PedSPAM December 2002
Welcome to the PedSPAM archive for December. Here are the month's daily SPAMlets from my update reading that you might have missed:
In the News
Tuesday, December 3: Pediatric ibuprofen suspension (Motrin®, Advil®) in normal over the counter doses is an effective treatment for migraine headache in boys. This study found it is significantly better than placebo within two hours of administration for this type of headache in boys, but the advantage is not as clear for girls because they respond more to placebo effects than boys. Ibuprofen reduced nausea as well, and reduced the need for stronger medications. Headache 2002;42:780-786.
Wednesday, December 4: Adolescents who have permanent tattoos are more likely to abuse substances, engage in sexual intercourse, exhibit violent behaviors and school problems. Adolescents with tattoos are more likely to live in single-parent households and have lower socio-economic status. Pediatrics 2002;110:1058-1063.
Friday, December 6: Strategies to alleviate discomfort and stress in newborns undergoing painful procedures such as blood drawing have included both oral sugar solutions and topical EMLA anesthetic cream. A controlled comparison of the two methods perhaps surprisingly found that oral glucose gave better pain reduction than the topical anesthetic. Pediatrics 2002;110:1053-1057.
Tuesday, December 10: Natural peptide antibiotics occur in the skin of newborns and in the cheesy white vernix caseosa that covers the skin of babies born before a full 40 weeks gestation, researchers report in the December issue of the British Journal of Dermatology. The study examined the inflammatory skin condition erythema toxicum in babies hours after being born and compared them with babies who did not have the inflammation. The findings suggest these natural antibiotics play a vital part in protecting babies during the transition from the sterile environment within the womb. The lead researcher said: "The human newborn is equipped with an antimicrobial skin defence system that is much more than just a mechanical barrier...This defence system is active prior to birth and is seen in the vernix caseosa and strengthened during the first days after birth by an acute cellular inflammatory skin response known as erythema toxicum...The vernix was found to exhibit a clear antibacterial activity, showing that microbicidal polypeptides are already present at elective concentrations during fetal life... The fetus has the capacity to secrete these peptides, perhaps in order to prepare for microbial colonisation."British Journal of Dermatology. 2002;147:1127-1134.
Wednesday, December 11: While there was a significant reduction at two weeks of therapy in the persistence of middle ear fluid in children treated with an antibiotic (amoxicillin) and an oral steroid, within two more weeks there was no significant difference in fluid persistence between steroid treatment and no steroids. This study found that treatment with steroids or treatment longer than 14 days for acute otitis media was not warranted. Pediatrics 2002;110:1071-1080
This study reaffirms what other studies have also shown. Oral steroids offer no compelling benefit for the treatment of middle ear fluid (effusion).
Thursday, December 12: The anesthetic ketamine is not a new drug. It fell out of favor with doctors in the past because of its tendency to sometimes produce unpleasant side effects - hallucinations or delirium - in patients who received it. A recent presentation at the New York State Society of Anesthesiologists' 56th Postgraduate Assembly in Anesthesiology reported on a study of the effects of ketamine on a large survey children, ranging in age from 2 months to 12 years who received small doses of ketamine by simple injection for sedation for MRI or CT scans. Only a few of the children had side effects from the ketamine, most commonly nausea and vomiting, which occurred in 23 patients. Only seven experienced delirium or hallucinations, described as "mild" and resolving within a few hours. The drug has several advantages: it is given as a small intramuscular injection, with small children held on the mother's lap. The drug acts within a couple of minutes, and does not need a breathing tube. Recovery after the scan is within minutes (it only lasts about 20 minutes), and the child can be safely discharged home without a long post-procedure observation period. Reuters Health.
Friday, December 13: Infant colic resolves within 3 months and does not have a lasting effect on the mother's mental health, this study from Canadian researchers found. The researchers identified about one fifth of babies in their study as having colic; symptoms had decreased by 3 months in 85% of these, paralleling the old adage, "three month colic." Mothers who had colicy infants had no greater incidence of anxiety or depression than those who did not. Dietary changes in the mother were of no value and the researchers stated that such changes as the milk free diet need not be recommended. They did warn clinicians to watch for signs of parental distress, especially in families lacking adequate resources, support or coping abilities, because of the increased risk of physical abuse (notably shaking) for babies with excessive crying. Archives of Pediatric and Adolescent Medicine 200;156:1172-1174,1183-1188.
I found the numbers for the diagnosis of colic in this study extraordinarily high. In my experience, true colic is quite rare. Most excessively fussy babies have a diagnoseable and treatable medical condition - usually gastroesophageal reflux disease (GERD) or cow milk allergy. Colic seems to be - no offense intended - a diagnosis favored in countries with treatment (i.e., cost) limiting national health insurance plans.
Monday, December 16: A growing number of claims alleging that vaccines caused autism in children may overwhelm the US government's tax-based injury compensation program. The National Vaccine Injury Compensation Program was designed to provide individuals injured by a vaccine with compensation while limiting litigation and keeping vaccines widely available. The number of new claims in the last several years related to thimerosal (a mercury-containing preservative used in vaccines since the 1930's) threatens to overwhelm the program's ability to evaluate claims. Thimerosal has been removed from almost all vaccines. No connection to autism has been established. Claims under the act have quadrupled in the past year and are on track for another record year. Until standards for evaluation of cases and settlement are established, the court is likely to approve more out of court settlements, regardless of the merits of the cases. Reuters Health
Tuesday, December 17: Findings presented last week at the 3rd World Congress of Pediatric Infectious Diseases in Santiago, Chile showed that immunization of healthy children without risk factors such as diabetes or congenital heart disease against influenza is both safe and effective. In an Italian study, vaccinated children showed a 31% reduction in respiratory illnesses in the following months compared with those infants who did not receive the flu shot. In addition, they required fewer medical prescriptions during the influenza season and missed fewer days at school. The vaccination also led to a 56% decrease in lost days of work for mothers due to caring for a sick child. A Finnish researcher commented that children younger than one year have similar rates of hospitalization for influenza-related complications to adults in high risk categories. Recent studies also indicate that influenza is the leading cause of febrile seizure in infants. Reuters Health.
In a similar vein, the Committee on Infectious Diseases of the American Academy of Pediatrics has recommended that healthy children aged 6 months to 2 years and those adults who care for them be vaccinated. The committee stated, "Young children also appear to be at higher risk of hospitalization for influenza than are healthy 50- to 64-year-olds, for whom routine immunization has been recommended since 2000." Pediatrics 2002;110:1246-1252.
Wednesday, December 18: Prominent ears can make anyone self-conscious, and children are no exception. While taping in the first few weeks can often help form a more acceptable ear shape, for many children this is not done. A new technique can painlessly correct prominent pinnae in young children, according to a recent report. The "Auri method," developed by two doctors in Denmark, uses a plastic clamp during the night and a nearly invisible double adhesive strip placed behind the ear during the day. Seventy children ages 2 weeks to 5-1/2 years were studied, and over half completed treatment. The main reason for treatment failure was that children pulled off the device; half the parents of these children wanted to try later when the child was older. Treatment time averaged about 6 months. Fair to good correction of prominent ears was achieved in more than half the patients studied. The researchers state: "We consider that nonsurgical treatment of prominent ears should be tried first and recommend using the Auri method, even in older children. If only partial correction is obtained, an excellent result with the help of (surgical) otoplasty would be made easier." They note that further information on the Auri method is presented online at http://www.aurimethod.com. Archives of Otolaryngology and Head and Neck Surgery 2002;128:1369-1376.
I'm fascinated by this study, and hope to get more information. I have thought about using skin adhesive (Dermabond®), because taping is such a problem. The kit, available from Europe, is ridiculously expensive, however.
Thursday, December 19: A nutritionist speaking at the annual meeting of the American Academy of Pediatrics said that restrictive diets for overweight children don't work and can reinforce a lifelong pattern of overeating and obesity. Ellyn Satter said in her presentation that restricting food intake systematically undermines the child's inborn ability to self-regulate the amount of food needed to maintain optimal growth. Restrictive diets teach a pattern of binge eating followed by more dieting, and more importantly, teach the body's internal hunger regulator to eat as much as possible when food is available.
Perhaps paradoxically, she says that the best way to help an overweight child is to offer unrestricted amounts of nutritious foods at controlled times. "The parent controls what and when to eat, and the child controls how much," she said. Allowing the child eat to satiety helps the body reestablish the natural regulators that signal when to stop eating, and when to eat again.
Meals and snacks should be eaten in a structured setting - ideally, with other family members at a "family table." This helps the child learn to associate food with positive social interactions, rather with negative comments from others and a feeling of self-loathing for overeating.
Satter admits that the method may seem counterintuitive to parents, who question allowing an overweight child to help himself or herself to large portions of food. However, it is important for parents to allow the child to eat all he or she wants of the offered foods at the appointed times, and not to allow grazing at other times.
Under this regime, the child will resume a normal childhood eating pattern - that is, he or she will be hungry at some meals and not at others, picky at some meals and accepting of many foods at other meals - an indication that the natural appetite regulator is being reestablished. Ms. Satter has written a book about the method, Child of Mine: Feeding With Love and Good Sense (Boulder, Colo.:Bull Publishing Co., 2000). ePediatric News, December 2002.
Friday, December 20: Babies exposed to cigaret smoke in utero may have an increased SIDS risk, this study found. Infants 8-12 weeks old, when the risk of sudden infant death syndrome (SIDS) is at it peak, have a depressed arousal response if they were exposed to cigaret smoke prenatally. Smoke-exposed babies in non-REM (deeper) sleep were more difficult to arouse than those with no history of maternal smoking (arousal from dream sleep - REM - was equal in both groups). The investigators concluded that "at the age when the incidence of SIDS is at its peak, infants of smoking mothers are less arousable than those of nonsmoking mothers in non-REM sleep, and this may partly explain why such infants are more at risk of SIDS." Archives of Disease in Childhood 2003;88:30-33.
Monday, December 23: The American Medical Association wants to ban beer and wine ads from prime time television and is asking both network and cable TV to ban all ads that feature "mascots, celebrities, or sports figures promoting alcohol products." The AMA is asking broadcasters to sign a voluntary agreement to hold off beer and wine ads until after 10 p.m. or initiate a total ban during programs that are aimed at a viewing audience that is at least 15% adolescent. The AMA has a longstanding policy opposing alcohol advertising aimed at children but is acting now because of "recent evidence that alcohol damages the brains of young people and that damage may be irreversible." The AMA also released a new report titled "Harmful Consequences of Alcohol Use on the Brains of Children, Adolescents and College Students." Reuters Health.
Tuesday, December 24: Teens with migraine headaches take heart. Adolescents with migraine headaches can expect that their symptoms will get better with time, regardless of what therapy, if any, that they employ. This study found that the prevalence of the most common migraine disorders in a study population of adolescents decreased with increasing age. The investigators stated that, "The high percentage of remission and/or improvement in adolescent migraine over time likely reflects the natural history of the disease." Headache 2002;42:1000-1005.
Friday, December 27: Dry powder inhalers for the delivery of corticosteroids for asthma are associated with greater systemic effects in asthmatic children, this study finds. This effect comes about because the powder inhalers deliver medication more effectively to the lungs than a metered-dose mist inhaler with spacer device. This greater deposition of active medication in the lungs increases steroid side effects, namely suppression of the adrenal glands. Annals of Allergy Asthma and Immunology 2002;89:566-571.
The powder inhalers are still more effective, and should not be abandoned! Their increased effectiveness in delivering the medication simply means we must be cognizant of this fact and lower dosing regimes to compensate for the increased delivery.
Monday, December 30: Allergy to peanuts is rising among young children, this study suggests. Early breast feeding seemed to increase the incidence of sensitization, perhaps because of increasing amounts of peanut allergens in prepared baby foods, or as a consequence of maternal peanut consumption. The study director and his colleagues suggest that "lactating mothers should perhaps avoid eating peanut if there is a history of atopy in the immediate family." Journal of Allergy and Clinical Immunology 2002;110:784-789.
Tuesday, December 31: Montelukast (Singulair®) reduced both asthma and migraine headaches in children in this very small Brazilian study. During a trial of the drug for the prevention of asthma symptoms, the researchers noted a dramatic decrease in migraines among the children taking the drug. Headache 2002;42:1044-1047.
What the basis of this effect would be, I do not know. The drug is very safe, approved down to age two. I hope more definitive studies will be forthcoming.