PedSPAM September 2000

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

In the News

A Finnish study presents pretty clear evidence that pacifier use is associated with increased ear infections. Parents of children less than 18 months old were either given a leaflet explaining the harmful effects of pacifier use and given explanation of this by the health nurse, or not. Children who did not use a pacifier had one third fewer ear infections than those who did. Pediatrics 2000; 106:483-488

This study reconfirms others that have found similar results. So there goes my old slogan, "Better a binky than a pinky." I guess I will have to admit, there is not much good to be said for pacifiers any more. But as John Maynard Keynes said, "When the facts change, I change my mind. What do you do?"
The research protocol did allow for letting the children fall asleep with the pacifier, then removing it. This is technically OK, but labor intensive for the parents. It also absolutely requires that the parents get rid of the pacifier by around 5-6 months at the latest, or there will be a real risk of reinforcing behavioral night waking and crying which begins around 6-7 months. Weighing the factors, I think no pacifier right from the start is probably the best solution in general. I have more to say about pacifiers in my Encyclopedia.

Pregnant mothers pass immunity to measles on to their fetuses, which protects them for the first few months of life. This immunity also interferes with the effectiveness of measles immunization. Almost all women currently of childbearing age were never exposed to natural measles, but were immunized instead. Their levels of immunity are lower than that of mothers who had true measles infection in the past, and the interference effect with measles vaccination is less in mothers today. For this reason, you will see the measles vaccination recommendations change over the next few years; the vaccine will probably be shifted from the 12-15 month range to as young as 9 months.

Researchers in the UK find that teenaged girls with low iron levels have lower IQ scores than those with normal iron levels. These findings will be published in the Spring issue of The Nutrition Society 2001, published by the UK Department of Health. Reuters

These findings could have many explanations, so a direct causative link is not established. However, there are plenty of other good reasons to ensure that growing teenaged girls receive iron and vitamin supplementation, given their often spotty diets.

A study finds that the parents of the majority of uninsured children in the US are eligible for state assistance. Existing programs cover seven million of the eleven million uninsured children in the US, but their parents are more often than not unaware of the fact.

A study of a very large number of Australian twins shows that nicotine dependence may be linked to the risk for alcohol dependence. The researchers speculate that some effect of nicotine may increase alcohol tolerance and thus lead to increased alcohol consumption and eventually alcoholism. Reuters Health.

Montelukast (Singulair®) is helpful to provide protection for young asthmatic children from asthma attacks precipitated by cold air, says a Finnish study. (Who better to study cold air challenges?) This study reaffirms the scientific basis for the very positive experience we have had treating asthmatics in this country with leukotriene inhibitors. Leukotrienes are hormones that aggravate inflammatory responses, and are especially important in asthma - an inflammatory disease of the lung. Singulair® has proven to be very safe, as well. The FDA has approved its use in children down to age 2. American Journal of Respiratory and Critical Care Medicine 2000;162:187-190.

Cochlear implants work best if implanted early, say UK researchers. They found that children who were younger at the time of implantation and those who primarily used oral communication (as opposed to signing) improved even more than others. Because early intervention does appear to be a key factor in the success of this procedure, the researchers feel their findings support the implementation of universal neonatal screening programs for deafness. Lancet 2000;356:466-468.

Whether they have specific reflux symptoms or not, gastroesophageal reflux may be common in asthmatics. A study in adults showed a significant number of patients with asthma have significant reflux. Gastroesophageal reflux, which may have minimal or no overt symptoms, has been shown to be potential trigger of asthma due to aspiration of small amounts of stomach contents into the lungs. American Journal of Respiratory and Critical Care Medicine 2000;162:34-39.

Asthmatic children who show any signs of reflux should probably have attention turned to this condition. "Refractory" asthmatics - those difficult to manage with aggressive, up to date care - should certainly have some evaluation of the possibility that silent reflux is part of the problem.

According to Danish researchers, approximately 30% to 40% of sudden infant death syndrome (SIDS) cases might be avoided if women stop smoking during pregnancy. They surveyed mothers during pregnancy about smoking habits and then monitored the outcomes of their babies. Babies of mothers who smoked during pregnancy had three times higher risk of SIDS. The researchers concluded that their findings confirmed earlier reports strongly linking a risk of SIDS with maternal smoking. Archives of Disease in Childhood 2000;83:203-206.

Rabies prophylaxis is often given or withheld inappropriately, according to an infectious disease expert. Dr. Gregory J. Moran Olive View-UCLA Medical Center, Sylmar, California, reported that his research group found that in a large sample of patients treated for animal bites (4 out of 5 of them dog bites), 40% of those who received rabies shots did not need them. Treatment was judged inappropriate when the animal was available for observation, and rabies was not known to be endemic in the area. On the other hand, treatment was withheld from about the same number of patients who should have received prophylaxis, usually because the animal was not available for observation. the good news was that 90% of the cases were handled appropriately. He cautioned that while dog and cat bites almost never lead to rabies, there does need to be a low threshold for initiating prophylactic treatment, since rabies infection is fatal. Journal of the American Medical Association 2000;284:1001-1007.

Yet another association with asthma risk: a Scottish researcher working with children in Saudi Arabia found that in addition to a family history of asthma and positive skin test results for allergies, a history of eating at fast food outlets was a significant risk factor for what he termed "wheezy illness." This was also true of the lowest intakes of milk, vegetables, fiber, and certain nutrients, including vitamin E and calcium. He speculated that the rise in consumption of fast food (with the overall deterioration in quality of diet) might account for the observed rise in asthma in urban areas over the last few decades. Thorax 2000;55:775-779.

There's an odd one!

Amitriptyline (Elavil®) reduces the frequency and severity of headaches in children, according to results of a recent study. Children with chronic headaches were given the medicine at a quarter of the final dose, increasing every two weeks to the full 1 mg/kg. Headache frequency was cut in half and severity was reduced significantly. The medicine was given as part of a more extensive headache management program, including medications to stop developing migraines as well as biobehavioral techniques. Headache 2000;40:539-549.

Finnish researchers found that a low-fat, low-cholesterol diet in infancy does not alter normal nervous system development, as had been maintained in an earlier study. They conducted a five year study with intervention beginning at 7 months of age to teach one group of parents about low-fat, low-cholesterol diets. The other group received no such intervention. Children in the low-fat intervention group had 3-5% lower cholesterol levels at 5 years, and had equally good or slightly better developmental scores compared to the control group. Journal of the American Medical Association 2000;284:993-1000.

Since proper nutrition is essential to brain growth and development, and fat is an important dietary component, whether fat restriction in childhood was healthy for the developing brain has been a concern. This study allays some concerns raised by an earlier one. Severe dietary restriction is still highly inadvisable, but moderate fat restriction to prevent later atheroschlerotic disease in adulthood seems to be quite healthy in all other aspects as well.

Children who are treated with allergy shots for hay fever seem to be much less likely to develop asthma later in life. So say findings presented at a conference sponsored recently by the American College of Allergy, Asthma, and Immunology. Children ages 6 to 14 years old were followed for 5 years. Those not on allergy shots were two and a half times more likely to develop asthma than those on the shots.

In another asthma-related story from the same conference, a monoclonal anti-IgE antibody, called omalizumab or rhuMAb-E25, was announced. It appears to be safe and may be effective in children with asthma. IgE is the class of antibodies that mediate allergic disease. The monoclonal antibody neutralizes these allergic antibodies. A study of school-aged children with moderately severe asthma showed some remarkable remissions of disease, with many children able to completely stop steroid use (steroids are a mainstay of asthma management).

The drug was reported to be very safe, and sounds to me that it will be another big step forward in asthma management for both children and adults. It is interesting to compare this story with the one just above about allergy shots. The purpose of allergy shots is to trick the body into forming blocking antibodies against antigens; the monoclonal antibody attacks the problem by a slightly different approach - blocking the body's antibody response to the antigen.

Sexually active inner city adolescent girls have an "extraordinarily high" rate of carriage of human papilloma virus (HPV). Ninety percent of girls tested were positive for the virus, which is strongly linked to cervical cancer. This is truly depressing. This is more documentation of the adverse health effects of low socioeconomic status and sexual promiscuity. Pediatric Infectious Disease Journal 2000;19:722-728.

If you like to take your young child out for a bike ride with you, it is safer to use a bicycle-towed trailer than a child bicycle seat. It is still important that the child wear a helmet in the towed trailer. Archives of Pediatric and Adolescent Medicine 2000, 154:351-353.

Answering the question, can the rash from zoster (shingles) after the Varivax® chickenpox vaccine transmit chickenpox: yes. Five months after chickenpox vaccination, a child developed zoster. A sibling developed a mild case of chickenpox, and viral typing proved it was the same virus type as the vaccine. Pediatrics 2000;106(2)

This finding is of curiosity nature only because of its rarity and the detail of scientific documentation; the vaccine is safe and effective and still highly recommended. Overall, the risk of later shingles has been found to be lower with the vaccine than natural chickenpox.

Chocolate is good for you! Findings presented at the 22nd congress of the European Society of Cardiology showed that certain substances (flavonoids) in cocoa may help protect from cardiovascular disease. These substances appear to raise prostacyclin levels and decrease leukotrienes (inflammatory hormones). Prostacyclin promotes blood vessel dilatation, inhibits platelet clumping and the formation of blood clots, and reduces the entry of LDL-cholesterol into the arterial wall to form plaques. But wait - it gets better! The fats in cocoa butter are such that there is little if any increased cardiac risk associated with them.

Head lice infestations are overdiagnosed both by the public and by physicians. A study by researchers at the Harvard School of Public Health, Boston, Massachusetts involved having doctors, nurses, and lay people to submit specimens taken from children thought to have head lice. A third of the samples contained no lice or eggs, and only half contained lice or viable eggs. Pediatric Infectious Disease 2000;19:689-693.

Yes, it is that time of year again: head lice hysteria time. Unfortunately, children are
overdiagnosed - every dandruff flake is a monumental crisis
treated willy-nilly - subjected to treatment after treatment with one over-the-counter or prescription
made into social pariahs - one nit known or even suspected is grounds for exclusion from some schools
Head lice are a nuisance, not a plague. They cause itching. They do not carry diseases. A little sanity is sorely needed here! Head lice should be treated only if
there are live lice discovered
there are viable eggs
Viable eggs (or "nits") lie firmly attached within about an eighth of an inch of the scalp on the hair shaft, and cannot be slid along the shaft. Nits that are more than 1/4 inch distant from the scalp surface have already hatched or are dead! Debris that slides along the hair shaft is probably dandruff. It does not warrant treatment, and certainly not exclusion from school or day care.

A new stool test for Helicobacter pylori (H. pylori) infections in children is a simple and non-invasive alternative (read: no gastroscopy or blood test) for diagnosing these infections. It compares very well with the current standard, the 13-C urea breath test, which is not readily available for testing in many areas of the country. A negative stool test is highly reliable for establishing the absence of disease. Archives of Disease in Childhood 2000;83:268-270.

Vitamin E is beneficial in the chorea (involuntary rapid, jerky, writhing movements) of rheumatic fever. The vitamin was studied because it has shown some value in the treatment of Parkinson disease and other movement disorders. "Vitamin E is safer than the conventional drugs used for chorea," the investigators concluded. "Its role needs further evaluation." Indian Journal of Pediatrics 2000;67:563-565.

Changes in toilet training may account for increased voiding problems in children, say researchers in Belgium. They compared toilet training methods of 40 years ago with those of today. They comment: "Most authors are convinced that the development of bladder and bowel control is a maturational process which cannot be accelerated by toilet training." But the present findings contradict this theory, according to the authors. "At 18 months, 71% of the children trained 60 years ago were 'drilled' to be dry and clean, but only 17% were when trained by today's group of parents." In the past, parents were also much more likely than today's parents to use a potty chair with a hole in the seat to help toilet-train the child. For the most part, younger parents in this study used standard toilets, usually without the help of a reducing seat or support for the feet. The investigators conclude 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.

I find this interesting. Attitudes about parental directivity in toilet learning seem to be slowing swinging back to a more centrist view after years of really quite permissive, laissez faire advice from doctors. Today's theories are of course a legacy of reaction to earlier advice which came to be characterized as "harsh toilet training," and blamed for all sorts of psychological woes.

The drug hydroxyurea is safe and effective in young children under the age of 5 years with sickle cell anemia. Treatment with the drug increased hemoglobin levels, reducing hospital admissions and the need for transfusions. The researchers expressed hope that starting hydroxyurea therapy early in children with sickle cell disease may help to prevent the progressive organ damage associated with this condition. "If hydroxyurea proves to be safe in [even] younger children with sickle cell disease, its use could have a significant impact on acute complications and chronic organ damage in patients with sickle cell disease." Journal of Pediatric Hematology and Oncology 2000;22:330-334.

This is simply a terrible disease, something that those who have not had an affected family member or cared for an affected patient cannot comprehend. Advances in new drug therapy and ultimately stem cell transplantation and gene therapy will conquer it not a day too soon.

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