t be discouraged or scared into behaving safely. has consequences if it isn’t followed. If restating a safety rule with a gentle warning doesn’t work, remove your child from the activity. Be sure to follow through on consequences.Teach your preschooler to follow these basic safety rules: “Stop, look and listen” when her name is called out loud. Listening and following your instructions are important first steps. “No” means “Stop and look at me.” “Okay” means “Go.” This rule is especially important around traffic, in the playground, on outings or during water play. Don’t cross the street without an adult. Hazard symbols mean “Danger. Stay away.” Ask your child to come and get you if he finds a product marked this way. Prevent trips and falls by picking up toys after play and keep the stairs and hallway floor clear of toys, clothing and shoes. Hold the handrail and turn on a light before going up or down stairs. Turn the cold water faucet on first when washing hands at the sink. Ask an adult before opening bottles or containers. Keep small objects and toys (anything small enough to fit inside an empty toilet roll) away from a younger child. Always wear a helmet when riding a bicycle, but take it off before playing on a playground. Don’t ever go into water (for example a pool, lake or river) without an adult. Avoid climbing or pulling on big pieces of furniture. An adult needs to be present to use the oven or the stove. Ask for help if you need to plug something in.Your preschooler loves to learn. She will be very open to basic safety routines if they are part of a family activity: talked about, practiced and shared.Source: The CPS Guide to Caring for Your Child from Birth to Age Five Well Beings: A Guide to Health in Child Care (3rd edition)Canadian Paediatric Society2305 St. Laurent Blvd.,Ottawa, Ont. K1G 4J8Phone: 613-526-9397, fax: 613-526-3332

Keep your baby safe

2011-10-11T19:33:00.001-07:00

Injury is the leading cause of death among children in Canada. Some of the biggest dangers to babies are falls, burns or scalds, drowning, choking, suffocation or strangulation, and car crashes. The good news is that these injuries are almost always entirely preventable. Parents can take steps to protect their new baby by: Recognizing everyday risks early, and taking precautions. Anticipating a baby’s new skills, and being prepared. Paying special attention at extra busy times of day. Actively supervising. The best way to prevent injury is to watch, listen and stay nearby. When you have to move away from your baby, put him in a safe place, like his crib. Remember: Your infant can’t lift her head until she is about 4 months old, when her neck muscles are stronger, and then only for a short time. She can’t avoid conditions or objects that make it hard for her to breathe. Your infant can squirm and move along a surface long before she can turn over by herself. Even a newborn can wriggle enough to fall off the change table, bed or sofa. Your infant can grasp and shake things, reach for dangling objects, wave a fist and push down firmly with his legs—and fast enough to knock hot or sharp things from your hand.Before you bring your baby home Make sure your crib has a permanent label with detailed manufacturing information, instructions and a warning statement about mattress size and proper use. Never use a crib that is missing this label, or one made before 1987. Check that all the crib bars are present and secure. The mattress should be firm, flat and fit tight within the crib frame. Sheets are smooth and tight-fitting as well. Corner posts shouldn’t be higher than 3 mm (1/8 inch) above the end panels. The frame must be solid, with no cut-out designs or openings where a baby could catch her head. Crib sides should lock securely in place when raised. Mattress support hangers must be secured by bolts and closed hooks. Don’t use a crib where these hooks are “Z” or “S”-shaped. Be sure to check for loose fittings regularly, especially whenever the crib is moved. Place the crib away from windows, window coverings and blind cords. Do not use bumper pads, pillows, lambskins, quilts, stuffed toys or comforters in the crib. Hang mobiles out of reach of your infant’s hands and fasten them securely to both sides of the crib. Don’t use a bassinet or cradle. Even an infant’s weight and movement can make them tip or collapse. Make sure that shelving or any heavy furniture is anchored securely to the wall. Install a smoke alarm in your baby’s room and check all the household smoke alarms to be sure they are working. Install a carbon monoxide detector in your home. Once baby is home, your precautions and behaviour will help protect her against the most common types of injury. Falls Never leave your infant unattended, or in a carrier on any raised surface, such as a bed, sofa or change table. Make sure your change table has a guard rail and safety strap, and always use them. If the phone rings while you are changing a diaper, take your baby with you to answer it or just let it ring. Store everything you need to change a baby within easy reach, so you don’t have to turn away. Make sure your baby sling or front carrier is appropriate for your baby’s age and size. It should support her head and shoulders and have small leg openings, so she can’t slip out. If you bend over, hold your baby against you with one hand so she won’t fall.Burns or scalds Smoke alarms should be installed on every level of the home and in every sleeping area. Check alarms once monthly to be sure they are working, and change the batteries twice each year, when you change the clocks in the spring and fall. Do not allow smoking in your home. Many house fires are caused by careless smoking or children playing with smoking materials such as lighters and matches. Also, cigarettes and butts are poisonous to young children. Set your hot water heater temperature to 49°C (120°F), or put an anti-scald device on your faucets. A baby’s skin burns very easily. Before bathing, check the water temperature with your elbow or wrist. It should feel warm, not hot. Bathe your baby away from the faucets, and remove him from the tub before running the hot water again. Never carry a baby and a hot drink at the same time. Use plastic mats instead of a table cloth that your baby might pull on and cause a spill of hot liquid. Don’t heat breast milk or formula in a microwave. Dangerous “hot spots” can burn an infant’s mouth. Warm a bottle in a pot of hot water instead, and test the milk on your wrist before feeding.Drowning An infant can drown—very quickly and quietly—in as little as 5 cm (2 inches) of water. Always watch and have at least one hand on your baby when she’s in the bathtub, wading pool or near any standing water. Have everything you need for bathing at hand, so that you never have to turn away. Don’t use a bath seat or ring. They are not safe. Never leave your baby alone in the bath with a brother or sister, even for a few seconds. Do not use a cell phone during bath time. If you must answer the telephone, take baby with you. Choking, suffocation or strangulation Vacuum often, and never leave small objects within a baby’s reach. He will put anything and everything in his mouth. Remove crib mobiles as soon as your baby is 4 months old or pushing up on hand and knees. Use a one-piece soother small enough for infants, with a shield to prevent him from sucking the nipple too far into his mouth. Discard any soother that shows any sign of wear or is more than 2 months old. Get rid of toys with pull strings longer than 20 cm (8 inches) or small, loose or breakable parts that a baby could swallow or inhale. Any object that is small enough to fit inside a toilet paper roll is a choking hazard. Don’t use bibs with ties, or hang pacifiers, a necklace or anything else around an infant’s neck that might catch and strangle her. Keep all plastic bags or wrapping out of reach and out of sight. Car safety All infants need a rear-facing car seat for their first ride home from the hospital. Your baby will use this seat whenever you travel-- even the shortest distance-- for one year or longer. Infants may use a forward-facing car seat once they are at least one year old and at least 10 kg, however it is best to rear-face as long as possible, so look for a car seat with the highest rear-facing weight and length limits once your child has outgrown their first car seat. Install the car seat in the middle of the rear seat—never in the front or near an airbag. Read the manufacturer’s instructions for the car seat and follow all age, height and weight specifications. Secure the car seat using the Universal Anchorage System (UAS or LATCH), which is now mandatory in all car models. Follow both the car seat and car manual instructions. If the UAS system does not secure the seat adequately, then use the seat belt, as indicated in the car seat instructions. Check that the car seat does not move more than 2.5 cm (1 inch) forward or from side to side once it is installed. Harness straps should be threaded just at or below your baby’s shoulders. The chest clip should be at armpit level and the harness should fit snugly. Tuck a blanket around your baby if needed instead of using a bunting bag. Don’t use a car seat that has been in a car crash, even a minor one. It is not safe. Never leave your baby unattended in a car, even to run a quick errand.For more information: Car seat safety Water safety for young children Transportation of infants and children in motor vehicles, a statement of the Canadian Paediatric Society Transport Canada: Safety in the carReviewed by the CPS Injury Prevention CommitteeUpdated: March 2009 This information should not be used as a substitute for the medical care and advice of your physician. There may be variations in treatment that your physician may recommend based on individual facts and circumstances.Canadian Paediatric Society2305 St. Laurent Blvd.,Ottawa, Ont. K1G 4J8Phone: 613-526-9397, fax: 613-526-3332

Social media: What parents should know

2011-10-11T19:25:00.001-07:00

Social media: What parents should knowChildren and teens are creating and sharing information more than ever using digital media such as cell phones, smart phones, and computers. They send text messages, use Facebook and Twitter, write blogs, share photos and video to stay in touch with friends and family and to make new friends.Social media offers lots of opportunity to help your child and teen be creative and stay connected and informed. But it’s important to learn about the different technologies and how your children use them so you can help keep them safe online.The social media landscape changes quickly. Because this document is only an introduction, we’ve included links to other websites you might find helpful.What is social media?Social media refers to the online tools that connect people with common interests on the Internet. Unlike traditional media (TV, radio, newspapers and so on), social media allow users to interact with each other. Popular social networking websites include Facebook, Twitter, YouTube, Flickr, and MySpace.There are many different ways that people use social media: Online profiles: Most social media sites require users to set up a profile. A profile usually includes a name, e-mail address, birth date, interests and a photo. Friends: Depending on the kind of social media, users “follow” or “request friends” from people they know such as classmates or family. They may also use social media sites to find and meet new friends. Messaging: Sending short text messages over the Internet, using instant messaging and between cell phones. Walls and boards: Social media sites allow people to post or send messages in many different ways. On Facebook, for example, information is posted to a “wall”. Some messages are visible to a wider audience, while others can be sent privately like e-mail. Photo and video sharing: Social networking sites allow users to upload personal photos and videos. Some sites, such as Flickr for photos and YouTube for videos, are used solely to share images. Blogs: A blog is a website kept by an individual who updates it with regular entries of text or photos and videos. It is a lot like a journal, only on the web. People who read blogs can comment and share published content among their own online networks. Joining groups: Many kinds of social media allow users to create groups. People join, “like” or follow these groups to get access to information and have conversations with other members. To play games: Children and teens visit online sites to play games, alone or with their friends. Some, like Facebook, include free online gambling applications.How can I keep my children safe using social media? Learn about the technologies your children and teens are using. Ask how they communicate with friends online. Tell them that you are willing and interested to learn about it. Keep computers in common areas where you can watch while your children use them. Be clear about the rules for using the computer and set limits on the amount of time and how they can be used. Set limits on cell and smart phone use. Talk about when it’s a good time to use a cell phone. Your child or teen’s school, for example, likely has rules about where and when they can or can’t be used. Teach them the value of “unplugging” from devices and computers for technology free time. Reinforce that no e-mail or message is so important that it can’t wait until the morning. Get 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. Tell your children and teens that you are monitoring their online activity. Be aware that some parent control programs will block information about puberty and sexuality that you might want your teen to look for. Ask your children and teens about the people they “meet” online. Showing genuine interest will help them feel comfortable talking about it. Explain that it’s easy for someone on the Internet to pretend to be someone they are not. Discuss what’s okay and safe to post online and what isn’t. People can’t always control the information others post about them. Explain that information and photos available online can turn up again years later. Ask your children and teens where else they access the Internet. Talk to teachers, caregivers and other parents about your rules for social media. Because people are not always who they pretend to be online, talk about the importance of keeping online friendships in the virtual world and how it can be dangerous to meet online friends face-to-face. Make it clear that if your child wants to meet a virtual friend in person, it must be with a trusted adult. If your child or teen is playing online games, join them (even if only to sit and watch) so you can see exactly what they are doing and talk to them about it.What should I know about online privacy?Social media websites have privacy policies and settings, but they are all different. Some sites are completely public, meaning that anyone can read or look at anything, anytime. Other sites let you control who has access to your information.Read a website’s privacy policy before providing any personal information. Some social media websites, like Facebook for example, don’t allow children under 13 to joint their site. Check your child’s privacy policy settings to make sure he isn’t sharing more information than you want.The following suggestions will help your children protect their online privacy: For some social media sites it is a good idea to choose an online nickname, instead of using a real name. Keep everything password protected, and change passwords often. Don’t accept friend requests from people you don’t know in real life. Think carefully about what you post online. Remember: things that are posted online stay online forever. As a general rule, don’t post anything you wouldn’t want a parent or teacher to see or read. Remember to protect a friend’s privacy too. Ask permission before posting something about a friend, a photo or a video. Be aware of what your friends are posting about you. If you use a GPS-enabled smart phone or a digital camera, you could be posting status updates, photos and videos with geotags. Geotags provide the exact location of where your photo was taken. Make sure these are turned off on your device. What is cyber-bullying?Just as some people are bullied in real life, people are bullied online. It happens many ways: by sending mean messages by e-mail or posting them in an online forum or by sharing photos and videos without permission.Talk to your children about cyber-bullying. If it isn’t too serious, suggest that they ignore it at first. If it doesn’t stop, is violent or sexually explicit or your child gets scared, encourage them to talk to you or another trusted adult.The Media Awareness Network has some more information on cyber-bulling at: http://www.bewebaware.ca/english/cyberbullying.htmlWhat is sexting?Sexting is a term used to describe sending sexually explicit messages, photos or videos between cell phones. It can also happen using e-mail or on social media websites. Ask your teen what she knows about sexting. Talk about the dangers of sexting. Remind her that words and photos posted online can easily be shared among many different people. Remind your teen that nothing is ever really deleted online. Friends, enemies, parents, teachers, coaches, strangers, and potential employers can find past postings.For more information: Tips for limiting screen time at home Impact of media use on children and youth, a position statement by the Canadian Paediatric Society Sexting: Keeping teens safe and responsible in a technologically savvy world, Canadian Paediatric Society Be Web Aware, 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. Web safety, a resource by the Royal Canadian Mounted Police (RCMP) Internet safety skills, a resource by the British Columbia RCMPReviewed by the CPS Adolescent Health Committee and Public Education Advisory CommitteePosted: July 2011This information should not be used as a substitute for the medical care and advice of your physician. There may be variations in treatment that your physician may recommend based on individual facts and circumstances.Canadian Paediatric Society2305 St. Laurent Blvd.,Ottawa, Ont. K1G 4J8Phone: 613-526-9397, fax: 613-526-3332

Antihypertensive Shows Promise for Autism

2011-10-09T21:31:00.000-07:00

From Medscape Medical News > PsychiatryFran LowryOctober 6, 2011 — The beta blocker propranolol, a drug widely used to treat hypertension and anxiety disorders, may also be beneficial for improving language and social function in people with autism, according to new research published in the March issue of Cognitive and Behavior Neurology."There is a lot of evidence to suggest a rigidity of the networks of the brain in autism," lead author David Q. Beversdorf, MD, from the University of Missouri, Columbia, told Medscape Medical News. "People take propranolol for anxiety, and we know from our past research that propranolol reverses the effect of stress, and can slow you down, so we thought it might be worth trying in people with autism."In previous studies, Dr. Beversdorf found that propranolol helped people solve word puzzles and also increased their semantic word fluency, or their ability to understand the definition of words. In the current study, they sought to see whether the drug would have a similar effect in people with autism.In 2 different testing sessions, 14 high-functioning teenagers and adults with autism and 14 matched control patients were given letter and category word fluency tasks.The first test was given 60 minutes after the administration of 40 mg oral propranolol, and the second test was given after administration of the placebo, administered in a double-blind, counterbalanced manner.Compared with the control participants, the patients with autism were significantly impaired on both the fluency tasks.The study found that propranolol significantly improved performance on category fluency, but not letter fluency, in participants with autism.After taking 1 dose of propranolol, patients with autism were able to name, on average, 11 types of animal in 30 seconds vs 9 types in the same time before taking the drug.Dr. Beversdorf added that he currently is seeking a grant to do a larger clinical trial, with more patients, to see whether they can predict who will respond to propranolol with brain imaging."Obviously, the downstream hope is that we will bring something that is clinically beneficial for patients. Propranolol doesn't cost a lot because it is generic and it has been used safely for a long time. We know what its side effects are, and we know who and who not to give it to."Innovative StudyMedscape Medical News invited Marjorie Solomon, PhD, from the MIND Institute at the University of California, Davis, Medical Center in Sacramento, to comment on the study."Although it is small and awaits replication, this is a very innovative trial for several reasons," Dr. Solomon, who was not part of the study, said in an interview."First, as pointed out by the authors, there has been very little work to assess the efficacy of psychopharmacological interventions for the cognitive impairments found in autism. Cognitive flexibility is one of the most frequently cited everyday problems for persons with autism," she said.Second, the authors developed their hypothesis within the context of a computational model of autism, Dr. Solomon noted. "Although this approach has been used to study other disorders like schizophrenia, they are the first to use it in autism."Dr. Beversdorf and Dr. Solomon have disclosed no relevant financial relationships.Cog Behav Neurol. 2011;24:11-17. Abstract

Steroids for Wheezing Slow Growth in Smallest Kids

2011-10-09T21:27:00.001-07:00

From Reuters Health InformationBy Anne HardingNEW YORK (Reuters Health) Sep 29 - Fluticasone treatment will not stunt growth in most preschoolers with recurrent wheezing, a new study shows.But the youngest, smallest children on corticosteroids did show a significant slowing of growth compared to their peers on placebo, Dr. Theresa W. Guilbert of the University of Wisconsin-Madison and her colleagues found."We speculate that this may have been a dose response, that smaller children getting the same amount of medication that the bigger or older children got caused them to have a decreased height velocity," Dr. Guilbert told Reuters Health. However, she added, more study is needed given that the new findings are based on a post-hoc analysis.Dr. Guilbert and her team reported their findings online August 5 in the Journal of Allergy and Clinical Immunology.In a study of the same group of children who were two or three years old at baseline and at high risk of asthma, the researchers had previously found that those who received daily corticosteroid treatment for two years grew 1.1 centimeter less than the study participants on placebo. However, the fluticasone-treated children caught up in the first year after they stopped receiving treatment, so the difference in height between the intervention and placebo groups was no longer significant.The current study looks at growth among study participants two years after the end of treatment. Overall, the researchers found, the children on fluticasone grew 0.2 cm less than the children on placebo, which was not a statistically significant difference.However, two-year-olds who weighed less than 15 kilograms at baseline had 1.6 cm less linear growth than children of the same age and weight who were given placebo (p=0.009).Every child in the treatment group received 176 micrograms of fluticasone propionate per day. Giving smaller children a lower dose, or only giving them medication during the viral season, could offset the drug's potential effects on growth, Dr. Guilbert said in an interview."You have to weigh the risk and benefit," she added. "We know it's an effective medication in these children, but the dose and the way you give it might be something you consider on a child-to-child basis. That and watching their growth very closely."Dr. Guilbert and her team are conducting another study comparing daily steroids to higher-dose steroid treatment when a child has a cold to determine which is best, and they plan to look at growth as a secondary outcome of this study as well."That will also shed some light on an additional way that an inhaled steroid could be used in this population," the researcher said.The current study was funded by several grants from the National Institutes of Health. Dr. Guilbert has consulted for GlaxoSmithKline, which makes Flonase, the brand-name version of fluticasone, as have some of her co-authors.SOURCE: http://bit.ly/q84ONWJ Allergy Clin Immunol 2011.

Prolonged Impact of Antibiotics on Intestinal Microbial Ecology and Susceptibility to Enteric Salmonella Infection

2011-10-03T21:43:00.000-07:00

Infect Immun. 2009 July; 77(7): 2741–2753.Published online 2009 April 20. doi: 10.1128/IAI.00006-09Copyright © 2009, American Society for MicrobiologyAmy Croswell,1 Elad Amir,1 Paul Teggatz,1 Melissa Barman,1 and Nita H. Salzman1,2*AbstractThe impact of antibiotics on the host's protective microbiota and the resulting increased susceptibility to mucosal infection are poorly understood.In this study, antibiotic regimens commonly applied to murine enteritis models are used to examine the impact of antibiotics on the intestinal microbiota, the time course of recovery of the biota, and the resulting susceptibility to enteric Salmonella infection. Molecular analysis of the microbiota showed that antibiotic treatment has an impact on the colonization of the murine gut that is site and antibiotic dependent. While combinations of antibiotics were able to eliminate culturable bacteria, none of the antibiotic treatments were effective at sterilizing the intestinal tract. Recovery of total bacterial numbers occurs within 1 week after antibiotic withdrawal, but alterations in specific bacterial groups persist for several weeks.Increased Salmonella translocation associated with antibiotic pretreatment corrects rapidly in association with the recovery of the most dominant bacterial group, which parallels the recovery of total bacterial numbers.However, susceptibility to intestinal colonization and mucosal inflammation persists when mice are infected several weeks after withdrawal of antibiotics, correlating with subtle alterations in the intestinal microbiome involving alterations of specific bacterial groups. These results show that the colonizing microbiotas are integral to mucosal host protection, that specific features of the microbiome impact different aspects of enteric Salmonella pathogenesis, and that antibiotics can have prolonged deleterious effects on intestinal colonization resistance.DISCUSSIONAntibiotic use carries both benefit and risk. Antibiotic therapy is critical for the treatment of life-threatening infection, but misuse of antibiotics leads to the development of antibiotic resistance in common pathogens. Even routine and appropriate use of antibiotics may have a detrimental impact on the host microbial ecosystem, which is important for host mucosal protection In this study, we investigated how the use of oral antibiotics perturbs the intestinal microbial ecosystem in mice and the impact of that disruption on host susceptibility to a common enteric pathogen, Salmonella enterica serovar Typhimurium.Using molecular methods to identify and quantify bacterial numbers, a more-complete understanding of the impact of antibiotics on the intestinal microbial ecosystem can be determined. While antibiotic treatment resulted in the loss of culturable bacteria, none of the antibiotic combinations tested was able to sterilize the gut. Since antibiotic treatment was limited to 1 week, it is reasonable to consider that the treatments would not be able to eliminate the slower-growing organisms. Nevertheless, complete elimination of the bacterial component of the intestinal microbiota by antibiotics is difficult to achieve and cannot be determined by culture-based methods. The various antibiotic regimens used resulted in changes in the abundance and composition of the intestinal microbiome that were antibiotic specific. The firmicute class of bacteria (including the E. rectale-C. coccoides group, Lactobacillus sp., and SFB) appears to be the most susceptible to all of the antibiotics used. This class of bacteria is also the most susceptible to disruption by diarrheal illness.After antibiotic treatment, the intestinal biome gravitates over time to that of untreated mice. Using bacterial culture analysis, after the initial elimination of culturable bacteria, anaerobes recover to the levels found in untreated mice within 3 days. Levels of aerobic bacteria expand dramatically but by 3 weeks closely approximate the levels found in untreated mice. Molecular analysis reveals that total bacterial numbers rapidly recover, driven by the swift recovery of the most dominant bacterial group, the E. rectale-C. coccoides group, members of the Firmicutes. Another member of the Firmicutes, the lactobacilli, also rapidly recovers, while other groups represented at a lower abundance, such as SFB, do not.If increased susceptibility to Salmonella infection was correlated with the quantity of colonizing bacteria eliminated by antibiotics, one would predict that streptomycin-treated mice would show less translocation and intestinal colonization by Salmonella and milder enteritis than would streptomycin-bacitracin- or AVNM-treated mice, but this was not evident in this study. Oral Salmonella challenge of antibiotic-treated mice resulted in comparable increases in intestinal Salmonella colonization, enteritis, and invasion irrespective of the antibiotic combinations used. Antibiotic recovery experiments allowed a more-complete dissection of specific aspects of Salmonella enteritis, including susceptibility to pathogen invasion, intestinal colonization, and mucosal inflammation.Interestingly, over the time course of biome recovery from antibiotics, mice regained resistance to Salmonella translocation rapidly, but susceptibility to increased Salmonella colonization and local mucosal inflammation persisted. This suggests that invasion is mediated by different pathogen-commensal-host interactions than colonization. The prevention of Salmonella translocation is associated with a recovery of total bacterial numbers, which is driven by the recovery of the dominant firmicute populations (the E. rectale-C. coccoides group and Lactobacillus sp.).The presence of an intact commensal biota could be preventing Salmonella invasion by effectively competing with Salmonella for attachment sites and nutrition, reducing the numbers of luminal Salmonella cells available for invasion. This would account for the association between biota recovery and resistance to translocation. However, commensal interactions with the host may also have an important role in the prevention of translocation. Several innate antimicrobial effectors produced by the intestinal epithelium are induced by intestinal colonization, including angiogenin 4 (19), RegIIIγ (9), and intestinal alkaline phosphatase (7), all of which have dual roles in intestinal homeostasis and host defense. The reduction in levels of intestinal bacteria by antibiotic treatment can result in decreased levels of expression of these effectors (44), allowing increased pathogen translocation.Specific bacterial species may also play a role in host protection. SFB, for example, are highly susceptible to both exogenous antibiotics, as shown here, and endogenous antimicrobial peptide activity (our unpublished observations). This organism is both immune stimulatory (38, 42) and highly immune responsive (20), with increased numbers found in immunoglobulin A-deficient mice (41). The absence of SFB has been associated with increased susceptibility to enteric pathogens (15) and enteritis. While SFB abundance does not correlate with pathogen translocation, it may be critical for the increased susceptibility of animals to Salmonella colonization and enteritis. It is possible that SFB have a directly protective effect by interacting with Salmonella and preventing pathogen interactions with the mucosa. SFB may also be acting through the stimulation of the mucosally associated lymphoid tissue, resulting in more-effective mucosal host responses to the invading pathogen. Additional work, using gnotobiotic mice and controlling for the presence of this unculturable bacterial group, is needed to address this issue.The finding that both extremely minimal disruptions in the intestinal biome, like those present 3 weeks after antibiotic withdrawal, and extremely profound disruption, such as that with AVNM treatment, result in similar luminal colonization by Salmonella was both unexpected and intriguing. It is unlikely that the intestinal biota is responsible for restricting the growth of Salmonella in these circumstances since it varies so profoundly between treatments. One explanation is that the limitation in Salmonella colonization is a result of innate host immune responses. Another possibility is that this is a colonization set point due to quorum sensing by Salmonella. Additional work will be required to distinguish these processes and determine whether this is specific to Salmonella or common to other enteric pathogens.It is evident that the intestinal microbial ecosystem serves an important but incompletely defined role in mucosal protection.In this study, we have demonstrated that although antibiotics cannot sterilize the intestinal tract, they can have a profound impact on intestinal colonization. The murine intestinal microbiome recovers from antibiotic disruption to closely recapitulate that of untreated mice, supporting the hypothesis that attributes of the host select for a core microbiome, as previously suggested using germfree models. Despite the rapid recovery of several measurable parameters of the biome, residual subtle alterations in bacterial composition can persist and result in profoundly enhanced susceptibility to bacterial enteritis. In conclusion, the host drives the selection of a core biome in which bacterial quantity and composition contribute to intestinal colonization resistance. Minimal disruption of this complex balance by antibiotics can result in prolonged harmful effects on the ability of the host to resist infection.

Tonsillectomy for PFAPA Syndrome

2011-10-02T21:01:00.000-07:00

From Medscape Pediatrics > ViewpointsTonsillectomy in Children With Periodic Fever With Aphthous Stomatitis, Pharyngitis, and Adenitis SyndromeGaravello W, Pignataro L, Gaini L, Torretta S, Somigliana E, Gaini RJ Pediatr. 2011;159:138-142Study Summary William T. Basco, Jr., MDPosted: 09/19/2011The clinical entity that includes periodic fever with aphthous stomatitis, pharyngitis, and adenitis (PFAPA syndrome) typically occurs in children 5 years of age and under. These children experience 3-4 days of illness that recur approximately every 4 weeks. Although the cause of this syndrome has been difficult to identify, the effects on these children and their families can be notable. Previous studies have shown that antibiotics do not alter symptoms from this condition, but corticosteroid therapy has been shown to quickly reduce fever.This study was a review of the literature on the utility of tonsillectomy in treating PFAPA syndrome. The investigators identified 15 studies published between 1999 and 2010 for this review, identifying articles that evaluated surgical tonsillectomy for PFAPA syndrome. The primary outcome of interest was whether the children experienced resolution of symptoms after tonsillectomy. Only 2 of the studies were randomized controlled trials. Of the 13 other case series, only 2 collected data prospectively. In 8 of the studies, the children underwent tonsillectomy alone, whereas the other 7 studies reported combinations of tonsillectomy with or without adenoidectomy. The 2 randomized trials were considered to be of better methodologic quality than the observational studies.The number of children in the studies varied from 2 to 27. The 2 randomized controlled trials had 14 and 19 children, respectively. After pooling outcomes from all the studies, 83% of the children experienced complete resolution of their symptoms after surgery. Looking at the 2 randomized trials individually, 100% of the children in one of the trials improved and 63% of the children in the other improved. The researchers were able to combine the data of the 2 randomized controlled trials for analysis, and the combined analysis demonstrated improved resolution after surgery with an odds ratio of 13 (95% confidence interval, 4-43). The investigators concluded that the evidence is insufficient that tonsillectomy is effective for treatment of PFAPA syndrome. They mentioned that limitations in the published literature, as well as varying definitions for enrollment among the trials, make true meta-analyses difficult.ViewpointI have to concur with Garavello and colleagues that the state of the literature is still at the hypothesis-generating point. These studies contained a grand total of 149 children, and the randomized, controlled trials contained a total of 29 patients. As the investigators state in their discussion, the combined results of the 2 randomized, controlled trials suggests a marked improvement after surgery, providing justification for a well designed prospective study. However, it appears that care should be taken during future trials in both patient selection and surgical approach so that the results are more generalizable.Abstract

Influenza Vaccination 2011-2012: Recommendations

2011-10-02T20:29:00.000-07:00

From CDC Expert Commentary MedscapeTim Uyeki, MD, MPH, MPPPosted: 09/19/2011The influenza vaccination recommendation this year is simple: Everyone 6 months of age and older should receive influenza vaccine. The annual "universal" influenza vaccination recommendation was first established in 2010 to expand protection against influenza to more people.You may receive questions from patients who were vaccinated last season about whether they still need an annual influenza vaccination because the influenza vaccine virus strains included in the 2011-2012 influenza vaccines are the same as those in last year's vaccines. It's not common for all 3 vaccine virus strains to be unchanged from one season to the next -- this has happened only 8 times since 1969.However, CDC has always recommended that people get vaccinated every year.Annual influenza vaccination, even when the vaccine strains are unchanged, is important because a person's immune protection from influenza vaccination declines over time. Immunity acquired from vaccine administered last season will have declined and may not be enough to prevent infection this season. So, annual influenza vaccination is recommended for optimal protection.Increasingly, there are influenza vaccination options. There are 3 trivalent inactivated vaccines (TIV) as well as live attenuated influenza virus vaccine (LAIV or the nasal spray vaccine).Trivalent inactivated vaccine has been around for decades and is approved for use in people 6 months and older, including people with high-risk medical conditions and pregnant women. It is administered intramuscularly. Different formulations of this vaccine are available from various manufacturers, and the minimum age varies from one formulation to another. Consult the package insert to ensure that a specific vaccine is suitable for your patient's age.In addition, the 2011-2012 Advisory Committee on Immunization Practices (ACIP) Influenza Vaccine Recommendations should be consulted. For example, ACIP recommends that the TIV Afluria® (Merck & Co., Whitehouse Station, New Jersey) not be given to children aged less than 9 years, although it is approved for children aged 5 years and older.The high-dose TIV was introduced in 2010 for people 65 years and older. It contains 4 times the amount of antigen as other influenza vaccines to prompt a stronger immune response. The high-dose influenza vaccine is also administered intramuscularly.The intradermal influenza vaccine was approved in 2011 for use in people aged 18 through 64 years. The intradermal vaccine contains less antigen than either of the other TIV formulations but provides a similar immune response. It is administered with a prefilled syringe into the dermal layer of the skin with a much smaller needle.Finally, the LAIV is available for healthy, nonpregnant persons aged 2 years through 49 years. There is no preferential recommendation for any of the formulations of TIV or LAIV for healthy, nonpregnant persons aged 2-49 years old, but clinicians should note the recommended age groups and possible contraindications for each.Whereas 1 dose of influenza vaccine is adequate for most people, young children who were not previously vaccinated against influenza require 2 doses of influenza vaccine for full protection in a given year. For the 2011-2012 season, children aged 6 months through 8 years of age will need 2 influenza vaccine doses spaced 4 weeks apart if they didn't receive at least 1 dose of influenza vaccine for the 2010-2011 season. Children in this age range who received at least 1 dose of the 2010-2011 influenza vaccine last season will need only 1 dose for the 2011-2012 season.New for the 2011-2012 season is a more permissive influenza vaccination recommendation for persons with egg allergies. Based on a thorough review of several recent studies, administration of both full doses and split doses of TIV have been tolerated by people with egg allergies without serious reactions. ACIP now recommends that for the 2011-2012 influenza season, people who have experienced only hives from consuming eggs can receive TIV intramuscularly as long as they are treated by a healthcare provider who is familiar with the potential manifestations of egg allergies and can be observed by a healthcare professional for at least 30 minutes after receiving each dose. LAIV should not be used in these patients.Other measures, such as dividing and administering influenza vaccine using a 2-step approach, are not necessary. People with more severe reactions from ingesting eggs or a previous severe reaction to influenza vaccination should not be given influenza vaccine before having a risk assessment performed. Please use the algorithm provided in the Figure to guide you when considering influenza vaccine for patients who report egg allergy (Figure).Figure. Approach to persons who report allergy to eggs. (Printable Pdf)Physicians and others who administer influenza vaccines, such as staff at pharmacies, grocery stores, and clinics, should begin vaccinating as soon as influenza vaccine is available to them and continue throughout the season as long as influenza viruses are still circulating. The influenza season generally occurs from October to May, so influenza vaccination during the winter months can still provide protective benefit for patients who have not yet received the vaccine.As a final note, CDC offers plenty of free resources, including brochures, posters, and fact sheets, to help educate consumers about influenza and influenza vaccines. Some of these materials can be ordered and shipped directly to your location and others are available online for downloading to an office printer. We also encourage you to use our prepared social media tools, which can be added to your Website. Visit www.cdc.gov/flu, and select the "Free Resources" link to access these materials. Contact fluinbox@cdc.gov if you have questions following this update.

Allergic to Eggs? It's OK to Get a Flu Shot

2011-09-01T23:06:00.000-07:00

From Medscape Internal Medicine > Medicine MattersSandra A. Fryhofer, MDPosted: 08/24/2011Egg-allergic patients can now get flu shots. Here is why it matters.Twenty percent of the US population comes down with influenza every year. So every year people should be vaccinated against it. But until now patients with egg allergy couldn't be vaccinated because chicken eggs are used in making vaccine, and there were theoretical concerns that traces of egg protein could trigger a serious allergic reaction.But the data indicate differently.At least 17 studies of more than 2600 egg-allergic patients showed no serious reactions, including respiratory distress and hypotension. The only reactions were minor, such as hives and mild wheezing.The likeliest reason for this surprising lack of reaction is the tiny amount of leftover egg protein in the vaccine. There is also good news for the healthcare professional who administers flu vaccines. No skin tests are needed. The results aren't predictive, and there is no need to divide the dose.Single-dose studies support giving the entire vaccine dose at one time. There are some special caveats. Egg-allergic patients must get the inactivated flu shot because this is what has been used in studies. They cannot get the nasal flu vaccine. Anyone giving vaccinations should be familiar with egg allergy. After administering the shot, patients should be observed for 30 minutes.The bottom line is that allergy experts have changed their tune. They now say it is safer for egg-allergic patients to get vaccinated than to risk getting the flu.

Fat Babies: Beginning Prevention Early

2011-09-01T23:02:00.000-07:00

From Medscape PediatricsAlan Greene, MD08/25/2011CommentaryThe earlier edition of the breast-feeding guide was a million-plus bestseller and a major influence on breast-feeding in the 21st century. Launched to coincide with the World Health Organization's (WHO) World Breastfeeding Week, the new edition features a decade of the latest research, including new research on ways that breast-feeding can reduce childhood allergies and childhood obesity, 2 pressing concerns for today's parents and clinicians.Perhaps most useful for parents and clinicians alike are the numerous question and answer sidebars with practical mom-tested solutions to common and not-so-common breast-feeding issues.Consider 3 important facts:Between 2002 and 2009 the C-section rate in the United States rose to an all-time high of 34%, according to a HealthGrades report released earlier this summer.The US Centers for Disease Control and Prevention (CDC) and March of Dimes report that the rate of babies born prematurely is dropping slightly but remains above 12%.In a report published in August 2011, the CDC noted that only a very small minority -- 3.5% -- of hospitals implemented 9 of 10 steps recommended in the WHO/UNICEF Ten Steps of Successful Breastfeeding.More than 40% of babies born in the United States are born in ways that produce special challenges -- and solutions -- to establishing breast-feeding.The odds of these mothers and infants being appropriately supported from the time of delivery are slim. The AAP's updated guide provides much-needed expert advice on best handling this sizeable minority of babies.However, providing a recommendation to purchase a book does not then give the clinician permission to just move on. For women with lower literacy, fewer resources, or just not enough time or inclination to read a book, there are many other resources. The Table provides a number of helpful Websites for both professionals and families. Many of the professional sites offer brochures in English and Spanish that are available for download and perfect for displaying in a waiting room or using for breast-feeding classes.Table: Breast-feeding Resources For Healthcare Professionals For FamiliesHospital Support for Breastfeeding This is part of the CDC Vital Signs program and provides important data to assist clinicians and hospital administrators in creating a baby-friendly hospital Your Guide to Breastfeeding This is available from the US Department of Health & Human Services (DHHS). This full-color downloadable pdf is available in English, Spanish, and Chinese.Breastfeeding Report Card -- United States, 2011 This report provides a wealth of information including process and outcomes indicators of change. Breastfeeding Answers from La Leche League This guide provides information in 11 languages, includes mother-to-mother forums, and provides online support.AAP Breastfeeding Initiatives This Web site includes breast-feeding guidelines, advocacy materials, and links to other resources. Breastfeeding Hotline This Website includes numerous fact sheets, breast-feeding videos, and links to a helpline with English and Spanish counselors.Although breast-feeding for the first 12 months of life is the best obesity prevention strategy, this is not the reality for many women and infants. With a plethora of preparations on the market, formula-feeding decisions are not as simple as they used to be. The United States Department of Agriculture (USDA) provides information about Infant Formula Feeding as part of their online publication, Infant Nutrition and Feeding: A Guide for Use in the WIC and CSF Programs.The timing and choice of solid food introduction is another important factor. A 2011 study found that starting solids before age 4 months (as is the case with a quarter of infants in the United States) is associated with 6 times the risk for obesity at age 3 years.Beyond this, for decades the top source of solid food calories in the first year has been processed white flour that we call rice cereal. Many parents have been advised to make this a first food for babies despite a lack of scientific evidence for this recommendation.

Does Varicella Vaccine Eliminate Deaths From Varicella?

2011-09-01T22:51:00.000-07:00

Medscape Infectious Diseases > Offit on VaccinesPaul A. Offit, MDPosted: 08/24/2011Hi. My name is Paul Offit and I'm speaking to you today from the Vaccine Education Center here at The Children's Hospital of Philadelphia. I want to discuss a recent paper from the US Centers for Disease Control and Prevention looking at the effectiveness of the varicella or chickenpox vaccine.The varicella vaccine was first introduced into the United States in 1995. The study authors looked at deaths from varicella during the 5-year period before 1995, specifically from 1990 to 1994, and then they looked at deaths from varicella during the 3-year period from 2005 to 2007. In 2006, there was a second dose recommendation for varicella, but for the most part this is a comparison of a 1-dose vaccine schedule that was initiated in 1995 to look at the death rate before and after the introduction of the vaccine.The researchers found that overall, there was an 88% decline in varicella-related deaths: deaths from pneumonia; deaths from encephalitis; and deaths from overwhelming group A beta-hemolytic streptococcal infections that arose in the blisters caused by varicella.They also found a significant 97% reduction in the number of deaths in children younger than 6 years of age, and a significant 96% reduction in deaths in adults under 50 years of age.What we have learned from this is that, not surprisingly, the varicella vaccine works. Not only did it work in prelicensure trials to show that it was efficacious, but it also has worked in postlicensure effectiveness trials. We can only expect a further decline in deaths now that we have a recommendation for a second dose, initiated in 2006. This should result in another 10-fold reduction in cases and, I think, a virtual elimination of deaths.We should take our hats off to all those who were involved in the development of this lifesaving vaccine.

First-Ever Guidelines Issued for Pediatric Pneumonia

2011-09-01T22:17:00.000-07:00

From Medscape Medical NewsEmma Hitt, PhDAugust 31, 2011 — The first-ever guidelines on the diagnosis and treatment of community-acquired pneumonia (CAP) in infants and children, from the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA), emphasize the importance of immunizations, including a yearly influenza vaccine, to protect children from life-threatening pneumonia.A 13-member panel, led by John S. Bradley, MD, with the Department of Pediatrics, University of California San Diego School of Medicine and Rady Children's Hospital of San Diego, in California, authored the new guidelines published online August 30 and to appear in the October 1 issue of Clinical Infectious Diseases. The document presents 92 specific recommendations in all, each with varying levels of evidence.Currently, guidelines exist for the diagnosis and treatment of pneumonia in adults, but in the pediatric setting, bacterial pneumonia often takes a different course, even when caused by the same pathogens. Consequently, there is widespread variability in the treatment of CAP among children.The current document is "designed to provide guidance in the care of otherwise healthy infants and children and addresses practical questions of diagnosis and management of CAP evaluated in outpatient (offices, urgent care clinics, emergency departments) or inpatient settings in the United States," Dr. Bradley and colleagues write.Recommendations for Diagnosis"Diagnostic methods and treatments that work well in adults may be too risky and not have the desired result in children," noted Dr. Bradley in an accompanying written release from the PIDS and IDSA.Regarding diagnosis, the guidelines state that blood cultures should not be routinely performed in nontoxic, fully immunized children with CAP treated in the outpatient setting."In these cases, there is no need to perform unnecessary medical interventions such as using x-rays (which expose the child to radiation needlessly) or prescribing antibiotics (which kill bacteria, not viruses, and may foster drug-resistant bacteria)," the written release states.However, blood cultures should be performed in children "who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration after initiation of antibiotic therapy," the study authors write.Hospitalization Based on Symptoms in InfantsThe guidelines also recommend that infants 3 to 6 months old with suspected bacterial pneumonia be hospitalized, even if the pneumonia is not confirmed by blood tests. "Blood testing in children often isn't accurate, so physicians need to pay close attention to symptoms, and, if unsure, err on the side of treating," Dr. Bradley indicates.Strong Recommendation for ImmunizationsAll children and adolescents at least 6 months old should be immunized annually with vaccines for influenza virus to prevent CAP, which the study authors state is a strong recommendation, based on high-quality evidence.Parents of children younger than 6 months should be vaccinated against influenza because these children cannot receive the preventive vaccine.Amoxicillin Sufficient for First-Line TherapyIn addition, amoxicillin should be used as first-line therapy for bacterial pneumonia, but more powerful antibiotics are not needed. Methicillin-resistant Staphylococcus aureus should be considered as a cause of pneumonia if first-line treatment is unsuccessful.According to the guidelines, overtreatment is a critical concern. Most cases of pneumonia in preschool-aged children are of viral origin and will therefore not develop into life-threatening bacterial pneumonia.Because of the difficulty in studying children, the guidelines all call for more research in several areas."With these guidelines, we are hopeful that the standard and quality of care children receive for community-acquired pneumonia will be consistent from doctor to doctor — providing much better treatment outcomes," Dr. Bradley indicates."We’re hopeful that in following these guidelines, physicians and hospitals will collect data and the results can be compared," he notes. "We envision this as the first of many revisions of guidelines to come."Guidelines Meet an Important Unmet NeedCarrie Byington, MD, a pediatric infectious disease specialist with the Department of Pediatrics, at the University of Utah School of Medicine in Salt Lake City, notes that these guidelines address a very important unmet need for all practitioners who care for children."Pneumonia is one of the most common reasons for hospitalization for children in the United States, and there's a huge variation in the care that's delivered to children," she told Medscape Medical News. Dr. Byington is an author on the new guidelines and is vice chair of the American Academy of Pediatrics Committee on Infectious Diseases."Often the care of children is not evidence based and result in both over- and undertreatment of children and less than ideal outcomes," she said. "This is the first attempt to review all the evidence available in the scientific literature and to provide explicit guidelines for practitioners that could assist them in their decision making for children with pneumonia."Areas of InterestAccording to Dr. Byington, pediatricians in primary care will probably be most interested in the guidelines for diagnostic testing and the recommendation for antibiotic therapy. Pediatricians in the hospital setting will also be interested in the guidelines for hospitalized children, including diagnostic testing and treatment of complicated pneumonia."We also really want to stress the prevention of pneumonia through immunization, so there is a large section to the research that demonstrates the importance of this," she said.This study was supported by the IDSA. Some of the study authors have disclosed various financial relationships with Wyeth/Pfizer, Sanofi Pasteur, Pfizer, GlaxoSmithKline, Novartis, Baxter Health Care, Halozyme Therapeutics, Pricara (Ortho-McNeil-Janssen), Rox-888, Venasite, the National Institutes of Health, and/or the Robert Wood Johnson Foundation.Clin Infect Dis. Published online August 30, 2011.

Few Adverse Events Linked to Vaccines, IOM Panel Says

2011-08-28T05:15:00.000-07:00

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

Steroids May Alleviate Acute Pyelonephritis in Children

2011-08-26T21:01:00.000-07:00

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

Exercise & Prevention of HTN in Children & Adolescents

2011-08-24T22:26:00.000-07:00

Obesity, Salt, Exercise and Blood Pressure in Children : Exercise & Prevention of HTN in Children & Adolescentshttp://www.medscape.com/viewarticle/746947_5Regular physical activity reduces the risk of cardiovascular disease morbidity and mortality, but also lowers BP and prevents the development of HTN. In a population-based prospective cohort study over an 11-year follow-up period, the incidence of HTN was reduced by 28% in men and 35% in women who engaged in high levels of physical activity.An immediate reduction in BP occurs after an aerobic exercise session (postexcercise hypotension). Several studies using ABPM demonstrated that the BP-lowering effects of exercise are most pronounced in people with HTN who engage in endurance exercise, with 24-h daytime BP decreasing by 5–7 mmHg after an isolated exercise session (acute) or following aerobic exercise training (chronic).BP remains lower for the rest of 24-h period after each 30-min period of moderate exercise (50% of maximal O2 uptake) with greater BP reductions for vigorous exercise (75% of maximal O2 uptake).The mechanisms involved in the postexercise hypotension may involve the reduced activity of sympathetic nervous and renin–angiotensin–aldosterone systems.Brownley et al. reported that 65% of the postexercise mean BP response difference could be accounted for by changes in sympathetic factors, with change in norepinephrine and pre-ejection period elongation being the single best predictors.Restoration of balance in functions of the autonomic nervous system was proposed to serve as a possible exercise-dependent mechanism of BP reduction in obese children.Moderate-intensity aerobic exercise has also been shown to augment endothelium-dependent vasodilation in humans through the increased production of nitric oxide.Data from a subset of the 1998–2002 NHANES survey, including 3110 healthy adolescents (aged 12–19 years) and 2205 adults (aged 20–49 years), revealed that cardiorespiratory fitness, estimated by the duration of a maximal treadmill exercise test, was inversely associated with the risk of developing HTN in both adolescents and adults.Low fitness was identified in 33.6% of adolescents and 13.9% of adults. Lobelo et al. also found an excess cluster of cardiovascular risk factors including SBP in both overweight and normal weight adolescents with lowest quintile of cardiovascular fitness distribution.SBP measured during exercise at the age of 9 years predicted resting SBP 6 years later in adolescent in healthy Danish children.Decline in duration and intensity of physical activity was associated with higher SBP in 12-year-old adolescents followed longitudinally for 5 years. A decline of one session of moderate to vigorous exercise session per week each year of age was reported to result in 0.40 and 0.18 mmHg higher SBP in boys and girls, respectively, at the end of the follow-up period.Intervention studies showed that aerobic exercise training at an intensity of 70–80% of maximal fitness, 5 days per week, reduced SBP in hypertensive and obese adolescents. However, a meta-analysis of 12 randomized controlled trials by Kelley et al. reported that exercise led to small, but not statistically significant, reductions in resting BP in children and adolescents.The lack of statistical significance was attributed to the fact that the majority of the subjects were normotensive, as well as to the lack of strictly defined sedentary control group in most of the included studies. More recent data provide increasing evidence for the positive influence of regular aerobic exercise in resting and 24-h SBP in obese and hypertensive children and adolescents.Apart from the positive effects on BP and HTN rate, Meyer et al. demonstrated that regular exercise, three-times per week, 60–90 min per day, over 6 months, improved early vascular changes as measured by flow-mediated dilation and carotid intima-media thickness. In a similar study by Maggio et al. the beneficial effects on BP, BMI and arterial stiffness remained 2 years after the cessation of training in obese children, in a recently published follow-up study.The majority of the subjects maintained physical activity with further improvements of BP and arterial function.Dietary supervision should be combined with regular physical activity, aiming to control BP, reduce extra weight, improve insulin sensitivity and establish a new lifestyle for children prone to developing HTN and cardiovascular disease. Children of parents with relatively high physical activity have been reported to be 5.8-times more likely to be active themselves than children of two inactive parentsThe main correlates of physical activity in a group of Singaporean adolescents were self-efficacy, enjoyment of physical activity, parental support and participation in sport teams. Current recommendations for exercise in healthy children and adolescents include 30–60 min per day of moderate-to-vigorous physical activity at least three-times per week.Moderate-to-vigorous-intensity exercise equals to 5–8 metabolic equivalents. This intensity should be maintained for a long duration of time to lower BP values in children with mild essential HTN (five-times per week for 30–60 min). Ideal levels of physical activity should be calculated for each individual separately, in connection with the expected cardiovascular benefit from a greater oxygen consumption.Moreover, children should be encouraged to reduce time spent in sedentary activities, such as playing video games or watching television to less than 2 h per day.

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

2011-08-24T22:20:00.000-07:00

Stella Stabouli†1,2, Sofia Papakatsika2, and Vasilios Kotsis2http://www.medscape.com/viewarticle/746947_4Dietary Salt Intake & BP in ChildhoodThe International Study of Salt and Blood Pressure (INTERSALT) has provided strong evidence for the association between dietary sodium and elevated BP in adults, especially in Western societies.Yanomamo Indians in the Amazon, who have a low-salt intake, present with a low average BP, no HTN and no positive slope of BP with age.There is also substantial evidence that a reduction in salt intake lowers BP and can prevent HTN and adverse cardiovascular outcomes.Most studies in children show that the average daily salt intake exceeds nutritional needs.As dietary habits create nutritional patterns for the young population, contamination of foods rich in salt increases over time in modern societies, emerging the need for prevention strategies that will reduce sodium exposure in the young through dietary modification.The effect of salt intake may begin early in life. A randomized trial, conducted among 476 Dutch newborn infants, studied the effect of low or normal sodium diets on BP. Infants fed with a low sodium diet had 2.1 mmHg lower SBP than those under a normal sodium diet at the age of 6 months.A subset of these populations was re-examined 15 years later. SBP and DBP at adolescence were 3.6 and 2.2 mmHg lower, respectively, in subjects assigned to the low sodium compared with the control group.Most observational epidemiological studies on salt and BP in children showed a significant positive association between dietary sodium and BP. However, in a study among Spanish school children, urinary excretion of sodium did not correlate with BP, whereas bodyweight correlated directly with BP and salt intake. The investigators assumed that the BP-raising effect of increased dietary sodium might not be seen until a certain age. Moreover, Howe et al. reported that dietary short-term sodium interventions, consisting of a 4-week high-salt diet following 4 weeks low-salt administration, had no significant alterations on BP levels in adolescents.A more reliable estimation of the sodium effects on BP could possibly be seen after a longer time period of sodium restriction. Sinaiko et al. enrolled 13-year-old adolescents in a study of 3-year period sodium interventions. Adolescent girls receiving a low-salt diet, presented a decrease in urinary sodium excretion and a slight decrease in BP levels. A recent meta-analysis of 13 controlled trials on salt reduction in children demonstrated that even a modest reduction in sodium intake causes immediate decreases in BP, and suggested that it may well lessen the subsequent rise in BP with age.The changes in salt intake were assessed by 24-h urinary sodium in four trials, overnight urinary sodium in three trials, spot urinary sodium/creatinine ratio in two trials, spot urinary sodium in two trials, food diary in one trial and random 24-h urinary sodium in one trial. Among the 13 trials, ten were in children and adolescents and three were in infants. The median reduction in salt intake was 42% (interquartile range: 7–58%) in children and adolescents and 54% (interquartile range: 51–79%) in infants.Individual variations in response to high or low sodium intake impact on BP define salt sensitivity or resistance. Children genetically predisposed to develop HTN, such as African–Americans, as well as those with a family history of HTN, more likely exhibit increased salt sensitivity. Simonetti et al. described the highest prevalence of salt sensitivity in children with intrauterine fetal growth retardation, born small for gestational age.In this study, salt sensitivity was defined if mean 24-h BP increased by 3 mmHg on a high-salt diet and was present in 37% of the low birthweight children. Kidney volume and length measured by ultrasound were reduced in low birthweight children and correlated with increased salt sensitivity, suggesting that a deficit of the normal nephron function in children with low birthweight, may lead to increased salt sensitivity and HTN. A similar relation of birthweight to salt sensitivity has been reported in adults.Several investigators examined the impact of salt sensitivity on the circadian variation of BP. Nondipping status, which is considered an early predictor of cardiovascular and renal complications, has been associated with increased salt sensitivity in hypertensive adults. It is assumed that in individuals with high-salt sensitivity, sodium retention and diminished excretory capability leads to elevation in nighttime BP values. This nocturnal HTN compensates for diminished natriuresis during the daytime and enhances pressure natriuresis during the night. Studies with regard to nondipping pattern and salt sensitivity in children and adolescents are controversial. Salt sensitivity has been associated with nondipping status in salt sensitive normotensive black adolescents.However, in a study conducted by Simonetti et al. normotensive children and young adults maintained normal nocturnal BP dipping independently of salt intake and sensitivity.In the same study, a steeper downward slope of BP from daytime to nighttime was observed in salt-sensitive as compared with salt-resistant children and in both groups of adults. The findings of this study may show that a time interval is needed for blunted dipping to develop, as in children the excretory sodium capacity seemed less affected than in young adults with longer exposure to salt.Salt sensitivity has been reported to involve endogenous ouabain, a modulator of the sodium pump in humans. In prehypertensive and hypertensive individuals, circulating levels of endogenous ouabain are not properly regulated in relation to sodium balance. The main mechanism of endogenous ouabain action, which has been described in animal models, may be an elevation in total peripheral resistance.In normotensive rats, acute elevations in salt intake lead to impairment of the muscular arteriolar response to vasodilator agonists in 3 days.The same effect was reported in normotensive and in reduced renal mass hypertensive rats receiving a high-salt diet for 4 weeks. In normotensive rats, impairment of the vascular function was proportionate to the remodeling of the microvessel wall, so that the sodium sensitivity remained unchanged. In reduced renal mass hypertensive rats the effects on the structure of microvessels was greater and resulted in increased sodium sensitivity and HTN.Despite the major role that sodium plays in the development of HTN in children and adolescents, salt sensitivity should be characterized as one component of the whole spectrum of cardiovascular risk factors. Sensitivity to sodium or high-salt intake alone may not directly cause a hypertensive profile, but could be interrelated to other factors, such as family history of HTN, race and obesity, which altogether contribute to the development of HTN and an adverse cardiovascular profile

Risks and Benefits of Second-Generation Rotavirus Vaccines

2011-08-24T22:02:00.000-07:00

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

Visual Problems in Infancy After the NICU

2011-08-24T21:58:00.000-07:00

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

ADHD Rates Continue to Rise in the United States

2011-08-24T21:55:00.000-07:00

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

Moms May Think Softer Is Safer for Sleeping Babies

2011-08-24T21:21:00.000-07:00

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