PedSPAM May 1998

Welcome to PedSPAM for May. Here are some more things from my update reading. This month's news is digested from various sources. Sure, it is a bit late... I have been swamped with this and that. The reorganization of the Encyclopedia really took it out of me. Call it spring fever, phlegmon vernalis. I hope you like the new format of the Encyclopedia - it makes surfing around much faster, and it is easier to maintain.

In the News

A series of studies on thumbsucking by Dr. Patrick Friman reviewed in Contemporary Pediatrics by Dr. Edward Christopherson described a procedure to stop the thumbsucking habit in most children 5 and older. Parents begin by giving the child a lot of brief, non-verbal pysical contact, such as pats on the back, roughing up the hair, hugs or whatever. The type of contact is unimportant as long as it is frequent, warm and loving.

After about two weeks of this attention, the parents start painting the thumb with one of the commercial thumb-sucking or nail-biting deterrents. This is done first thing in the morning and throughout the day every time he touches his face near the mouth. Positive reinforcement and praise for progress are naturally helpful. It is claimed that the child will usually give up the habit within two weeks of starting the second step of the treatment plan.

This was a new procedure to me, and I intend to try it out the next time this issue comes up as a parent question. Problem thumb sucking doesn't come to the doctors attention nearly as often as it occurs, I suspect, because parents have heard "He'll grow out of it," so often they are resigned to it. I hope this procedure can change that.

From the May issue of the American Journal of Epidemiology: Breast-feeding reduces the incidence and severity of lower respiratory illness in infants during the first 6 months of life. The annual incidence of lower respiratory illness, but not respiratory illness as a whole, was reduced in infants who were fully breast-fed compared with those not breast-fed or only partially breast-fed, especially in the first 4 months of life. In addition, the duration of all respiratory symptoms was slightly shorter, on average, for infants who were fully breast-fed compared with those who weren't or were only partially breast-fed. The authors stated "...promotion of breastfeeding is a worthwhile strategy for prevention of [lower respiratory illness] in young infants, the age group most likely to require hospitalization and to suffer long-term consequences of such illness." Yet another study documenting the medical advantages of breastfeeding. Of particular note is the observation that adding solids or formula to the diet in the first four months lowers the protective effect. I suspect that the explanation for that is that the substitution of other nutrition lowers the total amount of breast milk consumed, and likewise lowers the total amount of the protective substances - antibodiies, nucleotides and who knows what others - contained in breast milk.

An asthma management roundtable was held recently in New York City co-sponsored by American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology, the American Association for Respiratory Care, and Allergy and Asthma Network/Mothers of Asthmatics, Inc. The group issued recommendations about asthma treatment stressing the importance of aggressive control in childhood to prevent "airway remodeling." Airway remodeling refers to the permanent structural changes in airways due to chronic inflammation. They called for increased efforts by physicians to stress the importance of antiinflammatory drug therapy to prevent permanent changes in the lung. "Patients and physicians alike should know that if you use a bronchodilator more than twice a week, an antiinflammatory medication should be used to prevent long-term damage," according to Dr. Jill Karpel, Director of the Pulmonary Research Center at Montefiore Medical Center, Bronx, New York. The earlier asthma is identified and properly treated with drugs to control inflamation as well as environmental control to reduce exposure to dust mites, mold, pet dander, and especially cigarette smoke, the better the long term prognosis. Parents may tire of hearing about treating their childrens' asthma, but control of the inflammation is so crucial to long term outcome.

In the June issue of the Journal of the American Academy of Child and Adolescent Psychiatry, Dr. Myrna Weissman of Columbia University found in a ten year study that parental depression is associated with not only a higher incidence of childhood depression, but also an increased incidence of medical problems in their children. These findings are consistent with earlier studies that have linked parental depression with increased medical complaints and actual illnesses in their children. Parental depression is linked to childhood depression, whether the link is genetic or simply caused by the depressing nature of life with a depressed loved one. Depression is known to lower our resistance to physical ailments. This means that the parent who is depressed needs to seek help or be led to help by concerned family and friends, for the good of everyone including the children.

And in a related vein: Dr. Stanley Turecki, psychiatrist at Lenox Hill Hospital, New York, and author of one of my favorite recommended books, The Difficult Child, outlined the variablility of the signs and symptoms of depression in children of various ages at a recent conference reviewed in Pediatric News, April 1998.

Infants and Toddlers: lack of interest, sad facial expression, underactivity, withdrawn behavior, excessive whining and crying, and failure to thrive
Preschoolers: stomachaches, headaches, restlessness, fatigue, low tolerance for frustration, irritability, and reduced enthusiasm
School-Aged Children: physical complaints, irritabillity, sad mood, low self-esteem, changes in sleep patterns, easy crying, and reluctance to attend school
Adolescents: feeling of sadness and hopelessness, diminished or increased appetite, fatigue, physical slowness, agitation, changes in sleep patterns, drop in school grades, boredom, self-destructive behaviour, relationship difficulties, carelessness about appearance, sensitivity to rejection, and suicidal thoughts or acts

The older the child, the more the clinical picture becomes classical in terms of its similarity to the adult presentation of depression, according to Dr. Turecki. He noted that most children have difficulty expressing feelings of sadness and hopelessness. They will usually speak about boredom, rather than sadness - they seem more irritable than unhappy.

Depression in childhood is common, and woefully often missed or misdiagnosed. Many behavioral problems as well as apparent vague physical maladies have as their root cause depression. Parents as well as physicians need to be vigilant for signs of depression in children, and seek competent professional help if it is suspected.

Ordinarily, if a child is suspected to have appendicitis but the clinical picture does not give enough certainty to warrant operation, we admit the child for overnight observation with re-examination and perhaps a repeated blood count later. A study by Barbara Pena, M.D. at Boston Childrens Hospital found that children with suspected appendicitis can be safely discharged from the hospital if they have a normal abdominal CT scan. The average cost savings was about $2,000, with no increase in missed appendicitis.

Along the same lines, the question sometimes comes up in the emergency room, whether to admit a child who has suffered minor head trauma for observation in the hospital. The fear is that the child will develop delayed complications of the head trauma which will not be detected properly by the untrained parents and which will result in possibly catastrophic consequences. A study reported in the April 98 issue of Pediatrics found that if the child has a normal neurologic exam and a normal CT scan, the child could be observed safely at home by the parents. In their study, this would have saved on average $2,900 in hospital charges. Tells you a lot about hospital charges, too - $2,900 for an overnight stay with a nurse waking you up every hour to bother you. Ramada Inn would be cheaper and surely more pleasant 8-)

Almost 85% of all permanent childhood hearing impairment is present at birth. Britain's National Health Service finds in its Effective Health Care Bulletin that screening for hearing disorders within a few days of birth is more effective than testing infants at age 6 to 9 months. Late identification - meaning delay to even 6 to 9 months of age - of profound hearing loss compounds problems in speech and language acquisition and affects other areas of development and intellectual function. This is one area where early detection and intervention is absolutely critical.

About 400 US hospitals currently screen all newborns in the nursery. Several states have begun mandating screening, because the lifetime cost to government of remedial special education for even one missed case outweighs the cost of screening. Deaf children detected at birth can be fitted with hearing aids and early intervention begun. These children will generally be able to function normally in school with normal language development. Children detected even as early as 6 to 9 months usually wind up in special education classes and may not finish high school. The differences in outcome and associated costs are simply profound.

The only reason screening is not more widely done is cost, but modern computerized equipment is bringing the cost per screening down into very reasonable ranges. It is clear that universal screening will come to the US, and fairly soon. If screening is not done in your community and you are looking for a project - here is a good one.

From the April issue of Pediatrics, extremely preterm infants (28 weeks gestation or less) could be immunized for most illnesses on the same chronological schedule as full term infants. The antibody response of preterm infants to most vaccines was fairly equivalent to that of full term infants, with the exception of the H. influenzae type B (HiB) and oral polio. This means that we dont have to wait until the baby reaches a certain weight - we used to say 10 pounds - before beginning protective immunizations.

Chronic obstructive adenoidal hypertrophy may be caused by persistent or reoccurring infection of the adenoidal tissue with bacterial germs. Obstructive symptoms at night can interfere with sleep and place an undue load on the right ventricle of the heart by inducing pulmonary hypertension (increased blood pressure in the arteries of the lung). A thirty day course of amoxicillin/clavlanate (Augmentin®) reduced by half the need for surgery in children with chronic obstructive adenoidal enlargement. This effect persisted for a number of months following the treatment course, and this treatment plan might be a safer (and cheaper) alternative to surgery for certain children.

After having prepared, tested and licensed the new rotavirus vaccine, scientists were chagrined to find that a strain of the virus heretofore rare in the US has been isolated in the United States, and quite commonly at that. The vaccine is directed against four strains of the virus, G1-G4. The G9 strain, reported only onced before in the US in 1983, suddenly appeared in four cities. Researchers were hopeful, however, because repeated doses of a vaccine series may well induce broader immunity to other strains of the virus not specifically immunized against. From Pediatric News, April 1998.

A trial of hypoallergenic formula (Alimentum®, Nutramigen®) and reduced infant stimulation are the best approaches to the management of infantile colic, according to a literature review the British Medical Journal. A group of researchers in the Netherlands reviewed 27 controlled clinical trials of treatments for colic and concluded that hypoallergenic formula trial was often effective, but that soy formula substitution showed no clear evidence of benefit in reliable studies. Drug treatment with anticholinergic drugs (dicyclomine - Levsin®) treatment was effective but there are potentially serious side effects. Advising the parents to reduce stimulation was the single most effective intervention. Other parental behavior modifications, such as carrying and handling the infant more, were not effective. Simethicone was ineffective, and low-lactose formula was of questionable effectiveness.

I am intrigued by this article most because in our country, research has pretty much come to the conclusion that prompt response to crying babies with a sequential search for the cause of the crying (keep trying until you figure out what he needs) leads to less overall crying. The other obvious problem we always run into when talking about colic, is "what the heck is colic?" All fussy crying is not colic, in fact most fussy crying is definitely not colic. And I don't want to get too academic, but if a baby responds to hypoallergenic formula - that is milk allergy, not colic. Remember that colic is crying for which no medical condition can be found as the cause.

Of interest in an age when people seem bent on keeping exotic pets: an intestinal roundworm that inhabits raccoons can cause life-threatening disease in humans, especially children, according to researchers at San Jose State University in San Jose and Stanford University in Palo Alto, California, as reported at the 98th general meeting of the American Society of Microbiology. The larvae of the worm, Baylisascaris procyonis, survive in the raccoon's feces and can be ingested when children play in raccoon "latrines," which are communal defecation areas that the animals establish. B. procyonis eggs can remain infective in the soil for years. While health officials are aware of the risk of rabies associated with exposure to raccoons, most are unaware of the prevalence of B. procyonis, found by these researchers in about 60% of raccoons studied. The parasite is more common in raccoons that live in the northeast, midwest and Pacific northwest and less common in raccoons in the southeast.

Visceral larval migrans is the medical condition caused by the migration through the tissues of the body of the larvae of roundworms normally parasitic to dogs and other animals. The larvae can grow up to 2 mm in length. The immune response that the body mounts to infection can result in extensive organ damage and other complications such as meningitis. B. procyonis tends to cause a more virulent form of visceral larval migrans which can be fatal in children.

Conclusion: exotic pets are best left to adults, who can make their own decision whether they want to take the risk; adults need to be more inquisitive about the definite health risks inherent in exotic pet ownership (like the iguanas that smear Salmonella all over the house, mentioned in a previous PedSPAM).

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