PedSPAM November 1998

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

In the News

A study in Iceland finds that herpes zoster (shingles) is more common than previously believed and is usually quite benign in children and adolescents. They found a rate of 1.6 cases per 1,000 children per year. All patients recovered completely. No patient had pain for more than 1 month after onset, and most experienced no pain at all. In the others, pain and itching were mild. Contrary to earlier beliefs that infants under a year who contract chickenpox are more likely to have shingles later, the study showed no correlation between the age at which a child contracted chickenpox and the likelihood of developing shingles later in childhood.

The immunosuppressive drug tacrolimus can rapidly reduce the severity of childhood atopic dermatitis (eczema). The drug promises to provide fairly dramatic relief in moderate to severe atopic dermatitis cases without serious systemic side effects. FDA approval of the new preparation is not expected until about mid-2000. Journal of Allergy and Clinical Immunology 1998;102:555-557.

The Food and Drug Administration announced that that orally inhaled and intranasal corticosteroids will require new pediatric labeling. The new labeling will caution that use of these products by children "...may reduce their rate of growth." The new labels will recommend use of the lowest effective dose of the drugs and routine monitoring of patients' growth rates. The FDA noted, "Long-term effects of this reduction in growth velocity on final adult height are unknown." It has not yet been determined whether patients' growth will "catch up" if treatment is discontinued. The FDA cautioned patients not to stop using their inhaled or intranasal corticosteroids without consulting their physician first regarding benefits and risks.

The prevalence of sensitization to cockroach allergen in asthmatic children is directly related to the levels found in the dust in their bedrooms, researchers report in the October issue of the Journal of Allergy and Clinical Immunology. Efforts to eliminate roaches seem thus to be especially important for the bedroom areas.

The Food and Drug Administration has approved cefpodoxime proxetil (Vantin) as a 5-day treatment regimen for mild to moderate acute otitis media in children. Physicians can now prescribe 5 mg/kg of Vantin Oral Suspension for twice-a-day treatment over 5 days in children between the ages of 2 months and 12 years, which cuts the course of treatment in half from the earlier 10 day course. Shorter courses of antibiotics, if effective, are an improvement with regard to better patient compliance (i.e., parents remembering to give the medicine) as will as reduced cost (not inconsiderable, with the price of this and other antibiotics).

In a related area, a French study reports that contrary to other studies, the treatment duration for otitis media in children under two should remain 10 rather than the 5 days as recently advocated. The French researchers found that while short courses of treatment worked equally as well as longer courses in the older child, children under the age of two or who have a draining ear (otorrhea) should still recieve ten days of treatment.

Like chlamydia, cytomegalovirus (CMV) infection may be a risk factor for coronary atherosclerosis (hardening of the arteries). About 50% of adults have latent CMV infection. In the future, vaccination against CMV could conceivably reduce the incidence of atherosclerosis in adults.

Sore nipples in breast-feeding mothers are a common cause of premature weaning, and are difficult to treat owing to recurrent trauma and exposure to the infant's oral bacteria. A recent study of the problem concluded that the best strategy is the prevention of sore nipples by teaching proper technique on the initiation of breast-feeding. If sore nipples do develop, the old standby of breast shells and lanolin in association with instruction in breast-feeding technique are more effective than moist wound dressings, and should remain first-line therapy.

Garlic extract therapy has no significant effect on cardiovascular risk factors in pediatric patients with familial hyperlipidemia. Archives of Pediatric and Adolescent Medicine, 1998;152:1089-1094

There is no evidence that ibuprofen (Childrens Motrin, Childrens Advil) administration during fever prevents febrile seizure recurrence. A study in the Netherlands confirmed what we have long known about strategies to ward off repeat febrile seizures by giving fever-reducing medicine promptly: it doesn't work. This study looked at ibuprofen to see if the outcome would be different. No. Pediatrics, November 1998.

From the Departments of Pediatrics and Communication at Stanford University, Palo Alto, California, comes the finding that increased television and music video viewing are risk factors for the onset of alcohol use in adolescents. As is often the case, this article confuses correlation with causation. The same factors which lead children to initiate alcohol use might also lead them to watch more TV or videos, without the TV and videos actually causing the initiation of drinking. A subtle point perhaps, but one that leads to no end of confusion and silly prescriptions to solve any number of problems. Pediatrics, November 1998.

A comparison of 72 deaf or hard-of-hearing children whose hearing losses were identified by 6 months of age with 78 children whose hearing losses were identified after the age of 6 months confirmed earlier findings that children whose hearing losses were identified by 6 months of age demonstrated significantly better language scores than children identified after 6 months of age. This data will bolster the case for universal newborn hearing screening.

The Advisory Committee on Imunization Practices (ACIP) of the Centers for Disease Control voted recently to recommend the so-called sequential schedule for polio vaccination. This entails two doses of injectable polio vaccine followed by third and forth oral doses. The committee is said to have stopped just short of recommending an all-injectable schedule; the concensus is that the all-injectable schedule will be adopted by the year 2001. Since 1996, there have been four confirmed and three suspected cases of vaccine-related paralytic polio in the US (among perhaps 24 million doses of vaccine). Concerns about increasing the number of injections and the increased cost of injectable vaccine seem to be waning.

Alaska has mandated that all schoolchildren K-12 receive a second dose of measles vaccine in the face of a large outbreak of measles. There have been 45 confirmed, probable or suspected cases.

The rate for Sudden Infant Death Syndrome (SIDS) reached an all time low in the US in 1997, but one fourth of babies are still placed on their stomachs to sleep. Minority mothers in particular remain somewhat resistant to the change (often apparently at the instruction of the grandmother), and black babies remain 2.4 times more likely to die of SIDS.

In a related vein, it has been shown that babies who are placed in the proper back sleeping position are indeed slower to develop head control in the early months than babies placed on their tummies. However, the differences disappear after the first few months of life and overall milestone attainment is normal for back-sleepers. Of special note: babies who habitually sleep on the back should not be allowed to sleep on their stomachs in the early months. A study has suggested an increased risk of SIDS for those babies, probably because of the slower maturation of head control.

Good news: Apparently because fewer teens are having sex, and more are using birth control, the teen pregnancy rate (females 15-19 years) has hit an recent low at 101 per 1,000 adolescent girls in 1996. It had peaked in 1990 at 117/1000; data for 1997 look promising for a further drop.

Bad news: According to the CDC, the number of teens starting smoking increased by 30% and the number becoming daily smokers increased by 50% from 1988 to 1996.

Good news: At monitored hospitals where the CDC prevention guidelines have been adopted, there has been a 50% drop in cases of neonatal Group B streptococcal sepsis (severe bloodstream infection) since the adoption of the guidelines over the last two years.

Bad news: At the University of Chicago Hospital, non-Group B strep infections rose proportionately over this period as strep infections fell, and the overall rate of sepsis episodes, at least at that hospital, did not change.

The American Academy of Pediatrics has officially endorsed the rotavirus vaccine for oral administration at 2, 4 and 6 months. The vaccine protects against 50% of all episodes of diarrhea, about 80% of all episodes of severe diarrhea, and almost all episodes of hospitalization for rotavirus diarrhea. The cost of the vaccine is somewhat high, however, our local Blue Cross carrier has covered it right off the bat. This vaccine would certainly be a reasonable choice for children exposed to daycare settings; I will probably start offering it at least to selected patients who will be in that category. The rotavirus vaccine can be given along with other vaccines, such as DTP, Haemophilus influenzae b, hepatitis B or polio vaccines.

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