Anthony J. Brown, MD
Désirée Lie, MD, MSEd
Ann Emerg Med. 2009;54:553-560. Abstract
Reuters Health Information 2009. © 2009 Reuters Ltd.
Clinical Context
Children with simple fractures require adequate pain relief after discharge from the emergency department (ED). Although ibuprofen potentially provides similar pain relief as opioids, ED practices vary widely, and limited data are available comparing the 2 analgesics.
This is a randomized, double-blind controlled trial of children presenting with simple arm fracture to ED during 4 years to compare the efficacy of ibuprofen vs acetaminophen with codeine on outpatient pain relief, function, and satisfaction.
Study Highlights
Included were children aged 4 to 18 years weighing less than 60 kg presenting to a level I hospital ED within 12 hours of injury (2003-2007) with a fracture of the ulna, radius, or humerus visualized on a standard 2-view radiograph with fracture diagnosis confirmed by a pediatric radiologist.
Excluded were children with an isolated posterior fat pad of the elbow, open fractures, and those who required manipulation or reduction in the ED, with developmental delay, chronic illness, allergy to the medications, or a history of bleeding or gastrointestinal tract disorders.
All treatment decisions were made by board-certified emergency pediatricians and fellows; patients received usual care including splinting by ED personnel and analgesia in the ED.
Primary outcome was failure of pain relief, defined as use of rescue medication.
Secondary outcomes were pain relief, pain medication use, pain scores, functional outcomes, and adverse effects.
Outcomes were collected in a diary given to parents and returned in a stamped, addressed envelope with 2 telephone calls made in the first 72 hours after discharge from the ED to remind parents.
Ibuprofen suspension was dosed at 10 mg/kg (100 mg/5 mL) and acetaminophen with codeine at 1 mg/kg (120 mg/5 mg per 5 mL) of the codeine content, with a maximum of 4 permitted doses in 24 hours.
The medications were matched for color and volume but not taste.
Parents were instructed to use the rescue medication if pain was not relieved (pain score ≥ 3) 1 hour after dosing of the study medication.
The modified Bieri Faces Pain Scale was the validated pain scale used for assessment by parents; children were assessed at awakening, bedtime, and before and at 1 hour after each dose.
Daily total, median, maximal, and minimum scores were collected.
Parent satisfaction was recorded daily with a Likert scale, and the Total Quality Pain Management instrument was used for parent and child on day 3.
167 children were assigned to acetaminophen with codeine and 169 to ibuprofen, with a follow-up of 75% for acetaminophen with codeine and 78% for ibuprofen.
244 children were included in the analysis after some were ineligible or lost to follow-up (116 in the acetaminophen/codeine group and 128 in the ibuprofen group).
Mean age was 8 years, half were boys, mean weight was 28 kg, 75% were white, and 9.5% to 14.1% were black.
Half were radius-only fractures, and one fifth involved the radius and ulna.
There were no significant differences in the number of doses of medication received 3 days after ED discharge, and only 7% of children used no medication.
The difference in failure of medication was not significant between the ibuprofen group (20.3%) and the acetaminophen with codeine group (31.0%).
There were no differences in total pain scores for days 0 to 3 including scores at awakening, bedtime, and before and after medication.
For functional outcomes, ibuprofen was significantly superior in return to play and eating but not for return to school and sleep functions.
60% of children had at least 1 function affected on the day of injury and 29.4% by day 3.
The risk for an adverse effect was significantly greater in the acetaminophen with codeine group (50.9%) than the ibuprofen group (29.5%).
Nausea and vomiting were significantly more common in the acetaminophen with codeine group.
86% of parents who used ibuprofen vs 67% of those using acetaminophen with codeine were very satisfied or satisfied.
27.5% in the acetaminophen group vs 10% in the ibuprofen group said they would not use the medication again.
The authors concluded that ibuprofen was similar in efficacy for pain relief in children with simple arm fracture but superior in return to function and fewer adverse effects and that ibuprofen is preferable in the outpatient management of simple arm fracture.
Clinical Implications
Ibuprofen is similar to acetaminophen with codeine in efficacy for pain relief in children with simple arm fracture.
Ibuprofen is superior to acetaminophen with codeine for return to play and eating and fewer adverse effects in the outpatient management of simple arm fracture.
Monday, October 26, 2009
Vitamin D Supplementation 2008 Recommendation
Prevention and Management of Vitamin D Deficiency in Children: Part II. Vitamin D Supplementation: Dosing Recommendations
Medscape Pediatrics
The current recommendation from both the AAP and the Lawson Wilkins Pediatric Endocrine Society is a minimum dietary intake of 400 International Units/day (10 mcg/day) for neonates, children, and adolescents.[3,4]
If this amount cannot be achieved through their normal diet, a vitamin D supplement should be administered.
Exclusively breastfed infants and those consuming less than 1 L of infant formula/day should receive 400 International Units/day of an oral liquid vitamin D product.[3,4]
The Lawson Wilkins Pediatric Endocrine Society recommends that preterm infants should receive 400 to 800 International Units of vitamin D (10 to 20 mcg) per day to compensate for decreased placental transfer in utero and decreased gastrointestinal absorption after birth.[4]
For treatment of documented vitamin D deficiency, infants may be given 1,000 to 2,000 International Units/day (25 to 50 mcg) and older children may be given up to 5,000 International Units/day (125 mcg) for 2 to 3 months.[4,8]
A variety of alternative dosing regimens have been published over the past decade.
A high-dose short-course regimen providing a total of 100,000 to 600,000 International Units (2.5 to 15 mg) over 1 to 5 days has been suggested for patients who might not adhere to longer regimens.[4]
Vitamin D dosing in children with kidney disease or other chronic illnesses should be based on serum 25(OH)D levels. Table 1 provides general recommendations for these patients. Table 2 lists dosing recommendations for children with severe or chronic deficiency states.[3–7]
Vitamin D supplements may be taken with or without food.
Administration with food may be useful to reduce stomach upset.
Calcium supplementation (30 to 75 mg/kg/day oral elemental calcium) is often necessary to maximize response in patients with vitamin D deficiency.
Patients receiving vitamin D supplementation beyond the recommended daily dietary intake should undergo periodic monitoring of serum 25(OH)D levels, using an assay for both 25(OH)D2 and 25(OH)D3, as well as serum calcium, phosphorus, and alkaline phosphatase at one and three months or until stabilized, followed by annual reassessment. Parathyroid and bone mineralization studies should be conducted as needed.[3–7]
Medscape Pediatrics
The current recommendation from both the AAP and the Lawson Wilkins Pediatric Endocrine Society is a minimum dietary intake of 400 International Units/day (10 mcg/day) for neonates, children, and adolescents.[3,4]
If this amount cannot be achieved through their normal diet, a vitamin D supplement should be administered.
Exclusively breastfed infants and those consuming less than 1 L of infant formula/day should receive 400 International Units/day of an oral liquid vitamin D product.[3,4]
The Lawson Wilkins Pediatric Endocrine Society recommends that preterm infants should receive 400 to 800 International Units of vitamin D (10 to 20 mcg) per day to compensate for decreased placental transfer in utero and decreased gastrointestinal absorption after birth.[4]
For treatment of documented vitamin D deficiency, infants may be given 1,000 to 2,000 International Units/day (25 to 50 mcg) and older children may be given up to 5,000 International Units/day (125 mcg) for 2 to 3 months.[4,8]
A variety of alternative dosing regimens have been published over the past decade.
A high-dose short-course regimen providing a total of 100,000 to 600,000 International Units (2.5 to 15 mg) over 1 to 5 days has been suggested for patients who might not adhere to longer regimens.[4]
Vitamin D dosing in children with kidney disease or other chronic illnesses should be based on serum 25(OH)D levels. Table 1 provides general recommendations for these patients. Table 2 lists dosing recommendations for children with severe or chronic deficiency states.[3–7]
Vitamin D supplements may be taken with or without food.
Administration with food may be useful to reduce stomach upset.
Calcium supplementation (30 to 75 mg/kg/day oral elemental calcium) is often necessary to maximize response in patients with vitamin D deficiency.
Patients receiving vitamin D supplementation beyond the recommended daily dietary intake should undergo periodic monitoring of serum 25(OH)D levels, using an assay for both 25(OH)D2 and 25(OH)D3, as well as serum calcium, phosphorus, and alkaline phosphatase at one and three months or until stabilized, followed by annual reassessment. Parathyroid and bone mineralization studies should be conducted as needed.[3–7]
Quadrivalent HPV Vaccine (Gardasil) Cuts Rates of Genital Warts
From Medscape Medical News
Roxanne Nelson
October 21, 2009 — The quadrivalent human papillomavirus (HPV) vaccine (Gardasil, Merck & Co) can reduce the incidence of genital warts in women and girls, and might even benefit heterosexual men. According to Australian researchers, the proportion of young women diagnosed with genital warts declined by 25% each quarter in 2008 after the initiation of an HPV vaccine program.
This is in comparison to a 1.8% increase in new cases of genital warts per quarter from 2004 to 2007, before the beginning of the vaccination initiative. The results of this analysis were published online October 16 in Sexually Transmitted Infections.
The main aim of HPV vaccination is to reduce cervical cancer (caused by HPV types 16 and 18), but Gardasil, 1 of the 2 vaccines that is available, also offers protection against genital warts (HPV types 6 and 11); Cervarix (GlaxoSmithKline), the other one, does not.
The authors note that governments in different countries are currently trying to decide which of the 2 vaccines should be included in their immunization programs, and need robust data to determine the impact of the vaccine at a population level. Beginning in 2007, Australia became one of the first countries to offer the Gardasil vaccine free of charge to girls aged 12 to 18 years, in a school-based program, and to women younger than 27 years, through general practices. The coverage rate for women between 18 and 26 years is estimated to be 65% to 70%.
Although both vaccines are licensed in Australia, only Gardasil is being used in the program. "Gardasil is the only free one at this stage," lead author Christopher K. Fairley, MBBS, PhD, told Medscape Oncology. "But one can buy Cervarix privately."
There are also no programs targeting men at this point. "It is licensed for boys, but must be purchased privately," said Dr. Fairley, who is a professor of sexual health at the University of Melbourne and director of the Melbourne Sexual Health Centre (MSHC) in Australia.
Reduced Incidence of Warts in Targeted Population
The goals of the study were to evaluate the national HPV vaccination program and to determine if it had a measurable impact on the clinical presentation of genital warts in the year after its implementation.
In this retrospective study, Dr. Fairley and colleagues compared the proportion of new patients who were diagnosed with genital warts at the MSHC from January 2004 to December 2008. During that time, 36,055 patients were seen at MSHC for the first time, and genital warts were diagnosed in 3826 (10.6%).
Only women younger than 28 years showed strong evidence of a significant difference in the average quarterly change between time periods; there was a 1.8% increase before the end of 2007 and a 25.1% decrease after the end of 2007 (P < .001). Heterosexual men were the only other subgroup to show a decrease in presentations for genital warts in 2008, with an average quarterly decrease of 5% (P = .031).
No reduction was seen in homosexual men or women beyond the targeted age group (>28 years).
The reduction in genital warts observed in heterosexual but not homosexual men might be consistent with a reduction in heterosexual transmission of HPV as a result of the women's vaccine program, the authors write. "These data should be of value to governments making decisions about whether to implement HPV vaccination in women and may assist in informing the choice of vaccine," they conclude.
Dr. Fairley pointed out that, when determining the cost effectiveness of vaccination, the avoided costs must be taken into account as well as the actual cost of the vaccine, if the price between them differs.
"There is also the issue of the duration of the immune response, and whether other subtypes are covered," he said. "Both these issues are currently under debate by the 2 vaccine companies."
No funding was obtained to undertake this study. Dr. Fairley reports receiving honoraria and research funding from and owns shares in CSL Biotherapies, the manufacturer of Gardasil. Coauthor Jane S. Hocking, MPH, PhD, from the University of Melbourne, reports receiving honoraria from CSL Biotherapies. Coauthor Basil Donovan, MD, from the University of New South Wales in Australia, reports receiving research funding from CSL Biotherapies and honoraria from GlaxoSmithKline and CSL Biotherapies.
Sex Transm Infect. Published online October 16, 2009. Abstract
Roxanne Nelson
October 21, 2009 — The quadrivalent human papillomavirus (HPV) vaccine (Gardasil, Merck & Co) can reduce the incidence of genital warts in women and girls, and might even benefit heterosexual men. According to Australian researchers, the proportion of young women diagnosed with genital warts declined by 25% each quarter in 2008 after the initiation of an HPV vaccine program.
This is in comparison to a 1.8% increase in new cases of genital warts per quarter from 2004 to 2007, before the beginning of the vaccination initiative. The results of this analysis were published online October 16 in Sexually Transmitted Infections.
The main aim of HPV vaccination is to reduce cervical cancer (caused by HPV types 16 and 18), but Gardasil, 1 of the 2 vaccines that is available, also offers protection against genital warts (HPV types 6 and 11); Cervarix (GlaxoSmithKline), the other one, does not.
The authors note that governments in different countries are currently trying to decide which of the 2 vaccines should be included in their immunization programs, and need robust data to determine the impact of the vaccine at a population level. Beginning in 2007, Australia became one of the first countries to offer the Gardasil vaccine free of charge to girls aged 12 to 18 years, in a school-based program, and to women younger than 27 years, through general practices. The coverage rate for women between 18 and 26 years is estimated to be 65% to 70%.
Although both vaccines are licensed in Australia, only Gardasil is being used in the program. "Gardasil is the only free one at this stage," lead author Christopher K. Fairley, MBBS, PhD, told Medscape Oncology. "But one can buy Cervarix privately."
There are also no programs targeting men at this point. "It is licensed for boys, but must be purchased privately," said Dr. Fairley, who is a professor of sexual health at the University of Melbourne and director of the Melbourne Sexual Health Centre (MSHC) in Australia.
Reduced Incidence of Warts in Targeted Population
The goals of the study were to evaluate the national HPV vaccination program and to determine if it had a measurable impact on the clinical presentation of genital warts in the year after its implementation.
In this retrospective study, Dr. Fairley and colleagues compared the proportion of new patients who were diagnosed with genital warts at the MSHC from January 2004 to December 2008. During that time, 36,055 patients were seen at MSHC for the first time, and genital warts were diagnosed in 3826 (10.6%).
Only women younger than 28 years showed strong evidence of a significant difference in the average quarterly change between time periods; there was a 1.8% increase before the end of 2007 and a 25.1% decrease after the end of 2007 (P < .001). Heterosexual men were the only other subgroup to show a decrease in presentations for genital warts in 2008, with an average quarterly decrease of 5% (P = .031).
No reduction was seen in homosexual men or women beyond the targeted age group (>28 years).
The reduction in genital warts observed in heterosexual but not homosexual men might be consistent with a reduction in heterosexual transmission of HPV as a result of the women's vaccine program, the authors write. "These data should be of value to governments making decisions about whether to implement HPV vaccination in women and may assist in informing the choice of vaccine," they conclude.
Dr. Fairley pointed out that, when determining the cost effectiveness of vaccination, the avoided costs must be taken into account as well as the actual cost of the vaccine, if the price between them differs.
"There is also the issue of the duration of the immune response, and whether other subtypes are covered," he said. "Both these issues are currently under debate by the 2 vaccine companies."
No funding was obtained to undertake this study. Dr. Fairley reports receiving honoraria and research funding from and owns shares in CSL Biotherapies, the manufacturer of Gardasil. Coauthor Jane S. Hocking, MPH, PhD, from the University of Melbourne, reports receiving honoraria from CSL Biotherapies. Coauthor Basil Donovan, MD, from the University of New South Wales in Australia, reports receiving research funding from CSL Biotherapies and honoraria from GlaxoSmithKline and CSL Biotherapies.
Sex Transm Infect. Published online October 16, 2009. Abstract
Thursday, October 22, 2009
Cell Phones & Brain Cancer - the jury still out
From Medscape Medical News
Cell Phones and Brain Cancer -- Jury Still Out
Roxanne Nelson
October 14, 2009 — Cellular telephones have become an integral part of everyday life; they are now used by an estimated 4 billion people worldwide. But this is a relatively new technology, and there are lingering concerns about health risks, in particular a risk for brain cancer.
A new report suggests that that regular use of cell phones can result in a "significant" risk for brain tumors. But previous studies have been inconsistent. Even so, some European countries have taken precautionary measures, aimed specifically at children.
Cell phones can be made safer, and the technology to do so exists right now. For example, said Mr. Morgan, "you can get a 10,000-fold reduction in exposure simply by keeping the phone 6 inches away from the head."
There are also steps that can be taken right now to make cell phones safer to use, he said. These include using a wired headset (not a wireless headset such as a Bluetooth), using speaker-phone mode, or sending text messages; keeping the phone away from the body when not in use; avoiding use in a moving car, train, or bus, or in rural areas at some distance from a cell tower, because any of these uses will increase the power of the cell phone's radiation; and keeping the cell phone turned off until you need to use it.
The authors also recommend using a corded land-line phone whenever possible, instead of a wireless phone, and to avoid cell phones when inside buildings, particularly with steel structures. Since children face a greater health risk, they should not be allowed to sleep with a cell phone under their pillows or at the bedside, said Mr. Morgan. Ideally, those younger than 18 years should not use a cell phone at all, except for emergencies.
for full article see http://www.medscape.com/viewarticle/710492?sssdmh=dm1.542869&src=nldne&uac=71630FV or drtanpohtin.blogspot.com
Cell Phones and Brain Cancer -- Jury Still Out
Roxanne Nelson
October 14, 2009 — Cellular telephones have become an integral part of everyday life; they are now used by an estimated 4 billion people worldwide. But this is a relatively new technology, and there are lingering concerns about health risks, in particular a risk for brain cancer.
A new report suggests that that regular use of cell phones can result in a "significant" risk for brain tumors. But previous studies have been inconsistent. Even so, some European countries have taken precautionary measures, aimed specifically at children.
Cell phones can be made safer, and the technology to do so exists right now. For example, said Mr. Morgan, "you can get a 10,000-fold reduction in exposure simply by keeping the phone 6 inches away from the head."
There are also steps that can be taken right now to make cell phones safer to use, he said. These include using a wired headset (not a wireless headset such as a Bluetooth), using speaker-phone mode, or sending text messages; keeping the phone away from the body when not in use; avoiding use in a moving car, train, or bus, or in rural areas at some distance from a cell tower, because any of these uses will increase the power of the cell phone's radiation; and keeping the cell phone turned off until you need to use it.
The authors also recommend using a corded land-line phone whenever possible, instead of a wireless phone, and to avoid cell phones when inside buildings, particularly with steel structures. Since children face a greater health risk, they should not be allowed to sleep with a cell phone under their pillows or at the bedside, said Mr. Morgan. Ideally, those younger than 18 years should not use a cell phone at all, except for emergencies.
for full article see http://www.medscape.com/viewarticle/710492?sssdmh=dm1.542869&src=nldne&uac=71630FV or drtanpohtin.blogspot.com
High Blood Pressure in Children
From Medscape Pediatrics
New European Society of Hypertension Guidelines for Management of High Blood Pressure in Children: An Expert Interview With Empar Lurbe, MD, PhD
Pippa Wysong
Hypertension in the pediatric population is an ongoing concern; in response, the European Society of Hypertension recently released new guidelines. Lead author Empar Lurbe, MD, PhD, spoke to Medscape about the guidelines, and why hypertension needs to be addressed in this young population. Dr. Lurbe is from the Department of Pediatrics at Consorcio Hospital General, the University of Valencia, Spain. She was the lead author of the new guidelines, "Management of High Blood Pressure in Children and Adolescents: Recommendations of the European Society of Hypertension" published in the Journal of Hypertension.[1] She spoke to Medscape's Pippa Wysong.
Medscape: Guidelines addressing hypertension in children and adolescents were published in the United States in 2004. Why are new guidelines needed now?
Dr. Lurbe: The necessity for guidelines has become increasingly clear to physicians in light of growing evidence that cases of mild hypertension in children and adolescents are much more common than previously thought. In addition, progress made in pathophysiologic and clinical research has made clear links between pediatric hypertension and cardiovascular disease later in life, highlighting the need for improved cardiovascular prevention strategies for pre-adult individuals.
The Task Force set up by the European Society of Hypertension has combined considerable amounts of scientific data with clinical experience to represent a consensus among specialists involved in the detection and control of high blood pressure (BP) in children and adolescents. It is hoped that the publication of these guidelines will call attention to the huge burden of hypertension in this young population, and encourage public policymakers to develop a global effort to improve identification and treatment of high BP among young people. Primarily, however, these guidelines provide practical strategies for diagnosing and treating hypertension in children and adolescents.
Medscape: What adverse health effects are caused by uncontrolled hypertension in children? Are they different than those in adults?
Dr. Lurbe: There has been a lot of work on the pathophysiology and epidemiology of high blood pressure in children over the past couple of decades. Hypertension can cause organ damage in the heart, blood vessels, kidney, brain, and retina. Events tend to be rare, so most of the evidence we have is based on the use of the markers of organ damage -- such as left ventricular hypertrophy and increased urinary albumin excretion. Clinical experience shows that reducing high blood pressure in conditions such as acute heart failure, hypertensive encephalopathy, and malignant hypertension improves survival and reduces sequelae in children. There is no doubt that increased blood pressure in children can lead to serious problems.
Medscape: Does hypertension tend to be accompanied by elevated cholesterol and other risk factors? Should these be screened and treated too?
Dr. Lurbe: Risk factors include comorbidities such as elevated cholesterol. This is especially true in obese hypertensive children, and those who have a family history of cardiovascular disease.
Medscape: What portion of hypertensive children become hypertensive adults? How strong is the evidence for this?
Dr. Lurbe: The roots of hypertension in adulthood tend to extend back to the childhood years. Indeed, childhood blood pressure does continue on into adulthood. This underscores the importance of controlling blood pressure control in children and adolescents.
Medscape: Should all children be regularly screened?
Dr. Lurbe: Children older than 3 years of age who are seen in a medical setting should have their BP measured. In younger children, BP should be measured under special circumstances that increase the risk for hypertension, such as under neonatal conditions requiring intensive care, congenital heart disease, renal disease, treatment with drugs known to increase BP, and evidence of increased intracranial pressure.
Medscape: As children grow, their blood pressure changes, normally. Can you explain how values for different categories have been developed?
Dr. Lurbe: We use a chart to help determine what ranges are normal for specific age, gender, and height. The 95th percentile is used as a cut-off for defining hypertension in children and adolescents. There are normative data based on auscultatory measurements from large studies of children around the world. There are extensive data based on measurements from more than 70,000 children in the United States. Blood pressure percentiles were calculated for each gender, age group, and for 7 height percentile categories. Height percentiles are based on growth charts attained from the Centers for Disease Control and Prevention. In Europe, reference values were obtained in 1991 by pooling data from 28,043 children and adolescents using auscultatory blood pressure measurements. In 1999, normative values were calculated from auscultatory data in 11,519 school children aged 5 to 17 years in Italy - data in that project included age, gender, and height.
Medscape: Is height the most important factor?
Dr. Lurbe: The values are based on age, gender, and height. Values developed for the United States reflect all 3 criteria together, and these are found on Tables 2 and 3 of the new guidelines.[1] The reason why blood pressure values are referred to in age, gender, and height percentiles is to take into account children who are unusually short or tall for their age.
Medscape: How should blood pressure be measured in children? Do methods change with the age of the child?
Dr. Lurbe: The diagnosis of hypertension should be based on multiple office blood pressure measurements, taken on separate occasions over time.
Medscape: Which antihypertensive agents can be used in pediatrics?
Dr. Lurbe: The agents of choice are similar to those in adults: angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists, calcium antagonists, beta-blockers, and diuretics and other antihypertensive agents. There have been very few trials doing head-to-head comparisons of these agents in children.
Medscape: How strong is the evidence for their effectiveness? Are they safe?
Dr. Lurbe: Evidence for effectiveness is mostly of newer drugs, because many of the older drugs are now off-patent and studies weren't performed for the pediatric population. Recommendations in the guidelines are based primarily on a few industry-sponsored studies, and mostly case series from single centers. There is also collective clinical experience, expert opinions, and extrapolation from adult studies.
Medscape: Should doctors recommend lifestyle changes before trying drug therapy? Would lifestyle changes and weight loss be enough?
Dr. Lurbe: That might help for mild cases, but there is currently a lack of hard evidence. Studies are underway looking at lifestyle changes. With medications, generally, it is recommended that children begin with a low dose of a single drug. You don't want blood pressure to drop too rapidly. If a single drug doesn't do the trick, then combinations may be needed -- especially in severe hypertension.
Medscape: What lifestyle changes should physicians discuss with patients/parents?
Dr. Lurbe: Most interventions are common sense, such as exercise, weight loss, and a healthy diet. Some evidence suggests 40 minutes of aerobic-based exercise 3-5 times weekly improves vascular function and lowers blood pressure in children. Interventions that work together to reduce energy intake and increase activity are bound to help. Dietary trials clarifying what would work best in children are underway. Making sure diets are generally balanced, and reducing junk food is common sense.
Medscape: What does the future hold in this area?
Dr. Lurbe: A lot more research is necessary, ranging from high-quality clinical trials comparing treatments, as well as trials looking at long-term outcomes such as organ damage. There is also a need for robust values for home, office, and ambulatory blood pressure.
Medscape: You've touched on a lot of areas in the guidelines. Thanks for talking to Medscape today.
References
New European Society of Hypertension Guidelines for Management of High Blood Pressure in Children: An Expert Interview With Empar Lurbe, MD, PhD
Pippa Wysong
Hypertension in the pediatric population is an ongoing concern; in response, the European Society of Hypertension recently released new guidelines. Lead author Empar Lurbe, MD, PhD, spoke to Medscape about the guidelines, and why hypertension needs to be addressed in this young population. Dr. Lurbe is from the Department of Pediatrics at Consorcio Hospital General, the University of Valencia, Spain. She was the lead author of the new guidelines, "Management of High Blood Pressure in Children and Adolescents: Recommendations of the European Society of Hypertension" published in the Journal of Hypertension.[1] She spoke to Medscape's Pippa Wysong.
Medscape: Guidelines addressing hypertension in children and adolescents were published in the United States in 2004. Why are new guidelines needed now?
Dr. Lurbe: The necessity for guidelines has become increasingly clear to physicians in light of growing evidence that cases of mild hypertension in children and adolescents are much more common than previously thought. In addition, progress made in pathophysiologic and clinical research has made clear links between pediatric hypertension and cardiovascular disease later in life, highlighting the need for improved cardiovascular prevention strategies for pre-adult individuals.
The Task Force set up by the European Society of Hypertension has combined considerable amounts of scientific data with clinical experience to represent a consensus among specialists involved in the detection and control of high blood pressure (BP) in children and adolescents. It is hoped that the publication of these guidelines will call attention to the huge burden of hypertension in this young population, and encourage public policymakers to develop a global effort to improve identification and treatment of high BP among young people. Primarily, however, these guidelines provide practical strategies for diagnosing and treating hypertension in children and adolescents.
Medscape: What adverse health effects are caused by uncontrolled hypertension in children? Are they different than those in adults?
Dr. Lurbe: There has been a lot of work on the pathophysiology and epidemiology of high blood pressure in children over the past couple of decades. Hypertension can cause organ damage in the heart, blood vessels, kidney, brain, and retina. Events tend to be rare, so most of the evidence we have is based on the use of the markers of organ damage -- such as left ventricular hypertrophy and increased urinary albumin excretion. Clinical experience shows that reducing high blood pressure in conditions such as acute heart failure, hypertensive encephalopathy, and malignant hypertension improves survival and reduces sequelae in children. There is no doubt that increased blood pressure in children can lead to serious problems.
Medscape: Does hypertension tend to be accompanied by elevated cholesterol and other risk factors? Should these be screened and treated too?
Dr. Lurbe: Risk factors include comorbidities such as elevated cholesterol. This is especially true in obese hypertensive children, and those who have a family history of cardiovascular disease.
Medscape: What portion of hypertensive children become hypertensive adults? How strong is the evidence for this?
Dr. Lurbe: The roots of hypertension in adulthood tend to extend back to the childhood years. Indeed, childhood blood pressure does continue on into adulthood. This underscores the importance of controlling blood pressure control in children and adolescents.
Medscape: Should all children be regularly screened?
Dr. Lurbe: Children older than 3 years of age who are seen in a medical setting should have their BP measured. In younger children, BP should be measured under special circumstances that increase the risk for hypertension, such as under neonatal conditions requiring intensive care, congenital heart disease, renal disease, treatment with drugs known to increase BP, and evidence of increased intracranial pressure.
Medscape: As children grow, their blood pressure changes, normally. Can you explain how values for different categories have been developed?
Dr. Lurbe: We use a chart to help determine what ranges are normal for specific age, gender, and height. The 95th percentile is used as a cut-off for defining hypertension in children and adolescents. There are normative data based on auscultatory measurements from large studies of children around the world. There are extensive data based on measurements from more than 70,000 children in the United States. Blood pressure percentiles were calculated for each gender, age group, and for 7 height percentile categories. Height percentiles are based on growth charts attained from the Centers for Disease Control and Prevention. In Europe, reference values were obtained in 1991 by pooling data from 28,043 children and adolescents using auscultatory blood pressure measurements. In 1999, normative values were calculated from auscultatory data in 11,519 school children aged 5 to 17 years in Italy - data in that project included age, gender, and height.
Medscape: Is height the most important factor?
Dr. Lurbe: The values are based on age, gender, and height. Values developed for the United States reflect all 3 criteria together, and these are found on Tables 2 and 3 of the new guidelines.[1] The reason why blood pressure values are referred to in age, gender, and height percentiles is to take into account children who are unusually short or tall for their age.
Medscape: How should blood pressure be measured in children? Do methods change with the age of the child?
Dr. Lurbe: The diagnosis of hypertension should be based on multiple office blood pressure measurements, taken on separate occasions over time.
Medscape: Which antihypertensive agents can be used in pediatrics?
Dr. Lurbe: The agents of choice are similar to those in adults: angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists, calcium antagonists, beta-blockers, and diuretics and other antihypertensive agents. There have been very few trials doing head-to-head comparisons of these agents in children.
Medscape: How strong is the evidence for their effectiveness? Are they safe?
Dr. Lurbe: Evidence for effectiveness is mostly of newer drugs, because many of the older drugs are now off-patent and studies weren't performed for the pediatric population. Recommendations in the guidelines are based primarily on a few industry-sponsored studies, and mostly case series from single centers. There is also collective clinical experience, expert opinions, and extrapolation from adult studies.
Medscape: Should doctors recommend lifestyle changes before trying drug therapy? Would lifestyle changes and weight loss be enough?
Dr. Lurbe: That might help for mild cases, but there is currently a lack of hard evidence. Studies are underway looking at lifestyle changes. With medications, generally, it is recommended that children begin with a low dose of a single drug. You don't want blood pressure to drop too rapidly. If a single drug doesn't do the trick, then combinations may be needed -- especially in severe hypertension.
Medscape: What lifestyle changes should physicians discuss with patients/parents?
Dr. Lurbe: Most interventions are common sense, such as exercise, weight loss, and a healthy diet. Some evidence suggests 40 minutes of aerobic-based exercise 3-5 times weekly improves vascular function and lowers blood pressure in children. Interventions that work together to reduce energy intake and increase activity are bound to help. Dietary trials clarifying what would work best in children are underway. Making sure diets are generally balanced, and reducing junk food is common sense.
Medscape: What does the future hold in this area?
Dr. Lurbe: A lot more research is necessary, ranging from high-quality clinical trials comparing treatments, as well as trials looking at long-term outcomes such as organ damage. There is also a need for robust values for home, office, and ambulatory blood pressure.
Medscape: You've touched on a lot of areas in the guidelines. Thanks for talking to Medscape today.
References
Wednesday, October 21, 2009
Routine Poliovirus Vaccination
From Morbidity & Mortality Weekly Report
Updated Recommendations of the Advisory Committee on Immunization Practices (ACIP)
Published: 10/15/2009
Introduction
This report updates Advisory Committee on Immunization Practices (ACIP) recommendations for routine poliovirus vaccination.
These updates aim to 1) emphasize the importance of the booster dose at age ≥4 years, 2) extend the minimum interval from dose 3 to dose 4 from 4 weeks to 6 months, 3) add a precaution for the use of minimum intervals in the first 6 months of life, and 4) clarify the poliovirus vaccination schedule when specific combination vaccines are used.
On June 17, 1999, ACIP recommended that all poliovirus vaccine administered in the United States be an inactivated poliovirus vaccine (IPV) beginning January 1, 2000. This policy was implemented to eliminate the risk for vaccine-associated paralytic poliomyelitis, a rare condition that has been associated with use of the live oral poliovirus vaccine (OPV). Since 1999, no OPV has been distributed in the United States. Under these ACIP recommendations, the routine IPV vaccination schedule in the United States consists of 4 doses administered at ages 2 months, 4 months, 6–18 months, and 4–6 years with the minimum interval between all IPV doses as 4 weeks.[1,2]
Since the ACIP recommendation was made 10 years ago, three different combination vaccines containing IPV have been licensed for routine use in the United States (Table). Because of potential confusion in using different vaccine products for routine and catch-up immunization, ACIP recommends the following:
The 4-dose IPV series should continue to be administered at ages 2 months, 4 months, 6–18 months, and 4–6 years.
The final dose in the IPV series should be administered at age ≥4 years regardless of the number of previous doses.
The minimum interval from dose 3 to dose 4 is extended from 4 weeks to 6 months.
The minimum interval from dose 1 to dose 2, and from dose 2 to dose 3, remains 4 weeks.
The minimum age for dose 1 remains age 6 weeks.
ACIP also is making a new recommendation concerning the use of minimum age and minimum intervals for children in the first 6 months of life. Use of the minimum age and minimum intervals for vaccine administration in the first 6 months of life are recommended only if the vaccine recipient is at risk for imminent exposure to circulating poliovirus (e.g., during an outbreak or because of travel to a polio-endemic region). ACIP is making this precaution because shorter intervals and earlier start dates lead to lower seroconversion rates.[3–5]
In addition, ACIP is clarifying the poliovirus vaccination schedule to be used for specific combination vaccines. When DTaP-IPV/Hib* (Pentacel) is used to provide 4 doses at ages 2, 4, 6, and 15–18 months, an additional booster dose of age-appropriate IPV-containing vaccine (IPV [Ipol] or DTaP-IPV† [Kinrix]) should be administered at age 4–6 years. This will result in a 5-dose IPV vaccine series, which is considered acceptable by ACIP.
DTaP-IPV/Hib is not indicated for the booster dose at age 4–6 years. ACIP recommends that the minimum interval from dose 4 to dose 5 should be at least 6 months to provide an optimum booster response. In accordance with existing recommendations, if a child misses an IPV dose at age 4–6 years, the child should receive a booster dose as soon as feasible.[2]
* Diphtheria and tetanus toxoids and acellular pertussis adsorbed, inactivated poliovirus, and Haemophilus b conjugate (tetanus toxoid conjugate) vaccine.
† Diphtheria and tetanus toxoids and acellular pertussis adsorbed, and inactivated poliovirus vaccine.
References
Updated Recommendations of the Advisory Committee on Immunization Practices (ACIP)
Published: 10/15/2009
Introduction
This report updates Advisory Committee on Immunization Practices (ACIP) recommendations for routine poliovirus vaccination.
These updates aim to 1) emphasize the importance of the booster dose at age ≥4 years, 2) extend the minimum interval from dose 3 to dose 4 from 4 weeks to 6 months, 3) add a precaution for the use of minimum intervals in the first 6 months of life, and 4) clarify the poliovirus vaccination schedule when specific combination vaccines are used.
On June 17, 1999, ACIP recommended that all poliovirus vaccine administered in the United States be an inactivated poliovirus vaccine (IPV) beginning January 1, 2000. This policy was implemented to eliminate the risk for vaccine-associated paralytic poliomyelitis, a rare condition that has been associated with use of the live oral poliovirus vaccine (OPV). Since 1999, no OPV has been distributed in the United States. Under these ACIP recommendations, the routine IPV vaccination schedule in the United States consists of 4 doses administered at ages 2 months, 4 months, 6–18 months, and 4–6 years with the minimum interval between all IPV doses as 4 weeks.[1,2]
Since the ACIP recommendation was made 10 years ago, three different combination vaccines containing IPV have been licensed for routine use in the United States (Table). Because of potential confusion in using different vaccine products for routine and catch-up immunization, ACIP recommends the following:
The 4-dose IPV series should continue to be administered at ages 2 months, 4 months, 6–18 months, and 4–6 years.
The final dose in the IPV series should be administered at age ≥4 years regardless of the number of previous doses.
The minimum interval from dose 3 to dose 4 is extended from 4 weeks to 6 months.
The minimum interval from dose 1 to dose 2, and from dose 2 to dose 3, remains 4 weeks.
The minimum age for dose 1 remains age 6 weeks.
ACIP also is making a new recommendation concerning the use of minimum age and minimum intervals for children in the first 6 months of life. Use of the minimum age and minimum intervals for vaccine administration in the first 6 months of life are recommended only if the vaccine recipient is at risk for imminent exposure to circulating poliovirus (e.g., during an outbreak or because of travel to a polio-endemic region). ACIP is making this precaution because shorter intervals and earlier start dates lead to lower seroconversion rates.[3–5]
In addition, ACIP is clarifying the poliovirus vaccination schedule to be used for specific combination vaccines. When DTaP-IPV/Hib* (Pentacel) is used to provide 4 doses at ages 2, 4, 6, and 15–18 months, an additional booster dose of age-appropriate IPV-containing vaccine (IPV [Ipol] or DTaP-IPV† [Kinrix]) should be administered at age 4–6 years. This will result in a 5-dose IPV vaccine series, which is considered acceptable by ACIP.
DTaP-IPV/Hib is not indicated for the booster dose at age 4–6 years. ACIP recommends that the minimum interval from dose 4 to dose 5 should be at least 6 months to provide an optimum booster response. In accordance with existing recommendations, if a child misses an IPV dose at age 4–6 years, the child should receive a booster dose as soon as feasible.[2]
* Diphtheria and tetanus toxoids and acellular pertussis adsorbed, inactivated poliovirus, and Haemophilus b conjugate (tetanus toxoid conjugate) vaccine.
† Diphtheria and tetanus toxoids and acellular pertussis adsorbed, and inactivated poliovirus vaccine.
References
Wednesday, October 7, 2009
Guidelines for Vitamin D Intake
From Medscape Medical News
American Academy of Pediatrics Updates Guidelines for Vitamin D Intake CME/CE
Laurie Barclay, MD & Désirée Lie, MD, MSEd
10/14/2008
Pediatrics. Published online October 13, 2008. 2008;122:1142-1152.
Clinical Context
Rickets and vitamin D deficiency are preventable conditions with adequate nutritional intake of vitamin D but are still prevalent in the United States and other Western countries, particularly in exclusively breast-fed infants and in those with chronic diseases. Rickets has a peak incidence of ages 3 to 18 months and may present with hypocalcemic seizures.
This is an update of the 2003 AAP guidelines for vitamin D intake in children and adolescents, which recommended a daily intake of 200 IU of vitamin D daily beginning at 2 months of life, to account for evidence showing that a higher intake is necessary to avoid vitamin D deficiency and insufficiency.
Study Highlights
There is evidence that 400 IU of vitamin D daily not only prevents rickets but also treats the condition.
In adults, vitamin D deficiency is defined as a level of 25-hydroxyvitamin D less than 50 nmol/L and vitamin D insufficiency as a level of 50 to 80 nmol/L.
The main source of vitamin D is via skin synthesis from cholesterol after exposure to UVB light.
Those most susceptible to vitamin D insufficiency include breast-fed infants, those with low sunlight exposure, those with dark skin pigmentation that takes 5 to 10 times longer to generate vitamin D3, and those with chronic diseases such as cystic fibrosis and fat malabsorption.
Mothers who are vitamin D deficient may expose their fetuses and infants to higher risk for vitamin D deficiency after birth and during lactation, and their vitamin D status should be monitored.
Inadequate vitamin D status in pregnant women has an effect on fetal skeletal development, tooth enamel formation, and general fetal growth.
However, universal recommendations for high-dose vitamin D supplementation during pregnancy are not available at present, and recommendations for supplementation in children are thus necessary.
Vitamin D levels in breast milk vary from less than 25 IU/L to 78 IU/L, and infants who are exclusively breast-fed are at increased risk for deficiency.
Vitamin D supplementation should begin at birth or in the first few days of life with 400 IU per day for breast-fed and partially breast-fed infants.
Supplementation should be continued unless the infant is weaned to 1 L per day or 1 quart per day of vitamin D–fortified formula or whole milk.
Whole milk should not be used until after age 12 months, and reduced-fat milk is recommended for those with obesity.
All non–breast-fed infants and older children ingesting less than 1 L per day of vitamin D–fortified milk or formula should receive 400 IU of vitamin D daily.
Adolescents are at increased risk for vitamin D deficiency because the intake of milk was reduced by 36% between the 1970s and the 1990s.
Adolescents should be encouraged to drink milk daily (100 IU per 8-oz serving) and to consume vitamin D–fortified foods (cereals and eggs).
1 L of vitamin D–fortified milk daily is required to meet the daily vitamin D recommendations for adolescents.
Without adequate dietary intake, adolescents should be supplemented with 400 IU of vitamin D daily.
According to available evidence, serum levels of 25-hydroxyvitamin D in infants and adolescents should be 50 nmol/L or higher.
In children with additional risk factors for vitamin D deficiency, such as those with chronic diseases, those receiving seizure medications, or those with fat malabsorption, higher doses of vitamin D may be needed daily.
In these children, levels of 25-hydroxyvitamin D should be monitored every 3 months until normal levels have been achieved with vitamin D supplementation.
Pediatricians and other healthcare professionals should make vitamin D supplements readily available to children in their community, especially those at risk for deficiency or insufficiency.
Pearls for Practice
Vitamin D supplementation at 400 IU per day should begin within the first few days of life and is especially recommended in breast-fed children, and supplementation may be higher for children with additional risk factors.
Adolescents who do not consume adequate vitamin D in their diet should have an intake of 400 IU of vitamin D supplements daily.
American Academy of Pediatrics Updates Guidelines for Vitamin D Intake CME/CE
Laurie Barclay, MD & Désirée Lie, MD, MSEd
10/14/2008
Pediatrics. Published online October 13, 2008. 2008;122:1142-1152.
Clinical Context
Rickets and vitamin D deficiency are preventable conditions with adequate nutritional intake of vitamin D but are still prevalent in the United States and other Western countries, particularly in exclusively breast-fed infants and in those with chronic diseases. Rickets has a peak incidence of ages 3 to 18 months and may present with hypocalcemic seizures.
This is an update of the 2003 AAP guidelines for vitamin D intake in children and adolescents, which recommended a daily intake of 200 IU of vitamin D daily beginning at 2 months of life, to account for evidence showing that a higher intake is necessary to avoid vitamin D deficiency and insufficiency.
Study Highlights
There is evidence that 400 IU of vitamin D daily not only prevents rickets but also treats the condition.
In adults, vitamin D deficiency is defined as a level of 25-hydroxyvitamin D less than 50 nmol/L and vitamin D insufficiency as a level of 50 to 80 nmol/L.
The main source of vitamin D is via skin synthesis from cholesterol after exposure to UVB light.
Those most susceptible to vitamin D insufficiency include breast-fed infants, those with low sunlight exposure, those with dark skin pigmentation that takes 5 to 10 times longer to generate vitamin D3, and those with chronic diseases such as cystic fibrosis and fat malabsorption.
Mothers who are vitamin D deficient may expose their fetuses and infants to higher risk for vitamin D deficiency after birth and during lactation, and their vitamin D status should be monitored.
Inadequate vitamin D status in pregnant women has an effect on fetal skeletal development, tooth enamel formation, and general fetal growth.
However, universal recommendations for high-dose vitamin D supplementation during pregnancy are not available at present, and recommendations for supplementation in children are thus necessary.
Vitamin D levels in breast milk vary from less than 25 IU/L to 78 IU/L, and infants who are exclusively breast-fed are at increased risk for deficiency.
Vitamin D supplementation should begin at birth or in the first few days of life with 400 IU per day for breast-fed and partially breast-fed infants.
Supplementation should be continued unless the infant is weaned to 1 L per day or 1 quart per day of vitamin D–fortified formula or whole milk.
Whole milk should not be used until after age 12 months, and reduced-fat milk is recommended for those with obesity.
All non–breast-fed infants and older children ingesting less than 1 L per day of vitamin D–fortified milk or formula should receive 400 IU of vitamin D daily.
Adolescents are at increased risk for vitamin D deficiency because the intake of milk was reduced by 36% between the 1970s and the 1990s.
Adolescents should be encouraged to drink milk daily (100 IU per 8-oz serving) and to consume vitamin D–fortified foods (cereals and eggs).
1 L of vitamin D–fortified milk daily is required to meet the daily vitamin D recommendations for adolescents.
Without adequate dietary intake, adolescents should be supplemented with 400 IU of vitamin D daily.
According to available evidence, serum levels of 25-hydroxyvitamin D in infants and adolescents should be 50 nmol/L or higher.
In children with additional risk factors for vitamin D deficiency, such as those with chronic diseases, those receiving seizure medications, or those with fat malabsorption, higher doses of vitamin D may be needed daily.
In these children, levels of 25-hydroxyvitamin D should be monitored every 3 months until normal levels have been achieved with vitamin D supplementation.
Pediatricians and other healthcare professionals should make vitamin D supplements readily available to children in their community, especially those at risk for deficiency or insufficiency.
Pearls for Practice
Vitamin D supplementation at 400 IU per day should begin within the first few days of life and is especially recommended in breast-fed children, and supplementation may be higher for children with additional risk factors.
Adolescents who do not consume adequate vitamin D in their diet should have an intake of 400 IU of vitamin D supplements daily.
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