PedSPAM November 2000

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

In the News

Of course the big news has to be the banning by the Food and Drug Administration of all non-prescription as well as prescription medications containing phenylpropanolamine (PPA). This action was taken after a study commissioned by the FDA found a higher risk of hemorrhagic strokes (bleeding in the brain) in women aged 18-35 who had consumed PPA in the three days prior to the stroke.

The study matched cases of stroke in women in the 18-35 year age range with healthy women selected randomly and matched as closely as possible to the stroke victims for age, race, and a host of medical conditions. Both stroke patients and their matched controls were interviewed for use of PPA products around the time of the stroke. Comparisons of the reported use of the medications between the two groups were used to establish a risk factor for PPA and the risk of stroke.

PPA was a very common ingredient in over-the-counter and prescription medications. Its properties include a decongestant effect, making it useful for the symptoms of upper respiratory infections (colds). It also is an appetite suppressant (Dexatrim®). Like all commonly used decongestants, PPA can cause increase in blood pressure, especially with higher doses. Therein lies the problem: increased blood pressure causes the strokes, and any medication that can acutely increase blood pressure will predictably have the same effect on the tiny fraction of the population prone to this type of stroke. One wonders if similar studies will be undertaken to quantify the risk of pseudoephedrin and ephedrin use.

In my opinion this is a serious case of Chicken Little thinking. PPA was judged "safe and effective" by the FDA for cold preparations 24 years ago; for dieting almost 20 years ago. Reading the report upon which the ban is based, it is clear that the real problem was diet drug use. Stroke risk (which is very, very low for healthy women) was almost not elevated at all for cough and cold preparation use; it was sixteen times higher for women using PPA diet pills. So the response of the FDA was to ban all PPA use in children, who have NO risk of stroke, medication or no. This made little sense to me - it seems to be a case of regulatory overreaction. Banning diet pills, I could understand; banning children's Dimetapp®?

The World Health organization is still optimistic that polio can be eradicated from the world by the target date of 2005. The number of countries where polio is still circulating has dropped from 125 to 30, with the disease still active in certain parts of India and sub-Saharan Africa. Bulletin of the World Health Organization 2000; 78:281-410.

British researchers find that a fourth dose of Hib (Hemophilus influenzae type B)vaccine following infant vaccination is unnecessary. The three-shot primary series gives good protection at age six years. The British immunization schedule for HiB is slightly different from that in the US, but comparable. Journal of the American Medical Association 2000;284:2334-2340.

Smoking during pregnancy increases the risk of later wheezing in the child, according to a recent study. The researcher, Dr. Andrew L. Lux, of Royal United Hospital, Bath, Great Britain, said "The clinical implications are that exposure to tobacco smoke components or their metabolites during pregnancy and early infancy has persistent effects on lung health during early childhood, and may contribute to the high prevalence of asthma." Archives of Disease in Childhood 2000;83:307-312.

It is difficult to get asthmatic children first to use their inhalers as often as they should, and second to use them properly because of the issue of coordinating the inhalation with the spray. A new preparation and delivery system may help reduce these concerns. Once-daily fluticasone (Flovent®) powder inhalation (the Diskus inhaler) is effective in asthma treatment in a large series of asthmatics. Chest 2000;118:296-302.

I have seen this device, and it is pretty neat. It slips in a pocket (less paraphernalia for a busy teen to lug around), and the number of puffs remaining is indicated on the device, so the significant problem of puffing on an empty inhaler is prevented.

Compared to children who have survived a tornado or have "another ongoing social or academic stressor," children who have lost a parent to fatal illness or accident show a higher incidence of posttraumatic stress disorder (PTSD). Researchers at the University of Alabama, Tuscaloosa found that bereaved girls, younger children and children whose surviving parent scored high on PTSD measures were at greater risk of PTSD symptoms. They encouraged those who care for such children to be alert for signs of PTSD. Journal of the American Academy of Child and Adolescent Psychiatry 2000;39:1112-1119.

A recent national survey finds that parents think that sex education classes in public high schools are not as lengthy or as comprehensive as most parents think they should be. Teaching sexual abstinence until marriage remains at the top of parents' sex education priorities. The majority of parents also want their children to get more instruction about sexually transmitted diseases, contraception, and how to communicate with partners. Reuters Health.

A suggested link between disposable diapers and reduced male fertility raised recently in the October issue of Archives of Diseases of Childhood was rejected by representatives of the Personal Absorbents Products Council in Washington. (I will wager you did not know the name of the diaper lobby!) The original study done in Germany claimed that scrotal temperatures were higher with disposable diapers, and that this caused the observed drop in male fertility since World War II. The study was criticized because

Dr. Stern suggests that physicians need to reassure parents about their use of disposable diapers. "What doctors need to tell their patients is this was a small and badly done study whose results are not reliable or significant, and they should keep doing what they are doing." Reuters Health.

High-efficiency particle air (HEPA) filters used in the homes of asthmatic children are useless, according to a recent study. Levels of common antigens in household air and asthma symptoms of children were the same in test and control groups. "All kinds of allergens exacerbate asthma in children, notably pet allergens, mold, dust mites and cockroaches," lead researcher Dr. Kelly A. Quinn, of La Rabida Children's Hospital and Research Center in Chicago. "We found that the HEPA air filters did not change the level of the cat allergen or dust mite allergen in the air," said Dr. Quinn. "There were no significant differences, and, not surprisingly, the children's symptoms remained the same."

A new device for the treatment of deformational plagiocephaly has been approved by the FDA. The device, known as the "CranioCap," is a helmet that is worn 3-4 hours per day to put pressure on the more prominent areas of the skull, redirecting growth toward the less prominent parts and reducing head asymmetry. The device is worn for 3-4 months, and must be used before about one year of age, when the malleability of the skull decreases and no longer allows reforming. The patented device is made by Gillette Children's Specialty Healthcare of St. Paul, Minnesota.

Asthmatic children are less sensitive to significantly low blood oxygen (hypoxia) as determined by awareness of it measured by "breathlessness scores" given in the emergency room setting. Researchers compared subjects blood oxygen levels to their perceived breathlessness, and found that children with lower blood oxygen levels when admitted to the hospital actually perceived less distress than children admitted with normal blood oxygen levels. This has been reported before; it is significant because it means that the patient may not be aware just how much trouble he is in until the situation is dire. Archives of Disease in Childhood 2000;83:325-329.

Simple handwashing could significantly reduce the number of common infections in school age children. A study by the US Food and Drug Administration found that children who washed their hands more often were less likely to become sick. Children who washed their hands four times a day had one fourth fewer sick days due to respiratory illness and half as many days lost because of stomach upset.

A single dose of azithromycin (Zithromax®) is as effective for otitis media (middle ear infection) as 10 days of amoxicillin/clavulanate (Augmentin®) given twice a day, finds a study recently presented at the Infectious Diseases Society of America (IDSA) annual meeting in New Orleans, Louisiana. The company that produces Zithromax®, Prizer, will submit the data from their multicenter trial to the FDA for approval of the dosing schedule.

Do not pressure your doctor just yet to do this. It is known that no treatment at all has a significant "cure" rate; this finding may be an example of a true but clinically insignificant study. The reason it was funded apparently stemmed from the recent publication of guidelines for management of ear infections that found a very high prevalence of partial to complete resistance to azithromycin in many community strains of pneumococcus (a common disease causing bacterium). One time dosing is attractive certainly, but might be expected to encourage the development of more resistant strains of pneumococcus.

Parents, school officials and healthcare professionals often misdiagnose head lice infestations, leading to unnecessary treatment and exclusion from school. Healthcare professionals and lay persons were invited to submit specimens from children believed to have head lice. Only half of the samples contained either a louse or a viable egg. The study's authors, Dr. richard J. Pollack and colleagues at the Harvard School of Public Health, Boston, Massachusetts, stated that "Treatment is generally warranted solely when live trophic forms or if apparently viable eggs are present... Discovery of live head lice or their eggs does not seem to warrant exclusion of a child from school." The researchers conclude that "the no-nits policies that have been adopted by many schools should be reviewed and their merit considered critically." Pediatric Infectious Disease 2000;19:689-693.

Head lice hysteria. As they say, "Don't get me started!"

A new feces assay is effective for H. pylori screening in children. The new test (there are already blood tests for H. pylori infection) compares favorably in accuracy with the "gold standard" test, breath hydrogen test. Archives of Disease in Childhood 2000;83:268-270.

Vitamin E may be beneficial in treatment of rheumatic chorea (rapid, jerky movements caused by the effects of rheumatic fever on the brain), find Indian researchers. Oral vitamin E was given daily for two weeks, with a significant reduction in abnormal movements. The research group points out, "Vitamin E is safer than the conventional drugs used for chorea. Its role needs further evaluation." Indian Journal of Pediatrics 2000;67:563-565.

Vitamin E is cheap, safe, and it appears possibly effective. Let's hope this pans out. Rheumatic fever is quite rare in the US, but definitely not in the developing world.

Changes in toilet training methods may account for voiding problems in children, say Belgian researchers. They gave questionnaires to three groups of parents:

Customs have changed:

Older parents were also much more likely than younger respondents to use a potty chair with a hole in the seat to help toilet-train the child. For the most part, younger parents used standard toilets, usually without the help of a reducing seat or support for the feet.

"Most authors are convinced that the development of bladder and bowel control is a maturational process which cannot be accelerated by toilet training," the authors commented. But according to the authors their findings contradict this theory. "At 18 months, 71% of the children in group 1 were 'drilled' to be dry and clean, but only 17% were in group 3." The investigators say that these findings thus "strengthen our proposal" that the apparent increase in voiding problems in children may be the result of inadequate toilet training now widely used by younger parents. British Journal of Urology International 2000;86:248-252.

Hydroxyurea, already known to be beneficial for older children and adults with sickle cell disease, has been found to be safe and effective in young children with the condition. The drug increased hemoglobin levels and reduced hospitalizations and transfusion needs. Journal of Pediatric Hematology and Oncology 2000;22:330-334.

The few-joints (oligoarticular) form of juvenile idiopathic arthritis is more serious than previously thought. French researchers studying children who were diagnosed over a 10 year period found that not only was the remission rate lower than expected, but the rates of multiple joint progression, erosion and chronic eye inflammation were higher than they expected. About one third of the patients developed joint erosion, a third developed eye complications, and about a third were in complete remission 8 years after diagnosis. Arthritis and Rheumatology 2000;43:1858-1865.

Accutane (isotretinoin) does not increase the risk of psychiatric disorders in patients taking it for severe acne. A study found no support for a previously reported link between isotretinoin and depression, psychotic symptoms or suicide. The researchers commented that persons with severe acne are more likely to be depressed - but there was no link to the use of the medication. Archives of Dermatology 2000;136:1231-1236.

Expectant mothers with bad teeth - peridontal disease - are much more likely to deliver prematurely. This fact has been known for some time, but the new study presented at a American Academy of Peridontology conference allowed for factors such as co-existing urinary tract or genital infections as well as smoking. It demonstrated a 3-5 times higher risk of premature birth for women with peridontal disease. Infectious Diseases in Children, September 2000.

There is a new treatment for pediatric asthma emergencies. Intravenous magnesium is helpful in improving lung function in children with asthma seen in the emergency room. Children were first given standard inhalation treatments, and then randomly given magnesium sulfate or saline placebo by vein. The magnesium treated group did significantly better; half of the treated patients were able to go home, while all of the placebo group had to be admitted to the hospital. Archives of Pediatric Adolescent Medicine 2000;154:979-983.

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