PedSPAM February 1998

Welcome to PedSPAM for February. Here are some things from my update reading and a few additional topics for the Encyclopedia. This month's news is digested from various sources.

In the News

Single Injection Therapy for Otitis Media

An advisory committee of the Food and Drug Administration (FDA) has approved the first single-dose injection treatment for otitis media. The drug, ceftriaxone (Rocephin®) has been available in the US for 13 years. Previously it has been used mainly for serious infections in a hospital setting.

This is a thoroughly bad idea. Ceftriaxone is the pediatrician's friend when dealing with serious or potentially serious, life-threatening infections in children. It is the drug of choice in a number of situations - possible meningitis or blood-stream infections at the top of the list. When a child is very sick, blood, spinal fluid and urine cultures are obtained, and the child is placed on antibiotics with a broad enough spectrum of bacteria killing coverage to help the body eradicate the germs present. The availability of such a broad spectrum antibiotic, especially one that is just about as effective given intramuscularly as by vein (sometimes starting an IV can be extraordinarily difficult and time-consuming, especially in very small or very sick children) can be a life saver.

The fear is that if this antibiotic is used for routine ear infection treatment, resistant germs will emerge much more rapidly. The convenience factor of one shot therapy for the most common bacterial infection of childhood will not be lost on working parents. The drug is already overused in emergency rooms; we really don't need the drug for ear infections and we are going to be mighty sorry when Rocephin® resistant bacteria become a problem.

New Growth Charts Coming

The World Health Organization is revising infant growth charts to reflect the fact that breast fed infants gain 600-650 grams (1 pound 5 to 7 ounces) less weight in the first year of life. The growth charts in current use are based on data that was obtained largely with bottle fed infants. The new growth charts, which will more accurately reflect growth for breast fed babies, will take about five years to research and prepare.

I have mixed feelings about this one, too. It is clearly established that there are many benefits from breast feeding, and it is the feeding method of choice for infants. The problem I see is perhaps a subtle one, but potentially important. That is that in compiling averages for weight gain, there will be included in those averages babies whose mothers did not produce adequate amounts of breast milk for optimum nutrition. (Studies show approximately one in ten mothers is unable to produce enough milk to exclusively breast feed her infant.) Malnutrition in early infancy has potentially serious long-term sequelae; permanently smaller size and lower IQ being two important ones. The opinion of the group doing the new study seems to be that bigger babies are bad per se if they are bottle fed. I do not believe there is any evidence to support that assumption at all. I think I feel my face brushed by the breezes of political correctness.

EMLA is an anesthetic cream that can be applied to the skin or to a laceration to provide local anesthesia. It has been now tested for use in routine circumcision and it works. Measurements of pain and stress in babies undergoing circumcision were significantly lower when EMLA was applied beforehand. Previous concerns that the cream could cause methemoglobinemia, a blood disorder, were unfounded for single applications in newborns.

Rapid strep tests do not need to be backed up by overnight culture, according to an analysis of costs and benefits. Backing up the rapid strep with overnight culture is a basically a waste of money in the United States at this time. (I love a study that reconfirms my own belief.)

About 38% of children age 2 months to 5 years are exposed to environmental tobacco smoke (parental smoking) in the home according to the Third National Health and Nutrition Examination Survey. About 24% of babies were exposed to maternal smoking prenatally. Parental smoking is a confirmed risk factor for asthma, wheezing, and chronic bronchitis in the first few years of life.

Mild diet-treated gestational diabetes in the mother is not a risk factor for childhood obesity.

A study by the Kaiser Permanente Medical Center in Honolulu, Hawaii found an incidence of 1.4 of every 1000 well babies with severe bilateral hearing deficiency at birth. These children were identified with a computerized screening device at a significant cost - about $17,000 per case identified. However, the identified children were fitted with amplification hearing aids and all developed age-appropriate speech and language development. Infants who are missed fail to develop proper speech and suffer from language learning deficits that cost many times these screening costs to re mediate (the article I read estimated up to a million dollars in lifetime cost to miss one case).

Similac® infant formula has been reformulated to contain nucleotides (building blocks of DNA) found in human breast milk. A study confirmed that this enhances the formation of immunity to several vaccines as well as lowering the incidence of diarrheal disease in infants when compared to non-fortified formula. The benefit was the same as that of breast milk. This reconfirms the benefit of breast feeding, and argues for the use of nucleotide-fortified formula (Similac® being the only one currently available).

Three percent of US households now contain a lizard, turtle, tortoise or snake. Reptiles in the home do not mix well with small children. Even ostensibly healthy reptiles can transmit Salmonella germs to humans and cause serious bacterial gastrointestinal disease in the very young, as well as in the elderly, pregnant women and the immunosuppressed (cancer chemotherapy patients as well as HIV positive persons). A Centers for Disease Control (CDC) study found that 60% of all reptiles in stores in the San Francisco Bay area were positive for Salmonella germs in the stools. Bottom line: keep reptiles out of households where there are infants under one year of age or persons with weakened immune systems. If you already have such a critter and can't part with it:

wash your hands after handling the pet or any of its excreta
never wash the pet's bowls in the kitchen sink - wash them outside or in the laundry sink
do not let reptiles wander through the house - the Salmonella they smear around can survive up to 30 months

Hypospadias is a congenital malformation of the penis. Instead of the urethral opening appearing at the very end of the penile shaft, it is placed somewhere on the underside of the shaft. This may result in the opening being just a bit lower and more downward directed than normal, or in more severe cases the opening may be positioned anywhere along the shaft of the penis. This malformation occurs when the opening of the urethra, which starts out at the same point in both male and female fetuses, fails to migrate all the way up the shaft of the penis to the end. (Technically, this is because the urethral folds fail to "zip up" properly.) This migration is under the influence of fetal testosterone and is complete by about 12 weeks gestation. The incidence and severity of hypospadias has doubled in the United States over the last 25 years. This increase is believed to stem from environmental pollution with substances that have either estrogen-like effects or testosterone-blocking effects. These include common insecticides such as arsenic, parathion, atrazine, and alachlor. These pseudo-estrogens may be linked to lowered sperm counts in men as well as breast cancer, fibroids and other reproductive tract problems in women.

The cure rate for childhood leukemia has improved from 9% in 1962 to 75% today. Expectation is for a 90% cure rate within a few years.

A study of co-sleeping (sleep with mother) by breast feeding infants showed that the infants nursed more at night (surprise!) and had more night wakings even when they slept apart from the mother. This reinforces my observations and conclusion that allowing babies to sleep with the parents is not a good long-term plan, as it leads to a host of sleep-related problems later on in infancy. I have found it true in counselling mothers using my video that co-sleeping can lead to very dependent and demanding behavior from the child at night.

Sleep Tight Video© Site Information/Disclaimer