PedSPAM July 2001
Welcome to the PedSPAM archive for July. Here are the month's daily SPAMlets from my update reading that you might have missed:
In the News
Monday, July 2: Despite years of preaching by doctors, parents remain just as afraid of fever in their children as 20 years ago, says Dr. Michael Crocetti of the Johns Hopkins. Parents in his survey still see fever as a disease rather than just a symptom of illness. Parents
Even more distressing an increase in prevalence of false beliefs concerning fever:
- often gave acetaminophen or ibuprofen too often
- awakened children to give them fever medicines
- checked temperatures too often
- gave sponge baths with too-cold water or even alcohol (which can cause dangerous alcohol poisoning in young infants)
Neither belief, of course, is true. (See my entry on fever in my Parents Encyclopedia.) Pediatrics 2001;107:1241-1246.
- 14% thought fever could lead to death
- 35% believe that a temperature of 100° could cause brain damage
Tuesday, July 3: Breast feeding may reduce the risk of breast cancer, according to a report published in the American Journal of Epidemiology. This study confirms the suggestion of other (less conclusive) studies done in the past that the longer a women lactates, the lower her risk of breast cancer being diagnosed before age 40. The protective effect seemed much weaker for women diagnosed later than 40 years of age. Whether this apparent effect influences genetically inherited risk for breast cancer is not yet known. American Journal of Epidemiology 2001;154:37-42.
Wednesday, July 4: Short-acting bronchial dilating agents are not indicated in current guidelines for control of chronic asthma symptoms, and here is why: regular use of short-acting bronchial dilators (so-called beta-agonists) such as albuterol (Ventolin®, Proventil®) or metaproteranol (Alupent®, Metaprel®) for control of asthma seems to worsen lung function over time. Chest 2001;119:1306-1315,1297-1299.
- It has been shown that long-acting beta-agonists (e.g. salmeterol - Seravent®) do not exhibit this effect, however. They seem to prevent or reverse the "remodeling" effect of asthma on lung tissue (that is, more or less permanent damage to the lining of the bronchial tubes).
- The guidelines for asthma treatment are very clear on this point; beta-agonists are not for maintenance therapy for asthma. Inhaled corticosteroids are the first line therapy.
Thursday, July 5: It is known that persistent ear fluid (OME, serous otitis media) can hinder children's speech and language development, at least in the short run. This is the chief rationale for tube insertion in the first place. Researchers wanted to see if additional waiting time before tube insertion had long term adverse effects. In this study, children over the age of three who had tubes inserted in their ears early for persistent ear fluid were compared to those whose tubes were inserted after a much longer wait (up to nine months). No significant differences in speech, language, cognition, or psychosocial development were found between the early tubes and delayed tubes groups. While these results cannot technically be applied without further study to older children, they are very encouraging. New England Journal of Medicine 2001;344:1179-1187.
Friday, July 6: Iron-deficient children - especially iron deficient adolescent girls - may have impaired cognitive performance, find researchers at the University of Rochester School of Medicine, New York. School aged children were screened for iron deficiency, and iron status was compared to performance on standardized scholastic tests. Iron deficiency was found in adolescent girls at a rate of 8.7% - quite high. Iron deficient children in the study were twice as likely to score below average in math. This effect was unrelated to the presence of anemia. Pediatrics 2001;107,1381-1386.
Screening adolescent girls for anemia once they have started menstrual periods looks like a better and better idea.
Monday, July 9: A drug originally used for asthma, Singulair® (montelukast) can apparently be used to block migraine headaches. Montelukast has been approved for prevention of asthma flareups in adults and children as young as age two. In a small study of 20 patients, all achieved at least a 50% reduction in headache frequency, and the mean reduction in headaches was more dramatic: from 15.8 headaches per month to 3.5 per month. No patient had to discontinue the medication due to side effects. This is not surprising, given the excellent side effect profile we have seen with the drug when given for asthma.
I prescribe the antihistamine cyproheptadine (Periactin®) for childhood migraines as a first line choice, because it is very safe and works quite well for many children. While montelukast is not an antihistamine, it is generally an allergy blocker. Interesting finding.
Tuesday, July 10: LYMErix®, the new Lyme disease vaccine has been shown to be safe and effective in children 4 to 18 years old. Good antibody levels to the disease are achieved after vaccination, with better levels seen in children than adults, and a 100% "take" rate. Side effects from the vaccine were only mild to moderate, mainly headache, fever, or some joint aching, and lasted only a few days. Pediatrics 2001;108:123-128.
Wednesday, July 11: Amoxicillin given in shorter courses and at higher doses for treatment of infections seems to slow down the spread of resistant bacteria, a new study suggests. Standard dose therapy (40 mg/kg for 10 days) was more likely to be associated with the presence of penicillin resistant streptococcal germs at 28 days after starting therapy than high dose short course treatment (90 mg/kg for 5 days). Journal of the American Medical Association 2001;286:49-56.
Plain old amoxicillin (the "pink medicine," the "bubble gum medicine") is also quite effective against strep germs that are somewhat resistant to penicillin but not totally resistant - so-called intermediate sensitivity streptococcus. Here, amoxicillin is actually superior to many of the "stronger," more expensive cephalosporins and erythromycin type drugs such as azithrocin (Zithromax®) and clarithrocin (Biaxin®).
Thursday, July 12: Investigators in Canada have found that children with obstructive sleep apnea caused by enlarged adenoids may be helped by nasal corticosteroids, and may even avoid the need for surgical treatment. In their study, the need for adenoidectomy was reduced by a third. Patients in the nasal steroid treatment group (using fluticasone, Flonase®) had significant decreases in the number of nighttime apnea episodes. Journal of Pediatrics 2001;138:838-844.
Friday, July 13: The common respiratory bacterium Streptococcus pneumoniae is becoming resistant to antibiotics at an alarming and accelerating rate, according to a new report. According to the study, inappropriate use of antibiotics for colds continues to be the most important factor in fostering drug resistance. The researchers called for increased education of the public about the dangers of inappropriate antibiotic prescribing. The table below shows the increase in resistance of S. pneumoniae tracked at 30 different centers around the country:
Antimicrobial Agents and Chemotherapeutics 2001;45:1721-1729.
Monday, July 16: From the Reuters Health wire: A UK researcher finds that infants remember and prefer music they heard in utero up to a year after birth. It is known that a fetus can hear fully at 20 weeks post conception; the implications of this new work are significant. Mothers in the test group of babies played selected pieces of classical, reggae or pop music to their babies in the last trimester of pregnancy.
- The babies were not exposed again to the prenatally played music until they were tested at a year of age, proving that they actually remembered and preferred the test pieces. The test pieces were played to the control group of babies at a year, and these babies showed no preferences, proving that the babies who were exposed to the musical pieces prenatally actually remembered the music.
- Fast pop and reggae music seemed to be preferred and better remembered by babies at a year than classical music.
- When they recognized the music, some babies also turned round to their mothers, indicating that the music played some sort of role in developing an emotional bond.
- The researcher emphasized that there is no evidence that listening to music in the womb increases intelligence.
Tuesday, July 17: Children who have unexplained recurrent abdominal pain are much more likely to have anxiety disorders and have hypochondriacal complaints as adults. The researchers found that while children with recurrent abdominal complaints had a higher incidence of anxiety disorders in adulthood, they were no more likely to have abdominal pain as adults. In other words, the symptom got better but the underlying anxiety did not. Pediatrics 2001;108:e1.
Wednesday, July 18: The FDA has approved a disposable, needle-free injection device called Injex (catchy) made by the Equidyne Corporation. The device delivers a thin high pressure jet of medication at sufficient velocity to penetrate the skin. The injection is virtually pain-free, and eliminates the risk of accidental needle sticks. It will be used for injectable drug therapy at home, as well as some immunizations (not all vaccines would be appropriate candidates for this shallow jet injection). Reuters
Thursday, July 19: Children undergoing painful medical procedures can safely be given inhaled nitrous oxide to alleviate pain and anxiety. A study of 90 children undergoing lumbar puncture, bone marrow aspiration, vein catheter insertion or wound dressing changes, showed that nitrous oxide administered at least 3 minutes prior to and continuously throughout the procedure was safe and effective with a low incidence of minor side effects such as vomiting, agitation, or fear. Archives of Disease in Childhood 2001;84:492-495.
Dentists have used this gas for years with no problems. Why don't doctors?
Friday, July 20: A Canadian study finds that the use of pacifiers by breast-feeding infants does not lead to earlier weaning. The study was done by randomly assigning mother-infant pairs to one of two groups. One group received breast feeding counselling discouraging pacifier use, while the other group received no such recommendation. This randomized study found that while babies who used pacifiers were more likely to wean early, there was actually no difference between the group counselled to avoid the pacifier and the control group. In other words, pacifier use was a marker for breast feeding problems that lead to early weaning, but did not in itself cause early weaning.
"Breast feeding mothers can use pacifiers to soothe their crying or fussing infants without concern that it will interfere with continued breast feeding," the lead researcher told Reuters Health. He advises that physicians tell their breast feeding patients that "as long as pacifiers are not used as a substitute for breast feeding, they can be recommended as one means (among several) to calm a crying or fussing infant." Journal of the American Medical Association 2001;286:322-326.
Monday, July 23: Exciting news from India in the ongoing effort to prevent terrible, crippling neural tube defects such as spina bifida. Researchers in India report that mothers and babies with neural tube defects had significantly lower levels of zinc than normal mothers and their babies. Zinc levels were analysed by determining the levels of zinc present in hair samples. Indian Journal of Pediatrics 2001;68:519-522.
Further research is needed, but this finding is important! We have already seen a significant reduction in neural tube defects as a result of the campaign to increase folic acid supplementation of mothers in the first trimester. Now another cheap, safe nutritional approach may offer even greater reductions. Anyone who has had direct personal contact with these disorders knows how wonderful it would be to prevent them.
Tuesday, July 24: News for middle schoolers due for their Td booster: A nationwide shortage of the tetanus-diphtheria booster vaccine (Td) has led the manufacturer to cease shipments of the vaccine to physicians' offices, probably until some time next year. It is now available for shipment only to hospital emergency rooms, and public health clinics. This has come about because one manufacturer, Wyeth-Lederle, ceased making the vaccine. It takes 11 months to make a batch of the vaccine, so increasing production takes some time. The company has asked the Food and Drug Administration for clearance of vaccine made at their plant in Canada, so the shortage may be alleviated earlier than next year. Pediatric News, July 2001.
Wednesday, July 25: A Food and Drug Administration advisory panel has backed moving 3 potent antihistamines to over the counter status. A petition was filed asking for this change, not by the drug manufacturers, but by a large HMO, Wellpoint Health Network (formerly Blue Cross of California). The three drugs are cetirizine (Zyrtec®), loratadine (Claritin®), and fexofenadine (Allegra®). The move is opposed by major allergy-related professional societies. Pediatric News, July 2001.
The motives of the HMO are not hard to figure out; over the counter status would not only result in a price decrease, but it would shift a major pharmaceutical expense from the health plan to the patients. Sneaky. Over the counter status for these medications both trivializes allergic rhinitis as a major cause of misery and probably would divert patients from obtaining proper first-line therapy (inhaled nasal steroids).
Thursday, July 26: The Centers for Disease Control reports that comparing the year 2000 to 1999, the teen birth rate dropped 22%. This continues a trend that started in 1991; since then the teen birth rate has fallen about 30%. This comes after a June CDC report that stated that the teen pregnancy rate had declined to numbers not seen since the mid-1970s. The reason for the decline is thought to be increasing use of birth control by teens and a "leveling off" of teen sexual activity. Reuters Health.
Friday, July 27:
Researchers have apparently been able to correlate brain scan findings with persistent developmental stuttering. MRI exams of adult stutterers were significantly different from matched non-stuttering individuals in the areas of brain cortex known to be involved with the abilities of speech and language. Neurology 2001;57:171-172,207-215.
Monday, July 30: American doctors are less likely than their European counterparts to use sedation or pain relief for painful procedures such as bone marrow tests. A survey of pediatric cancer treatment centers in the US and Europe found that cancer specialists in Europe were more likely to use deep sedation for painful procedures; American doctors were more likely to use opioid drugs such as Demerol in combination with anti-anxiety drugs. A common reason given for this was the difficulty in arranging for anesthesiologist standby assistance for the event of anesthetic complications. Archives of Diseases of Childhood 2001;85:12-15.
I believe a lot of this reluctance is driven by malpractice suit fears; deep sedation does (rarely) result in bad outcomes, and so these fears are justified if no anesthesiologist is present to administer medication for the procedure.
Tuesday, July 31: The National Institutes of Health will undertake a $10 million study to better determine those social and environmental factors that aid normal childhood cognitive development. According to Grover Whitehurst, a literacy researcher who is now the Bush Administration's Assistant Secretary of Education for Educational Research, almost 40% of American fourth graders are unable to read at a basic level; in the poorest school districts this number jumps to as high as 70%. Reuters Health