PedSPAM April 2001

Welcome to PedSPAM for April. Here are some more things from my update reading that might interest you:

In the News

American schoolchildren get more fruits and vegetables in their school lunches now, but the amounts still fall short of recommended levels. A US Department of Agriculture survey found that fat levels in school lunches have fallen from 38% to 34% of total calories; the goal is 30%. About 18% of elementary school lunches and 22% of high school lunches met the 30% goal, up from 1% of all school lunches in 1992. Pediatric News, February 2001

The diagnosis and treatment of sinusitis remains open to some disagreement. A recent review by the federal Agency for Healthcare Research and Quality found that in multiple studies there were no clear differences in outcomes among different antibiotics (so your child does not need the most expensive, broad spectrum, resistance-inducing antibiotic), and that studies found no convincing data to support the use of antihistamines and decongestants. Pediatric News, February 2001.

Group A Streptococcus, the sore throat germ, can cause skin infections as well. Dr. Ilona Frieden, speaking at an American Academy of Pediatrics update seminar recently, stated that she is seeing an increased number of cases of streptococcal skin infections under the arms, on the neck, or in the buttocks and groin areas. Infected skin appears moist and pink, mimicking yeast (Candida) infections and irritant dermatitis. The bacterial strain causing the infection is the same as that causing throat infections, and is treated with oral antibiotics. Pediatric News, February 2001.

A large study from California data refutes the claim made by British researchers that the MMR vaccine (measles-mumps-rubella) causes autism. Analysis of data comparing immunization rates with the rate of autism in California showed that the incidence of diagnosed autism rose dramatically over the study period, while the immunization rate remained fairly steady. The study showed that the rate of autism began to increase before MMR immunization rates increased, and then continued to increase well past the time that immunization rates leveled off. Journal of the American Medical Association 2001;285:1183-1185.

Another study in Britain based on analysis of detailed National Health Service records also exonerates the MMR vaccine as a cause of increased rates of diagnosed autism in children. As in the American study, rates of autism went up by a factor of almost 4 while the rate of MMR vaccination remained stable. The lead researcher, Dr. James A. Kaye, is of the opinion that the documented increase in the reported incidence of autism in recent years is due to better diagnosis, often of milder autism variants. British Medical Journal 2001;322:00-00.

The Centers for Disease Control is urging the resumption of routine hepatitis B vaccination of newborns. Rates of newborn vaccination against hepatitis B dropped dramatically in July of 1999 when probably groundless concerns were raised about the tiny amounts of mercury-containing preservative thimerosal present in the vaccine. Thimerosal-free vaccine was available within two months, but hospitals did not change their policies back. Morbidity and Mortality Weekly Report 2001;80;94-97.

The inhaled steroid fluticasone propionate (Flovent®) is better than the inflammatory hormone blocker zafirlukast (Accolate) in treatment of asthma, according to these researchers. Patients maintained on the inhaled steroid had half the asthma complications of ER visits and hospital admissions, at lower per-patient cost. "These results, along with the findings of previous studies, complement the position of the National Institutes of Health Guidelines for the Diagnosis and Management of Asthma that inhaled corticosteroids should be selected as first-line maintenance treatment for asthma," the research team concludes. Journal of Allergy and Clinical Immunology 2001;107:94-98.

Despite recent criticisms that it is antiquated and not an informative indicator of perinatal asphyxia, the Apgar score is still useful. Researchers at the University of Texas Southwestern Medical Center at Dallas reviewed records of 145,627 newborns and found that low 5 minute Apgar scores were associated with significant risk of death in the first four weeks of life. New England Journal of Medicine 2001;344:467-471,519-520.

A long term study of childhood asthma rates lends support to the hypothesis that early exposure to infections tends to reduce the chance of a child developing asthma. This is referred to as the "hygiene hypothesis," which states that repeated infections in early childhood program the immune system towards a less allergy-prone state. British Medical Journal 2001;322:390-395.

This dovetails nicely with the observation that having a several siblings seems to be protective against the development of asthma as well (probably because of all the infections they bring home). Working mothers can lose a little of the guilt, perhaps.

A United Nations campaign to distribute high dose vitamin A capsules in developing countries has saved an estimated million lives since 1993, at an annual cost per child protected of less than a dollar. Adequate vitamin A supplementation by itself reduces the death rate by almost 1/4 for children receiving the capsules. Using local volunteers, many of whom are uneducated and illiterate, UNICEF expects to wipe out vitamin A deficiency in Nepal, for example, by 2002. Reuters Health.

A long-term school-based smoking prevention program, carried out with strict controls and careful design over a 15 year period, has ended in failure. Students in 40 school districts were tracked over 15 years into young adulthood. The intervention group had the same rates of smoking by seven different measures. Journal of the National Cancer Institute 2000, 92:1979-91.

I suggest the authors of the study read Malcolm Gladwell's new book, The Tipping Point. Adolescents do not smoke because it is cool, he says, they smoke because people viewed as cool smoke. Smoking is part of adolescent experimentation and rebellion. We can never change the facts of adolescent development. Kids will try smoking, no matter what. However, the majority of them will not continue to smoke, and we can do things to make cigarets less addictive and lower the rate of those who continue. For example, reducing the amount of nicotine per pack of cigarets to 5 mg has been shown to dramatically lessen the chance of addiction.

A new treatment for the pesky little warts known as molluscum contagiosum is on the horizon. The antiviral drug cidofovir was used to treat cytomegalovirus infections, and coexisting molluscum infections cleared as well. Topical cidofovir in two children with HIV infection led to clearing of the lesions with minimal skin irritation. Archives of Dermatology 2000, 136:983-83

Having a female comforter (a "doula," a Greek word for a woman experienced in childbirth who supports the mother-to-be) present for mother during labor and delivery significantly benefits both mother and baby. The rate of cesarian deliveries decreased by half, forceps use decreased by 40%, requests for epidural anesthesia decreased by 60%, oxytocin use to speed delivery was cut by 40%, and labor was shortened by 25%. Presence of a doula was twice as effective in reducing the cesarian section rate as the presence of the father. Presented at the annual meeting of the American Association for the Advancement of Science - Reuters.

Gene therapy experiments aimed at inserting a gene against the human immunodeficiency virus via stem cells have reached the stage of human trials. Stem cells from the bone marrow of HIV infected children aged 3-13 years old were treated to insert an anti-HIV gene, then the stem cells were reinjected into the infected child's bloodstream. The long term results are awaited. Pediatric News, February 2001.

British researchers conclude that very tiny premature babies born at less than 28 weeks gestation (40 weeks is full term) have worse outcomes if their blood oxygen is maintained at a higher level (as has been standard care). Babies whose blood oxygen saturation (which is expressed as a percentage of the total oxygen carrying capacity of the blood) was maintained at a somewhat lower range had not only significantly less eye damage from the effects of oxygen therapy, but also spent less time on a ventilator, and higher weight at discharge. They rarely had umbilical arterial catheters inserted, and subsequently required fewer blood transfusions. Archives of Disease in Childhood, Fetal Neonatal Edition 2001;84:F106-F110.

These findings are not surprising to me, since I have wondered about this very point for many years. The fetus thrives in a low oxygen environment. Why does simply being born change the oxygen requirement? Medicine can sometimes be a bit too aggressive. In our zeal to help the patient, we can sometimes do things that go counter to nature's mechanisms.

Cesarian section is a risk factor for potentially very serious persistent pulmonary hypertension (persistent fetal circulation, "PFC") in babies. The authors surmise that passage of the baby through the birth canal is in some way beneficial for the blood vessel network of the fetal lungs. Obstetrics & Gynecology, March 2001.

In a related story, the use of nonsteroidal anti-inflammatory drugs ("NSAIDs," notably aspirin, ibuprofen, naproxen and indomethacin) by pregnant women is strongly associated with the development of persistent pulmonary hypertension of the newborn. Mothers in the study group were often unaware they had even taken these medications, although the drugs could be easily detected in the infants' meconium. Pediatrics 2001;107:519-523.

A new drug, deflazacort, offers some hope for the treatment of Duchenne muscular dystrophy. Treated boys with the disease (it does not affect girls) were stronger on average, significantly less likely to need surgery for scoliosis, and maintained lung function better, even after becoming full time wheelchair users. Chief side effects were silent cataracts, and growth suppression. Journal of Pediatrics 2001;138:45-50.

Watch out for candle wicks with metallic cores. These could be lead, and give off amounts of lead vapor that are potentially very toxic to children. The Consumer Product Safety Commission has begun the process of banning these candles because they are still available despite a voluntary industry agreement to remove lead from candle wicks. Pediatric News, April 2001.

A study sure to raise eyebrows: British researchers found that adults who had breast fed as infants longer than about four months had higher degrees of artery distensibility, said to be an early indicator of increased heart attack risk. They concluded however that the advantages of breast feeding outweighed any such risk. They think this link relates to already known alterations of cholesterol levels in breast fed babies, and that it may also be a complex interaction of early breast feeding with the typical Western diet, which is high in fat. They observed that while the advantages of breast feeding are well documented, the optimum time for weaning has never been seriously studied and remains unknown. Advice to mothers to breast feed as long as possible might be modified at some future time. British Medical Journal 2001;322:625-626, 643-647.

A US judge has rejected claims in a class action lawsuit that pharmaceutical companies and the American Psychiatric Association conspired to expand the diagnosis of attention deficit hyperactivity disorder (ADD or ADHD) to promote sales of the drug and psyciatric services. Reuters.

An interesting study gives increasing evidence of an infectious basis for childhood leukemia. British researchers looked at what happened on two small islands off the coast of Scottland, Orkney and Shetland, when American servicemen "invaded" in large numbers during World War II. The group of children living on the island before the war and born during it had a 3.6-fold risk of developing leukemia. Children born after the servicemen left had no increased leukemia risk. The researchers say this points to an infectious cause, spread by adults, which only rarely triggers the disease. Lancet 2001;357:858.

Many women are still unaware of the importance of folic acid in their diets through the childbearing years. A Centers for Disease Control and Prevention (CDC) study found that only 42% of women of childbearing age were taking multivitamins with folic acid. The regular intake of folic acid in the childbearing years dramatically reduces the risk of so called neural tube defects, notably spina bifida. Mortality and Morbidity Weekly Report 2001;50:185-189.

For shame. Some maternity ward nurses are not following the back-to-sleep guidelines we try to impress upon mothers during the hospital stay. So finds a survey of nurses at 94 hospitals in Iowa. Many were still using side-sleeping positions, which are unstable. Concerns about vomiting and aspiration are unsupported by any scientific data; SIDS apparently relates to smothering, not aspiration of milk (which is not found at true SIDS autopsies). what nurses do in the hospital is very important, since parents tend to imitate what the hospital caregivers do when they arrive home with the baby. Pediatrics March 2001.

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