PedSPAM November 2001

Welcome to the PedSPAM archive for November. Here are the month's daily SPAMlets from my update reading that you might have missed:

In the News

Thursday, November 1: Turkish neurologists find that children with bedwetting exhibit signs of delayed brain maturation on their electroencephalograms (EEG). They detected higher levels of delta-wave activity, and lower levels of alpha-wave activity in bedwetters when compared to non-bedwetting children. Journal of Child Neurology 2001;16:714-718.

I have always considered bedwetting to be a maturational phenomenon rather than a pathological condition. To my mind, the best way to view bedwetting is in terms of a sleep disorder (parasomnia) such as night terrors, sleep walking and sleep talking. Instead of talking in sleep or thrashing around, the child wets involuntarily. This study supports that view, I believe.

Note: There will likely be no SPAMlet tomorrow. I will be travelling. Back on Monday, November 5. - Dr. Hull

Monday, November 5: In a presentation at the annual meeting of the American Academy of Child and Adolescent Psychiatry in Oahu, Hawaii, researchers report that children with children with attention deficit hyperactivity disorder (ADHD) are half as likely to become substance abusers if they receive treatment with a stimulant such as methylphenidate (Ritalin®).Reuters Health

This is not news to me; similar findings have been made previously. See my essay on ADHD in simple terms in the Parents Encyclopedia if you have not read it already.

Tuesday, November 6: Children with juvenile diabetes have a significant risk of having concomitant celiac disease (sensitivity to the wheat protein gluten). Children with diabetes can and should be screened with a blood test for celiac disease. Journal of Pediatric Gastroenterology and Nutrition 2001;33:462-465.

More than half of the children in this study had none of the classic symptoms, which parallels recent findings that celiac disease is more common than we have thought, and is often not diagnosed until later in life.

Wednesday, November 7: Children who receive the recommended daily dose of 2000 IU of vitamin D during infancy have only one fourth the likelihood of developing type 1 (juvenile) diabetes than children who receive less than the recommended amount. The suspected mechanism of this protective effect, if it is confirmed, lies in the fact that vitamin D is known to act as an immunosuppressant. Type 1 diabetes is considered an autoimmune disease, and vitamin D may suppress the autoimmune phenomenon. The investigators speculate that ensuring that infants receive adequate vitamin D supplementation might help lower the incidence of type 1 diabetes, which until now has been on the rise. Since vitamin D overdose can be harmful, parents should consult with their physician about proper dosage for any vitamin supplementation. Lancet 2001;358:1500-1503.

Friday, November 9: Illness and limitation of activity from asthma in children "need not be tolerated for most patients most of the time," say researchers at the University of Iowa College of Medicine. Enrollment in their specialty asthma clinic dramatically reduced hospitalizations, ER visits, and missed school days. Children and their parents were taught a systematic plan for managing flareups and provided with 24 hour toll-free telephone support. The researchers observed that chief among the difficulties in asthma care are

confusion caused by complex guidelines
failure to teach patients that colds are not preventable and will cause flareups even with the best care
failure of asthma patients to see the doctor for review and modification of the treatment plan

The authors note as well that

hospitalizations are usually the result of parents doing "too little, too late"
with a good comprehensive management plan, frequent antibiotic use for cold symptoms can be eliminated, and
maintenance medications can be eliminated for children whose asthma only flares up with colds and respiratory infections, and that
urgent physician visits, ER visits, and hospitalizations are virtually completely avoidable with good care.

Annals of Allergy Asthma and Immunology 2001;87:335-343.

Our understanding of what it takes to successfully control childhood asthma is good enough, and the available medications are effective enough, that parents should expect a very high level of control in their children who have asthma. Specialist care may be needed to achieve this level of success, but it should almost always be attainable. Asthmatic kids should lead normal lives!

Monday, November 12: War has broken out between the American Speech-Language-Hearing Association (ASHA) and US Preventive Services Task Force regarding the validity and cost effectiveness of newborn hearing screening. The USPS Task Force stated that the available evidence did not warrant recommending universal hearing screening for newborns. Among the criticisms leveled by the Task Force was the fact that "prospective, controlled studies" have not been done to show long term benefit in terms of improving speech, language, or educational development. A spokesman for the Speech-Language-Hearing Association replied, "We believe some standards of evidence are unreasonable. It is unethical to do double-blind, clinical trials in this type of situation." Reuters Health

I agree. This is a settled issue in other developed countries in Europe. Screening dramatically lowers the age at which hearing loss is identified and treated. That early identification and treatment of hearing loss are beneficial to hearing impaired infants is not in question, but rather do the dollars stack up favorably in a mathematical model. Technology gets better and cheaper as time goes on, making yesterday's "cost-benefit" ratio irrelevant.

Tuesday, November 13: A very large study of over 700,000 children finds that febrile seizures triggered by immunization with DTP or MMR vaccines have no long-term adverse effects. Children were monitored for at least 5 years, and there was no increase found in risk for attention-deficit hyperactivity disorder, learning disorders, mental retardation, obsessive-compulsive disorder, and other psychoses of early childhood. These findings parallel earlier studies which have found no serious long-term consequences of simple febrile seizures which were not associated with immunizations. New England Journal of Medicine 2001;345:656-61.

Wednesday, November 14: Teenaged girls are twice as likely to become pregnant if they are distressed, find these researchers. Their study found that girls under stress are more likely to engage in risky behaviors in general and specifically those such as unprotected sex that lead to unwanted pregnancy. The investigators found that almost half the girls they interviewed in their study suffered from "mental distress," a form of mild depression. These girls had twice the rate of pregnancy as those without this emotional state. Pediatrics 2001;108:e85.

This study was pretty shocking, and not for the reasons above. I doubt anyone would be surprised to find that people under stress make more mistakes. This was a survey of 522 African-American girls between the ages of 14 to 18 years old living in the southeastern US, presumably the Atlanta area. Eleven percent of the distressed girls became pregnant compared with "only" 6% of those who were not distressed - in a six month period of the study! That means roughly one of every six girls in this age cohort became pregnant per year. That is pretty dismal.

Thursday, November 15: Atomexetine is a new investigational medication for attention deficit/hyperactivity disorder (ADHD) that shows promise in testing. It differs from current therapies in that it is not a stimulant medication such as methylphenidate (Ritalin®). It has shown promise of effectiveness in its clinical trials thus far, and has a similar side effect profile to other medications currently used for ADHD treatment. Reuters Health

Friday, November 16: Guess what? Histamine may be responsible for cold symptoms after all. For years doctors have lectured their patients that antihistamine cold medicines do not make sense because the inflammatory hormone histamine (target of said antihistamines) is not involved in cold symptoms - just allergic rhinitis (hay fever). Patients have largely ignored the advice, and sought relief with over the counter cold preparations with antihistamines, that seem to work. Now a new study provides the first direct evidence that increased histamine release accompanies viral upper respiratory infections. Annals of Allergy, Asthma, and Immunology 2001;87:303-306.

Monday, November 19: A non-invasive test for the presence of Down syndrome has been discovered by British researchers. Screening by ultrasound for absence of the nasal bone at 11-14 weeks gestation correctly identifies 75% of fetuses with the Trisomy 21 abnormality. This finding, in conjunction with other findings on the first-trimester ultrasound, can further increase the sensitivity of screening for this abnormality in the first trimester. The authors report that their results are promising, but preliminary, and urge further studies to confirm these results. Lancet 2001;358:1658-1659,1665-1667.

Tuesday, November 20: Amoxicillin may be an alternative to ciprofloxacin or doxycycline for post exposure anthrax prophylaxis, say these experts at the US Centers for Disease Control and Prevention. There are known adverse effects associated with ciprofloxacin or doxycycline use in children, and the safety of these drugs in breastfeeding is unknown. Penicillins, including amoxicillin, do not kill germinating spores in the lung, and scientists are concerned that the bacterium may become resistant to penicillin type antibiotics after exposure to them. However, in low level anthrax exposure situations, amoxicillin may be an effective alternative for children or nursing mothers for whom ciprofloxacin or tetracyclines are contraindicated. Morbidity and Mortality Weekly Report 2001;50:1014-1016.

Wednesday, November 21: Vagus nerve stimulation (electrical stimulation of the nerve that supplies the diaphragm and other organs) has been used in adolescents and adults in the management of seizures resistant to multiple seizure medications. Now a study of this technique in children aged 3 to 18 years old finds that it seems to be both safe and effective, and offers promise for children with very difficult to treat epilepsy. The device is called the NeuroCybernetic Prosthesis System, and is already approved by the US Food and Drug Administration for use by selected patients 12 years of age and older. The investigators added that early initiation of this therapy in appropriate children may help avoid the development of some serious complications of severe epilepsy, such as brain damage and death. Journal of Child Neurology 2001;16:843-848.

Friday, November 23: Children born with upper limb deficiencies such as a missing hand or fused fingers (syndactyly) usually adapt well to their handicap. Dr. Michelle James is an orthopedic surgeon at the Sacremento, California Shrine Hospital. She states that most upper-limb deficiencies do not impose great functional handicaps, especially if the deficiency affects only one side. Parents may experience a period of grieving and may even require professional help to get through it, but if they "treat their child like a normal child and think that they're great in every way, the kids seem to do pretty well," says Dr. James.

Superkids is a support newsletter and website for children with limb deformities founded by the parents of an affected child. Dr. James suggested visiting their Web site at www.super-kids.org, or writing to them at Superkids, 60 Clyde St., Newton, MA 02460-2250. ePediatric News October 2001 35;10.

Monday, November 26: Reconfirming what we more or less knew already from experience, the influenza vaccine is safe for children and adults with asthma, according to this controlled study. There was no significant increase in asthma in the two weeks following the flu shot in a large study group of patients. The authors conclude that given the potentially serious effects of influenza in asthmatics and the demonstrated safety of the shot, all those with asthma should receive the vaccine annually. New England Journal of Medicine 2001;345:1529-1536.

Tuesday, November 27: A thorough review of published, randomized, double-blind, placebo-controlled trials on probiotics ("friendly" bacteria administered purposely to restore the normal balance of gut microbes) finds that they are indeed effective in the treatment of acute diarrhea in children. They significantly shortened the course of diarrhea, especially in rotavirus infections. Only Lactobacillus GG showed a consistent effect in the studies reviewed. The study did not confirm a preventive effect of these bacteria which other studies have shown. Journal of Pediatric Gastroenterology and Nutrition 2001;33:S17-S25.

Thursday, November 29: Children who have both attention deficit hyperactivity disorder and oppositional defiant disorder are at much higher risk (30 times as great) for conduct disorder in adolescence as those children with ADHD without oppositional defiant disorder. Oppositional defiant disorder is characterized by not listening to authorities, getting easily irritable, and talking back. Conduct disorder is characterized by unlawful acts such as stealing, setting fires, or treating animals cruelly. Individuals with conduct disorder often end up being school drop-outs or in prison. Presented at the annual scientific meeting of the Canadian Psychiatric Association, in Montreal, Quebec, Canada. Reuters Health

Friday, November 30: Intranasal steroid inhalers work better than oral antihistamines for persons with hay fever (allergic rhinitis), finds this study. The intranasal corticosteroid fluticasone (Flonase®) was superior to the oral antihistamine loratadine (Claritin®) in the treatment of all seasonal allergic rhinitis. In the past, the accepted recommendation has been oral antihistamines first line, and nasal steroids next if these do not provide relief. This study reinforces a growing belief that intranasal steroid sprays, which have been shown to be safe and more effective than oral antihistamines, should come first in the treatment plan. Archives of Internal Medicine 2001;161:2581-2587.

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