PedSPAM July 2000

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

In the News

Having more children born into a family does not necessarily result in lower-IQ children. Theories have been advanced in the past that children born later have lower IQ's because of less parental attention. "There are many good reasons why parents might consider limiting their family sizes, but the belief that, for a particular set of parents in a modern country like the United States, a larger family will lead to children with lower IQs appears to be, simply, wrong. The belief that birth order acts directly to decrease the intelligence of children born later in a given family also appears to be, simply, wrong," state the authors. American Psychologist, June 2000

As the father of four, I suppose I can stop feeling guilty.

The use of sunscreen for children slows the development of moles (nevi), especially in children with freckles. The authors of this study point out that since half of all melanomas (malignant skin cancers) arise from moles, reducing the development of moles ought to reduce the incidence of melanoma when the children are older.Journal of the American Medical Association, 2000;283:2955-2960.

In a finding that confirms what I have always observed in practice, Swedish researchers find that children hospitalized for respiratory syncytial virus (RSV) bronchiolitis in infancy have a significantly increased risk for asthma and allergy in the 1 to 3 year old age group. American Journal Respiratory and Critical Care Medicine 2000;161:1501-1507.

Early and active treatment of children with urinary reflux does not lower the incidence of end-stage kidney failure in later life, say Australian researchers. They suggest that the use long-term antibiotics and surgery to treat vesicoureteral reflux should be tested in a randomized trial. Pediatrics 2000;105:1236-1241

I would take these findings with a grain of salt and wait for other confirmation before recommending any change in current practice, because not only are the findings counterintuitive, they are based on data that dates from many years ago.

Eight Russian children were hospitalized after playing with discarded smallpox vaccine. Russian doctors had difficulty diagnosing the disease, since the last case of smallpox was registered in 1977 in Africa, and all countries stopped vaccinating against it in 1980. The vaccine was kept on hand for civil defense purposes (in case of terrorism) and when it expired, instead of incinerating it, the workers just threw it out in the trash. They face criminal charges. The disease suffered by the children was luckily not life threatening, and apparently was not transmittable to others. Reuters.

Amblyopia, or lazy eye, is often treated by occlusion (patching) of the stronger eye to force the brain to strengthen vision in the weaker one. Patching therapy has been found to be maximally effective within first 3 months of treatment. The researchers found that full-time occlusion of at least 8 hours daily resulted in significantly better improvement in visual acuity than part-time patching. "Occlusion may be prolonged unnecessarily in many cases," Dr. Marie Cleary of Glasgow Caledonian University in the UK concludes. "It would seem that if 'normalization' of visual acuity is not achieved in response to 6 months of occlusion, the prognosis for achieving this is poor." Reuters Health.

For children using inhalers for asthma, a homemade spacer crafted from a half-liter soft drink bottle works better than expensive commercial devices. Archives of Diseases in Childhood June, 2000.

Streptococcal infection may be a stimulus for the sudden onset of tic disorders in some children. The authors of this study found a subset of children with new tic disorders in their clinic who had either a sudden onset or abrupt worsening of symptoms within 6 weeks of having a streptococcal infection. The normal onset of tic disorders is much more gradual. The research group cautioned that more evidence is required to establish that an infectious process is involved in triggering tic disorders. Pediatric Neurology 2000;22:380-383.

Advanced degrees of coronary atherosclerosis (hardening of the arteries) is common among US young people in the 15 to 34 age group. An autopsy study showed that the incidence of advanced atheroschlerosis 2% for men in the 15-19 age group; no women had atheroschlerosis in the same age group. The rate rose to 20% of men in the 30-35 age group, with 8% of women 30-35 showing this finding. The investigators in this study confirms that risk factor control, especially of obesity, should begin in adolescence. Circulation 2000;103:374-379.

Rickets is a now rare vitamin deficiency disease in which growing bone does not properly calcify or "mineralize." Breast fed, dark skinned infants are known to be at risk for developing rickets if they are not supplemented with vitamin D. This vitamin is ordinarily transformed in the skin by exposure to sunlight (ultraviolet radiation). Dark skin pigment (melanin) filters out the ultraviolet and prevents vitamin D from undergoing the first step in transformation to the active hormone that regulates bone calcification. Breast milk is a fairly poor source of vitamin D, and in dark skinned infants, the "double whammy" may result in vitamin D deficiency rickets. These researchers report on a series of eight Black infants and one Hispanic infant, who were breast fed and developed vitamin D deficiency rickets. They urged renewed attention to vitamin D supplementation of breast fed infants, especially those with dark skin. Texas Medicine 2000;96:64-68.

The drugs Singulair® (montelukast) and Claritin® (loratadine) can be combined to provide better relief of seasonal allergic rhinitis (hay fever). The combination of the antihistamine and the leukotriene antagonist was significantly superior to either drug alone or placebo for daytime nasal symptoms scores. Journal of Allergy and Clinical Immunology 2000;105:917-922.

I have heard from the drug representatives that a combination product is already in the works and will be on the market in the foreseeable future. Our experience with Singulair in asthmatics has been very good - I am excited about the possible significance of this new combination for my allergic patients.

Vaccinating infants against Hemophilus influenzae type b (Hib vaccine) protects not only the infants, but unvaccinated adults around them as well. So finds a CDC study in Alaska, where invasive H. influenzae disease is a particular problem among the Native Alaskan population. Journal of the American Medical Association 2000;283:3089-3094.

A report by the Institute of Medicine of the National Academy of Sciences says that the nation's immunization system is being stretched beyond capacity. It called for an infusion of Federal and state funds to the tune of 1.5 billion dollars over the next five years to increase both childhood and adult immunization levels. Vaccine-preventable diseases cause the deaths of about 300 children and up to 70,000 adults each year. The commission, formed at the request of the Senate of the U.S. and the Centers for Disease Control, warns that the current system of vaccine programs is being strained by the availability of new vaccines, funding cutbacks, and problems with the ways vaccines are made available to patients. Reuters

The World Health Organization has recommended a worldwide ban on all cigaret advertising and marketing. WHO estimates 80,000 to 100,000 young people become addicted to cigarets each day, and advocates a combination of heavy taxation with anti-smoking campaigns to reduce the number of smokers and smoking-related illness. Reuters

20 year followup of children whose mothers received a single course of steroids prior to delivery to promote maturation of the fetal lung to prevent or ameliorate respiratory distress syndrome showed no long term adverse effects. Pediatrics 2000;105:e77

Researchers believe they have identified a gene for severe childhood gastroesophageal reflux (GER) and have located it on the human chromosomes. Before this finding, GER was not generally thought to be hereditary. The investigators studied five families in which severe GER followed an autosomal dominant inheritance pattern. Using gene mapping, the location of the gene was narrowed down to a very small region of the chromosome number 13. Journal of the American Medical Association 2000;284:325-334

The International Red Cross says that the uncontrolled spread of infectious diseases is taking a far larger toll of deaths than any natural disasters such as storms, floods and earthquakes. The number of deaths from AIDS, malaria and diarrhea worldwide is 160 times greater than all natural disasters combined. They estimate that most of the 13 million deaths form infectious disease last year could have been prevented for about $5 per person. Rather than relying on expensive technological solutions, the most cost effective programs are those aimed at changing behavior: vaccination of children, sleeping under treated mosquito nets to prevent malaria, and condom use to prevent AIDS spread.

Hemolytic-uremic syndrome is a disease characterized by hemolytic anemia, low platelet count, and kidney failure. It is most commonly caused by infection with E. coli O157:H7, a strain of E. coli that produces a toxin damaging to the lining of blood vessels. The E. coli infection presents as diarrhea, which is often bloody. Antibiotic treatment of the infection substantially increases the risk of this very severe complication. the researchers warn against treating diarrhea with antibiotics unless a specific germ is identified by culture for which antibiotics are indicated. New England Journal of Medicine 2000;342:1930-1936.

Universal hearing screening of newborns with computerized equipment is becoming more widespread all the time. Questions have been raised about potential adverse effects of falsely positive test results, that is, the erroneous identification of normal babies as having profound hearing loss. This study found that careful rescreening of positives before discharge from the nursery lowered the false positive rate significantly, and that any adverse effects on the families were very minimal.

I have always found that parents would rather know that everything possible is being done to help their child, and if an abnormal test is later found to be normal, they are more relieved than upset. The researchers advise, as I personally hope always to practice, that better information about the test, its limitations, and why it is done are the best insurance against any misunderstandings or unnecessary fear on the part of the parents.

Pediatrics 2000;106:e7.

A new immunologic test for Helicobacter pylori (the ulcer germ) can be performed on the stool. It avoids endoscopy, is much simpler and cheaper to perform than the standard breath hydrogen test, and is quite accurate. Pediatrics 2000;106:115-117

Mare's milk can be tolerated by most children with cow milk allergy. "The composition of mare's milk is much more similar to human milk than is cow's milk," the authors of this Italian study explain. "The high lactose content makes it pleasant to eat and also qualitatively preferable to [other substitutes] that contain carbohydrates other than lactose." Journal of Allergy and Clinical Immunology 2000;105:1031-1034.

Now if we could just find it here in America. It sure sounds more palatable than Nutramigen® or Alimentum®, the standard hypoallergenic formulas we use.

Children allergic to cow milk may experience very delayed reactions when tested by cow milk challenge, say allergists in Italy. While the large majority of reactions were apparent within 72 hours of restarting cow milk in formerly allergic children, a few patients showed allergic symptoms up to two weeks later. These symptoms again disappeared on a milk-free diet. The researchers advised a one week challenge, followed by a milk-free period to watch for delayed symptoms. Allergy 2000;55:574-579.

The diet of American adolescents has gone from bad to worse in the 35 years since 1965. A survey of dietary data from US Department of Agriculture studies over the years shows that teens are consuming less iron, folate, and calcium than required for health, and that intake of fruits and vegetables remained below the recommended levels. Total fat consumption has fallen, but at the expense of milk intake (replaced largely by soft drinks and noncitrus juices). Archives of Diseases in Childhood 2000;83:18-24.

Lithium (a drug used for bipolar disorder) reduces aggression in children with severe conduct disorder. Archives of General Psychiatry 2000; 57:649-654.

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