Radiographic Pneumonia Uncommon in Children With Wheezing
by Laurie Barclay & Penny Murata
July 10, 2009 — Because radiographic pneumonia in children with wheezing but without fever is uncommon, the routine use of chest radiography in these children should be discouraged, according to the results of a prospective cohort study reported in the July issue of Pediatrics.
"The diagnosis of pneumonia in children with wheezing can be difficult, because the clinical history and auscultatory findings may be difficult to distinguish from those for children without pneumonia," write Bonnie Mathews, MD, from Children's Hospital Boston and Harvard Medical School in Boston, Massachusetts, and colleagues.
The study sample consisted of 526 individuals not older than 21 years who were seen in the ED, who had wheezing on clinical examination, and who underwent chest radiography because of possible pneumonia. Before learning the chest radiograph results, treating physicians obtained a medical history and performed and recorded a physical examination. Two blinded radiologists independently read the chest radiographs.
Factors linked to an increased risk for radiographic pneumonia were a history of fever at home; a history of abdominal pain, triage temperature of 38°C or higher, maximal temperature in the ED of 38°C or higher and triage oxygen saturation of less than 92%.
"Radiographic pneumonia among children with wheezing is uncommon," the study authors write. "Historical and clinical factors may be used to determine the need for chest radiography for wheezing children. The routine use of chest radiography for children with wheezing but without fever should be discouraged."
Pediatrics. 2009;124:e29-e36.
Clinical Context
In children with wheezing, underlying pneumonia can be difficult to diagnose. In the July 1999 issue of Clinical Pediatrics, a retrospective study by Mahabee-Gittens and colleagues found that in wheezing children younger than 18 months, the factors associated with radiographic pneumonia were a history of fever, a temperature of at least 38.4°C, and crackles by examination. A prospective study by Mahabee-Gittens in the July 2000 issue of Clinical Pediatrics noted that in wheezing children younger than 18 months, the factors associated with radiographic pneumonia were grunting and oxygen saturation less than 94% but not fever or tachypnea.
This prospective cohort study of wheezing children who undergo chest radiography in the ED evaluates which historical and examination features are associated with pneumonia.
Clinical Implications
•In children with wheezing in the ED, the rate of radiographic pneumonia is 4.9%.
•In children with wheezing in the ED, the risk for pneumonia is increased by fever at home, at triage, and in the ED, as well as by a history of abdominal pain and triage oxygen saturation less than 92%. The rate of pneumonia in afebrile, wheezing children is 2.2%.
Tuesday, July 14, 2009
Friday, July 3, 2009
HPV Vaccination Is Not Cost-Effective in the Netherlands
From Medscape Medical News
Roxanne Nelson
July 2, 2009 — Vaccination against the human papillomavirus (HPV) is not cost-effective in the Netherlands, even under favorable assumptions that include lifelong protection against 70% of all cervical cancers, administration to all women regardless of their risk for cervical cancer, and no adverse effects.
According to a report published online July 1 in the Journal of the National Cancer Institute, in order for the HPV vaccine to become cost-effective among Dutch women, the price would have to be considerably reduced, depending on the long-term effectiveness of the vaccine.
Cost Effectiveness Tied to Declining Incidence
As in many industrialized nations, cervical-cancer–associated mortality has dramatically declined in the Netherlands, due to efficient and widespread screening programs. In 2005 it was 1.6 per 100,000 woman-years [World Standardized Rate (WSR)] in the Netherlands, and this rate is lower than the WSR of 2.5 per 100,000 woman-years in the United States for the period 2001–2005 and 1.9 in the United Kingdom in 2005, according to the authors.
A number of analyses have concluded that HPV vaccination should be cost-effective, but this conclusion is primarily dependent on the incidence and mortality rates of cervical cancer. Low incidence and mortality rates might limit the cost-effectiveness of adding HPV vaccination to a screening program, the researchers comment.
The team, led by Inge M.C.M. de Kok, from the department of public health at Erasmus MC University Medical Center, in Rotterdam, the Netherlands, examined the effect of adding HPV vaccination to the current Dutch cervical-cancer screening program..
Using a microsimulation screening analysis (MISCAN) model, the researchers estimated costs and effects of adding HPV vaccination to the current screening protocol in the Netherlands and examined the impact of changes in the price of vaccination, number of booster vaccinations, vaccination attendance rate, vaccination efficacy, cervical-cancer incidence level, and quality-of-life assumptions on the cost-effectiveness of HPV vaccination.
Cost Efficacy Lower Under Less Favorable Assumptions
There were limitations to the analysis, the researchers note. For example, the impact of herd or community immunity was underestimated, and the impact of the vaccine on other types of HPV-related diseases was also not taken into account.
While long-term adverse effects are not yet known and only a small number of adverse events have been reported in women between the ages of 15 to 26 years, most countries intend to vaccinate 12-year-old girls. Both safety and efficacy have not been tested in the age group, the researchers note, and since cervical cancer is a relatively rare disease in the Netherlands, adverse events due to vaccination will also influence the risk/benefit ratio of vaccination. This highlights the importance of future studies that will evaluate adverse effects among vaccinated 12-year-old girls, primarily for safety and also for cost-effectiveness estimates.
“In conclusion, many uncertainties still exist about the effects of HPV vaccination on HPV-related diseases,” the authors write. “Our cost-effectiveness analysis shows that in the Netherlands, a country with low cervical-cancer incidence and mortality, HPV vaccination is not cost-effective.”
GlaxoSmithKline provided funding for the study, to the department of public Health of the Erasmus University Medical Center. The authors made no disclosures.
J Natl Cancer Inst. Published online July 1, 2009.
for full article go to:
http://www.medscape.com/viewarticle/705220?sssdmh=dm1.493985&src=nldne
Roxanne Nelson
July 2, 2009 — Vaccination against the human papillomavirus (HPV) is not cost-effective in the Netherlands, even under favorable assumptions that include lifelong protection against 70% of all cervical cancers, administration to all women regardless of their risk for cervical cancer, and no adverse effects.
According to a report published online July 1 in the Journal of the National Cancer Institute, in order for the HPV vaccine to become cost-effective among Dutch women, the price would have to be considerably reduced, depending on the long-term effectiveness of the vaccine.
Cost Effectiveness Tied to Declining Incidence
As in many industrialized nations, cervical-cancer–associated mortality has dramatically declined in the Netherlands, due to efficient and widespread screening programs. In 2005 it was 1.6 per 100,000 woman-years [World Standardized Rate (WSR)] in the Netherlands, and this rate is lower than the WSR of 2.5 per 100,000 woman-years in the United States for the period 2001–2005 and 1.9 in the United Kingdom in 2005, according to the authors.
A number of analyses have concluded that HPV vaccination should be cost-effective, but this conclusion is primarily dependent on the incidence and mortality rates of cervical cancer. Low incidence and mortality rates might limit the cost-effectiveness of adding HPV vaccination to a screening program, the researchers comment.
The team, led by Inge M.C.M. de Kok, from the department of public health at Erasmus MC University Medical Center, in Rotterdam, the Netherlands, examined the effect of adding HPV vaccination to the current Dutch cervical-cancer screening program..
Using a microsimulation screening analysis (MISCAN) model, the researchers estimated costs and effects of adding HPV vaccination to the current screening protocol in the Netherlands and examined the impact of changes in the price of vaccination, number of booster vaccinations, vaccination attendance rate, vaccination efficacy, cervical-cancer incidence level, and quality-of-life assumptions on the cost-effectiveness of HPV vaccination.
Cost Efficacy Lower Under Less Favorable Assumptions
There were limitations to the analysis, the researchers note. For example, the impact of herd or community immunity was underestimated, and the impact of the vaccine on other types of HPV-related diseases was also not taken into account.
While long-term adverse effects are not yet known and only a small number of adverse events have been reported in women between the ages of 15 to 26 years, most countries intend to vaccinate 12-year-old girls. Both safety and efficacy have not been tested in the age group, the researchers note, and since cervical cancer is a relatively rare disease in the Netherlands, adverse events due to vaccination will also influence the risk/benefit ratio of vaccination. This highlights the importance of future studies that will evaluate adverse effects among vaccinated 12-year-old girls, primarily for safety and also for cost-effectiveness estimates.
“In conclusion, many uncertainties still exist about the effects of HPV vaccination on HPV-related diseases,” the authors write. “Our cost-effectiveness analysis shows that in the Netherlands, a country with low cervical-cancer incidence and mortality, HPV vaccination is not cost-effective.”
GlaxoSmithKline provided funding for the study, to the department of public Health of the Erasmus University Medical Center. The authors made no disclosures.
J Natl Cancer Inst. Published online July 1, 2009.
for full article go to:
http://www.medscape.com/viewarticle/705220?sssdmh=dm1.493985&src=nldne
Friday, June 26, 2009
H1N1 Influenza Test Interpretation
Fact Sheet For Patients: Understanding Swine Influenza Kit Test Results
May 2, 2009
An emergency has been declared by the Secretary of Health and Human Services because of the 2009 outbreak caused by a novel H1N1 flu virus. Novel means that the virus was newly found. This virus has also been referred to as swine influenza (H1N1) virus. This Fact Sheet will refer to the virus as novel influenza A (H1N1) virus.
The Food and Drug Administration (FDA) has authorized the emergency use of the Swine Influenza Test Kit to test for the presence of novel H1N1 flu virus. This authorization will terminate on April 26, 2010, when the emergency has ceased to exist, or when the authorization has been revoked, whichever is earlier. The information in this Fact Sheet is the minimum necessary to inform you of the significant known and potential risks and benefits of the emergency use of the Swine Influenza Test Kit.
Why was my sample tested using the Swine Influenza Test Kit?
There are no FDA cleared or approved tests that can identify novel H1N1 flu virus. Therefore, y our sample was tested using the Swine Influenza Test Kit because you may have been infected with the novel H1N1 flu virus. This test could help to determine whether you are infected with the novel H1N1 flu virus, so that public health officials could quickly identify a case and limit its spread. The results of this test, along with other information, may also help your doctor take better care of you.
What is novel H1N1 flu?
Novel H1N1 flu is a respiratory disease caused by type A influenza virus . Human cases of novel H1N1 flu virus infection have been identified in the United States and internationally. CDC has determined that this virus is contagious and is spreading from human to human. Like seasonal flu, novel H1N1 flu in humans can vary in severity from mild to severe.
What is the Swine Influenza Test Kit?
The Swine Influenza Test Kit is believed to be a good test to detect the novel H1N1 flu virus. The FDA has not cleared or approved this test. The FDA has agreed that we can use this test under an Emergency Use Authorization. We don’t know for sure if this test can identify all people who may get sick with novel H1N1 flu.
What are the known risks and benefits of Swine Influenza Test Kit?
The results of this test from nasopharyngeal swabs, nasal swabs, throat swabs, dual nasopharyngeal swabs/throat swabs, and nasal aspirates, along with other information, can help your doctor take better care of you. Knowing your test results may help you to prevent the spread of the virus to your family or others.
If this test is positive, does that mean that I have novel H1N1 flu?
Yes, although there is a very small chance that this test can give a result that is wrong (false positive), it is not likely. If your result from this test is positive, your doctor may decide how to care for you based on the test results along with other factors.
If this test is negative, does that mean that I do not have novel H1N1 flu?
If this test is negative you may be sick with something that is not novel H1N1 flu. There is a small chance that this test can give a result that is wrong (false negative). A false negative result should not affect your care. No changes in your medical care should be solely based on a negative result.
* Any significant new findings observed during the course of the emergency use of Swine Influenza Test Kit will be made available at http://www.cdc.gov/h1n1flu/.
http://www.fda.gov/MedicalDevices/Safety/EmergencySituations/ucm161580.htm - - Updated: 06/18/2009
May 2, 2009
An emergency has been declared by the Secretary of Health and Human Services because of the 2009 outbreak caused by a novel H1N1 flu virus. Novel means that the virus was newly found. This virus has also been referred to as swine influenza (H1N1) virus. This Fact Sheet will refer to the virus as novel influenza A (H1N1) virus.
The Food and Drug Administration (FDA) has authorized the emergency use of the Swine Influenza Test Kit to test for the presence of novel H1N1 flu virus. This authorization will terminate on April 26, 2010, when the emergency has ceased to exist, or when the authorization has been revoked, whichever is earlier. The information in this Fact Sheet is the minimum necessary to inform you of the significant known and potential risks and benefits of the emergency use of the Swine Influenza Test Kit.
Why was my sample tested using the Swine Influenza Test Kit?
There are no FDA cleared or approved tests that can identify novel H1N1 flu virus. Therefore, y our sample was tested using the Swine Influenza Test Kit because you may have been infected with the novel H1N1 flu virus. This test could help to determine whether you are infected with the novel H1N1 flu virus, so that public health officials could quickly identify a case and limit its spread. The results of this test, along with other information, may also help your doctor take better care of you.
What is novel H1N1 flu?
Novel H1N1 flu is a respiratory disease caused by type A influenza virus . Human cases of novel H1N1 flu virus infection have been identified in the United States and internationally. CDC has determined that this virus is contagious and is spreading from human to human. Like seasonal flu, novel H1N1 flu in humans can vary in severity from mild to severe.
What is the Swine Influenza Test Kit?
The Swine Influenza Test Kit is believed to be a good test to detect the novel H1N1 flu virus. The FDA has not cleared or approved this test. The FDA has agreed that we can use this test under an Emergency Use Authorization. We don’t know for sure if this test can identify all people who may get sick with novel H1N1 flu.
What are the known risks and benefits of Swine Influenza Test Kit?
The results of this test from nasopharyngeal swabs, nasal swabs, throat swabs, dual nasopharyngeal swabs/throat swabs, and nasal aspirates, along with other information, can help your doctor take better care of you. Knowing your test results may help you to prevent the spread of the virus to your family or others.
If this test is positive, does that mean that I have novel H1N1 flu?
Yes, although there is a very small chance that this test can give a result that is wrong (false positive), it is not likely. If your result from this test is positive, your doctor may decide how to care for you based on the test results along with other factors.
If this test is negative, does that mean that I do not have novel H1N1 flu?
If this test is negative you may be sick with something that is not novel H1N1 flu. There is a small chance that this test can give a result that is wrong (false negative). A false negative result should not affect your care. No changes in your medical care should be solely based on a negative result.
* Any significant new findings observed during the course of the emergency use of Swine Influenza Test Kit will be made available at http://www.cdc.gov/h1n1flu/.
http://www.fda.gov/MedicalDevices/Safety/EmergencySituations/ucm161580.htm - - Updated: 06/18/2009
Saturday, June 20, 2009
Vaccinate Kids to Control H1N1 Flu
From Reuters Health Information
LONDON (Reuters) Jun 18 - Targeting children for vaccination may be the best way of using limited supplies of vaccine to control the current H1N1 flu pandemic, British researchers said on Thursday.
Drugmakers are racing to make a vaccine against the new flu strain but if the disease increases significantly in the northern hemisphere autumn, as many experts fear, there are unlikely to be enough shots to vaccinate entire populations.
Researchers from the University of Warwick said that vaccinating children rather than adults would not only help protect a group at greatest risk of exposure to the virus, but would also offer protection to unvaccinated adults.
This so-called "herd immunity" effect would mean significantly less vaccine would be needed to help control the spread of H1N1, also known as swine flu, which was first detected in Mexico in April.
"Our models suggest that the larger the household -- which in most cases means the more children living at home -- the more likely the infection is to spread," said researcher Matt Keeling.
"This doesn't mean that everyone in the household needs to be vaccinated but suggests that vaccination programmes for children might help control a potential pandemic."
Keeling and colleague Thomas House used computer modelling to predict the spread of pandemic influenza and published their findings in the journal Epidemiology and Infection.
Leading flu vaccine makers include Sanofi-Aventis, GlaxoSmithKline and Novartis.
LONDON (Reuters) Jun 18 - Targeting children for vaccination may be the best way of using limited supplies of vaccine to control the current H1N1 flu pandemic, British researchers said on Thursday.
Drugmakers are racing to make a vaccine against the new flu strain but if the disease increases significantly in the northern hemisphere autumn, as many experts fear, there are unlikely to be enough shots to vaccinate entire populations.
Researchers from the University of Warwick said that vaccinating children rather than adults would not only help protect a group at greatest risk of exposure to the virus, but would also offer protection to unvaccinated adults.
This so-called "herd immunity" effect would mean significantly less vaccine would be needed to help control the spread of H1N1, also known as swine flu, which was first detected in Mexico in April.
"Our models suggest that the larger the household -- which in most cases means the more children living at home -- the more likely the infection is to spread," said researcher Matt Keeling.
"This doesn't mean that everyone in the household needs to be vaccinated but suggests that vaccination programmes for children might help control a potential pandemic."
Keeling and colleague Thomas House used computer modelling to predict the spread of pandemic influenza and published their findings in the journal Epidemiology and Infection.
Leading flu vaccine makers include Sanofi-Aventis, GlaxoSmithKline and Novartis.
Weight gain after Tonsillectomy
Adenoidectomy and Tonsillectomy Linked to Subsequent Overweight in Children
Laurie Barclay & Désirée Lie Medscape News
April 7, 2009 — Tonsillectomy with or without adenoidectomy, or (adeno)tonsillectomy, are linked to subsequent overweight in children, according to the results of a study reported in the April issue of Pediatrics.
"Studies among patients have shown accelerated weight gain after (adeno)tonsillectomy," write Alet H. Wijga, PhD, from the Centre for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven, Netherlands, and colleagues. "Whether (adeno)tonsillectomy is also a risk factor for the development of overweight is unknown. We investigated the association between (adeno)tonsillectomy and the subsequent development of overweight in the general population."
The study sample included 3963 children enrolled in the Dutch Prevention and Incidence of Asthma and Mite Allergy birth cohort. Annual questionnaires completed by the parents provided data on weight and height; adenoidectomy and tonsillectomy; and covariates including sex, birth weight, maternal education, maternal overweight, maternal smoking during pregnancy, breast-feeding, and smoking in the home. The investigators also measured the children's weight and height at 8 years of age.
Undergoing (adeno)tonsillectomy from birth to age 7 was significantly associated with overweight and obesity at 8 years of age. Being overweight at 2 years of age did not predict increased risk for (adeno)tonsillectomy at older ages, suggesting that preexisting overweight did not explain the association between (adeno)tonsillectomy and overweight.
"Longitudinal data on weight and height in the years before and after surgery suggest that (adeno)tonsillectomy forms a turning point between a period of growth faltering and a period of catch-up growth, which might explain the increased risk to develop overweight after the operation," the study authors write. "Children who undergo (adeno)tonsillectomy are at increased risk to develop overweight in the years after surgery."
Limitations of this study include loss to follow-up for the medical examination where weight and height were measured and that most data were parental reported.
"Dietary and lifestyle advice at the time of surgery and growth monitoring thereafter might help parents to keep their child's catch-up growth within healthy limits," the study authors conclude.
Pediatrics. 2009;123:1095–1101.
Clinical Context
Accelerated weight gain has been observed in several studies after adenoidectomy and tonsillectomy, but this has not been considered a risk factor for overweight and obesity in children. In the Netherlands, the rate of the procedures is higher than in the rest of Europe or the United States.
This is a follow-up study of a birth cohort in the Netherlands followed up from birth to age 8 years to examine the cumulative incidence of the procedures and the effect of either adenoidectomy alone or adenoidectomy and tonsillectomy from age 0 to 7 years on the risk for overweight and obesity at 8 years of age.
Pearls for Practice
•The cumulative incidence of adenoidectomy and (adeno)tonsillectomy to age 8 years are 12% and 15%, respectively, and 70% of those who undergo adenoidectomy and tonsillectomy have both procedures at the same age.
•(Adeno)tonsillectomy between 0 and 7 years are associated with a increased risk for overweight and obesity at 8 years.
Laurie Barclay & Désirée Lie Medscape News
April 7, 2009 — Tonsillectomy with or without adenoidectomy, or (adeno)tonsillectomy, are linked to subsequent overweight in children, according to the results of a study reported in the April issue of Pediatrics.
"Studies among patients have shown accelerated weight gain after (adeno)tonsillectomy," write Alet H. Wijga, PhD, from the Centre for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven, Netherlands, and colleagues. "Whether (adeno)tonsillectomy is also a risk factor for the development of overweight is unknown. We investigated the association between (adeno)tonsillectomy and the subsequent development of overweight in the general population."
The study sample included 3963 children enrolled in the Dutch Prevention and Incidence of Asthma and Mite Allergy birth cohort. Annual questionnaires completed by the parents provided data on weight and height; adenoidectomy and tonsillectomy; and covariates including sex, birth weight, maternal education, maternal overweight, maternal smoking during pregnancy, breast-feeding, and smoking in the home. The investigators also measured the children's weight and height at 8 years of age.
Undergoing (adeno)tonsillectomy from birth to age 7 was significantly associated with overweight and obesity at 8 years of age. Being overweight at 2 years of age did not predict increased risk for (adeno)tonsillectomy at older ages, suggesting that preexisting overweight did not explain the association between (adeno)tonsillectomy and overweight.
"Longitudinal data on weight and height in the years before and after surgery suggest that (adeno)tonsillectomy forms a turning point between a period of growth faltering and a period of catch-up growth, which might explain the increased risk to develop overweight after the operation," the study authors write. "Children who undergo (adeno)tonsillectomy are at increased risk to develop overweight in the years after surgery."
Limitations of this study include loss to follow-up for the medical examination where weight and height were measured and that most data were parental reported.
"Dietary and lifestyle advice at the time of surgery and growth monitoring thereafter might help parents to keep their child's catch-up growth within healthy limits," the study authors conclude.
Pediatrics. 2009;123:1095–1101.
Clinical Context
Accelerated weight gain has been observed in several studies after adenoidectomy and tonsillectomy, but this has not been considered a risk factor for overweight and obesity in children. In the Netherlands, the rate of the procedures is higher than in the rest of Europe or the United States.
This is a follow-up study of a birth cohort in the Netherlands followed up from birth to age 8 years to examine the cumulative incidence of the procedures and the effect of either adenoidectomy alone or adenoidectomy and tonsillectomy from age 0 to 7 years on the risk for overweight and obesity at 8 years of age.
Pearls for Practice
•The cumulative incidence of adenoidectomy and (adeno)tonsillectomy to age 8 years are 12% and 15%, respectively, and 70% of those who undergo adenoidectomy and tonsillectomy have both procedures at the same age.
•(Adeno)tonsillectomy between 0 and 7 years are associated with a increased risk for overweight and obesity at 8 years.
Friday, June 19, 2009
AAP Recommendations in Lipid screening & CVS Health
Obesity Epidemic in Children Fuels Need for New Recommendations in Lipid Screening and Cardiovascular Health
Michael O'Riordan & Charles Vega Medscape News
July 7, 2008 — The American Academy of Pediatrics has issued a new clinical report on lipid screening and cardiovascular health in children [1], a report that has taken on new urgency given the epidemic of childhood obesity and the subsequent increased risks of type 2 diabetes mellitus, hypertension, and cardiovascular disease, say its authors.
The new report is published in the July 1, 2008 issue of Pediatrics and replaces the 1998 policy statement, "Cholesterol in Childhood." New data, write the authors, emphasize the negative effects of the excess dietary intake of saturated fats, trans fats, and cholesterol, and the effects of carbohydrates, the obesity epidemic, the metabolic/insulin resistance syndrome, and the decreased level of physical activity and fitness on the risk of adult-onset cardiovascular disease.
"In addition," write Daniels and colleagues, "more data are now available on the safety and efficiency of pharmacologic agents used to treat dyslipidemia. Most of these data were not available at the time of the previous statement."
The recommendations
The new report recommends a diet for all children older than 2 years that is based on the Dietary Guidelines for Americans, which is published by the Department of Health and Human Services and the Department of Agriculture.
For children or adolescents at higher risk for cardiovascular disease or with elevated low-density lipoprotein (LDL)–cholesterol levels, changes in diet based on nutritional counseling and other lifestyle modifications are also recommended.
For overweight or obese pediatric patients with high triglyceride levels or low high-density lipoprotein (HDL)-cholesterol levels, weight management is the primary treatment, and includes improvement in diet with nutritional counseling and increased physical activity.
The writing committee also states that the current recommendation is to screen children and adolescents with a positive family history of dyslipidemia or premature cardiovascular disease.
It is recommended that pediatric patients for whom family history is not known and those with other cardiovascular risk factors, such as being overweight, obesity, hypertension, smoking history, and diabetes mellitus, be screened with a fasting-lipid profile.
Screening should take place after 2 years of age, but no later than 10 years of age.
Clinical Context
By approximately 2 years of age, most children have lipid concentrations that approximate those of young adults. Girls usually have higher total and LDL cholesterol levels vs boys, and adolescent girls also generally have higher HDL cholesterol levels vs postpubertal boys.
In a national study among US adolescents completed between 1988 and 1994, there were 10% of participants who had total control cholesterol concentrations that exceeded 200 mg/dL. The current clinical report describes screening and treatment recommendations for dyslipidemia among children.
Study Highlights
•A healthful, low-fat diet should be recommended to all children older than 2 years, and some research suggests that limiting fat in children younger than 2 years has no negative effect on growth or neurologic function. Reduced-fat milk may be appropriate for children beginning at age 12 months if there is concern for overweight or obesity, or if a family history of cardiovascular disease is present.
Only children at increased risk for future cardiovascular events should receive routine screening for serum lipid concentrations.
Children and adolescents with any of the following risk factors should receive screening:
◦Family history of dyslipidemia
◦Family history of premature cardiovascular disease
◦Overweight or obese children
◦Children with hypertension
◦Children who smoke cigarettes
◦Children with diabetes mellitus
•Children who qualify for screening should receive a full fasting lipid profile.
•At-risk children should be screened after age 2 years but no later than age 10 years.
•Children with normal lipid values at screening may be retested in 3 to 5 years.
All children with abnormal lipid levels should receive education on diet and exercise. This is particularly important for pediatric patients whose primary lipid level abnormality is a high triglyceride or low HDL cholesterol level.
Pharmacologic treatment should be considered for children who are at least 8 years old and meet one of the following qualifications:
◦LDL cholesterol level at least 190 mg/dL
◦LDL cholesterol level at least 160 mg/dL with a family history of premature cardiovascular disease or at least 2 other risk factors present
◦LDL cholesterol level at least 130 mg/dL and patient has diabetes
•Pharmacologic treatment may be considered for LDL cholesterol levels as low as 110 mg/dL if there are very compelling indications.
•Bile acid-binding resins can reduce cholesterol levels by 10% to 20%, and these medications do not have systemic effects.
•Statins have been demonstrated to be effective in short-term studies in children and have also been demonstrated to reduce atherosclerosis in children with hyperlipidemia.
•Fibrates should be reserved for use in special clinics for children with hyperlipidemia. Because of a high rate of adverse events such as flushing (up to three quarters of treated patients) and elevated transaminase concentrations (26% of children in 1 study), niacin should be avoided for the treatment of pediatric dyslipidemia.
Pearls for Practice
•The current clinical report suggests that children and adolescents with a family history of dyslipidemia, a family history of premature cardiovascular disease, or a personal history of overweight or obesity, hypertension, cigarette smoking, or diabetes should receive routine screening for serum lipid concentrations.
•Bile acid-binding resins and statins are the most recommended medical treatments for the management of pediatric dyslipidemia, and fibrates may be used by specialists in these disorders. The use of niacin is discouraged in children.
Source
Daniels SR, Greer FR, and the Committee on Nutrition. Lipid screening and cardiovascular health. Pediatrics. 2008;122:198-208.
Heartwire at www.theheart.org
Michael O'Riordan & Charles Vega Medscape News
July 7, 2008 — The American Academy of Pediatrics has issued a new clinical report on lipid screening and cardiovascular health in children [1], a report that has taken on new urgency given the epidemic of childhood obesity and the subsequent increased risks of type 2 diabetes mellitus, hypertension, and cardiovascular disease, say its authors.
The new report is published in the July 1, 2008 issue of Pediatrics and replaces the 1998 policy statement, "Cholesterol in Childhood." New data, write the authors, emphasize the negative effects of the excess dietary intake of saturated fats, trans fats, and cholesterol, and the effects of carbohydrates, the obesity epidemic, the metabolic/insulin resistance syndrome, and the decreased level of physical activity and fitness on the risk of adult-onset cardiovascular disease.
"In addition," write Daniels and colleagues, "more data are now available on the safety and efficiency of pharmacologic agents used to treat dyslipidemia. Most of these data were not available at the time of the previous statement."
The recommendations
The new report recommends a diet for all children older than 2 years that is based on the Dietary Guidelines for Americans, which is published by the Department of Health and Human Services and the Department of Agriculture.
For children or adolescents at higher risk for cardiovascular disease or with elevated low-density lipoprotein (LDL)–cholesterol levels, changes in diet based on nutritional counseling and other lifestyle modifications are also recommended.
For overweight or obese pediatric patients with high triglyceride levels or low high-density lipoprotein (HDL)-cholesterol levels, weight management is the primary treatment, and includes improvement in diet with nutritional counseling and increased physical activity.
The writing committee also states that the current recommendation is to screen children and adolescents with a positive family history of dyslipidemia or premature cardiovascular disease.
It is recommended that pediatric patients for whom family history is not known and those with other cardiovascular risk factors, such as being overweight, obesity, hypertension, smoking history, and diabetes mellitus, be screened with a fasting-lipid profile.
Screening should take place after 2 years of age, but no later than 10 years of age.
Clinical Context
By approximately 2 years of age, most children have lipid concentrations that approximate those of young adults. Girls usually have higher total and LDL cholesterol levels vs boys, and adolescent girls also generally have higher HDL cholesterol levels vs postpubertal boys.
In a national study among US adolescents completed between 1988 and 1994, there were 10% of participants who had total control cholesterol concentrations that exceeded 200 mg/dL. The current clinical report describes screening and treatment recommendations for dyslipidemia among children.
Study Highlights
•A healthful, low-fat diet should be recommended to all children older than 2 years, and some research suggests that limiting fat in children younger than 2 years has no negative effect on growth or neurologic function. Reduced-fat milk may be appropriate for children beginning at age 12 months if there is concern for overweight or obesity, or if a family history of cardiovascular disease is present.
Only children at increased risk for future cardiovascular events should receive routine screening for serum lipid concentrations.
Children and adolescents with any of the following risk factors should receive screening:
◦Family history of dyslipidemia
◦Family history of premature cardiovascular disease
◦Overweight or obese children
◦Children with hypertension
◦Children who smoke cigarettes
◦Children with diabetes mellitus
•Children who qualify for screening should receive a full fasting lipid profile.
•At-risk children should be screened after age 2 years but no later than age 10 years.
•Children with normal lipid values at screening may be retested in 3 to 5 years.
All children with abnormal lipid levels should receive education on diet and exercise. This is particularly important for pediatric patients whose primary lipid level abnormality is a high triglyceride or low HDL cholesterol level.
Pharmacologic treatment should be considered for children who are at least 8 years old and meet one of the following qualifications:
◦LDL cholesterol level at least 190 mg/dL
◦LDL cholesterol level at least 160 mg/dL with a family history of premature cardiovascular disease or at least 2 other risk factors present
◦LDL cholesterol level at least 130 mg/dL and patient has diabetes
•Pharmacologic treatment may be considered for LDL cholesterol levels as low as 110 mg/dL if there are very compelling indications.
•Bile acid-binding resins can reduce cholesterol levels by 10% to 20%, and these medications do not have systemic effects.
•Statins have been demonstrated to be effective in short-term studies in children and have also been demonstrated to reduce atherosclerosis in children with hyperlipidemia.
•Fibrates should be reserved for use in special clinics for children with hyperlipidemia. Because of a high rate of adverse events such as flushing (up to three quarters of treated patients) and elevated transaminase concentrations (26% of children in 1 study), niacin should be avoided for the treatment of pediatric dyslipidemia.
Pearls for Practice
•The current clinical report suggests that children and adolescents with a family history of dyslipidemia, a family history of premature cardiovascular disease, or a personal history of overweight or obesity, hypertension, cigarette smoking, or diabetes should receive routine screening for serum lipid concentrations.
•Bile acid-binding resins and statins are the most recommended medical treatments for the management of pediatric dyslipidemia, and fibrates may be used by specialists in these disorders. The use of niacin is discouraged in children.
Source
Daniels SR, Greer FR, and the Committee on Nutrition. Lipid screening and cardiovascular health. Pediatrics. 2008;122:198-208.
Heartwire at www.theheart.org
Thursday, June 18, 2009
Avoid TV in children under 2 years?
Study Confirms TV Viewing Deleterious for Very Young Children
by Rosemary Frei
From Medscape Medical News
June 11, 2009 — Infants vocalize significantly less, and the adults who are with them also speak much less, while they are watching TV, a study published in the June issue of the Archives of Pediatric and Adolescent Medicine has confirmed.
Researchers analyzed digital recordings of 2- to 48-month-old children and their parents that were made once a month on random days for up to 2 years. Each hour of audible television was associated with a significant drop in how much the children vocalized and engaged in conversational exchanges with the adults present.
The adults also spoke 770 fewer words during each hour that the TV was audible — a dramatic bite out of the average 940 word-per-hour rate adults usually speak.
"That 770-word reduction is almost a complete 1-to-1 displacement [of the amount adults talk]," said lead investigator Dimitri Christakis, MD, from the Center for Child Health, Behavior, and Development at the Seattle Children's Research Institute and the University of Washington School of Medicine.
The American Academy of Pediatrics recommends that TV exposure should be avoided in children under the age of 2 years and that older children should view only 2 or fewer hours of TV per day. This is to ensure that children engage in as much interaction as possible with adults and thus have normal language development and brain growth.
A Major Problem
Benard Dreyer, MD, from Bellevue Hospital and the New York University School of Medicine, in New York City, was an author of a previous, retrospective study of low-income families that also showed TV exposure is associated with less parent-child vocal interaction (Mendelsohn AL et al. Arch Pediatr Adolesc Med. 2008;162:411-417). He said he "completely" agrees with the veracity of the new study's findings.
"I think that this [TV watching by young children] is a major problem, especially with respect to language development and all other types of early-childhood development that are predicated on interacting with adults, including cognitive development," Dr. Dreyer told Medscape Psychiatry. "Children who are interacting less with their parents and hearing less language are going to develop less language and also fewer other cognitive skills," he added.
Dr. Christakis and his colleagues obtained the data for the study from the LENA Foundation Natural Language Study. In the study, parents and their children aged 2 to 48 months were recruited and matched to the national-average levels of maternal education and child sex. The parents agreed to put a digital language-processing device in the front pocket of a specially designed vest that their child wore once a month for up to 24 months.
A total of 329 child-parent pairs contributed at least 1 recording with usable speech data to the study. The children's average age at the first session was 18 months, 51% were boys, and 79% were white; they were exposed to a mean of 1.3 hours of audible TV per day.
The investigators performed regression analyses that revealed that television exposure was linked with significantly reduced child vocalization count and duration as well as reduced conversation. These effects increased with every additional hour per day of television exposure.
Likewise, every additional hour of television exposure was associated with a 636-word decrease in the number of words the children heard from the female adults in their vicinity and a 134-word decrease in words heard from adult males, for a total reduction of 770 adult words.
Arch Pediatr Adolesc Med. 2009;163: 554-558. Abstract
by Rosemary Frei
From Medscape Medical News
June 11, 2009 — Infants vocalize significantly less, and the adults who are with them also speak much less, while they are watching TV, a study published in the June issue of the Archives of Pediatric and Adolescent Medicine has confirmed.
Researchers analyzed digital recordings of 2- to 48-month-old children and their parents that were made once a month on random days for up to 2 years. Each hour of audible television was associated with a significant drop in how much the children vocalized and engaged in conversational exchanges with the adults present.
The adults also spoke 770 fewer words during each hour that the TV was audible — a dramatic bite out of the average 940 word-per-hour rate adults usually speak.
"That 770-word reduction is almost a complete 1-to-1 displacement [of the amount adults talk]," said lead investigator Dimitri Christakis, MD, from the Center for Child Health, Behavior, and Development at the Seattle Children's Research Institute and the University of Washington School of Medicine.
The American Academy of Pediatrics recommends that TV exposure should be avoided in children under the age of 2 years and that older children should view only 2 or fewer hours of TV per day. This is to ensure that children engage in as much interaction as possible with adults and thus have normal language development and brain growth.
A Major Problem
Benard Dreyer, MD, from Bellevue Hospital and the New York University School of Medicine, in New York City, was an author of a previous, retrospective study of low-income families that also showed TV exposure is associated with less parent-child vocal interaction (Mendelsohn AL et al. Arch Pediatr Adolesc Med. 2008;162:411-417). He said he "completely" agrees with the veracity of the new study's findings.
"I think that this [TV watching by young children] is a major problem, especially with respect to language development and all other types of early-childhood development that are predicated on interacting with adults, including cognitive development," Dr. Dreyer told Medscape Psychiatry. "Children who are interacting less with their parents and hearing less language are going to develop less language and also fewer other cognitive skills," he added.
Dr. Christakis and his colleagues obtained the data for the study from the LENA Foundation Natural Language Study. In the study, parents and their children aged 2 to 48 months were recruited and matched to the national-average levels of maternal education and child sex. The parents agreed to put a digital language-processing device in the front pocket of a specially designed vest that their child wore once a month for up to 24 months.
A total of 329 child-parent pairs contributed at least 1 recording with usable speech data to the study. The children's average age at the first session was 18 months, 51% were boys, and 79% were white; they were exposed to a mean of 1.3 hours of audible TV per day.
The investigators performed regression analyses that revealed that television exposure was linked with significantly reduced child vocalization count and duration as well as reduced conversation. These effects increased with every additional hour per day of television exposure.
Likewise, every additional hour of television exposure was associated with a 636-word decrease in the number of words the children heard from the female adults in their vicinity and a 134-word decrease in words heard from adult males, for a total reduction of 770 adult words.
Arch Pediatr Adolesc Med. 2009;163: 554-558. Abstract
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