From Medscape Pediatrics > Viewpoints
William T. Basco, Jr., MD
Pediatrics. 2010;125:e1024-e1030
Study Summary
In this article, Chung, Huang, and Schneider review the conflicted state of affairs with respect to giving influenza vaccine to patients with egg allergy. Given that many patients with egg allergy also have asthma, which places them at high risk for morbidity from influenza illness, the patients who might benefit most from influenza vaccination have difficulty getting it.
The current approach for administration of influenza vaccine to patients with egg allergy involves 3 steps:
(1) skin prick testing with the vaccine;
(2) administration of a low dose of vaccine; and
(3) administration of the remainder of the vaccine. The sequence is completed only if the patient does not react at each successive stage.
The aim of this study was to determine the safety of skipping the first stage, skin prick testing.
The investigators reviewed the outcomes of patients with egg allergy who were immunized against influenza at 1 institution from the 2002/2003 influenza season to the 2008/2009 season.
The participants were 6 months to 18 years old; all had egg allergy as determined by a series of criteria that included skin test results, RAST test results, and history of clinical allergic reaction to egg.
During the first 5 influenza seasons studied, the institution followed the 3-step protocol of skin testing, followed by administration of 10% of the vaccine dose (followed by 30 minutes of observation), followed by administration of the remaining 90% of the vaccine dose.
During the last 3 seasons evaluated, the investigators eliminated the skin-testing step and gave the influenza vaccine in the graded fashion. The clinical notes included data about both local and systemic reactions (urticaria, wheezing, or exacerbation of eczema). They skin-tested 146 participants before influenza vaccination during the first 5 influenza seasons. Ninety-one (62.3%) had a positive skin-prick test, and 55 had negative skin tests (53 of whom received influenza vaccine). Three subjects with a positive skin-prick test still received the influenza vaccine. Therefore, 56 participants received influenza vaccine under the 3-step protocol compared with 115 who received the vaccine later under the 2-step protocol.
A large majority of participants in both the 3-step group and the 2-step group had allergies to more than 1 food (91% and 84%, respectively) and had atopic dermatitis (71% and 64%, respectively). The groups were slightly different in other ways; specifically, the 3-step group had a higher mean age (6.2 years vs 3.9 years), a higher frequency of asthma (76.8% vs 49.6%), and higher rates of allergic rhinitis. Many of the differences were a result of a change in influenza vaccine recommendations during the study period such that the later period included more patients without asthma and younger children who had egg allergy. The study authors attempted to adjust for these between-group differences by using propensity scores in their regression analyses. No differences were seen in the percentages of participants who tolerated influenza vaccine without any reaction (78.6% in the 3-step group and 79.1% in the 2-step group). The frequency of tolerating vaccine without a systemic reaction was 94.6% and 96.5%, respectively, in the 3-step and 2-step groups. Seven subjects (3 in the 3-step group and 4 in the 2-step group) had systemic adverse reactions, and another 29 experienced localized adverse reactions. None of the participants experienced anaphylaxis. The investigators concluded that the influenza vaccine can be administered safely to patients with egg allergy in a graded approach, without first conducting skin prick testing.
Viewpoint
Although propensity scores can eliminate bias, they do not eliminate all bias. It is difficult to know how much the differences between groups might have affected the outcomes, but the raw percentages for adverse reactions are similar despite the differences in the patient populations. The investigators reviewed several advantages of skipping the skin-testing step, including the time required to administer and observe the test, the fact that patients must discontinue antihistamines prior to skin testing, and the fact that false-positive skin-testing results can occur from local irritation reactions. It is also important to remember that none of these subjects had a history of anaphylactic reaction to eggs, so these results should not be extended to that high-risk group.
Abstract
Sunday, August 29, 2010
Headache in Teens Related to Lack of Exercise, Weight Gain, Smoking
From Medscape Medical News
Allison Gandey
August 19, 2010 — Teenagers who get little exercise, are overweight, or who smoke are more likely to have frequent headaches or migraines, report researchers.
"There was a significant trend for stronger associations between the number of negative lifestyle factors that were present and the different headache diagnoses and headache frequency," point out the investigators led by John-Anker Zwart, MD, from Oslo University in Norway. "We believe that the associations observed and the additive effect of these negative lifestyle factors on the prevalence of recurrent headache strongly indicates that these lifestyle factors are possible targets for headache preventive measures."
The new study appears in the August 18 issue of Neurology. As part of the cross-sectional study, researchers interviewed more than 5500 students about headache complaints. The adolescents also completed a questionnaire and underwent a clinical examination with height and weight measurements.
Investigators classified adolescents who were very physically fit and who were not current smokers as having a good lifestyle. Negative lifestyle factors were surprisingly common with low physical activity in 31%, smoking in 19%, and overweight in 16% of these teens.
In adjusted multivariate analyses, recurrent headache was associated with overweight (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2 – 1.6; P < .0001), low physical activity (OR, 1.2; 95% CI, 1.1 – 1.4; P = .002), and smoking (OR, 1.5; 95% CI, 1.3 – 1.7; P < .0001). The presence of more than 1 negative lifestyle factor heightened the risk of headache.
This study shows overweight, low physical activity, and smoking are independently and in combination associated with recurrent headache among adolescents, report the study authors.
In an accompanying editorial, Dr. Andrew Hershey and Dr. Richard Lipton say that "this study is a vital step toward a better understanding of lifestyle effects and the potential for behavioral interventions for adolescents with headache disorders."
Dr. Hershey is at the University of Cincinnati in Ohio and Dr. Lipton is at the Albert Einstein College of Medicine in the Bronx, New York. They point out the effects of each negative lifestyle factor were similar in magnitude for each headache type. "This lack of specificity for headache type raises the possibility that these factors may be associated not just with headache but with all-cause pain."
These results mirror those of another study published in June in the journal Headache. Investigators led by Rudiger von Kries, MD, from Ludwig-Maximilians-University in Munich, Germany, found that being physically active and abstaining from alcohol, caffeine, and tobacco could help prevent headaches in adolescents.
The study included 1260 students, and after controlling for socioeconomic variables, the prevalence of any headache was increased in teens who reported regularly drinking cocktails (OR, 2.0; 95% CI, 1.3 – 3.0), who drank at least 1 cup of coffee per day (OR, 2.0; 95% CI, 1.2 – 3.5), and who were physically less active (OR, 2.0; 95% CI, 1.3 – 3.1). Smoking daily had an OR of 1.8.
These findings, say editorialists, suggest that a better understanding of modifiable risk factors and trigger factors may lead to novel intervention strategies.
Neurology. 2010;75:712-717.
Allison Gandey
August 19, 2010 — Teenagers who get little exercise, are overweight, or who smoke are more likely to have frequent headaches or migraines, report researchers.
"There was a significant trend for stronger associations between the number of negative lifestyle factors that were present and the different headache diagnoses and headache frequency," point out the investigators led by John-Anker Zwart, MD, from Oslo University in Norway. "We believe that the associations observed and the additive effect of these negative lifestyle factors on the prevalence of recurrent headache strongly indicates that these lifestyle factors are possible targets for headache preventive measures."
The new study appears in the August 18 issue of Neurology. As part of the cross-sectional study, researchers interviewed more than 5500 students about headache complaints. The adolescents also completed a questionnaire and underwent a clinical examination with height and weight measurements.
Investigators classified adolescents who were very physically fit and who were not current smokers as having a good lifestyle. Negative lifestyle factors were surprisingly common with low physical activity in 31%, smoking in 19%, and overweight in 16% of these teens.
In adjusted multivariate analyses, recurrent headache was associated with overweight (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2 – 1.6; P < .0001), low physical activity (OR, 1.2; 95% CI, 1.1 – 1.4; P = .002), and smoking (OR, 1.5; 95% CI, 1.3 – 1.7; P < .0001). The presence of more than 1 negative lifestyle factor heightened the risk of headache.
This study shows overweight, low physical activity, and smoking are independently and in combination associated with recurrent headache among adolescents, report the study authors.
In an accompanying editorial, Dr. Andrew Hershey and Dr. Richard Lipton say that "this study is a vital step toward a better understanding of lifestyle effects and the potential for behavioral interventions for adolescents with headache disorders."
Dr. Hershey is at the University of Cincinnati in Ohio and Dr. Lipton is at the Albert Einstein College of Medicine in the Bronx, New York. They point out the effects of each negative lifestyle factor were similar in magnitude for each headache type. "This lack of specificity for headache type raises the possibility that these factors may be associated not just with headache but with all-cause pain."
These results mirror those of another study published in June in the journal Headache. Investigators led by Rudiger von Kries, MD, from Ludwig-Maximilians-University in Munich, Germany, found that being physically active and abstaining from alcohol, caffeine, and tobacco could help prevent headaches in adolescents.
The study included 1260 students, and after controlling for socioeconomic variables, the prevalence of any headache was increased in teens who reported regularly drinking cocktails (OR, 2.0; 95% CI, 1.3 – 3.0), who drank at least 1 cup of coffee per day (OR, 2.0; 95% CI, 1.2 – 3.5), and who were physically less active (OR, 2.0; 95% CI, 1.3 – 3.1). Smoking daily had an OR of 1.8.
These findings, say editorialists, suggest that a better understanding of modifiable risk factors and trigger factors may lead to novel intervention strategies.
Neurology. 2010;75:712-717.
allergies - simple to severe slide show
http://www.medscape.com/features/slideshow/allergic-reactions?src=mp&spon=17&uac=23823SG
Saturday, August 28, 2010
New 13-Valent Pneumococcal Vaccine Expands Protection in Young Children
From Reuters Health Information
NEW YORK (Reuters Health) Aug 23 - The 13-valent pneumococcal conjugate vaccine (PCV13) is as effective as the seven-valent vaccine against the original seven pneumococcal serotypes and should provide further protection against the six additional serotypes, a multicenter team reports.
PCV13, also known by the brand name Prevnar 13 (Wyeth), was approved by the US Food and Drug Administration in February 2010 for preventing invasive pneumococcal disease in children aged 6 weeks to 71 months.
One of the pivotal studies of the immunogenicity and safety of PCV13 in infants and toddlers appeared online today in Pediatrics.
Lead author Dr. Sylvia H. Yeh, at the UCLA-Kaiser Vaccine Research Center in Torrance, California, and colleagues explain that the 7-valent pneumococcal conjugate vaccine (PCV7) covers the serotypes that caused up to 90% of invasive disease in the U.S. before its introduction.
"The widespread use of PCV7 in the U.S. has dramatically reduced the burden of this disease in children, with herd immunity benefiting adults as well," she said in an e-mail. "However, pneumococcal disease still occurs in the U.S. due to replacement serotypes."
The six additional serotypes in PCV13 account for up to 92% of invasive cases worldwide in children under five. "Whereas the potential impact of PCV7 was limited in certain countries such as Africa and Asia, PCV13 potentially expands the impact of disease prevention through vaccine use in these countries," Dr. Yeh said.
The current study compared PCV13 with PCV7 in terms of immunogenicity and safety in toddlers and infants. Ultimately, the authors report, "The evaluable immunogenicity populations consisted of 504 infants (PCV13: 252; PCV7: 252) and 462 toddlers (PCV13: 239; PCV7: 223)."
The immunoglobulin G titers elicited by PCV13 for the original seven serotypes were noninferior but somewhat lower than those elicited by PCV7. The PCV13 toddler dose produced higher immune responses than the infant-series doses, according to the authors.
Local and systemic reactions were mild for the most part and much the same in both vaccine groups. "For specific reactions, the only statistical difference was in the incidence of moderate fever after dose 1 (2.8% vs 0.0% for PCV13 and PCV7, respectively; p=0.026)," the report states.
"Data from this study support that PCV13 will be as effective as PCV7 in preventing disease caused by serotypes common to both vaccines," the authors conclude. "In addition, PCV13 should mediate protection against the 6 additional serotypes, all of which are important worldwide causes of severe pneumococcal disease."
Pediatrics. Posted online August 23, 2010. Abstract
NEW YORK (Reuters Health) Aug 23 - The 13-valent pneumococcal conjugate vaccine (PCV13) is as effective as the seven-valent vaccine against the original seven pneumococcal serotypes and should provide further protection against the six additional serotypes, a multicenter team reports.
PCV13, also known by the brand name Prevnar 13 (Wyeth), was approved by the US Food and Drug Administration in February 2010 for preventing invasive pneumococcal disease in children aged 6 weeks to 71 months.
One of the pivotal studies of the immunogenicity and safety of PCV13 in infants and toddlers appeared online today in Pediatrics.
Lead author Dr. Sylvia H. Yeh, at the UCLA-Kaiser Vaccine Research Center in Torrance, California, and colleagues explain that the 7-valent pneumococcal conjugate vaccine (PCV7) covers the serotypes that caused up to 90% of invasive disease in the U.S. before its introduction.
"The widespread use of PCV7 in the U.S. has dramatically reduced the burden of this disease in children, with herd immunity benefiting adults as well," she said in an e-mail. "However, pneumococcal disease still occurs in the U.S. due to replacement serotypes."
The six additional serotypes in PCV13 account for up to 92% of invasive cases worldwide in children under five. "Whereas the potential impact of PCV7 was limited in certain countries such as Africa and Asia, PCV13 potentially expands the impact of disease prevention through vaccine use in these countries," Dr. Yeh said.
The current study compared PCV13 with PCV7 in terms of immunogenicity and safety in toddlers and infants. Ultimately, the authors report, "The evaluable immunogenicity populations consisted of 504 infants (PCV13: 252; PCV7: 252) and 462 toddlers (PCV13: 239; PCV7: 223)."
The immunoglobulin G titers elicited by PCV13 for the original seven serotypes were noninferior but somewhat lower than those elicited by PCV7. The PCV13 toddler dose produced higher immune responses than the infant-series doses, according to the authors.
Local and systemic reactions were mild for the most part and much the same in both vaccine groups. "For specific reactions, the only statistical difference was in the incidence of moderate fever after dose 1 (2.8% vs 0.0% for PCV13 and PCV7, respectively; p=0.026)," the report states.
"Data from this study support that PCV13 will be as effective as PCV7 in preventing disease caused by serotypes common to both vaccines," the authors conclude. "In addition, PCV13 should mediate protection against the 6 additional serotypes, all of which are important worldwide causes of severe pneumococcal disease."
Pediatrics. Posted online August 23, 2010. Abstract
Prepubertal Overweight Children With Prediabetes May Have Lower Bone Mass
From Medscape Medical News
Laurie Barclay, MD
August 24, 2010 — Prepubertal overweight children with prediabetes may have lower bone mass and an increased risk for poor skeletal development, according to the results of a study reported online July 16 in the Journal of Bone and Mineral Research.
"Childhood studies of the fat-bone relationship are conflicting, possibly reflecting the influence of metabolic abnormalities in some but not all obese children," write Norman K. Pollock, from Medical College of Georgia's Prevention Institute in Augusta, and colleagues.
The investigators compared bone mass in 41 prepubertal overweight children with prediabetes with that in 99 prepubertal overweight children without prediabetes. The study authors also evaluated associations of bone mass with measures of total and central adiposity, glucose intolerance, insulin sensitivity, lipid profile, markers of systemic inflammation, and osteocalcin. Age range of the children was 7 to 11 years.
Prediabetes was identified from an oral glucose tolerance test, which also allowed measurement of glucose, 2-hour glucose, glucose area under the curve (AUC), insulin, 2-hour insulin, and insulin AUC. Blood levels of lipids, C-reactive protein, and osteocalcin were also measured. Using dual-energy x-ray absorptiometry, the investigators measured total body bone mineral content (BMC), fat-free soft tissue mass (FFST), and fat mass (FM), whereas visceral adipose tissue (VAT) and subcutaneous abdominal adipose tissue (SAAT) were evaluated with magnetic resonance imaging scans.
After adjustment for sex, race, height, and weight, overweight children with prediabetes had a total body BMC 4% lower than those without prediabetes (P = .03). FM correlated directly with BMC in the total sample (β = .16; P = .01), after adjustment for sex, race, height, and FFST.
"This finding provides the first clue linking childhood obesity to skeletal fractures," Dr. Pollock said in a news release. "While overweight children may have more bone mass than normal-weight kids, it may not be big or strong enough to compensate for their larger size."
After controlling for sex, race, height, FFST, FM, and SAAT or VAT, however, VAT (β = -.13; P = .03) and SAAT (β = -0.34; P = .02) were inversely associated with BMC. BMC was not significantly associated with any of the biochemical measurements.
"Taken together, it seems that excessive abdominal fat may play a key role linking pre-diabetes to lower bone mass," Dr. Pollock said. "Our greatest window of opportunity to enhance bone strength and ultimately reduce the risk of osteoporosis is during childhood, before the capacity to build bone diminishes. One of the best things you can do for bone development and general health is exercise."
Limitations of this study include bone measurements derived only from dual-energy x-ray absorptiometry of the total body; and small sample size, precluding separate analysis of data by boys and girls or by white and black race.
"Children have a lot of potential and a whole lot of time to make positive changes," said coauthor Catherine Davis, also from the Prevention Institute. "If you could patent exercise as a drug, somebody would be really, really rich."
J Bone Mineral Res. Published online July 16, 2010. Abstract
Laurie Barclay, MD
August 24, 2010 — Prepubertal overweight children with prediabetes may have lower bone mass and an increased risk for poor skeletal development, according to the results of a study reported online July 16 in the Journal of Bone and Mineral Research.
"Childhood studies of the fat-bone relationship are conflicting, possibly reflecting the influence of metabolic abnormalities in some but not all obese children," write Norman K. Pollock, from Medical College of Georgia's Prevention Institute in Augusta, and colleagues.
The investigators compared bone mass in 41 prepubertal overweight children with prediabetes with that in 99 prepubertal overweight children without prediabetes. The study authors also evaluated associations of bone mass with measures of total and central adiposity, glucose intolerance, insulin sensitivity, lipid profile, markers of systemic inflammation, and osteocalcin. Age range of the children was 7 to 11 years.
Prediabetes was identified from an oral glucose tolerance test, which also allowed measurement of glucose, 2-hour glucose, glucose area under the curve (AUC), insulin, 2-hour insulin, and insulin AUC. Blood levels of lipids, C-reactive protein, and osteocalcin were also measured. Using dual-energy x-ray absorptiometry, the investigators measured total body bone mineral content (BMC), fat-free soft tissue mass (FFST), and fat mass (FM), whereas visceral adipose tissue (VAT) and subcutaneous abdominal adipose tissue (SAAT) were evaluated with magnetic resonance imaging scans.
After adjustment for sex, race, height, and weight, overweight children with prediabetes had a total body BMC 4% lower than those without prediabetes (P = .03). FM correlated directly with BMC in the total sample (β = .16; P = .01), after adjustment for sex, race, height, and FFST.
"This finding provides the first clue linking childhood obesity to skeletal fractures," Dr. Pollock said in a news release. "While overweight children may have more bone mass than normal-weight kids, it may not be big or strong enough to compensate for their larger size."
After controlling for sex, race, height, FFST, FM, and SAAT or VAT, however, VAT (β = -.13; P = .03) and SAAT (β = -0.34; P = .02) were inversely associated with BMC. BMC was not significantly associated with any of the biochemical measurements.
"Taken together, it seems that excessive abdominal fat may play a key role linking pre-diabetes to lower bone mass," Dr. Pollock said. "Our greatest window of opportunity to enhance bone strength and ultimately reduce the risk of osteoporosis is during childhood, before the capacity to build bone diminishes. One of the best things you can do for bone development and general health is exercise."
Limitations of this study include bone measurements derived only from dual-energy x-ray absorptiometry of the total body; and small sample size, precluding separate analysis of data by boys and girls or by white and black race.
"Children have a lot of potential and a whole lot of time to make positive changes," said coauthor Catherine Davis, also from the Prevention Institute. "If you could patent exercise as a drug, somebody would be really, really rich."
J Bone Mineral Res. Published online July 16, 2010. Abstract
Friday, August 27, 2010
An Update on Autism -- Perspectives and Treatment
From Medscape Neurology & Neurosurgery
Andrew N. Wilner, MD
An Autism Update: Introduction
Autism is a common disorder of children that presents with a spectrum of neurobehavioral and cognitive disorders, particularly problems with socialization, communication, and repetitive behaviors. There are no biologic markers for autism. The diagnosis is clinical, based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM IV).[1] Lack of timely development of language, or regression in communication skills, are indications for an evaluation for autism (Table 1). Multiple diagnostic tools are available to assist clinicians in the assessment of a child with suspected autism (Table 2).
Table 1. Absolute Indications for Autism Evaluation
No babbling, pointing, or other gesture by 12 months
No single words by 16 months
No 2-word spontaneous (not echolalic) phrases by 24 months
Any loss of any language or social skills at any age
Data from the American Psychiatric Association.[1]
Table 2. Diagnostic Tools
Diagnostic Parental Interviews
The Gilliam Autism Rating Scale
The Parent Interview for Autism
The Pervasive Developmental Disorders Screening Test-Stage 3
The Autism Diagnostic Interview-Revised
Diagnostic Observation Instruments
The Childhood Autism Rating Scale
The Screening Tool for Autism in 2-Year-Olds
The Autism Diagnostic Observation Schedule-Generic
Data from the American Psychiatric Association.[1]
Like epilepsy, autism is a not a single syndrome. There is no cure, but early intervention can improve quality of life. The devastating nature of the disorder has attracted many unproven approaches, providing many opportunities for misguided, expensive, and potentially harmful "alternative" treatments.
An Update on Treatment
Medscape: What is the treatment for autism?
Dr. Goldstein: There are very little data concerning efficacy of behavioral treatments for autism. Most rely on close personal interactions between therapists/teachers and the children. Medications may be used to treat abnormal behaviors, but there are no medications that address the underlying disorder.
Dr. Chez: Treatment is purely symptomatic. For example, I sometimes use risperidone, which is US Food and Drug Administration approved for children with autism with aggressive behavior. We need more controlled studies of treatments. Clinical trials are now ongoing for memantine, an N-methyl-D-aspartic acid and glutamate antagonist that plays a role in brain neurogenesis, epilepsy, learning, and neuroglial inflammation, all of which may be important in autism. Designer drugs based on single gene defects, and stem cells are some other possibilities for the future.
Dr. Pellock: Autism has many faces and treatment must be individualized to each child. When children are referred with autism, they need a comprehensive evaluation to identify symptoms and developmental delays that may accompany autism. Treatment goals need to be identified. For example, is the therapy to decrease impulsiveness, hyperactivity, improve sleep, or treat seizures? The biggest issue is usually behavior. Children need behavioral controls throughout the day to learn which behaviors are acceptable and which are not to allow them to achieve to the best of their ability within the school system. A comprehensive, multimodal approach is necessary. Educational and environmental treatments are frequently at least as important, if not more important, than medications.
Conclusions
Autism remains a frustrating and challenging problem for many children and their families. While the experts do not agree on all of the details regarding management, all children with symptoms suggestive of autism should receive a comprehensive evaluation by a pediatric neurologist or other expert to determine whether the child has autism or another developmental disorder. If autism is diagnosed, the child’s behavioral, communication, and cognitive problems should be identified, as well as comorbidities such as epilepsy, sleep disorders, and gastrointestinal problems, so that a comprehensive treatment plan can be implemented. Early diagnosis and intervention offer children with autism the best opportunity to improve their social integration and quality of life.
http://www.medscape.com/viewarticle/726778?src=mp&spon=9&uac=71630FV
Andrew N. Wilner, MD
An Autism Update: Introduction
Autism is a common disorder of children that presents with a spectrum of neurobehavioral and cognitive disorders, particularly problems with socialization, communication, and repetitive behaviors. There are no biologic markers for autism. The diagnosis is clinical, based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM IV).[1] Lack of timely development of language, or regression in communication skills, are indications for an evaluation for autism (Table 1). Multiple diagnostic tools are available to assist clinicians in the assessment of a child with suspected autism (Table 2).
Table 1. Absolute Indications for Autism Evaluation
No babbling, pointing, or other gesture by 12 months
No single words by 16 months
No 2-word spontaneous (not echolalic) phrases by 24 months
Any loss of any language or social skills at any age
Data from the American Psychiatric Association.[1]
Table 2. Diagnostic Tools
Diagnostic Parental Interviews
The Gilliam Autism Rating Scale
The Parent Interview for Autism
The Pervasive Developmental Disorders Screening Test-Stage 3
The Autism Diagnostic Interview-Revised
Diagnostic Observation Instruments
The Childhood Autism Rating Scale
The Screening Tool for Autism in 2-Year-Olds
The Autism Diagnostic Observation Schedule-Generic
Data from the American Psychiatric Association.[1]
Like epilepsy, autism is a not a single syndrome. There is no cure, but early intervention can improve quality of life. The devastating nature of the disorder has attracted many unproven approaches, providing many opportunities for misguided, expensive, and potentially harmful "alternative" treatments.
An Update on Treatment
Medscape: What is the treatment for autism?
Dr. Goldstein: There are very little data concerning efficacy of behavioral treatments for autism. Most rely on close personal interactions between therapists/teachers and the children. Medications may be used to treat abnormal behaviors, but there are no medications that address the underlying disorder.
Dr. Chez: Treatment is purely symptomatic. For example, I sometimes use risperidone, which is US Food and Drug Administration approved for children with autism with aggressive behavior. We need more controlled studies of treatments. Clinical trials are now ongoing for memantine, an N-methyl-D-aspartic acid and glutamate antagonist that plays a role in brain neurogenesis, epilepsy, learning, and neuroglial inflammation, all of which may be important in autism. Designer drugs based on single gene defects, and stem cells are some other possibilities for the future.
Dr. Pellock: Autism has many faces and treatment must be individualized to each child. When children are referred with autism, they need a comprehensive evaluation to identify symptoms and developmental delays that may accompany autism. Treatment goals need to be identified. For example, is the therapy to decrease impulsiveness, hyperactivity, improve sleep, or treat seizures? The biggest issue is usually behavior. Children need behavioral controls throughout the day to learn which behaviors are acceptable and which are not to allow them to achieve to the best of their ability within the school system. A comprehensive, multimodal approach is necessary. Educational and environmental treatments are frequently at least as important, if not more important, than medications.
Conclusions
Autism remains a frustrating and challenging problem for many children and their families. While the experts do not agree on all of the details regarding management, all children with symptoms suggestive of autism should receive a comprehensive evaluation by a pediatric neurologist or other expert to determine whether the child has autism or another developmental disorder. If autism is diagnosed, the child’s behavioral, communication, and cognitive problems should be identified, as well as comorbidities such as epilepsy, sleep disorders, and gastrointestinal problems, so that a comprehensive treatment plan can be implemented. Early diagnosis and intervention offer children with autism the best opportunity to improve their social integration and quality of life.
http://www.medscape.com/viewarticle/726778?src=mp&spon=9&uac=71630FV
Friday, August 20, 2010
The Clinicians Approach to Genetic Testing for Autistic Children
Bruce Buehler, MD, Pediatrics, General, 07:43PM Jul 25, 2010
The incidence of Autism is estimated at 1/100 children by the CDC. Often, families with children who are speech delayed, inattentive, or motorically delayed will search the internet or ask teachers about what might be wrong. Autism is often considered. The family usually seeks a diagnosis from their clinician, asking whether it is Autism.
The broad criteria are:
1. qualitative impairment in social interaction
2. qualitative impairments in communication
3. restricted repetitive and stereotyped patterns of behavior,interests, and activities ( Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR). Washington DC: American Psychiatric Association; 2000:75.)
If the clinician feels the child fits criteria for Autism Spectrum Disorder (ASD), or the child has had psychological testing suggesting Autism, should there be further work up before referral to the schools for interventions? This is an individual decision by the clinician. If testing is indicated, a basic guideline for laboratory studies was proposed by Mendelsohn and Schaefer, Genetic Evaluation of Autism, Seminars in Pediatric Neurology, Volume 15, Issue 1, March 2008, Pages 27-31, Advances in Clinical Genetics (Part III).
In our clinic we have developed a limited approach for initial screening of children with ASD that can be used by the clinician prior to referral for a more extensive developmental or genetic evaluation.
It is our experience that this approach will identify a specific genetic syndrome or abnormality in a percentage of patients brought in by the family for Autism. After initial examination, the child with dysmorphic features or neurologic findings who meets the criteria for Autism Spectrum Disorder will yield the highest percentage, approximately 20% positive tests. Whereas the child without any physical anomalies or neurologic findings will rarely show positive results on this screen.
The tests recommended are Microarray, Fragile X, methylation of Chromosome 15, and MECP2 in females. Microarray will identify small deletions or duplications including Chromosome 16 that cause a condition with Autistic behavior. Fragile X accounts for approximately 10% of males and females with Autistic behavior. Methylation of Chromosome 15 will identify Angelman's Syndrome. MECP2 will diagnose approximately 50% of girls with Retts Syndrome. MRI can be considered if there are significant neurologic findings, including a history of unexplained seizures. If these tests are negative then it is appropriate to refer to a Developmental Pediatrician or Geneticist for further evaluation. Metabolic testing and specific gene tests are very complicated and have a lower yield. Having a specific syndrome or laboratory diagnosis aids in intervention and type of treatment for that child. It also provides information necessary to families for support, prognosis, and risk to future children.
If the evaluation suggests Autism Spectrum Disorder or Autistic behaviors, referral to the schools should be initiated for further educational testing and services. School referral should be made even if the laboratory testing is negative. Early intervention and treatment programs for Autism are most successful when initiated before 2 years of age. .
The incidence of Autism is estimated at 1/100 children by the CDC. Often, families with children who are speech delayed, inattentive, or motorically delayed will search the internet or ask teachers about what might be wrong. Autism is often considered. The family usually seeks a diagnosis from their clinician, asking whether it is Autism.
The broad criteria are:
1. qualitative impairment in social interaction
2. qualitative impairments in communication
3. restricted repetitive and stereotyped patterns of behavior,interests, and activities ( Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR). Washington DC: American Psychiatric Association; 2000:75.)
If the clinician feels the child fits criteria for Autism Spectrum Disorder (ASD), or the child has had psychological testing suggesting Autism, should there be further work up before referral to the schools for interventions? This is an individual decision by the clinician. If testing is indicated, a basic guideline for laboratory studies was proposed by Mendelsohn and Schaefer, Genetic Evaluation of Autism, Seminars in Pediatric Neurology, Volume 15, Issue 1, March 2008, Pages 27-31, Advances in Clinical Genetics (Part III).
In our clinic we have developed a limited approach for initial screening of children with ASD that can be used by the clinician prior to referral for a more extensive developmental or genetic evaluation.
It is our experience that this approach will identify a specific genetic syndrome or abnormality in a percentage of patients brought in by the family for Autism. After initial examination, the child with dysmorphic features or neurologic findings who meets the criteria for Autism Spectrum Disorder will yield the highest percentage, approximately 20% positive tests. Whereas the child without any physical anomalies or neurologic findings will rarely show positive results on this screen.
The tests recommended are Microarray, Fragile X, methylation of Chromosome 15, and MECP2 in females. Microarray will identify small deletions or duplications including Chromosome 16 that cause a condition with Autistic behavior. Fragile X accounts for approximately 10% of males and females with Autistic behavior. Methylation of Chromosome 15 will identify Angelman's Syndrome. MECP2 will diagnose approximately 50% of girls with Retts Syndrome. MRI can be considered if there are significant neurologic findings, including a history of unexplained seizures. If these tests are negative then it is appropriate to refer to a Developmental Pediatrician or Geneticist for further evaluation. Metabolic testing and specific gene tests are very complicated and have a lower yield. Having a specific syndrome or laboratory diagnosis aids in intervention and type of treatment for that child. It also provides information necessary to families for support, prognosis, and risk to future children.
If the evaluation suggests Autism Spectrum Disorder or Autistic behaviors, referral to the schools should be initiated for further educational testing and services. School referral should be made even if the laboratory testing is negative. Early intervention and treatment programs for Autism are most successful when initiated before 2 years of age. .
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