PedSPAM March 2000

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

In the News

Major news on the immunization front is that the first pneumococcal conjugate vaccine (Prevnar®, Wyeth Lederle) was recently approved for use in infants to prevent invasive pneumococcal disease. It is effective in preventing invasive disease, bacteremia and meningitis caused by the seven strains of Streptococcus pneumoniae contained in the vaccine. It is given at the 2, 4, 6 and 12-15 month checkups. The Advisory Committee on Immunization Practices (ACIP) recommended that all children up to 23 months receive the vaccine, especially known high-risk populations. This is definitely an advance in immunization technology. There are still questions to be answered in terms of cost. At $58 or so a dose, widespread use of the vaccine will depend upon the willingness of insurance companies to do the right thing and cover the vaccine.

The rate of antibiotic-associated diarrhea can be cut by two thirds by the administration of special preparations of Lactobacillus GG. Children were given measured amounts of the harmless germ by mouth during antibiotic administration, with reduction in both the incidence of diarrhea during the time antibiotics were taken, and a shorter course of diarrhea in those patients who did develop the complication. Journal of Pediatrics, 1999 135:564-568

The use of oral erythromycin for prophylaxis (protection) against known exposure of newborns to whooping cough (pertussis) at a hospital in Tennessee apparently led to an increase in the incidence of pyloric stenosis in the babies. A stunning 4.5% of babies given the antibiotic developed pyloric stenosis, which ordinarily affects 1 to 3 out of every 1,000 newborns. Morbidity and Mortality Weekly Report, December 17, 1999.

An article in the Journal of the American Medical Association notes an increase in so-called psychotropic medications such as stimulants and antidepressants in young children in recent years. The article warns that we really don't know the long term effects of such medications on the developing brain, and efficacy studies are lacking for many uses of these medications. An accompanying editorial makes an interesting point about why this increase has come to pass: Medicaid provides limited reimbursement for evaluation of behavioral and psychological disorders, and its regulations have essentially abolished the multidisciplinary team approach to diagnosis and treatment. Journal of the American Medical Association 2000;283:1025-1030,1059-1060.

My own perspective is that those who object most loudly to medication for children's psychiatric problems usually have not a clue about the challenges facing parents and primary care physicians to get proper evaluation and treatment for these children. As our understanding of the metabolic origins of many of these conditions increases, it becomes clear that drug treatment is often not a quick fix or a cop-out - it is the rational and humane thing to do for the child's benefit.

Cafcit® (caffeine citrate) injection has been approved by the FDA for short-term treatment of apnea of prematurity in infants between 28 and 33 weeks of gestational age. I can recall from my days as a resident in pediatrics when we gave caffeine orally for this indication. It has long been known to be effective. Reuters Health.

Note to those who believe caffeine consumed by nursing mothers makes their babies irritable: we never noticed any such effects in our "premies." They seemed to sleep, well, like babies. I have always allowed my nursing mothers to consume reasonable amounts of caffeine and have yet to have one report back any problems...

For children older than 12 months who have nighttime symptoms suggestive of obstructive sleep apnea, pulse oximetry has the ability to quickly and more cheaply identify children with sleep-disordered breathing who would ordinarily require expensive sleep studies. More involved and expensive polysomnography is still required for those children who have normal pulse-oximetry readings, because about half of those children actually have sleep apnea. However, the majority of children can be identified with the simple pulse oximetry readings. Pediatrics 2000;105:405-412.

Immunotherapy (allergy shots) in childhood may have long term positive effects on asthma in young adults. A retrospective study undertaken in Belgium found that compared to the allergy shot group, control patients who did not receive allergy shots as children "suffered almost 3.5 times more from frequent asthmatic symptoms and used more medication" in young adulthood than did those who had immunotherapy. Allergy 2000;55:69-73.

The US and the Russian Federation share the highest teen pregnancy rates in the developed world. Teen pregnancy rates in the US are four or more times higher than rates in France, Germany and Japan, despite a 17% decline in the teen pregnancy rate in the United States during the 1990s. Reuters.

The American Cancer Society, Great Lakes Division, offers college scholarships for young cancer survivors. Scholarships are now available for the fall 2000 school year. A special program of the American Cancer Society Inc., scholarships of $1000 will be awarded to a qualified group of young cancer survivors in Indiana and Michigan to help them achieve their goals of higher education. Applications must be submitted to the American Cancer Society, Great Lakes Division office at 1205 E. Saginaw, Lansing, MI, 48906 by April 14, 2000. The application process includes submission of letters of recommendation, a 500-word essay, a copy of academic grades 9-12, SAT and/or ACT scores, and financial information. To request a scholarship application packet, call the American Cancer Society, Great Lakes Division, at 800-723-0360.

Supplementing infant formula with two types of long-chain polyunsaturated fatty acids, docosahexaenoic acid (DHA) and arachidonic acid (AA) increases intelligence significantly according to a recent study. There was a significant 7 point difference in Mental Development Index between the group given DHA and AA as compared to no supplement. DHA alone produced a 4 point increase in average scores. DHA and AA are added to formulas in many countries, but not the US. I hope these results get the FDA moving to work with the formula companies to streamline the certification of these supplements. Developmental Medicine and Child Neurology 2000;42:174-181.

At least in black children, diagnosing fungal scalp infections (tinea capitis, or "ringworm" of the scalp) is made simpler by observing this rule: lymph node swelling in the occipital area (behind the ears) is a very reliable sign of fungal infection if combined with the finding of two or three other signs. The signs are

Researchers found that children with one or two findings rarely tested positive for fungal infection, but those with three or four signs almost always tested positive for the Trichophyton tonsurans fungus. Archives of Pediatrics and Adolescent Medicine, 1999:153:1150-53

Mothers who as newborns had a low birth weight are three times more likely to deliver babies who suffer from respiratory distress syndrome (RDS). This is at least partially caused by an association of low birth weight in babies with low birth weight of their mothers. Researchers speculate that improvements in perinatal outcomes will follow generational improvements in birth weight. Obstetrics and Gynecology 2000;95:174-179.

In smoking mothers who smoke during pregnancy, the known adverse effects are significantly increased for mothers carrying twins as compared with the risks of maternal smoking form their singleton gestations. This table shows the additional complications for smoking mothers (compared to non-smoking mothers) in twins versus singletons. That is, these are twins and singletons of smoking mothers; the rates of complications are the increase over non-smoking mothers experience.

per 1000 births
Twins Singletons
Low birthweight 122.9 55.3
Very low birthweight 32.8 4.3
Less than 33
weeks gestation
32.6 7.9

The Food and Drug Administration has approved marketing of a new antibiotic preparation for ear infections. Primsol® (trimethoprim) solution is approved for treatment of acute otitis media caused by susceptible organisms in children 6 months to 12 years of age. Primsol is pure trimethoprim, a component of the familiar antibiotics Septra® and Bactrim®, but it does not contain the sulfa component of these two drugs. The sulfa portion is said to add little to the efficacy of the antibiotic, while involving the risk of potentially allergic reactions to the sulfa component. (Reuters)

A study reported in the British Medical Journal found no association with increased childhood leukemia for children who had prenatal ultrasound examinations. British Medical Journal, 2000;320:282-283.

Nine-year-old to 14-year-old children who frequently eat dinner with their families have healthier dietary patterns than those who eat fewer family dinners. Researchers found that eating family dinner is associated with higher consumption of fruits and vegetables and several beneficial nutrients, including fiber, folate, calcium, iron, vitamins B6, B12, C, and E. There was lower consumption of saturated fats, soda, fried foods, and foods that raise blood sugar levels. Archives of Family Medicine 2000;9:235-240

Infants are often observed to hold the thumb in the fist with the fingers curled around it. Physicians have been warned for years that this so-called "cortical thumb" may be a sign of brain injury or defect. Researchers in Israel investigated the prevalence of this finding and found that the finding was quite common in normal infants (63%) and disappeared in all normal children by 7 months. Later resolution of the thumb-in-fist posturing was associated with later development of speech milestones, however. The researchers were unsure of the significance of this finding. So if someone were to note this finding on your otherwise normal appearing baby, remember this article. Pediatrics 105 No. 3 March 2000, p. e41

One attempted strategy to reduce teen pregnancy has been to give adolescents a taste of life as a parent by requiring them to mother a doll ("Baby Think It Over"). Sounds like a logical idea - let teens experience first hand some of the responsibilities of parenthood - they will think twice before having sex. It did not work. To quote the authors: "Little learning about the difficulties of parenting took place during the study... The results of this study demonstrate that the propensity of people this age for rationalizing their own immunity to the nocuous aspects of potentially desirable situations (the personal fable of omnipotence) allows those who perceive parenthood to be attractive to overlook the negative aspects of any parenting experience they have." Pediatrics 105 No. 3 March 2000, p. e30

Overweight teens already show evidence of heart disease, according to reports at the annual scientific session of the American College of Cardiology. Poor diet has already led to thickening of the coronary artery walls (atherosclerosis), high blood pressure, and elevated LDL cholesterol levels. The fatter the kid, the worse the overall picture. On a positive note, the researchers reported that they showed the ultrasound pictures of arterial disease to the affected children in their study, and at one year followup, a significant number of them had gotten the message and changed their diets. Reuters Health.

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