Thursday, January 8, 2015

Breast Cancer Prevention Starts in Childhood

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Breast-fed Newborns: How Much Weight Loss Is Normal?

Diedtra Henderson  Mescape Pediatrics December 01, 2014
Exclusively breast-fed newborns typically lost as much as 10% or more of their birth weight before beginning to gain again in the first days after birth, according to a recent study. By 48 hours, almost 5% of babies born vaginally and 10% of those born by cesarean delivery lost at least 10% of their birth weight. By 72 hours, 25% of cesarean delivered infants lost at least 10% of their birth weight. These metrics may help identify babies with steeper weight loss trajectories that could increase morbidity risk.
Valerie J. Flaherman, MD, MPH, from the Department of Pediatrics and the Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, and colleagues report the findings of their study in an article published online December 1 in Pediatrics.
According to the authors, 60% of newborns in the United States are breast-fed exclusively in the first 2 days after birth, in keeping with recommendations from a number of expert organizations, including the American Academy of Pediatrics. Most of those infants lose weight daily, but a small number of infants suffer complications from excessive weight loss, including hyperbilirubinemia and dehydration.
"These results provide the first graphical depiction of hourly weight loss for exclusively breastfed newborns from a large, diverse population," Dr Flaherman and coauthors write. "Because weight changes steadily throughout the birth hospitalization and is measured at varied intervals from the hour of birth, these new nomograms should substantially aid medical management by allowing clinicians and lactation support providers to categorize newborn weight loss and calibrate decision-making to reflect hour of age."
The authors note that hour-by-hour bilirubin levels, tracked to guard against jaundice, have been incorporated into practice guidelines. To provide a similar type of nomogram for neonate weight loss in exclusively breast-fed newborns, Dr Flaherman and coauthors studied data from 108,907 newborns born at 36 weeks' gestation at Northern California Kaiser Permanente hospitals from January 1, 2009, through December 31, 2013.

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Sunday, March 23, 2014

Breastfeeding Past Two Years Linked to Infant Tooth Decay

By Kathleen Raven
March 17, 2014
NEW YORK (Reuters Health) - Breastfeeding is credited with a long list of benefits, but one downside of extended and intensive breastfeeding may be a higher risk of cavities in baby's first teeth, according to a new study.
The more frequently a mother breastfed her child beyond the age of 24 months during the day, the greater the child's risk of severe early tooth decay, researchers found.
Benjamin Chaffee of the University of California, San Francisco led the study as a doctoral student at the University of California at Berkeley. He and his team looked at a possible link between longer-term breastfeeding and the risk of tooth decay and cavities in a survey of 458 babies in low-income families in the city of Porto Alegre, Brazil.
Because the study lasted more than one year, most babies were consuming various kinds of solid food and liquids in addition to breast milk.
The World Health Organization (WHO) recommends that babies are fed breast milk exclusively for the first six months of their lives, with solid foods added to the diet at that point. However, the WHO also recommends continued breastfeeding up to age two and beyond, the authors note.
For the study, the researchers checked in on babies when they were about six, 12 and 38 months old. At six months, the study team gathered data on the number of breast milk bottles the baby drank the day before and any other liquids, like juice.
At the 12-month mark, parents reported whether they fed their babies any of 29 specific foods, including fruits, vegetables, beans, organ meat, candy chips, chocolate milk, cookies, honey, soft drinks or sweet biscuits.
Two trained dentists examined all of the babies at each of the visits.
Nearly half of the children had consumed a prepared infant formula drink by age six months, the researchers reported February 19 online in the Annals of Epidemiology, but very few still drank formula by age one.
The researchers found that about 40% of children who were breastfed between ages six and 24 months had some tooth decay by the end of the study. For babies breastfed for longer than two years and frequently, that number rose to 48%.
"Our study does not suggest that breastfeeding causes caries," Chaffee told Reuters Health.
It is possible that breast milk in conjunction with excess refined sugar in modern foods may be contributing to the greater tooth decay seen in babies breastfed the longest and most often, the authors speculate in their report.
More research is needed to determine what's going on, but the findings are in keeping with professional dental guidelines that suggest avoiding on-demand breastfeeding after tooth eruption, they write.
"There are two aspects of breastfeeding - the actual human milk, which has some, but very little, ability to promote tooth decay," said William Bowen, professor emeritus in the Center for Oral Biology at the University of Rochester Medical Center in New York.
"The second is the physical aspect of breastfeeding, or even bottle-feeding, and that's where the problem arrives," he said.
Bowen was not involved in the new study.
When a baby sucks on a mother's breast or from a bottle, the baby's teeth are sealed off from saliva in the mouth. This physical barrier prevents the saliva from breaking down bacteria, and increases the chances of tooth decay, Bowen said.
Even though participants in the study came from poor backgrounds, "bad habits can form at any socioeconomic level," Bowen told Reuters Health.
About 16% of babies in the U.S. were still exclusively breastfed at age six months last year, according to the National Center for Chronic Disease Prevention and Health Promotion.
The good news, Bowen said, is that it's very easy to clean an infant's teeth.
A simple wipe in the mouth with a water-dampened cloth or Q-tip can effectively remove food before the baby's first teeth, he said, adding: "It's important to get the excess food out of the mouth."
One not-so-good habit is allowing infants to stay on a mother's nipple throughout the night, Bowen said. This usually means very little saliva circulates in the baby's mouth, which can increase the risk of decay.
The primary caregiver of the baby should also maintain good dental health because the bacteria that cause tooth decay in a baby usually come from the primary caregiver, Bowen explained.
The American Academy of Pediatric Dentistry recommends that parents take their child for a first dental visit when the first tooth appears, or no later than the first birthday.
Brushing teeth might help, Chaffee said, The study researchers collected data on tooth brushing habits, but did not investigate a specific link between cleaning teeth after the last feeding and caries.
"But anything that removes carbohydrates and sugars from the oral cavity should help prevent too decay," Chaffee said.
SOURCE: http://bit.ly/1eSbAB9
Ann Epidemiol 2014.
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Limit Food Allergy Panels, AAP Says in Choosing Wisely List


Larry Hand
March 18, 2014

The American Academy of Pediatrics (AAP) has released its second list of common tests and treatments to question as part of the Choosing Wisely initiative.
The AAP also announced on March 17 the launch of an online learning module pediatricians can use to help with 2 items on its first Choosing Wisely list, released in February 2013. The module is designed to avoid use of antibiotics for viral respiratory illnesses and the use of unnecessary computed tomography scans.
"The AAP strongly supports partnerships and tools that improve the quality of care for patients," AAP President James M. Perrin, MD, said in a news release. "Pediatricians want the best possible tests and treatments for their patients, and they want them to be used appropriately. This is particularly important when treating children, because they are still growing and developing."
The new evidence-based recommendations are:
  • "Don't prescribe high-dose dexamethasone (0.5mg/kg per day) for the prevention or treatment of bronchopulmonary dysplasia in the pre-term infant.
  • Don't perform screening panels for food allergies without previous consideration of medical history.
  • Avoid using acid blockers and motility agents such as metoclopramide (generic) for physiologic gastroesophageal reflux...that is effortless, painless, and not affecting growth. Do not use medication in the so-called 'happy-spitter.'
  • Avoid the use of surveillance cultures for the screening and treatment of asymptomatic bacteruria.
  • Infant home apnea monitors should not be routinely used to prevent Sudden Infant Death Syndrome."
The AAP's complete list of Choosing Wisely recommendations is available online. The first 5 recommendations are:
  • "Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
  • Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under four years of age.
  • Computed tomography (CT) scans are not necessary in the immediate evaluation of minor head injuries; clinical observation/Pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is indicated.
  • Neuroimaging (CT, [magnetic resonance imaging]) is not necessary in a child with simple febrile seizure.
  • [CT] scans are not necessary in the routine evaluation of abdominal pain."
Choosing Wisely was launched in 2012 by the American Board of Internal Medicine. A national campaign, Choosing Wisely involves more than 50 medical specialty societies identifying common medical tests and treatments that may not be necessary or of benefit to patients.
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Supplement May Reduce Diarrhea Burden in Preschoolers

Larry Hand
March 17, 2014
Daily doses of live bacterial supplementation may reduce the occurrence and duration of diarrhea and respiratory tract infection (RTI) in preschool children, as well as lower the costs of treatment, according to a study published online March 17 inPediatrics.
Pedro Gutierrez-Castrellon, MD, DSc, from the National Perinatology Institute, Mexico City, Mexico, and colleagues conducted a randomized, double-blind, placebo-controlled trial at 4 day care centers near the institute between April 2011 and June 2012.
A computer-generated randomization placed 336 healthy children aged 6 to 36 months who were born at term (≥36 weeks' gestation) and who had similar socioeconomic characteristics in 2 equal-number groups. Half the children (168) received Lactobacillus reuteri DSM 17938 (1 × 108 colony-forming unit) and half (168) received placebo once a day for 12 weeks. All of the children completed the study with no breached protocols, the researchers report.
Parents gave the dropper doses on first feedings in the morning, and researchers assessed compliance on the basis of empty bottles returned and parent-kept diaries. Researchers instructed parents on how to monitor daily the stool consistency of their children and to report any respiratory symptoms. Confirmed RTI cases led to hospitalized or outpatient care.
L reuteri supplementation helped reduce the number of days with diarrhea per child from 0.96 (0.2) to 0.32 (0.1; P = .03) during the trial and from 1.1 to 0.5 (P = .01) during a 12-week follow-up period.
In addition, the researchers report that 99 episodes of diarrhea occurred among the L reuteri group compared with 152 episodes among the placebo group (P = .01). Diarrhea lasted an average of 1.6 ± 0.9 days in the L reuteri group and 2.7 ± 1.1 days in the placebo group (P = .02).
L reuteri supplementation helped reduce the number of days with RTI per child from 4.6 (1.8) to 1.5 (0.6; P = .01) during the trial and from 4.4 (1.1) to 2.1 (0.8; P = .01) during follow-up.
L reuteri supplementation also helped significantly reduce the number of days of school absences (P = .03), the number of healthcare visits (P = .04), and the number of days of antibiotic use (P = .04) during the trial and in follow-up. In a cost–benefit analysis, the first such analysis they are aware of, the researchers found that L reuteri supplementation also helped reduce healthcare costs.
"The prophylactic use of L reuteri was associated with a reduction of $36 US dollars (USD) for each case of diarrhea and $37 USD for each case of RTI," the researchers write. They calculated the incremental cost effectiveness ratio at −35.7 for diarrhea and −37.4 for RTI.
"This study adds independent support to previously published evidence that can now be used in systematic reviews to establish evidence-based recommendations for the use of L reuteri DSM 17938 in the prevention of infectious diseases in day care Centers," the researchers conclude.
This research was supported by GioGaia AB, Stockholm, Sweden, who supplied the L reuteri and placebo products used in the trial. The authors have disclosed no relevant financial relationships.
Pediatrics. Published online March 17, 2014. Abstract
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Friday, February 14, 2014

Varicella Vaccine Works Well Over Time

April 03, 2013
By David Douglas
NEW YORK (Reuters Health) Apr 03 - Since its introduction in the mid-1990s, varicella vaccine has reduced the average incidence of chickenpox by as much as tenfold, according to researchers.
The vaccine was licensed in the US in 1995 for children at least 12 months old. In 2006, a second dose was recommended.
For a study reported Monday in Pediatrics, Dr. Roger Baxter of the Kaiser Permanente Vaccine Study Center, Oakland, California and colleagues tracked 7,585 children vaccinated in 1995 when they were in their second year of life. This group included 2826 youngsters who received a second dose between 2006 and 2009. All were members of the Kaiser Permanente Northern California health delivery system.
The study showed "the long-lasting effectiveness of varicella vaccine, and the benefit of the second dose," Dr. Baxter told Reuters Health by email.
More than 97% of the children enrolled completed the study. Overall, over 14 years, the average incidence of varicella was 15.9 per 1000 person-years, nine- to tenfold lower than in the prevaccine era.
Annual vaccine effectiveness ranged from 73% to 80% in the first two years of the study to 80% to 90% in the last 10 years. Effectiveness did not seem to wane.
Most cases of varicella were mild and occurred early after vaccination, at which time varicella virus zoster was still widely circulating. No child developed varicella after a second dose. In addition, herpes zoster cases were mild and rates were lower in the vaccine era than earlier (relative risk, 0.61).
The investigators concluded, "Varicella vaccine was effective at preventing chicken pox, and no evidence of waning protection was noted over a 14-year period. One dose provided excellent protection against moderate to severe disease, and most cases occurred shortly after the cohort was vaccinated."
SOURCE: http://bit.ly/17dteyU  Pediatrics 2013.


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    Daily Sunscreen May Prevent Skin Aging

    June 04, 2013

    By Genevra Pittman
    NEW YORK (Reuters Health) Jun 04 - Using sunscreen every day may help protect against aging skin, according to a new study from Australia.
    Although the benefits of sunscreen are well know when it comes to preventing sunburns and lowering skin cancer risks, researchers said rigorous studies were lacking on how sunscreen use affects photoaging.
    Still, one dermatologist who wasn't involved in the new study said the findings just reinforce what skin doctors already know and tell their patients.
    "If you ask most dermatologists... they'll tell you the two things they recommend for people who really want to avoid photoaging are, don't smoke and use sunscreen," said Dr. Alan Boyd, from Vanderbilt University Medical Center in Nashville.
    "There are definitely a diminished number of people who have pre-cancerous (skin) changes if they are regular users of sunscreen," he told Reuters Health. "It's not too much of a leap to assume the signs and features of photoaging would follow hand in hand."
    For the new study, Dr. Adele Green from the Queensland Institute of Medical Research and her colleagues analyzed data from 903 adults younger than 55 who were followed between 1992 and 1996.
    Half of them were told to put sunscreen of SPF 15 or greater on their head, neck, arms and hands every morning, and to reapply when necessary. The others used sunscreen according to their own discretion.
    At the start and end of the study, the researchers measured photoaging using the skin on the back of each person's left hand. They found that over four years, there were no detectable changes in the skin condition of people who were told to use sunscreen daily, once other sun-related factors were taken into account.
    Australians in that group were 24% less likely to show any increased aging - clinical changes that might not be visible to the naked eye - than those who decided on their own when to wear sunscreen, Dr. Green and her colleagues reported June 3 online in the Annals of Internal Medicine.
    Beta carotene, which was also given to some of the participants, did not seem to have any protective effect on skin aging, however.
    Photoaging happens after long-term exposure to ultraviolet radiation, which penetrates the skin and can cause collagen to break down and DNA to mutate, said Dr. Brundha Balaraman, a dermatology researcher from the Washington University School of Medicine in St. Louis.
    "This study effectively shows that daily sunscreen can reduce the signs of photoaging and photodamage," Dr. Balaraman, who also wasn't part of the research team, told Reuters Health in an email.
    "I believe that daily use of broad-spectrum sunscreens with frequent reapplications may have more profound measurable effects on photoaging," she added. "But the key to prevention is to develop these healthy sun-protective habits at a young age."
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    Ultrasound Poor Screen in Kids With Fever, UTI

    Veronica Hackethal, MD
    February 10, 2014
    Renal and bladder ultrasound (RBUS) is a poor screening tool for genitourinary (GU) abnormalities identifiable on voiding cystourethrogram (VCUG) after febrile urinary tract infections (UTIs) in children, according to a study published online February 10 in Pediatrics.
    "Neither positive nor negative ultrasounds reliably identify or rule out [genitourinary] abnormalities," write Caleb P. Nelson, MD, MPH, from the Department of Urology, Boston Children’s Hospital, Harvard Medical School, Massachusetts, and colleagues. "Ultrasound and VCUG provide different, but complementary, information."
    American Academy of Pediatrics (AAP) 2011 guidelines advise RBUS to screen for GU abnormalities in children aged 2 to 24 months with index cases of febrile UTIs, according to the authors, with VCUG used for confirming abnormalities suggestive of high-grade vesicoureteral reflux (VUR) or obstructive uropathy or after a second febrile UTI. The implication of these guidelines, the authors point out, is that a normal RBUS rules out clinically significant GU pathology.
    The researchers looked at 3995 medical records between January 1, 2006, and December 31, 2010, in which VCUG and RBUS were conducted on the same day and then selected only those with UTI as an indication for imaging. They excluded records with postnatal GU imaging or prenatal GU abnormalities. They then placed both RBUS and VCUG into 4 categories each, based on GU abnormality type, with VUR graded on the 5-point international grading system. They also assigned diagnostic criteria thresholds for positive tests, ranging in severity from relaxed to stringent.
    The researchers identified 2259 children younger than 60 months whose indication for imaging was UTI. RBUS was normal in 75%, but VCUG indicated 41.7% had evidence for any VUR, 20.9% had VUR greater than grade 2, and 2.7% had VUR higher than grade 3. Among those with a first febrile UTI, these percentages were 47.5%, 26.9%, and 2.6%, respectively. Depending on threshold, RBUS had a sensitivity ranging from 5% (specificity, 97%) to 28% (specificity, 77%), with the sensitivity of VUR higher than grade 3 ranging from 18% (specificity, 97%) to 55% (specificity, 77%).
    There were 1203 children aged 2 to 24 months who received imaging after an initial febrile UTI. The positive predictive value of RBUS in this group was 37% to 47% for VUR higher than grade 2 and 13% to 24% for VUR higher than grade 3, with negative predictive values ranging from 72% to 74% (VUR higher than grade 2) and 95% to 96% (VUR higher than grade 3).
    Limitations include possible misdiagnosis relating to the study's retrospective nature. In addition, the initial radiologist review was unblinded and not confirmed by independent review. To minimize verification bias, only patients with RBUS and VCUG on the same day were selected, which could have introduced selection bias if foregoing a second test was based on the first test's results.
    "A negative RBUS does not rule out significant GU pathology (particularly VUR grades III and higher)," the authors conclude, "whereas a positive RBUS is a poor predictor."
    In an independent commentary, Stephen M. Downs, MD, from Children’s Health Services Research, Indiana University School of Medicine, Indianapolis, commends this study for being the largest and most well-conducted of its kind.
    However, although noting that this study's results are valid and consistent with past studies, and agreeing that RBUS is a "lousy screen for VUR," Dr. Downs ultimately supports the AAP guidelines. He points out that the guidelines actually suggest watchful waiting, rather than RBUS, to screen for high-grade VUR, with VCUG recommended only after the second UTI. Early RBUS is recommended for identifying parenchymal damage and obstructive uropathy associated with infection, he explains. Children with VUR are likely to have another UTI, he continues, and most (about 90%) will never have another UTI and would be unnecessarily exposed to the discomfort, cost, and radiation of VCUG.
    "Readers should know that the RBUS recommended by the AAP guideline does serve a critical role in the evaluation of young children who have a first febrile UTI," Dr. Downs argues, "but it is watchful waiting that screens for VUR."
    The authors and Dr. Downs have disclosed no relevant financial relationships.
    Pediatrics. Published online February 10, 2014. Abstract
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    Dexamethasone Tames Acute Asthma in Kids, With Less Vomiting

    Diedtra Henderson
    February 10, 2014
    Giving children with acute asthma flare-ups 1 or 2 doses of dexamethasone in the emergency department (ED) provides equivalent relief to a 5-day course of prednisone while reducing the chance of triggering vomiting, according to a meta-analysis by Grant E. Keeney, MD, from the Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and colleagues, who published the results of their analysis online February 10 in Pediatrics.

    Some 6 million children in the United States suffer from asthma, a chronic inflammatory disease that accounts for 2% of all ambulatory care and ED visits by pediatric patients, the authors write. Oral prednisone, which tamps down inflammation and decreases mucus production, is the cornerstone of treatment for acute asthma exacerbations, but the remedy exacts a cost: vomiting.
    The authors sought to determine whether dexamethasone might provide the same therapeutic benefit with fewer doses and less vomiting than is associated with a 5-day course of oral prednisone or prednisolone. Searching PubMed, the researchers identified 667 articles describing randomized clinical trials comparing the medicines of interest; they included 6 trials in the meta-analysis.
    Each study was performed in the ED and enrolled from 15 to 272 patients, 63.5% of whom were boys. Dexamethasone was given as a single dose, either orally or intramuscularly, in 4 studies and was given as multiple doses in 2 studies. There was no statistically significant difference between the 2 therapies when it came to relapses to the clinic, ED, or hospitalization.
    "Significantly fewer patients receiving dexamethasone vomited in the ED or at home after discharge. This finding has clinical significance for improving patient and parental satisfaction," according to the authors.
    "This is a huge win for those of us in emergency medicine and, more importantly, for the families we take care of, when you consider that asthma is the most common chronic disease of children," Stephen J. Teach, MD, MPH, associate chief of the Division of Emergency Medicine at Children's National Medical Center in Washington, DC, told Medscape Medical News.
    According to Dr. Teach, the facility handles 1% of ED visits made by children in the country for asthma. Practitioners recognized that if prednisone was given as early as possible during a significant asthma flare-up, it cut down on emergency admissions, and children missed less school.
    "It was big breakthrough," he told Medscape Medical News. However, "prednisone is a terrible medication to take. It tastes awful. It's hard to mask it.... When it hits the stomach, it's an irritant. Kids throw it up all the time. It became this wonderful–terrible thing."
    Dexamethasone's noxious taste, in contrast, can be masked with cherry syrup. Large-volume EDs already have begun to make the shift.
    "There's really no difference, and it's more patient-centered," said Dr. Teach, who was not involved in the current study. "Kids take it better. They take fewer doses.... All of the available data suggest there is no difference in short-term outcomes."
    The authors note that their results were based on studies based in the ED, making it unclear whether they apply to the ambulatory clinic setting.
    "Based on our findings, emergency physicians should consider single or 2-dose dexamethasone regimens over 5-day prednisone/prednisolone regimens for the treatment of acute asthma exacerbations," the authors conclude.


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    Thursday, February 13, 2014

    The 2014 Child/Teen Immunization Schedule: Changes You Should Know

    William T. Basco, Jr., MD, MS
    February 03, 2014extracts 

    Hepatitis A Vaccine Changes

    Hepatitis A vaccine is routinely given at 12-23 months of age, but the previous footnotes were not specific as to which older children are considered "high risk" and therefore should receive the vaccine. The new footnotes provide clearer recommendations. Those specific recommendations now include children who may travel to countries that have a high or intermediate degree of endemic infection. Other recommended populations that might be cared for by pediatric providers include males who have sex with other males, users of illicit drugs (injectable or not), and patients with clotting factor disorders or chronic liver disease.

    Human Papillomavirus Vaccine Changes

    There are no global changes to the recommendations for human papillomavirus (HPV) vaccine. For pediatric providers, however, it is worth remembering that only the quadrivalent HPV vaccine is recommended for boys, whereas either the bivalent or quadrivalent HPV vaccine can be used for girls.  The third dose should be administered at least 12 weeks after the second dose and at least 24 weeks after the first dose.

    Meningococcal Vaccine Changes

    There is no change to the recommendation that 11- to 12-year olds should universally receive the vaccine and that a booster should be administered at 16 years of age. Changes in the meningococcal vaccine recommendations are mostly limited to expanded indications for the quadrivalent conjugate meningococcal vaccine MenACWY-CRM (meningococcal groups A, C, and Y and W-135 oligosaccharide diphtheria CRM197 conjugate vaccine; Menveo®) among younger children considered at high risk for meningococcal disease.
    It is probably also worth reminding pediatric providers that certain older children should receive the meningococcal vaccine. Indicated populations include those with complement deficiencies or anatomical or functional asplenia, as well as children traveling to areas in Africa where meningitis is endemic or those undertaking the Hajj. Specific catch-up recommendations for children with high-risk conditions are also provided and require accessing additional CDC documents.

    Pneumococcal Vaccine Changes

    First, one of the most interesting changes is the addition of a clear statement about when pneumococcal polysaccharide vaccine (PPSV23) should be given relative to pneumococcal conjugate vaccine (PCV13): The footnotes state clearly that children in need of PPSV23 should receive the recommended PCV13 doses before receiving PPSV23. The PPSV23 dose should also be given at least 8 weeks after completion of PCV13series or catch-up. That sequencing was often probably the case for most children who received the polysaccharide vaccine, but there needs to be a continual emphasis on trying to complete the PCV13 series for all children before considering who should receive PPSV23.
    Second, it is worth emphasizing that we are still seeing some children < 59 months of age who received pneumococcal vaccination as PCV7. Providers should ensure that children who received part of their pneumococcal vaccination as PCV7 receive the appropriate PCV13 follow-up doses. 
    The footnotes also contain details on which children should receive PPSV23. For children 24 through 71 months of age, several chronic conditions indicate a need for PPSV23, including chronic cardiac disease; chronic lung disease; diabetes mellitus; cerebrospinal fluid leak; cochlear implants; sickle cell disease and other hemoglobinopathies; other asplenia; or immune suppression, including from HIV, renal failure, or receipt of immunosuppressive drugs.
    Of all the indicated populations in a pediatric practice, the most prevalent is probably asthmatics who have received systemic steroids. That is a group of personal interest to me as a researcher, and one that we probably underemphasize for receipt of PPSV23.
    Finally, the footnotes expand upon the description of who should receive a second dose of PPSV23 vaccine after age 5 years; it is worth noting that children with diabetes, chronic heart, lung, and liver disease are not among that group. The recommendation for a second PPSV23 dose is confined to those with immune-compromising conditions, now listed in the footnotes.

    Tdap Vaccine Changes

    In regard to Tdap, additional clarifications are provided in the footnotes. The universal recommendation that everyone 11 years of age or older receive at least 1 Tdap vaccination is still present. However, there is no current recommendation for further booster doses with Tdap, except among pregnant women. Pregnant women should receive Tdap with each pregnancy, preferably during the 27- to 36-week gestational age period.
    A previous recommendation that warrants emphasis is the recommendation that Tdap be used for any child older than 7 years who needs a tetanus booster as part of wound management or as the first dose of a catch-up series, provided that they did not already receive a Tdap booster. They should not receive a second Tdap booster, however, if they have received one after age 7 years. As a reminder, this section also contains detailed recommendations for how to handle an older child who inadvertently receives DTaP and how this might affect the decision to later boost with Tdap.
    For all vaccines, additional detail on indicated populations or indications for travelers can be found at the ACIP's vaccine-specific site.
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    Friday, December 20, 2013

    Review Article: The Management of Acute Gastroenteritis in Children

    M. Pieścik-Lech, R. Shamir, A. Guarino, H. Szajewska
    Aliment Pharmacol Ther. 2013;37(3):289-303

    Introduction

    Acute gastroenteritis (AGE), characterised by the sudden onset of diarrhoea with or without vomiting, is one of the most common infectious diseases of childhood. In Europe, it is estimated that the incidence of diarrhoea ranges from 0.5 to 1.9 episodes per child per year in children up to 3 years of age.[1] In low- and middle-income countries, while the incidence of acute diarrhoea has declined from 3.4 episodes/child year in 1990 to 2.9 episodes/child year in 2010, the incidence of AGE remains high, especially in infants aged 6–11 months (4.5 episodes/child year).[2] Moreover, worldwide diarrhoea remains one of the leading causes of mortality among children younger than 5 years.[3]
    In 2008, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society of Paediatric Infectious Diseases (ESPID) developed evidence-based guidelines for the management of AGE for practitioners at all levels of health care – primary care physicians, paediatricians and family physicians – practising in Europe.[1] In addition, a number of national guidelines have been developed, although their quality varies.[4] Perhaps the best known among them are those developed by the National Institute for Health and Clinical Excellence (NICE).[5]
    Both ESPGHAN/ESPID and the NICE guidelines largely agree on key issues in the management of AGE. Oral rehydration therapy with a hypotonic solution remains central to the management of AGE. Fast oral rehydration with rapid return to regular food is recommended. 
    The routine use of special or diluted formulas is unjustified. Continuation of breastfeeding is strongly recommended. 
    The guidelines recommend against the routine use of antibiotics in otherwise healthy children presenting with AGE. 
    Regarding drugs, both sets of guidelines recommend against the use of antiemetics, but they strongly emphasise the need for further research. Compared with the NICE guidelines, the ESPGHAN/ESPID guidelines make a stronger recommendation for the use of probiotics for the management of AGE, particularly those with documented efficacy such as Lactobacillus GG and Saccharomyces boulardii. 
    The ESPGHAN/ESPID guidelines state that treatment with racecadotril (an enkephalinase inhibitor) may be considered in the management of AGE. Both sets of guidelines state that there is evidence suggesting that smectite (a natural hydrated aluminomagnesium silicate that binds to digestive mucus and has the ability to bind endotoxins and exotoxins, bacteria and rotavirus) is an effective antidiarrhoeal agent, but only the ESPGHAN/ESPID guidelines recommend that the use of smectite may be considered in the management of AGE.
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    Got (Raw) Milk? Consider the Risk

    Janis C. Kelly
    February 23, 2012
    February 23, 2012 — Researchers from the US Centers for Disease Control and Prevention (CDC) are calling for all states to further restrict or prohibit the sale or distribution of products made from unpasteurized ("raw") milk in the wake of data showing that risk for disease is 150-fold higher after consumption of nonpasteurized dairy products, and that 60% of the resulting outbreaks involve children. CDC epidemiologist Adam J. Langer, DVM, MPH, and colleagues reported their analysis of disease outbreaks from nonpasteurized dairy products in an article published in the March issue of Emerging Infectious Diseases.
    Although the distribution of nonpasteurized dairy products in interstate commerce has been prohibited by the US Food and Drug Administration (FDA) since 1987, sale of unpasteurized products within the state where they are produced is regulated by each state. During the time of the study (1993 - 2006), sale of nonpasteurized milk was legal in 25 states.
    During that period, the CDC researchers found 121 outbreaks of dairy-related diseases for which the product's pasteurization status was known. This included 73 (60%) outbreaks involving nonpasteurized products, although such products account for less than 1% of total dairy product consumption. In outbreaks involving milk, 82% were from nonpasteurized milk. In outbreaks involving cheese, 42% were from cheese made from unpasteurized milk.
    Outbreaks involving nonpasteurized dairy products resulted in 1571 illnesses, with a median of 11 patients, a hospitalization rate of 13%, and 2 deaths. All of the outbreaks from nonpasteurized dairy products were caused by bacteria, most commonly Campylobacter spp (54%), Salmonella spp (13%), and Shiga toxin–producing Escherichia coli (4%), which have animal reservoirs.
    Outbreaks involving pasteurized dairy products (which account for 99% of approximately 2.7 trillion pounds of milk consumed during the study period) included 2842 illnesses, resulted in a hospitalization rate of 1%, and caused 1 death. The most common causative agents were norovirus (44%) Salmonellaspp. (20%), and Campylobacter spp (13%). Norovirus has a human reservoir.
    "These results suggest that outbreaks caused by nonpasteurized dairy products are probably caused by pathogens in the dairy environment, which would be eliminated by proper pasteurization, and that outbreaks caused by pasteurized dairy products are probably caused by contamination of the products at some point after pasteurization," the authors write.
    Of the outbreaks associated with unpasteurized dairy products, 75% occurred in 21 states where it was legal to sell raw milk products during the study period.
    "This study shows an association between state laws and the number of outbreaks and illnesses from raw milk products," said Robert Tauxe, MD, MPH, deputy director of the CDC's Division of Foodborne, Waterborne and Environmental Diseases (DFWED). "Restricting the sale of raw milk products is likely to reduce the number of outbreaks and can help keep people healthier. The states that allow sale of raw milk will probably continue to see outbreaks in the future," Dr. Tauxe told Medscape Medical News.
    Outbreaks from unpasteurized milk also disproportionately affect people younger than 20 years (60% vs 23% from pasteurized milk). The authors write, "Public health and regulatory authorities are obligated to protect persons who cannot make fully informed decisions (e.g., children) from potential health hazards. Dietary decisions for younger children, in particular, are often made by caregivers. The American Academy of Pediatrics advises against giving nonpasteurized dairy products to children and recommends that pediatricians counsel caregivers against use of these products."
    "While some people think that raw milk has more health benefits than pasteurized milk, this study shows that raw milk has great risks, especially for children, who experience more severe illnesses if they get sick," said study coauthor Barbara Mahon, MD, MPH, deputy chief of CDC's DFWED Enteric Diseases Epidemiology Branch. "Parents who have lived through the experience of watching their child fight for their life after drinking raw milk now say that it's just not worth the risk," she told Medscape Medical News.
    Of the known sources for 9 of the 15 outbreaks that occurred in states where sale of nonpasteurized dairy products was illegal, 7 (78%) were associated with products obtained directly from the dairy farm, 1 was limited to members of a family who consumed nonpasteurized milk from their own cow, and 1 was associated with products obtained under a "cow shares" communal program, which the CDC report describes as "a scheme used to circumvent state restrictions on commercial sales of nonpasteurized dairy products." Cow share owners argue that they have the legal right to drink raw milk from the cow they partly own.
    The CDC researchers also note, "[I]n recent years, foodborne outbreaks involving nonpasteurized dairy products have been reported in association with traditional nonpasteurized products marketed to the growing Hispanic community in the United States."
    The researchers warn, "Consumption of nonpasteurized dairy products cannot be considered safe under any circumstances."
    In a related development, on February 22 a federal court granted the FDA a permanent injunction preventing Amish farmer Daniel L. Allgyer and his Rainbow Acres Farm from distributing packaged raw milk and raw milk products across state lines from his Pennsylvania farm to participants in a cow share program in the Washington, DC, metropolitan region.
    Emerg Infect Dis. 2012;18:385-391. 
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    Monday, November 11, 2013

    Drugs and the Breastfeeding Mother: A New Clinical Report


    Laurie Scudder, DNP, NP, Hari Cheryl Sachs, MD
    Disclosures
    October 29, 2013
    Editor's Note:
    Many breastfeeding women are advised to stop taking necessary medications or to discontinue nursing because of potential harmful effects on their infants. The reality is that few medications are contraindicated in breastfeeding mothers.
    The American Academy of Pediatrics (AAP) has just released a new clinical report, The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics, to provide guidance on drug exposure and reaffirm the recommendation that most medications and immunizations are safe during lactation. Medscape spoke with lead author and pediatrician Hari Cheryl Sachs, MD, the US Food and Drug Administration (FDA) liaison to the AAP Committee on Drugs, about the key recommendations from the report and resources to assist clinicians in obtaining current information on specific drugs to help guide their advice to breastfeeding women.
    Medscape: The key message of this report is that although some drug classes should be avoided or at least used cautiously in lactating women after a careful risk/benefit assessment, many medications can and should be continued. When a healthy nursing mom presents to primary care with a common, mild illness -- such as bacterial sinusitis, migraine, intermittent asthma, or an allergic reaction -- that requires an anti-infective agent, a beta-agonist, an antihistamine, or a triptan, can providers feel comfortable treating this woman and encouraging her to continue nursing?
    Dr. Sachs: As stated in the report, not all medications are present in breast milk in clinically significant levels or pose a risk to the nursing infant. The prescribing information (drug label) and LactMed (a drugs and lactation database, also available in a mobile app) will have the information to help a provider decide whether to use a drug in a lactating patient.
    Medscape: The report points out that the age of the infant is an important factor in deciding how to treat a mother, because most adverse events associated with drug exposure through breast milk occur in infants younger than 2 months. What other infant factors should clinicians consider when deciding on treatment for a nursing mom?
    Dr. Sachs: An important consideration for all drugs is related to the adverse-event profile and properties of the specific drug. Several excellent resources are available to inform clinicians about specific drugs, such as product labeling or LactMed. For example, the FDA recently approved newlabeling information for trimethoprim/sulfamethoxazole (Septra®), emphasizing the need for caution in administering this drug to nursing women, particularly if the infant is jaundiced, ill, stressed, or premature, because of the potential risk for bilirubin displacement and kernicterus.
    Medscape: Depression and mood disorders are common in women of childbearing age, and the risks of not treating these women are potentially severe. Data on the long-term safety of psychoactive drugs are limited, yet the report does not recommend advising these women to stop breastfeeding.
    Dr. Sachs: Caution is definitely warranted here. As stated in the report, the infant could potentially be exposed to clinically significant levels of these drugs, and the long-term effects are unknown. Decisions about breastfeeding for these patients should be evidence-based. The drug label and LactMed should be consulted for information on drugs that a clinician may be considering.
    Medscape: What do you recommend for the care and monitoring of nursing infants whose mothers are being treated with an antidepressant, anxiolytic, or antipsychotic?
    Dr. Sachs: Use of these products by nursing women should be discussed with the infant's healthcare provider. Adverse events as well as growth and development should be monitored in these infants. Any adverse events should be reported to the FDA's Adverse Event Reporting System.
    Medscape: Treatment of pain is another subject discussed in detail in the report. What is recommended for short-term use in women whose pain is not controlled by over-the-counter analgesics?
    Dr. Sachs: Caution is advised for nursing women using narcotic pain relievers because of the potential for adverse effects in nursing infants, and some are not recommended at all for use in nursing women because they are concentrated in breast milk.
    Codeine has been associated with rare fatalities in nursing infants. In women with normal codeine metabolism, the amount of codeine (and its active metabolite, morphine) in breast milk is low and related to the dose. However, in ultra-rapid metabolizers, higher-than-expected concentrations of the active metabolite (morphine) may occur in breast milk, and potentially dangerous levels may be reached in breastfed infants.
    Thus, the risk of infant exposure to codeine and morphine through breast milk should be weighed against the benefits of breastfeeding for both the mother and the baby. Close monitoring of mother/infant pairs is recommended when codeine is administered to a nursing woman. The lowest dose should be prescribed for the shortest period to achieve the desired clinical effect. Mothers using codeine should be informed about when to seek immediate medical care and how to identify the signs and symptoms of toxicity in their infants, such as drowsiness or sedation, difficulty breastfeeding, breathing difficulties, and decreased tone. Nursing mothers who are ultra-rapid metabolizers may also experience overdose symptoms, such as extreme sleepiness, confusion, or shallow breathing.
    Of note, safety labeling changes for extended-release and long-acting opioid analgesics announced by the FDA in September will highlight the risk for neonatal opioid withdrawal syndrome (NOWS) in a boxed warning. Symptoms of NOWS may include poor feeding, rapid breathing, trembling, and excessive or high-pitched crying.
    For more information on codeine and other treatment options, see the drug label and LactMed.
    Medscape: The report reviewed agents that have been used to stimulate lactation, including dopamine antagonists, such as domperidone, and herbal products, such as fenugreek. What is the bottom line on these agents? Does any evidence support their use?
    Dr. Sachs: The FDA issued a warning on domperidone. There is little evidence of benefit with domperidone, and safety information on many of these products is lacking. Nonpharmacologic methods of stimulating lactation are preferred. The report encourages breastfeeding mothers to discuss all products that they take, including herbal products, with their healthcare professionals.
    Medscape: The report acknowledges that information in this area changes rapidly, making it impossible for written reports to keep pace with new developments. Drug labels will continue to be an essential source of information. Can you outline some of the key changes in the pregnancy and lactation sections of labeling?
    Dr. Sachs: Under the proposed rule, the Pregnancy and Lactation subsections of labeling would each include 3 sections:Risk summary, Clinical considerations, and Data.
    In the Pregnancy subsection, the Fetal Risk summary will provide a narrative description based on risk evaluations of human, animal, and pharmacologic data that describe the likelihood that a drug increases the risk for adverse developmental outcomes. The Fetal Risk summary replaces the current pregnancy letter categories (A, B, C, D, X). The Clinical considerations section is intended to further inform prescribing and risk/benefit counseling. Labor and delivery information, when available, will be incorporated into this section. Pregnancy registry information with contact information, when available, must be included in the pregnancy subsection. The Data section will provide a detailed overview of both the human and animal data used to inform the previous sections.
    In the Lactation subsection, the Risk summary will summarize what is known and unknown about the amount of drug likely to be present in human milk and any potential effect on breastfeeding infants. The Clinical considerations section will include methods to minimize exposure when applicable, as well as information about monitoring the infant for toxicity or adverse effects. The Data section will provide a detailed overview of available human data used to inform the Risk summary and Clinical considerationssections.
    Medscape: What are the best resources for a clinician who needs to access information about a particular pharmacologic agent quickly, in the middle of a busy clinical day?
    Dr. Sachs: Drug labeling and LactMed, which I've noted several times, are important resources and are available online at:
    • Drugs@FDA (the FDA's database of approved drugs);
    • Daily Med (drug information, including FDA labels and package inserts);
    • LactMed (drugs and lactation database); and
    Editor's note: Medscape's Drugs, OTCs & Herbals provides rapid lookup.
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