PedSPAM January 2002
Welcome to the PedSPAM archive for January. Here are the month's daily SPAMlets from my update reading that you might have missed:
In the News
Thursday, January 3: Researchers at the US Centers for Disease Control (CDC) reviewed all reported cases of tetanus in children under 15 years old for the period of 1992-2000. There were 15 cases. While no child died, the mean hospital stay was a month and half the children required artificial ventilation. Twelve of the fifteen cases were due to "objection to vaccination, either religious or philosophic." Pediatrics 109:e2.
Sorry, but I have to put in my 2¢ worth: serious illness in a child caused by lack of immunization - especially one so safe, widespread and standard - ought to be investigated by child protective services. It is odd that I have never heard of a parent being allowed to avoid child seat belt laws by citing "objection to seat belts, either religious or philosophic."
Friday, January 4: An expert panel of the FDA has recommended approval of both a 1-day and a 3-day course of azithromycin (Zithromax®) for acute otitis media (ear infection) in children. The total dose of 30 mg per kilogram, now given over a 5 day period with 1/3 of the total dose given the first day, would be administered either all at once or split into 3 equal doses for the three day course. The approval was not unanimous; several of the panel members expressed concern about efficacy in younger children, especially if they vomit after receiving the first (and only) dose of medicine. ePediatricnews December 2001, Volume 35, Number 12.
Monday, January 7: The Centers for Disease Control and Prevention (CDC) find that the 7-strain vaccine against the common germ Streptococcus pneumoniae is proving effective in reducing the number of cases of serious disease such as sepsis and meningitis caused by these bacteria in children. The vaccine is now in widespread use in the United States, and reductions in the number of cases of serious pneumococcal disease can be directly traced to the increasingly widespread adoption of the vaccine. (Presented at the 41st Interscience Conference on Antimicrobial Agents and Chemotherapy, in Chicago, Illinois December 19, 2001.)
Tuesday, January 8: Due to a shortage of vaccine, the United States Centers for Disease Control and Prevention (CDC) is now recommending that doctors temporarily delay fourth and possibly the fifth doses of DTaP (diphtheria, tetanus and acellular pertussis) vaccine for children. Infants ordinarily receive the first three doses of the vaccine at ages 2, 4 and 6 months. A fourth dose given at 15 to 18 months, and a final, fifth dose is usually given as the child enters kindergarten. The vaccine shortage arose in 2000, when two major suppliers--Wyeth Lederle and Baxter Hyland Immuno Vaccines--both discontinued production of the vaccine. Two manufacturers, Glaxo SmithKline and Aventis Pasteur, continue to produce the vaccine. Diphtheria and tetanus are rare in the US, but during the year 2000 nearly 1900 US cases of pediatric pertussis were reported to the CDC, including 16 deaths in infants aged 6 months or younger. Morbidity and Mortality Weekly Report 2002;50:1159.
Wednesday, January 9: A small pilot study finds that for children with a ruptured appendix, a short course of intravenous antibiotics followed by oral antibiotics is as effective as a prolonged course of IV antibiotics. A 10-day course of three antibiotics - "triple therapy" - given intravenously is standard treatment at many hospitals for postoperative infection treatment after ruptured appendix. In a treatment group of patients selected randomly, a course of amoxicillin/clavulanate (Augmentin®) and metronidazole (Flagyl®) given orally once bowel function returned to normal was as effective as the intravenous regimen given for the full 10 days. The cost savings of this approach are significant, about $1,500 per patient. A larger study is planned to confirm these findings. Archives of Surgery 2001;136:1391-1395.
Thursday, January 10: Babies with moderate to severe bronchiolitis caused by RSV get significant relief from breathing a mixture of 30% oxygen and 70% helium. Babies treated with this mixture had lower respiratory and heart rates than those breathing conventional oxygen mixtures, which means that they were less stressed than the controls. The "heliox" treated babies were discharged from the intensive care unit almost two days earlier, as well. Pediatrics 2002;109:68-73.
Further studies have to be done, but this looks promising. Helium is an inert gas which is nontoxic. It is primarily used in breathing mixtures for scuba divers operating at great depth.
Friday, January 11: The growth charts your pediatrician uses to evaluate your children's growth (and indirectly, general health) have been officially revised. The revised charts take into account the increased prevalence of breast feeding and the changing ethnic makeup of the country. Pediatrics 2002;109:45-60.
This was first mentioned in PedSPAM in June of 2000, and the charts available in the Encyclopedia since that time. The new growth charts can also be found on the CDC's Web site at www.cdc.gov/growthcharts.
Monday, January 14:
The position of twins in the womb is linked to the risk of deformational plagiocephaly (flattening of the skull). The twin who leads, with the head in the lower part of the uterus when labor begins, is more likely to exhibit such flattening after birth.
Certain early signs can alert parents to developing plagiocephaly. These include a significant flattening at the back of the head, ear misalignment when looking down from the top of head, and facial asymmetry, such as one eye appearing a different size or shape from the other. Methods to lessen deformation of the infant skull include limiting the use of anything that puts a "deforming force" on the back of the head, such as "bouncy seats," swings and carriers. Babies who sleep on their backs as recommended should spend as much parent-supervised time as possible on their stomachs for play. Lastly, parents should be reassured that such malformations if they occur are not believed to be related to developmental or neurological problems in children. Pediatrics 2002;109:19-25.
Tuesday, January 15: A single oral dose of the steroid dexamethasone (Decadron®) is even more effective (as well as simpler, faster, and cheaper) for mild croup than nebulized dexamethasone. In a controlled study, children who received the oral dose were much less likely to need a second physician visit in the next 7 days, and were rated after the first day by their caregivers as doing significantly better than those children in the nebulized steroid group. Archives of Pediatric and Adolescent Medicine 2001;155:1340-1345.
Anything that makes life simpler is good. I have become more liberal in recent years with short courses of a steroid for even milder croup cases because it saves on parental anxiety and a lot of emergency department visits. For an anxious toddler, an oral dose of medicine is much better tolerated than a "breathing treatment."
Wednesday, January 16: If doctors utilize rapid tests for the diagnosis of influenza virus type A infection in infants and toddlers seen in emergency rooms with high fever, they can reduce the number of other laboratory tests needed and reduce the unnecessary usage of antibiotics. So finds a preliminary study of children aged 2 months to 2 years, who were seen at Children's Mercy Hospital, Kansas City, Missouri with fevers above 39°C (102.2°F). A larger study is needed "to confirm our findings and to test the effects on other factors such as patient satisfaction with care and return visits to the emergency department or primary care physician offices," says the lead investigator.
Archives of Pediatric and Adolescent Medicine 2002;156:41-43.
Flu season is upon us again full force; I hope your children got flu shots. They can be given to children as young as 6 months old. The best protection for parents from the flu after getting their own flu shots is to give them to their children. Children are the vectors who carry the flu home from school to infect their parents.
Thursday, January 17: This study found that the practice of most pediatricians to order urine tests selectively, focusing on younger and more ill-appearing infants and on those without an apparent fever source, yields good results detecting urinary tract infections (UTI's). Selective urine testing, with close follow-up, misses few late UTI's. Urine testing should focus particularly on uncircumcised boys, girls, the youngest and sickest infants, and those with persistent fever. Archives of Pediatric and Adolescent Medicine 2002;156:44-54.
This study is comforting in that few infections were missed by selective testing, and reaffirms the importance of checking a urinalysis and possible culture in young children with persistent fever with no obvious source - especially uncircumcised boys, who are at much greater risk of UTI. Whatever one's views on circumcision, no one is in favor of kidney infection and scarring.
Friday, January 18: Two SPAMlets about diabetes in childhood:
Children who have juvenile diabetes (Type I, "juvenile onset") do not have lower academic performance compared with their siblings and classmates. They scored as well or better than sibs and classmates in reading and math. Academic performance was linked to the overall level of diabetes control, an effect that was paralleled by the diabetics' siblings. Pediatrics 2002;109:e9.
The oral antidiabetic agent metformin is as effective and well tolerated in children as it is in adults for treatment of Type II diabetes ("adult onset"). A study of the drug in children with Type II diabetes showed it to be effective for achieving blood sugar control, with no adverse effects on body weight or blood lipids. Type II diabetes (often linked to overweight) is increasing in United States children, but metformin had not been studied for pediatric patients heretofore. Diabetes Care 2002;25:89-94.
Monday, January 21: The antihistamine cetirizine (Zyrtec®) seems to prevent the onset of asthma in infants with eczema (atopic dermatitis) who are allergic to some specific allergens. Children 1 to 2 years old with atopic dermatitis who are allergic to grass pollen or to house dust mites were less likely to develop asthma if they were given cetirizine versus a placebo twice a day for 18 months. There was no overall difference in the incidence of asthma between treated and placebo groups after three years, but the subgroup of infants who had grass or dust mite allergy did have a lower incidence of asthma. This suggests that at least for some children, the onset of asthma can be delayed or perhaps even prevented. Journal of Allergy and Clinical Immunology 2001;108:929-937.
Tuesday, January 22: A study in Japan finds that while height and weight measurements of children who had suffered Kawasaki disease were equal to controls years later, electrocardiogram (ECG) results were three times as likely to be abnormal (10% in patients vs 3% in controls). Archives of Pediatric and Adolescent Medicine 2002;156:77-80
It is reassuring that long term outcome for Kawasaki disease seems to be good. Persistent ECG abnormalities are actually absent for 90% of recovered Kawasaki patients. While present in the minority of patients, they probably do not translate into any real danger for the majority of the remaining patients. Conversely, since a small but significant minority of children will have persistent ECG abnormalities, parents should not ignore long term followup with a cardiologist.
Wednesday, January 23: Common body rocking and rhythmic behaviors such as hand waving in the first year or so of life do not indicate nervous system abnormalities. Children with developmental disabilities may exhibit these sorts of behaviors; this study looked at 13 month olds at play and snacking by videotaping the children and evaluating such behaviors to see if they were associated with later developmental disability. No connection was found; in fact, the investigators speculate that these behaviors may be part of or encourage normal development. Journal of the American Academy of Child and Adolescent Psychiatry 2002;41:67-74.
Thursday, January 24: Excessive consumption of caffeine is associated with an increase in small-for-gestational age infants in this study, especially if the mother smoked. Researchers studied blood levels of a caffeine metabolite and found they correlated well with the risk of small for dates babies. American Journal of Epidemiology 2002;155:32-37.
Friday, January 25: A study in Great Britain finds that cochlear implantation for congenital or acquired deafness in young deaf children under two years of age is very feasible and gives results comparable to the procedure when done at an older age. This is important because there is evidence that speech and language development of deaf children is better when hearing is restored earlier. Archives of Otolaryngology and Head and Neck Surgery 2002;128:11-14.
I know from personal experience that American otorhinolaryngologists perform this procedure younger than age two, since one of my little patients had the procedure done recently with excellent results.
Monday, January 28: Pediatricians are dealing as best they can with a significant nationwide shortage of several vaccines. The most serious shortage currently is with Prevnar®, the seven-strain pneumococcal vaccine. There are also shortages of diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) and tetanus-diphtheria toxoids (DT). Chickenpox vaccine (Varivax®), measles-mumps-rubella (MMR) and hepatitis B vaccines are on backorder in some areas as well. These shortages are due to the exit from vaccine production of several manufacturers.
Lest anyone be confused about what this really means: this is a combined victory for plaintiff's attorneys, who have done what they could to drive manufacturers out of the business of vaccine production, in combination with bottom-feeding media types (20/20, Dateline and the ilk) who put making a buck on advertising ratings ahead of the lives and safety of little children.
Wednesday, January 30: Thanks to the vaccine first introduced in 1969, rubella (aka German measles or three-day measles in the US) has largely been eliminated in this country. There were 57,000 cases of rubella reported in the US in 1969; the annual number of cases in the decade of the 90's ranged from about 130 to 1,400. However, public health authorities warn that US adults born in Latin America, where rubella vaccination programs are less pervasive, are at higher risk of infection. Mothers of children with congenital rubella syndrome were likely to be Hispanic and/or foreign born. Journal of the American Medical Association 2002;287:464-472.
Thursday, January 31: A fairly common practice in the past has been the use of preventative antibiotics to ward off new ear infections. This has fallen into disfavor because of concerns about the efficacy of this practice and whether resistant bacteria would be more likely to arise in the treated patients. This study finds that in a "real life" pediatric practice setting, prophylactic use of antibiotics to prevent recurrent ear infections does not lead to increased attacks of otitis media or increase the rate of ventilating tube insertion if patients are carefully selected. International Journal of Pediatric Otorhinolaryngology 2001;61:47-60.