PedSPAM February 2001

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

In the News

In the "I told you so" department, a study in Australia confirms what common sense tells me: tooth eruption does not necessarily correlate with teething symptoms. Researchers found that there was no real relation of tooth eruption to symptoms such relating to the child's mood, sense of wellness/illness, drooling/dribbling, sleep, diarrhea, strong diapers, red cheeks, and rashes or flushing.

The researchers pointed out that these findings go against widespread parental and professional beliefs that tooth eruption is associated with a range of teething symptoms in children. "Such beliefs," they add, "may preclude optimal management of common patterns of illness and behavior in young children." That is, parents or doctors may blame observed symptoms on teething and delay proper treatment of real illness. Pediatrics 2000;106:1374-1379.

Radiation exposure for children undergoing CT examination is much higher than necessary, according to a, dare I say, blockbuster study released this month. Dr. Lane F. Donnelly, from the Children's Medical Center in Cincinnati, Ohio and colleagues compared the radiation exposures of pediatric CTs performed at other centers with the exposures measured at their institution using a pediatric weight-based sliding scale. They found that power settings used at other centers were up to five times that which is necessary for good imaging. This has come about because settings recommended by the manufacturers of the scanners are based on adult patients, and the increased sensitivity of more modern scanners has not been taken into account. American Journal of Roentgenology 2001:176;303-306.

A companion article contained calculations of increased lifetime cancer risk for children who underwent CT examination with higher doses. The authors conclude that children scanned at these doses are at significantly more risk of cancer attributable to CT examination than are adults. They urged efforts at reducing the total radiation exposure from CT scans in children. The authors commented, by the way, that most pediatric centers were already following the guidelines; this may be more of an issue when children are scanned in an adult-oriented hospital. American Journal of Roentgenology 2001:176:289-296.

If your child needs a CT scan, he or she needs it. The cancer risk is there, but still very low. The risk of radiation exposure has to be balanced against the sometimes life-saving information obtained, and the diagnostic procedures which are rendered unnecessary by the scan. It would be wise to question if the facility doing the scan is using the weight-based tube current guidelines, and to insist that they be used before consenting to an elective CT scan.

There has been an outbreak of cases of meningococcal meningitis - commonly termed "spinal meningitis" - in the Houston, Texas area since the first of October, 2000. A total of 33 cases with three deaths have been reported. A mass vaccination program was instituted in New Caney, a town 25 miles north of Houston, when 3 cases were confirmed in the small town of 2,700 people. Reuters Health

Many asthmatic children are unaware of how much airway obstruction they really have, according to researchers at the Medical College of Georgia, in Augusta. They were seeking to find a way to identify those children whose poor perception of just how sick they are might make them at risk for fatal asthma attacks. Journal of Asthma 2000;37:613-624.

Asthma fatalities, while rare, are especially tragic, given the availability of so many medications for treatment. Kids who are tight and wheezy all the time can become so used to feeling this way that it seems like a normal state. Additional airway constriction added to already narrow, tight bronchial tubes can cause sudden and dramatic worsening of breathing ability. Neglecting a child's asthma - assuming that chronic cough or shortness of breath "is not that bad" - can be dangerous.

The US Food and Drug Administration (FDA) has approved Tamiflu® (oseltamivir phosphate) for both the treatment and prevention of influenza A and B. The drug is available in capsules as well as a new pediatric suspension. For treatment of influenza, the dose is one 75 mg capsule twice a day for 5 days. Dosing of the pediatric suspension is approved for children from one year of age. The drug can be used for prevention after exposure, too, in a dose of one capsule once a day for 7 days after exposure, or one capsule a day for 42 days during peak seasonal or outbreak time. Reuters.

Teen smokers have an increased rate of fatalities from injuries, accidents, suicides, and homicides. After adjusting for other factors, smokers between 15 and 19 years old were twice as likely to die from an injury. They had an increased risk of death by homicide of 1.44, and suicide was 4.5 times as likely in teen smokers aged 15-19. Reuters Health.

Physical abuse, not sexual abuse, is by seven-fold the most common form of abuse by parents according to a study from the UK. A large survey of young adults by the National Society for the Prevention of Cruelty to Children (NSPCC) found that one in 14 young adults surveyed had suffered physical abuse, and about 1 in a hundred had been sexually abused. Mothers were more somewhat more likely to have been seriously abusive than fathers. The majority of childhood sexual abuse reported in the survey was perpetrated by brothers or stepbrothers; father-daughter incest was rare, occurring in less than 4 in 1000 children. Reuters Health.

In a letter published in the November issue of the Journal of Cataract and Refractive Surgery, Dr. Jonathan M. Davidorf, from the University of California, Los Angeles said that LASIK refractive surgery should be considered for children with amblyopia who cannot or will not wear corrective lenses or glasses. Eventually, he predicts the surgery will be more widely used for children and adolescents with significant visual defects. Journal of Cataract and Refractive Surgery 2000;26:1567-1568.

In something of a surprise, an apparent protective effect against diarrheal disease has been found in children colonized with Helicobacter pylori. It is surmised that H. pylori bacteria may block the establishment of disease-causing bacteria in the gut by both stimulating the body to secrete protective antibodies and by the H. pylori bacteria themselves secreting substances that inhibit the growth of competing bacteria in the gut. The authors think that attitudes about H. pylori infection may change for children in the developing world, where diarrheal disease is a major killer, and the long term deleterious effects of H. pylori infection (such as ulcer disease or stomach cancer) are rare. Journal of Infectious Diseases 2000;182:1446-1449.

Maternal diabetes has long been recognized as a risk factor for congenital heart defects in newborns. Brazilian researcher Dr. Ivo Behle, of the Fetal Cardiac Unit, Porto Alegre, Brazil found that the higher the hemoglobin A1c level (HbA1c) in the mother during pregnancy, the greater the risk of fetal heart malformations. He advised that diabetic women whose HbA1c level is greater than 7.5% ought to consider delaying pregnancy until their diabetes is better regulated. Reuters Health

The number of scooter injuries seen in hospital emergency rooms has increased dramatically since May of 2000, according to the Centers for Disease Control Morbidity and Mortality Weekly Report. The most common injuries seen have been wrist and arm sprains and fractures, dislocations, as well as cuts and bruises. Two deaths have been reported: an adult who fell and sustained a fatal head injury while showing his daughter how to ride the scooter, and a six year old boy who was struck by a car.

The CDC recommends:

Morbidity and Mortality Weekly Report 2000;49:1108-1110.

Babies exposed to antiepileptic drugs in utero are at significantly increased risk for developmental delay and later school problems, finds a group of researchers in Britain. The rate of school problems was doubled in the group of children exposed to these drugs in utero. Almost a third of children exposed to valproate (Depakote®) prenatally had school problems. Journal of Neurology, Neurosurgery and Psychiatry 2001;70:15-21.

A long term Australian study of allergic children followed from age 7 to 35 finds that allergic features in childhood asthmatics - eczema (atopic dermatitis) or hay fever (allergic rhinitis) - predict an increased risk of severe asthma symptoms in later life. Conversely, more severe asthma in childhood is related to increased odds of having eczema and hay fever later in life. American Journal of Respiratory and Critical Care Medicine 2000;162:2177-2181.

Children who were low birthweight prematures seen to have no greater problems with respiratory tract illness in their teenaged years than normal birthweight babies. This is good news for parents of low birthweight babies, who often have increased respiratory illness in early infancy and childhood. There are some differences in lung function studies still apparent in ex-prematures, but the researchers found that lung function in adolescence for these children was by and large comparable to that of term babies. Archives of Disease in Childhood 2000;84:40-44.

Good news for parents of prematures who may suffer increased respiratory illness early on - the long term outlook is good for these kids.

Parents who smoke seek fewer medical visits for their asthmatic children's respiratory disease, finds a Scottish study. The researchers were trying to determine how much passive smoking correlates with asthmatic illness in children of smokers. What they found was that the more the parents smoke, the fewer doctor visits for asthmatic illness. The researchers are unsure whether this is because the parents do not recognize the severity of the symptoms, or if they simply do not want to get a lecture about their smoking affecting the child's health. Thorax 2001;56:9-12.

That one just has to sink in for a while. It is so very sad. In a masterful bit of medical understatement, they wrote, "may not be receiving adequate management."

A rare disorder, mucopolysaccharidosis 1, may now be treated with a genetically engineered replacement enzyme announced by researchers at the University of North Carolina at Chapel Hill. Mucopolysaccharidosis is one of a class of "storage diseases," in which certain substances (in this case complex carbohydrates known as mucopolysaccharides) build up within cells because an enzyme which normally disposes of the substance is missing. The resultant buildup causes progressive cell damage. The most severe form of mucopolysaccharidosis 1, known as Hurler syndrome, is usually fatal by age four or five years. It causes progressive developmental delays, clouding of the corneas, lung obstructions, heart disease, and severe joint stiffness. Children with milder forms of the disease (Hurler-Scheie and Scheie syndrome) may live into their 20's or even longer; their disease is more slowly progressive. The enzyme, iduronidase, was made by recombinant DNA technology, and given weekly intravenously. It produced significant improvements when given to children with intermediate severity disease. New England Journal of Medicine, January 18, 2001 as reported in Science Daily.

Pregnant women should not eat shark, swordfish, king mackerel or tilefish, because these fish may contain enough methylmercury to damage the fetus's nervous system, warns the Food and Drug Administration. Nearly all fish contain trace amounts of methylmercury, but longer-living, larger fish that feed on other fish, such as shark or swordfish, accumulate the highest amounts and pose the largest threat to people who eat them regularly. "You can safely eat 12 ounces per week of cooked fish. You can choose shellfish, canned fish, smaller ocean fish or farm-raised fish--just pick a variety of different species." says the FDA bulletin.

Also, the Environmental Protection Agency cautions that pregnant women, women who might become pregnant, nursing mothers and young children should eat only one meal per week (6 ounces of fish) of freshwater fish caught by family members or friends. Six states have issued warnings on methylmercury in fish from their waters: Connecticut, Maine, Michigan, Minnesota, New Jersey and Vermont.Reuters Health

The FDA has given approval for over the counter sale of a liquid bandage product similar to the maker's product (Dermabond®) that is already in use for repair of lacerations in the doctor's office or emergency room. The bandage - Liqiderm® - is painted over the wound for cuts and scrapes. The maker claims superior wound healing with reduced bacterial contamination, and it stops bleeding.

Dermabond® has been a mixed blessing for me. It is sometimes ideal; but it is not appropriate for every cut. In addition, at least in these hands it is somewhat tricky to apply (as anyone who has worked much with Superglue® can appreciate). We shall see how this works in general use as a band-aid replacement. Based on the exorbitant cost of Dermabond®, I expect it will be somewhat expensive.

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