From Reuters Health Information
By Amy Norton
NEW YORK (Reuters Health) Feb 03 - While some studies have suggested that giving babies antibiotics might boost their risk of asthma later on, a new analysis concludes that much of that evidence is flawed.
The new analysis, of 21 studies conducted since 2002, found that the majority had limitations that could have biased them toward finding a link between infant antibiotic use and asthma risk.
According to the researchers, several studies were hampered by reverse causation. In other words, the babies' wheezing symptoms could have prompted the antibiotic prescriptions, rather than antibiotics causing wheezing and asthma to develop later on.
A couple of studies in the current review could not rule out the possibility of reverse causation. In a few others, there was initially a connection between early antibiotic use and asthma, but it disappeared after the researchers controlled for reverse causation.
In other studies, the issue was "confounding by indication," that is, the infection for which the antibiotic was prescribed could be the real risk factor for wheezing and asthma.
One study found babies with "chest" infections with symptoms of wheezing were twice as likely to be prescribed antibiotics as babies with upper respiratory infections, like colds. And it was the chest infections, rather than the antibiotics, that appeared to account for the increased risk of asthma symptoms before the age of five.
Several other studies did not account for the possibility of confounding by indication.
"The overall conclusion of our meta-analysis was that after excluding the studies that were at high risk of bias due to reverse causation and confounding by indication, there was only a very small increased risk of wheeze/asthma in children exposed to antibiotics in infancy," said lead researcher Dr. John Penders, of Maastricht University Medical Center in The Netherlands.
Another issue, he told Reuters Health by e-mail, is that only three of the studies looked at asthma risk beyond the age of five or six.
Asthma is tricky to diagnose in children younger than six, both because wheezing can be caused by respiratory infections rather than asthma, and because young children usually cannot perform the lung function tests used to objectively diagnose asthma.
When Dr. Penders' team combined the results of the three studies that included older children, there was no clear association between early antibiotic use and later asthma risk.
The bottom line, the researchers said in a January 13th online paper in the European Respiratory Journal, is that there is still a need for more well-designed studies that follow children over a longer period.
In the meantime, though, it is important to give babies and young children antibiotics only when absolutely necessary, according to Dr. Penders.
"Studies have shown that up to 50% of antibiotic prescriptions for children given by primary care physicians are unnecessary," he said, adding that the rate does vary widely among countries.
Dr. Anita Kozyrskyj, an associate professor at the University of Alberta in Edmonton, Canada, agreed on the need for further, long-range studies.
In an e-mail to Reuters Health, she pointed out that her own 2007 study, which was included in the analysis, did find a link between antibiotic prescriptions for non-respiratory conditions -- like urinary tract infections -- and later asthma risk.
Further studies that zero in on the reasons for babies' antibiotic prescriptions would be helpful, Dr. Kozyrskyj said.
She also agreed on the need for judicious use of antibiotics in infants -- especially when it comes to broad-spectrum antibiotics.
What is worrisome, Dr. Kozyrskyj said, is that guidelines in both the U.S. and Canada now call for greater use of wide-spectrum antibiotics for kids' ear infections.
"In Sweden and Norway, basic penicillin remains the antibiotic of choice," she noted.
Middle-ear infections are among the most common reasons for antibiotic prescriptions in American toddlers. But about 80% of children would get better without antibiotics, according to the American Academy of Pediatrics.
In its treatment guidelines, the academy says infants and children without severe symptoms can often wait 48 to 72 hours before starting antibiotics to see if the infection improves on its own.
Eur Resp J. Posted online January 13, 2011. Abstract
Wednesday, February 9, 2011
Tuesday, February 8, 2011
Added Sugar Intake in US Adolescents Linked to Cardiovascular Risk
From Medscape Education Clinical Briefs
News Author: Laurie Barclay, MD
CME Author: Hien T. Nghiem, MD
January 31, 2011 — Added sugar intake in US adolescents is linked to increased cardiovascular disease risk, according to the results of a cross-sectional study reported online January 10 in Circulation.
"Whereas increased carbohydrate and sugar consumption has been associated with higher cardiovascular disease risk among adults, little is known about the impact of high consumption of added sugars (caloric sweeteners) among US adolescents," write Jean A. Welsh, MPH, RN, from the Nutrition and Health Science Program, Emory University School of Medicine in Atlanta, Georgia, and colleagues.
Dietary data from one 24-hour recall of 2157 US adolescents enrolled in the National Health and Nutrition Examination Survey 1999 to 2004 were merged with added sugar content data from the US Department of Agriculture MyPyramid Equivalents databases. Measures of cardiovascular disease risk were estimated as a function of added sugar intake level (< 10%, 10% to < 15%, 15% to < 20%, 20% to < 25%, 25% to < 30%, and ≥ 30% of total energy). Multivariable means were weighted to be representative of US adolescents, and variances were adjusted to account for the complex sampling methods. Average daily intake of added sugars was 21.4% of total energy. Added sugar consumption correlated inversely with mean high-density lipoprotein (HDL) cholesterol levels (mmol/L). The lowest consumers had a mean HDL of 1.40 (95% confidence interval [CI], 1.36 - 1.44), and the highest consumers had a mean HDL of 1.28 (95% CI, 1.23 - 1.33; P for trend = .001). Added sugar intake correlated positively with geometric mean triglyceride levels (mmol/L), which were 0.81 (95% CI, 0.74 - 0.88) in the lowest consumers and 0.89 (95% CI, 0.83 - 0.96) in the highest consumers (P for trend = .05). Added sugar intake also correlated positively with low-density lipoprotein (LDL) cholesterol levels (mmol/L), which were 2.24 (95% CI, 2.12 - 2.37) in the lowest consumers and 2.44 (95% CI, 2.34 - 2.53) in the highest consumers (P for trend = .01). For adolescents who were overweight or obese, defined as a body mass index at or above the 85th percentile, added sugars correlated positively with the homeostasis model assessment of insulin resistance (HOMA-IR; P for linear trend = .004). "Consumption of added sugars among US adolescents is positively associated with multiple measures known to increase cardiovascular disease risk," the study authors write. Limitations of this study include cross-sectional design with exposures and outcomes measured at the same time, precluding determination of causality; use of a single 24-hour dietary recall; possible residual confounding; and lack of information on the validity of the process used to estimate added sugar content data in the US Department of Agriculture MyPyramid Equivalents databases. "Though long-term trials to study the effect of reducing the consumption of added sugars are needed, the results of this study suggest that future risk of CVD [cardiovascular disease] may be reduced by minimizing consumption of added sugars among adolescents," the study authors conclude. One of the study authors (Miriam B. Vos, MD, MSPH) is supported in part by a career award from the National Institutes of Diabetes and Digestive and Kidney Diseases and by the Children's Digestive Health and Nutrition Foundation. Dr. Vos is also the author of The No-Diet Obesity Solution for Kids, for which he receives royalties. The remaining study authors have disclosed no relevant financial relationships. Circulation. Published online January 10, 2011. Abstract Clinical Context In 1986, the Sugars Task Force of the US Food and Drug Administration concluded that there was no evidence of an association between sugar consumption and cardiovascular disease or its risk factors. Since then, several epidemiologic and experimental studies have demonstrated more evidence linking the intake of carbohydrates and sugars with an increased risk for cardiovascular disease. The Institute of Medicine suggests a limit of 25% total energy from added sugars to ensure adequate intake of important nutrients, the World Health Organization advises limiting added sugars to less than 10% total energy to prevent dental caries, and the American Heart Association advises that daily intake of added sugars be limited to less than 100 calories daily for women and 150 calories for men for the prevention of heart disease. Whereas increased carbohydrate and sugar consumption has been associated with higher cardiovascular disease risk among adults, little is known about the impact of high consumption of added sugars (caloric sweeteners) among US adolescents. The aim of this study was to determine if there is an association between the consumption of added sugars and indicators of cardiovascular disease risk among US adolescents and to determine if body weight modifies this association. Study Highlights * In a cross-sectional study of 2157 US adolescents in the National Health and Nutrition Examination Survey 1999 to 2004, dietary data from one 24-hour recall were merged with added sugar content data from the US Department of Agriculture MyPyramid Equivalents databases. * Exclusion criteria were adolescents with unreliable or implausible (< 600 or > 4500 kcal/day) dietary data, those who were pregnant, those with extreme triglyceride levels (> 300 mg/dL), those with previously diagnosed diabetes mellitus, and those with missing covariate data.
* Measures of cardiovascular disease risk were estimated by added sugar consumption level (< 10%, 10% to < 15%, 15% to < 20%, 20% to < 25%, 25% to < 30%, and ≥ 30% of total energy). * Biological indicators known to be associated with cardiovascular disease were measured, including lipids and glucose metabolism. * HOMA-IR was calculated. This is an estimate of insulin resistance derived from fasting glucose and insulin levels, with higher levels representing greater degrees of insulin resistance. * Multivariable means were weighted to be representative of US adolescents, and variances were adjusted for the complex sampling methods. * No significant differences were observed between the level of added sugars consumed and demographic factors, physical activity, or total energy intake. * Results demonstrated that daily consumption of added sugars averaged 21.4% of total energy. * Added sugar intake correlated inversely with mean HDL cholesterol levels (mmol/L), which were 1.40 (95% CI, 1.36 - 1.44) among the lowest consumers and 1.28 (95% CI, 1.23 - 1.33) among the highest consumers (P for trend = .001). * Added sugars correlated positively with LDL cholesterol levels (P for trend = .01) and geometric mean triglyceride levels (P for trend = .05). * Among the lowest and highest consumers, respectively, LDL cholesterol levels (mmol/L) were 2.24 (95% CI, 2.12 - 2.37) and 2.44 (95% CI, 2.34 - 2.53), and triglyceride levels (mmol/L) were 0.81 (95% CI, 0.74 - 0.88) and 0.89 (95% CI, 0.83 - 0.96). * Among overweight or obese adolescents (> 85th percentile of body mass index), added sugars correlated positively with HOMA-IR (P for linear trend = .004) and higher fasting insulin levels.
* No significant trends were observed between consumption of added sugars and fasting glucose levels, systolic or diastolic blood pressure, waist circumference, or body mass index.
Clinical Implications
* Recently, the American Heart Association released recommendations advising that daily intake of added sugars be limited to less than 100 calories daily for women and 150 calories for men for the prevention of heart disease.
* Higher consumption of added sugars among US adolescents is positively associated with multiple measures known to increase cardiovascular disease risk.
CME Test
News Author: Laurie Barclay, MD
CME Author: Hien T. Nghiem, MD
January 31, 2011 — Added sugar intake in US adolescents is linked to increased cardiovascular disease risk, according to the results of a cross-sectional study reported online January 10 in Circulation.
"Whereas increased carbohydrate and sugar consumption has been associated with higher cardiovascular disease risk among adults, little is known about the impact of high consumption of added sugars (caloric sweeteners) among US adolescents," write Jean A. Welsh, MPH, RN, from the Nutrition and Health Science Program, Emory University School of Medicine in Atlanta, Georgia, and colleagues.
Dietary data from one 24-hour recall of 2157 US adolescents enrolled in the National Health and Nutrition Examination Survey 1999 to 2004 were merged with added sugar content data from the US Department of Agriculture MyPyramid Equivalents databases. Measures of cardiovascular disease risk were estimated as a function of added sugar intake level (< 10%, 10% to < 15%, 15% to < 20%, 20% to < 25%, 25% to < 30%, and ≥ 30% of total energy). Multivariable means were weighted to be representative of US adolescents, and variances were adjusted to account for the complex sampling methods. Average daily intake of added sugars was 21.4% of total energy. Added sugar consumption correlated inversely with mean high-density lipoprotein (HDL) cholesterol levels (mmol/L). The lowest consumers had a mean HDL of 1.40 (95% confidence interval [CI], 1.36 - 1.44), and the highest consumers had a mean HDL of 1.28 (95% CI, 1.23 - 1.33; P for trend = .001). Added sugar intake correlated positively with geometric mean triglyceride levels (mmol/L), which were 0.81 (95% CI, 0.74 - 0.88) in the lowest consumers and 0.89 (95% CI, 0.83 - 0.96) in the highest consumers (P for trend = .05). Added sugar intake also correlated positively with low-density lipoprotein (LDL) cholesterol levels (mmol/L), which were 2.24 (95% CI, 2.12 - 2.37) in the lowest consumers and 2.44 (95% CI, 2.34 - 2.53) in the highest consumers (P for trend = .01). For adolescents who were overweight or obese, defined as a body mass index at or above the 85th percentile, added sugars correlated positively with the homeostasis model assessment of insulin resistance (HOMA-IR; P for linear trend = .004). "Consumption of added sugars among US adolescents is positively associated with multiple measures known to increase cardiovascular disease risk," the study authors write. Limitations of this study include cross-sectional design with exposures and outcomes measured at the same time, precluding determination of causality; use of a single 24-hour dietary recall; possible residual confounding; and lack of information on the validity of the process used to estimate added sugar content data in the US Department of Agriculture MyPyramid Equivalents databases. "Though long-term trials to study the effect of reducing the consumption of added sugars are needed, the results of this study suggest that future risk of CVD [cardiovascular disease] may be reduced by minimizing consumption of added sugars among adolescents," the study authors conclude. One of the study authors (Miriam B. Vos, MD, MSPH) is supported in part by a career award from the National Institutes of Diabetes and Digestive and Kidney Diseases and by the Children's Digestive Health and Nutrition Foundation. Dr. Vos is also the author of The No-Diet Obesity Solution for Kids, for which he receives royalties. The remaining study authors have disclosed no relevant financial relationships. Circulation. Published online January 10, 2011. Abstract Clinical Context In 1986, the Sugars Task Force of the US Food and Drug Administration concluded that there was no evidence of an association between sugar consumption and cardiovascular disease or its risk factors. Since then, several epidemiologic and experimental studies have demonstrated more evidence linking the intake of carbohydrates and sugars with an increased risk for cardiovascular disease. The Institute of Medicine suggests a limit of 25% total energy from added sugars to ensure adequate intake of important nutrients, the World Health Organization advises limiting added sugars to less than 10% total energy to prevent dental caries, and the American Heart Association advises that daily intake of added sugars be limited to less than 100 calories daily for women and 150 calories for men for the prevention of heart disease. Whereas increased carbohydrate and sugar consumption has been associated with higher cardiovascular disease risk among adults, little is known about the impact of high consumption of added sugars (caloric sweeteners) among US adolescents. The aim of this study was to determine if there is an association between the consumption of added sugars and indicators of cardiovascular disease risk among US adolescents and to determine if body weight modifies this association. Study Highlights * In a cross-sectional study of 2157 US adolescents in the National Health and Nutrition Examination Survey 1999 to 2004, dietary data from one 24-hour recall were merged with added sugar content data from the US Department of Agriculture MyPyramid Equivalents databases. * Exclusion criteria were adolescents with unreliable or implausible (< 600 or > 4500 kcal/day) dietary data, those who were pregnant, those with extreme triglyceride levels (> 300 mg/dL), those with previously diagnosed diabetes mellitus, and those with missing covariate data.
* Measures of cardiovascular disease risk were estimated by added sugar consumption level (< 10%, 10% to < 15%, 15% to < 20%, 20% to < 25%, 25% to < 30%, and ≥ 30% of total energy). * Biological indicators known to be associated with cardiovascular disease were measured, including lipids and glucose metabolism. * HOMA-IR was calculated. This is an estimate of insulin resistance derived from fasting glucose and insulin levels, with higher levels representing greater degrees of insulin resistance. * Multivariable means were weighted to be representative of US adolescents, and variances were adjusted for the complex sampling methods. * No significant differences were observed between the level of added sugars consumed and demographic factors, physical activity, or total energy intake. * Results demonstrated that daily consumption of added sugars averaged 21.4% of total energy. * Added sugar intake correlated inversely with mean HDL cholesterol levels (mmol/L), which were 1.40 (95% CI, 1.36 - 1.44) among the lowest consumers and 1.28 (95% CI, 1.23 - 1.33) among the highest consumers (P for trend = .001). * Added sugars correlated positively with LDL cholesterol levels (P for trend = .01) and geometric mean triglyceride levels (P for trend = .05). * Among the lowest and highest consumers, respectively, LDL cholesterol levels (mmol/L) were 2.24 (95% CI, 2.12 - 2.37) and 2.44 (95% CI, 2.34 - 2.53), and triglyceride levels (mmol/L) were 0.81 (95% CI, 0.74 - 0.88) and 0.89 (95% CI, 0.83 - 0.96). * Among overweight or obese adolescents (> 85th percentile of body mass index), added sugars correlated positively with HOMA-IR (P for linear trend = .004) and higher fasting insulin levels.
* No significant trends were observed between consumption of added sugars and fasting glucose levels, systolic or diastolic blood pressure, waist circumference, or body mass index.
Clinical Implications
* Recently, the American Heart Association released recommendations advising that daily intake of added sugars be limited to less than 100 calories daily for women and 150 calories for men for the prevention of heart disease.
* Higher consumption of added sugars among US adolescents is positively associated with multiple measures known to increase cardiovascular disease risk.
CME Test
Sunday, February 6, 2011
AAP Practice Guideline Stresses Cause in Children With Febrile Seizure
From Medscape Medical News
Nancy Fowler
February 2, 2010 — Physicians examining infants and young children after simple febrile seizure should contemplate meningitis as a possible cause of fever, according to new American Academy of Pediatrics (AAP) practice guidelines published online January 31 in Pediatrics.
"Meningitis should be considered in the differential diagnosis for any febrile child, and lumbar puncture should be performed if there are clinical signs or symptoms of concern," write Patricia K. Duffner, MD, of the AAP's Subcommittee on Febrile Seizures, 2002-2010, and colleagues.
Febrile seizure occurs in 2% to 5% of all children ages 6 to 60 months. It is characterized by a fever, or a body temperature of at least 100.4°F or 38°C, taken by any method, in children with no central nervous system infection. Complex febrile seizure is focal (affecting only specific parts of the body), lasts 15 minutes or longer, and/or recurs within 24 hours.
Simple febrile seizure is generalized, lasts for less than 15 minutes, and does not return within 24 hours. In 1980, the National Institutes of Health designated simple febrile seizure as a benign event, with excellent patient prognosis.
The new guidelines, which replace 1996 practice standards, pertain to patients presenting within 12 hours of simple febrile seizure. They are not intended for children who have experienced complex febrile seizure or those with prior neurologic insults, abnormalities of the central nervous system, or a history of seizures not related to fever.
Signs and symptoms of meningitis include stiff neck, Kernig's sign (lower back or posterior thigh pain during knee extension while the patient's hip is flexed and he or she is lying supine), and Brudzinski's sign (knee and hip flexion with flexed neck while in supine position). Lumbar puncture, also known as spinal tap, is used to diagnose meningitis. It involves the removal and examination of cerebrospinal fluid that surrounds the brain and spinal cord.
Updated Guidelines Stem From Comprehensive Review
Before issuing the new guidelines, AAP investigators examined evidence-based literature made available from 1996 to February 2009. They gave preference to population-based studies. However, a dearth of such research necessitated inclusion of information from hospital-based studies and data gathered from various groups of young children with febrile and other illnesses.
The researchers reviewed 372 articles, 169 more than were evaluated for the 1996 guidelines. Key action statements resulting from their investigation, and all pertaining to children presenting with simple febrile seizure, are as follows:
* Children with meningeal signs, or young patients with a suggestion or history of meningitis or intracranial infection, should undergo lumbar puncture, without exception.
* Any infant between the ages of 6 and 12 months should have lumbar puncture as an option when Haemophilus influenzae type b or Streptococcus pneumoniae immunizations are not current, or are not known.
* A child who has been pretreated with antibiotics should have lumbar puncture as an option because antibiotics can mask meningitis.
* In neurologically healthy children, an electroencephalogram (EEG) should never be performed.
* In the quest to identify simple febrile seizure cause, diagnosticians should not perform the following tests: serum electrolytes, calcium, phosphorus, magnesium, or blood glucose measurements; or complete blood cell count.
* Routine evaluation of children with simple febrile seizure should not include neuroimaging.
"In general, a simple febrile seizure does not usually require further evaluation, specifically EEGs, blood studies, or neuroimaging," the authors of the guideline write.
Regarding parental input on the performance of lumbar puncture, the researchers acknowledge that the procedure is invasive, often painful, and frequently costly. However, they point out that observational data and clinical principles are the foundation of their guidelines and that in the instances that they recommend lumbar puncture, the benefits outweigh possible harm.
"Although parents may not wish to have their child undergo a lumbar puncture, health care providers should explain that if meningitis is not diagnosed and treated, it could be fatal," the guideline authors write.
The guideline authors have disclosed no relevant financial relationships.
Nancy Fowler
February 2, 2010 — Physicians examining infants and young children after simple febrile seizure should contemplate meningitis as a possible cause of fever, according to new American Academy of Pediatrics (AAP) practice guidelines published online January 31 in Pediatrics.
"Meningitis should be considered in the differential diagnosis for any febrile child, and lumbar puncture should be performed if there are clinical signs or symptoms of concern," write Patricia K. Duffner, MD, of the AAP's Subcommittee on Febrile Seizures, 2002-2010, and colleagues.
Febrile seizure occurs in 2% to 5% of all children ages 6 to 60 months. It is characterized by a fever, or a body temperature of at least 100.4°F or 38°C, taken by any method, in children with no central nervous system infection. Complex febrile seizure is focal (affecting only specific parts of the body), lasts 15 minutes or longer, and/or recurs within 24 hours.
Simple febrile seizure is generalized, lasts for less than 15 minutes, and does not return within 24 hours. In 1980, the National Institutes of Health designated simple febrile seizure as a benign event, with excellent patient prognosis.
The new guidelines, which replace 1996 practice standards, pertain to patients presenting within 12 hours of simple febrile seizure. They are not intended for children who have experienced complex febrile seizure or those with prior neurologic insults, abnormalities of the central nervous system, or a history of seizures not related to fever.
Signs and symptoms of meningitis include stiff neck, Kernig's sign (lower back or posterior thigh pain during knee extension while the patient's hip is flexed and he or she is lying supine), and Brudzinski's sign (knee and hip flexion with flexed neck while in supine position). Lumbar puncture, also known as spinal tap, is used to diagnose meningitis. It involves the removal and examination of cerebrospinal fluid that surrounds the brain and spinal cord.
Updated Guidelines Stem From Comprehensive Review
Before issuing the new guidelines, AAP investigators examined evidence-based literature made available from 1996 to February 2009. They gave preference to population-based studies. However, a dearth of such research necessitated inclusion of information from hospital-based studies and data gathered from various groups of young children with febrile and other illnesses.
The researchers reviewed 372 articles, 169 more than were evaluated for the 1996 guidelines. Key action statements resulting from their investigation, and all pertaining to children presenting with simple febrile seizure, are as follows:
* Children with meningeal signs, or young patients with a suggestion or history of meningitis or intracranial infection, should undergo lumbar puncture, without exception.
* Any infant between the ages of 6 and 12 months should have lumbar puncture as an option when Haemophilus influenzae type b or Streptococcus pneumoniae immunizations are not current, or are not known.
* A child who has been pretreated with antibiotics should have lumbar puncture as an option because antibiotics can mask meningitis.
* In neurologically healthy children, an electroencephalogram (EEG) should never be performed.
* In the quest to identify simple febrile seizure cause, diagnosticians should not perform the following tests: serum electrolytes, calcium, phosphorus, magnesium, or blood glucose measurements; or complete blood cell count.
* Routine evaluation of children with simple febrile seizure should not include neuroimaging.
"In general, a simple febrile seizure does not usually require further evaluation, specifically EEGs, blood studies, or neuroimaging," the authors of the guideline write.
Regarding parental input on the performance of lumbar puncture, the researchers acknowledge that the procedure is invasive, often painful, and frequently costly. However, they point out that observational data and clinical principles are the foundation of their guidelines and that in the instances that they recommend lumbar puncture, the benefits outweigh possible harm.
"Although parents may not wish to have their child undergo a lumbar puncture, health care providers should explain that if meningitis is not diagnosed and treated, it could be fatal," the guideline authors write.
The guideline authors have disclosed no relevant financial relationships.
Friday, February 4, 2011
Elimination Diet May Improve ADHD Symptoms
From Medscape Medical News > Psychiatry
Investigators Suggest 'Diet Therapy" Should Be Considered in All Children With ADHD
Megan Brooks
February 4, 2011 — In a group of young children with attention-deficit/hyperactivity disorder (ADHD), nearly two-thirds who followed a restricted elimination diet experienced a significant reduction in ADHD symptoms and oppositional defiant behavior. Going off the diet led to relapse.
The findings, from the Impact of Nutrition on Children with ADHD (INCA) study, are published in the February 5 issue of The Lancet.
"We think that dietary intervention should be considered in all children with ADHD, provided parents are willing to follow a diagnostic restricted elimination diet for a 5-week period and provided expert supervision is available," Lidy M. Pelsser, PhD, of the ADHD Research Centre in Eindhoven, the Netherlands, and colleagues write.
"Children who react favorably to this diet should be diagnosed with food-induced ADHD and should enter a challenge procedure to define which foods each child reacts to and to increase the feasibility and to minimize the burden of the diet," they advise.
But in comments to Medscape Medical News, Jaswinder Ghuman, MD, of the Division of Child and Adolescent Psychiatry at University of Arizona, Tuscon, author of a linked commentary, said further investigation is needed "to make recommendations for children who are more likely to benefit."
IgG Measurements Not Helpful
Hypersensitivity or intolerance to foods or food additives is thought to contribute to ADHD. The children in the INCA study were unselected for any food sensitivities, and the researchers found that performing blood tests to identify ADHD "trigger" foods was not helpful.
Blood tests assessing IgG levels against foods did not predict which foods might have a deleterious impact on a child's behavior.
"Total IgE levels were increased in only a few children, equally in (diet) responders and nonresponders, suggesting that the underlying mechanism of food sensitivity in ADHD (which could be related to genetic factors) is nonallergic," Dr Pelsser and colleagues report.
The INCA study was a 2-phase randomized trial involving 100 children aged 4 to 8 years with ADHD. During a baseline period (weeks 1 to 3), 50 control children continued their normal diet and their parents were given healthy food advice and kept a diary of their child's behavior.
The other 50 children started an open trial with a restricted elimination diet (mainly rice, meat vegetables, pears, and water, complemented with potatoes, fruits, and wheat).
By the end of week 2, 17 of 41 children in the diet group (41.5%) had no behavioral response to the diet, and their diet was further restricted to rice, meat, vegetables, pears, and water.
According to the investigators, by the end of phase 1 (weeks 4-9), symptoms of ADHD and oppositional defiant disorder were significantly improved in 64% of children in the diet group compared with no improvement in controls.
Between baseline and the end of phase 1, the difference between the diet group and the control group in the mean ADHD rating scale (ARS) total score was 23.7 (95% confidence interval [CI], 18.6 – 28.8; P < .0001). The between-group difference in the mean abbreviated Conners' scale between baseline and phase 1 end was 11.8 (95% CI, 9.2 – 14.5; P < .0001).
Children in the diet group who had a clinical response in phase 1, defined as at least a 40% improvement on ARS score, proceeded to phase 2, a 4-week, double-blind, crossover food challenge, in which high-IgG or low-IgG foods (selected based on individual total IgG levels to 270 different foods) were added to the diet.
After challenges with either high- or low-IgG foods, relapse of ADHD symptoms occurred in 19 of 30 children (63%), regardless of IgG blood test results.
Diet 'Complex and Challenging'
Dr. Pelsser's team concludes that a strictly supervised restricted elimination diet "is a valuable instrument to assess whether ADHD is induced by food, [but] the prescription of diets on the basis of IgG blood tests should be discouraged."
In her commentary, Dr. Ghuman notes restricted elimination diet studies are "complex and challenging." The INCA study was "well-designed and carefully done, showed a benefit with a supervised elimination diet, and provides an additional treatment option for some young children with ADHD.
"For interested parents," Dr. Ghuman told Medscape Medical News, "clinicians should encourage them to seek the advice of the child's primary care provider and a nutritionist for appropriate monitoring of the child's nutritional status and needs. The parents will need appropriate guidance and supervision for a structured protocol to determine any benefit and identify incriminated foods."
In her commentary, Dr. Ghuman says it's important to note that 36% of children either didn't respond to the elimination diet or didn’t stick to it in phase 1 and 16 children eligible children (and parents) were not motivated to participate in the study.
She also points out that the blinded assessments in the study were based on information provided by parents. However, parents and teachers were aware whether the children were on the elimination diet or not in phase 1.
They also knew that the children entering phase 2 received challenge foods but not whether the foods were high- or low-IgG foods. The beliefs and expectations of the parents and teachers about changes in the ADHD symptoms could have been influenced by this knowledge, Dr. Ghuman notes.
Lancet. 2011;377:446-448, 494-503.
Investigators Suggest 'Diet Therapy" Should Be Considered in All Children With ADHD
Megan Brooks
February 4, 2011 — In a group of young children with attention-deficit/hyperactivity disorder (ADHD), nearly two-thirds who followed a restricted elimination diet experienced a significant reduction in ADHD symptoms and oppositional defiant behavior. Going off the diet led to relapse.
The findings, from the Impact of Nutrition on Children with ADHD (INCA) study, are published in the February 5 issue of The Lancet.
"We think that dietary intervention should be considered in all children with ADHD, provided parents are willing to follow a diagnostic restricted elimination diet for a 5-week period and provided expert supervision is available," Lidy M. Pelsser, PhD, of the ADHD Research Centre in Eindhoven, the Netherlands, and colleagues write.
"Children who react favorably to this diet should be diagnosed with food-induced ADHD and should enter a challenge procedure to define which foods each child reacts to and to increase the feasibility and to minimize the burden of the diet," they advise.
But in comments to Medscape Medical News, Jaswinder Ghuman, MD, of the Division of Child and Adolescent Psychiatry at University of Arizona, Tuscon, author of a linked commentary, said further investigation is needed "to make recommendations for children who are more likely to benefit."
IgG Measurements Not Helpful
Hypersensitivity or intolerance to foods or food additives is thought to contribute to ADHD. The children in the INCA study were unselected for any food sensitivities, and the researchers found that performing blood tests to identify ADHD "trigger" foods was not helpful.
Blood tests assessing IgG levels against foods did not predict which foods might have a deleterious impact on a child's behavior.
"Total IgE levels were increased in only a few children, equally in (diet) responders and nonresponders, suggesting that the underlying mechanism of food sensitivity in ADHD (which could be related to genetic factors) is nonallergic," Dr Pelsser and colleagues report.
The INCA study was a 2-phase randomized trial involving 100 children aged 4 to 8 years with ADHD. During a baseline period (weeks 1 to 3), 50 control children continued their normal diet and their parents were given healthy food advice and kept a diary of their child's behavior.
The other 50 children started an open trial with a restricted elimination diet (mainly rice, meat vegetables, pears, and water, complemented with potatoes, fruits, and wheat).
By the end of week 2, 17 of 41 children in the diet group (41.5%) had no behavioral response to the diet, and their diet was further restricted to rice, meat, vegetables, pears, and water.
According to the investigators, by the end of phase 1 (weeks 4-9), symptoms of ADHD and oppositional defiant disorder were significantly improved in 64% of children in the diet group compared with no improvement in controls.
Between baseline and the end of phase 1, the difference between the diet group and the control group in the mean ADHD rating scale (ARS) total score was 23.7 (95% confidence interval [CI], 18.6 – 28.8; P < .0001). The between-group difference in the mean abbreviated Conners' scale between baseline and phase 1 end was 11.8 (95% CI, 9.2 – 14.5; P < .0001).
Children in the diet group who had a clinical response in phase 1, defined as at least a 40% improvement on ARS score, proceeded to phase 2, a 4-week, double-blind, crossover food challenge, in which high-IgG or low-IgG foods (selected based on individual total IgG levels to 270 different foods) were added to the diet.
After challenges with either high- or low-IgG foods, relapse of ADHD symptoms occurred in 19 of 30 children (63%), regardless of IgG blood test results.
Diet 'Complex and Challenging'
Dr. Pelsser's team concludes that a strictly supervised restricted elimination diet "is a valuable instrument to assess whether ADHD is induced by food, [but] the prescription of diets on the basis of IgG blood tests should be discouraged."
In her commentary, Dr. Ghuman notes restricted elimination diet studies are "complex and challenging." The INCA study was "well-designed and carefully done, showed a benefit with a supervised elimination diet, and provides an additional treatment option for some young children with ADHD.
"For interested parents," Dr. Ghuman told Medscape Medical News, "clinicians should encourage them to seek the advice of the child's primary care provider and a nutritionist for appropriate monitoring of the child's nutritional status and needs. The parents will need appropriate guidance and supervision for a structured protocol to determine any benefit and identify incriminated foods."
In her commentary, Dr. Ghuman says it's important to note that 36% of children either didn't respond to the elimination diet or didn’t stick to it in phase 1 and 16 children eligible children (and parents) were not motivated to participate in the study.
She also points out that the blinded assessments in the study were based on information provided by parents. However, parents and teachers were aware whether the children were on the elimination diet or not in phase 1.
They also knew that the children entering phase 2 received challenge foods but not whether the foods were high- or low-IgG foods. The beliefs and expectations of the parents and teachers about changes in the ADHD symptoms could have been influenced by this knowledge, Dr. Ghuman notes.
Lancet. 2011;377:446-448, 494-503.
Tuesday, February 1, 2011
US Task Force Issues Updated Statement on Visual Screening in Young Children
From Medscape Medical News
Laurie Barclay, MD
January 31, 2011 — The 2004 US Preventive Services Task Force (USPSTF) statement about screening for visual impairment in children 1 to 5 years old has been updated and published online January 31 in Pediatrics.
"The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors (grade B recommendation)," write Mary Barton, MD, from the Agency for Healthcare Research and Quality, Center for Primary Care, Prevention, and Clinical Partnerships in Rockville, Maryland, and colleagues from the USPSTF. "The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of vision screening for children <3 years of age (I statement)."
In developing its updated recommendations, the USPSTF considered evidence from a systematic review of the association of screening for visual impairment in children 1 to 5 years old with improved health outcomes, the accuracy of risk factor evaluation and screening tests, the efficacy of early detection and intervention, the potential harms of screening and treatment, and the net benefit of screening in this population. However, the USPSTF respects the need for clinical or policy decisions to be based on additional considerations. Therefore, they recommend that clinicians and policy makers tailor their decisions to the specific patient or situation.
"Approximately 2% to 4% of preschool-aged children have amblyopia, an alteration in the visual neural pathway in the developing brain that can lead to permanent vision loss in the affected eye," the statement authors write.
"Amblyopia usually occurs unilaterally but can occur bilaterally. Identification of vision impairment before school entry could help identify children who may benefit from early interventions to correct or to improve vision."
On the basis of the evidence, the USPSTF concluded with moderate certainty that screening for visual impairment in children ages 3 to 5 years had a moderate net benefit.
Screening tests that can be used in primary care to identify visual impairment in children include visual acuity tests, stereoacuity tests, the cover-uncover test, and the Hirschberg light reflex test (for ocular alignment/strabismus). Also potentially useful are autorefractors, or automated optical instruments that detect refractive errors and photoscreeners, or instruments that detect amblyogenic risk factors and refractive errors.
Evidence was adequate that vision screening tools are reasonably accurate in the detection of visual impairment, including refractive errors, strabismus, and amblyopia, and that early treatment for amblyopia, including cycloplegic agents such as atropine or patching of the nonaffected eye, and eyeglasses, for children 3 to 5 years old is associated with improved visual outcomes. For children younger than 3 years, however, evidence was inadequate that early treatment of amblyopia results in better visual outcomes.
Evidence was limited regarding psychosocial or other harms of screening for children at least 3 years old. False-positive screening results could result in overprescribing of corrective lenses or reversible loss of visual acuity because of patching of the nonaffected eye. For children younger than 3 years, evidence of the harms of screening and treatment was inadequate.
On the basis of the evidence, the USPSTF concluded with moderate certainty that screening for visual impairment in children ages 3 to 5 years had a moderate net benefit. For children younger than 3 years, however, the USPSTF concluded that the benefits of vision screening are uncertain and that the balance of benefits and harms cannot be determined for this age group. The USPSTF did not find adequate evidence to determine the optimal screening interval.
Review: Efficacy of Vision Screening Limited
An accompanying updated evidence-based review by Roger Chou, MD, from Oregon Evidence-Based Practice Center, Oregon Health & Science University in Portland, and colleagues aimed to evaluate the efficacy of screening preschool-aged children for impaired visual acuity on health outcomes. The reviewers searched MEDLINE from 1950 to July 2009 and the Cochrane Library through the third quarter of 2009, reviewed bibliographies of identified articles, and consulted experts.
They found that direct evidence was limited regarding the efficacy of preschool vision screening for improving visual acuity or other clinical outcomes and did not adequately resolve whether screening is more effective than no screening. Indirect evidence included the ability of several screening tests to detect vision problems in preschool-aged children.
Diagnostic accuracy was not clearly different in different age categories, but testability rates were generally lower in children 1 to 3 years old. Compared with no treatment, treatments of amblyopia or unilateral refractive error were associated with mild improvements in visual acuity, but no study to date assessed school performance or other functional outcomes.
"Although treatments for amblyopia or unilateral refractive error can improve vision in preschool-aged children and screening tests have utility for identifying vision problems, additional studies are needed to better understand the effects of screening compared with no screening," the review authors write.
Commentary: Newer Technology Praised
An accompanying commentary by Sean P. Donahue, MD, PhD, from Vanderbilt University School of Medicine in Nashville, Tennessee; and James B. Ruben, MD, from Northern California Permanente Medical Group in Roseville and University of California, Davis, commend the USPSTF recommendation for vision screening at least once for all children between the ages of 3 and 5 years.
"Newer technologies now allow the identification of amblyopia risk factors before strabismus and amblyopia develop and become entrenched, and evidence supports the effectiveness of treatment of children so identified," Drs. Donahue and Ruben write. "It should be emphasized that the I (inconclusive) rating given by the USPSTF for screening children younger than 3 years should not be misinterpreted as 'ineffective.'
We welcome the USPSTF level B recommendation for at least 1 vision screening in the child aged 3 to 5 years and believe that there is now adequate evidence to support an earlier screening using photorefraction or autorefraction in younger children."
Pediatrics. Published online January 31, 2011. Abstract
Laurie Barclay, MD
January 31, 2011 — The 2004 US Preventive Services Task Force (USPSTF) statement about screening for visual impairment in children 1 to 5 years old has been updated and published online January 31 in Pediatrics.
"The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors (grade B recommendation)," write Mary Barton, MD, from the Agency for Healthcare Research and Quality, Center for Primary Care, Prevention, and Clinical Partnerships in Rockville, Maryland, and colleagues from the USPSTF. "The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of vision screening for children <3 years of age (I statement)."
In developing its updated recommendations, the USPSTF considered evidence from a systematic review of the association of screening for visual impairment in children 1 to 5 years old with improved health outcomes, the accuracy of risk factor evaluation and screening tests, the efficacy of early detection and intervention, the potential harms of screening and treatment, and the net benefit of screening in this population. However, the USPSTF respects the need for clinical or policy decisions to be based on additional considerations. Therefore, they recommend that clinicians and policy makers tailor their decisions to the specific patient or situation.
"Approximately 2% to 4% of preschool-aged children have amblyopia, an alteration in the visual neural pathway in the developing brain that can lead to permanent vision loss in the affected eye," the statement authors write.
"Amblyopia usually occurs unilaterally but can occur bilaterally. Identification of vision impairment before school entry could help identify children who may benefit from early interventions to correct or to improve vision."
On the basis of the evidence, the USPSTF concluded with moderate certainty that screening for visual impairment in children ages 3 to 5 years had a moderate net benefit.
Screening tests that can be used in primary care to identify visual impairment in children include visual acuity tests, stereoacuity tests, the cover-uncover test, and the Hirschberg light reflex test (for ocular alignment/strabismus). Also potentially useful are autorefractors, or automated optical instruments that detect refractive errors and photoscreeners, or instruments that detect amblyogenic risk factors and refractive errors.
Evidence was adequate that vision screening tools are reasonably accurate in the detection of visual impairment, including refractive errors, strabismus, and amblyopia, and that early treatment for amblyopia, including cycloplegic agents such as atropine or patching of the nonaffected eye, and eyeglasses, for children 3 to 5 years old is associated with improved visual outcomes. For children younger than 3 years, however, evidence was inadequate that early treatment of amblyopia results in better visual outcomes.
Evidence was limited regarding psychosocial or other harms of screening for children at least 3 years old. False-positive screening results could result in overprescribing of corrective lenses or reversible loss of visual acuity because of patching of the nonaffected eye. For children younger than 3 years, evidence of the harms of screening and treatment was inadequate.
On the basis of the evidence, the USPSTF concluded with moderate certainty that screening for visual impairment in children ages 3 to 5 years had a moderate net benefit. For children younger than 3 years, however, the USPSTF concluded that the benefits of vision screening are uncertain and that the balance of benefits and harms cannot be determined for this age group. The USPSTF did not find adequate evidence to determine the optimal screening interval.
Review: Efficacy of Vision Screening Limited
An accompanying updated evidence-based review by Roger Chou, MD, from Oregon Evidence-Based Practice Center, Oregon Health & Science University in Portland, and colleagues aimed to evaluate the efficacy of screening preschool-aged children for impaired visual acuity on health outcomes. The reviewers searched MEDLINE from 1950 to July 2009 and the Cochrane Library through the third quarter of 2009, reviewed bibliographies of identified articles, and consulted experts.
They found that direct evidence was limited regarding the efficacy of preschool vision screening for improving visual acuity or other clinical outcomes and did not adequately resolve whether screening is more effective than no screening. Indirect evidence included the ability of several screening tests to detect vision problems in preschool-aged children.
Diagnostic accuracy was not clearly different in different age categories, but testability rates were generally lower in children 1 to 3 years old. Compared with no treatment, treatments of amblyopia or unilateral refractive error were associated with mild improvements in visual acuity, but no study to date assessed school performance or other functional outcomes.
"Although treatments for amblyopia or unilateral refractive error can improve vision in preschool-aged children and screening tests have utility for identifying vision problems, additional studies are needed to better understand the effects of screening compared with no screening," the review authors write.
Commentary: Newer Technology Praised
An accompanying commentary by Sean P. Donahue, MD, PhD, from Vanderbilt University School of Medicine in Nashville, Tennessee; and James B. Ruben, MD, from Northern California Permanente Medical Group in Roseville and University of California, Davis, commend the USPSTF recommendation for vision screening at least once for all children between the ages of 3 and 5 years.
"Newer technologies now allow the identification of amblyopia risk factors before strabismus and amblyopia develop and become entrenched, and evidence supports the effectiveness of treatment of children so identified," Drs. Donahue and Ruben write. "It should be emphasized that the I (inconclusive) rating given by the USPSTF for screening children younger than 3 years should not be misinterpreted as 'ineffective.'
We welcome the USPSTF level B recommendation for at least 1 vision screening in the child aged 3 to 5 years and believe that there is now adequate evidence to support an earlier screening using photorefraction or autorefraction in younger children."
Pediatrics. Published online January 31, 2011. Abstract
AAP Issues Recommended Childhood and Teen Immunization Schedules
From Medscape Medical News
Laurie Barclay, MD
February 1, 2011 — The American Academy of Pediatrics (AAP) has issued 2011 immunization schedules recommended for childhood and adolescents and published a policy statement describing the new schedules online February 1 in Pediatrics.
The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and the American Academy of Family Physicians have also approved the new recommendations, which were written by the Committee on Infectious Diseases, chaired by Michael T. Brady, MD.
Highlights of the new schedules include guidance on hepatitis B vaccine administration to children who did not receive the recommended birth dose, and new recommendations on the use of 13-valent pneumococcal conjugate vaccine (PCV13), which replaced the 7-valent pneumococcal conjugate vaccine (PCV7).
Because of recent outbreaks of pertussis nationwide, the new recommendations offer guidance for a dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in 7- to 10-year-old children who have not been adequately immunized against pertussis. The updated schedules now recommend a booster dose of the conjugated meningococcal vaccine to improve protection of adolescents throughout the greatest period of risk for meningococcal disease. Instructions on dosing of influenza vaccine are now based on a history of receiving monovalent 2009 H1N1 vaccine. The policy statement also offers guidance on administering human papillomavirus (HPV) vaccines to boys 9 to 18 years old to lower their risk of acquiring genital warts.
Specific Updated Changes
Specific changes in the 2011 schedules from last year include the following:
* For children who did not receive the recommended birth dose of hepatitis B vaccine, the new recommendations offer guidance for administering the hepatitis B vaccine series. The catch-up schedule now includes a minimal age for dose 3 of hepatitis B vaccine, so that the final (third or fourth) dose in the series should be given no sooner than age 24 weeks.
* New recommendations are included on the use of PCV13, so that a PCV series started with PCV7 should be completed with PCV13. All children 14 through 59 months old who received an age-appropriate series of PCV7 should receive a single supplemental dose of PCV13. All children 60 through 71 months old with underlying medical conditions who have received an age-appropriate series of PCV7 should receive a single supplemental dose of PCV13. The supplemental PCV13 dose should be given at least 8 weeks after the previous dose of PCV7. Children 6 through 18 years old with functional or anatomic asplenia, HIV infection or other immunocompromising conditions, cochlear implant, or cerebrospinal fluid leak may be given a single dose of PCV13. Children at least 2 years old who have certain underlying medical conditions should be given the pneumococcal polysaccharide vaccine (PPSV) no sooner than 8 weeks after the last dose of PCV. Children with functional or anatomic asplenia or an immunocompromising condition should receive a single revaccination with PPSV after 5 years.
* On the basis of the child's history of receiving monovalent 2009 H1N1 vaccine, the new recommendations offer guidance for administering 1 or 2 doses of influenza vaccine. Children 6 months through 8 years old who are receiving influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but only received 1 dose at that time should receive 2 doses at least 4 weeks apart. Two doses of 2010-2011 seasonal influenza vaccine should be given to children 6 months through 8 years old who received no doses of monovalent 2009 H1N1 vaccine or in whom the dosing schedule is unknown.
* Adolescents should be routinely immunized with quadrivalent meningococcal conjugate vaccine (MCV4), preferably at ages 11 through 12 years, and the new recommendations call for a booster dose at age 16 years. Adolescents given their first dose at ages 13 through 15 years should receive a booster dose at ages 16 through 18 years. A 2-dose primary series should be given 2 months apart to people at ages 2 through 54 years who are at higher risk for meningococcal disease.
* A single dose of Tdap should be given to children 7 through 10 years old who are not fully immunized against pertussis, including those who were never vaccinated or those with unknown pertussis vaccination status. Children 7 through 10 years old should be vaccinated according to the catch-up schedule if further doses are needed for complete immunization against tetanus and diphtheria. If adolescents 13 through 18 years old have not received the Tdap vaccine, they should receive a dose followed by a tetanus and diphtheria toxoids vaccine (Td) booster dose every 10 years thereafter. For children 7 through 18 years old, there is no longer a specified interval between the Td and Tdap vaccines.
* The policy statement contains guidance for use of Haemophilus influenzae type b vaccine in persons at least 5 years old who are at greater risk. Clinicians should consider giving 1 dose of Haemophilus influenzae type b vaccine to persons who are at least 5 years old who have sickle cell disease, leukemia, or HIV infection or in children who have undergone splenectomy.
* To prevent cervical precancerous lesions and cancers in girls, the new guidelines recommend the quadrivalent HPV vaccine (HPV4) and the bivalent vaccine (HPV2). To help prevent genital warts, HPV4 is also recommended for girls, and boys 9 through 18 years old may be given a 3-dose series of HPV4.
"Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS)," the statement authors conclude. "Guidance about how to obtain and complete a VAERS form can be obtained on the Internet at www.vaers.hhs.gov [new Web address is http://vaers.hhs.gov/index] or by calling 800-822-7967. Additional information can be found in the 2009 RedBook1 and at Red Book Online (www.aapredbook.org)."
Pediatrics. Published online February 1, 2011. Full text
Laurie Barclay, MD
February 1, 2011 — The American Academy of Pediatrics (AAP) has issued 2011 immunization schedules recommended for childhood and adolescents and published a policy statement describing the new schedules online February 1 in Pediatrics.
The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and the American Academy of Family Physicians have also approved the new recommendations, which were written by the Committee on Infectious Diseases, chaired by Michael T. Brady, MD.
Highlights of the new schedules include guidance on hepatitis B vaccine administration to children who did not receive the recommended birth dose, and new recommendations on the use of 13-valent pneumococcal conjugate vaccine (PCV13), which replaced the 7-valent pneumococcal conjugate vaccine (PCV7).
Because of recent outbreaks of pertussis nationwide, the new recommendations offer guidance for a dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in 7- to 10-year-old children who have not been adequately immunized against pertussis. The updated schedules now recommend a booster dose of the conjugated meningococcal vaccine to improve protection of adolescents throughout the greatest period of risk for meningococcal disease. Instructions on dosing of influenza vaccine are now based on a history of receiving monovalent 2009 H1N1 vaccine. The policy statement also offers guidance on administering human papillomavirus (HPV) vaccines to boys 9 to 18 years old to lower their risk of acquiring genital warts.
Specific Updated Changes
Specific changes in the 2011 schedules from last year include the following:
* For children who did not receive the recommended birth dose of hepatitis B vaccine, the new recommendations offer guidance for administering the hepatitis B vaccine series. The catch-up schedule now includes a minimal age for dose 3 of hepatitis B vaccine, so that the final (third or fourth) dose in the series should be given no sooner than age 24 weeks.
* New recommendations are included on the use of PCV13, so that a PCV series started with PCV7 should be completed with PCV13. All children 14 through 59 months old who received an age-appropriate series of PCV7 should receive a single supplemental dose of PCV13. All children 60 through 71 months old with underlying medical conditions who have received an age-appropriate series of PCV7 should receive a single supplemental dose of PCV13. The supplemental PCV13 dose should be given at least 8 weeks after the previous dose of PCV7. Children 6 through 18 years old with functional or anatomic asplenia, HIV infection or other immunocompromising conditions, cochlear implant, or cerebrospinal fluid leak may be given a single dose of PCV13. Children at least 2 years old who have certain underlying medical conditions should be given the pneumococcal polysaccharide vaccine (PPSV) no sooner than 8 weeks after the last dose of PCV. Children with functional or anatomic asplenia or an immunocompromising condition should receive a single revaccination with PPSV after 5 years.
* On the basis of the child's history of receiving monovalent 2009 H1N1 vaccine, the new recommendations offer guidance for administering 1 or 2 doses of influenza vaccine. Children 6 months through 8 years old who are receiving influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but only received 1 dose at that time should receive 2 doses at least 4 weeks apart. Two doses of 2010-2011 seasonal influenza vaccine should be given to children 6 months through 8 years old who received no doses of monovalent 2009 H1N1 vaccine or in whom the dosing schedule is unknown.
* Adolescents should be routinely immunized with quadrivalent meningococcal conjugate vaccine (MCV4), preferably at ages 11 through 12 years, and the new recommendations call for a booster dose at age 16 years. Adolescents given their first dose at ages 13 through 15 years should receive a booster dose at ages 16 through 18 years. A 2-dose primary series should be given 2 months apart to people at ages 2 through 54 years who are at higher risk for meningococcal disease.
* A single dose of Tdap should be given to children 7 through 10 years old who are not fully immunized against pertussis, including those who were never vaccinated or those with unknown pertussis vaccination status. Children 7 through 10 years old should be vaccinated according to the catch-up schedule if further doses are needed for complete immunization against tetanus and diphtheria. If adolescents 13 through 18 years old have not received the Tdap vaccine, they should receive a dose followed by a tetanus and diphtheria toxoids vaccine (Td) booster dose every 10 years thereafter. For children 7 through 18 years old, there is no longer a specified interval between the Td and Tdap vaccines.
* The policy statement contains guidance for use of Haemophilus influenzae type b vaccine in persons at least 5 years old who are at greater risk. Clinicians should consider giving 1 dose of Haemophilus influenzae type b vaccine to persons who are at least 5 years old who have sickle cell disease, leukemia, or HIV infection or in children who have undergone splenectomy.
* To prevent cervical precancerous lesions and cancers in girls, the new guidelines recommend the quadrivalent HPV vaccine (HPV4) and the bivalent vaccine (HPV2). To help prevent genital warts, HPV4 is also recommended for girls, and boys 9 through 18 years old may be given a 3-dose series of HPV4.
"Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS)," the statement authors conclude. "Guidance about how to obtain and complete a VAERS form can be obtained on the Internet at www.vaers.hhs.gov [new Web address is http://vaers.hhs.gov/index] or by calling 800-822-7967. Additional information can be found in the 2009 RedBook1 and at Red Book Online (www.aapredbook.org)."
Pediatrics. Published online February 1, 2011. Full text
Added Sugar Intake in US Adolescents Linked to Cardiovascular Risk
From Medscape Medical News
Laurie Barclay, MD
January 31, 2011 — Added sugar intake in US adolescents is linked to increased cardiovascular disease risk, according to the results of a cross-sectional study reported online January 10 in Circulation.
"Whereas increased carbohydrate and sugar consumption has been associated with higher cardiovascular disease risk among adults, little is known about the impact of high consumption of added sugars (caloric sweeteners) among US adolescents," write Jean A. Welsh, MPH, RN, from the Nutrition and Health Science Program, Emory University School of Medicine in Atlanta, Georgia, and colleagues.
Dietary data from one 24-hour recall of 2157 US adolescents enrolled in the National Health and Nutrition Examination Survey 1999 to 2004 were merged with added sugar content data from the US Department of Agriculture MyPyramid Equivalents databases. Measures of cardiovascular disease risk were estimated as a function of added sugar intake level (< 10%, 10% to < 15%, 15% to < 20%, 20% to < 25%, 25% to < 30%, and ≥ 30% of total energy).
Multivariable means were weighted to be representative of US adolescents, and variances were adjusted to account for the complex sampling methods.
Average daily intake of added sugars was 21.4% of total energy. Added sugar consumption correlated inversely with mean high-density lipoprotein (HDL) cholesterol levels (mmol/L). The lowest consumers had a mean HDL of 1.40 (95% confidence interval [CI], 1.36 - 1.44), and the highest consumers had a mean HDL of 1.28 (95% CI, 1.23 - 1.33; P for trend = .001).
Added sugar intake correlated positively with geometric mean triglyceride levels (mmol/L), which were 0.81 (95% CI, 0.74 - 0.88) in the lowest consumers and 0.89 (95% CI, 0.83 - 0.96) in the highest consumers (P for trend = .05). Added sugar intake also correlated positively with low-density lipoprotein (LDL) cholesterol levels (mmol/L), which were 2.24 (95% CI, 2.12 - 2.37) in the lowest consumers and 2.44 (95% CI, 2.34 - 2.53) in the highest consumers (P for trend = .01).
For adolescents who were overweight or obese, defined as a body mass index at or above the 85th percentile, added sugars correlated positively with the homeostasis model assessment of insulin resistance (HOMA-IR; P for linear trend = .004).
"Consumption of added sugars among US adolescents is positively associated with multiple measures known to increase cardiovascular disease risk," the study authors write.
Limitations of this study include cross-sectional design with exposures and outcomes measured at the same time, precluding determination of causality; use of a single 24-hour dietary recall; possible residual confounding; and lack of information on the validity of the process used to estimate added sugar content data in the US Department of Agriculture MyPyramid Equivalents databases.
"Though long-term trials to study the effect of reducing the consumption of added sugars are needed, the results of this study suggest that future risk of CVD [cardiovascular disease] may be reduced by minimizing consumption of added sugars among adolescents," the study authors conclude.
Circulation. Published online January 10, 2011. Abstract
Laurie Barclay, MD
January 31, 2011 — Added sugar intake in US adolescents is linked to increased cardiovascular disease risk, according to the results of a cross-sectional study reported online January 10 in Circulation.
"Whereas increased carbohydrate and sugar consumption has been associated with higher cardiovascular disease risk among adults, little is known about the impact of high consumption of added sugars (caloric sweeteners) among US adolescents," write Jean A. Welsh, MPH, RN, from the Nutrition and Health Science Program, Emory University School of Medicine in Atlanta, Georgia, and colleagues.
Dietary data from one 24-hour recall of 2157 US adolescents enrolled in the National Health and Nutrition Examination Survey 1999 to 2004 were merged with added sugar content data from the US Department of Agriculture MyPyramid Equivalents databases. Measures of cardiovascular disease risk were estimated as a function of added sugar intake level (< 10%, 10% to < 15%, 15% to < 20%, 20% to < 25%, 25% to < 30%, and ≥ 30% of total energy).
Multivariable means were weighted to be representative of US adolescents, and variances were adjusted to account for the complex sampling methods.
Average daily intake of added sugars was 21.4% of total energy. Added sugar consumption correlated inversely with mean high-density lipoprotein (HDL) cholesterol levels (mmol/L). The lowest consumers had a mean HDL of 1.40 (95% confidence interval [CI], 1.36 - 1.44), and the highest consumers had a mean HDL of 1.28 (95% CI, 1.23 - 1.33; P for trend = .001).
Added sugar intake correlated positively with geometric mean triglyceride levels (mmol/L), which were 0.81 (95% CI, 0.74 - 0.88) in the lowest consumers and 0.89 (95% CI, 0.83 - 0.96) in the highest consumers (P for trend = .05). Added sugar intake also correlated positively with low-density lipoprotein (LDL) cholesterol levels (mmol/L), which were 2.24 (95% CI, 2.12 - 2.37) in the lowest consumers and 2.44 (95% CI, 2.34 - 2.53) in the highest consumers (P for trend = .01).
For adolescents who were overweight or obese, defined as a body mass index at or above the 85th percentile, added sugars correlated positively with the homeostasis model assessment of insulin resistance (HOMA-IR; P for linear trend = .004).
"Consumption of added sugars among US adolescents is positively associated with multiple measures known to increase cardiovascular disease risk," the study authors write.
Limitations of this study include cross-sectional design with exposures and outcomes measured at the same time, precluding determination of causality; use of a single 24-hour dietary recall; possible residual confounding; and lack of information on the validity of the process used to estimate added sugar content data in the US Department of Agriculture MyPyramid Equivalents databases.
"Though long-term trials to study the effect of reducing the consumption of added sugars are needed, the results of this study suggest that future risk of CVD [cardiovascular disease] may be reduced by minimizing consumption of added sugars among adolescents," the study authors conclude.
Circulation. Published online January 10, 2011. Abstract
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