PedSPAM January 2000

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

In the News

Janssen Pharmaceutica, makers of Propulsid® (cisapride), issued a drug warning to doctors about the need to obtain an electrocardiogram (ECG) on any patient receiving the drug for the treatment of gastroesophageal reflux. They gave these additions to the product labelling in the "Contraindications, Warnings, Precaustions, and Adverse Reactions" section.

The AP picked up the story as well. This story is of interest to parents because cisapride is sometimes used to treat gastroesophageal reflux disease in children, especially infants. However, the recommendation to obtain an ECG before starting therapy actually came out in the medical literature last year; most pediatricians and certainly all pediatric gastroenterologists were aware of the reservations about use of the medicine in infants since studies appeared last year pointing out the potential for problems.

The actual risk in taking cisapride for healthy term infants who have no preexisting heart problems and are on no other medications aside from acid blockers such as cimetidine (Tagamet®) or ranitidine (Zantac®) is exceedingly low. If an ECG is obtained before therapy and checked again in a week or two, the risk is probably even lower. This drug seems to help some infants quite dramatically, although there has been published (Journal of Pediatrics 134:287-92) at least one article which found it no better than placebo. This is a matter for consultation with your child's doctor. My own personal opinion is not to discard the medicine from use out of hand, but to use appropriate caution including patient selection and to wean from it as soon as practical.

Only one in eight boys who are unusually physically aggressive in kindergarten will be that way in high school. In a Canadian study, teachers rated boys for physical aggression, oppositional behavior, and hyperactivity in kindergarten and annually from 10 to 15 years old. Among 1,037 boys, 15-25% never exhibited any of these findings; half showed low levels of problem behaviors at age 6, which disappeared by age 10-12 years. Between 20% to 30% showed high levels of problem behavior at age 6, but much lower levels by age 15. These findings refute the popular notion that boys become more aggressive with age. Child Development 1999, 70:1181-96

To confuse further the quest for understanding whether there is value in the treatment of autism with the gastrointestinal hormone secretin, researchers from the University of Maryland School of Medicine report that an unusually high percentage of children with autism have unrecognized gastrointestinal problems. Two thirds of their study group suffered from gastroesophageal reflux disease, judging both by symptoms and confirmed by laboratory studies. They documented other abnormalities of the small intestine as well. In light of recent studies that failed to confirm any positive effect of secretin infusion on autistic symptoms, the waters around this topic are best described as muddy. Journal of Pediatrics 1999;133:559-563.

According to a study presented by a researcher at the University of Kentucky, back pain in children under 10 can be serious and should be investigated aggressively. If plain xrays are normal, she advised imaging studies to search for causes such as infection or certain benign tumors that may cause pain. "Just because an X-ray is negative does not mean that a problem doesn't exist," the chief researcher warned. In younger children, for example, "diskitis may be the cause since the disk still has a blood supply until sometime in adolescence. Thus, a systemic infection may readily find its way to the spine."

Streptococcus pyogenes, a bacterium sometimes referred to in the more colorful press as the "flesh eating virus," is better treated with the antibiotic clindamycin (Cleocin®) that the more common penicillin treatment. The cure rate for clindamycin and penicillin was double that of penicillin alone. Early treatment is extremely important for this infection, known properly as necrotizing fasciitis, because

A severe infection can begin with infection of an apparently minor wound, or chicken pox sore. The warning signs of severe infection are high fever associated with any of the following:

If these symptoms are present, patients should seek medical attention immediately. Pediatric Infectious Disease Journal, December 1999.

Few if any deaths are attributable to hepatitis B vaccination, finds a study published last month. During a period when 86 million doses of pediatric hepatitis B vaccine were administered, 18 infants died following immunization, according to the study. Twelve of the cases were attributed at the time to death to ' the remaining deaths were associated with infections, heart or brain problems, or in one case, accidental suffocation. The researchers concluded that there was no way to prove or disprove scientifically a causal relationship between immunization and the hepatitis vaccination. Since 1991 when HepB immunization was recommended for newborns, there has been no evidence of an increased trend in the overall number of neonatal deaths or in reported deaths after the hepatitis B vaccination. Archives of Pediatric and Adolescent Medicine 1999;153:1279-1282.

This rate of death is so low ( one SIDS death per 7 million doses), however, that one should be very skeptical of any claims to causal connection.

The Synar amendment, passed by Congress in 1992, requires states to enact and enforce laws prohibiting the sale of tobacco products to minors. Twenty-seven states have other provisions in their laws which hinder enforcement; 15 could not prove there were any inspections leading to prosecution, and 18 failed to show any successful prosecutions arising from the law. Archives of Pediatric and Adolescent Medicine 1999, 153:1089-97

Surprise! I never cease to be impressed with the ease that our local youth can obtain cigarets. A number of small groceries are known suppliers - nothing is every done about them.

The good news on the teen smoking front is that the proportion of teens who are smoking continues its slow decline in 1999. Cigaret smoking by adolescents peaked in 1996-97, and the rate has been gradually drifting lower since then. While teens say they find cigarets very easy to obtain (see previous article), they express increasingly negative attitudes toward smoking as being unhealthy. Unfortunately, over one third of adolescents are active smokers by the time they leave high school, with more than 1 in every 6 an active smoker as early as eighth grade. College bound students in the upper grades are least likely to smoke. Lower grade students who have no plans to attend college are most likely to smoke as youngsters. Medscape.

Long term followup investigation found that nicotine patch therapy with minimal behavioral intervention is not effective for adolescent smokers trying to quit. Researchers concluded that "...other pharmacological treatments and/or more intensive behavioral counseling interventions tailored to adolescents are clearly needed." Archives of Pediatric and Adolescent Medicine 2000;154:31-36.

Epidural anesthesia for childbirth is a risk factor for maternal fever during labor. In a study at Harvard Medical School, 16% of women who received an epidural developed a fever of at least 100.5°F. Only 0.6% of women who did not receive an epidural developed fever. Babies born to women whose fevers exceeded 101° were four times as likely to have a lower Apgar score. Babies born to mothers who had epidural anesthesia also were more likely to be hypotonic (floppy), although these differences disappeared by the time of discharge. Pediatrics 2000;105:8-13.

Accutane®-related birth defects continue despite warnings that it not be prescribed to women who might become pregnant while taking the drug. According to the Centers for Disease Control, women

Morbidity and Mortality Weekly Report (MMWR) 2000;49:28-31.

President Clinton has signed a bill to protect breastfeeding on federal property. A "right-to-breastfeed" provision was included in the annual spending bill for the Department of Treasury and the Postal Service. Federal funds may not be used to "...implement, administer, or enforce any prohibition on women breastfeeding their children in Federal buildings or on Federal property."

French researchers reported that most children thought to be allergic to beta-lactam antibiotics such as amoxicillin actually were reacting to a viral infection rather than the antibiotic. They performed skin tests on children with suspected antibiotic allergies and found that only 12% actually had confirming allergy tests by skin prick or an oral test dose. Pediatrics 1999;104/e45:E1-E9.

Many infants with head injury have significant brain injury despite a lack of symptoms, according to a doctor at Childrens Hospital, Boston Massachusetts. Further CT scan studies are warranted for many infants with apparently benign injuries. He found

are at higher risk of brain injury, even if there are no signs or symptoms of injury. The researchers advise physicians to consider CT imaging studies in these patients. Pediatrics 1999;104:861-867.

Young kids seem to have a lot of trouble learning to blow their noses. Maybe they know something we don't. By using dye that would show up on CT scan of the sinuses, a researcher found that the pressure generated in the nose during the act of blowing was about 10 times greater than during sneezing or coughing, and that dye in the nose was forced into the sinus cavities by blowing the nose, but not by sneezing or coughing. This phenomenon may contribute to the development of sinus infections by forcing bacterial germs into the sinus cavities during nose blowing. Reuters.

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