PedSPAM March 2002
Welcome to the PedSPAM archive for March. Here are the month's daily SPAMlets from my update reading that you might have missed:
In the News
Friday, March 1: Children in the youngest age groups are at "substantially increased risk for influenza-related hospitalizations," according to a statement from the CDC's Advisory Committee on Immunization Practices. Annual flu shots are now recommended by the CDC for all children from 6 months to 3 years starting with the 2002-2003 flu season, according to a statement from the vaccine advisory committee. those children and adults most at risk from influenza should receive their vaccinations first: health care workers, children who have not had a flu shot previously (because they need a booster a month later), and children with chronic conditions such as asthma, heart disease, or diabetes. Household members of at-risk people and healthy people between the ages of 50 to 64 years should have their shots in November.
Monday, March 4: A survey of pediatric training programs finds that only slightly more than half of pediatricians in training receive some type of formalized education of the major childhood problem of ear infections, and the majority of this training consists of infrequent lectures. Pediatrics 2002;109:404-408.
Well, the dirty little secret is out. I know from experience that this was so in my residency - no formal instruction of note in my training program. I also know from personal experience recently (I attended an excellent workshop sponsored by a drug company) that training in the diagnosis of otitis media can be done easily and very effectively with modern audiovisual tools and guided learning. In light of the existing data on physician accuracy (or lack thereof) in the diagnosis of otitis media, all training programs ought to be using the available teaching aids.
Tuesday, March 5: It has long been recognized that children with sleep problems have trouble functioning normally in school the next day. This study examined the prevalence of "sleep-disordered breathing" (mainly snoring and sleep apnea) and problems with inattention and hyperactivity in school. The authors found that inattention and hyperactivity in school children - especially in young boys - are often linked to increased daytime sleepiness and snoring and other symptoms of disordered sleep. Pediatrics 2002;109:449-456.
Wednesday, March 6: It can be very difficult for a child to communicate to adults what he or she feels when a headache strikes. Pediatric neurologists seek just such a way to understand what children are trying to say about their headaches in order to differentiate the types of headaches and treat them appropriately and effectively. In this study, children were asked to draw a picture to show how their headache felt. Pediatric neurologists who were not told anything about the child or the headaches then scored the pictures as depicting migraine or nonmigraine headaches. A different pediatric neurologist then made an independent clinical diagnosis of the headache type, and the results were compared. The researchers found that children's drawings correlated with very well with actual diagnosis of migraine with almost 90% predictive value. Pediatrics 2002;109:460-472.
Thursday, March 7: Methylphenidate (Ritalin®, Concerta®, Metadate® and others) in combination with clonidine is the most effective combination for children who have ADHD with co-existent tics.
Methylphenidate is the most commonly used medication for ADHD, but there have been reports that it worsened tics and Tourette syndrome. These researchers studied clinical response to and side effects of regimens of placebo, methylphenidate or clonidine alone, or the two drugs in combination. The combined treatment regimen gave best results. Clonidine was best for limiting impulsivity and hyperactivity, while methylphenidate seemed to be best for treating inattention. Methylphenidate or the combination of methylphenidate and clonidine actually reduced the severity of tics. Sedation was the major side effect noted during the study in any group that received clonidine. Neurology 2002;58:527-536.
Friday, March 8: A British study finds that the risk of major birth defects or low birth weight for babies conceived with the aid of "assisted reproductive technologies" such as in vitro fertilization is about twice that of normally conceived babies.
Another study from the US Centers for Disease Control and Prevention in Atlanta found that infants conceived with assisted reproductive technologies seem to represent a disproportionate number of the low- and very-low-birth-weight infants born in the US, based on data from 1996 and 1997.
An accompanying editorial points out that while the risk of birth defects with assisted conception is still low, couples should reflect carefully before going ahead with infertility treatment if they have not tried natural conception for at least 12 months. New England Journal of Medicine 2002;346:725-737,769-770.
Monday, March 11: A new report highlights the steady increase in antibiotic resistance in the Streptococcus pneumoniae bacterium (the "pneumococcus"). Over a six-year surveillance period, the proportion of penicillin resistant strains of pneumococcus increased from 4% to 15%. An illuminating finding: 30-35% of children with pneumococcal disease had received an antibiotic in the 30 days prior to diagnosis of their illness. Not only that, but penicillin-resistant pneumococci were found in 37% of children who had received an antibiotic in the 30 days before the illness, compared with just 17.5% of children who had not received an antibiotic. Pediatric Infectious Disease Journal 2002;21:141-147.
Takehome lesson: efforts to limit unnecessary antibiotic use - especially for viral upper respiratory infections - are more important than ever.
Wednesday, March 13: In some neonatal nurseries, light levels are kept very low to simulate the intrauterine environment as closely as possible. This is because constant bright light is too stressful for very small babies. It turns out that cycled light mimicking a day-night-day-night pattern produces better growth in premature babies. In the study, babies who received cycled light from birth were on average about 28 weeks gestation (12 weeks premature). Both this group and babies who received cycled light starting at 32 weeks of age after conception grew better than babies who received cycled light starting at 36 weeks post conception. Additionally, even the group that started day/night light cycling at 36 weeks grew better once the cycling was started. Further study will follow to discover the optimum time to begin cycled light, and what long term consequences might result from the practice. Journal of Pediatrics 2002;140.
Thursday, March 14: A statement released this week by a committee of the American Academy of Pediatrics (AAP) states that all
children should be screened for amblyopia, a condition which affects 1 t 4% of all children. Photoscreening, a photographic technique, is a test that could help increase vision screening rates, especially in young children. When this type of vision test is performed, a camera or video system is used to obtain images of the eyes which show the reflected light bouncing off the retina and back through the lens of the eye. The images obtained this way can show near or far sightedness, astigmatism, cataracts, or eye tumors. Traditional eye screening is still recommended for children aged 4 and 5 years. Pediatrics 2002;109:524-525.
I have used this technique in my practice for several years, and I have been very impressed with it's usefulness. I would not practice without a photoscreener now.
Friday, March 15: Daily atropine drops have been found to be as effective as occlusive eye patching in the treatment of amblyopia in children. In this treatment, a drop of 1% atropine was given in the eye once a day. Patching as done in this study involved the child wearing the patch a minimum of 6 hours a day. Parents found the drug treatment easier and less socially stigmatizing since they did not have to explain the patch. Results were similar in both patching and drug treatment groups. Archives of Ophthalmology 2002;120:268-278.
It can be quite difficult to get children to wear a patch. They are forever wiggling it around so that they can see around it, which destroys the effectiveness of the treatment completely. This sounds great to me.
Monday, March 18: A long term outcomes study of growth hormone therapy during childhood for short stature was done by "meta-analysis" of previously published results in a number of published controlled and uncontrolled studies. The study found that growth hormone treatment adds about 2 inches to adult height for children who have constitutional short stature not related to disease - so-called idiopathic short stature. but the cost is significant. Growth hormone treated children gained about an extra inch a year during treatment, and each of those inches cost about $35,000. Archives of Pediatric and Adolescent Medicine 2002;156:230-240.
Tuesday, March 19: Finnish researchers find that soy formula is a good alternative to cow's milk for milk-allergic infants. Contrary to past medical opinion, they say that soy allergy rarely develops. Soy formulas are cheaper and much more palatable than extensively hydrolyzed formulas such as Alimentum® or Nutramigen®. This prospective controlled trial was the first to examine the issue of cross-sensitization formally. While the rate of reaction to soy formula was slightly higher than to hypoallergenic hydrolyzed formulas, soy was still a good first choice alternative for infants beyond 6 months of age. Journal of Pediatrics 2002;140:219-224.
Wednesday, March 20: Day care attendance seems to protect against the development of allergies for children whose parents have allergies. Levels of IgE, the antibody involved in allergic disease, were on average significantly lower for children who attended day care in the study group of children of allergic parents. This apparent protective effect was seen by age two years. Archives of Pediatric and Adolescent Medicine 2002;156:241-245.
What does this mean? Recall that a lot of European data now exists to suggest that exposure to animals in the first few years of life protects against the development of allergies in young children. It is likely that some degree of exposure to "the slings and arrows of an outrageous environment" is required for what might be termed, for lack of a better idea, a balance within the immune system. That is, a certain amount of dirt and grime, animal dander, and snotty noses is not necessarily harmful to children in the long run. It does seem to toughen them up. This are is of course poorly understood as yet, and I am certainly not advocating exposing kids willy-nilly to illness. But parents should feel at least a little relieved to learn that they really do not have to raise children in a bubble for them to be healthy.
Thursday, March 21: Merck & Co. Inc. has recalled certain lots of its Vaqta® hepatitis A vaccine because of concerns it might not be potent enough to protect against the disease. Physicians can get a list of the lots in question from the AAP website (this is a physicians only link). Children affected would have been vaccinated after August 9, 1999, with the pediatric/adolescent formulation and after May 29, 2001, with the adult vaccine. Antibody testing can be done to determine if the child is immune to hepatitis A at no charge to the patient. Physicians would contact Merck at 1-800-439-4958 for instructions. Revaccination doses will also be provided free of charge by Merck if necessary.
AAP News, March 2002.
Friday, March 22: An experimental screening program for neuroblastoma, a treatable cancer of early childhood, finds that while there is a dramatic increase in diagnosis of the cancer, there is little or no significant decrease in mortality from it. The cumulative Japanese study was carried out over the past thirty years. The investigators concluded that mass screening for the disease was unlikely to be beneficial, because of the very minimal if any reduction in deaths from the disease compared to significant costs of screening and the adverse effects on children and families of falsely positive tests. Similar results have been announced by researchers in Germany as well. Journal of Clinical Oncology 2002;20:1209-1214.
Monday, March 25: Average life expectancy for patients with Down syndrome has doubled from 25 to 49 years in just the period from 1983 to 1997. Researchers surmise there may be several factors at work, but the decrease in institutionalization of persons with Down syndrome and the attendant better health care received may play a major role. Minority individuals with Down syndrome still have shorter life expectancies than white people with the chromosomal disorder. While persons with Down syndrome suffer death due to congenital heart defects, dementia, hypothyroidism, or leukemia, they are less likely to die of most types of cancer. This relative immunity to cancer could be due to the extra dose of tumor suppressor genes located on the three chromosome number 21's that Down syndrome patients possess. Lancet 2002;359:1019-1025.
Tuesday, March 26: This study reports that exclusive breast feeding of small for dates babies (SGA, small for gestational age) for the first 6 months seems to lead to higher IQ's (by a significant 11 points). A small benefit (3 points) was also reported for appropriate for gestational age (AGA) babies. SGA infants were less likely to remain exclusive breast fed by 3 months of age than AGA infants; only one third of them lasted 3 months before supplemental foods were offered. The authors stated that SGA infants who remained exclusive breast-feeders grew just as well as those who received nutritional supplementation. "Duration of exclusive breast-feeding has a significant impact on cognitive development without compromising growth among children born SGA," the authors point out. "These data suggest that mothers should breastfeed exclusively for 24 weeks to enhance cognitive development." Acta Paediatrica 2002;91:267-274.
An alternative explanation for the fact that exclusively breast fed SGA infants "grew just as well" as those who were supplemented is that those were the babies whose mothers had adequate milk for them. The deleterious effects upon IQ of caloric deprivation on babies in the early months have already been documented. The problem with studies such as this one is that there are many confounding factors to muddy the waters. For example, smoking causes small for dates babies; mothers who smoke during pregnancy are probably least likely to exclusively breast feed for six months. One study that would be helpful is what happens when the supplement given is a fortified formula such as the new Lipil® from Mead-Johnson Laboratories which contains the nutrients DHA (docosahexaenoic acid) and ARA (arachidonic acid). These are important building blocks of brain and eye tissue, routinely added to formula in Europe for some time now, and known to have comparable beneficial effects on infant mental development. Another question I would ask is "Where has the FDA been all these years?"
Wednesday, March 27: Too much or too little iron in the unborn fetus may impair brain development, finds this study. Fetal iron status was determined by levels in umbilical cord blood routinely collected at delivery. Children were then tested at five years of age in various areas of abilities, including language, IQ, attention, and several other areas. Children ranked in the lowest 25% for iron status at birth scored significantly lower on these tests. Children with the highest iron levels prenatally had slightly lower IQ scores. Journal of Pediatrics 2002;140:145-148,165-170.
Interpreting this type of study in which two events are associated, is not without peril. Low fetal iron level could be explained by poor maternal health and nutrition, and these factors do not stop at delivery. In other words, a poor environment for mother before delivery may be a poor environment for baby after delivery. But the relationship of proper levels of iron to brain development is well known (no formula without iron, please). The study is thought-provoking at least. My question: where did they find mothers who had too much iron in their systems? That must be very rare.
Thursday, March 28: A single dose of a reformulation of the anti-viral medicine zanamivir can treat influenza in mice, and holds promise for treating and preventing influenza A and B in humans. Zanamir dimer (two molecules linked together) stays in the lungs in very high concentration for up to a week after it is inhaled. A very tiny dose of the dimer form reduced viral levels in lung tissue more than 90%, and lasted up to a week. Safety studies will proceed in animals, and eventually in humans if this promise holds true. Reuters Health.
Friday, March 29: I hope you never need this one: the Environmental Protection Agency (EPA) has approved the emergency use of ordinary chlorine bleach for anthrax decontamination. I have recommended common household bleach (which contains the chemical sodium hypochlorite) for use in my practice for years. It has been a registered anti-microbial pesticide since 1957. It is used in the whirlpool baths of burn units for example, because it kills bacteria while sparing healing tissue. I find diluted bleach solutions very useful for soaking wounds of the feet, especially ingrown toenails, because it is active against the usually highly antibiotic resitant Pseudomonas bacterium as well as Staphylococcus. Reuters Health.