PedSPAM April 2002
Welcome to the PedSPAM archive for April. Here are the month's daily SPAMlets from my update reading that you might have missed:
In the News
Monday, April 1: No big surprise (and no April Fool) in this report: children of women who drink alcohol and smoke during pregnancy have more than double the risk of developing attention-deficit/hyperactivity disorder (ADHD). This study excluded children with fetal alcohol syndrome from inclusion. These children suffer from the effects of more pronounced alcohol exposure in utero and are already known to have these problems more often. The study compared medical records of 280 children diagnosed with ADHD with another group of 242 children without ADHD. All mothers were surveyed about their personal alcohol and cigaret consumption during pregnancy. Mothers of children with ADHD were 2.1 times more likely to have smoked during pregnancy and 2.5 times more likely to have drunk alcohol.Journal of the American Academy of Child and Adolescent Psychiatry 2002;41:378-385.
Tuesday, April 2: The number of reported cases of polio worldwide has fallen by more than 99% in the years since 1988. In 2001 there were 473 confirmed cases of polio worldwide, down from 719 the year before. In 1988, 125 countries were listed as having endemic polio; the number of such countries is now just 10. The major remaining reservoirs of poliovirus are Nigeria, India and Pakistan. Officials are now expecting mass vaccination programs in the remaining reservoirs of infection will lead to eradication of the wild type polio virus within 12 to 24 months. Morbidity and Mortality Weekly Report 2002;51:253-256.
Wednesday, April 3: The "Back to Sleep" campaign, wherein mothers are urged to lay babies on the back to sleep (supine position) rather than on the stomach (prone position), has reduced SIDS deaths without a rise in choking. Between 1991 and 1996, SIDS deaths fell by more than one third, with no rise in deaths from choking on regurgitated stomach contents. The authors of the study say that parents can now be reassured that their infants are at no greater risk of choking when they are placed on their backs to sleep. Pediatrics 2002;109:661-665.
I still get questions, mainly via email, about this. Back sleeping is really the only way to go now - the data are clear.
Thursday, April 4: Parents are often unaware of how much their children are exposed to asthma triggers in the home, and do not appreciate the importance of avoidance of these triggers. Asthma management guidelines stress the importance of reducing indoor allergy triggers and irritants. A survey of parents of asthmatic children found that their children were frequently exposed to triggers. Almost 60% of households had furry pets, 30% had a smoker and 18% had pests such as mice and cockroaches. Most children did not have proper plastic pillow covers or mattress covers and likewise had bedroom carpeting. Archives of Pediatric and Adolescent Medicine 2002;156:258-264.
Friday, April 5: Physicians in the UK have successfully cured a Welsh child of a fatal immune disorder, X-linked severe combined immunodeficiency disease (X-SCID). The procedure used involved removing bone marrow stem cells from the patient, an 18 month old toddler, and using a mouse virus to transfer DNA for the functional gene lacking in the boy into his cells. These cells were reinjected into him, and he was colonized with descendents of this modified strain of blood cells. The procedure had been done once in France about two years ago with two other children. It is not known how long the cure will last, but it is hoped that it will be permanent. The hope is that this type of gene therapy will eventually offer cures for other severe immune deficiencies as well as for blood diseases such as hemophilia and sickle-cell anaemia. Reuters Health
Monday, April 8: Centers for Disease Control surveys show that while the percentage of pregnant women who consume any alcohol at all during pregnancy has fluctuated to some extent - the percentage of women who report drinking 5 or more drinks at a sitting during pregnancy (defined as binge drinking) or drinking seven or more drinks per week (frequent drinking) has remained depressingly constant over the years. Either many women of childbearing age are not getting the message about the adverse effects of alcohol use during pregnancy, or they are ignoring the message. Morbidity and Mortality Weekly Report 2002;51:273-276.
Tuesday, April 9: The likelihood of cross sensitivity of cephalosporin antibiotics with penicillin has been greatly exaggerated. Most children who are truly penicillin allergic can be safely treated with cephalosporins.
The original paper1 that stated an 8% cross-reactivity rate for patients allergic to penicillin who were given a cephalosporin. Subsequent studies failed to confirm this figure; instead, re-analysis of the cephalosporin test material showed it was contaminated with penicillin2. Unless a child previously had a true anaphylactic or severe reaction to a -lactam antibiotic, physicians should feel comfortable in prescribing cephalosporins, even without allergy testing.
Pediatric News 2002 36:3;17
1. J. Infect. Dis. 137[Suppl]:S74-S79, 1978
2. Ann. Intern. Med. 107:204-15, 1987
Wednesday, April 10: By age 2, children in large day care centers suffer from somewhat more colds than those kept in small day care centers or at home. But by age 8, the tables are turned and children who attended large day care centers have dramatically fewer colds than other children. By age 13, the differences in the groups disappear, with frequent colds in a given child (6 to 9 colds a year) being equal in all three groups. Colds were characterized by the authors of this paper as a "training ground for the immune system," and an accompanying editorial pointed out that children who have a lot of colds when they are toddlers will miss school less often "later, when it counts." Archives of Pediatric and Adolescent Medicine 156 :121-26, 2002 and Archives of Pediatric and Adolescent Medicine 156:104, 2002.
Thursday, April 11: A new study finds that childhood falls from heights of less than 15 feet have a higher risk of hidden brain injury - bleeding or blood clots inside the head - than previously thought. Half of the children in the study who had experienced falls from fairly low levels - bicycles, monkey bars, swings, skate boards, low windows and balconies, shopping carts, trees, fences, walls, being accidentally dropped by adults, falling down stairs, etc. - had some significant abnormality identified on CT scan. These lower level falls, typically from 15 feet or less, have been largely ignored in severity studies. The investigators urged doctors in the emergency setting to be much less reluctant to order brain scanning to identify possible serious brain injury. Reuters Health.
Friday, April 12: The asthma drug montelukast (Accolate®) has a direct anti-inflammatory action on the airways of asthmatic patients in addition to relieving bronchial spasm and narrowing of the airways. This effect is an important finding; asthma is an inflammatory disease of the lung, and any medication that can reduce the requirement for steroids is to be desired. Chest 2002;121:732-738.
Leukotrienes are hormones released by white cells to trigger inflammatory responses. Blocking the action of the hormone blocks inflammation. The other widely used leukotriene blocker is zafirlukast (Singulair®); I would expect similar results from this drug. These medicines are not indicated for first line treatment of asthma but are recognized as valuable adjuncts to inhaled steroids. The drugs are particularly attractive with children; Singulair® is approved as young as age 2 and is a single chewable tablet taken at bedtime. Accolate® can be given as young as age 5; it is a twice daily medication. Both can be helpful in keeping kids with asthma from having attacks while reducing the amount of steroids needed.
Monday, April 15: A comprehensive literature review of childhood obstructive sleep apnea finds that
Pediatrics 2002, 109:e69.
- sleep apnea is common in children and has significant impact on health
- the only truly reliable test for it is overnight polysomnography - an inpatient sleep study
- unfortunately, the criteria to interpret sleep studies for significant obstructive sleep apnea still have not been definitively validated
- it is not clear whether simple snoring without sleep apnea is benign
- removal of tonsils and adenoids is the first-line treatment for sleep apnea but requires careful postoperative monitoring because of the high risk of complications
- children with persistent snoring after tonsillectomy and adenoid removal should have the sleep study repeated postoperatively
Tuesday, April 16: "Feed a cold, starve a fever." This traditional advice may actually have truth to it, find these Dutch investigators. Food intake was found to be linked to immune response, and the amount of food intake stimulates one or the other arms of the immune system. Higher food intake stimulate the white cell mediated immunity, which is indeed the type of immunity needed to ward off a viral infection such as a cold. On the other hand, reduced food intake stimulates antibody production ("humoral immunity"), which is important to fight bacterial infections. Clinical Diagnostic Laboratory Immunology 2002;9:182-183.
Wednesday, April 17: European data show that if children born with HIV survive the first 10 years of life they are often in relatively good health. "With the increased use of potent antiretroviral therapies survival into adolescence and young adulthood is likely to become increasingly common," the researchers noted. Journal of Acquired Immune Deficiency Syndrome 2002;29:396-401.
Thursday, April 18: When a vaccine for the prevention of rotavirus diarrhea, Rotashield® was introduced, it had to be withdrawn in October of 1999 after a year on the market because of concerns that it was linked to an increased risk of intussusception. An unanswered question since that time has been whether naturally occurring rotavirus infection carries a similar risk for this rare condition of bowel obstruction. Pediatric Infectious Disease Journal 21:97-102, 2002. While the vaccine was around, it promised to be a good idea. Too bad it did not work out.
Friday, April 19: Asthmatic children and adolescents have trouble correctly using spacers with their metered-dose asthma medicine inhalers, and do not use peak flow meters enough. In this study about half of patients using inhalers with or without a spacer device used them incorrectly. Younger patients and patients with younger parents had the most difficulty with proper use. Three fourths of the patients who had a peak flow meter used it correctly, but about the same proportion of patients who should have been using a peak flow meter at home did not use one. Archives of Pediatric and Adolescent Medicine 2002;156:378-383.
Take home: it is not enough to have an inhaler for asthma; if it is not used correctly, it is useless or worse. Proper instruction of use of the inhaler and spacer system is vital to success in controlling asthma symptoms. The peak flow meter is the most useful tool for objectively measuring how well or poorly a child is doing with his or her asthma. It can pick up signs of impending trouble before the child or anyone else is aware of it.
Monday, April 22: Researchers in Pittsburg have made a fairly startling discovery: the outbreak of erythromycin-resistant group A streptococci (the causative germ for "strep throat" infections). Children thought to be penicillin allergic are often given erythromycin or similar drugs such as azithrocin (Zithromax®) or clarithrocin (Biaxin®) to treat group A strep infections. These doctors found that almost half of the streptococci in Pittsburg found by throat culture are resistant to this family of drugs. How fast this strain of resistant germs spreads nationwide remains to be seen. New England Journal of Medicine 2002;346:1200-1206,1243-1245.
Not the end of the world, but it looks like the genie is out of the bottle on this one. Alternative drugs to penicillins would be one of the large family of cephalosporins; cephalexin (Keflex®) or similar. I have asked our hospital lab to start surveillance for resistance in positive strep cultures. Try to get at least a rapid strep test done before committing to antibiotics for a sore throat!
Tuesday, April 23: A treatment course of 14 days of Lamisil® (terbinafine) for two weeks works best for treatment of fungal scalp infection (tinea capitis), find these researchers of the Tinea Capitis Study Group. The research groups found that higher doses may be required in hard to treat cases. Early treatment of other affected family members and use of a topical antifungal shampoo could help increase the rate of treatment success.Pediatrics 2002;109:602-607.
The previous standard treatment has been griseofulvin daily for 6-8 weeks. Given its longer use in children and significantly lower cost, I suspect it will retain its crown.
Wednesday, April 24: Parents often subject their asthmatic children to environmental asthma triggers such as tobacco smoke and pet allergens without appreciating the effects of such indoor exposures, even if they have received written guidelines about trigger avoidance.
This study found that asthmatic children in the surveyed households were frequently exposed to asthma triggers. 59% of households had furry pets, 30% had a smoker and 18% had pests such as mice and cockroaches. Most children did not have impermeable pillow covers (84%) or mattress covers (65%) and 78% had bedroom carpeting. About half of the surveyed parents had received written instructions concerning asthma triggers, but "there was no association of reduced exposures with prior receipt of environmental control instructions." Archives of Pediatric and Adolescent Medicine 2002;156:258-264.
Thursday, April 25: This study finds that asthmatic children who use peak flow meters to monitor their condition appear to do better than those who rely on symptoms alone. In a randomized test, children who used a peak flow meter to monitor their asthma symptoms had lower asthma severity scores, fewer days with symptoms and fewer doctor and ER visits than children who relied on perceived symptoms. Annals of Allergy, Asthma and Immunology 2002;88:283-291.
Friday, April 26: Antibiotic ear drops are far superior to oral antibiotic therapy for infected ears that drain, says this expert. "Topical therapy is not only safer and cheaper than systemic therapy, but there's also a tremendous amount of evidence that it's more effective," said Dr. Peter Roland, professor and chairman of otolaryngology at the University of Texas, Dallas. Ear drops deliver tremendously high levels of antibiotic directly to the infection, giving great killing power and reducing the risk of resistant strains of bacteria developing. ePediatric News 2002;36:4.
Monday, April 29: A new two-drug combination has improved treatment outcomes of malaria among children in Gabon and Kenya. Resistance to standard antimalarial drugs is an increasing problem in treating malaria in sub-Saharan Africa. Lancet 2002;359:1365-1372.
This is a sad story that I mention to make a broader point. Since the world wide ban on DDT, there have been approximately 20,000,000 preventable deaths from malaria in children - yes, children - world wide. There is no insecticide that matches it efficacy in killing the transmitting agent (vector), the anopheles mosquito. If well-off American children were dying of this disease, you can bet we would use DDT.
Tuesday, April 30: Respiratory syncytial virus (RSV) not only is the most common respiratory virus linked to asthma exacerbations, but it is responsible for the majority of attacks severe enough to require ICU admission. Asthma, Allergy and Immunology 2001;15:69-75.
An immunization against this common but potentially serious respiratory virus would be a great advance.