PedSPAM September 1999

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

In the News

Say goodbye to the oral polio vaccine. In July, the CDC issued recommendations to go to an all-injectable schedule of polio immunization (as predicted in PedSPAM for January 1999). There had been fear that the switch to the "sequential" schedule (first two immunizations injectable, then oral at 18 months and 5 years) would lead to a drop in immunization rates. That has not happened; parents apparently accept the new schedule.

Deaths due to child abuse may be seriously under reported in the United States according to a study of child homicides in North Carolina. The state records system underrecorded the coding of child deaths due to battering or abuse by 59%. The researchers found that "caregiving males, biological parents and caregivers of children under one year are the most common perpetrators of fatal abuse," and that "strangers were responsible for only 3% of all child homicides in North Carolina in this 10-year period." Journal of the American Medical Association, August 4, 1999;282:463-467

Among children, bullies, not just those who are victims of bullies, are at increased risk of depression, suicidal thoughts and psychosomatic symptoms. Half of all bullies are also victims of bullying, "and this group who experiences both sides of bullying is most in need of attention," conclude researchers reporting in the August 7th British Medical Journal. BMJ 1999;319:330,344-351

Findings published in the August issue of Pediatrics show that rather than put children at risk for subsequent drug abuse, treatment of ADHD with stimulant medications (Ritalin®, Adderall®, etc.) lowers the ultimate risk of drug dependency and abuse later in life. Pediatrics 1999;104.e20

The Back to Sleep program has been very successful in reducing the number of SIDS cases in the US but has resulted in "an epidemic of plagiocephaly," according to Dr. John M. Graham, director of the Craniofacial Clinic at Cedars-Sinai Hospital in New York City. Plagiocephaly is flattening of the back of the head. In the past, it was most often associated with torticollis, a shortening of the strap muscle of the neck on one side. The incidence of the diagnosis in infants has risen from 1 in 300 live births to 1 in 60. Plagiocephaly is important to pick up upon. Either it is caused by habitual sleep positioning, and can be treated by simple repositioning maneuvers, or it is due to torticollis, which is treated most successfully in the first year of life with physical therapy or sometimes minor surgery. (Reuters Health)

Fallout continues from the previously reported problem of increased risk of intussusception associated with administration of the Rotashield® rotavirus vaccine. The Food and Drug Administration is now also investigating preliminary reports of intussusception that may be related to the oral polio vaccine (also rapidly going out of use in this country). The Association of American Physicians and Surgeons has urged Congress to start an inquiry into the FDA's vaccine approval process The AAPS is concerned that the RotaShield© experience may indicate problems with the system of vaccine approval. (Reuters Health)

Metered-dose asthma "rescue" inhalers should be exempted from the "zero tolerance" drug policies of many American schools. An article in the American Academy of Pediatrics AAP News, September 1999 warns pediatricians that the now common policy of not allowing children to possess medications of any kind on school grounds can seriously hinder an asthmatic child's access to critically needed asthma medication during school, with potentially disastrous consequences. Parents of asthmatic children who need rescue inhalers should work with their pediatricians to get permission for the child to carry the inhaler at all times to prevent delay.

British researchers found no link between the MMR (measles-mumps-rubella) vaccine and autism. There has been an increase in the prevalence of the diagnosis, but there was no correlation found between administration of the vaccine and subsequent diagnosis of autism. The investigators attribute the steady rise in the prevalence of the diagnosis to better recognition of the disorder. Lancet, 1999;353:2026-29

According to a study published in the Journal of the American Academy of Child and Adolescent Psychiatry, contrary to popular belief, stimulant medications for ADHD (attention deficit hyperactivity disorder) are underprescribed rather than overused for American children. They found that in a survey of 1,285 children from three states and Puerto Rico, 5% met the published criteria of the National Institutes of Health for ADHD. JAACAP 1999;38(7):797-804

A rubella ("German measles," "three day measles") outbreak in three midwestern states has reached at least 116 known cases. Most cases involved meat packing workers from Central and South America, where routine immunization for rubella is not done. Some centers of small outbreaks occurred in children in day care who were too young to have received the rubella immunization, but had no known contact with the meat packing industry.Rubella in adults is not a serious illness per se, but if a women contracts the disease in the first trimester of pregnancy the illness can be devastating for her child. Congenital rubella syndrome can lead to deafness, blindness, serous heart defects, mental retardation, or fetal death. Symptoms of rubella include a rash that usually starts behind the ears, swollen lymph nodes in the head and neck region (classically behind the ears - that is "postauricular"), and pain in the finger, knee and other joints.

Babesiosis is a malaria-like tick-borne disease caused by the protozoal (one-celled) parasite Babesia microti. The primary endemic area of babesiosis in the United States lies along the northeast Atlantic coast, centering around Nantucket Island, Martha's Vineyard, Cape Cod, Massachusetts; Long Island and Shelter Island, New York. It has now been reported in three patients in New Jersey, which is now considered to be a new endemic area. Symptoms can include fever, fatigue, muscle aches, headache, and joint pain. The illness can be mistaken for Lyme disease, and if treated with the standard antibiotic for Lyme disease infection (doxycycline), the patient may show some improvement. Accurate diagnosis and complete treatment is important, because if only partially treated, the parasite can remain in the body for months to years, and the disease can recur. Complete eradication of the parasite requires treatment with two antimicrobials, clindamycin and quinine together. Infectious Diseases in Children, September 1999.

The Food and Drug Administration (FDA) now is warning us to avoid eating uncooked clover and alfalfa sprouts. They can carry Salmonella germs and have caused at least 223 people to become ill following clover sprout consumption, and anther 85 were sickened by alfalfa sprouts. Sprouts should not be served in day care centers or school lunch programs. Infectious Diseases in Children, September 1999.

Say goodbye to needles for immunizations? Maybe. A new technology of transdermal immunization is described in this month's Pediatric Infectious Disease Journal. Immune receptive (Langerhans') cells are found in the epidermis, the topmost layer of the skin. Antigens applied to the skin need only penetrate to reach these cells to trigger an immune response in the body. Previous attempts at needle free administration - notably air guns that force a jet of vaccine through the epidermis into the deeper layer of the skin - have been hampered by the fact that the skin is a good barrier to the large molecules needed to trigger immunity. The transdermal patch system

Exclusive breast feeding (meaning avoidance of formula supplementation) for at least the first four months appears to significantly reduce the risk asthma developing by age six in children, according to a study out of Australia reported in the British Medical Journal. The researchers did not address supplemental cereal or solid feedings. British Medical Journal 1999;319:815-819.

The FDA has now approved zafirlukast (Accolate®) for asthma therapy in children down to age seven, as opposed to the earlier lower limit of age 12. The recommended dosage for children aged 7 to 11 is now one 10 mg mini-tablet twice a day. The tablet is said to have no flavor. Zafirlukast is one of the new class of leukotriene receptor blockers that block the body'inflammatory response to asthma triggers such as allergens, cold, or viral infection. (Reuters Health)

Abbott Laboratories has recalled its drug pemoline (Cylert®) in Canada over concern for potentially severe side effects involving the liver. Since its introduction in 1975, there have been 16 cases of severe liver toxicity traced to Cylert®. The drug has not been withdrawn in the US, but American physicians have been alerted to monitor for potential liver toxicity, and warned that side effects may not appear for months after starting the drug. The drug will still be available in Canada through Canada's Special Access Program. (Reuters Health)

Personal Note: My surgery went very well and I have been back at work full steam for two weeks. Many thanks for your personal best wishes. The recuperation time at home finally gave me a chance (or an incentive at least) to begin serious work on my book. Some day... 8-)

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