January 2012 Journal Watch

Dermatology

Vogel, Y. Trends in pediatric psoriasis outpatient health care delivery in the United States. Arch Derm 2012;148:66-71.
Psoriasis affects approximately 2.5% of the US population, and one-third of patients present before the age of 20 years. The treatment of psoriasis in children can be challenging due to lack of data and standardized guidelines specific to the pediatric population. In this study, National Ambulatory Medical Care Survey (NAMCS) data were reviewed from 1979 to 2007. There were 3.8 million visits for psoriasis over the study interval, with an average of 123,420 visits per year. The majority of the patients were seen by dermatologists (63%), while the rest were seen by pediatricians (17%) and internists (14%). There was no significant difference in gender, but significant difference in age (47% age 13-18 years, 35% age 8-12 years, and 18% age 0-7 years). The treatment approach differed by physician specialty and patient age. Pediatricians were more likely to prescribe topical tacrolimus compared to dermatologists and internists who were more likely to prescribe high-potency topical steroids. Overall, the most prescribed medication across all ages was betamethasone. However, among those ages 0 to 9 years, the most prescribed medication was topical tacrolimus. These discrepancies in treatment might be due to differences in the severity of the patient’s disease. However, the authors concluded that treatment guidelines and additional education to dermatology and non-dermatology specialties would be helpful in reducing treatment variability.
Submitted by: Willa Moore
Comment: Psoriasis is a systemic disease, with skin inflammation thought to be driven by T cell activity. Many newer therapies target T cells or their mediators. Consensus guidelines for plaque psoriasis are available at http://archderm.ama-assn.org/cgi/content/full/148/1/95, but our patients surely will benefit from the diagnostic and therapeutic expertise of a treating dermatologist. LF

General Pediatrics

Subcommittee on ADHD. ADHD clinical practice guidelines. Pediatrics 2011;128: 1007-1022.
A subcommittee consisting of primary care pediatricians, developmental behavioral pediatricians, a CDC epidemiologist, and representatives from pediatric psychiatry, psychology, and neurology organizations developed a series of research questions, met over a 2 year period, and conducted extensive literature review in order to update the clinical recommendations for diagnosis, evaluation, and treatment of attention-deficit and hyperactivity disorder (ADHD), which were first published in 2000 and 2001. The subcommittee developed 6 action statements. #1: Since ADHD affects approximately 8% of children and often goes undiagnosed, the PMD should monitor for symptoms and initiate an evaluation whenever there is a suspicion. #2: In order to make a diagnosis, the PMD should receive input from parents and teachers, rule out alternative causes, and use the DSM-IV criteria. #3: The evaluation should also screen for other conditions that may coexist with ADHD, such as depression, anxiety, conduct disorder, learning disorders, and tics. #4: ADHD is a chronic condition, with symptoms that will continue and require treatment for many years, even into adulthood. #5 Treatment recommendations vary according to age. For children age 4-5 years, the first line treatment is behavior therapy followed by methylphenidate. For children age 6-11 years, first line therapy is medication, with stronger evidence for stimulants. Behavior therapy is second line or adjunctive. For children age 12-18, medications continue to be first line therapy and behavior therapy continues to be second line or adjunctive. There is less evidence to support behavior therapy in this age group. #6: Medications should be titrated in order to achieve maximum benefit with minimum adverse effects. Since ADHD occurs in approximately 8% of the population, it is a condition that general pediatricians will see on a regular basis and should feel comfortable diagnosing and managing. It is important to keep in mind the age of the child when designing a treatment plan. In younger children, there is stronger evidence for behavior therapy than for medication. Conversely in older children, there is stronger evidence for medication than for behavior therapy. In a time when people often desire quick fixes with a pill, it is important to remember that medication may not always be the first line choice in treatment.
Submitted by: Shannon Moore
Comment: I think it is extremely important that other problems are ruled-out before diagnosing ADHD (learning disorder, depression, sleep problem, OSA, etc). I am also uncomfortable treating preschool aged children with ADHD medication and would focus on the behavior modification. If a 4-5 year old had severe behavior problems, they should probably be evaluated by a specialist. That is my opinion! LC

Guerrero, AD et al. Disparities in provider elicitation of parents’ developmental concerns for US children. Pediatrics 2011;128:901-907.
The AAP recommends that developmental surveillance be a part of every pediatric visit throughout the first five years of life. However, there is significant variability in developmental screening resulting in many problems that are not identified until children reach school age. The authors used the 2007 National Survey of Children’s Health (NSCH), sponsored by the Maternal and Child Health Bureau to study factors associated with provider elicitation of parents’ developmental concerns. The authors sampled children 0-5 years old, excluding children older than 5 and those without a physician visit in the previous 12 months because their parents were not asked about developmental concerns. Only about one half of US parents reported provider elicitation of their concerns about their child’s development. Parents of children who were poor, older and uninsured were less likely to have their concerns elicited by their child’s pediatrician. There was a significant racial and ethnic disparity in Latino and African-American populations. In addition, compared to white children, Latino and African-American children were more likely to live in poverty, be uninsured, and not have a medical home. Minority patients were more likely to have moderate to high risk for a developmental or behavioral disorder. This article is another reminder of how important it is to ask parents at each visit if they have any concerns but I will try to be more direct and ask specifically about developmental concerns especially considering that our patient population fits those shown to be at higher risk to not have their concerns addressed.
Submitted by: Megan Knowles
Comment: Use of formal developmental screening tools as recommended by the AAP will help also. Children living in poverty have urgent needs related to housing, food sufficiency and safety- the challenge is to address these issues without neglecting our responsibility for ongoing high quality developmental surveillance. LF

Limbos MM and Joyce DP. Comparison of the ASQ and PEDS in screening for developmental delay in children presenting for primary care. J Dev Behav Pediatr. 2011; Sep 32 (7): 499-511.
Developmental delay affects up to 15% of children, but with early screening, kids can receive early interventions which have shown to improve long term outcomes. This study recruited children aged 12-60 months presenting to their primary care physician for well-child care and compared the Parents’ Evaluation of Development Status screen (PEDS) to the Ages and Stages questionnaire (ASQ). 334 children participated in the study, which took place about 4 hours north of Toronto. Screening results were compared to blind, independent testing performed by a psychologist to determine if the child was delayed. The PEDS was found to have a sensitivity of 74% and a specificity of 64% in screening for delays when one area of concern was used as a positive screen. The PEDS screen had highest sensitivity and specificity in the < 30 month age subgroup. The ASQ had a sensitivity of 82% and a specificity of 78% when any single failed domain was used as a positive screen. However, the PEDS screen was quicker to fill out, and the ASQ required more parent-child interaction to determine responses for some questions. In comparison, there was moderate disagreement between the two screens, more in children without delay. When using the ASQ as a second screen following a failed PEDS, specificity improved greatly but sensitivity fell to 59%. Likewise, using two failed questions/domains as a positive screen greatly improved specificity as the price of a sensitivity < 50%. Both screens are acceptable options for use in children less than 30 months, and the individual practitioner should determine which screen to use based on the level of concern, population, and time available for the family.
Submitted by: Steve Posluszny
Comment: Dr. Posluszny has done a nice job summarizing this information. No method is perfect, and physician vigilance, surveillance, and attention to parental concern are key also. Perhaps we need to ask parents which tool is better for them? LF

Franck L, Gay C, Lynch M, Lee K. Infant sleep after immunization: randomized controlled trial of prophylactic acetaminophen. Pediatrics 2011;128:1100-1108.
This is a randomized controlled trial to see how prophylactic acetaminophen affects infant sleep after immunizations. The study was prompted by the fact that adults have been shown to have decreased antigen-specific antibody formation during sleep deprivation. The control group received no interventions while the intervention group had prophylactic acetaminophen. The infants’ sleep was measured by acitigraphy and broken down into active and quiet sleep times. The results noted no difference in post immunization sleep with the acetaminophen group but did note that the later in the afternoon of immunization administration and the higher the infant’s temperature the more sleep the child had. In conclusion acetaminophen did not seem to make a difference but administering immunizations later in the day did help the infant sleep more. In my opinion, further studies looking into the time of day in relation to post- immunization sleep will have to be done before changing our standard of care to recommend afternoon immunizations.
Submitted by: Devi Jhaveri
Comment: I agree with Dr. Jhaveri. This is interesting, but would not change the timing of standard immunizations. Many parents give acetaminophen anyway on the day of immunization for pain. LC

Stokley, S et al. Adolescent vaccination-coverage levels in the United States: 2006-2009. Pediatrics 2011,128(6):1078-1086.
During the span of 2005-2007, adolescent vaccine schedules were expanded. Specifically, Tdap, Menactra, and Gardasil were added to the regiment. This article assesses the success rates of the new schedule as well as identifying several areas of improvement that can continue to increase vaccinations. The authors gathered data from the 2006-2009 National Immunization Survey conducted by the CDC. This is a provider survey of vaccination coverage of adolescents ranging from ages of 13-17. The results showed that between the years of 2006 and 2009 Tdap percentage rose from 11% to 56%, Menactra from 12% to 54%, and Gardasil from 25% to 44% (only female patients were included). The survey also questioned providers as to why adolescents did not get vaccinated and answers included: no knowledge about the vaccine, the provider did not recommend it, adolescent is not sexually active, and the vaccine is not necessary/needed. To continue to improve vaccination rates, the article encouraged continued education of parents as well as teens about the vaccines necessary and the diseases they prevent. Unfortunately, many teens do not have regular well child checks, so it is crucial to advise parents early on to continue to come yearly in order for their child to maintain optimal health. With that being said, even at sick visits I have become accustomed to checking the shot record to see if I can use the opportunity to vaccinate that day. Even if the parent refuses, it is important to educate them about the shots that are due and to encourage them to return as soon as possible.
Submitted by: Ivana Dylag
Comment: It is good news that the vaccination rates have improved overall, but there is a lot of room for improvement. The authors point out that providers should recommend all the vaccines needed and not delay vaccines for a future visit, as this may give parents the impression that they are not important. LC

Mitchell K, Finkelhor D, Jones L, Wolak J. Prevalence and characteristics of youth sexting: a national study. Pediatrics 2011;129:13-20.
With the advent of digital media, the exchange of nude photos has become a more common occurrence. This study sought to investigate the frequency and qualities of youth “sexting,” described in the article as “sending sexual images and sometimes sexual texts via cell phone and other electronic devices.” As part of the Third Youth Internet Safety Survey the investigators conducted random phone interviews with individuals 10-17 years of age with frequent Internet use. A total of 1560 youth were interviewed. The study found 9.6% reported making, sending or receiving nude or almost nude photos. The majority of subjects involved were age 16-17. Only 2.5% appeared in or made images. Of those in or making the images, 61% were girls, 21% were upset/afraid due to photos, 54% of images showed breasts, genitals or buttocks, and 31% of incidences involved alcohol or drugs. Of those receiving the images 56% were girls, 25% were upset/afraid due to photos, and 84% of images were sexually overt. In both groups only 28% reported it to a higher power and incidents occurred more than once in over 50% of cases. Most of the episodes involved someone the youth knew and most frequently romance was a part of the connection. This study provides insight into the frequency and characteristics of youth sexting which affects our adolescent patient population. In the history, if red flags are raised, it is important to remember to discuss with patients the consequences of making or possessing nude photos.
Submitted by: Lauren Ebe
Comment: This is quite a disturbing recent trend. It is very important that teenagers are aware of the widespread consequences of such actions. I have heard of cell-phones being banned in gym locker rooms because of this problem, which seems like a good idea. LC

Neurology

Bruijn J et al. Psychopathology in children and adolescents with migraine in clinical studies: a systematic review. Pediatrics 2010;126(2):323-332.
The authors performed a literature search using Medline, Embase, PsychINFO, and Cochrane Database to examine psychologic comorbitidy in children with migraines. They went through a detailed determination of study quality, pooling evidence from seven studies. The following conclusions were made: 1) strong evidence against children with migraines having more withdrawn behavior, social problems, or aggressive behavior compared to healthy children, 2) a higher rate of somatic complaints and internalizing behavior, which were attributed to the illness itself, 3) limited evidence that children with migraines were not more frequently diagnosed with ADHD, conduct disorder, dysthymia, or depression. In neurology clinic and primary care practice, migraines are very common and sometimes are accompanied by psychological symptoms. Especially in cases of chronic migraines, as with other chronic diseases, patients may get depressed as a result of dealing with their illness. Thus, it is important to screen for the effect of migraines on mood and behavior. I do not believe this study refutes this concept, but rather argues that psychiatric diagnoses are not necessarily more common in migraineurs than the general population. However, the study had significant limitations, including being based in the Netherlands, having small sample sizes with some studies that were self-admittedly of low quality, and only examining studies that compared children with migraines to healthy children.
Submitted by: Katy Swearingin
Comment: We can start by early identification of migraine in young children, which is not always easy. Tips include awareness that migraine may be frontal rather than unilateral, and that parents often report the child looks pale or ill during the headache. Young children may need to draw an aura or have help explaining what they experience. Screening for mood and behavior issues is always a good idea. LF

Pulmonology

Agarwal R, et al. Role of inhaled corticosteroids in the management of serological allergic bronchopulmonary aspergillosis (ABPA). Internal Medicine. 2011;50(8):855-60.
When treating an asthma patient who fails to get better despite intensive outpatient follow-up and multiple home controller medications it is important to remember to expand your differential. In addition to getting a detailed asthma history including potential triggers, the physician should also send testing for allergic bronchopulmonary aspergillosis (ABPA) which can often have symptoms of poorly controlled asthma. If ABPA is diagnosed the next step is treatment. The aim of treatment is to suppress the immune reaction to the fungus; therefore oral steroids are the first line of defense. Unfortunately oral steroids can be poorly tolerated and have adverse side effects. For these reasons, some physicians choose to treat with inhaled corticosteroids (ICS), which are better tolerated and have fewer systemic side effects. This journal article attempts to clarify if ICS are as efficacious as oral steroids in controlling asthma symptoms in patients with ABPA. 21 patients were enrolled and treated with Symbicort and followed closely with both clinical and laboratory data. The Global Initiative for Asthma (GINA) criteria were used to access asthma control and oral steroids were started if IgE levels continued to rise after 6 months of ICS therapy. Although everyone seemed to have some mild improvement in asthma symptoms after starting ICS, no one was truly well controlled on ICS alone, and therefore everyone eventually required the addition of oral steroids. The authors concluded that ICS alone are not recommended for the management of ABPA and should only be used as a supportive medication for the control of asthma symptoms. ABPA is an important disease process to keep in mind when managing poorly controlled asthmatics and ICS is just a supportive medication when it comes to treating ABPA.
Submitted by: Justin Greiwe
Comment: This is interesting data and can highlight the fact that not all wheezing is caused by asthma. LC

Marion TL and Bradshaw WT. Congenital central hypoventilation syndrome and the PHOX2B Gene Mutation. Neonatal Network 2011;30(6):397-401.
This article outlines Congenital Central Hypoventilation Syndrome (CCHS), an autosomal dominant disease presenting in the first 48 hours of life with apnea and lack of response to hypoxia and hypercapnia during sleep. The authors reviewed articles from 1999 to 2010 using CINAHL and PubMed. In approximately 90 percent of cases, CCHS is associated with a polyalanine repeat expansion in the PHOX2B gene. CCHS is associated with higher rates of tumors of neural crest origin, Hirschprung disease, and generalized autonomic dysfunction. In children suspected to have CCHS, the appropriate genetic testing is PCR to look for the polyalanine repeat expansion, followed by sequencing of the gene if the PCR is negative. Although the disease is autosomal dominant, parents that are carriers of the mutation are often asymptomatic. Children with CCHS should have a tracheostomy placed soon after diagnosis, as mechanical ventilation is required during sleep and possibly also while awake. This syndrome was brought up during a consult we had in the NICU for a family with 2 prior siblings with CCHS and a newborn that was suspected of also having the disease due to prolonged apnea during sleep. By going through this article and the American Thoracic Society recommendations, we knew to order PCR and were able to discuss the potential future implications with the family.
Submitted by: Katy Swearingin
Comment: Pushing oneself to examine the literature about a patient problem or diagnosis is always a challenge due to time pressures- Dr. Swearingin points out how useful and satisfying it is. Of course this effort complements in-person consultation with knowledgeable subspecialists who will care for and follow the child and family. LF

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