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Updates June 2013
Most children probably do not finish the course of antibiotics they receive from their pediatrician. Furthermore, how come we give all children the same length of treatment. Shouldn’t we treat them based on personalized regimen – their age ? severity of symptoms ? clinical improvement ? Interesting BMJ article.
Bedtime Reading – DSM-5 is Published
After a decade of revisions the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is now released by the American Psychiatric Association.
Expect a lots of changes and mental health “shift” in pediatrics.
Ethics Board – A friend or Foe
Be part of the ‘inner circle’ – here is a recipe to make ethics your friend and not your foe – at least by these UK based authors.
What Would ER’s Dr Doug Ross Say ?
So how many of your patients come out of the emergency department and know exactly what the nurse, physician assistant or emerg doc told them ? probably very few. Limited health providers’ time and level of understanding by patients and families have always been a problem. A group from Augusta, Georgia, report in Pediatric Emergency Care their effort to improve discharge instructions for common pediatric conditions such as fever, vomiting or diarrhea and wheezing. They randomized families to regular discharge or to watching a 3 minute video with some discharge instructions. Of more than 436 caregivers, parents receiving video discharge instructions scored a post discharge questionnaire significantly higher in the emergency (12 vs 9) and 2 to 5 days after discharge (11 vs 8). At follow-up, 29% of the written and 42% of the video groups rated their discharge instructions as being extremely helpful. In the age of YouTube and Vimeo, watching the “tube” is probably better the written instructions.
Honey, Can You Clean the Pacifier ?
The fear of botulism is the fundamental cause of recommending no honey be given to infants in their first year of life. A group from a county hospital pediatric clinic in Houston, Texas, asked parents about the practice of cleaning pacifiers with Honey. Surprisingly, 11% of about 400 families use this ‘method’. This is a group of children with a ‘potential’ for severe illness. One of the challenges is likely the level of awareness to the risks. Only about 20% of all parents were aware of botulism as a risk. As always, knowledge is power. Read Pediatrics.
Dear Doc ! Wash your hands – Big Bro sensing you
Protocols, advice, interesting reminders about treating sepsis
A group from Boston determined recently that changing adult prescription drugs resulted in pediatric medication exposures and poisonings. The findings were among all age groups, mostly among 0 to 5 years old, and opioids were the biggest ‘offenders’. These poisoning reports were not benign. Emergency department visits were highest for events related to hypoglycemics (60%) and beta-blockers (60%); serious injuries and hospitalizations occurred with opioids (27% and 35%) and hypoglycemics (20% and 50%). Read in Pediatrics.
Which are your 10 best medical advancement in the last decade ? Here is CNN’s list.
The Doctor Will Not See You Now
Patients may diagnose themselves, using technology, and prescribe themselves medications without ever seeing the doctor. Sounds far-fetched until learning that the Food and Drug Administration (FDA) is seriously considering this option.
Pediatric research established the connection between viral infection (such as respiratory syncytial virus) and asthma. In a recent New England Journal of Medicine issue the Dutch RSV Neonatal Network reported a randomized, double-blind, placebo-controlled trial and found that premature infants that were given palivizumab (monoclonal antibody for respiratory syncytial virus) had a significant 61% decrease in the total number of wheezing days during their first year of life, compared to not receiving the (extremely expensive) regimen. Reduced wheezing persisted after the prophylaxis period. Is this the future of asthma prevention ? time will tell.
Read NEJM paper and Editorial.
The Real Risks of Early Life Obesity
A group from Australia followed children from early life to 8 years of age and found the correlation that pediatricians intuitively think about. Weight gain from 0-18 months is significantly associated with later childhood overweight and obesity. More importantly, it is also correlated with excess central adiposity, higher systolic blood pressure, higher inflammatory markers (CRP) and greater carotid artery wall thickness. Read in pediatrics.
What was known as one of the risk factors for sudden infant death syndrome (SIDS) is now curved in “stone”. Sharing a bed with a baby increased their risk of SIDS fivefold, even without any other known risk factor such as smoking at home and alcohol use. The trend of co-sleeping is abundant in many countries, so advice from the pediatric provider is important. While the rate of SIDS declined in the last decade to 1 in 2000 babies, the decline has plateaued. BMJ Open. Picture: rubyblossom on flickr.
So a group from Ireland had to find an answer to the question – how do children like their hospital glove - ‘Jedward’ or ‘Mohawk’ ?
First a clarification on ‘Jedward’ for those not watching The X Factor TV show. The name relates to the twin performers John and Edward Grimes, known by the name Jedward, who have a unique hair do. ‘Mohawk’ needs no explanation.
Distracting kids during a procedure is important and in the age of iPad and video on demand, some clinicians are still looking for low-cost, easy to use bed-side distractions. So to answer the ‘Jedward’ or ‘Mohawk’ was provided by the Irish investigators who randomized children arriving to their hospital and 75 picked the ‘Jedward’ version and 61 the ‘Mohawk’ version of the glove-baloon.
One thing is for sure – never let the kids play with the glove – this is a choking hazard !
Picture: Wikipedia
Nice review on the management of Asthma. Full text in Paediatric Child Health.
Desaturation a Killer for Premature Babies
In a world wide effort to improve quality of life and reduce mortality of premature babies younger than 28 week gestation, three international randomized, controlled trials, compared oxygen saturation of 85-89%, to a level of 91-95% on disability-free survival at 2 years of age.
Lower oxygen saturation was associated with reduced rate of retinopathy of prematurity (relative risk 0.79) but was also associated with an increased rate of necrotizing enterocolitis (relative risk 1.31).
But more importantly, when a trial stops early, such as this one, the message is clear – there is no need for more research. In this large trail, now in the New England Journal of Medicine, interim analysis showed an increased rate of death at 36 weeks in the group with a lower oxygen saturation.
While past recommendations were against pacifier use in children that breastfeed, a recent PRETx review in Canadian Family Physician suggests that breastfeeding cessation is more a parental decision than use of pacifiers. Free full-text.
Routine penicillin prophylaxis and conjugate vaccines are making a difference. This time it is for children with Sickle Cell Disease. While up to 5% were shown to be bacteremia in the past, a recent study from Boston Children’s reports 18 years’ worth of data, and only 9 out of over 1100 children with febrile episodes had bacteremia. There was no morbidity or mortality, even in children discharged from the emergency. Pediatrics is getting closer to the vision of managing children outside the hospital. The paper in Pediatrics.
The Centers for Disease Control and Prevention’s 2011 national Youth Risk Behavior Survey continues to provide alarming data on generation “young”. Among over 8500 adolescents 16 years old or over (US national representative sample), almost half report texting while driving during a 30 days period. Risky in itself, the authors from Atlanta found that these students are more likely to engage in additional risky motor-vehicle behaviors. Now in Pediatrics. t
Tell your adolescent patients, or just text them the link for this YOUTUBE video from “Responsible Young Drivers” : http://www.youtube.com/watch?feature=player_embedded&v=emu25nWf2Do
Formula To Help Breastfeeding ?
A group from University of California San Francisco reports randomizing newborn babies who lost 5% or more of their birth weight at 1-2 days of life to continue just breastfeeding or receive some additional formula. For those receiving supplementation – rate of formula use at 1 week was lower and rate of breastfeeding at 3 months was higher. The bottle may have just been what these babies needed – a bridge to better breastfeeding. Read in Pediatrics.
The last recommendation you may expect from the pediatrician is to prescribe children with more video gaming. A study from Australia, now in Journal of Pediatrics, may suggest just that.
Active console games (exergaming) on Xbox 360–Kinect in a small group of children (15) induced significant increase in heart rate and increased energy expenditure, but only if the game was ‘high intensity’ such as 200m Hurdles. Low intensity game like bowling did not ‘do the trick’. Well, this actually make sense. An even better recommendation for children and their parents ? do the actual 200m hurdles outside !
In a meta-analysis published in Pediatrics by a group from Greece, eating frequent meals was associated with lower body weight. The author reviewed 1707 papers and ended summarizing 11 studies with over 18000 children. The findings were true especially in boys.
How Far Do you Go (to Test Urine)
Fever – the essence keeping pediatric medicine awake at night. With advanced vaccination, invasive testing in the non-verbal febrile child is diminishing slowly. But Urinary Tract Infection is still a culprit. In Annals of Emergency Medicine a good review of past search for UTI and the shifting paradigm for testing less. The authors from New York conclude that it is reasonable to withhold or delay testing for urinary tract infection if signs of other sources are apparent or if the fever has been present for fewer than 4 to 5 days. In the “fever without a source” we still need to “chase” UTI.
Children account for 20% of US emergency department visits, yet specialized peds emergency is far from perfect. A group from Boston, Massachusetts called over 200 randomly selected Emergency Departments and found lack of progress compared to a decade ago. Only a third had pediatric departments, only 1/8 had intensive care units and only a tenth had a separate pediatric ED. Most EDs treated only mild-to-moderate cases of childhood bronchiolitis and asthma and only half were able to care for children with acute appendicitis. In case of Emergency our children may be in trouble. Read International Emergency Medicine.
‘Best news ever’ for parents cleaning their children’s pacifiers by putting it in their mouth ! Of 184 infants 18 and 36 months of age whose parents sucked on their pacifiers to clean them during the first 6 months of life had only a 1/3 of the risk of developing eczema at 18 months of age, compared to children whose parents did not cleaning the pacifiers this way. So possibly saliva stimulate baby’s immune system. Forget hot water, soap or alcohol rub to pacifiers – start sucking on them to clean. See Pediatrics.
More and more evidence is available that chronic fatigue syndrome (CFS) affects children and not only adults as thought before. Among close to 550 adolescents in a specialized UK clinic, the rate of depression among children with CFS the prevalence of depression is close to 29%. As one would expect, this high rate, much more significant than in the population of adolescents, was associated with the amount of disability.
Couch Potato – The Scientific Proof ?
Among 91 adolescents 13-15 who completed a week long random surveys on their activities (primary, secondary, and tertiary attention), watching TV as a primary activity was associated with higher BMI. The amount of time spent watching television was unrelated to BMI.
Could it be commercials seen on the screen ? preferring energy-dense, nutritionally questionable foods ? eating while distracted by TV ? asks the authors from Boston Children’s.
Another interesting finding was that duration of use or extent of attention paid to video games or computers was not associated with BMI. It would have been interesting to determine if “computer time” means active engagement (compared to watching streamed video) that suppressed the desire to eat. Read more in Pediatrics.
Conflicting Advice By Pediatricians
Why pediatrics is so exciting and pediatricians so contradictory with their advice …… a great post by Claire McCarthy, MD, a Boston Children’s Hospital pediatrician, on the different pieces of advice we give parents. This one started from discussing sleep advice, but the issue is true for all aspects of parents’ advice.
Will you be satisfied with a drop of almost 50% in the rate of CT scans for children with suspected appendicitis ? we will. Less radiation (and reduced risk of cancer in the future), reduced cost and likely even shorter wait for operation ?
All a group from South Carolina had to do was to sit down and create clinical practice guideline. Pre-guidelines as many as 90% of children had a CT scan, and after implementation – only 48%. Ultrasound rate increased significantly but the no-imaging group also tripled. Published in Pediatric Emergency Care.
Maybe others just need to ‘sit’ and create guidelines.
A brave girl. An impossible diagnosis. A 12 year old with an emotional story about Familial Adenomatous Polyposis, a colon resection and how genetic testing changed her life, for now at least. Sanjay Gupta in Everyday Health.
Look for errors at home as well as in the hospital and clinic setting. After reviewing almost 1000 medications in the homes of children with cancer, a group from Massachusetts School of Medicine report 3.6 errors/100 patients and 36 errors/100 patients with potential for injury. Still lots to do, even at home !
Food allergy increases in the US. 8% have allergy and 30% of them more than one allergy. Dr. Wayne Shreffler from Massachusetts General and Dr. Ruchi Gupta from Chicago on this interesting NPR’s Radio show. GoEpiGo !
Compliance with anti-acne meds seems very low. In a study led by a pharmacist from University of Michigan, reviewing prescription databases of over 24000 patients (90% under 18 years old), average adherence rate to acne drugs was only 11.7%. Patients were less adherent to antibiotics and topical retinoids. The use of oral antibiotics dramatically reduced acne-related outpatient visits (by half) and reduced acne-related total health care cost by half !
Why are they not filling the script ?
Our (childrens’) life by YouTube. In a new paper in Pediatrics, investigators from Miami are concerned about the “Cinnamon Challenge” seen over 50,000 times on YouTube, and resulted in adolescents needing ER visits and hospitalizations. The video calls to try and swallow a tablespoon of cinnamon powder in 60 seconds with no water. The main problem with cinnamon is that it is a caustic powder that neither dissolve nor biodegrade in the lungs. Extensive cough, vomiting, nosebleed, and chest tightness were among the more serious symptoms.
Coping With Stress after Boston Marathon Bombing
Children want to know. Children need to know. And they usually have three questions on their mind, even if they do not articulate them well. Parents, teachers and pediatric health care providers must de-stress and allow children to understand the news. Psychology Today provides some practical advice to helping children cope with the stress.
Small Metallic Element That Makes a Difference
Zinc supplementation made a huge difference to the lives of millions of children in developing countries. Zinc is a safe and effective measure to shorten diarrhea-related illness in children and to possibly reduce other complications – including death !. Read in Canadian Family Physician.
Music to My Ears ….and for Neonatal Health
In a New York based randomized clinical trial, almost 300 premature babies in a neonatal intensive care unit were monitored while listening to lullabies. Cardiac and respiratory function was improved and even feeding behaviors and sucking patterns were better. But maybe more important, the music significantly decreased parental stress perception. Read the Pediatrics paper.
Sleep was shown over the years to improve physical and mental health. In a large cohort from Philadelphia, published in pediatrics, investigators report that the BMI of adolescents 14-18 years of age can benefit from sleep.
Follow-up on almost 1400 adolescents from ninth to twelfth grade found that the largest increase in BMI observed at the 90th BMI percentile. Each additional hour of sleep was associated with decreases in BMI at percentiles 10th to 90th. Increasing sleep from 7.5 to 10 hours per day at age 18 predicted a reduction in the proportion of adolescents with BMI >25 by 4%.
The challenge of getting adolescents off their computer and social media outlets, and have them sleep more is yet to be addressed.
While the season of bronchiolitis in North America is almost over, effort to find supportive therapy for the viral induced illness are continuing. In pediatrics, a group from the UK, reported an RCT looking at Heliox (21% oxygen + 79% helium) and Airox (21% oxygen + 79% nitrogen) for over 300 infants with bronchiolitis.
Length of treatment required to alleviate hypoxia and respiratory distress was not different between the two groups. When heliox was given via a nasal cannula – treatment was ineffective.
Following the decade-old Institute of Medicine (IOM) report determining no causal relationship between vaccines and autism, a new study in the Journal of Pediatrics challenges the belief that “too many vaccines too soon” may be associated with autism.
Comparing 256 children with autism spectrum disorder compared with 752 children without autism spectrum disorder, the amount of antigens from vaccines received on one day of vaccination and the amount of antigens from vaccines received in total during the first two years of life was not different.
“vaccine phobia” will continue to affect many parents’ decision making when it comes to vaccinating children, but the this study may provide health care providers with more tools to explain the safety of vaccines.
Parents Don’t Follow The Doctor’s Orders
Two-thirds of parents say they don’t always follow the advice they get from their child’s doctor, according to a new poll from the University of Michigan C.S. Mott Children’s Hospital National Poll on Children’s Health. Enhancing health literacy will also increase compliance. We can tell them what they need to know, answer parents’ questions and refer them to resources.
Antidepressants for functional gastrointestinal disorders in children
We know very little on treating functional gastrointestinal disorders in children and keep on learning how little we know. This recent Canadian Family Physician Journal review paper from the PRETx program (www.pretx.org) reflects on the use of antidepressants. Not enough evidence for their effectiveness.
Kids Play – AEDs are easy to use and can save lives. High school students can use them effectively the first time they see them. Read Contemporary Pediatrics with a nice summary on AEDs.
Clarity Around Otitis Media Diagnosis and Treatment
The American Academy of Pediatrics came out this month with an updated Clinical Practice Guideline for the ‘The Diagnosis and Management of Acute Otitis Media’. Bottom line – make the correct diagnosis (redness and effusion are not otitis), reduce pain as part of treatment, antibiotics for severe otitis in everyone 6 month and older, antibiotics for non-severe bilateral otitis in 6-23 month of age, choose observation (and reassessment) or treatment for non-severe unilateral otitis in 6-23 month of age or any otitis in older children.
Amoxicillin still the drug of choice. Give antibiotics with lactamase coverage for recurrent infections, recurrent purulent conjunctivitis and non-responders to Amox.
A must read for everyone treating children !
The High Toll of Giving Drugs To Children
Zed et al in Journal of Pediatrics reviewed papers with medication-related ED visits and hospital admissions. 0.5%-3.3% ended up in emergency department, 0.16%-4.3% had to be admitted, and up to two thirds were preventable !
From wrong prescription to overdose, allergic reaction and adverse drug reactions – all were documented well. The biggest offenders : antibiotics, CNS drugs, analgesics, hormones, cardiovascular and respiratory drugs and even vaccines.
Breastfeeding Good But Not For Obesity Prevention
In a finely designed study, Martin et al found breastfeeding does not promote reduced obesity later in life. In a cluster-randomized controlled trial in Belarus, with over 17 000 breastfeeding mother-infant pairs in 31 hospitals, child adiposity and circulating insulin-like growth factor (IGF)-I were not affected by exclusivity breastfeeding. Children may still be overweight or obese.
Read the CNN piece on enhancing attention using stimulants in healthy children. The American Academy of Neurology position paper againt the common practice of prescribing stimulants (and other drugs) to boost cognitive function in healthy children and teens.
FDA Warning On Azithromycin Intensify
Based on a New England Journal of Medicine paper on the known risk for prolonged QT interval and torsades de pointes - a new FDA warning is published. Should an ECG be done on every child on Azithro ?
Proton pump inhibitors for irritable infants
They cry – so lets treat them. While tolerated, PPIs in infants and children who cry do not show efficacy. They can cause gastro, pneumonia and other complications. Read this PRETx update in Canadian Family Physician.
Tonsillectomy for Strep Throat
Predicting ER Visits in Diabetes
Guillain-Barré Syndrome Review
Severe Bacterial Infection Score
Overdiagnosing ADHD
Celiac Disease and Immunization
Probiotics and Allergic Rhinitis
Water Safety
Smart Phone for Otitis Rescue
Track Migraine
Children Still Suffer
Physicians and Drug Reps
Geographic Variability of Food Allergy
The ‘First Dinner’
Localized Purpuric Rash
Acute Rhinosinusitis
The Benefits of Friends (the real ones….)
The Best Children’s Hospitals in the US
Anaphylaxis Following Immunization
Children Grow Online
Boxing for Children – a Health Issue ?
CT scans induce radiation exposure and Cancer
Baby Genome for a Price
Free Med School ?
Hypertonic Saline for Wheezing
The Clinical Picture of a Perforated appendix
Healthy Swimming
Biomarker for Head Injury
Music and the Brain
Cancer and Folic Acid
Internet Exposure in Childhood
Nebulizers or Pressurized MDIs for Asthma
Marketing Breast Milk Substitutes
Nighttime wakening post maternal Java
Hypertension on the Rise
Analgesia for Vaccinations
Time Magazine challenges Attachment parenting
Seizure Alert
Prolonged Pregnancy and ADHD
Overweight and Diabetes