PedSPAM April 1999

In the News

The US Consumer Product Safety Commission (CPSC) wants more stringent US bedding guidelines in an aim to further reduce sudden infant death syndrome (SIDS) incidence. They recommend that infants under 12 months should have no soft bedding of any kind in their crib. "Even if [parents] see retailers displaying cribs with fancy quilts and comforters, and they may be given them as gifts -- when they have a new baby one thing they should remember is that none of that material should be in the bed with the baby until after the baby is 12 months old," and is ready to move from a crib to a bed, says Russ Rader of the CPSC. "We still have about 900 infants a year who die, we think, because they suffocate in soft bedding in some way," he said. "In some cases, it is when they pull it up over themselves, so even while they are sleeping on their back they can suffocate."

The CPSC released the following revised recommendations in conjunction with the American Academy of Pediatrics and the National Institute of Child Heath and Human Development:

Place the baby on his or her back on a firm mattress that fits in the crib tightly.
Remove all soft products from the crib, such as pillows, quilts, comforters, sheepskins and stuffed toys.
Consider using just a sleeper with no blanket. If using a blanket, tuck a thin blanket around the mattress and baby, only as far up as the baby's chest.
Make sure the baby's head is uncovered during sleep.

A study in this month's Pediatrics finds that early pacifier introduction was associated with reduced rates of long term breast feeding. There was no measurable difference for the first three months, but after that time, early pacifier introduction was associated with a reduction in the length of time mothers breast fed their babies. Early pacifier introduction was defined as introduction before 6 weeks of age. I have seen few breast fed babies even take a pacifier first introduced after 6 weeks, so I think this study is seriously flawed by preselecting for children of mothers who are more dedicated to prolonged breast feeding. Pediatrics 1999;103:e33.

A study finds that maternal smoking during pregnancy increases the chances that infants will have wheezing in the first year of life. What? Mothers who smoke during pregnancy sure don't stop just for a little thing like the birth of their baby. Maternal smoking around little babies has been well documented to increase the incidence of wheezing in the children. I am certainly no fan of maternal smoking, but this must have been National Fuzzy Conclusions Month. From the February issue of the American Journal of Respiratory and Critical Care Medicine.

The American Academy of Pediatrics has released a new policy statement on circumcision. The new statement has a somewhat softer tone than the previous one, stating that while there are medical benefits to circumcision, "...these benefits are not compelling enough to warrant the AAP to recommend routine newborn circumcision."

Infants identified with hearing loss by newborn screening exams should have genetic testing for the connexin 26 (Cx26) gene. This mutation can cause progressive and profound hearing loss, and if present, warrants "aggressive intervention." Pediatrics 1999;103:546-550.

A study sure to cause some controversy finds that children of mothers who work while the children are young appear in general to fare no better or worse in the long run than children of stay-at-home mothers, according to a study in the March issue of Developmental Psychology, March 1999. There were slight differences identified in the areas of language development and academic performance, but these disappeared by age 12. Children of mothers who reenter the work force before the child is about 3 or 4 are somewhat more likely to be a "compliance problem," but this, too apparently disappears with time. Developmental Psychology 1999;35:445-459.

Premature babies, especially those who had significant lung disease, are now benefitting from a new therapy to prevent serious viral lung infections caused by respiratory syncytial virus (RSV). The American Academy of Pediatrics (AAP) released guidelines for use of the newest RSV treatment, palivizumab (Synagis¨). This is an intramuscularly administered monoclonal antibody preparation directed against a protein of RSV. This preparation should largely replace administration of anti-RSV gamma globulin (RSV-IGIV), the previous treatment option (which has some associated complications). However, RSV-IGIV provides additional protection against other respiratory viral illness and may be preferred for selected high-risk children, so it will still be around. Both of these treatments are very expensive and are definitely not for general use; there is ongoing debate about how "cost effective" they are.

If your child is treated for streptococcal pharyngitis (strep throat) and has another bout of it soon after the first round of treatment is over - treatment failure - suspect contaminated toothbrushes or orthodontic appliances. So implies a recent study that found the strep germs persisting on toothbrushes and appliances that were not rinsed properly. The researchers were not sure whether the persistence of the germ on the toothbrushes was the cause or the result of treatment failure, but it makes sense to thoroughly clean dental appliances daily during strep treatment and either replace or thoroughly clean children's toothbrushes during strep treatment.

And of course don't forget last month's report that once-a-day amoxicillin ("the pink medicine" 8-) is just as good as three-times-a-day administration (and a heck of a lot easier to remember).

Exercise may be a safer approach to weight control than dieting for adolescent girls, according to a study of eating disorders. The researchers found that teenaged girls, severe dieting increases the risk of new eating disorders by up to 18 times, moderate dieting increases the risk 5-fold. British Medical Journal 318:765-768, 1999

Overweight children and adolescents are at increased risk of adult obesity and other cardiovascular risk factors, but a reduction in the rate of weight gain during childhood and adolescence may be enough to eliminate such risks during adulthood, according to the Minneapolis Children's Blood Pressure Study, in which weight and other cardiovascular risk factors were measured serially in 679 children for 16 years. Height, weight and body mass index at age 7 years were associated with height, weight, body mass index, fasting insulin levels (a predictor of diabetes), lipid levels and systolic blood pressure at age 23 years. While the implications of the findings are "compelling," the investigators say in the report that the solution to the problem is not as simple as introducing weight loss programs for children and adolescents. Issues such as compliance and resources, as well as the sensitivity of this age group to eating disorders, make weight management a difficult topic to address. Circulation 1999;99:1471-1476.

Physicians' perceptions of parental expectations for antibiotics was the only significant predictor of prescribing antibiotics for presumed viral illnesses (for which antibiotics are worthless). In the study, physicians routinely prescribed antibiotics if they thought the parents expected them; however, if the physician explained the reasoning for withholding the antibiotics well, parents were generally satisfied. Pediatrics 103:711-718.

British researchers who studied long-term outcomes in 5- and 10-year-olds born in 1970 with histories of middle ear disease warn that early interventions are necessary to prevent development of behavioral problems and other long-term complications. The study was begun at a time in Britain when, at least to my understanding, otitis media was treated much less aggressively than is today the case in the US. It points out the danger of accepting too quickly the premise that treatment of ear disease with antibiotics is a bad idea. This study only confirms what used to be common knowledge: we treat ear disease in children for a good reason. The question of the optimal way to manage chronic ear infections is still important. Archives of Disease in Childhood 1999;80:28-35.

British researchers also report that delay of up to 9 months in placing tympanostomy tubes in the ears of children with chronic middle ear effusion does not lead to permanent impairment of a child's language and speech development. A 9-month period of waiting prior to surgery had "no detrimental effect" on expressive language and verbal comprehension following. But the researchers caution that waiting longer than 9 months to correct the hearing deficit caused by chronic ear fluid could delay expressive language development. American recommendations are usually to place tubes after at least three or more months of ear fluid; this study simply reconfirms that there is no rush to get to the operating room. Lancet 1999;353:960-963

So we can conclude from these studies that ignoring ear disease is a bad idea, but a good trial of medical intervention before surgical treatment is certainly not harmful. What role antibiotics should play in the medical intervention - how much to treat, whether to use preventative antibiotics - remains the current debate topic.

The expected incidence of sudden infant death syndrome (SIDS) cases in child care settings should be less than 10% of the total incidence of SIDS, but about a fifth of all SIDS cases - twice the expected rate - occur in child care settings. When compared with deaths that occurred outside of child care, deaths in these settings occurred in older infants, infants of more educated mothers, in non-African American infants and during regular workday hours. Infants in the day care setting were more likely to be found in the prone (stomach-sleeping) position. Parents must emphasize the importance of back sleeping for their infants and insist on it with their child care facility. (As reported at the annual meeting of the Ambulatory Pediatric Association.)

Adderall¨ is at least as effective as and in some ways is superior to Ritalin¨ in children with ADHD. Children were evaluated in a crossover study with Ritalin¨, Adderall¨, and a placebo and evaluated while participating in an intensive behavioral intervention program. The study also found that with both drugs, there were still significant positive effects at midday, when the drugs are said to wear off. The researchers say this is why a lower noon dose is often effective. Pediatrics 1999;103:e43.

Children of alcoholics have an altered brain chemistry that appears to make them more likely to become alcoholics themselves, according to a recent study by Johns Hopkins scientists. By using a drug-based technique that highlights differences in natural opioid activity in the brain, the researchers found that the young adults they studied from strongly alcoholic families had much lower levels of natural opioids in the brain. They speculate that this results in a heightened response to the "rewards" of alcohol, increasing the likelihood for dependence. In the December Annals of General Psychiatry.

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