Wednesday, February 29, 2012

Teens and Elective Cosmetic Surgery

An Expert Commentary on Real-World Scenarios

Sherrell J. Aston, MD; Robert L. Findling, MD, MBA; Laurie Scudder, DNP, PNP

Posted: 02/23/2012

Read this article on Medscape's
free mobile app. Download Now

Editor's Note:
The topic of plastic surgery in teens has been in the news lately and raises many clinical and ethical questions. Medscape asked experts in psychiatry, cosmetic surgery, and bioethics to help us explore this issue.

Robert L. Findling, MD, MBA, Professor of Psychiatry and Pediatrics at Case Western Reserve University and Director of Child & Adolescent Psychiatry at Rainbow Babies & Children's Hospital, presented the mental health perspective. Sherrell J. Aston, MD, Professor of Surgery in the Department of Plastic Surgery at New York University School of Medicine and Chairman, Department of Plastic Surgery, Manhattan Eye, Ear and Throat Institute of Lenox Hill Hospital provided input from the surgeon's perspective. The participants also discussed some cases that, although hypothetical, represent real-world scenarios.

Medscape: Appearance is important to all of us -- none more so than teens, who are often uncomfortable with their evolving bodies. Perceived flaws do not only diminish a teen's self-image but can affect his or her social interactions, leading to difficulties in school, withdrawal, or aggression. Teens sometimes have valid cosmetic conditions that may benefit from plastic surgery.

Child and adolescent cosmetic surgery is not new, but the topic has come to the forefront as a result of recent media attention. A major factor in consideration is the fact that the patient is still growing, both physically and emotionally. The decision requires input and agreement from both the child and the parent. What are the very first factors that a clinician should consider when approached about cosmetic concerns by either a patient or a family member?

Dr. Findling: It's important to understand the psychological effects of the cosmetic concern. Certainly, there are issues where cosmetic issues could clearly affect a youngster's emotional well-being. However, there are cases where the degree of the effect of a more modest cosmetic concern on the psychological state of the patient may be less clear. Along the same line, there are times when a patient may express negative emotional sequelae about a perceived flaw, and that cosmetic concern is not even readily apparent.

Simply put, discrepancies can exist between the magnitude of the visible cosmetic concern and the expressed emotional distress associated with it. Appreciating this disconnect can be quite important. This is because such disconnects can lead to unrealistic expectations about the degree to which a surgical procedure might improve a youngster's well-being. Certainly, when the discrepancy between the emotional concern and the physical manifestations are apparent, an understanding of such disconnects can be pivotal.

According to current psychiatric nosology, there is a condition known as body dysmorphic disorder. Patients with this condition may be inordinately distressed by or preoccupied with a minor or even nonexistent cosmetic concern. I should point out that body dysmorphic disorder should be differentiated from developmentally expected body image concerns.

Dr. Aston: First, it is important for the plastic surgeon to determine that the teenager, not the parents or boyfriend or girlfriend, is initiating the request for the cosmetic procedure. The surgeon must determine that the patient has reached a level of physical maturity and that further growth is unlikely to occur. The surgeon must also decide whether the patient's anticipated surgical result is appropriate and consistent with their anatomy, and whether the patients anticipated change in their life is realistic. The surgeon needs to determine that the teenager has realistic requests and goals, as well as sufficient emotional maturity to understand the nature of their requested surgical procedure, the potential problems, the recovery process, and the anticipated long-term results.

Medscape: You both referred to the importance of determining whether the teen's desire for a cosmetic change is realistic. Dr. Findling voiced concern that the magnitude of the perceived flaw may be less significant than the teen believes it to be; Dr. Aston noted the importance of determining whether the desired change is achievable. Recognizing that there is a degree of subjectivity to these assessments, what are the metrics that can be used to evaluate both the degree of distress and the desired change on the part of the teen? Are there strategies that should be implemented in the primary care arena -- where many teens and families will begin this process -- that can assist providers in making a determination as to which child and family can and should be referred for follow-up, whether by a cosmetic practitioner or a mental health provider?

Dr. Findling: From the emotional and psychological perspective, several strategies should be considered.

Identify the cosmetic concern and try to gauge the subjective degree to which the cosmetic concern is "atypical." This assessment applies to both the youngster and the guardian. Compare this concern with that of the "typical" child and family -- recognizing, of course, that there is a wide range of "normal" and that a cosmetic issue that may cause great concern for one teen may be acceptable to another. That same range of perspectives applies to parents.
Try to assess the magnitude of distress due to the physical concern.
Try to assess the sequelae associated with the distress due to the cosmetic concern.
Attempt to identify how the youngster's life might change due to the cosmetic surgery. Is the expectation reasonable or rational?

Although there certainly is a subjective quality to this, physicians, particularly those who are familiar with working with teens, can help identify thoughts, beliefs, and ideas that would raise red flags.

Dr. Aston: Dr. Findling and I are saying the same thing, just in different words. It boils down to the individual cases. I've operated on several thousand teenagers and can't remember a case where there was a postoperative psychological problem. In general, teenagers just want to correct their area of concern and get on with life. Teens, or adults, who are emotionally immature or have unrealistic expectations should not have surgery.

Putting It Into Practice: Case Discussions

Medscape: Perhaps we could briefly discuss some individual cases to illuminate key clinical considerations.

First case: A 15-year-old moderately obese boy presents with concerns about gynecomastia. Both of his parents, who are also obese, accompany him to the visit. All report that they have engaged in multiple unsuccessful attempts at weight loss. The young man voices concern about his "embarrassing" breast development and, upon questioning, notes that he is frequently teased by other kids in school. What are the specific issues that should be addressed in this young man? For situations with alternative treatment options-- in this case, more intensive weight-loss programs -- should surgery be considered? If so, are there any guidelines to determine at what point other options can be deemed unsuccessful and a decision made to move to a surgical option?

Dr. Findling: As you noted, the question for the surgeon is, "When should surgery be done"? It is not an either/or answer of surgery or other therapies. Surgery does not preclude other strategies.

Dr. Aston: A 15-year-old moderately obese young man with concerns about gynecomastia needs a more strict dietary control regimen and exercise plan for weight loss. At 15 years of age, it is possible that hormonal influences are causing his breasts to be larger than they may be in 4 or 5 years. I would defer surgery on this young man until he is 19 or 20 years old, and then consider it only after significant dieting, exercise, and weight loss.

Medscape: Now, a second hypothetical case: A 17-year-old girl, Tanner stage 5, with mild cerebral palsy and developmental delay is referred to a local cosmetic dermatology practice. She and her parents report that she has long been teased about the size and shape of her nose. Her parents delayed seeking surgical correction until they thought she was "old enough to decide." She attends her local high school but is in special education classes and has limited interaction with students outside of her self-contained classroom. Most of the history is provided by her parents, but the teen confirms that other students are "mean" to her. Is her developmental delay a relative contraindication to surgery? Does she require assessment beyond that provided to teens whose intellectual status is age-appropriate?

Dr. Findling: There are several issues that should be explored in a situation like this:

The emotional magnitude of the concern for the patient;
The degree of objective substantiveness of the physical defect;
The severity of the developmental delay, which can clearly influence the decision-making capacity of this teen, and
The probable postoperative outcome with regard to the amount of teasing/emotional distress this youngster is likely to continue to experience.

Dr. Aston: This young lady's developmental delay is probably cause to decline surgery at this time. Most of the information is provided by her parents, making a determination of her intellectual status difficult. Although the patient will soon be of legal age to give consent for her own surgery, it is not clear from this information whether she understands the nature of the surgical procedure and its potential risks and complications, and whether she has a perspective on the anticipated result. If she undergoes surgery with an excellent cosmetic change, it is still possible that other students may continue to be "mean" to her.

Medscape: Thank you. Now, on to our third and final case: An 18-year-old woman who has just graduated from high school is preparing to enter a performing arts program at a very prestigious university. She is unaccompanied by her parents but reports that they are aware of her request for breast augmentation surgery. She described their feelings as ambivalent but states that they are "leaving the decision" in the young woman's hands. She notes that her appearance will be a strong factor in her ability to be successful in musical theater and does not believe that she will be cast for roles requiring a more robust physique. What are the issues to be considered in an older teen who makes a request for surgery to enhance her appearance that is not motivated by social concerns, such as teasing? Would you suggest that parents be involved in this decision in a teen who has reached the age of consent but is still financially dependent on parents?

Dr. Findling: Ideally, parents would be involved. Even though the child in this case is 18 years old, family support can be helpful. An important question is, How realistic is the chance of success in the performing arts with this operation? The concern about looks and performing arts is a realistic one. This was noted poignantly in the 1975 musical A Chorus Line, in the song "Dance: Ten; Looks: Three..."

Dr. Aston: This is the kind of patient whom plastic surgeons see frequently. It is important for the surgeon to determine that the patient has a realistic expectation of the benefits of the surgical procedure. Plastic surgeons understand that patients may not be cast for roles in musical theater regardless of the robustness of their physique. Such decisions are probably made on overall appearance, ability, talent, personality, and other factors. The patient needs to understand these points.

The fact that the patient's request for surgery is not motivated by social concerns, such as teasing, is not particularly important. What is most important is that the patient has a realistic expectation and understanding that breast augmentation will give her more of her desired body shape but will not guarantee success in musical theater.

The extent to which parents are involved in the decision-making process for a young adult varies from family to family. I think it is important for parents to give their opinions to their children. It is stated that they are leaving the decision in the young woman's hands, which suggests that they are not against her having the procedure. Who pays, and other financial considerations, should be left to the patient and her family.

Resources

As these experts have made clear, decisions about elective cosmetic surgery are complex and individual. Arguments, pro and con, are found on parenting Websites, and the lay press reports that the number of procedures is on the rise. The American Society of Plastic Surgeons (ASPS) reports that cosmetic procedures in persons aged 13-19 years accounted for 2% of the over 13 million procedures performed in 2010, although the number of procedures in this age group increased 4% between 2009 and 2010.^[1] It is likely that if a primary care provider has not had yet had the experience of dealing with a family requesting information or a referral for a cosmetic procedure, it will happen sooner or later.

Initial screening can and should occur in the primary care environment. Medscape's Aesthetic Medicine resource center provides stories on the latest news, links to full-text articles from leading journals, and in-depth discussion.

The ASPS provides several helpful online resources for professionals and parents. For clinicians, Plastic Surgery For Teenagers Briefing Paper provides information about specific procedures, accreditation, and informed consent issues. For parents, Cosmetic Surgery and Your Teen -- Talking to Young Adults about Cosmetic Surgery includes discussion about specific procedures, questions for interviewing a potential surgeon, and information about insurance and payment.

Pediatric Pneumonia n antibiotics use

From Archives of Disease in Childhood

Why Do Children Hospitalised With Pneumonia Not Receive Antibiotics in Primary Care?

CC Grant; A Harnden; D Mant; D Emery; G Coster

Authors and Disclosures

Abstract and Introduction
Methods
Results
Discussion

Abstract and Introduction

Abstract

Background Although antibiotics are recommended for the primary care management of community-acquired pneumonia, a recent UK study reported that most children admitted to hospital had not received antibiotics.
Objective To describe primary care antibiotic use for children subsequently hospitalised with community-acquired pneumonia.
Design/methods A case series of 280 children <5 years old hospitalised with pneumonia in Auckland, New Zealand. Pneumonia was defined as an acute illness with cough or respiratory distress, the presence of tachypnoea or indrawing and an abnormal chest radiograph. Receipt of antibiotics was determined by parental report and medical record review.
Results Fewer than half (108, 39%) of the children had received an antibiotic before hospital admission. For 60 children (21%) there had been no opportunity to prescribe because the illness evolved rapidly, resulting in early hospital admission. For the remaining 112 children (40%) an opportunity to receive antibiotics was missed. The parent failed to obtain the antibiotic prescribed for 23 children (21% of 112), but in 24 children (21%) pneumonia was diagnosed but no antibiotic prescribed and in a further 28 children (25%) the diagnosis was not made despite parental report of symptoms suggesting pneumonia. Missed opportunities to prescribe were not associated with increased overall severity of symptoms at hospital presentation but were associated with an increased risk of: focal chest radiological abnormalities (rate ratio (RR)=2.14; 95% CI 1.49 to 2.83), peripheral leucocytosis >15×10⁹/l (RR=2.29; 95% CI 1.61 to 2.98) and bacteraemia (RR=6.68, 95% CI 1.08 to 58.44).
Conclusions Young children with community-acquired pneumonia may not receive an antibiotic before hospital admission because the illness evolves rapidly or the prescribed medicine is not given by parents. However, missed opportunities for appropriate antibiotic prescribing by health professionals in primary care appear to be common.

Introduction

Antibiotics are recommended as first-line treatment for community-acquired pneumonia and are almost always prescribed to preschool aged children on hospital admission with pneumonia. For example, the British Thoracic Society recommends amoxicillin as first-line treatment for children <5 years old with community-acquired pneumonia. However, the same guideline also says that children with 'mild' symptoms of lower respiratory tract infection (LRTI) do not require antibiotics. This creates a diagnostic challenge for primary care doctors. Not treating serious disease can result in death. Antibiotic overprescribing for lower respiratory infections increases the risk of antimicrobial resistance.

A case series of children hospitalised with community-acquired pneumonia in England called into doubt whether primary care doctors are meeting the diagnostic challenge effectively. It reported that only 22% of infants and 31% of children 1–15 years old had received antibiotics before admission.^[1] Moreover, the children not prescribed antibiotics had more severe disease on hospital admission.^[1] However, the report was not based on a consecutive series of cases from a defined population and no information was reported about the primary care given or the reasons for non-prescribing.

We therefore analysed a consecutive series of admissions of children from a defined catchment population in New Zealand (NZ) to confirm, in a country with a similar health system to the UK, the low rate of preadmission antibiotic prescribing for community-acquired pneumonia. We also sought to go further by consulting parents and reviewing primary care records to explore why this might happen.

Wednesday, February 15, 2012

Vision loss in Children

From Archives of Disease in Childhood

Visual Impairment in Children in Middle- and Lower-income Countries

Paul Courtright; Amy K Hutchinson; Susan Lewallen

Abstract and Introduction
Retinopathy of Prematurity
Paediatric Glaucoma
Amblyopia
Vitamin A Deficiency
Cataract
Refractive Error
Other Causes
The Need for Special Programmes for Children's Vision Health
Summary Box

References

Abstract and Introduction

Abstract

Reducing visual impairment and blindness in children in resource-poor countries is one of the key components of the major global prevention of blindness initiative, VISION 2020 the Right to Sight. Although visual impairment and blindness among children is much less common than among adults, the potential lifespan of a child means that the lifelong impact of such impairment is very large. Over 10 years ago, it was estimated that, globally, 1.4 million children were blind. Much has changed in the past 10–20 years and there is a need to reassess both the magnitude and causes of global childhood blindness and visual impairment. While the widespread implementation of vitamin A supplementation and measles immunisation programmes have led to a reduction in vitamin A deficiency-related blindness in many poor countries, retinopathy of prematurity is now undergoing a third wave of endemicity, particularly in newly industrialising countries in Latin America and Asia. Childhood cataract is better recognised as an important potentially avoidable problem, as is paediatric glaucoma and refractive error in some populations. Trained paediatric ophthalmologists, although still too few, are growing in number in poor countries. A programmatic approach with a multidisciplinary team is essential to reducing childhood blindness. The elements of such programmes and the need for planning are discussed.

Introduction

Reducing vision loss in children in resource-poor settings has been the focus of considerable efforts by governments, non-governmental organisations, donors, public health professionals and eye care providers for the past 30 years. Research on vitamin A deficiency in Indonesia and elsewhere provided the link between specific ocular conditions and childhood morbidity and mortality.^[1] This body of work was instrumental in including childhood blindness in VISION 2020 Right to Sight, a broad initiative by the WHO and non-governmental organisations to eliminate avoidable blindness by the year 2020.^{[2 3]} At the launch of VISION 2020, over 10 years ago, it was estimated that 1.4 million children were blind with about half of these cases being avoidable. There are no reliable estimates of disability-adjusted life years (DALYs) lost owing to childhood blindness in low- and middle-income countries. Because of the devastating immune effects of vitamin A deficiency, it was further estimated that 60% of children die within 1 year of becoming blind.^[4]

At the launch of VISION 2020, based on the known strong link between childhood mortality and vitamin A deficiency blindness, an estimate of overall childhood blindness and visual impairment was made using country-and region-specific under-5 deaths.^[5] WHO defines blindness as presenting visual acuity (better eye) of <3/60, severe visual impairment as presenting visual acuity (better eye) of <6/60 (but ≥3/60) and visual impairment as presenting visual acuity (better eye) of <6/18 (but ≥6/60 or better). Additional information on causes of blindness was provided by many systematic surveys in blind schools in developing countries, although it was always acknowledged that the children attending these schools did not necessarily represent all blind children.^[6] Much has changed in the past couple of decades and there has been a recent call to reassess both the magnitude and causes of childhood blindness.^[6]

Childhood blindness is uncommon, relative to blindness in adults and thus poses a great challenge to obtaining true population-based data. However, surveys using key informants and other approaches to identify children with blindness provide some information on the likely magnitude of blindness in some settings. These surveys,^[7,–,12]summarised in Table 1 uggest that in many resource-poor settings, the prevalence of blindness is lower than the previously suggested figures of >1/1000 children in most of sub-Saharan Africa or 0.5–0.9/1000 children in most of Asia. In addition, more recent studies in schools for the blind,^[13,–,16] while not providing data on blindness prevalence, have shown changing patterns in the causes of blindness, with fewer children with corneal conditions secondary to measles and vitamin A deficiency and more congenital conditions (disorders of the whole globe or retina) and inadequately treated cataract ( Table 2 ). The population-based surveys shown in Table 1 also present a mixed picture, with lens-related causes and posterior segment causes being the most frequent. Causes of blindness in childhood are different in the industrialised countries and it is difficult to make direct comparisons; most surveys in resource-poor settings use a WHO form for classifying causes,^[17] reporting one major anatomical site responsible for blindness. On the other hand, reports from industrialised countries rely on more specialised testing and extensive history and recognise that multiple anatomical sites are often involved. An extensive study in the UK^[18] reported 'lens' as a site of abnormality in only 5% of incident cases, found that 77% of cases had additional non-ophthalmic disorders and that 75% of cases were neither preventable nor treatable.

It seems there is no longer one single leading cause of global blindness in children. We will review the major causes, then discuss programme issues relevant to reducing childhood blindness.

UTI in Children and MCU

From Medscape Pediatrics > Viewpoints

Judicious Urinary Tract Imaging in Pediatric UTI

William T. Basco, Jr., MD, MS

Posted: 02/03/2012

Impact of a More Restrictive Approach to Urinary Tract Imaging After Febrile Urinary Tract Infection

Schroeder AR, Abidari JM, Kirpekar R, et al
Arch Pediatr Adolesc Med. 2011;165:1027-1032

Study Summary

In 2007, the United Kingdom instituted updated guidelines for the management of urinary tract infection (UTI) in children. The guidelines recommend more limited use of renal ultrasound (RUS) and voiding cystourethrogram (VCUG). The UK guidelines recommend RUS for most children with UTI but limit the use of VCUG to children meeting the following criteria:

UTI with bacteremia;
inadequate clinical response in the first 48 hours;
UTI caused by pathogens other than Escherichia coli;
any clinical indication of poor urine flow;
elevated serum creatinine level;
palpable abdominal mass; or
abnormal findings on the initial RUS.

The new guidelines do not generally recommend prophylactic antibiotics.

This study by Schroeder and colleagues reports the implementation of the UK guidelines to a medical center in California in September 2008, with periods of data collection corresponding to 1 year before and after implementation of the algorithm, separated by a period of time during which the new guidelines were being implemented. This study was conducted to determine how implementation of these guidelines affected the ordering of urinary tract imaging after UTI and whether the guidelines led to changes in prophylactic antibiotic use. They also compared the frequency of recurrent UTI before and after instituting the restricted guidelines.

The subjects of the analysis were children under 2 years of age. Urine cultures positive for pathogens were identified using clinical databases, the medical records for each child were reviewed, and any second UTI within 6 months of the index UTI was defined as a "recurrent UTI." Children with previous UTIs, genitourinary or neuromuscular abnormalities, or other conditions that might affect the results were excluded. The prealgorithm group included 98 children, and the postalgorithm group included 103. The groups were very similar at baseline.

A comparison of pre- and postimplementation findings includes the following:

VCUG frequency declined from 99% to 12.6%.
RUS frequency declined from 99% to 67%.
Rates of recurrent UTI were almost identical, at 7.1% in the preguideline children compared with 7.8% in the postguideline children (not statistically significant).
Frequency of grade 4-5 vesiculoureteral reflux was not different preguideline (2.0%) vs postguideline (2.9%)
No grade 1-3 vesiculoureteral reflux was identified after implementation of the guidelines.
Almost complete elimination of prophylactic antibiotic use was seen between completion of treatment for UTI and VCUG attainment.
Indefinite prophylaxis with antibiotics decreased from 26.5% prealgorithm to 2.9% postalgorithm.
Frequency of obtaining follow-up cultures for any reason between the 2 groups was identical, at 0.3%-0.4%.

The main effect of following the more restricted guidelines for post-UTI imaging was in not identifying low-grade vesiculoureteral reflux. Furthermore, fewer children received prophylactic antibiotics. Schroeder and colleagues support the application of this more restricted approach to the child with UTI.

Viewpoint

Many readers will be familiar with the updated American Academy of Pediatrics (AAP) guidelines for diagnosis and management of UTI in children,^[1] released in the fall of 2011. Those guidelines suggest the basic approach outlined in this article with respect to the first febrile UTI. The change in guidelines was prompted by building evidence that most children with high-grade reflux will have an abnormal RUS during the acute illness, allowing the clinician to avoid obtaining a VCUG in children whose initial RUS is normal. Viewing the results another way, most of the reflux identified through universal VCUG testing will be low grade and clinically inconsequential. I suspect that over the next 5 years we will see additional publications reporting short-term outcomes (1-5 years) in children with UTI after widespread implementation of the AAP guideline in the United States.

Infantile Hemangiomas

From Medscape Dermatology > Viewpoints

Therapy for Infantile Hemangiomas

Propanolol Blows Away Corticosteroids

Graeme M. Lipper, MD

Posted: 02/08/201

Propranolol vs Corticosteroids for Infantile Hemangiomas: A Multicenter Retrospective Analysis

Price CJ, Lattouf C, Baum B, et al
Arch Dermatol. 2011;147:1371-1376

Study Summary

Infantile hemangiomas (IH) are proliferative vascular tumors that, despite their benign nature, may cause pain, bleeding, scarring, or functional impairment with potentially life-threatening consequences. Because most IHs involute within the first decade of life, noncritical lesions are typically followed for expected gradual regression. In contrast, lesions that obstruct vision, respiration, hearing, feeding, or defecation require prompt medical or surgical intervention. Large or multifocal lesions pose significant risks, including high-output cardiac failure and cosmetic disfigurement.^[1] In the past, such high-risk IHs were treated with systemic corticosteroids, an option that is limited by variable efficacy and common adverse effects such as cushingoid features, adrenal suppression, gastritis, hypertension, and growth impairment.

In 2008, French investigators made the serendipitous discovery that propranolol, a beta-blocker traditionally used for the treatment of hypertension, tachycardia, and congestive heart failure, can induce dramatic IH regression.^[2]Subsequent reports confirming the impressive efficacy and safety of propranolol have been met with growing optimism.^[3-5] However, one pressing question remained: How does propranolol compare with systemic corticosteroids? In a landmark multicenter study, Price and colleagues convincingly answered this question. It turns out that propranolol blows the historical gold standard out of the water.

In order to reach this conclusion, Price and colleagues retrospectively analyzed the clinical outcomes in 110 infants and children with IH (77% female; 78% located on the head and neck; mean age of treatment initiation, 4.7 years). The patients were subdivided into 2 treatment groups: those receiving propranolol (n = 68; mean treatment duration, 7.9 months; target dose, 2 mg/kg/d) and those receiving oral corticosteroids (n = 42; mean treatment duration, 5.2 months; target dose, 4 mg/kg/d). To insure comparability, investigators matched these groups for patient age and lesion size, location, and type.

Outcome measures included percentage of IH clearance (< 75% or ≥ 75%), adverse effects, percentage of patients needing subsequent surgical referral, and average treatment cost per IH. Propranolol proved superior in all of these criteria:

82% of patients treated with propranolol achieved ≥ 75% clearance vs 29% of patients treated with oral corticosteroids (P < .01).
1 of 68 patients treated with propanolol had transient hypoglycemia, 2 patients (3%) had nonspecific skin eruptions, all patients completed treatment, and no patients suffered serious adverse events, whereas all patients treated with oral corticosteroids had adverse effects, including cushingoid features (100%), gastroesophageal reflux (n = 4), and hypertension (n = 2). One patient had a life-threatening bleed due to IH ulceration eroding into the external carotid artery.
12% of patients treated with propranolol required surgery after therapy vs 29% of patients treated with oral corticosteroids.
The average cost per IH treated (excluding monitoring costs and prophylaxis/treatment of adverse effects) was $205.32 for propranolol vs $416.00 for oral corticosteroids.

Viewpoint

After its recent introduction by French investigators, oral propranolol has revolutionized the management of severe infantile hemangiomas. Now, thanks to Price and colleagues' seminal study, no lingering doubt should exist that propranolol is the first-line agent for treating symptomatic or cosmetically disfiguring IH. When comparing safety and efficacy of the 2 drugs, the results are not even close.

Although "propranolol blows away corticosteroids" is the headline here, the investigators of this study also made several other important observations. For example, they found that:

Propranolol induced IH regression even when treatment was initiated after the first year of IH growth, confirming previous reports that the drug works to debulk more mature lesions beyond the proliferative phase.^[6]
Initial treatment with oral corticosteroids followed by oral propranolol showed a trend toward slightly improved efficacy over propranolol alone, although this benefit was not statistically significant.
IHs were less likely to relapse if propranolol therapy continued until at least 1 year of age.
The risk for propranolol-related side effects can be minimized with proper monitoring (eg, cardiac preclearance and checking for signs or symptoms of bradycardia, hypotension, and hypoglycemia).

Finally, Price and colleagues acknowledged that at least one more critical question remains: We still do not knowhow propranolol works to slow IH and induce regression. Does it trigger endothelial cell apoptosis, inhibit proangiogenic cytokines, or cause vasoconstriction by reducing nitric oxide levels? As researchers try to solve this complex puzzle, powerful new IH treatments will surely follow
.

Thursday, February 9, 2012

Prevent Obesity in Child

Chest Pain in Children - majority not cardiac

From Medscape Pediatrics > Viewpoints

Chest Pain in Children: Is It Cardiac?

William T. Basco, Jr., MD

Authors and Disclosures

Posted: 01/30/2012

Like this article?

Read medical news in 32 specialty
areas with our Medscape App.
Choose the specialties you want
to follow.

Learn More

Effectiveness of Screening for Life-Threatening Chest Pain in Children

Saleeb SF, Li WY, Warren SZ, Lock JE
Pediatrics. 2011;128:e1062-e1068

Chest Pain in Children

Studies have consistently shown that most chest pain experienced in childhood and adolescence is not cardiac in nature. Therefore, chest pain in children does not have the same concerning connotation that it does in adults. This study was done to determine whether unexpected cardiac events occurred in children who were evaluated in a cardiology clinic and determined to have a noncardiac origin for their pain.

Study Summary

All children were evaluated at a single medical center in Boston over a 10-year period, 2000-2009. Children were older than 6 years and had no known cardiac defects or cardiovascular disease. Children who were seen for chest pain were identified from medical records. Additional data included demographic features, clinical characteristics, cardiac testing, discharge diagnoses, other medical diagnoses, and follow-up.

Children were divided into those who had chest pain on exertion and those who had chest pain at rest. In general, children who experienced chest pain on exertion as one of the presenting symptoms had more extensive testing. ECGs were performed on all children, but additional testing varied during the study period at the discretion of the cardiologist evaluating the patient. Two sources were used to identify deaths after the visit: the National Death Index from the Centers for Disease Control and Prevention and the Social Security Death Index.

The final cohort included 3700 children. The median age at the time of the cardiac evaluation was 13.4 years, and the children had a median of 4.4 years of follow-up. Chest pain at rest was the most common scenario (56%), followed by exertional chest pain (33%). Palpitations accompanied the chest pain in 22% of patients, shortness of breath in 16%, dizziness in 11%, and syncope in 1.3%. Almost 1 of 5 children had made at least 1 emergency department visit for chest pain before the cardiac evaluation. Fifteen percent of the children had a history of asthma, and almost 2% had a history of gastroesophageal reflux. Approximately 1% had a minor congenital heart problem, and an additional 1% had an inflammatory disorder. The physical examination findings were mostly normal.

Results of cardiac evaluations. Identified cardiac abnormalities included clicks (1.4%), structural abnormalities of the sternum (1.1%), and pathologic murmurs (0.8%). The ECG evaluations were largely normal, with left ventricular hypertrophy demonstrated in only 2.5% of children and abnormal ST segments, abnormal T waves, right ventricular hypertrophy, or conduction abnormalities demonstrated in less than 1%. Echocardiography was done in 38% of patients; these evaluations were normal in 88%, and an additional 11% had incidental findings that the investigators felt were unrelated to chest pain. In 0.8% of patients, the echocardiograms identified abnormalities that might be related to the chest pain; these incidental findings included mild dilations of the aorta, mild mitral regurgitation, mitral valve prolapse, and miscellaneous problems.

Causes of chest pain. The discharge diagnoses from the cardiology clinic evaluation for chest pain were apportioned as follows:

Unknown origin, 52%;
Musculoskeletal origin, 36%;
Pulmonary origin, 7%;
Gastrointestinal origin, 3%;
Anxiety, 1%; and
Cardiac origin, 1%.

Deaths during follow-up. Among the 3700 patients, 3 deaths (0.1%) occurred during follow-up. Two of these deaths were suicides, and the third was the result of retroperitoneal hemorrhage. The researchers concluded that chest pain is a common pediatric symptom that rarely has a cardiac cause and that, in almost 18,000 patient-years of follow-up, no patient discharged from the clinic died of a cardiac condition.

Viewpoint

This is an excellent study that may or may not reassure primary care practitioners. Although the incidence of cardiac diagnoses was exceedingly low at 1%, some of the conditions that were identified are potentially serious cardiac abnormalities. Allaying residual concerns about missing even the small percentage of true cardiac diagnoses is exactly why these investigators conducted the main analyses that looked at deaths after discharge from their clinic. Children discharged with a diagnosis of chest pain are probably a selected group, so the investigators repeated the analysis to include the 41 children who had chest pain as a presenting symptom but ended up with a more severe cardiac diagnosis. This increased the overall incidence of cardiac disease in children with chest pain to 2%. Even among the 41 children with a more serious cardiac diagnosis, no deaths occurred.

It is worth noting that this is a subspecialty referral population, meaning that primary care practitioners probably filtered out many other cases of chest pain before they arrived at the pediatric cardiology clinic. Therefore, the incidence of cardiac disease is probably even lower among all children in a primary care who are experiencing chest pain. Nevertheless, Saleeb and colleagues are evaluating an outpatient application of a decision approach to referral and testing for chest pain in primary care practitioner offices, and I know that having such a validated guideline would be very welcome to most pediatric practitioners when seeing a patient with chest pain.

Abstract