PedSPAM October 1998

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

In the News

Well, the big news this month is the new polyvalent pneumococcal vaccine. In the past, vaccination against Streptococcus pneumoniae, the "pneumococcus," has been hampered by the fact that the currently used vaccine induces very poor immunity in children under the age of two. The seven strains of the germ used in the new vaccine account for about 85% of serious pneumoccocal disease in the US. A trial of the new vaccine involving 38,000 children showed it to be 100% effective in preventing serious pneumococcal disease such as meningitis and bacteremia (bacterial germs in the bloodstream).

The researchers stopped the test and will give the vaccine to the placebo group because it when obvious what dramatic protection the vaccine confers. The vaccine was given at 2, 4, and 6 months, with a booster at 12-15 months. There are ongoing trials for other multiple strain vaccines (up to 11 strains covered) here and abroad. The data must be further analysed to see whether the new vaccine is protective against ear infections and pneumonia. This has the potential to radically alter the pediatric infectious disease landscape if the vaccine is even partially effective in reducing the number of less serious pneumococcal infections.

A retrospective study of 325 children referred from 1985 to 1994 for the evaluation of asymptomatic microscopic hematuria (trace blood in the urine), reported in Pediatrics for October 1998, found that microscopic hematuria in children is a benign finding in the vast majority of children. "Our data demonstrate that a renal ultrasound, voiding cystourethrogram, cystoscopy, and renal biopsy are not indicated in the work-up of microscopic hematuria, and microhematuria in the otherwise healthy child is a minimal health threat, rarely indicative of serious illness."

Also from the October Pediatrics: Phimosis is a condition of uncircumcised boys whose foreskin is not properly retractable after age four. The authors found that the most cost-effective management for treating phimosis was daily topical steroid therapy with betamethasone 0.05% cream for 4 to 6 weeks. The cream was applied from the tip of the foreskin to the corona (the ridge around the head of the penis). The authors say that surgical intervention (circumcision) should not be considered until topical therapy has been given an adequate trial.

Well, it had to happen. The lay press picked up the xylitol (sugar) strategy for prevention of otitis media. Xylitol is a 5 carbon sugar alcohol found in many plant materials, including raspberries and plums, used as a sweetening substitute overseas. Good news: as I have reported previously, it did seem to be effective in the Finnish study in reducing episodes of ear infection in day care exposed children. Bad news: there is no American source of xylitol, even though this sugar is apparently used in Europe in chewing gum! Not only that, but xylitol is a regulated food additive under the Food and Drug Administration regulations. If someone were to try to introduce such a gum for the prevention of ear infections, the FDA would have to be involved in certification because a medicinal claim was made. Also, from what I understand of the trial, these kids got pretty massive amounts of gum or sugar syrup and there is a question as to the practicality for this in the average American day-care setting. See chewing gum bezoars, PedSPAM September 98.

Doctors at Department of Pediatrics, University of Connecticut School of Medicine, Connecticut Children's Medical Center, Hartford, Connecticut found in a long term review of cases of childhood Lyme arthritis that "the prognosis for children with Lyme arthritis who are treated with appropriate antimicrobial therapy is excellent." While a few children still had some muscular complaints years after treatment for Lyme disease, none of the children had active arthritis.

Good news for a lot of teenage girls: researchers at Johns Hopkins University School of Medicine, Baltimore, Maryland state that vaginal infections in adolescent women can be adequately diagnosed without a vaginal speculum exam. Now that urine-based diagnosis of gonorrhea and chlamydia is becoming well established, it may be possible to perform evaluations for uncomplicated genitourinary complaints without using a speculum." Pediatrics October 1998.

The risk of SIDS in premature babies and what can or should be done to prevent SIDS in these children was discussed in a commentary article in the October Pediatrics. The overall risk in Los Angeles County in 1996 was 1.5 per 1000 live births, that for babies born before 37 weeks' gestation was approximately five times as high and for infants whose birth weight was less than 1500 g, corresponding to a gestational age of 32 weeks, the risk increased to 1 per 100. However, and a big however, the authors say that "home monitoring of premature infants is not indicated for risk of SIDS. There is no evidence that monitoring is effective, and there are no criteria available including the history of apnea of prematurity to identify the infant who is more likely to die." They advised against the practice of obtaining cardiorespiratory recordings (so-called pneumograms) to identify risk for SIDS in the premature infant and to recommend home monitoring based on the findings.

FluMist is a new live, attenuated virus nasal spray vaccine that has been shown to offer good protection against influenza without a shot. Trial results show that 13% of children who received the placebo spray developed influenza during the study, as confirmed by laboratory testing but, only 2% of children who received the FluMist spray developed culture-confirmed influenza. Children who received the vaccine were less likely to develop pneumonia and other lower respiratory diseases. FDA licensing issues make it unlikely to be available for next year's (1999-2000) flu season. This really disappoints me. The benefits of influenza vaccination for kids from 6 months and up in reducing respiratory infections and especially ear infections is pretty clear. Such a vaccine will be a blessing - no shot!

A serious new streptococcal infection is being transmitted by tilapia, a fish growing in popularity throughout North America and being harvested in the United States. The fish is becoming a staple in many Asian grocery stores. Puncture wounds from its sharp dorsal fin that occur during handling or cleaning allow entry of Streptococcus iniae. Wearing of gloves to protect against wounds from the fishes sharp spines is preventative. Treatment with antibiotics can eradicate the agent, but if the infection remains untreated, it can become fulminant and cause spreading cellulitis and serious systemic infection.

Simple skin-to-skin care is as good as an incubator for treating newborns with too-low body temperature after delivery, according to Dr. Kyllike Christensson of the Department of Public Health Sciences in Stockholm and as reported in British medical journal The Lancet of October 3. The authors note that skin-to-skin care is at least as good as care in an incubator and may be a suitable therapy for neonates in countries with limited resources. "STS [skin-to-skin] care by the mother also promotes stable cardiac and respiratory function, keeps unnecessary movements to a minimum, improves behavioural state, and facilitates mother-infant interactions," Dr. Christensson and associates write.

In children with a genetic predisposition to Tourette syndrome, streptococcal infection may trigger the onset of symptoms. Tourette syndrome, along with Sydenham chorea, tics and obsessive compulsive disorder "may represent immune-mediated symptoms," according to a report presented at the 5th International Congress of Movement Disorders in New York. If this association holds, it could mean more aggressive treatment regimens or preventative regimens against strep infections for children with a family history of Tourette syndrome or other movement disorders.

An intolerance to cow's milk may be a common cause of chronic constipation in infants and young children, according to a report in the October 15th issue of The New England Journal of Medicine. Researchers in Palermo, Italy studied children with chronic constipation resistant to the usual laxative therapy. Many of the children had anal fissures and chronic perianal irritation. The researchers found that changing to soy-based milk cured the constipation and perianal lesions in almost 70% of the children.

Beware of the Skateboard! says an article in the October issue of Archives of Pediatrics & Adolescent Medicine. A survey of 80 hospitals and pediatric trauma centers found that skateboarders had a much higher likelihood of sustaining serious injuries, especially head injuries, as in-line or regular roller skaters. Skateboarders were 8 times more likely than roller skaters, and more than twice as likely as in-line skaters, to have severe or critical injuries.

It has been known for some time that folic acid supplementation for mothers around the time of conception is important to reduce the chance of serious brain and spinal malformations in babies. Investigators in Ontario, Canada found that very few women knew that periconceptional folic acid supplements will prevent these malformations. They urged greater effort to spread this message. From Archives of Family Medicine.

Many parents miss warning signs for teen suicide according to an article in the November Journal of the American Academy of Child and Adolescent Psychiatry. Among the adolescents, 56% met diagnostic criteria for major depression when they made their suicide attempts, the researchers found. Parents reported noticing symptoms of depression in only 13% of cases, the researchers report. Parents were better at recognizing the signs of drug abuse, but they underestimated the severity of drinking problems among their children.

Routine childhood vaccination against hepatitis A may be advisable in areas where hepatitis A (infectious hepatitis) is prevalent. An infectious disease specialist speaking at a Centers for Disease Control advisory committee meeting stated, "Hepatitis A vaccination is particularly important for children because they often do not display signs or symptoms of the disease and unknowingly place classmates and other family members at risk for infection." An Oklahoma law which will go into effect on November now requires hepatitis A vaccination for kindergarteners and 7th graders, because the incidence of hepatitis A in Oklahoma has quadrupled in the past 10 years. Arizona, California, Missouri, New Mexico, Oregon, Tennessee, Utah and Washington have also had similar problems with increasing incidence of hepatitis A.

And on a stranger note: The incidence of nickel allergy is rising with the increasing popularity of body piercing. The American Academy of Dermatology's Derm Update '98 press briefing in New York warned that nickel is now the leading cause of contact allergy in the US. Home test kits to determine if nickel is present in a metal are available, should your teen be so inclined. Surgical-grade stainless steel and titanium probably represent safer materials. Teens contemplating body piercing should be prepared to consult a dermatologist or their physician at the first sign of infection or allergy.

A study of 325 children referred to several pediatric nephrology specialty centers for the evaluation of symptom-free microscopic hematuria (red blood cells in the urine only detectable on lab tests or office dipstick test, not grossly visible in the urine) demonstrated that a renal ultrasound, voiding cystourethrogram, cystoscopy, and renal biopsy are not indicated in the work-up of microscopic hematuria, and microhematuria in the otherwise healthy child is a minimal health threat, rarely indicative of serious illness. Reported in the October issue of Pediatrics.

There is sharp controversy over how effective steps to reduce household dust mite exposure really are for asthmatics. A study reported in the British Medical Journal concluded that dust mite control measures "...seem to be ineffective and cannot be recommended as prophylactic treatment for asthma patients sensitive to mites." But there were criticisms of the study methods and a spokesperson for the American Academy of Allergy, Asthma and Immunology warned that asthmatics "should absolutely not stop taking dust mite avoidance measures as a result of this study." Clinically, these programs done correctly seem to help some of our patients; I will come down on the side of dust mite allergen elimination until a better study comes along.

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