Thursday, May 19, 2011

Effectiveness of DTaP Wanes Substantially Over Time

Medscape Medical News from the National Foundation for Infectious Diseases (NFID) 14th Annual Conference on Vaccine Research

Sandra Yin

May 19, 2011 (Baltimore, Maryland) — The protective power of the diphtheria, tetanus, acellular pertussis vaccination (DTaP) wanes with time, according to a study presented here at the National Foundation for Infectious Diseases 14th Annual Conference on Vaccine Research.

"The most surprising finding is that the vaccine wanes as much as it does over time," lead author Roger Baxter, MD, told Medscape Medical News. He is codirector of Kaiser Permanente's Vaccine Study Center in Oakland, California, where he helps track and monitor the safety of vaccines for the US Centers for Disease Control and Prevention in Atlanta, Georgia.

Each year that elapses after vaccination is associated with a 36% increased risk of acquiring pertussis, he said.

"If you look over time, this means that whatever your DTaP vaccine was worth to begin with, at 3 years it's 32% and at 5 years it's 16% of your initial effectiveness," Dr. Baxter told meeting attendees.

The study, which is based on a population of 22,700 Kaiser Permanente of Northern California members, 4 to 11 years of age, was conducted between December 2005 and December 2010. Researchers analyzed pertussis rates, confirmed with polymerase chain reaction (PCR), and assessed the risk for a positive pertussis test in relation to days elapsed since the fifth dose of DTaP. In 2010, California saw its highest rate of pertussis in more than 50 years.

PCR tests revealed that 5.7% of tests were positive for Bordetella pertussis. Rates were highest in infants and in children 8 to 12 years of age. Decreasing rates in children 10 to 14 years coincided both with the use of the adolescent formulation of Tdap (tetanus, diphtheria, pertussis vaccination), rather than DTaP, and with the use during infancy of whole-cell vaccines.

In a related finding, the researchers found that acellular pertussis vaccines appeared to offer much less protection than whole-cell vaccines.

Dr. Baxter explained that the mix of proteins in the vaccine plays a role in the decreased efficacy of the acellular vaccine, compared with the whole-cell vaccine. "The whole-cell vaccine really stimulates a lot more of all different types of immunities," he told Medscape Medical News.

Since the 1990s, acellular pertussis vaccines replaced whole-cell vaccines in the United States, starting with the fourth and fifth doses, then moving to priming doses. Many states mandate the fifth dose for school entry. It is generally given to children 4 to 6 years of age.

The study seems to explain why pertussis has been increasing over the past 25 years, Dr. Baxter said. He explained that researchers have noticed blips every few years that seem to be getting bigger each year, "and it does seem to be happening since we moved to the acellular pertussis vaccine."

He characterized DTaP as both wonderful and problematic. "They're just not as good as the whole-cell vaccines," he said. But part of the problem with the latter is that parents don't want to return to a vaccine that could have severe adverse effects.

What's more, it's hard to get a good read on how effective the acellular vaccine is, the investigator said. When DTaP showed up, pertussis had been wiped out because whole cell "is that good," Dr. Baxter said. There wasn't a way to study how well DTaP vaccines really work, other than by determining whether they produced antibodies to certain antigens. Although they work as well or better at actually producing antibodies, that didn't mean they work as well, he observed.

Myron Levine, MD, DPTH, from University of Maryland School of Medicine in Baltimore, who moderated the presentation, had a different take. The researchers "did not take into account the severity of the disease," Dr. Levine told Medscape Medical News, "and the efficacy is related to the severity of disease." The acellular pertussis vaccine is more protective the more severe the disease gets, he explained.

When asked to clarify context, Dr. Baxter said: "In this case, we're simply using a test and only saying this is how well it protects vs actual tests of positivity."

Dr. Levine later told Medscape Medical News that whole-cell vaccines, which are still used routinely in the developing world, were unfairly attacked in the past. "We're seeing some of the downside of getting rid of the old whole-cell vaccine," but it's impossible to go back to whole cell, because of its detractors who impugned the vaccine for causing severe reactions, he said.
"It really turns out that there's no difference between acellular and the old whole cell for those rare severe events," he said.

There's a longer-term effect to moving away from the old whole-cell vaccine, Dr. Levine warned. "What one loses is the adjuvant effects of the whole-cell vaccine," he explained, "and, I think, the more potent stimulation of immunity."

National Foundation for Infectious Diseases (NFID) 14th Annual Conference on Vaccine Research: Session S22. Presented May 18, 2011.

Correct Acetaminophen Dose Depends on Children's Weight

From WebMD Health News
Daniel J. DeNoon

May 18, 2011 — An FDA advisory panel says that pediatric doses of acetaminophen should be based first on a child's weight, then on age.

The panel noted that infant acetaminophen -- Tylenol is the best-known brand -- should be labeled only for fever reduction in children under age 2.
Labels may recommend acetaminophen for both fever and pain in children over age 2.

The panel found too little evidence to label over-the-counter acetaminophen for pain relief in infants under age 2, although doctors often prescribe the drug for this punsumer Healthcare Products Arpose.

The recommendation not to include pain as an indication for acetaminophen in kids under age 2 is the only part of the panel's advice to which the over-the-counter drug industry trade group objects. Otherwise, the Cossociation (CHPA) applauds the panel's advice.

In addition to weight-based dosing and the infant fever recommendation, the panel also advised the FDA to:

Require that bottles of infant acetaminophen carry dosing instructions for children ages 6 months to 2 years. Although this information is often requested by parents, current labels warn parents of the danger of fever in kids under age 2 years and tell them to call a doctor.
Require acetaminophen makers to change the bottles of liquid acetaminophen to make it harder for kids to take an accidental overdose.
Require liquid acetaminophen bottles to come with a measuring device clearly marked in milliliters using the standard "mL" abbreviation.
Require all solid, pill forms of acetaminophen for children to come in the same concentration. Previous panels already recommended this for liquid formulations of acetaminophen.

The FDA usually, but not always, follows the advice of its advisory panels.

Beating the FDA panel to the punch, the CHPA recently announced that acetaminophen makers would voluntarily convert all single-ingredient liquid acetaminophen products to a single concentration, doing away with the more concentrated infant drops that reduce the amount of liquid an infant has to swallow.

The industry also announced it would put flow restrictors on liquid acetaminophen bottles to make it hard for kids to drink large amounts of the drug in an accidental, unsupervised ingestion. Moreover, the companies will provide clearly marked syringes with all products for kids ages 3 and younger, and will add clearly marked dosing cups to all products for kids ages 2 to 12.

Acetaminophen Overdose: Common Reasons

In providing information to the panel, the FDA found that only a fraction of fatal and non-fatal acetaminophen overdoses in children are reported to the federal agency. However, it listed common reasons for acetaminophen overdoses in children:

Inadequate prominence of the concentration on the container label.
Providers not specifying what formulation parents should use.
Providers not aware of varying concentrations available in the market.
The use of adult formulations of acetaminophen in children.
Confusion regarding how to measure with dosing devices.
Use of devices not packaged with the medication.
Dangerous abbreviations used on dosing devices.
Misinterpretation or misunderstanding of provider instructions.
Misinterpretation of labels, labeling, and dosage charts.
Not following labeled directions or simply guessing how to dose.
Miscalculation when trying to convert measuring units (e.g. mL to teaspoons).
Miscalculation of doses.
Inconsistency of dosing based on weight vs. dosing based on age.
Administration of acetaminophen by multiple parents or caregivers.
Parents were not aware that other products contained acetaminophen.
Caregivers who were not aware that acetaminophen and Tylenol have the same active ingredient.

Avoiding Acetaminophen Overdose

To avoid these errors -- as well as accidental overdoses by children themselves -- the CHPA offers this advice:

Always read and follow the label.
Only use the medicine that treats your child’s specific symptoms.
Store ALL of your family’s medicines, including products you use every day, high up and out of sight from children.
Put medicines away -- out of reach and out of sight -- EVERY time you use them.
Always lock the child safety cap completely every time you use a medicine.
Always tell children what medicines are, and do not refer to them as candy.
Remind house guests not to put medicines in purses, bags, coats, or other places small children can get into.
Keep the poison control help line number handy, or program it into your phone: 800-222-1222


FDA briefing information, FDA advisory panel, May 17-18, 2011.

Tuesday, May 10, 2011

Antibiotics Less Effective Than Surgery for Appendicitis

From Medscape Medical News

Laurie Barclay, MD

May 10, 2011 — Treating acute appendicitis with amoxicillin plus clavulanic acid was not noninferior to emergency appendectomy, according to the results of an open-label, noninferiority, randomized controlled trial reported in the May 7 issue of The Lancet.

"Researchers have suggested that antibiotics could cure acute appendicitis," write Corinne Vons, MD, PhD, from Assistance Publique-Hôpitaux de Paris and Université Paris XI, France, and colleagues. "We assessed the efficacy of amoxicillin plus clavulanic acid by comparison with emergency appendicectomy for treatment of patients with uncomplicated acute appendicitis."

At 6 university hospitals in France, 243 patients aged 18 to 68 years with uncomplicated acute appendicitis diagnosed on computed tomography (CT) scan were enrolled and randomly assigned, using a computer-generated sequence, either to receive amoxicillin plus clavulanic acid (3 g/day) for 8 to 15 days (n = 123) or to emergency appendectomy (n = 120).
The main study outcome was development of postintervention peritonitis within 30 days of starting treatment. Noninferiority was defined beforehand as the upper limit of the 2-sided 95% confidence interval (CI) for the difference in rates being lower than 10 percentage points. Analyses were by intention-to-treat, as well as per protocol.

Because of early dropout before receiving treatment, 4 patients were excluded from the intention-to-treat analysis, leaving 120 patients in the antibiotic group and 119 in the appendectomy group. Compared with the appendectomy group, the antibiotic group had a significantly higher frequency of postintervention peritonitis within 30 days (8% vs 2%; treatment difference, 5.8; 95% CI, 0.3 - 12.1).

Despite preoperative CT scan evaluation, 21 (18%) of 119 patients in the appendectomy group were unexpectedly found at surgery to have complicated appendicitis with peritonitis. Appendectomy was performed during the first 30 days in 14 of 120 patients (12%; 95% CI, 7.1% - 18.6%) in the antibiotic group, and in 30 of 102 patients (29%; 95% CI, 21.4% - 38.9%) in this group between 1 month and 1 year. Acute appendicitis was present in 26 of these patients (recurrence rate, 26%; 95% CI, 18.0% - 34.7%).

"Amoxicillin plus clavulanic acid was not non-inferior to emergency appendicectomy for treatment of acute appendicitis," the study authors write. "Identification of predictive markers on CT scans might enable improved targeting of antibiotic treatment."

Limitations of this study include a short follow-up period and the lack of masking of participants, clinicians, and research assessors.

In an accompanying comment, Rodney J. Mason, MD, PhD, from the University of Southern California Keck School of Medicine in Los Angeles, notes that antibiotics may have failed in some cases because of development of resistance, and that a different antibiotic regimen could produce better results in those cases.

"This acceptable alternative strategy is analogous to the present standard of care for recurrent uncomplicated diverticulitis," Dr. Mason writes. "Hopefully [the investigators'] conclusion, once the biases have been considered, will not overshadow major advances that have been made in the past 15 years towards the conservative treatment of appendicitis.
The fact that two-thirds of patients can be spared an operation deserves more attention."

The French Ministry of Health, Programme Hospitalier de Recherche Clinique 2002, supported this study. The study authors and Dr. Mason have disclosed no relevant financial relationships.

Lancet. 2011;377:1545-1546, 1573-1579. Summary

Monday, May 9, 2011

AAP Issues Guidelines on Chaperone Use During Pediatric Exam

From Medscape Education Clinical Briefs
News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD

Pediatrics. Published online April 25, 2011

The purpose and extent of the physical examination in a pediatric patient should be communicated clearly from the physician to the patient and parents. In infants, toddlers, or children, the examination should be performed with a parent or guardian present or, in certain cases, with a chaperone present.

This policy statement from the AAP Committee on Practice and Ambulatory Medicine addresses the use of chaperones during the physician examination of the pediatric patient.

Study Highlights

The physician should clearly communicate the extent of the physical examination to the patient and parents to prevent misunderstanding about the purpose and conduct of the examination.
In case of possible physical or psychological discomfort during the examination, measures to preserve privacy should be used for patient and parent support.
Some state medical boards have regulations regarding chaperone use.
A chaperone is recommended for adolescents or young adults who require inspection or palpation of the anorectal or genital areas or of the female breast.
The chaperone serves to reinforce the professional nature and content of the examination and as a witness in case of any misunderstandings.
The decision to use a chaperone should be shared between the patient and the physician.
The patient's preference should have highest priority.
It is advisable that male clinicians have a chaperone for the female anorectal, genital, or breast examination.
Chaperones can be indicated for same-sex examinations.
The patient's wishes and comfort should determine the sex of the chaperone.
The chaperone should be a nurse or medical assistant.
Family members or friends should not be chaperones unless requested by the patient and, if possible, in the presence of another chaperone.
Reasons that patients might not want a chaperone present include belief that privacy and confidentiality are compromised and embarrassment and vulnerability.
Reasons that pediatricians might find use of a chaperone problematic include the need for additional staff or inability to provide either a male or a female chaperone.
Reasons for a physician to request a chaperone include patient or parent with mental health issues, developmental issues, and anxiety, tension, or reluctance about the examination.
Physicians should explain to the patient and parent why a chaperone is required in these circumstances.
If the patient refuses a chaperone and the physician is concerned about possible false allegations or medicolegal risk, then the physician is not obligated to provide further medical care.
If the patient requests a chaperone, but a chaperone is not available, then the patient can refuse further treatment, and the physician should discuss risks of not receiving care and offer alternatives to care.
Pediatricians should develop a policy about chaperone use for the office or clinic setting. The chaperone's respect for privacy and confidentiality should be included in this policy.
Medical record documentation should reveal that the scope and findings of the examination were reviewed with the patient and parents, the name of the chaperone, whether the patient declines a chaperone, if the patient's request for a chaperone cannot be accommodated and alternatives offered, and if the office policy or state medical board regulations on chaperones cannot be followed.

Clinical Implications

A chaperone for an adolescent or young adult in the medical office is recommended when the physical examination requires inspection or palpation of anorectal or genital areas or of the female breast.
The decision to use a chaperone for the physical examination of an adolescent or young adult in the medical office setting should be shared between the patient and the physician. The chaperone should be a nurse or medical assistant, and the sex of the chaperone should be determined according to the patient's wishes and comfort level.

Sunday, May 8, 2011

Recurrent Abdominal Pain in Children May Be Migraine

From Medscape Medical News > Neurology
Pauline Anderson

May 5, 2011 — Up to 15% of recurrent abdominal pain in children meets criteria for abdominal migraine (AM), a new study suggests.

The findings underline the importance of recognizing AM in children with recurrent abdominal pain because there are now a wide range of treatments available, researchers say.

"The message is that this is out there," said Donald Lewis, MD, professor of pediatrics and neurology at Children's Hospital of the King's Daughters and Eastern Virginia Medical School in Norfolk. "US physicians just aren't thinking about it, aren't recognizing it, and there are kids with recurrent abdominal pain who might benefit from the interventions we have for migraine."

The study appears in the May issue of the journal Headache.

Family History

The retrospective study included 458 male and female subjects aged 1 to 21 years with idiopathic recurrent abdominal pain who were evaluated at the Pediatric Gastroenterology Clinic at the Children's Hospital of the King's Daughters in Norfolk. None of these children were identified as having AM by clinic physicians.

The study showed that of the 458 patients, 50 (11%) met criteria for "probable" AM, meaning that they lacked at least 1 criterion, and 20 patients (4.4%) met formal criteria for AM.

Of all 458 patients, 75% had a family history of recurrent abdominal pain and 46% had a family history of migraine, but of those who met formal criteria for AM, 62.5% had a family history of migraine.

A personal history of migraine was noted in 15% of all subjects but in 38% of the children who met formal AM criteria. This, said the study authors, indicates that it is 4 times more likely for patients with recurrent abdominal pain to have AM if they also have migraine headache (95% confidence interval, 1.56 – 11.92; P < .024) In 2004, the International Headache Society included AM among its "periodic syndromes of childhood that are precursors for migraine," the study authors note. Genetic Link? Although the link between childhood abdominal pain and adult migraine headache isn't exactly clear, experts hypothesize that the gene for migraine may not yet be expressed completely in childhood. "There are lots of examples of disorders that begin in childhood but don't have the full-fledged manifestations," said Dr. Lewis. He noted that the brainstem, where "revved up" circuits can cause the pain of migraine, are adjacent to the centers for vomiting and nausea. In this study, young patients suspected of having AM were more likely to have nausea, vomiting, and anorexia. To date, the overwhelming body of literature pertaining to AM comes from Europe, primarily Scotland. In the United States, children with recurrent abdominal pain are typically referred to gastroenterologists, who explore organic causes and rarely consider migraine, said the study authors. Lack of Training AM is not typically covered in medical school residency programs, added Dr. Lewis. "When you find a gap in the education like this, you've got to fill it." Most gastrointestinal physicians are capable of managing pediatric AM, although "it opens up an armamentarium of treatments they really hadn't considered," said Dr. Lewis. Research shows that ibuprofen and acetaminophen are useful in managing migraine without aura in young children, although there are no data on these agents in AM. Similarly, there are no data on the use of triptans for AM. There is evidence, however, that pizotifen, propranolol, and cyproheptadine may prevent recurrent attacks. Anecdotal evidence indicates that other strategies used to treat migraine headache — for example, getting regular exercise, eating regular meals, getting enough sleep, and avoiding triggers, such as chocolate and caffeine — are also useful in AM. Dr. Lewis said that about one-third of migraines are triggered by a food.

Sometimes just telling a teen to eat breakfast or to exercise every day helps, he added.

For children with AM who are genetically predisposed to get migraines, changing lifestyle habits, using medications judiciously, and avoiding triggers may help reduce disability later in adulthood, at least to some degree, said Dr. Lewis. "There's no evidence to back that up, but it makes sense."

Physicians should also ask about a family history of migraine. "It's not a formal criteria for AM, but I think it's a supporting bit of history," as is the episodic nature of the attacks, said Dr. Lewis.

Alert Physicians

Asked for a comment, Michael Goldstein, MD, Western Neurological Associates, Salt Lake City, Utah, and previous vice president, American Academy of Neurology, said the study will alert physicians that some children with unexplained abdominal pain may respond to treatment for migraine.

However, the study does not show that children who fulfill the criteria for AM have migraine or that treatment for migraine will improve their symptoms.

The next and possibly more important step would be to show that children with abdominal pain who fulfill criteria for abdominal migraine are improved when treated for migraine.

"The study helps highlight a possible cause for abdominal pain but is only a first step in helping these children," he wrote in an email to Medscape Medical News.

"The next and possibly more important step would be to show that children with abdominal pain who fulfill criteria for abdominal migraine are improved when treated for migraine."

Dr. Goldstein noted that amitriptyline, which has been shown to help patients with migraine, is commonly used for children with unexplained abdominal pain.

The study authors have disclosed no relevant financial relationships.

Headache. 2011;51:707-712. Abstract

Conservative Care Effective in Acute Mastoiditis

From Reuters Health Information

NEW YORK (Reuters Health) Apr 27 - Conservative management can replace mastoidectomy as primary treatment for acute mastoiditis with subperiosteal abscess, a new study shows.

Subperiosteal abscess is the most common complication of acute mastoiditis, the researchers note in a report in the April issue of Archives of Otolaryngology-Head and Neck Surgery.

Before 2002, say Dr. David Bakhos of the Universite Francois-Rabelais de Tours in France and his colleagues in their paper, patients at their center routinely had mastoidectomy for subperiosteal abscess.

Beginning in 2002, the investigators changed their approach, first treating patients conservatively, with postauricular puncture or a tympanostomy tube, with the goal of avoiding mastoidectomy.

For this month's report they reviewed their data on 50 consecutive patients with acute mastoiditis, all younger than 14 and all hospitalized between 1994 and 2008. Thirty-one children had subperiosteal abscess identified by computed tomography, including three patients with sigmoid sinus thrombosis and one patient with a subdural abscess.

Fifteen were treated before 2002 and 16 afterward. All patients received broad-spectrum intravenous antibiotics, and all were cured without complications.

Just one of the post-2002 patients had a mastoidectomy. This patient, a 16-month-old with sigmoid sinus thrombosis, did not get better after 2 days of conservative treatment. An ear culture was negative, but his blood culture was positive for Fusobacterium necrophorum.

Children treated primarily with mastoidectomy stayed in the hospital for an average of 15 days and took antibiotics for an average of 24 days. In the conservatively managed group, the mean hospital stay was 9 days and the mean course of antibiotics was 18 days.

"Antibiotic drug use combined with retroauricular puncture and grommet insertion is an effective alternative to mastoidectomy in the treatment of acute mastoiditis with subperiosteal abscess in children," the researchers conclude.

But, they add, "when mastoiditis is caused by F. necrophorum, physicians must be aware that this infection may be more aggressive and more complicated to treat. If conservative management fails, mastoidectomy must be considered."


Arch Otolaryngol Head Neck Surg 2011;137:346-350.

Low-Fat Dairy Doesn't Help Kids Drop Pounds: Study

From Reuters Health Information

By Leigh Krietsch Boerner

NEW YORK (Reuters Health) Apr 28 - Kids who swap out regular dairy products for low-fat forms consume less saturated fat but don't seem to lose weight, according to Australian researchers.

They found neither weight nor body mass index (BMI) had changed noticeably six months after children switched to low- or reduced-fat dairy products.

Instead of trimming their waistlines, kids who slashed fat intake appeared to compensate by eating more calories from other sources, according to the new findings, which appeared online March 23rd in The American Journal of Clinical Nutrition.

Still, there might be other benefits to cutting back on saturated fat, said Dr. Frank Franklin, a retired professor of nutrition and pediatrics at the University of Alabama at Birmingham, who was not involved in the study.

For instance, it might help kids stave off heart disease as they grow up, Dr. Franklin told Reuters Health.

For the study, Gilly Hendrie and Rebecca Golley of the Commonwealth Scientific and Industrial Research Organization divided 145 kids ages four to 13 into two groups. The researchers asked one group to replace their dairy products with low-fat varieties for six months, while the other got no dietary advice.

Both groups consumed similar amounts of dairy products, and the total calorie intake remained more or less stable over the study, which was supported in part by Dairy Australia.

Nurses interviewed the kids and parents on their dairy eating habits at the beginning of the study, and at three and six months. They also drew blood and measured BMI and waist circumference.

The low-fat group did consume less overall fat. At the end of the study, they got 13.3% of their total calories from saturated fat, compared to 16.6% in the comparison group.

This is a significant change, Dr. Franklin noted, but still above the 10% recommended by the U.S. Department of Agriculture. He added that American kids generally are closer than Australians to getting the recommended amount.

There was also a small drop in cholesterol levels in the low-fat group, but their waistline, BMI and weight were no different.

According to Greg Miller of the National Dairy Council (NDC), which represents the industry in the U.S., this falls in line with other research on kids, where milk shows either a positive or neutral impact on body composition.

"A lot of researchers say that if we just get people to consume low-fat or reduced-fat products, we can have an impact on weight," Miller told Reuters Health.

But as this study shows, the kids made up for the lost calories elsewhere in their diet. So looking at milk alone is not that helpful, Miller said.

Dr. Franklin said it's safe to switch to leaner dairy products, which have less cholesterol but the same amount of nutrients, mainly calcium and vitamin D.

"The only thing given up is saturated fat, which you don't need," he said, adding that skim and two-percent milk cost the same as whole milk.


Am J Clin Nutr 2011.

Characteristics of Bullies Revealed

From Medscape Medical News
Brian Hoyle

May 3, 2011 (Denver, Colorado) — A survey of school-aged children has identified a cluster of factors that is associated with bullying, and more than one third of children fit the definition of a bully, according to the study, presented here at the Pediatric Academic Societies and Asian Society for Pediatric Research 2011 Annual Meeting.

Being a school bully can lay the framework for miseries in later life that include depression, suicidal thoughts or attempts, and misbehavior that can result in arrest and imprisonment.
This information could be valuable in developing more focused and effective antibullying programs.

"In the past, studies have focused on bullying victims, not on the perpetrators, and most bully prevention programs are directed at everyone, not those most at risk of becoming a bully. Our results indicate that students who both fight and carry weapons are at the highest risk of being bullies," Rashmi Shetgiri, MD, from the division of general pediatrics at the University of Texas Southwestern Medical School in Dallas, told Medscape Medical News.

In the United States, 30% of adolescents are victims of the taunting, verbal ridicule, physical violence, and ostracism that are the hallmarks of bullying inflicted by 13% of their peers.

Traditionally, antibullying campaigns are directed at all school-aged adolescents. In an effort to aid in the development of more targeted programs, Dr. Shetgiri and colleagues sought to identify clusters of risk factors that would identify those most prone to bullying.

The study used data from the 2001/02 Health Behavior in School-Aged Children, a national survey of more than 13,000 American students in grades 6 to 10. The analyses of the survey data involved bivariate analysis, in which 2 variables were analyzed to determine if they were related, and recursive partitioning analysis, which linked together the different factors in a "decision tree" to generate a cluster of factors that were linked to an increased likelihood of bullying.

Of the 13,710 students surveyed, 37% fit the criteria for bullying (which included verbal and physical hallmarks and their frequency of occurrence, and more prevalent feelings of irritation and sadness in the perpetrators).

Bullies were more likely than nonbullies to have been in a physical fight in the previous 12 months (53% vs 28%), to have carried a weapon in the previous month (26% vs 10%), to be a current smoker (24% vs 10%), and to have ever used illicit drugs (65% vs 29%).

When the various factors were clustered together in the recursive partitioning analysis, those most apt to bully carried a weapon and had physically fought (67%), followed by those who did not carry a weapon but who had been in a physical fight, smoked, and used drugs (62%), those who had fought but who did not carry a weapon or use drugs (38%), and those who had not been in a physical fight in the previous year (28%).

"Our data indicate that bullying treatment and prevention interventions might be most effective when targeted at risk clusters rather than at individual risk factors in isolation.
Such interventions should focus on students who fight, carry weapons, smoke, and use drugs," Dr. Shetgiri told Medscape Medical News.

"These are important data. It does seem to me, though, that adolescent depression would be another important factor to look at, particularly for males. The attributes of feeling low or irritable may not adequately reveal depression," session moderator Ruth Stein, MD, from the Department of Pediatrics at Albert Einstein College of Medicine, Bronx, New York, told Medscape Medical News.

"The analysis starts off by separating participants by fighting or not fighting. I don't get that partitioning. Maybe it would be better to separate by gender, since fighting in the past 12 months accounted for only 53% of the students," James Sargent, MD, professor of pediatrics at Dartmouth Medical School, Lebanon, New Hampshire, told Medscape Medical News.

Pediatric Academic Societies (PAS) and Asian Society for Pediatric Research 2011 Annual Meeting: Abstract 1185.4. Presented April 30, 2011.

5-Minute Screen for Signs of Autism Works in 1-Year-Olds

From WebMD Health News

Kathleen Doheny

April 28, 2011 — A simple checklist completed by parents can help doctors screen for signs of autism as early as the child’s first birthday, according to new research.

''I am hoping it will become the standard of care," researcher Karen Pierce, PhD, an assistant professor of neuroscience at the University of San Diego School of Medicine, tells WebMD.

She recently tested the screen, asking 137 pediatricians throughout San Diego County to take part. At the 12-month well baby visit, the doctors asked the parents to answer the 24-item checklist. The questions ask about their child's emotions, eye gaze, communication, gestures, and other behaviors.

The screen found suspected autism, autism spectrum disorder, language delays, or other developmental problems about 75% of the time, Pierce says.

"One of every four times, it will be wrong," she says. "The price to pay for that is actually very tiny" compared to the benefit of early intervention.

Currently, 5.7 years is the median age (half older, half younger) at which children receive an autism diagnosis, according to a 2009 study.

About one in 110 children in the U.S. has autism or autism spectrum disorder, a group of developmental disabilities that cause social, behavioral, and communication challenges.

The new study is published online in the Journal of Pediatrics.

Screen for Autism: A Closer Look

The screen used is already published and is available online for free download. It is called the CSBS DP IT checklist (Communication and Symbolic Behavior Scales Developmental Profile Infant-Toddler).

The questionnaire takes about five minutes to complete, Pierce says.

Among the questions:

Do you know when your child is happy and when your child is upset?
Does your child do things just to get you to laugh?
Does your child string sounds together, such as uh oh, mamma, gaga, bye-bye?
When you call your child's name, does he/she respond by looking or turning toward you?
Does your child wave to greet people?
Does your child smile or laugh while looking at you?

"This is not an autism-specific screen," Pierce tells WebMD. "It's a screen to catch autism and other developmental delays."

The doctors screened 10,479 infants. Of them, 1,318 children failed. Pierce evaluated 184 of the children who failed the screen and were evaluated for autism, autism spectrum disorder, language delays, or other developmental delays. The researchers also tracked 41 of the 9,161 children who passed the checklist, who served as a comparison group.

To date, 32 of the children got a final or provisional diagnosis of autism or autism spectrum disorder, which encompasses a wider spectrum of developmental problems. Another 46 received a false-positive diagnosis of autism, uncovered with evaluation.

Five babies who tested positive for ASD later no longer met the criteria. Fifty-six were diagnosed with learning disabilities, nine with developmental problems, and 36 with "other" developmental problems.

It is critical, Pierce says, that a doctor who uses the screen has access to a center where he can refer patients for more evaluation.

In 2007, the American Academy of Pediatrics issued a report introducing universal screening for autism at ages 18 months and 24 months.

The new finding is an important step forward, says Geraldine Dawson, PhD. She is the chief science officer for Autism Speaks. Autism Speaks supported the study as did the Organization for Autism Research and the National Institute of Mental Health.

"We do know that many babies who go on to develop autism begin to show symptoms early on," she says.

It may be half or more of all children with autism, she says.

''For babies who have this pattern of early onset, to use a screen that is quick and can be used in a pediatrician's office efficiently is of great value," she says. The earlier autism is detected, the earlier intervention can begin.


Karen Pierce, PhD, assistant professor of neuroscience, University of California San Diego School of Medicine and Autism Center of Excellence.

Geraldine Dawson, PhD, chief science officer, Autism Speaks.

Pierce, K. The Journal of Pediatrics, published online April 28. 2011.

Shattuck, P. Journal of the American Academy of Child and Adolescent Psychiatry, May 2009; vol 48: pp 474-483.

Wednesday, May 4, 2011

How Should We Sedate Children for CT Scans?

Posted: 03/11/2011 Question

What is the safest and most effective way to sedate a child for a head CT scan?
Response from Sergey M. Motov, MD Assistant Program Director, Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York

Cooperation for diagnostic studies, such as CT, is a frequent indication for pediatric procedural sedation in the emergency department (ED).
ED physicians are armed with a variety of sedative agents, including chloral hydrate, pentobarbital, propofol, midazolam, and etomidate.
However, controversies exist with regard to the safest and most effective agent for procedural sedation in children who require a head CT scan. A review of the recent literature may help inform opinions.

A study by Mason and colleagues, appearing in the journal Radiology, compared the effectiveness and safety of oral pentobarbital and oral chloral hydrate for sedation in infants younger than 1 year of age during MRI and CT scans.
The results demonstrated that both medications were equally effective in providing successful sedation (50 mg/kg chloral hydrate and 4 mg/kg pentobarbital).
However, the overall adverse-event rate during sedation was lower with pentobarbital (0.5%) than with chloral hydrate (2.7%).

Moro-Sutherland and colleagues conducted a prospective, randomized clinical trial of 55 children undergoing head CT scans in the ED that compared the efficacy of sedation with intravenous (IV) midazolam with IV pentobarbital.
The results, published in the journal Academic Emergency Medicine, showed that 97% patients were successfully sedated and scanned in the pentobarbital group with mean dose of 3.75 mg/kg vs 19% of patients who were successfully scanned with midazolam alone. The study authors concluded that IV pentobarbital was more effective than IV midazolam for sedation of children requiring CT imaging.

Dr. Steven E. Zgleszewski led a prospective, observational study of 104 children who underwent sedation before CT scans at the Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts. The researchers compared the incidence of adverse respiratory events and the recovery time of propofol sedation with similar data from a retrospective review of sedation with pentobarbital in patients who underwent CT imaging.

The results showed that patients sedated with propofol had more airway manipulation to relieve obstruction than the pentobarbital group (23% vs 0%), had more adverse respiratory events (12% vs 0%), but had faster recovery (34 minutes vs 100 minutes). The study authors concluded that sedation with propofol was associated with a greater incidence of adverse respiratory events.

In a prospective, randomized, double-blind trial of 61 patients between the ages of 6 months and 6 years, Kienstra and colleagues compared etomidate with pentobarbital for sedation in children for head and neck CT scans.The results demonstrated a 97% success rate with pentobarbital at a dose of 5 mg vs a 57% success rate with etomidate at a dose of 0.3 mg/kg. The study authors concluded that pentobarbital was more effective than etomidate for procedural sedation for head CT scans in children. However, the etomidate group had significantly shorter induction times, sedation times, and total examination times. Moreover, more parents of the children receiving etomidate reported that their children were at baseline at the time of discharge, and fewer parents in this group had concerns over their children's behavior after discharge.

Finally, a report by Baxter and colleagues for the Pediatric Sedation Research Consortium compared the efficacy, sedation duration, and adverse effects of etomidate and pentobarbital in 842 children undergoing head CT scans.
The study authors demonstrated that the etomidate group (446 patients) had 1 unsuccessful sedation vs 11 unsuccessful sedations in the pentobarbital group (336 patients); shorter sedation time (34 minutes vs 144 minutes); and less adverse effects, including oxygen desaturations, apnea, and prolonged recovery (0.9% vs 4.5%). They concluded that etomidate was more effective and efficient than pentobarbital for sedating children for head CT scans.


The cited literature demonstrated that pentobarbital performed better then chloral hydrate (less adverse effects), midazolam (better success rate), and propofol (less adverse effects). However, in a head-to-head comparison, etomidate outperformed pentobarbital with respect to successful sedations, shorter sedation time, and less adverse effects. Thus, etomidate is the safest and most effective sedative agent for children undergoing head CT scans.

Food Allergy in Dermatology: The Patient With Atopic Dermatitis

From Medscape Allergy & Immunology
Highlights of the NIAID Guidelines

Laura A. Stokowski,

Posted: 03/17/2011

Dermatology and Food Allergy

Food allergy is an immune-based disease that may be increasing in prevalence in the United States. Fears about food allergy have become heightened in the general public, although many of these fears are born of myths and misunderstandings about food allergy that occasionally are perpetuated by healthcare professionals.

The National Institute of Allergy and Infectious Diseases (NIAID) recently issued Guidelines for the Diagnosis and Management of Food Allergy in the United States ,which are a "harmonization of best clinical practices related to food allergy across a wide range of medical specialties." The guidelines address misconceptions surrounding food allergy and attempt to improve the diagnosis and management of this widespread condition. For more information about the NIAID guidelines, see Food Allergy: The Definitive Guide to Clinical Practice .

Patients with suspected food allergy present to many different settings for care depending on the nature and severity of their symptoms. One such setting is the dermatology practice, where the typical nonurgent presentation of a patient with potential food allergy is the infant or child with atopic dermatitis (AD).
A skin-based treatment regimen is recommended for most patients with AD, but parents often wonder whether their child's AD suggests an underlying food allergy that warrants either further testing or dietary restriction.

Atopic Dermatitis

AD (also known as atopic eczema) is a red, scaly, pruritic chronic inflammatory rash that is 2-3 times more prevalent than it was 40 years ago.
This remitting and relapsing disorder also shows predilection for certain body sites: the face, scalp, neck, and extensor surfaces in infants; and the flexural areas (such as the back of the knees and front of elbows) and the hands in children and adults. The skin of affected individuals is often very dry.
AD is managed primarily with topical corticosteroids, emollient therapy, and education about skin care for affected children.

Many children outgrow AD by the time they reach adolescence.
In the meantime, however, AD can have a significant impact on the child's quality of life. It is not surprising that parents seek an explanation for their child's AD, hoping that perhaps a quick fix will be offered by food allergen avoidance, or fearing a life-threatening reaction that could be prevented by taking simple precautions.

The Real Connection Between Atopic Dermatitis and Food Allergy

Children with AD, those with a family history of atopy, and those with concurrent asthma or hayfever are at risk for the development of food allergy.[1] However, this risk is lower than many people believe, and the true nature of the link between AD and food allergy has long been a source of misinformation.

"Many think the disease [AD] is caused by the food allergy, whereas it's the other way around. Food allergy is caused by the disease," explains Jon Hanifin, MD, a specialist in AD from Oregon Health Sciences University Department of Dermatology, and coauthor of the NIAID food allergy guidelines. In most patients with coexisting AD and food allergy, AD precedes the food allergy.

Dr. Hanifin emphasizes that the likelihood of an infant or child with AD having food allergy must be kept in perspective. Dr. Hanifin and colleagues recently completed a 5-year multicenter study in infants age 3-18 months and found that even in reported mild cases of AD, roughly 15% of infants had definite food allergies.

The more severe the AD, the higher the risk for food allergy. In patients with moderate-to-severe AD, the prevalence of food allergy may be as high as 30%-40%. "We must remember, however, that 85% of infants with AD don't have food allergy," says Dr. Hanifin.

Patients with AD typically have higher levels of immunoglobulin E (IgE) antibodies; in the past this has been interpreted as evidence of food allergy causation. Dr. Hanifin emphasizes that elevated IgE antibodies are evidence only for sensitization to a food but are not proof of a food allergy.
The presence of antibodies is a consequence of the pruritic nature of AD, causing children to scratch their skin, allowing food allergens to be absorbed via this disrupted skin barrier, and inducing the development of antibodies.

"AD usually comes on in infancy, before any possible food reactions, and the cellular infiltrate in the skin of patients with AD does not reflect a specific allergic reaction. The major stimulus for the cellular reaction seems to be irritants," explains Dr. Hanifin. "The only proven allergic response is IgE-mediated, and the relative frequency of those reactions seems tied to absorption and sensitization to food proteins through the defective barrier."

Furthermore, emphasizes Dr. Hanifin, "An immediate reaction to food -- usually within 30 minutes -- hives, lip swelling, vomiting, is required for diagnosis of food allergy."

The knowledge that AD is a precursor to rather than a consequence of food allergy has not eradicated all of the uncertainty about which children ought to be formally tested for food allergy. It is still not uncommon to see such testing initiated solely on the basis of a bout of AD. The NIAID guidelines attempt to provide unambiguous recommendations for testing children with AD for food allergy.

Which Patients With Atopic Dermatitis Should Be Tested for Food Allergy?

The link between AD and food allergies compels practitioners to conduct or refer patients for appropriate testing for food allergy, but only when specific criteria are met. With the high prevalence of AD in children (as high as 17% in school-aged children, testing every child for food allergy is neither practical nor useful.

Insufficient evidence supports a specific age for testing response to foods known to cause IgE-mediated food allergy in infants or young children with AD.
In weighing benefit vs harm, the NIAID guidelines recommend 2 indications for consideration of food allergy testing (milk, egg, peanut, wheat, and soy) in children younger than 5 years with moderate-to-severe AD:

1. A child who has persistent AD despite optimized management; or
2. A child who has a reliable history of an immediate reaction after eating a specific food.

In these children, the benefits of diagnosing food allergy at an earlier age include better management of food allergy and prevention of a severe reaction to an allergen. However, it is also recognized that such testing is time-consuming and expensive and could lead to overly restrictive diets in these children.
Care should be taken to ensure that a child is clinically allergic to a food prior to removing it completely from the child's diet.

Appropriate testing for a clinical food allergy means an oral food challenge, conducted by experienced specialists in a controlled medical setting that has appropriate supervision, medications, and equipment for managing anaphylaxis.

Food allergy testing is also indicated in individuals who present with anaphylaxis or symptoms (cutaneous, respiratory, gastrointestinal, and/or cardiovascular) that occur within minutes to hours of ingesting food, and/or if the symptoms have occurred following ingestion of a specific food on more than a single occasion.

Managing Food Allergy Concerns in Patients With Atopic Dermatitis

In practice, the clinician is often faced with parents' overriding concern about food allergy in the infant or child with AD.

Dr. Hanifin describes a typical scenario. "A baby with inflamed cheeks (irritation of AD from feeding) is brought in to the office. The parents think their child is having a food allergy reaction. The physician agrees, or is not certain, and tells the parents to stop giving milk, and sends them to an allergist who does blood or skin tests. Of course, the infant has high levels of antibodies, and the parents are told to restrict 1 or more foods which can, in some cases, lead to malnutrition and nutrient deficiencies. Ironically, these antibodies are not necessarily diagnostic for food allergy."

What should happen when parents bring in a child with AD starts with a careful history. If no history of an immediate reaction to food is revealed, the parents should be advised that although their child is at risk for food allergy, AD alone is not evidence of food allergy. They should be educated about true food allergy and the immediate nature of food allergy symptoms. "Otherwise," adds Dr. Hanifin, "they will chase every flare of AD as if it is an allergic reaction to food. AD can flare for any number of reasons: stress, infection, or even cold, dry weather."

Another misconception is that food allergy exacerbates AD, lending support to the role of food exclusion in the management of AD. Current evidence suggests that for the most part, food exclusion does not improve or prevent AD. However, the NIAID guidelines point out that some research has documented improvements in pruritus when patients with egg allergy avoided egg consumption.The bottom line is that in individuals without documented or proven food allergy, avoiding potentially allergenic foods as a means of managing AD is not recommended. Unwarranted food avoidance, particularly in children, can produce nutritional deficiencies and adversely affect growth.


Food allergy and AD are clearly related conditions, but this relationship is frequently misunderstood and often assumed to be more prevalent than it really is. To avoid unnecessary pain, expense, anxiety, and nutritional deficiency, clinicians should generally stick to the NIAID guidelines and refer for appropriate food allergy testing only those patients who have evidence of IgE-mediated immediate reaction to a food or who meet additional criteria detailed in the guidelines. Management of the active clinical condition -- the AD -- and education of the parents about the risk for and symptoms of true food allergy are the mainstays of care for these patients.