PedSPAM October 1999

Welcome to PedSPAM for October. Here are some more things from my update reading that might interest you.

In the News

The following recommendations for bedding for infants under one year of age have been released by the American Academy of Pediatrics, the National Institute of Child Health and Human Development, and the United States Consumer Product Safety Commission:

Place the baby on his or her back on a firm, tight-fitting mattress in a crib that meets current safety standards
Remove pillows, quilts, comforters, sheepskins, stuffed toys and other soft products from the crib
Consider using a sleeper or other sleep clothing as an alternative to blankets, with no other covering
If using a blanket, put baby with feet at the foot of the crib. Tuck a thin blanket around the crib mattress, reaching only as far as the baby's chest.
Make sure your baby's head remains uncovered during sleep.
Do not place baby on a waterbed, sofa, soft mattress, pillow or other soft surface to sleep.

Italian doctors have reported that latex pacifiers may provoke latex allergy in infants. They reported the case of an 11 month old girl who had multiple allergy symptoms with an intractable cough that was unresponsive to normal treatment. Skin testing revealed allergy to latex but not to foods. Her symptoms resolved when her latex pacifier was replaced with a silicone one. Allergy 1999;54:1007.

A single oral dose of dexamethasone in the emergency room was as good as or better than a nebulized steroid treatment in resolving mild to moderate croup in a recent study reported at the annual meeting of the Pediatric Academic Societies. According to the researchers, the oral dose of dexamethasone is so much less expensive (about 50 cents) and so effective, that it is now the preferred steroid treatment for croup. And it sure hurts less than a shot of dexamethasone!

Dr. Patrick C. Friman, of the Father Flanagan's Boys' Home, Boys Town, Nebraska, reports in this month's Archives of Diseases in Childhood that children who have trouble staying quietly in bed after bedtime may be coaxed toward more acceptable behavior if parents give them a 'pass' good for one visit out of the bedroom per night. The children are allowed to exchange the card without penalty for one visit out of their room after bedtime. The visits are to be short and for a specific purpose -- a drink of water, a hug or a bathroom visit. Parents are instructed to ignore all crying out and to return the children to their room, without eye contact or verbal response, if the child left the room after the pass was surrendered. According to Dr. Friman, he has tried the technique with about 50 families to date. "The main thing parents like about it is that the kids like it so much."

I have not used this technique yet, but it sounds like a reasonable thing to try - I like to meet kids half way and shift the responsibility for their behavior to them as much as possible. The potential problem with this technique is the second part - what parents are to do if the child persists in misbehavior. This type of night intrusion by older children is an issue of failed limit-setting; the parents have already identified themselves as having trouble handling these issues. This technique will still require the parents to be firm in the event their child tests the limits by getting up after his one "free" trip.

To me this technique is reminiscent of the technique to stop pestering behavior: warn the child, "You can ask for the toy two more times, but then you will have to have a consequence." This generally stops the pestering cold and the child does not ask again.

Dr. Suad Nakamura of the US Consumer Product Safety Commission in Bethesda, Maryland, says that children younger than two years who are put to sleep in adult beds are at risk of death due to accidental overlying by the adult in the bed, suffocation by bedclothes or in waterbeds and death from head entrapment in the bed railings or adjacent furniture. A review of three Consumer Product Safety Commission databases generated between 1990 and 1997 revealed 515 deaths over an 8-year period among children younger than 2 years of age who slept in adult beds. Surprisingly, drug or alcohol consumption was a factor in only two cases. Because no one knows how many young children actually sleep in adult beds, the overall risk of death is unknown, the Nebraska clinician commented. "One of the most troubling aspects of these deaths is that they are largely preventable," Dr. Nakamura said.

A press release from the University of Notre Dame in Notre Dame, Indiana, calls Dr. Nakamura's findings "...too simplistic and inadequate for the sweeping recommendation being made." The advisory describes research by the university's Dr. James McKenna showing that "...even in the deepest stages of sleep, mothers arouse within seconds of the baby's strange sounds, sudden movements or touches." His data suggest beneficial effects to bed sharing when done safely, "...particularly when combined with breast feeding." Archives of Pediatric Medicine 1999:153,1019-1023,1027-1029.

Mothers rolling over on babies is really not the issue. I agree that this is exceedingly rare; fathers however have no such protective instincts, so inadvertant smothering by fathers is a real concern. Additionally, there were many instances documented i the study in which the infant or toddler slipped (was pushed) off the bed into the space between the bed and the wall, suffocating there.

I deal with childhood sleep problems all many times a day, literally every day of the year. My perspective is simple and my opinion well known: bed-sharing leads to an unacceptable number of problems relating to poor sleep in co-sleeping children. I find no convincing evidence in published literature that long term emotional or psychological outcomes are any better for co-sleeping children, and any preventable deaths at all are too many. Sorry if that offends the co-sleeping crowd; "That's my story, and I'm sticking to it."

It has long been known that boys with an undescended testicle were at 4-fold increased risk for testicular cancer. Danish researchers biopsied testicular tissue from undescended testes in 1,249 boys undergoing surgery for undescended testicle (cryptorchidism). Seven of the boys (eight involved testicles) had testicular cancer at the time of surgery. Those boys with intra-abdominal testicles, abnormalities of the external genitalia, and chromosomal abnormalities are more likely to have testicular cancer. Boys with none of these risk factors had no cases of testicular malignancy when biopsied at corrective surgery. British Medical Journal 319:888-889, 1999

Many physicians feel mounting frustration at having to spend more and more time responding to parental queries triggered by irresponsible media reports on vaccine side effects, Dr. Natalie J. Smith (chief of the immunization branch of the California Department of Health) said at a national immunization conference sponsored by the Centers for Disease Control and Prevention. A recent example was a series of articles in the San Jose Mercury News (available online as well) suggesting a connection between the combination measles-mumps-rubella vaccine (MMR) and autism and inflammatory bowel disease in children. No such link has been demonstrated in extensive expert reviews of the data. Pediatric News 33(9):9, 1999

The accusation, spoken or unspoken, is that somehow there is a conspiracy of - whom? scientists? - to suppress the truth about the evils of immunization, for some unspecified personal gain. Get a life! Childhood immunizations are a Godsend. They have prolonged the average life span more than any other advance in the history of medicine.

Check out:

http://www.nlm.nih.gov/research/visible/visible_human.html

the online digital library of MRI and CT images of the human body that can be viewed in different ways. A very impressive look at the body in ways that even doctors have never seen until now.

A Swedish study found that children exposed to pets in the first year of life had a lower incidence of allergic rhinitis (hay fever) and asthma in the school age years than those children who had no pet exposure. Children exposed to a cat in the first year of life had a lower incidence of a positive skin test for allergy to cats. The researchers say that early pet exposure may have a protective effect against the development of later allergic diseases. Clinical and Experimental Allergy 1999;29:611-17

Children who seem to have exercise induced asthma (wheezing and reduced lung airflow brought on by exercise) may actually have exercise induced hyperventilation, with very similar symptoms of shortness of breath and feelings of tightness in the chest. Clues to recognizing this phenomenon include the lack of wheezing and coughing with the attack and sometimes, the failure of rescue inhalers to improve the symptoms. Annals of Allergy, Asthma, and Immunology.

Comment: a neat way to differentiate the two conditions is to have the child take his or her peak flow meter to PE class, and to do a peak flow measurement during the attack. If the child is having an attack of exercised induced asthma, the peak flow reading will be sharply reduced. If the reading taken while symptoms are occurring is normal, then the child is hyperventilating.

A clinical trial will begin soon for a new vaccine against group A streptococcus (GAS), the causative bacterial agent of strep throat. Several million people suffer from strep throat infections each year, about 10,000 to 15,000 cases of serious invasive disease occur, causing about 2,000 deaths in the US. There are more than 90 distinct immunologic variations of the GAS germ, which has hindered development of a single vaccine. The trial vaccine will be directed against six types of GAS; the ultimate vaccine will most probably be a "polyvalent" vaccine against many different types.

The risk of melanoma from congenital moles or those acquired through young adulthood has been vastly overstated, according to Dr. Seth J. Orlow, a pediatric dermatologist of New York University Medical School, speaking at the annual meeting of the American Academy of Pediatrics. "Most moles are not precursors to melanoma." He added that it is highly unusual to see melanoma in children, calling such cases "unbelievably rare." He urged pediatricians to identify children at risk, make sure that they are closely followed, and recommend sun protection for everyone.

Complaints of back pain in school-age children are increasing due to the use of heavy backpack-style book bags according to a recently published survey of pediatricians by the American Academy of Orthopaedic Surgeons. Because some schools have eliminated lockers for security reasons, backpacks seem to be getting heavier and heavier. Backpacks that weigh more than 20% of the child's weight are potentially injurious. Backpacks should have wide padded shoulder straps, a padded back and even a hip strap if possible.

Specialized brain scanning during mental activity has shown that dyslexic children use significantly more brain area than healthy children during language tasks. "Because most children respond positively to instructional interventions, many educators have rejected the notion that reading problems are brain-based," Dr. Todd L. Richards, of the University of Washington in Seattle. This research refutes that view; brain metabolism was found to be significantly different in dyslexic children compared to control individuals with good reading skills. American Journal of Neuroradiology 1999;20:1393-1398.

Why does it seem your asthmatic child flares up with every cold? According to Dr. William Busse of the University of Wisconsin in Madison, Wisconsin, "The common cold virus is the most frequent cause of asthma exacerbations..." Dr. Busse found that 61% of asthma exacerbations in children and 44% of asthma exacerbations in adults are related to infection with rhinoviruses - the common cold viruses. This is because these viruses somehow stimulate the immune system of the lung airways to release inflammatory hormones that hyper-sensitize the lungs and trigger asthma attacks.

A new inhaled steroid preparation has been released which will greatly aid the care of small children with asthma. Nebulized medication (the "breathing machine") is generally the most effective for acute asthma flareups. Until now we have been hampered in treatment of very young children who cannot cooperate effectively with metered-dose canister medication systems, and no inhaled steroid (the most effective medication) was available for use with nebulizer machines. Now a new dosage formulation of nebulizable budesonide has been tested with infants as young as 6 months with good results. Annals of Allergy Asthma and Immunology 1999;83:231-239.

Laser myringotomy proponents were promoting this new technology at the American Academy of Otolaryngology Head and Neck Surgery Foundation annual meeting in New Orleans. They stated that children who underwent the procedure were all symptom free at one week, and that only 8% had middle ear fluid three months after undergoing the procedure versus 47% of those children treated with antibiotics over the same time frame. Children younger than 24 months who have had ongoing ear infection or middle ear fluid for 4 months or less and who have normal hearing experience the best outcomes with laser-assisted myringotomy. Downside: the laser is very expensive - about $60,000 - which will limit its use.

The National Highway Traffic Safety Administration (NHTSA) has issued a consumer advisory warning about potentially serious and fatal injuries to children from side air bags in automobiles. "Side impact air bags can provide significant supplemental safety benefits to adults in side impact crashes. However, children who are seated in close proximity to a side air bag may be at risk of serious or fatal injury, especially if the child's head, neck, or chest is in close proximity to the air bag at the time of deployment." The agency warns parents to ask dealers to deactivate rear side air bags unless the manufacturer of the car determines that the air bags are safe for children.

Screening newborns for congenital hearing loss is an increasingly accepted practice at hospitals. According to Dr. Albert Mehl, a pediatrician on the Colorado Infant Hearing Advisory Committee, it is cost-effective. Testing for hearing loss is more expensive initially than other screening tests given neonates, but that long-term savings outweigh the initial expense. He estimates the frequency of congenital hearing loss at 260 per 100,000 births. Children with congenital hearing loss who are not screened at birth generally are not diagnosed until about 30 months, which is too late in the development of language skills to avoid permanent harm to speech and language development. Screening is mandated in a handful of states, which are reluctant to deal with the considerable costs involved in the screening programs.

The Academy of Pediatrics will issue diagnostic guidelines for Attention Deficit/Hyperactivity Disorder (ADHD) next year. The guidelines are to be used to diagnose ADHD in children 6 to 12 years of age. ADHD affects at least 3% to 5% of school-aged children. Studies from primary care and school settings that were reviewed as part of the AAP guideline development process show that the prevalence may be as high as 8% to 10%. A majority of pediatricians feel they are overdiagnosing the condition, while about a quarter of pediatricians think they are underdiagnosing the condition.

On October 15, 1999 Wyeth Lederle Vaccines announced it was withdrawing the Rotashield® rotavirus vaccine from the market.

The following brief announcement was provided by the Centers for Disease Control and Prevention (CDC) on that day:

"Wyeth Lederle Vaccines announced this morning that it has withdrawn its RotaShield vaccine from the market and has requested the immediate return of all doses of the vaccine. The company's press release can be accessed at the web address below."

http://www.ahp.com/releases/wa_101599.htm

According to Wyeth Lederle's press release, for more information physicians may call (877) 768-2543. Consumers may call CDC's National Immunization Information Hotline at (800) 232-2522 (in English) or (800) 232-0233 (in Spanish).

CDC has previously published documents about rotavirus vaccine on the National Immunization Program website at: http://www.cdc.gov/nip/news/rotavirus.htm

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