MMRV - Mumps Measles Rubella Varicella vaccine

Medscape Medical News

ACIP Issues New Guidelines for Use of Combination Measles, Mumps, Rubella, Varicella Vaccine

Laurie Barclay, MD

May 11, 2010

Specific Recommendations for Use

Specific recommendations for use of the MMRV vaccine are as follows:

• Routinely recommended ages for MMRV vaccination continue to be ages 12 to 15 months for the first dose and ages 4 to 6 years for the second dose.
• At ages 12 to 47 months, either measles, mumps, and rubella (MMR) vaccine and varicella vaccine or MMRV vaccine may be used for the first dose of measles, mumps, rubella, and varicella vaccines. Clinicians should inform the parents or caregivers regarding the benefits and risks of both vaccination options. The CDC recommends that MMR vaccine and varicella vaccine be given for the first dose in this age group unless the parent or caregiver expresses a preference for MMRV vaccine.
• For the second dose of measles, mumps, rubella, and varicella vaccines at any age (15 months - 12 years) and for the first dose at age 48 months or older, the MMRV vaccine is preferred to separate injections of MMR vaccine and varicella vaccine, but provider evaluation, patient preference, and the risk for adverse events should be considered.
• A precaution for MMRV vaccination is a personal history of seizures of any cause or a family history of seizures in a sibling or parent. These children generally should be vaccinated with MMR vaccine and varicella vaccine.

"Studies have not demonstrated that antipyretics (e.g., acetaminophen or ibuprofen) prevent febrile seizures," the report authors conclude. "Vaccination with either MMR vaccine or MMRV vaccine can cause fever and, rarely, febrile seizures. Most fevers and febrile seizures after administration of a measles-containing vaccine occur 5–12 days after vaccination with the first dose."

MMWR Morb Mortal Wkly Rep. 2010;59(RR-3):1-12.

Dexamethasone May Help Atopic Infants With Bronchiolitis

Medscape Medical News

Laurie Barclay, MD

Sep 16, 2013

Oral dexamethasone for 5 days reduced hospital stay for infants with bronchiolitis and eczema or a family history of asthma, according to results from a placebo-controlled trialpublished online September 16 in Pediatrics.

"Because steroid use is known to decrease admission rate and length of emergency stay in children with asthma but failed to do so in bronchiolitis, identifying asthmatic or preasthmatic patients and targeting them with steroid treatment early might improve symptoms and hasten recovery," write Khalid Alansari, MD, FRCPC, from the Division of Pediatric Emergency Medicine, Hamad Medical Corporation in Doha, Qatar, and colleagues. "A shorter stay and possibly a lower chance of needing return visits or subsequent hospitalization are desirable goals of better bronchiolitis therapy."

Therefore, the researchers designed a study to test the addition of dexamethasone to salbutamol in infants at risk for asthma, based on eczema or a family history of asthma in a first-degree relative. They enrolled 200 previously healthy infants, median age 3.5 months, with a diagnosis of bronchiolitis and asthma risk., All were treated with inhaled salbutamol and randomly assigned 1:1 to receive either dexamethasone, 1 mg/kg and then 0.6 mg/kg for 4 more days, or placebo.

Shorter Hospital Stay With Dexamethasone

Infants treated with salbutamol plus dexamethasone had a mean time to readiness for discharge of 18.6 hours (95% confidence interval [CI], 14.9 - 23.1 hours) compared with 27.1 hours (95% CI, 21.8 - 33.8 hours) for infants treated with salbutamol plus placebo. Dexamethasone was therefore associated with a 31% shortening of hospital stay (P = .015). In addition, during infirmary treatment, 5 infants in the placebo group, but none in the dexamethasone group, had to be admitted to intensive care (P = .02).

In the week after discharge, 22 infants in the dexamethasone group and 19 in the control group were readmitted to the short-stay infirmary (P = .9). During 7 days of monitoring, there were no reported hospitalizations or adverse effects.

"Dexamethasone with salbutamol shortened time to readiness for infirmary discharge during bronchiolitis episodes in patients with eczema or a family history of asthma in a first-degree relative," the study authors write. "Infirmary and clinic visits in the subsequent week occurred similarly for the 2 groups."

Limitations of this study include limited detail in safety reporting and lack of measurement of prevalences of patient eczema or atopy in the first-degree family of the bronchiolitis population.

"We speculate that a somewhat more prolonged dosing regimen may also reduce the need for post-discharge visits," the study authors conclude.

This study was sponsored by Hamad Medical Corporation. The authors have disclosed no relevant financial relationships.

Pediatrics. Published online September 16, 2013. Abstract

Home Birth 10 Times More Likely to Result in Apgar of 0

Medscape Medical News

Jenni Laidman

Sep 18, 2013

Home deliveries were 10 times more likely to result in an Apgar score of 0 than hospital deliveries, according to a studypublished online June 21 in the American Journal of Obstetrics & Gynecology.

Further, the research, which includes data on nearly 14 million singleton, full-term births of infants of normal weight from 2007 to 2010, found a nearly 4-fold greater risk for neonatal seizure or serious neurologic dysfunction among home births.

Amos Grünebaum, MD, chief of labor and delivery, New York–Presbyterian/Weill Medical College of Cornell University, New York City, and colleagues used data from the National Center for Health Statistics of the Centers for Disease Control and Prevention to assess deliveries by both physicians and midwives in hospitals, freestanding birth centers, and homes. All of the infants in the study were of 37 weeks' gestation or more and weighed at least 2500 g at birth. Five-minute Apgar scores of 0 and neonatal seizures or serious neurologic dysfunction were analyzed according to where the births took place and whether the delivery was performed by a hospital midwife, a freestanding birth center midwife, a home midwife, or a hospital physician.

Researchers found a relative risk (RR) of 10.55 (95% confidence interval [CI], 8.62 - 12.93) for an Apgar score of 0 for midwife-attended home births (98/60,296 births), compared with the risk during hospital physician delivery (1943/12,615,994 births). The RR for midwife-attended deliveries at freestanding birth centers was 3.56 (95% CI, 2.36 - 5.36; 23/42,000 births). The RR for an Apgar of 0 during hospital midwife delivery was 0.55 (95% CI, 0.45 - 0.68; 95/1,115,794 births), suggesting the critical factor is the location of the birth, not the training of the professional involved in delivery, the authors write.

Risks were greatest for home deliveries of nulliparous patients, with an RR of 14.24 (95% CI, 10.16 - 19.96) for a 5-minute Apgar score of 0 (35/14,801 births) compared with nulliparous patients who had a physician-attended hospital delivery (856/5,155,779 births).

In addition, home births attended by midwives resulted in an RR of 3.80 (95% CI, 2.80 - 5.16) for neonatal seizures or serious neurologic disorders (42/49,091 births) compared with hospital delivery by physicians (1823/8,102,337 births). The RR for freestanding birth centers was 1.88 (95% CI, 1.11 - 3.17; 14/33,188 births). For hospital midwifes, the RR was 0.74 (95% CI, 0.62 9 0.89; 121/727,395 births) compared with physicians.

The authors state that risks determined by this study may be underestimates because some of the bad outcomes marked in the hospital column resulted from transfers to the hospital from a home birth.

"The magnitude of risk associated with home delivery is alarming," Dr. Grünebaum said in a news release from New York–Presbyterian/Weill Cornell Medical Center. The findings, he said, mean caregivers must warn patients of the risks attendant in home birth. "Physicians therefore should not offer and should recommend against birth settings outside the hospital," the authors write.

The key problem is a lack of available resources to deal with emergencies during a home birth, Frank Chervenak, MD, a study coauthor and director of maternal-fetal medicine at New York–Presbyterian/Weill Cornell, said in the release. "[T]here can be unpredictable complications requiring immediate surgical intervention. If an emergency occurs at home that requires hospital transport, it's often difficult to beat the clock to prevent death or neurological issues."

The study contradicts claims that home deliveries have a low risk profile, as a 2012 National Center for Health Statistics Data Brief stated. The data brief based its conclusions on a lower number of preterm births among home deliveries and a lower percentage of low birth-weight infants. It also counted the reduced numbers of teenaged births and reduced deliveries of multiples at home. However, the current study concluded that the risk is higher even after excluding early deliveries, low-birth infants, and multiple deliveries.

The study also contrasts with a Dutch study published in June that looked at maternal morbidity. That research, published in BMJ, involved some 147,000 low-risk women. It found a risk for maternal morbidity of 1 per 1000 among parous women, for an adjusted odds ratio of 0.43. The odds ratio was adjusted for maternal age, gestational age, socioeconomic status, and ethnicity (Dutch or non-Dutch).

The authors have disclosed no relevant financial relationships.

Am J Obstet Gynecol. Published online June 21, 2013. Abstract

Managing ADHD: Don't Neglect the Parents

Medscape Psychiatry > Medscape Psychiatry Minute

Peter M. Yellowlees, MBBS, MD
Sep 12, 2013

Attention-deficit/hyperactivity disorder (ADHD) is commonly diagnosed, but we know little about the comparative effectiveness of the various behavioral and pharmacologic treatment options, especially in preschoolers at risk for ADHD because of clinically significant disruptive behavior. The US Agency for Healthcare Research and Quality has sponsored a comparative effectiveness review^[1] of interventions for this group of children.

This comprehensive review examined 55 studies between 1980 and 2011. The interventions that were evaluated in these studies were parent behavior training, combined home and school/day care interventions, and methylphenidate use. Data were extracted using customized software.

The investigators found that more studies of all of these interventions are consistently documenting effectiveness, but parent behavior training interventions had greater evidence of effectiveness than methylphenidate for treatment of preschoolers at risk for ADHD.

As clinicians, we must be careful in our prescribing of stimulants for young children, and we should consider behavioral approaches first. I'm Dr. Peter Yellowlees.

Abstract

Acute Otitis Media in children - empiric therapy

Empiric Therapy Regimens

Empiric therapeutic regimens for acute otitis media in children are outlined below, including general recommendations, first- and second-line treatments, treatment for penicillin-allergic patients, and treatments for patients with recurrent illness or treatment failures.^{[1, 2, 3, 4, 5, 6, 7]}

General recommendations

Adequate pain and fever control with either oral acetaminophen or ibuprofen or topical pain control with topicalbenzocaine preparations is imperative whether antibiotics are given or not.

Age < 6mo:

• Should receive antibiotics whether the diagnosis of acute otitis media is certain or not

Age 6mo to 2y:

• Should receive antibiotics if the diagnosis is certain
• If the diagnosis is uncertain, an observation period can be considered if the illness is nonsevere

Age > 2y:

• Should receive antibiotics if the diagnosis is certain and if the illness is severe
• An observation period is advised if the diagnosis is uncertain or if it is certain and nonsevere

First-line treatment

• Amoxicillin 80-90 mg/kg/day PO (maximum 3 g/24h) divided BID for 5-7d; 10d may be required if illness is severe or
• Ceftriaxone 50 mg/kg IM × 1 dose (maximum 1 g); recommended for children unable to take antibiotics PO and for patients with compliance issues

Children with acute otitis media with tympanostomy tubes:

• Ciprofloxacin 0.3%/dexamethasone 0.1% otic solution 4 drops BID × 7d or
• Ofloxacin otic solution 5 drops BID × 10d

Second-line treatment

Penicillin allergic:

Non – type-1 hypersensitivity:

• Cefdinir 14 mg/kg/day (maximum 600 mg/24h) PO qd or divided BID for 5-10d or
• Cefpodoxime 10 mg/kg/day (maximum 400 mg/24h) PO qd or divided BID for 5-10d or
• Cefuroxime 30 mg/kg/day PO (maximum 1 g/24h) divided BID for 5-10d

Type-1 hypersensitivity:

• Azithromycin 10 mg/kg/day (maximum 500 mg) PO × 1 dose, then 5 mg/kg/day (maximum 250 mg/24h) PO qd × 4d or
• Azithromycin 10 mg/kg/day (maximum 500 mg/24h) PO qd × 3d or
• Clarithromycin 15 mg/kg/day (maximum 1 g/24h) PO divided BID for 5-10d

Recurrent acute otitis media/treatment failure

• Amoxicillin-clavulanate 90 mg/kg/day (based on amoxicillin component using ES formulation; maximum 4 g/24h) PO divided BID for 5-7d or
• Cefdinir 7 mg/kg q12h or 14 mg/kg q24h for 5-7d or
• Cefpodoxime 10 mg/kg/day as a single dose or
• Cefprozil 15 mg/kg q12h for 5-7d or
• Cefuroxime 30 mg/kg/day divided q12h for 5-7d or
• Ceftriaxone 50 mg/kg qd IM (maximum 1 g/24h) for 3d

Persistent treatment failure

• Ceftriaxone 50 mg/kg qd IM (maximum 1 g/24h) for 3d or
• Clindamycin 20-30 mg/kg/day divided QID for 5-7d

Best Practices to Identify Gay, Lesbian, Bisexual, or Questioning Youth in Primary Care

Kyle C. Chaplic, MSN, APRN, NP-C, Patricia Jackson Allen, MS, RN, PNP-BC, FAAN
Pediatr Nurs. 2013;39(2):99-103.

Abstract

Compared to heterosexual youth, gay, lesbian, bisexual, and questioning (GLBQ) adolescents engage disproportionately in a variety of health risk behaviors and are at risk for numerous negative health outcomes. Adolescents reporting same-sex sexual attraction, romantic relationships, and sexual experience are also at increased risk, regardless of self-identified sexual orientation. While adolescents feel it is important to discuss sexuality with primary care providers, they are unlikely to initiate discussion about sexuality or to openly disclose GLBQ sexual orientation to their providers. Primary care providers should identify GLBQ youth to increase delivery of targeted preventive health services to this at-risk population. However, providers do not routinely address sexual orientation in their clinical encounters with adolescents, and the majority of GLBQ youth are not identified in the primary care setting. To better serve the needs of this population, providers should initiate open, sensitive, nonjudgmental, and confidential discussion of sexuality with all adolescents. Providers should inquire about sexual orientation, sexual attraction, romantic relationships, and sexual partners.

Introduction

Healthy People 2020 states that gay, lesbian, bisexual, and transgender (GLBT) health "requires specific attention from health care and public health professionals to address a number of disparities," including mental health and suicidal behavior (U.S. Department of Health and Human Services, 2012). In addition to the usual issues faced by all adolescents, GLBT and questioning (GLBTQ) adolescents must also face the persistent social stigma associated with sexual minorities in America. In a recent study, 3.4% of male and 9.5% of female adolescents 14 to 17 years of age self-identified as gay, lesbian, bisexual, or "other" (Herbenick et al., 2010).

It is clear that GLBQ adolescents constitute a vulnerable subpopulation of adolescents in which particular vigilance in health promotion and disease prevention is required. However, these youth are often "invisible" to pediatric primary care providers (Frankowski & the American Academy of Pediatrics [AAP] Committee on Adolescents, 2004). To better meet the unique health care needs of this population, providers must be able to sensitively elicit a detailed and accurate social and sexual history from adolescents to identify these youth. This clinical article synthesizes pertinent recent research pertaining to social and sexual history taking in GLBQ adolescents to increase identification of these youth in primary care practice.A 2011 Centers for Disease Control and Pre vention (CDC) report concluded that "compared to students who are not sexual minorities, a disproportionate number of sexual minority students engage in a wide range of health risk behaviors" (CDC, 2011b, p. 49). A number of previous studies have also shown that these youth are at significantly increased risk for victimization and violence, mental health problems and substance abuse, a variety of health risk behaviors, and suicide (Bontempo & D'Augelli, 2002; Faulkner & Cranston, 1998; Garofolo, Wolf, Kessel, Palfrey, & DuRant, 1998; King et al., 2008; Robin et al., 2002; Russell & Joyner, 2001).

Discussion and Recommendations

Given the increased prevalence of health risk behaviors in GLBQ adolescents demonstrated in the literature, it is important to identify these youth, contrary to the AAP position (Frankowski & AAP Committee on Adolescents, 2004) to provide additional counseling and health care services. These youth would be better served by primary care providers if their sexual orientation was identified in a supportive, confidential environment where services were available to address their health care needs. Key findings and recommendations for sensitive sexual history taking to identify GLBQ youth based upon the review of the literature are outlined in Table 2.

Recommendations for Sensitive Care of GLBQ Adolescents

While it is important to recognize that GLBQ youth are an at-risk population, it is essential that providers avoid a narrow view of these adolescents and provide them with the same sensitive, individualized, comprehensive care as they would other adolescents (Catallozzi & Rudy, 2004; Coker, Austin, & Schuster, 2010; Garofolo & Katz, 2001). GLBQ adolescents value the same characteristics in providers and clinical settings as other adolescents (Ginsburg et al., 2009; Hoffman et al., 2002; Rosenthal et al., 1999). Current guidelines for adolescent care should be followed, and counseling should be based on individual risk factors, not solely sexual orientation (Coker et al., 2010).

A number of resources are available online and in print that clinicians may find useful in developing their skills with GLBQ individuals. One such guideline is the Gay and Lesbian Medical Association'sGuidelines for Care of Lesbian,Gay, Bisexual, and Transgender Patients (Dunn et al., 2006). Although lacking in evidence-based preventive care guidelines, it contains a wealth of useful information on how to sensitively interact with GLBQ individuals and how to create a welcoming, inclusive practice environment. Additionally, the Gay and Lesbian Medical Association's guideline recommends that providers 1) avoid assumptions about adolescents and their sexual orientation or sexual practices, including assumptions of heterosexuality; 2) use inclusive, gender-neutral language on forms and in adolescent interviews; 3) observe and reflect language and terminology used by adolescents; 4) initiate open discussion of sexual history; and 5) use open-ended questions (see Figure 1). To help create a welcoming, inclusive practice environment, the Gay and Lesbian Medical Association recommends creating, posting, and enforcing a nondiscrimination policy (Dunn et al., 2006). Further, although the display of support symbols, brochures, and education materials pertinent to GLBQ youth are far less important to GLBQ adolescents than provider sensitivity (Ginsburg et al., 2002), the Gay and Lesbian Medical Association recommends the display of such materials (Dunn et al., 2006).

Bright Futures

AAP's Bright Futures Guidelines for Health Supervision ofInfants, Children, and Adolescents (Hagan, Shaw, & Duncan, 2008) is widely used and considered to be the standard of care in the provision of pediatric preventive health care in the United States. Providers using Bright Futures, however, should be aware that the guidelines contain limited information on the care of GLBQ adolescents; they echo the findings of Frankowski and AAP Committee on Adolescents (2004) and are not consistent with recommendations based upon this literature review.

The Bright Futures forms may be used to encourage discussion, but providers must be aware of their deficiencies in regard to eliciting sexual orientation or attraction in youth. It is particularly important that adolescents who indicate they are not sexually active still be interviewed regarding sexuality regardless of the forms' instruction to skip to the next section. Providers should review all adolescent history forms or electronic medical records used in their practice to determine their appropriateness for obtaining confidential, unbiased, sexual orientation and practice histories.Bright Futures health history forms for teens 11 to 14 years of age do not address sexual activity directly, but they include a box to check to indicate if the young adolescent has questions for the provider about sexuality. Forms for middle (15 to 17 years of age) and older (18 to 21 years of age) adolescents ask if the adolescent has ever had sex (a term often interpreted to apply only to sexual intercourse, not all forms of sexual activity), but they also instruct adolescents to skip the rest of the section if their response is "no." These forms ask males if they have "ever had sex with other men," but do not inquire about same-sex activity in females. No questions pertain to relationships of any kind nor same-sex attraction (Hagen et al., 2008).

Does a Failure to Respond to Antipyretics Predict Serious Illness in Children With a Fever?

David King

Disclosures

Arch Dis Child. 2013;98(8):644-646. 

 

Fever in children is a common reason for parents to seek medical advice. Around 25% of emergency department assessments in children are because of high temperature.

Many of these children have trivial self-limiting viral infections but a significant minority will have a serious bacterial illness requiring prompt treatment with appropriate antibiotics. Despite the introduction of national guidelines, there is still considerable controversy on how to manage these children. One method commonly used by both clinicians and parents to identify whether they think a febrile child requires further evaluation is the response of the temperature to antipyretics. There is a general belief that a fever of benign aetiology responds better to antipyretics compared with a fever due to a serious bacterial illness.

A review of the literature revealed eight studies that test this hypothesis. All the studies were heterogeneous and had a number of different methodological weaknesses. They were also quite old, with the most recent being published nearly 20 years ago. 

In general, the published literature suggests that response to antipyretics in febrile children cannot be used to accurately predict the likelihood of serious bacterial illness. There are three prospective cohort studies that showed that there was no difference in temperature response to antipyretics in children with a bacteraemia compared with children with no bacteraemia.Two further prospective studies examined the response to antipyretics in children with bacterial illnesses compared with viral illnesses, and in children according to the severity of underlying illness. Again, temperature response to antipyretics was not significantly less in children with bacterial illnesses. Indeed, in one of these studies, febrile children with either a bacteraemia, pneumonia or group A streptococcus infection actually had a better response to paracetamol compared with children with other illnesses. A case-control study that compared children with a non-bacterial febrile illness with those with meningitis or an isolated bacteraemia also concluded that response to antipyretics cannot predict serious illness.

Two of the identified studies did suggest that a poor response to antipyretics predicted serious illness in febrile children. However, both these studies were by the same authors and were based on exactly the same cohort of patients. There were also significant methodological limitations that would be expected to affect the results of these studies. These include their retrospective nature that patients were not enrolled consecutively, that a standard dose of paracetamol was not used and that the time at which the temperature was rechecked after receiving paracetamol was variable. In addition, in Mazur et al, the temperature decrease in bacteraemic children compared with non-bacteraemic children following paracetamol is unlikely to be clinically useful (1.0°C vs 1.2°C), even though it reached statistical significance.

It is interesting to note that all the studies published on this topic examined temperature response to either paracetamol or aspirin. Aspirin is no longer prescribed to children due to the risk of Reye's syndrome while the use of ibuprofen as an antipyretic in children is now widespread. There are currently no studies that examine whether temperature response to ibuprofen predicts serious illness in children. As the results of studies using paracetamol or aspirin are not necessarily generalisable to ibuprofen, this remains an area for future research.

In conclusion, the majority of published evidence indicates that clinicians cannot rely on response to antipyretics to predict serious illness in febrile children. Further research should aim to discover whether this finding applies to ibuprofen. In the meantime, assessment by an experienced examiner together with judicious use of laboratory tests and/or a period of observation probably remains the best way to decide on the management of febrile children.