August 2011 Journal Watch

Allergy / Immunology:

Baroody, FM et al. Oxymetazoline adds to the effectiveness of fluticasone furoate in the treatment of perennial allergic rhinitis. J Allergy Clin Immunol 2011;127:927-34.
Summary and Implications For Your Practice:
This study evaluated whether the effect of the combination of fluticasone furoate with oxymetazoline was more effective than either agent alone and whether rhinitis medicamentosa developed after treatment. Sixty patients ages 18 to 55 years with perennial allergies were enrolled in this double-blind, placebo-controlled study and randomized to 4 weeks of once-a-night fluticasone furoate, oxymetazoline hydrochloride, the combination, or placebo. They were monitored using total nasal symptom scores and acoustic rhinometry during the treatment and 2 weeks after. The combination group had significantly lower total nasal symptom scores and better acoustic rhinometry scores during and after the 4 week treatment than the placebo or oxymetazoline-alone groups. A non-significant improvement was seen in the fluticasone furoate-alone group. There was no evidence of rhinitis medicamentosa. Therefore, it appears the addition of oxymetazoline adds to the effectiveness of fluticasone furoate without the negative side effect of rhinitis medicamentosa. However, this is a very small study using an adult population. A large, multi-center study involving children with allergic rhinitis would be beneficial at this point.
Submitted by: Kim Blazerr

Dermatology:

Lovett A, et al. Large congenital melanocytic Nevi and Neurocutaneous Melanocytosis: One Pediatric Center's Experience. J Am Acad Dermatol. 2009 Nov;61(5):766-74.
Summary and Implications For Your Practice:
Large congenital melanocytic nevi (LCMN) are almost invariably a stunning experience for a family when a child is born. It is also a condition that should be carefully evaluated in terms of risk for central nervous system involvement. In this study the authors did a retrospective chart review of 52 patients with LCMN. Only 26 had imaging done, and of those 6 (23%) had neurocutaneous lesions. The ones that had neurocutaneous melanocytosis (NM) were more likely to have satellite lesions or a posterior midline location. This study aids in the discussion with new parents about possible outcomes for their child. The recommendation of this specific set of authors is that MRI should be performed by 4 months of age for those at higher risk of NCM. It is however controversial because there is currently no treatment. MRI should be done only after thoughtful discussion with the family.
Submitted by: Gabrielle Lapping-Carr

Endocrine:

Hassan, K., Heptulla, R. Glycemic control in pediatric type 1 diabetes: role of caregiver literacy. Pediatrics May 2010;125(5):e1104 -e1108.
Summary and Implications For Your Practice:
This article hypothesized that a patient’s Type 1 Diabetes control may be related to the level of literacy of the primary caregivers of the patient. The authors acknowledged that when children are initially diagnosed with Type 1 Diabetes, their parents are initially flooded with a great amount of new material to learn. A certain amount of mathematical skill is required to calculate insulin doses and carbohydrate ratios. Caregivers were evaluated with a tool called Newest Vital Sign, which is a screening tool that identifies people at risk for low health literacy. It assesses general literacy as well as mathematical skills by asking a person questions based on the nutrition label from an ice cream container. Not surprisingly, a significant correlation was found between literacy levels of caregivers and the patients’ HbA1C. There was also a correlation between increased levels of caregiver income and better HbA1C. I do think that there was probably not only a link between literacy levels and HbA1C, and separately income and HbA1C, but a much interconnected relationship in which many related factors contributed to HbA1C. I think that this study can be expanded to many of our patients with other illnesses, not just those with diabetes. While diabetes definitely is one illness with a pretty good amount of math skills required, even something as simple as dosing a medication can be difficult mathematically for a parent who has little to no math skills. We ask parents to do things such as limit their child’s sodium to 2000 g daily, but what if a parent cannot add numbers up to 2000? This problem is probably more common than we might think and should always be in the back of our minds as a possibility.
Submitted by: Jackie Hatch

General Pediatrics:

Huh SY, et al. Timing of solid food introduction and risk of obesity in preschool-aged children. Pediatrics 2011;127:e544-551.
Summary and Implications For Your Practice:
Obesity is the leading public health challenge facing children today and has become more prevalent among preschool-aged children. The first few months of life may be a critical window for risk of obesity due to parental feeding practices. This study looked at early introduction of solid foods between breast and bottle fed children and risk of obesity at age 3. This was a prospective cohort study that looked at age of introduction of food along with breast or formula feeding. They found that in the first four months, 67% were breastfed and 32% were bottle fed. At 3 years 9% were obese. Among breast fed infant, timing of introduction of solids foods prior to 4 months had no association with obesity but in the formula-fed group introduction before 4 months had a six-fold increase in obesity at age 3. 7% of breastfed vs. 13% of formula fed children were obese at age 3. This study is relevant because the majority of our RAP patients are formula fed and some are getting solids prior to 4 months. This could be a good counseling point as obesity is also becoming a problem in our clinic.
Submitted by: Rachael Zanotti

Esernio-Jenssen D. Abusive head trauma in children: a comparison of male and female perpetrators. Pediatrics 2011;127(4):649-657.
Summary and Implications For Your Practice:
Abusive head trauma (AHT) can lead to long-term neurological and developmental problems. Estimates of incidence range from 14.7-40.5 per 100,000 children. Males are frequently identified as the perpetrators but females may be underestimated. This study looked at the effect of perpetrator gender on victim presentation and legal outcomes for AHT. This was a retrospective chart review of AHT from 1998-2008. 34 cases were identified. Mean age of victim was 9.4 months. 32 had intracranial hemorrhage, 28 had retinal hemorrhage and 6 died. The median age for female perpetrators was 34 years and the median age for males was 27 years. Six areas were more prevalent with male perpetrators—acute presenting symptoms of cardiopulmonary arrest, worse clinical outcome, neurosurgical intervention, death, perpetrator confession and conviction. 82% of males were convicted while just 30% of females were convicted. In summary, this study showed significant gender differences in AHT.
Submitted by: Rachael Zanotti

Lazzerine, M et al. Oral zinc for treating diarrhea in children. Sao Paulo Med J. 2011:129(2):118-9.
Summary and Implications For Your Practice:
This is a review which evaluated the effect of zinc supplementation for treating children ages 1 month to 5 years with acute or persistent diarrhea including dysentery. The Cochrane Library, EMBASE, MEDLINE, LILACS, CINAHL, mRCT, reference lists, and researchers were searched in November 2007. Articles were included in the study if they were randomized, placebo-controlled trials comparing zinc supplementation at greater than 5mg/day for any duration. Diarrhea duration and severity were the primary outcomes. Eighteen trials including 6165 patients met inclusion criteria. In acute diarrhea, zinc resulted in shorter diarrhea duration and less diarrhea amount on days 3, 5, and 7. Patients who received zinc did vomit more (RR 1.7), but no other adverse effects were found. Thus, it appears that in areas where diarrhea is an important cause of child mortality, children may benefit from zinc supplementation during acute diarrhea.
Submitted by: Kim Blazer
Comment: Some evidence suggests that the beneficial effects of zinc are not limited to zinc deficient children and are not dependent on zinc absorption, and also that zinc may have pathogen specific effects – studies in developed countries would be welcome. LF

Ogbuanu C, et. al. The effect of maternity leave length and time to return to work on breastfeeding. Pediatrics 2011; 127;e1414-1427.
Summary and Implications For Your Practice:
The American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of age. A mother returning to work is a big factor in noncompliance with this recommendation. This study looked at the effects of maternity leave length, paid maternity leave length and time of return to work as factors in length of breastfeeding. The authors found that 69.4% of mothers initiated breastfeeding with 36.5% breastfeeding for greater than 6 months and 26.4% breastfeeding for greater than 3 months. The average time to return to work was 12 weeks. Women who took greater than 13 weeks of leave had the highest rate of initiation of breastfeeding. Those who had paid maternity leave also had higher rates of initiation. There was no difference in duration of breastfeeding according to total or paid maternity leave length but the highest proportion of mothers still breastfeeding at 9 months were those who had not returned to work and the lowest was in those who returned to work in 7-12 weeks. This study shows that returning to work can shorten the duration of breastfeeding and that longer durations of leave may lengthen time of breastfeeding. However, in today's world where delaying return to work in many cases is not possible, this should not be used to deter mothers from initiating and continuing breastfeeding.
Submitted by: Rachael Zanotti

Shields BJ, Pollack-Nelson C, Smith GA. Pediatric submersion events in portable above-ground pools in the United States, 2001-2009. Pediatrics July 2011;128(1):45-52.
Summary and Implications For Your Practice:
Drowning is one of the leading causes of morbidity and mortality in children and many of these incidents occur in private backyard swimming pools. Within the past several years, new portable swimming pools have become more common although safety risks associated with these pools have not been thoroughly studied. This study was a retrospective analysis of fatal and non-fatal drowning incidents involving portable swimming pools in the United States between 2001 and 2009 using four databases maintained by the U.S. Consumer Product Safety Commission. A total of 244 drowning incidents (209 fatalities) involving portable swimming pools were reported involving water depths ranging from 2 inches to 4 feet. Children less than 5 years were involved in 94% of incidents, and 73% of events occurred in the patient’s own backyard. Moreover, several events occurred despite the presence of a pool cover or in children who managed to slip out of flotation safety devices. The authors acknowledge that this analysis is not comprehensive because all drowning incidents may not be reported to the safety commission and thus this study likely provides an underestimate of the morbidity and mortality associated with portable pools. Overall, this data demonstrates the importance of anticipatory guidance regarding portable backyard swimming pools during health supervision visits. Families with these pools should be instructed to empty and safely store the pool after each use or to use appropriate fencing if pool remains full. In addition, adult supervision is needed at all times and strategies to prevent children from slipping into pools unsupervised should be discussed.
Submitted by: Lindsay Burrage
Comment: I agree whole-heartedly that this is an extremely important safety topic to discuss at WCC visits. Parents may become complacent about small pools, inflatable pools, and even bathtubs, but as this study points out, children can drown in only a few inches of water. LC

Schmidt RJ, Hansen RL, Hartiala J, et al. Prenatal vitamins, one-carbon metabolism gene variants, and risk for autism. Epidemiology. 2011;22(4): 476-485.
Summary and Implications For Your Practice:
In this population-based case-control study, children ages 24-60 months were classified as typically developing (278 children), autistic (288 children) or autistic spectrum disorder (144 children). Via phone interview, retrospective data were collected about whether and when the mother took prenatal vitamins and multivitamins both preconceptually (defined as 3 months prior to conception) and throughout the pregnancy. Common one-carbon metabolism gene variants were selected based upon existing research, and genotype data were collected from all family members. Odds-ratios were calculated for associations between autism and maternal vitamin intake. These were adjusted for identified confounding factors of maternal education and child’s year of birth. Even after adjustment, prenatal vitamin intake preconceptually and during the first month of pregnancy was associated with a lower risk for autism. Similar associations were not identified for prenatal vitamin intake during the rest of the pregnancy or multivitamin intake at any point. Interactions were identified for autism between the absence of periconceptional prenatal vitamins and maternal genotypes of MTHFR 677 TT and CBS rs234715 GT + TT. Children with genotype COMT 42 were at a much higher risk for autism if their mothers had not taken prenatal vitamins. Overall analysis demonstrated that the risk of autism was significantly greater for children with the combination of mothers who did not take prenatal vitamins periconceptually and any of the aforementioned gene variants than with the risk of either exposure alone, thus suggesting a gene-by-environment interaction for autism. This type of study demonstrates only correlation, not causation. However, in practice it would be prudent to recommend to women considering having children that they begin taking prenatal vitamins. It would be especially important to recommend to mothers of children with autism who are considering having another child. In this situation, it would be important to inform the mother of the finding of the study without placing blame on or inducing guilt in her if she did not take prenatal vitamins periconceptually with the autistic child.
Submitted by: Renee Willett

Zhang et al. Feeding of dietary botanical supplements and teas to infants in the United States. Pediatrics. June 2011;127:1060-1066.
Summary and Implications For Your Practice:
This study used data from the Infant Feeding Practices Study to look at the practice of giving infants dietary botanical supplements or teas in the first year of life. The purpose of the study was to look at the prevalence of use of these products and to find out something about the caregivers who use them. Obviously, these products are inconsistently regulated and have the potential to be contaminated, cause drug interactions or possibly even be helpful, but data on this are limited. The common factors associated with caregivers that gave these products (like gripe water, chamomile, teething tablets, etc) were primiparous, married women with higher income levels. The Midwest was the region where these supplements were the least common. Most mothers stated that they gave these for fussiness, digestion, colic, and relaxation. Overall, approximately 9% of infants were fed some dietary supplement or tea. In general, enough parents use supplements that it is worth asking parents if they use any botanical agents. There are not many studies looking at the efficacy of things like gripe water for colic that I could find, but the studies I saw did not suggest that there were any real dangers. The real danger is whether or not there are contaminating ingredients (like heavy metal) that parents are unwittingly giving their children. I also would suggest parents not give their child tea as a beverage simply because of caffeine content.
Submitted by: Sarah Youssef

McGowan JE, Alderdice FA, Holmes VA, Johnston L. Early childhood development of late-preterm infants: a systematic review. Pediatrics 2011;127(6):1111-1124
Summary and Implications For Your Practice:
Late-preterm infants (born at 34-36 weeks gestation) are considered at risk for adverse developmental outcomes, but few studies have looked at early childhood development of this group. Late-preterm infants account for 75% of all preterm births. From 1990-2006, a 25% increase in late preterm births occurred. A systematic review of the literature revealed that early childhood outcomes in late-preterm infants are not well studied. The authors looked at ten studies following development of late-preterm infants up to the age of seven years, only four of which focused solely on the late-preterm infant category. In these studies, late-preterm infants up to age seven consistently had lower school performance than their term peers and required more special education and academic support. Also consistent in the studies, late-preterm infants performed more favorably than their very-preterm peers. The authors suggest there is a continuous relationship between decreasing gestational age and increasing risk of developmental disabilities and poor academic performance. This relationship suggests that late-preterm infants may have more subtle than severe developmental issues. This article should encourage pediatricians to monitor for mild developmental disabilities in late-preterm infants during preschool years as this could help identify and alleviate potential learning difficulties at school age.
Submitted by: Brittany Massare
Comment: This is helpful information for clinicians that makes intuitive sense; however, additional prospective studies that use non-admitted controls matched for gestational age and comprehensive outcome measures will be welcome. LF

Dempsey, et al. Behavior in early adolescence and risk of human papillomavirus infection as a young adult: results from a population-based study. Pediatrics 2008; 122(1):1-7.
Summary and Implications For Your Practice:
The objective of this study was to see if Human Papillomavirus (HPV) risk could be determined by examining early adolescent behaviors, allowing the Gardasil vaccine to be targeted to certain women preferentially. Using the National Longitudinal Study of Adolescent Health (Add Health), this study examined 3181 teenage women using a prospective design, following the women’s responses to questionnaires over several years and determining their HPV status at the end of the study. The results showed that adolescent sexual activity status and participation in other “risky” behaviors were not correlated with risk of HPV infection later in life. While the study had limitations including the transient nature of HPV infections and the potential for women to change risk groups during the course of the study, additional calculations were made to adjust for these factors which did continue to support the study’s overall conclusions. I was searching for an article to help me communicate with parents who are hesitant about vaccination for HPV because it is sexually transmitted. I believe the information in this article gives me evidence to tell parents that sexual activity status at a young age and even other risky behaviors may not correlate well with their lifetime risk for HPV infection. Thus, it is important to vaccinate everyone and not just supposedly “at risk” teens.
Submitted by: Katherine Swearingin

Pierce, K. et al. Detecting, studying and treating autism early: the one-year well-baby check-up approach. The Journal of Pediatrics 2011;36:1-7.
Summary and Implications For Your Practice:
The importance of early intervention in children with autism spectrum disorders (ASD) has led to routine screening at 18 and 24-month well-child appointments. However, many children still do not receive any intervention until much later. In 2002, the “Communication and Symbolic Behavior Scales Developmental Profile Infant-Toddler Checklist” (CSBS-DPIT) was developed to detect a wide range of disorders, including developmental delay (DD), language delay (LD) and ASD. This study examined the feasibility of screening all 1 year-olds by educating 137 San Diego pediatricians on CSBS-DPIT screening, tracking the number of total screenings completed and referring all patients who failed the screen for further evaluation and treatment. All patients who failed the initial screen were re-evaluated every 6 months until age 3, when final diagnoses were established. 10,479 patients (mean age: 12.54 months) were screened. 1318 (12.5%) children failed the screening, 346 were referred for further evaluation and 184 patients completed follow-up (32 with ASD, 56 with LD, 9 with DD, 36 with “other” and 55 false positives). Based on the data collected, the positive predictive value of the CSBS-DPIT for detecting DD, LD or ASD was 75%. This is a free screening tool that can be completed at the 12-month visit, but may be difficult to implement in busy clinics, and concern for reliable follow-up must be considered. There is a risk of increased false positives, but it may be outweighed by the potential for early intervention in kids with ASD, LD and/or DD, which will greatly benefit their future.
Submitted by: Julie Abraham
Comment: It seems that this screening test may be useful for detecting delay in general, but it does not seem specific to autistic spectrum disorders. It would be interesting to compare this screening tool to the PEDS screen that we are currently using in clinic. LC

Wilkinson, P. et al. Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the adolescent depression antidepressants and psychotherapy trial (ADAPT). Am J Psychiatry 2011;168(5):495-501.
Summary and Implications For Your Practice:
Psychiatric disorders are present in 90% of adolescents who commit suicide, with major depressive disorder (MDD) being the most common single disorder. Teens with previous attempts are 60 times more likely to commit suicide. Other elements, such as non-suicidal self-injury (i.e. cutting), are also being studied as strong risk factors in future suicidal attempts. In this study, clinical and psychosocial factors in 164 depressed 11-17 year old adolescents were assessed with various rating scales, from baseline to 28 weeks of follow-up, to determine predictability in suicide attempts. Patients were recruited from the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT), meeting DSM-IV criteria for baseline MDD. Self-injury and suicide attempts one month prior to baseline were recorded. 28 teens (17%) made 1+ suicide attempts in the pre-baseline period. 50 adolescents (30%) made 1+ attempts during the follow-up period. Higher risk of suicide attempt was significantly associated with depression severity, hopelessness, impaired family functioning and pre-baseline suicide attempt or self-injury. The results demonstrate that adolescents with pre-baseline non-suicidal self-injury had a 10-fold greater risk of suicide attempt during treatment than those without self-injury. This is the first longitudinal study demonstrating that self-injury is associated with future suicide attempts. Limitations include lack of information on confounding factors (substance use, family history) and generalizability only to depressed adolescents. To treat depression in teens successfully, it is crucial to consider many factors that lead to recovery and reduction of harmful outcomes. Recognizing self-harm, among other factors, as a strong risk of future suicidal attempt allows an opportunity for intervention and should not be dismissed.
Submitted by: Julie Abraham

WRadecki L, Sand-Loud N, O’Conner KG, Sharp S, Olson LM. Trends in the use of standardized tools for developmental screening in early childhood: 2002-2009. Pediatrics 2011;128:14-19.
Summary and Implications For Your Practice:
Approximately 14% of children at 24 months have developmental delays that make them eligible for early intervention services. In 2001 the American Academy of Pediatrics (AAP) recommended that all children should receive standardized developmental screening as part of well-child care. In 2006, the AAP added to their statement, recommending use of standardized developmental screening tools at 9, 18, and 30 month well-child visits. This study looked at changes in developmental screening practices of pediatricians between 2002 and 2009, in response to the AAP’s recommendations. In 2002, 1617 pediatricians were mailed a developmental screening survey and in 2009, 1620 pediatricians received a similar survey. 55% responded in 2002 and 57% in 2009. Use of standardized screening tools more than doubled between 2002 and 2009. Use of specific instruments increased with a significantly greater percentage of responders using the Ages and Stages Questionnaire (ASQ) and the Parents’ Evaluation of Developmental Status (PEDS) in 2009. But, half of pediatricians who responded in 2009 reported not routinely using recommended formal screening tools. Because of the importance, additional research identifying barriers to use of screening tools is needed. Pediatricians are the only professional young children reliably see during the first five years of life; therefore it is our responsibility to assess development with formal screening tools.
Submitted by: Brittany Massare

Kabir Z, Connolly GN, Alpert HR. Secondhand smoke exposure and neurobehavioral disorders among children in the United States. Pediatrics 2011;128(2):e1-e8.
Summary and Implications For Your Practice:
This cross-sectional study analyzed the association between postnatal second-hand smoke (SHS) at home and parent-reported neurobehavioral disorders in children across the US under age 12. Data were collected via a telephone survey about a variety of topics, including neurobehavioral disorders, smoking in the home, socioeconomic status of the child, and people living at home with the child. Neurobehavioral questions included whether the parent had ever been told that the child had ADD/ADHD, a learning disability, or a behavioral disorder such as oppositional-defiant disorder or conduct disorder. Multivariable logistic regression models were used to analyze the data and correct for potential confounders, including poverty, parent education level, race and marital status of the parents. Overall, 6% of the children in the study were exposed to SHS. The adjusted odds of a parent reporting the child had one neurobehavioral disorder were increased 51% if the child was exposed to SHS. Exposed children also had a 50% increased odds of the parent reporting 2 or more neurobehavioral disorders compared to unexposed peers. This study is limited in that the findings only indicate association and not causation. Additionally, the data is parent-reported which may have led to improper classification or recall bias. However, this study is important because it specifically looked at postnatal SHS exposure, whereas many previous studies have looked at prenatal SHS. The study findings reinforce the need to encourage parents to stop smoking, both for their own health and their children’s health.
Submitted by:Renee Willett

Hematology and Oncology:

Sayed HA, et al. Profile of infections in newly diagnosed patients with acute leukemia during the induction phase of treatment. Journal of the Egyptian Nat. Cancer Inst., Vol. 21, No. 4, December: 315-322, 2009.
Summary and Implications For Your Practice:
Patients very commonly present with infections and are found to have leukemia. Within any institution it is crucial to have an idea of what the common infections in the area are. It is also important to keep an open mind, however, because many patients travel across the world for therapies, especially bone marrow transplants. This study, done in Egypt, did a retrospective study of infections in new onset ALL and AML over a 6 month period. They had 100 patients with 348 infections. Gram positive organisms caused 78%, while gram negative organisms caused 19%; the rest were fungal. The spectrum in each group was similar to what we see in the United States. This is somewhat reassuring, but the antibiotic susceptibilities should be evaluated as well.
Submitted by: Gabrielle Lapping-Carr

Ladas EJ, et al. A randomized controlled double-blind pilot study of milk thistle for the treatment of hepatotoxicity in childhood acute lymphoblastic leukemia (ALL). Cancer 2010;116:506– 13.
Summary and Implications For Your Practice:
Treatment of pediatric cancers requires many chemotherapies and antibiotics that are damaging to the liver. This can eventually limit treatment capabilities because of morbidity. Some practitioners use milk thistle to decrease hepatotoxicity although there is not very much data to support this. So, in this study the authors performed a double-blinded study on patients with ALL and hepatotoxicity. Patients were given milk thistle or placebo for 28 days. Milk thistle was not associated with a significant change at 28 days, but was associated with a significant reduction in AST and a trend toward a significant reduction in ALT at Day 56. A larger study needs to be done to show if this can actually limit the need for chemotherapy reduction. If that proves to be the case, milk thistle may be a nice supplement to use in patients that develop hepatotoxicity.
Submitted by: Gabrielle Lapping-Carr
Comment: Google taught me that Milk thistle (Silybum marianum) has been used for some 2,000 years as a remedy for liver and gall bladder disease. The active ingredient appears to be silymarin, which is a group of flavonoids (silibinin, silidianin, and silicristin) thought to have anti-inflammatory and antioxidant properties- certainly more data is worth pursuing. LF

Noll RB, et al. Child-rearing practices of primary caregivers of children with sickle cell disease: the perspective of professionals and caregivers. Journal of Pediatric Psychology 1998;23(2):131-140.
Summary and Implications For Your Practice:
Patients very commonly present with infections and are found to have leukemia. Within any institution it is crucial to have an idea of what the common infections in Illness of a child can be stressful for the entire family. Chronic illness can be exceptionally stressful and can make consistent discipline difficult. This study looked at the reports from parents on how they cared for their children and then surveyed experts to see if they expected the differences between parents of children with sickle cell disease (SCD) and parents of children without a chronic illness. They found that there was little difference between parents of children with SCD and those without regarding how they raised their children (protectiveness, discipline, and extent of worrying). The experts, however, expected there to be a large difference. I think it is important for parents of children with any chronic disease to expect their child to still perform at their best and provide the same structure they would normally. It is a positive finding that patients with SCD have parents that treat them no different than those without. I am concerned, though, that experts are out of touch with that experience.
Submitted by: Gabrielle Lapping-Carr

Infectious Disease:

Mahmud, et al. Maternal and perinatal factors associated with hospitalized infectious mononucleosis in children, adolescents, and young adults; record linkage study. BMC infectious disease 2011; 11(51):1-9. Summary and Implications For Your Practice:
This article discusses the maternal or perinatal factors associated with infectious mononucleosis later in life. The authors conducted a prospective record-linkage study set in the south of England looking at perinatal risk factors for patients hospitalized with infectious mononucleosis. The study involved examining the Oxford record linkage study (ORLS) which includes abstracts of birth registries, maternity and inpatient hospital records for all patients in a defined geographical area. From these records, patients who were hospitalized for infectious mononucleosis up to the age of 30 years were identified. The ORLS maternity record was reviewed and compared to patients who had no hospitalization record for infectious mononucleosis. The results showed that there was a significant association between hospitalized infectious mononucleosis and lower SES (p=0.02) and children with married mothers (p<0.001). There was an almost statistically significant association of infectious mononucleosis with singleton births (p=0.06). Other factors that were investigated which did not increase the risk of hospitalized infectious mononucleosis included low birth weight, lower gestational age, maternal smoking, and late age at motherhood. The authors conclude that it is helpful to know that advanced maternal age does not increase risk for mononucleosis with the current trends for delaying motherhood. They do not have an explanation for the children of married women having a higher risk.
Submitted by: Sophia Chen
Comment: This is interesting and quite peculiar data. It would be interesting to see if this association is true in other countries as well. LC

Nephrology:

Gerson et.al. Health-related quality of life of children with mild to moderate chronic kidney disease. Pediatrics Feb 2010;125(2):e349 -e357.
Summary and Implications For Your Practice:
This article set out to explore the differences in quality of life for children with mild to moderate chronic kidney disease, as compared with healthy control children. The authors had noted that while this was greatly studied in those patients who had advanced to end stage renal disease, it was not often studied in children at earlier stages of kidney disease. The Pediatric Inventory of Quality of Life Core Scales was used, which assesses physical, emotional, social, and school functioning. As would have been predicted, there were statistically significant differences between the children with mild/moderate kidney disease and the control group, with the biggest difference being in school functioning. The authors hypothesized that the children with kidney diseases had the lowest scores in school functioning due to medical appointments or care that often interfered with school time or school work. Interestingly though it was found in this study that the level of kidney disease, as measured by GFR, did not directly correlate with worsening quality of life scores. Also contrary to the authors’ hypothesis, patients who had had chronic kidney disease for longer periods of time were found to be better functioning physically and emotionally, possibly due to the ability to accommodate to the situation over time. While most of the time these children are followed extremely closely by their nephrologists, they still will come to see their primary care doctor for routine care. I think it is important to note that even though they still may be in the earliest stages of kidney disease, and may not outwardly be showing signs of the physical illness, they still may be at risk for lower quality of life. Close attention should be paid to these children’s needs, especially if they need extra help in school or help from mental health professionals.
Submitted by: Jackie Hatch
Comment: Nice summary and nice comments by Dr. Hatch- thank you and I agree. LF

Neurosurgery:

Lipira, et. al. Helmet versus active repostitioning for plagiocephaly: a three dimensional analysis. Pediatrics 2010;126:e936.
Summary and Implications For Your Practice:
Deformational Plagiocephaly (DP) is a common abnormality seen in pediatric clinics. A tenfold increase in this deformity has probably resulted in large part to new recommendations about infants sleeping on their backs. DP is unilateral occipital flattening that can occur with frontal bulging and ear displacement. This study aimed to compare helmet therapy versus active repositioning using three-dimensional (3D) scans. 70 infants were studied, 35 with helmet use and 35 with active repositioning. 3D scans were done before and after therapy. Both groups had similar deformities at the start. After therapy, the helmeted group was found to have a larger improvement in the deformity. This was the first study using 3D analysis. However, it would be interesting to see if the results are the same when the children are several years older. Whether this would change management is questionable because it is unclear what asymmetry is severe enough to treat and I am not sure if the use of 3D scans on all children with DP is cost effective.
Submitted by: Rachael Zanotti
Comment: The authors point out that orthotic helmets are expensive ($1500-$2500) and active repositioning is free. Therefore, insurance companies may not be willing to pay for this treatment option. Studies such as this one may help with this issue. LC

Palliative Care:

Thompson LA, et al. Pediatricians’ perceptions of and preferred timing for pediatric palliative care. Pediatrics. 2009;123(5)
Summary and Implications For Your Practice:
The Institute of Medicine recommends initiating palliative care after the diagnosis of a life-limiting illness to meet a child’s needs. However, the term “palliative care” is often misconstrued and to some carries a negative connotation. In addition, palliative care services are limited in range and coverage. Regardless, the early initiation of palliative care can be crucial to the care for patients with life-limiting illnesses and it is important that physicians understand the definition of and appropriate timing for referral to palliative care services. This study surveyed approximately 300 general pediatricians and subspecialists, most of whom were in outpatient private practice, on definitions of palliative care and when they would refer patients with different life-limiting diseases (including cystic fibrosis, cancer, sickle cell disease, cerebral palsy and others) to palliative care. While most physicians felt that these patients do need counseling and pain/symptom management, nearly 40% of respondents thought palliative care was the same as hospice care. This may explain why nearly half indicated they would refer patients late in the course of disease when the goal was no longer curative. This study shows that many pediatricians practicing in the community are unaware of the definition of and resources for palliative care, which appears to be the reason most would refer late, under the assumption that “palliative” and “end-of-life” are one in the same. Of course, at large academic centers such as Rainbow, where palliative care services are becoming more established, knowledge about their role in pain management helps encourage earlier involvement in chronic disease. A consensus definition of palliative care will likely contribute to increased awareness of the role of these services, thus prompting more knowledge of resources and earlier referral for children who would benefit from these services.
Submitted by: Anandhi Gunder

Pulmonology:

Paul I, et al. Antibiotic prescribing during pediatric ambulatory care visits for asthma. Pediatrics 2011;127:1014-1021.
Summary and Implications For Your Practice:
It is recommended by the National Asthma Education and Prevention Program to not use antibiotics during acute asthma exacerbations or for long term therapy except for patients with documented pneumonia or other bacterial infection. This has been a great area of research in the last several years especially focusing on macrolide antibiotics and their anti-inflammatory effects. This study looked to see how frequently doctors were prescribing antibiotics in an outpatient setting for asthma exacerbations. Frequency of antibiotic use was looked at during years 1989-2007 using data from ambulatory surveys. They found a total of 5198 asthma visits during this time period. Antibiotics were prescribed 15.6% of time without a coexisting diagnosis to support giving these medications, determined by ICD-9 code. 48.8% of antibiotics prescribed were macrolides, 26% were penicillin-derivatives and 20% were cephalosporins. Factors that increased antibiotic prescription were systemic corticosteroid prescriptions and winter season during illness. Treatment in an ER decreased the likelihood of being given antibiotics.
Submitted by: Rachael Zanotti
Comment: We have been exposed to the possible immunomodulatory properties of azithromycin, and have learned about chronic sinusitis as a possible factor in refractory asthma; thus although we are all opposed to excessive antibiotic use, it is hard to see a child with asthma and not want to provide every possible treatment to prevent worsening of an exacerbation. This is a challenging issue and it is helpful to review national guidelines. LF

K. De Boeck et al. Coprescription of antibiotics and asthma drugs in children. Pediatrics. June 2011;127:1022-1026.
Paul et al. Antibiotics during ambulatory pediatric asthma visits. Pediatrics. June 2011; 127:1014-1021.

Summary and Implications For Your Practice:
These are two studies published in the same issue of Pediatrics focused on coprescription of antibiotics and asthma medications in outpatient pediatric visits. The article by Boeck looked at a very large population in Belgium. The study showed that overall an antibiotic was dispensed with an asthma drug 73.5% of the time. The second study by Paul looked at US data from outpatient pediatric visits. The data in this study was analyzed slightly differently, but they found that in 15.6% of visits for asthma an antibiotic was prescribed inappropriately (in most of these visits the patient was given a macrolide). Interestingly, the study found that a child was more likely to be given an antibiotic if they had private insurance. We should be careful that we have very specific criteria and good reason to give our patient’s antibiotics for outpatient visits where we believe they are having asthma exacerbations. If we continue to inappropriately prescribe antibiotics for what is truly reactive airway disease/asthma, we may miss the opportunity to give education to families regarding appropriate asthma therapy and help prevent a future asthma exacerbation by not emphasizing appropriate preventative care. Also to be considered is the added health care costs associated with these unnecessary prescriptions (not to mention the cost of extra outpatient visits for poorly controlled asthma!)
Submitted by: Sarah Youssef

Dawood FS, et al. Children With Asthma Hospitalized With Seasonal or Pandemic Influenza, 2003-2009. Pediatrics 2011;128;e27-e32.
Summary and Implications For Your Practice:
This study examined the characteristics of children ages 2-17 with underlying asthma hospitalized with laboratory-confirmed influenza from 2003-2009. The study found that 32% of all children hospitalized with influenza also had asthma; most of these children (63-83%) had no additional medical conditions. During the 2009 H1N1 influenza season, an even higher percentage of those admitted for influenza also had asthma (44%). Pneumonia was also diagnosed in 40% of asthmatics with seasonal influenza and 46% of asthmatics with H1N1 pandemic influenza, a significant increase. In addition, compared to those with seasonal influenza, a higher proportion of asthmatic children with H1N1 influenza required ICU care, while equal proportions had respiratory failure and died. This study offers a unique look at the characteristics of children with asthma hospitalized for influenza. It highlights the increased risk of complications from influenza in asthmatic children, even when they have no other medical problems besides asthma, and impresses the importance of influenza vaccines in helping prevent these complications. It is limited as it does not take into account the underlying severity of the patient’s baseline asthma, did not examine children less than 2 years of age, and does not compare specific complications against the general population, but instead compares seasonal vs. H1N1 flu in asthmatics. This provides more information supporting the recommendation for routine influenza vaccination in asthmatic children.
Submitted by: Julie McClave

Sports Medicine:

Sroufe, NS et al. Postconcussive symptoms and neurocognitive function after mild traumatic brain injury in children. Pediatrics 2010;125(6):1331-1339.
Summary and Implications For Your Practice:
This study aimed to characterize the trend of post-concussive symptoms (PCS) in patients with mild traumatic brain injury (MTBI) compared to patients with non-head trauma. Symptoms were followed using a prospective, longitudinal, observational design where children reporting to an ED were given a post-concussive symptom questionnaire and neurocognitive testing, followed by retesting at 1 week and 4-5 weeks. All patients were tested within 24 hours of their initial injury and those in the MTBI group had specific requirements including normal intracranial imaging. The MTBI group had more PCS than the control group at all visits and these PCS decreased significantly between the 1 week visit and the 4-5 week visit. My goal in reading this study was to find information about the general prognosis of MTBI and what to tell parents to expect regarding a recovery timeline. The age range was 10-17, which would include teenage athletes as well as non-athletes. The number of patients in the study was fairly low (77) and there was only a 60% completion rate, which may have skewed results. While athletes may push to be allowed to return to play, it is important to realize that symptoms often persist for weeks or months afterwards, making it essential to assess each patient individually and possibly perform neurocognitive testing or a PCS survey prior to granting sports clearance.
Submitted by: Katherine Swearingin
Comment: : The more we learn about concussions in children, the more difficult it is to sort out appropriate “return to play”. The Consensus Statement on Concussion in Sports continues to be an excellent resource for practitioners. (http://sportconcussions.com/html/Zurich%20Statement.pdf). LF

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