Spring 2012 Journal Watch

Adolescent Medicine

DiClemente R et al. Association between sexually transmitted diseases and young adults' self-reported abstinence. Pediatrics 2011;127(2):208-211.
This study prospectively assessed the correlation between adolescent self-reported sexual behavior in the last 12 months and the presence of laboratory-confirmed, non-viral sexually-transmitted infections (STIs). The comparison included 14,012 demographically representative young adults (92% of all National Longitudinal Study of Adolescent Health participants) who were interviewed about their penile/vaginal sex and provided a urine specimen to test for Chlamydia trachomatis and Neisseria gonorrhea, and a polymerase chain reaction (PCR) assay to detect Trichomonas vaginalis. The study found that ten percent of adolescents reporting no sexual intercourse in the last year nonetheless had positive urine for STIs. This subpopulation was indistinguishable from its STI-negative peers in race, education, sex, or socioeconomic status. These results, therefore, further strengthen the current clinical practice of many adolescent clinics of STI testing for all sexually-active patients, even those denying recent intercourse. The investigation did, however, have several notable weaknesses. Foremost, adolescents who completed the survey but opted out of STI testing were not identical to the included population; they were more likely to be affluent, Caucasian or Asian, and have completed high school. Additionally, since this was the third wave of the National Longitudinal Study of Adolescent Health, an adolescent cohort first selected in the early 1990s, the mean age of participants for interview was 21.9 years - while the mean age of the average sexually active adolescent is far younger. These weaknesses minimally undermine the study’s wider application of the magnitude of incongruence between self-reported sexual activity and STI testing and strongly support STI testing for adolescents independent of sexual activity screening questions.
Submitted by: Anya Kleinman
Comment: Nice review by Dr. Kleinman. At the Pediatric Practice we screen every 6 months for STIs and there is more data in support of same. Of course, STI screening does not take the place of a sensitive and confidential interview regarding sexual activity and practices, which is still an important part of good adolescent well care. LF

Allergy and Immunology

Burks AW, Jones SM, Boyce JA, Sicherer SH, Wood RA, Assa'ad A, and Sampson HA. NIAID-sponsored 2010 guidelines for managing food allergy: applications in the pediatric population. Pediatrics 2011;128:955-965.
This article reviews guidelines for food allergy from the 2010 NIAID guidelines. Diagnosis of food allergy should be made with consistent history (anaphylaxis or skin, eye, respiratory or GI symptoms consistent with food allergy) in combination with diagnostic testing (skin prick or food specific IgE testing). Food challenge is the gold standard for diagnosis. Comorbidities include moderate to severe atopic dermatitis, eosinophilic espohagitis, gastritis, enteritis or enterocolitis, enteropathy or allergic proctocolitis, along with other atopic diseases. The article suggested allergy testing in children with moderate-to-severe atopic dermatitis not responsive to optimal therapy. In addition, it reinforced that no restrictions need to be placed on solid foods introduced after 4-6 months, including potentially allergenic foods. Management of food allergy is primarily avoidance. No preventive medications are available and immunotherapy is not currently recommended. For children who do not have a proven food allergy, avoiding potentially allergenic foods is not recommended in the management of atopic dermatitis, asthma, or eosinophilic esophagitis. Retesting children for food allergy can be done annually for young children and every 2 – 3 years for older children. The mainstay for treatment for acute, systemic allergic reactions to food is intramuscular epinephrine (Epipen). Antihistamines can be used for mild allergic symptoms. The article recommended all patients with previous anaphylaxis to a food, a food allergy and asthma, or a known food allergy to peanut, tree nuts, fish or crustacean shellfish be prescribed an Epipen. Proper education regarding the use and storage of an Epipen is essential. This helps general practitioners recognize the signs and symptoms of food allergy, other associated diseases and when to refer to allergist for allergy testing. In addition, it reinforced that restrictions on potentially allergenic foods is not necessary unless a proven food allergy is documented. This will help in providing anticipatory guidance to parents with the introduction of solid foods and the management of other atopic diseases.
Submitted by: Julie McClave
Comment: Dr. McClave provides a very good summary of the current guidelines. As general pediatricians, one of the most important things to remember at WCC visits for children with food allergy is to make sure they have an epi-pen that is not expired, and that the parents know how to use it properly if necessary. LC

Magnusson JO, Kull I, Mai X, Wickman M, Bergstrom A. Early childhood overweight and asthma and allergic sensitization at 8 years of age. Pediatrics 2012;129:71-76.
This study looked at whether body mass index (BMI) trends during patients’ first 7 years were associated with asthma and allergic sensitization at 8 years. The study population consisted of 2075 children who were part of a larger birth cohort. Children were followed with parent surveys, data from schools, and a clinical examination at 8 years. A high BMI was defined as greater than or equal to the 85th percentile. Asthma was defined as at least 4 episodes of wheeze in the previous 12 months or at least 1 episode of wheeze and use of inhaled steroids. Allergic sensitization was defined as having at least 1 allergen-specific IgE result of great than 0.35kU/L. High BMI values at age 1, 4, and 7 years resulted in increased risk of asthma at 8 years. High BMI at 4 years, but normal at 7 years, showed no increased risk for asthma. High BMI at 7 years led to increased risk of sensitization to inhalant allergens. When children with wheeze before 1 year and with a diagnosis of asthma before 2 years were excluded from a second analysis, a high BMI at 7 years was still significantly associated with asthma at 8 years. Future research should focus on factors associating overweight and asthma. We already know the importance of preventing childhood obesity. With this new knowledge that overweight at 7 years leads to a higher risk of asthma and sensitization to inhalant allergens, more time and effort should be put into preventing weight gain and helping with weight loss.
Submitted by: Brittany Massare
Comment: This is very interesting data. In the same issue of Pediatrics, there is a comment by Dr. Ciprandi that proposes leptin as a possible link: “an adipokine that also exerts pro-inflammatory activities.” LC

General Pediatrics

McGowan, J., Alderdice, F., Holves, V., and Johnston, L. Early childhood development of late-preterm infants: a systematic review. Pediatrics 2011;127: 1111-1124.
In this systematic review, the authors’ goal was to examine literature about early childhood development in age 1-7 year olds who were born as late-preterm infants (LPIs) at 34-36 weeks gestational age. They used 9 online databases searching from January 1980 to March 2010. Studies were assessed for quality and meeting certain inclusion criteria. Over 4500 studies were assessed, and 10 studies were found to meet all necessary requirements. This included 3 prospective and 7 retrospective cohort studies. Neurodevelopmental disabilities, educational ability, early-intervention needs, medical needs, and physical growth had poorer outcomes in LPIs when compared to term children. The authors were unable to find any studies that compared LPIs that were admitted to a NICU to LPIs that were not admitted. Their review showed that LPIs are at increased risk of poor developmental and academic outcomes through age 7 years old when compared to infants born at full term. More studies are still necessary to look into early childhood development in LPIs. It is easy in a busy clinic day to see a LPI and worry more about any medical issues present than developmental issues. Often former LPIs are medically well and we can be easily lulled into thinking that they are “out of the woods.” This study highlights the importance of having development and academic issues on our radar for former LPIs for an extended period of their childhood.
Submitted by: Sheila Bigelow
Comment: We have become used to thinking about early and late developmental outcomes for very premature infants; however, it is clear that late preterm birth is an important risk factor that does not “disappear” after the first few months of life, and reverberates into school age and possibly later. LF

Dusza S et al. Prospective study of sunburn and sun behavior patterns during adolescence. Pediatrics Feb 2012;129(2):e309-317.
Ultraviolet radiation (UVR) exposure at a young age is linked to increased risk of adult melanoma. A recent meta-analysis showed that reporting sunburn during childhood doubled the risk for developing melanoma later in life. The Study of Nevi in Children is a longitudinal prospective study that evaluated 360 students from Framingham, Massachusetts. This included administering surveys to 10 year olds in 2004 and again 3 years later in the months of September and October. This study looked to evaluate the prevalence of sunburn and sun behaviors as well as the changes over time. A study nurse evaluated students and classified each for phenotypic skin characteristics. The students had complete information regarding UVR exposure, sunburn and sun protection at both time points. Approximately 53% of the participants reported having at least 1 sunburn the prior summer (in 2004), which only increased to 55% in 2007. However, liking a tan (53% to 66%) and spending time outside purposefully to get a tan (21.8% to 39.8%) increased significantly over the 3-year period. In addition, the number of students using sunscreen “often or always” when outside for at least 6 hours dropped from 50% to 25% at the 3 year follow-up evaluation. This study showed that sun exposure behaviors change during the pre-adolescence period and this is a great time to counsel patients on risky sun behavior. The pediatrician’s office is a great environment to educate youth about sun behaviors and use of sunscreen as well as the harms of UVR exposure.
Submitted by: Lauren Riney
Comment: I agree; this is definitely a topic that should be addressed at all WCC visits, especially when seeing pre-teens and teens! LC

Genetics

Botkin JR et al. Public attitudes regarding the use of residual newborn screening specimens for research. Pediatrics 2012;129;231-238.
This study explored public opinion on the use of residual dried bloodspots from state newborn screen (NBS) tests for research purposes. Various methods were used to elicit opinions: focus groups (n = 157), paper or telephone surveys (n = 1418), and a “Knowledge Networks” (KN) panel (n = 2280). In total 3855 participants were involved. All were surveyed using the same 38-item questionnaire, which contained brief information about the NBS and bloodspot sample retention. Some participants (n = 1769) additionally viewed a 22-minute educational film about NBS sample retention, and potential risks, benefits, and ethical concerns. Focus groups were conducted, during which the video was shown, and physician investigators authoring the study led a discussion. Telephone and paper surveys were also distributed through commercial groups and through the Utah Department of Public Health (DPH). The Knowledge Networks company also conducted Internet surveys and online focus groups (some including the educational video) with a sample population pre-determined to be nationally representative. Most participants (93.5%) were supportive of NBS in general. Participants were evenly divided with regard to bloodspot retention, with 25% “not at all concerned” and 30% “very concerned.” 62% of participants approved of retaining samples if parental consent obtained an “opt in” rather than “opt out” approach. Overall, 81.5% approved of doing research on retained blood samples. Participants were significantly more in favor of NBS and bloodspot retention and research after viewing the educational film. In summary, this study indicates that the public prefers an “opt in” approach to research on residual NBS samples, and that education increases support for these programs.
Submitted by: Leslie White
Comment: Although issues of informed consent are frequently contentious, it is helpful to hear from parents themselves the preference for ability to “opt in” rather than “opt out” of use of their infant’s residual blood sample. Kudos to the researchers for asking! This approach would respect the parent’s autonomy while permitting access to potentially useful research materials. LF

Infectious Disease

Hiromi M et al. Late IVIG treatment in patients with Kawasaki Disease. Pediatrics 2012; 129:e29.
This retrospective study used a nationwide survey in Japan and compared patients with Kawasaki Disease (KD) who were treated with IVIG on days 11-20 of disease versus those treated on days 4-8. After exclusions the sample size was small with only 75 children in each group. The end points studied were additional treatments needed, incidence of coronary artery lesions (CALs) present before and after IVIG, and inflammatory markers. The study found that the proportion of patients that required additional treatment after IVIG was slightly lower in the late group compared to the conventional treatment group; however this was not statistically significant. They found no changes in reduction of inflammatory markers. The proportion of patients that had not developed CALS prior to initial IVIG were similar to the proportion with CALs during the acute phase. However, more patients developed CALs in the convalescent phase in the late group compared to the conventional group. About one-half of the patients in the late group had already developed CALs before initial IVIG. In summary, late IVIG appears to be less effective for preventing CALs despite decreasing ongoing inflammation. If there is a strong suspicion of KD, even when patients do not meet classic KD criteria, giving IVIG as early as possible is important in reducing the risk of CAL formation.
Submitted by: Megan Knowles
Comment: When a child meets full criteria for Kawasaki disease, it is much easier to treat promptly; however, diagnosis of “incomplete Kawasaki disease,” in which a child meets some but not all criteria, is a huge challenge for clinicians, and may result in treatment delay. Prospective studies examining the IVIG timing question in children with the spectrum of incomplete Kawasaki disease would be welcome. LF

Nephology

Yoon EY, Cohn L, Rocchini A, et al. Antihypertensive prescribing patterns for adolescents with primary hypertension. Pediatrics 2012;129;e1-8.
Historically, essential hypertension has been a rare finding in adolescents. However with the obesity epidemic hypertension is becoming more common among pediatric patients. This study was designed to assess the current usage of antihypertensive medications in adolescents by provider type. Michigan Medicaid claims for adolescents were searched for ICD-9 codes for hypertension and/or elevated blood pressure. Secondary and malignant hypertension were excluded. Results demonstrated that most patients were diagnosed at age greater than 15 years and 23% were treated with anti-hypertensives (977 patients). Patients were significantly more likely to be treated if they were white, obese, or greater than 15 years old (the significance remained when controlled for the other variables). The vast majority of adolescents receiving anti-hypertensives were seen by adult primary care physicians (62%) and most commonly received ACE inhibitors, Beta-blockers, diuretics, or combination therapy (specialist prescribing patterns mirrored the adult providers). Pediatricians were less likely to utilize anti-hypertensives and usually prescribed ACE inhibitors or diuretics. This study demonstrates that there is a large percentage of hypertensive adolescents not being treated (especially by pediatric providers) and that there is a racial disparity in prescribing practices. This study has its limitations, but it still demonstrates a significant portion of the patient population requires treatment. Providers need to assess their patients for hypertension and initiate therapy when indicated. With the rising rates of obesity and hypertension feeling comfortable with anti-hypertensive medications is a new demand on the pediatrician.
Submitted by: Nathan Beins
Comment: This study seems to have several possible flaws. First, the authors looked at ICD-9 codes, not the charts. There is no way of knowing if the physician counseled the patient about diet/lifestyle changes or referred them to a specialist. Second, although the authors also looked at pharmacy claims to see if a medication was prescribed, it is possibile that a prescription was given but never filled. LC

Sports Medicine

Tucker AK. Chronic exertional compartment syndrome of the leg. Current Review Musculoskeletal Medicine. 2010 Oct;3(1-4):32–37.
Athletes can have many causes of exertional leg pain. Chronic exertional compartment syndrome (CECS) is one condition that often goes overlooked. CECS is most common in young adult runners, elite athletes, and military recruits. With increased intracompartmental pressure in a limited fascial space comes pain. Patients most commonly complain that the pain occurs at the same time and distance every time and resolves with rest. Risk factors include creatine use and anabolic steroids which both increase muscle volume. Other risk factors include eccentric exercise and poor running technique. To confirm the diagnosis, intracompartmental pressures must be taken. Pressures are taken prior to exercise and 5 minutes after. A resting pressure >15mmHg and 5 min post-exercise >20mmHg are diagnostic. While conservative measures are often tried first, if the patient would like to continue their active lifestyle a fasciotomy is often required (option of open fasciotomy vs. endoscopic subcutaneous fasciotomy). While most patients tolerate the procedure well, complications happen and include hemorrhage, infection, nerve damage and entrapment. Rate of recurrence is about 6-11%. Because CECS can mimic other causes of lower extremity pain in athletes this diagnosis often goes unnoticed. With a better understanding of CECS presentation and treatment, earlier and more conservative intervention can be trialed first with potential better long term outcomes. In summary, chronic exertional pain can often be overlooked in a well child care setting, especially in a healthy athlete. This article demonstrates the importance of remembering simple clues when taking an exercise history because a very straightforward diagnosis can be overlooked. Discussing proper exercise techniques as well as the importance of stretching can prevent a lot of overuse injuries and avoid more invasive operations and procedures in the future.
Submitted by: Justin Greiwe
Comment: This article serves as a reminder that chronic pain that does not go away with standard treatments such as rest, ice, and NSAIDs should be a clue that something more rare or serious must be considered. LC

Field AE et al. Prospective study of physical activity and risk of developing a stress fracture among preadolescent and adolescent girls. Arch Pediatr Adoles Med 2011;165(8):723-728.
This study investigates predictors of developing stress fractures (SF) in adolescent girls. 6831 girls (9-15 years old) who were daughters of women participating in the Nurses Health Study II were recruited. Questionnaires were sent every 12-18 months (1996-2003), asking about weight, height, menarchal age, weight-control behaviors and physical activity. Activity was divided into high, medium, and low impact (for example, cheerleading, baseball, swimming respectively). Incidence of SF was determined by additional questionnaires sent to the subjects’ mothers, asking if a doctor diagnosed a SF, body part involved and if it was activity-related. 267 (3.9%) of 6831 females developed SF. Higher risk of developing SF was associated with: 1) Later onset of menarche (~30% increase in risk with each year delay); 2) Family history of osteoporosis or low bone mass density (~twice as likely); 3) ≥8 hours per week of activity (twice as likely compared to peers with <4 hrs/wk); and 4) High-impact activity (8% increased risk). Running, basketball and cheerleading/gymnastics were independently predictive of SF. Disordered eating or being under/overweight were not statistically significant. This is the first large general population-based study in adolescent girls. However, over 90% were Caucasian, making it difficult to generalize the results to our own clinic population, who are, additionally, at less risk of osteoporosis. Nevertheless, many of our adolescents are involved in high-impact sports; therefore it may be helpful to suggest varied training programs that incorporate low-impact activities. This would decrease the amount of high-impact activity time and therefore may decrease their risk of developing stress fractures.
Submitted by: Julie Abraham
Comment: The number of high school girls whose sports programs include >8 hours/week of practice is likely to be considerable. What we need now is a prospective study looking at prevention of stress fractures – a rate of 3.9% is just not acceptable. LF

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