Thursday, April 30, 2009


Author: Hakan Leblebicioglu, MD, Chairman, Professor, Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University Medical School, Turkey
Coauthor(s): Itzhak Brook, MD, MSc, Professor, Department of Pediatrics, Georgetown University School of Medicine
Updated: Apr 27, 2009


Influenza is the one of the most significant acute upper respiratory tract infections. Influenza viruses cause a broad array of respiratory illnesses responsible for significant morbidity and mortality in children. Influenza viruses cause epidemic disease (influenza virus types A and B) and sporadic disease (type C) in humans.


Influenza is an acute infection of the respiratory tract in the nose, throat, and, sometimes, the lungs. Following respiratory transmission, the virus attaches to and penetrates respiratory epithelial cells in the trachea and bronchi. Viral replication occurs, which results in the destruction of the host cell. Viremia does not occur. The virus is shed in respiratory secretions for 5-10 days.

Influenza occurs as sporadic illness, epidemics, or pandemics. Epidemic disease occurs annually, especially in the winter months.

Influenza viruses cause global pandemics, in part because of the high degree of transmissibility and the emergence of an influenza virus with a major antigenic shift (major antigenic variations on the hemagglutinin surface protein) in a nonimmune population. The most recent pandemics included the 1889 pandemic, the 1918-1919 Spanish pandemic (influenza virus subtype H1), the 1957 pandemic (subtype H2N2), the 1968-1969 pandemic (Hong Kong subtype H3N2), and, to a lesser extent, the Russian pandemic in 1977 (subtype H1N1). Approximately 21 million persons died worldwide in the 1918-1919 influenza pandemic, with 549,000 deaths in the United States.

H1N1 swine influenza

On April 26th, 2009, the US Department of Health and Human Services issued a nationwide public health emergency regarding human cases of swine influenza A (H1N1) virus (swine flu).1 In the preceding weeks, an outbreak of the virus was reported in Mexico (approximately 1600 cases) and the United States (40 cases as of 1 pm on April 27, according to the Centers for Disease Control and Prevention [CDC]); the outbreak is due to a new strain of influenza virus that contains a combination of swine, avian, and human influenza virus genes.

In Mexico, 103 deaths are suspected to be caused by the recent swine influenza (swine flu) outbreak. The virus has been confirmed in patients in California (7), Kansas (2), New York City (28), Ohio (1), and Texas (2). No deaths from the virus have been confirmed in the United States.2 Internationally, confirmed cases have also been reported in Canada, New Zealand, Spain, and the United Kingdom (Scotland), with suspected cases in Brazil, Israel, and France.3

If swine influenza (swine flu) is suspected, clinicians should obtain a respiratory swab for swine influenza (swine flu) testing and place it in a refrigerator (not a freezer). Once collected, the clinician should contact their state or local health department to facilitate transport and timely diagnosis at a state public health laboratory.4

The new virus is resistant to the antiviral agents amantadine and rimantadine but sensitive to oseltamivir (Tamiflu) and zanamivir (Relenza).
Initiation of antiviral agents within 48 hours of symptom onset is imperative to provide treatment efficacy against influenza virus.
The usual vaccine for influenza administered at the beginning of the influenza season is not effective for this viral strain.

Initial symptoms of swine influenza (swine flu) include high fever, myalgias, rhinorrhea, and sore throat. Nausea, diarrhea, and vomiting have also been reported.

Infection control precautions (ie, handwashing, covering mouth with tissue when sneezing or coughing) are encouraged.
If suspected swine influenza occurs, isolation is recommended for infected individuals and household contacts.

United States

Approximately 250,000-500,000 new cases of influenza occur each year in the United States.

Influenza viruses cause 20,000 deaths and 200,000 hospitalizations each year in the United States.

No difference based on race has been identified.

No difference based on sex has been identified.

The infection rate of influenza viruses is high in all age groups. The infection rate and the frequency of isolation of influenza viruses are highest in young children. The infection rate in healthy children is 10-30% annually.

Clinical History
Typical symptoms of influenza begin 2-3 days after exposure to the virus.
Influenza produces an acute febrile respiratory illness with cough, headache, and myalgia for 3-4 days, with symptoms that may persist for up to 2 weeks.
Patients may present with sudden onset of the following:
High fever

Subsequent respiratory symptoms include the following:
Sore throat/pharyngitis
Nasal congestion
Nonproductive cough
Cervical lymphadenopathy
Conjunctivitis, rhinitis, and GI tract symptoms are more common in infants and young children than in adults.

In young infants, influenza may produce a sepsislike picture with shock; occasionally, influenza viruses can cause croup or pneumonia.
Similar symptoms can be seen in close contacts or family members.

Influenza is an acute infection caused by any of 3 types of viruses (A, B, C). Types A and B cause epidemic disease, and type C causes sporadic disease. Type A is the most common.
Influenza is highly contagious. The virus is spread when an individual inhales infected air-borne droplets (following coughing or sneezing by an infected person) or comes in direct contact with an infected person's secretions (eg, kissing, sharing of handkerchiefs and other items, sharing of objects such as spoons and forks). Viruses may also be transmitted via touching of smooth surfaces, such as doorknobs, handles, and telephones.
Influenza virus types A and B usually occur in the winter and spring.
At-risk groups include elderly persons; individuals with chronic respiratory disease, chronic cardiac disease, chronic renal failure, diabetes mellitus, immunosuppression; and persons living in residential care homes and long-stay facilities.

Severe acute respiratory syndrome (SARS)
SARS is a serious, infectious, pulmonary illness that is spreading through many countries in Asia, with suspected cases in Europe, Australia, Canada, and the United States. The main symptoms include a high fever, cough, and shortness of breath or other breathing difficulties.

On March 24, 2003, scientists at the CDC and in Hong Kong announced that a new coronavirus had been isolated from patients with SARS. Over the next 2 weeks, the machinery to discover and characterize the pathogen was set in full motion by scientists at the CDC and in 10 other World Health Organization (WHO) –collaborating laboratories. Coronavirus has not been proven to be the cause of SARS, but strong supportive evidence is accumulating.


Saturday, April 25, 2009

ADHD Management Reviewed

Attention-Deficit/Hyperactivity Disorder Management Reviewed

Laurie Barclay, MD

April 24, 2009 — Diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) in the primary care setting are reviewed in an article published in the April 15 issue of the American Family Physician.

"...ADHD is a chronic, neurobiologic, behavioral disorder that affects 2 to 16 percent of school-aged children, depending on the diagnostic criteria and population studied (e.g., primary care versus referral)," write Robert Rader, MD, DPh, from Saint Anthony Family Medicine Residency in Oklahoma City, Oklahoma, and colleagues. "The symptoms of ADHD affect cognitive, academic, behavioral, emotional, social, and developmental functioning....Although there are many theories, no single etiology for ADHD has been substantiated."

ADHD is the most frequently diagnosed neurodevelopmental disorder in children and adolescents. Although the pathogenesis of ADHD is still poorly understood, most recent studies have attempted to clarify the role of neurotransmitters including dopamine, norepinephrine, and, most recently, serotonin.

Three general subtypes of ADHD have been identified for purposes of classification: predominantly hyperactive-impulsive, predominantly inattentive, and combined. To facilitate diagnosis and management, screening tools and rating scales have been developed. These include broadband assessments, narrowband assessments, and evaluation of medication adverse effects.

The functioning of the child with ADHD and the quality of life of the patient and family can be dramatically improved with appropriate treatment. A combination of pharmacotherapy and behavioral management is usually recommended.

Pharmacologic treatment includes methylphenidate, mixed amphetamine salts, or other stimulants, and/or nonstimulants such as atomoxetine. There is no evidence supporting the use of 1 stimulant vs another, and short-acting, intermediate-acting, and long-acting preparations have similar effectiveness. Short-acting preparations timed appropriately may facilitate certain activities, whereas long-acting formulations eliminate the need to give medication during school, improve compliance, and decrease opportunity for abuse.

"Treatment should be initiated at low dosages and then titrated over two to four weeks until an adequate response is achieved or unacceptable adverse effects occur," the study authors write. "If one stimulant is not effective, another should be attempted before second-line medications are considered. Although some children benefit from daily psychostimulant therapy, weekend and summer 'drug holidays' are suggested for children whose ADHD symptoms predominantly affect schoolwork or to limit adverse effects (e.g., appetite suppression, abdominal pain, headache, insomnia, irritability, tics)."

Behavioral approaches are also effective, especially those that immediately reward desirable behavior with tokens or points. The efficacy of psychotherapy and cognitive behavioral therapy for the treatment of ADHD has not been tested in high-quality studies.

Key clinical recommendations for practice, and their accompanying level of evidence, are as follows:

• Obtaining information from teachers, family members, and non–family members who are familiar with the child's behavior is essential to properly diagnose ADHD (level of evidence, C).

• The first-line treatment for most patients with ADHD is pharmacologic treatment with stimulant medication (level of evidence, A).

• Compared with intensive behavioral treatment alone, carefully monitored pharmacotherapy is typically more effective for ADHD (level of evidence, B).

• Support groups for parents of children with ADHD facilitate networking with others who have children with similar problems (level of evidence, B).

Combined recommendations from the American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry (AACAP) for the evaluation of children with suspected ADHD are as follows:

• A child aged 6 to 12 years presenting with inattention, hyperactivity, impulsivity, academic underachievement, or behavioral problems should be evaluated for ADHD by the primary care physician. This evaluation should include the following:

o Standard history and physical examination. The AACAP also recommends evaluating the patient's developmental history, hearing and vision, history of learning difficulties or psychiatric disease illness, and family history of ADHD.

o Neurologic examination

o Family evaluation. The AACAP also recommends assessment of family stressors and family coping style.

o School evaluation.

• Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision (DSM-IV) diagnostic criteria for ADHD must be met to diagnose this condition.

• Information obtained directly from parents or caregivers is needed for accurate diagnosis of ADHD. This should include a description of the main symptoms of ADHD in different settings, age at onset of symptoms, duration of symptoms, and severity of functional impairment.

• Information obtained directly from the classroom teacher, or other school-based professional, should be an important part of the evaluation for ADHD. This should highlight information regarding the core symptoms of ADHD, duration of symptoms, severity of functional impairment, and comorbid conditions. The physician should review all available reports from a school-based multidisciplinary evaluation, including evaluations from the child's teacher or other school-based professional.

• Assessment of a child with ADHD should include workup for comorbid conditions including learning and language disabilities, oppositional defiant disorder, conduct disorder, anxiety, and depression.

• Diagnostic testing in the absence of specific indications is not routinely recommended. Tests that might be appropriate in certain clinical settings include measurement of lead and thyroid hormone levels, neuroimaging, and/or electroencephalography.

In an editor's note, Caroline Wellbery, MD, writes: "As this article was going to press, a study by Molina and colleagues was released questioning the long-term effectiveness of ADHD drug therapy. The study showed that there were no significant differences among pharmacologic, behavioral, and combined therapy groups after six to eight years, and that all children in the study had significant impairment compared with unaffected peers."

Am Fam Physician. 2009;79:657-665.

Thursday, April 23, 2009

Pacifier Use and Breastfeeding

Pacifier Use May Not Adversely Affect Breast-Feeding Duration or Exclusivity

by Laurie Barclay

April 15, 2009 — Pacifier use may not adversely affect breast-feeding duration or exclusivity, according to the results of a systematic review reported in the April issue of the Archives of Pediatrics & Adolescent Medicine.

"Physicians who counsel families about pacifier use must now weigh the potential protective effect against SIDS [sudden infant death syndrome] against the potential deleterious effect on breastfeeding," write Nina R. O'Connor, MD, from University of Virginia School of Medicine in Charlottesville (at the time of the study), and colleagues. "To assist in this decision balance, a systematic review of the literature regarding the impact of pacifier use on breastfeeding was undertaken in an attempt to summarize the current evidence."

The investigators searched MEDLINE, CINAHL, the Cochrane Library, EMBASE, POPLINE, and bibliographies of identified articles for English-language records from January 1950 through August 2006 containing the Medical Subject Heading terms pacifiers and breast-feeding. Of 1098 reports identified, and after exclusion of duplicate and irrelevant studies, 29 studies met inclusion criteria for the review, including 4 randomized controlled trials (RCTs), 20 cohort studies, and 5 cross-sectional studies.

Two independent reviewers abstracted data from these studies and graded them for quality, with disagreements settled through consensus opinion reached using a third investigator. The exposure of interest was pacifier use, and the primary study endpoints were breast-feeding duration or exclusivity.

The 4 RCTs showed no difference in breast-feeding outcomes associated with different pacifier interventions, ie, pacifier use during tube feeds, pacifier use at any time after delivery, maternal education emphasizing avoidance of pacifiers, and a UNICEF(United Nations Children's Fund)/World Health Organization Baby Friendly Hospital environment. Pacifier use was associated with reduced duration of breast-feeding in most observational studies.

Limitations of this review include the possibility that pacifier use may be a marker for breast-feeding problems, inclusion of English-language reports only, and that none of the studies looked at pacifier use only at nap time or bedtime.

"The highest level of evidence does not support an adverse relationship between pacifier use and breastfeeding duration or exclusivity," the study authors write. "The association between shortened duration of breastfeeding and pacifier use in observational studies likely reflects a number of other complex factors, such as breastfeeding difficulties or intent to wean. Ongoing quantitative and qualitative research is needed to better understand the relationship between pacifier use and breastfeeding."

The University of Virginia Children's Hospital Research Grants Program supported this study in part. The review authors have disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. 2009;163:378-382.

Laurie Barclay, MD, is a freelance writer and reviewer for Medscape.

Saturday, April 11, 2009

Confinement Home with Pediatric Backup in Kuching

After 32 years in medical practice and the last 20 years as a pediatrician, I have seen the difficulties many young parents (and new grandparents!) face after leaving the hospital with their new baby.

Those fortunate enough to find good confinement nannies still have to cope with their increasing demands - no cooking for rest of family; no looking after other kids; no laundry; one day off a week etc. Others, not so fortunate, have nannies who cannot help at the last minute or end their services prematurely; or those whose hygeine and traditional practices makes one wonder if the baby is really in good hands (sometimes, really, they are not - but parents by then are too scared to upset the nanny - in case she quits or worse - does bad things to the baby).

No wonder 13% of pregnant women and new mothers have depression! (Dads have postnatal depression too !)

Why are medical professionals not involved in helping parents through this tough and tiring confinement period and have left it to the (usually uneducated) confinement nannies for so long?

So why not provide this service in a safe confinement centre - so mum can rest while the baby is medically monitored and professionally taken care of?
At the same time provide a venue where young and new parents can learn how to safely hold, bathe, dress, soothe and massage baby and all the essentials of parenting and child care?

So, one year ago, I started the process of applying for a license from the Ministry of Health Malaysia to operate a confinement home in Kuching. The plans had to meet the stringent requirements of MOH to ensure client safety and hygiene and was finally approved after several revisions.

Finally the confinement center is completed and ready - the first of its kind in Sarawak.

Medically run and with pediatric backup, Havilah Confinement Home hopes to become your confinement service of choice.

But above all, if you are expecting your baby and really need to learn how to take care of this wonderful gift (who unfortunately does not come with an operator's manual!) - we can help you!

Call +06 082 366452 or +06 016 85 20 200 (or sms - we will call back)

website :

Thursday, April 9, 2009

Parenting Practices and ADHD

Robert L. Findling, MD, discusses the relationship between ADHD symptom expression and parenting practices in his latest video blog.

From Medscape Psychiatry & Mental Health
Findling on Psychiatry

Posted 03/30/2009