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Welcome to PedSPAM for July. I am back from vacation - had a great time with my sons sailing aboard HMS Rose. Here are some more things from my update reading; I should be back on a roughly monthly schedule for the fall.
The first trial of zinc lozenges for treatment of common colds in children found they are ineffective in treating cold symptoms in children. So says a study in the June 24th Journal of the American Medical Association. The researchers found no difference in the time it took for any of nine cold symptoms, including cough, nasal congestion, nasal drainage, and sore throat, to resolve in the students in the intervention and control groups. Note: among students in both groups, it took an average of nine days for symptoms to resolve. More students in the zinc lozenge group reported side effects, including bad taste, nausea, diarrhea, and mouth, tongue or throat discomfort. Five of 10 previous double-blind, placebo-controlled studies have found that zinc gluconate lozenges can reduce the duration of cold symptoms in adults. The zinc boomlet may be waning...
A new lyme disease vaccine has been recommended for approval by the FDA. SmithKline Beecham will distribute LYMErix Lyme disease vaccine. The vaccine against the causative organism Borrelia burgdorferi was given in three doses during a 1-year period. Pasteur Merieux Connaught has produced its own Lyme disease vaccine, Immulyme, which is in final testing. Connaught expects to submit a license application for the vaccine this summer.
Maternal vaccines against serious or life-threatening infections can offer immunologic protection to both the pregnant woman and their babies. A "two-for-one" vaccine is being developed against group B streptococcus that could protect both the pregnant woman and her newborn against serious systemic infections. In the US, group B streptococcus has been the most common bacterial infection causing death in the first 3 months of life. Respiratory syncytial virus infection (bronchiolitis) is another disease in which maternal immunization could reduce disease for both the mothers and infants. Maternal antibodies to respiratory syncytial virus are protective for infants in the first few months. Trials with an experimental RSV vaccine for mothers show that they enhance natural passive immunity in their infants.
For the first time ever, transmission of indigenous (cases not imported from overseas) measles was effectively interrupted in the United States during 1993, according to the Centers for Disease Control and Prevention (CDC). For about three months, there were only four cases of indigenous measles, and no cases in geographic proximity to each other. This confirms the effectiveness of current immunization practices.
In a similar vein, we are close to global eradication of poliomyelitis. The global infant immunization rate is now 81%; the lowest rate of immunization is in Africa at about 54%. According to a CDC report, the annual incidence of polio worldwide has declined 89% since the World Health Assembly established its global eradication goal in 1988. "As of 1998, a total of 4,116 polio cases with onset during 1997 were reported worldwide."
Canadian researchers reported in the Journal of the American Medical Association that for routine ear infections (otitis media) a 5 day course of antibiotics gave similar results as 8-10 day courses. There was a slightly higher rate of failure in the short course therapy group, but by 30 days after the initial infection, this group had essentially the same outcome as the longer therapy group. BUT, and a big but - the researchers warned that the findings do not apply to children younger than 2 years or to children with underlying disease, perforated eardrums, or recurrent or chronic otitis media. Which means most cases of ear infections. But for the older child with a sporadic ear infection, short course therapy seems quite reasonable.
Left-handed people are no more likely to have premature death than right-handers. This from a study published in the British medical journal Lancet. There had been earlier reports of increased premature death rates in left-handers, which were refuted by these researchers. Breathe easy, lefties.
An historical review of the management of congenital diaphragmatic hernia (CDH) in the May 1998 issue of Archives of Surgery showed that survival has improved from 42% in the early era of immediate repair to 79% in the current era of preoperative extracorporeal membrane oxygenation (ECMO) and delayed operation if at all possible. I personally think that prenatal diagnosis on routine fetal ultrasound examinations has had a great deal to do with increased survival, as well.
Exercise, problem-solving skills and social support are the most important predictors of success in a weight-loss program, Dr. John P. Foreyt, of Baylor College of Medicine in Houston, Texas, told an American Heart Association conference on obesity and cardiovascular disease. He stated that interventions that have a chance to succeed with obese individuals are those that educate the patient to cope with the "eating cues" in the environment. Patients who exercise as part of their weight loss program are more likely to succeed, but not because exercise itself is a more efficient remover of excess fat than dieting. The direct effects of exercise on weight loss are substantially less than the effects of diet changes, but the patient who exercises is more likely to develop the self-monitoring skills to deal with high-risk situations. He recommended food and exercise diaries to help the patient become aware of what situations lead to overeating and reduce self-control. Family support and stress management techniques for some patients are also important.
Hypertonic saline (salt water) can be effective therapy for pediatric chronic sinusitis. Systemic anti-inflammatory agents and antibiotics are standard treatments for chronic sinusitis in children, but a simple nasal wash with hypertonic saline also appears to be effective, according to a study in the Journal of Allergy and Clinical Immunology. A 1 mL squirt of hypertonic saline (3.5%) three times a day in each nostril was done for 4 weeks. At the end of the study and at 1-month follow-up, clinical and xray evaluation showed that the hypertonic saline-treated group had significantly improved in all scores, according to the Israeli researchers. How it works is unknown, but it sure beats the price of antibiotics!
Innocent heart murmurs in healthy newborns are often related to pulmonary branch stenosis (peripheral pulmonic stenosis - a narrowing of the artery in one short segment), a condition that resolves by 6 months of age. Echocardiograms (heart ultrasound exam) showed that 50% of babies with a murmur had pulmonary branch stenosis compared with 12% of matched babies who had no murmur. The research group performed follow-up investigations at 6 weeks, 3 months, and 6 months. The murmur had resolved in 64% of babies at 6 weeks, in 84% at 3 months and in 98% at 6 months. The pulmonary branch stenosis had resolved in all babies by 6 months. The authors concluded that "Innocent heart murmurs in healthy babies born at term are mostly related to pulmonary branch stenosis, which resolves in two thirds by 6 weeks and in all by 6 months." From Archives of Diseases of Childhood, Fetal and Neonatal Edition.
Researchers found that being exposed to alcohol in mother's milk affects an infants' sleep and activity level, leading to less rather than more sleep. Newborn infants whose mothers were lactating were tested to monitor sleep and the activity pattern - in two days, once after drinking unaltered breast milk and once after a contolled amount of alcohol had been added to the breast milk. Both in the duration of the longest sleep episode and the amount of time in active sleep, the infants spent significantly less time sleeping after drinking breast milk with added alcohol. This is not surprising to me in light of the fact that alcohol ingestion disturbs the sleep cycle in adults.
Strains of group A beta-hemolytic streptococci collected over the past 80 years have shown no change in susceptibility to penicillin, researchers report in the May issue of The Pediatric Infectious Disease Journal. Penicillin-resistant strains of Streptococcus pneumoniae, Staphylococcus aureus and enterococci have emerged during the past 50 years, but there has been little evidence of the development of resistant strains of group A beta-hemolytic streptococci. This means that treating strep throat with anything other than penicillin is wrong unless the patient is allergic to penicillin. Pushing your doctor for "a stronger antibiotic to really knock it out" is a bad idea. Your child will just get resistant germs.
There is new evidence reported in Neurology that infection may play a role in the development of Tourette syndrome. Genetics and environmental factors - namely recent infections, especially streptococcal infections - may interact to produce anti-neuron antibodies that affect certain centers of the brain, leading to the development of the syndrome. Antineuronal antibodies are known to develop in response to a preceding streptococcal infection; an example of this phenomenon is chorea (writhing movements) that can be caused by strep infection. While this finding is too premature to have much practical benefit, it could lead to some better interventions for this very frustrating affliction. Certainly, parents of affected children would like an explanation for why this condition arises.
Researchers in Israel think oral cephalosporins may not be the best choice for second-line treatment of children with persistent acute otitis media (meaning a hot red ear, not just old fluid). They recommend high-dose amoxicillin (60 to 80 mg/kg), clindamycin, amoxicillin/clavulanate (Augmentin®) or intramuscular ceftriaxone (Rocefin®) when persistent acute otitis media is caused by Streptococcus pneumoniae. Ceclor® was especially singled out as not a good choice of therapy.
Young children with rotavirus diarrhea (the leading cause of diarrheal disease leading to hospitalization in young children) can continue to shed virus for up to 57 days, much longer than has previously been believed. Researchers in Australia and New Zealand found that intermittent mild diarrhea, vomiting or both was a marker for continued intermittent excretion of infectious rotavirus. This may account for the syndrome of the youngster who apparently gets over his diarrhea, only to have intermittent relapses. These children may also contribute to spread in daycare centers when they return form the illness, only apparently well.
A UK medical panel issued an advisory for pregnant or breast-feeding women who have a close family history of allergic disease to avoid eating peanuts or foods containing peanut products. Peanut allergy is the leading cause of severe allergic reactions (anaphylaxis) to foods, and seems to be on the rise. Substances in peanuts seem to have a particular ability to cross over via breastmilk into the nursing infant and stimulate allergy. The warning only applies to women who have food allergies or who have a husband or other blood relatives with such a history.
In the June 1998 issue of Archives of Pediatrics & Adolescent Medicine, a study group found that most children with bedwetting do not have significant behavioral difficulties. For the most part, pediatricians should approach bedwetting as a common "biobehavioral" problem that is not, to any clinically relevant degree, a psychiatric disorder. This was a good study that simply confirms what practicing pediatricians already know from experience.
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