Wednesday, October 26, 2011

The Evolution of Bullying

Gregory Lawton, MD, Pediatrics, Sep 27, 2011 During the first recess on the first day in the first year of the first school (approximately 80,000 BC), an impressively hirsute Neanderthal pushed a smaller, more studious Neanderthal to the ground before depositing him into a trash container. The same thing happed on the second day, only before a larger crowd. And thus bullying began. In the year 2011, the basic characteristics of bullying remain the same. It's about one person or group acting in a manner that is intent on hurting, harming, or humiliating another person or group. It's about doing this on a regular basis. It's about doing this because one side is bigger or stronger than the other side. Might makes Right. So what's new? VOLUME. A single bully is a solo singer. There is one (really loud) singer and one speaker. Maybe the bully has a couple of sidekicks. Now it's a trio, but there is still only one speaker. Welcome to 2011. With the near ubiquity of social media (Facebook and Twitter) and smart phones that permit instant access, the number of speakers has multiplied. Throw in texting and the number of speakers multiplies again. Once upon a time, bullying might only take place on the bus, or at lunch, or after practice. Now, it can be a 24/7 event, whether in the car, at the mall, in the kitchen, or even while on a family vacation during the summer in another state. Cyber bullies can post a hateful message on Facebook or a vengeful text message anytime, anywhere. What's more, if it's done via a video upload to YouTube, the number of speakers increases exponentially. The volume can be devastating. This degree of now public (thanks to social media) humiliation can be realized in a number of horrific scenarios. Victims of bullying have taken revenge to heinous extremes at Columbine High School and Virginia Tech. According to the website Bullying Statistics, other victims, feeling isolated, resort to suicide. As pediatricians, we see bullies every day. They are our patients. The trouble is, they don't wear a sign announcing that they are bullies when they come in for a physical. Perhaps we are more observant of the victims of bullying. They are the kids with belly pain, headaches, slipping grades, or insidious school aversion. What can we do? What should we do? A recent article on Medscape,, offers a wealth of resources on programs to counter bullying. The trick, however, remains in recognizing it in our offices. What can we, as pediatricians do to prevent bullying? 1. Remain open to the idea that every child can be a bully, or a victim. Listening for clues when a patient indicates that he doesn't like school or doesn't "fit in" may indicate that could be a potential target. Ask about discipline issues at school. Are detentions for academic reasons or altercations? The answers could lead to insight that the patient may be more likely to bully others. 2. Caution parents about social media and the need to monitor its use in their home. Encourage them to know what is on their child's Facebook page. Look at the text posts periodically. Advise parents to keep computers and smart/cell phones out of the bedrooms at night so as to keep their child's room nominally safe from electronic intrusions, vicious or otherwise. 3. Consider speaking with parents separately before or after an appointment. Ask explicitly about school, it's social and academic aspects. Communicate that you are willing to work with the kids, their parents, and the schools as part of a coordinated anti-bullying effort. As with so many aspects of our professional lives, there are no easy answers, nor is there a one size fits all approach. We can make a difference however, as we always do, one patient at a time. By enforcing social media rules in our homes, we decrease the potential for cyber bullying in our personal lives. By listening a bit differently to our patients, we may unearth the real reason for school aversion. The Neanderthal will always be out there. But now he or she has evolved; Facebook and smart phones are the new weapons. Pediatricians can (and for the sake of our patients must) evolve faster.

Parents Can Detect, Contribute to, or be Affected by Critical Events During a Child's Hospitalization

From ISMP Medication Safety Alert!® Acute Care Edition Posted: 09/23/2011; ISMP Medication Safety Alert © 2011 Institute for Safe Medication Practices Problem Today, parents are often permitted around-the-clock visiting hours to stay with their hospitalized children, even in neonatal and pediatric intensive care units (ICUs). Many parents take advantage of this option and remain with their children as much as possible. For an ill child, this can be comforting and provides an important emotional benefit. At the same time, parents may be carefully watching and interacting with healthcare professionals, and observing the specialized equipment at their child's bedside, including infusion pumps, IV lines, and drainage systems. A study published by Frey et al. in 2009 suggests that parents who stay with their hospitalized children are inevitably involved in safety issues. In particular, the study showed that parents can help detect critical (harmful or potentially harmful) events precipitated by healthcare professionals. However, the study also showed that parents can contribute to a critical event and are often adversely affected by a critical event. The study was conducted over a 5½ year period in a neonatal-pediatric intensive care unit and a neonatal intermediate care unit in a university children's hospital. During the first 2 years of the study, visiting hours for parents were limited to afternoons and evenings; morning visitations were not allowed and overnight stays were strongly discouraged. Around-the-clock visiting hours were permitted during the last 3½ years of the study. During the span of the study, a total of 2,494 critical events were recorded; 101 of these events directly involved parents. In 18 cases, a parent contributed to the critical event. In 11 cases, a parent detected a critical event. In the remaining 72 cases, a parent was one of the affected individuals. For each event, the actual and potential severity was determined to be minor (requiring no interventions), moderate (requiring routine therapy available outside a critical care unit), or major (requiring therapeutic interventions specific to critical care units, or resulted in death). In the group of critical events that involved parents (n=101), medication events (38%) and line disconnections/reconnections (28%) were most prevalent. In the group of critical events that did not involve parents (n=2,393), events involving medications were again most prevalent (33%), but issues with line disconnections/reconnections (2.7%) were significantly lower. Most events precipitated by parents and subsequently detected by healthcare professionals caused actual harm determined to be of moderate severity, and some events had the potential to cause a high severity of harm. On the other hand, critical events detected by parents did not cause actual harm, although the events had the potential to cause harm of moderate severity. Further details about the study follow. Parents Detecting Safety Problems The most common safety problems detected by parents involved medication errors, tubes or drains that became disconnected, and respiratory distress. Examples include: A mother who realized that a physician had prescribed a five-fold overdose of carvedilol for her child (5 mg BID instead of 1 mg BID) A mother who noticed the wrong weight listed on her child's medical record used for prescribing medications Parents who called attention to their child's respiratory distress or failure. It took parents between 0–70 hours (median 10 hours) to detect a critical event precipitated by a healthcare professional. This suggests that without the parents' interventions, some critical events might have continued without correction. The authors determined the potential harm from continuation of the detected critical events to be severe in 4 cases, moderate in 6 cases, and minor in 1 case. All of the events detected by parents occurred only after around-the-clock visiting hours were made available. This observation suggests that it is easier for parents to detect safety problems if they spend more hours at their child's bedside, observing and participating in their care. Parents Contributing to Safety Problems The most common safety problems precipitated by parents involved the disconnection of tubes and drains, medication errors, and physical trauma. Examples include: A mother accidentally disconnected a central venous line while breast feeding her baby A mother accidentally disconnected a pleural drain while holding her infant A father fell off a chair with his child on his lap. All of the disconnected tubes and drains happened in young infants, from 4 days to 1½ years old. It took healthcare professionals between 0–29 hours (median 0.25 hours) to detect a critical event precipitated by a parent. The authors note that this finding suggests that healthcare professionals are providing appropriate supervision of parents and hospitalized children. Most of these events caused moderate harm (10 cases) before being detected. In all but one event, quick discovery of the problems averted severe harm. Parents Affected by Safety Events The most common types of problems affecting parents involved miscommunication and feeding mix-ups. One can expect parents to be emotionally affected by most critical events that involve their children, especially those leading to harm. However, with some critical events, parents were directly affected in ways that were not anticipated. One of the most common examples included mothers who were subjected to viral testing because their breast milk was accidentally fed to another child. Failures such as this increase parental stress during a child's hospitalization. Safe Practice Recommendations Consider the following recommendations to strengthen the partnership between the treatment team and a hospitalized child's parents, prevent parental contribution to critical events, promote parental detection of errors, and protect the hospitalized child from harm. Educate Parents. Teach parents about the disease/condition, medical tests, and treatment plan for their hospitalized child. Specifically tell parents about all the medications their child is receiving, the prescribed doses (including the fact that it differs from the dose taken at home, if applicable), potential side effects, and when and how they are given. Write down important information for parents to reference as needed. Parents who know what to expect can help recognize when something is not right. Update Parents. Provide parents with timely and comprehensive updates regarding their children in language they understand. Some children's hospitals encourage parents to be part of "family-centered" rounds, allowing them to gain a better understanding of their child's total treatment plan and current status since the entire medical team is available to answer questions and address concerns. Anticipate Involvement. Be aware of increasingly independent parental involvement in the medical care of their children. A 2001 study by Hurst showed that parents continuously analyze hospital procedures and develop an action plan to protect their babies.[2] A fundamental challenge for mothers in this study was to increase their position of authority relative to the medical team, thereby safeguarding their babies. Parents may intervene during the care of their children, which can lead to prevention and detection of a critical event, or contribution to a critical event despite good intentions. Close parental involvement in the child's treatment plan should be encouraged, supervised, and monitored. Encourage Parents to Speak up. Encourage parents to report any concerns or worries they have regarding their child's care. Frey et al. suggests periodically asking parents these two questions: "Are there aspects of your child's care that you find concerning?" and "What do you worry about when you leave your child?" Encourage parents to keep asking questions or voicing concerns until they receive an answer with which they are comfortable and fully understand. Remind parents that they know their child better than anyone on the medical team; thus, communication of their observations is extremely important. Respond to Parents' Queries Appropriately. Parents do not want to be labeled as being "difficult" or "demanding;" they fear no one will want to take care of their child if they are perceived this way.[2] Some may even view basic questions or requests for information about their child's condition as a slight to the medical team's competence. So, when parents do speak up, healthcare professionals should perceive and reflect their actions in a manner that fosters true collaboration and empowerment, and should encourage and reinforce the parents' role in making queries by providing thoughtful and complete answers. Provide Access to a Rapid Response Team. Allow parents to activate a rapid response team if they feel no one is addressing their expressed concerns regarding their child's condition and/or medical treatment. Instruct parents, upon their child's admission, regarding the purpose of the rapid response team and how to activate it. Establish Safe Handling Guidelines. To reduce the risk of tubing disconnections, establish guidelines for safe handling of infants and children with lines and drains, teach these guidelines to parents, and monitor adherence to the guidelines. Teach Parents Not to Reconnect Tubes. Orient parents to the tubes or drains attached to their child. Teach them about the dangers of reconnecting tubes and drains themselves and how to call for immediate help from a healthcare professional if their child's tubes or drains become dislodged or disconnected.

Infant Cataracts: Screening in Primary Care

From CHOP Expert Commentary Monte D. Mills, MD Posted: 09/26/2011 Director of the Division of Ophthalmology at Children's Hospital of Philadelphia. Infant cataracts are rare. About 1 in 2000 to 1 in 5000 children will have unilateral or bilateral cataracts during infancy. Early detection and treatment are crucial to getting the best visual outcomes for our infants with cataracts. The primary care provider is in the perfect situation to detect and refer these infants for treatment early on during early infant examinations in the hospital and office. The critical and best instrument to detect cataract is the direct ophthalmoscope that you have in your office and in the hospital. You would use it by setting it to the large white spot setting and shining it in a darkened room into the infant's eyes. As you look through the peephole, look at the quality of the red reflex in both eyes simultaneously, examining for symmetry, redness, and brightness of the red reflex. Cataracts would be seen as a dull red reflex or as an asymmetrical red reflex, bright in one side and dull in the other side. It can also be visible as a white pupillary reflex. Children with asymmetry, a dull red reflex, or a white reflex should be referred for evaluation to an ophthalmologist. Infant cataracts should be treated during the first 6 weeks of life to get the best visual outcome. With prompt detection and an early referral and treatment, we can get the best possible outcomes for our patients with infant cataracts. Later in life, infant cataracts might be seen with symptoms including nystagmus, poor visual fixation and following, poor social smile, or strabismus. These children, of course, should also be referred for a full evaluation to an ophthalmologist and potentially for treatment. With early detection using the red reflex test with the direct ophthalmoscope, you'll be able to detect early cataracts. Refer them promptly to achieve the best possible visual outcomes.

New Method of Scoliosis Assessment

From Spine Preliminary Results Using Computerized Photogrammetry Rozilene Maria Cota Aroeira, MSc; Jefferson Soares Leal, MD; Antônio Eustáquio de Melo Pertence, PhD Posted: 09/26/2011; Spine. 2011;36(19):1584-1591. © 2011 Lippincott Williams & Wilkins Study Design. A new method for nonradiographic evaluation of scoliosis was independently compared with the Cobb radiographic method, for the quantification of scoliotic curvature. Objective. To develop a protocol for computerized photogrammetry, as a nonradiographic method, for the quantification of scoliosis, and to mathematically relate this proposed method with the Cobb radiographic method. Summary of Background Data. Repeated exposure to radiation of children can be harmful to their health. Nevertheless, no nonradiographic method until now proposed has gained popularity as a routine method for evaluation, mainly due to a low correspondence to the Cobb radiographic method. Methods. Patients undergoing standing posteroanterior full-length spine radiographs, who were willing to participate in this study, were submitted to dorsal digital photography in the orthostatic position with special surface markers over the spinous process, specifically the vertebrae C7 to L5. The radiographic and photographic images were sent separately for independent analysis to two examiners, trained in quantification of scoliosis for the types of images received. The scoliosis curvature angles obtained through computerized photogrammetry (the new method) were compared to those obtained through the Cobb radiographic method. Results. Sixteen individuals were evaluated (14 female and 2 male). All presented idiopathic scoliosis, and were between 21.4 ± 6.1 years of age; 52.9 ± 5.8 kg in weight; 1.63 ± 0.05 m in height, with a body mass index of 19.8 ± 0.2. There was no statistically significant difference between the scoliosis angle measurements obtained in the comparative analysis of both methods, and a mathematical relationship was formulated between both methods. Conclusion. The preliminary results presented demonstrate equivalence between the two methods. More studies are needed to firmly assess the potential of this new method as a coadjuvant tool in the routine following of scoliosis treatment. Introduction Scoliosis has been defined as a lateral curvature of the spinal column superior to 10° Cobb, generally associated to vertebral rotation. Monitoring of this angle has been one of the principal parameters used in defining the type of treatment to be instituted in young patients who are still growing. The most trustworthy method to accompany the evolution of the curvature has been the standing posteroanterior full length spine radiograph, with curvature measurement using the Cobb method.[3] However, over the course of follow-up, this can result in taking more than 25 radiographs. Nearly 15% of patients in one study had undergone 50 or more radiographic examinations, and approximately 17% had received an estimated cumulative radiation dose of 20 cGy or greater. This high number of radiographs can expose patients to relatively high doses of ionizing radiation. Various studies have shown that repeated exposure to radiation in children could be harmful to their health. Many nonradiographic methods of scoliosis accompaniment have been proposed as an alternative to radiographic evaluation.Nevertheless, the majority has not demonstrated a good correlation with the Cobb method. Photogrammetry can be regarded as the science and technology of obtaining spatial measurements, and other geometrically reliable information, derived from photographs.The computerized photogrammetry method proposed in this study can be considered one of many uses of photogrammetry. It has been used in different fields, such as: cartography, architecture, engineering, quality control, and three-dimensional modeling. However, its use in the evaluation of scoliosis has not been well studied. To the authors' knowledge, no data are presently available in the literature that proposes a protocol for photogrammetric measurement of scoliosis, which is applicable to clinical practice. The goals of this investigation were to develop a protocol for computerized photogrammetry method for the quantification of scoliosis curvature as well as to compare the results with those from the Cobb radiographic method in the group of volunteers. Our hypothesis is that both methods yield similar results in obtaining the scoliosis curvature angle.

Allergic to Antihistamines---really!

Gary Stadtmauer, MD, Allergy & Clinical Immunology, 08:22AM Oct 17, 2011 How many times have we heard patients say they are "allergic" to drugs like antihistamines and corticosteroids? Hypersenstivities to medications used to treat allergic diseases are fortunately uncommon. Both the allergy literature and the dermatology literature describe delayed (and even immediate) hypersensitivity reactions to corticosteroids. Patch testing is the preferred method of detecting Type IV hypersensitivity to corticosteroids since intradermal testing may cause dermal atrophy. Corticosteroids with C16 methylation (such as betamethasone) are less allergenic than other steroids. I have seen a couple of cases of drug exanthema from antihistamines but never immediate hypersensitivity...until now. I recently saw a young woman who has had recurrent urticaria/angioedema of immediate onset due to Benadryl. She had no associated symptoms. Scratch testing to Benadryl 5mg/ml was negative but ID was positive at 0.5 mg/ml (W/F of 4/10) and 5 mg/ml (W/F o 5/10). See image below. One could question whether this is an IgE-mediated event. Perhaps it is or perhaps in the occasional patient the antihistamine acts as an agonist, binding to the receptor instead of blocking it thereby triggering histamine release. Anaphylactic shock caused by a challenge with 12.5 mg oral diphenhydramine has been reported and the authors of this case suggest the mechanism was IgE-mediated.

Tuesday, October 25, 2011

Low-Dose Intradermal Flu Vaccine Effective as Intramuscular

From Medscape Medical News Daniel M. Keller, PhD October 24, 2011 (Boston, Massachusetts) — Injecting a lower dose of 2010/11 trivalent influenza vaccine (TIV) intradermally was more immunogenic than a traditional full-dose intramuscular injection for chronically adults, Ivan Hung, MD, clinical assistant professor in the Department of Medicine at the University of Hong Kong, China, reported here at the Infectious Diseases Society of America (IDSA) 49th Annual Meeting. Dr. Hung and colleagues used 1 of 2 devices to administer intradermal injections using 20% or 60% of the standard dose, and compared the immunogenicity with standard doses delivered intramuscularly in an open-label, prospective, randomized trial. From December 2010 to March 2011, 282 chronically ill adults were randomly assigned to 1 of 4 treatments: TIV containing 3 μg of hemagglutinin antigen per strain, administered with a MicronJet600 device; the same treatment but with 9 μg of hemagglutinin antigen per strain; 9 μg of Intanza9 vaccine, administered with the Soluvia device (Sanofi-Aventis); and 15 μg of TIV administered intramuscularly (control group). Immunogenicity was determined through a hemagglutination inhibition assay at baseline and 21 days after vaccination. Of the 282 subjects enrolled, 262 completed the study — approximately evenly divided among the 4 groups (63 to 68 per group.) Demographically, the groups were similar, with a median age of 73.5 years (range, 68.0 to 78.5 years). At day 21, the seroconversion rates for influenza A/H1N1 for all the intradermal lower-dose groups were higher (approximately 50%) than for the intramuscular full-dose group (approximately 13%; P = .017). Similarly, seroprotection, determined by hemagglutination inhibition assay, was greater for all the intradermal groups than for the intramuscular group (P = .024). In all cases, seroconversion, seroprotection, and geometric mean titer fold increases were at least as good or better for the intradermal groups than for the intramuscular group in terms of response to the A/H1N1, H3N2, and influenza B components of the vaccines. "The reason for that is perhaps [because] the intradermal vaccination attracted dendritic cells, and that actually mounted a much better immune response," Dr. Hung said, also noting that no serious adverse effects were detected. He recommends that all elderly and immunocompromised individuals receive intradermal influenza immunizations to compensate for their reduced reactivity to vaccines. "Intradermal vaccination actually mounted a much better immune response, and that would offer better protection against influenza and the complications of influenza (for example, pneumonia) in the elderly population and also for those immunocompromised hosts," Dr. Hung told Medscape Medical News. "For the lower dose, you have slightly fewer side effects in terms of swelling, in terms of redness, which is important for elderly people and perhaps has less systemic effects." He explained that intradermal injection is quite easy to give, and suggested that intradermal dose reduction might be an effective way to make vaccine go further in situations of high demand during future pandemics, once the efficacy of dose-sparing vaccination in healthy individuals has been demonstrated. Andrew Pavia, MD, chief of pediatric infectious disease at the University of Utah, Salt Lake City, and chair of the Pandemic Influenza Task Force of the IDSA, who was not involved in the study, told Medscape Medical News that it is worthwhile investigating better ways for influenza immunization. "The weakness of flu vaccine is that it doesn't cause as good an antibody response in the elderly. One of the things that we'd like to do is to get a flu vaccine or a way of delivering the old flu vaccine that works just as well in the frail elderly as it does in healthy young and middle-aged adults." Besides the equivalent or better efficacy that Dr. Hung showed, Dr. Pavia sees other advantages of intradermal injections. "There have been reports that with intradermal devices, it hurts much less going in because the needle is a microneedle, which people barely feel, but there may be increased itching or redness at the site, compared to getting a deeper injection with an intramuscular vaccine. Some people may prefer itching to injection pain," he said. "The efficacy studies really haven't been done to show that they're truly equivalent. Cost would be the only other barrier. I think as an alternative, this is very interesting and potentially very useful." He also sees intradermal injection as an advantage for people who are "relatively needle-phobic." "It may be useful when you've got a less-skilled population because this is pretty much an automatic device — you don't have to be skilled in giving an intramuscular injection, and of course, there's less risk of needle sticks," he explained. The study received no commercial funding. Dr. Hung reports a collaboration with and receiving research support from NanoPass Technologies. Dr. Pavia has disclosed no relevant financial relationships. Infectious Diseases Society of America (IDSA) 49th Annual Meeting: Abstract 533. Presented October 21, 2011.

Do Not Give Flu Vaccine by Jet Injection, FDA Says

From Medscape Medical News > Alerts, Approvals and Safety Changes > Medscape Alerts Robert Lowes October 24, 2011 — Clinicians should not administer influenza vaccines with needleless "jet injectors" because the vaccines have not been approved for such devices, the US Food and Drug Administration (FDA) has warned. The announcement, issued October 21, follows recent advertisements by major retailers such as Kroger stating that customers can receive such a needleless seasonal flu vaccine instead of the standard injection at their in-store pharmacies. Kroger announced October 21 that it had discontinued the use of this administration technique. A jet injector shoots a high-pressure stream of liquid medication that can penetrate the skin and deliver a dose to tissues underneath. Two manufacturers of jet injectors, PharmaJet and Bioject Medical Technologies, have contested the FDA warning, noting that their products already have received FDA clearance for delivering drugs and vaccines. FDA spokesperson Shelly Burgess told Medscape Medical News that the manufacturers are entirely correct on that point. However, influenza vaccines themselves need to be approved for specific administration methods, regardless of whether the device is approved, Burgess said. So far, the FDA has not cleared any influenza vaccine for jet injection. The agency is advising clinicians to abide by label instructions for administration, whether it is by needle injection or nasal spray. The only vaccine cleared for use with approved jet injectors is for measles, mumps, and rubella (MMR). "Jet injectors represent a different method of delivery that has the potential to change the characteristics of an approved vaccine," the FDA stated in its announcement. "Therefore, each vaccine preparation must be individually evaluated for administration by jet injector, and safety and effectiveness data for that vaccine must be submitted to [the FDA's Center for Biologics Evaluation & Research] for review and approval." The FDA has not received any reports of adverse events associated with jet-injected influenza vaccine, nor is it voicing specific safety concerns, Burgess told Medscape Medical News. "We just haven't studied it yet." When asked whether customers who received influenza vaccine by jet injection should get immunized again during the current influenza season, Burgess referred the matter to a spokesperson for the US Centers for Disease Control and Prevention (CDC). CDC spokesperson Thomas Skinner told Medscape Medical News that "based on current, though limited, information from publications, CDC and FDA believe that it is not necessary for people who got their flu vaccine via jet injector to be re-vaccinated." More information about the FDA announcement is available on the agency's Web site. To report adverse events related to jet injection of an influenza vaccine, contact MedWatch, the FDA's safety information and adverse event reporting program, by telephone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at, or by mail to MedWatch, FDA, 5600 Fishers Lane, Rockville, Maryland 20852-9787.

Monday, October 24, 2011


News Release from the American Academy of Pediatrics. BABIES AND TODDLERS SHOULD LEARN FROM PLAY, NOT SCREENS October 18 BOSTON - The temptation to rely on media screens to entertain babies and toddlers is more appealing than ever, with screens surrounding families at home, in the car, and even at the grocery store. And there is no shortage of media products and programming targeted to little ones. But a new policy statement from the American Academy of Pediatrics (AAP) says there are better ways to help children learn at this critical age. In a recent survey, 90 percent of parents said their children under age 2 watch some form of electronic media. On average, children this age watch televised programs one to two hours per day. By age 3, almost one third of children have a television in their bedroom. Parents who believe that educational television is "very important for healthy development" are twice as likely to keep the television on all or most of the time. The policy statement, "Media Use by Children Younger Than Two Years," will be released Tuesday, Oct. 18, at the AAP National Conference & Exhibition in Boston and will be published in the November 2011 issue of Pediatrics (published online Oct. 18). Ari Brown, MD, FAAP, lead author of the policy, will discuss the recommendations in an embargoed news briefing for reporters at 10 a.m. ET Monday, Oct. 17, at the Boston Convention & Exhibition Center. The AAP first provided guidance on media use for children under age 2 in 1999. This consisted of a recommendation in the Academy's policy statement, "Media Education," which discouraged TV viewing for children in this age group. At the time, there was limited data on the subject, but the AAP believed there were more potential negative effects than positive effects of media exposure for the younger set. Newer data bears this out, and the AAP stands by its recommendation to keep children under age 2 as "screen-free" as possible. More is known today about children's early brain development, the best ways to help them learn, and the effects that various types of stimulation and activities have on this process. "The concerns raised in the original policy statement are even more relevant now, which led us to develop a more comprehensive piece of guidance around this age group," said Dr. Brown, a member of the AAP Council on Communications and Media. The report set out to answer two questions: Do video and televised programs have any educational value for children under 2? Is there any harm in children this age watching these programs? The key findings include: Many video programs for infants and toddlers are marketed as "educational," yet evidence does not support this. Quality programs are educational for children only if they understand the content and context of the video. Studies consistently find that children over 2 typically have this understanding. Unstructured play time is more valuable for the developing brain than electronic media. Children learn to think creatively, problem solve, and develop reasoning and motor skills at early ages through unstructured, unplugged play. Free play also teaches them how to entertain themselves. Young children learn best from-and need-interaction with humans, not screens. Parents who watch TV or videos with their child may add to the child's understanding, but children learn more from live presentations than from televised ones. When parents are watching their own programs, this is "background media" for their children. It distracts the parent and decreases parent-child interaction. Its presence may also interfere with a young child's learning from play and activities. Television viewing around bedtime can cause poor sleep habits and irregular sleep schedules, which can adversely affect mood, behavior and learning. Young children with heavy media use are at risk for delays in language development once they start school, but more research is needed as to the reasons. The report recommends that parents and caregivers: Set media limits for their children before age 2, bearing in mind that the AAP discourages media use for this age group. Have a strategy for managing electronic media if they choose to engage their children with it; Instead of screens, opt for supervised independent play for infants and young children during times that a parent cannot sit down and actively engage in play with the child. For example, have the child play with nesting cups on the floor nearby while a parent prepares dinner; Avoid placing a television set in the child's bedroom; and Recognize that their own media use can have a negative effect on children. The report also recommends further research into the long-term effects of early media exposure on children's future physical, mental and social health. According to Dr. Brown, "In today's ‘achievement culture,' the best thing you can do for your young child is to give her a chance to have unstructured play-both with you and independently. Children need this in order to figure out how the world works."

Tdap Vaccine for Pregnant Women

From Medscape Medical News Updated Recommendations for Tdap Include Pregnant Women Ricki Lewis, PhD October 21, 2011 — The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention is taking measures to fill a gap in the protection of infants from pertussis, by vaccinating pregnant women and people in contact with infants younger than 1 year. The tetanus, diphtheria, and pertussis (Tdap) vaccine consists of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine. Vaccinating pregnant women and those in contact with infants will supplement the current practice of "cocooning," in which unvaccinated postpartum mothers and other family members receive Tdap. Although ACIP has recommended cocooning since 2005, compliance has been poor. ACIP also recommends Tdap for people aged 11 through 18 years after they complete the childhood vaccine regimen of diphtheria and tetanus toxoids and pertussis/diphtheria and tetanus toxoids and acellular pertussis, as well as for adults between the ages of 19 and 64 years who have not received Tdap, in addition to people older than 65 years who may be in contact with infants who have not received the vaccine. The reason for the new recommendations is that infants, especially those younger than 2 months, which is when vaccination begins, are particularly vulnerable to developing severe illness and death from pertussis. Vaccinating pregnant women will pass antibodies to the newborn before and during birth. ACIP advises administration after 20 weeks' gestation to minimize the confounding effects of early pregnancy loss in evaluating safety and to maximize the maternal antibodies transmitted to the fetus and infant, given that the half-life of such antibodies is 6 weeks. This new perinatal exposure should provide protection until the infant's first vaccination at 2 months. In the United States each year since 2004, a mean of 3055 infants contract pertussis, with 19 or more deaths, according to the National Notifiable Diseases Surveillance System of the US Centers for Disease Control and Prevention. The total number of cases reported for 2010 was 27,550. Abundant evidence indicates that tetanus and diphtheria vaccines are safe during pregnancy. Although the possible teratogenicity of the vaccine was not initially studied, data from patient registries maintained by the vaccine manufacturers (Sanofi Pasteur and GlaxoSmithKline Biologicals) indicate that Tdap is safe. Further studies will investigate whether exposure to maternal antibodies is indeed protective, or whether it blunts the infant's vaccine response. MMWR Morb Mortal Wkly Rep. 2011;60:1424-1426. Full text

Friday, October 21, 2011

Acne Vulgaris Treatment & Management

James Fulton Jr, MD, PhD; Chief Editor: Dirk M Elston, MD more... Medical Care Treatment should be directed toward the known pathogenic factors involved in acne. These include follicular hyperproliferation, excess sebum, P acnes, and inflammation. The grade and severity of the acne help in determining which of the following treatments, alone or in combination, is most appropriate. When a topical or systemic antibiotic is used, it should be used in conjunction with benzoyl peroxide to reduce the emergence of resistance. Topical treatments Topical retinoids are comedolytic and anti-inflammatory. They normalize follicular hyperproliferation and hyperkeratinization. Topical retinoids reduce the numbers of microcomedones, comedones, and inflammatory lesions. They may be used alone or in combination with other acne medications. The most commonly prescribed topical retinoids for acne vulgaris include adapalene, tazarotene, and tretinoin. These retinoids should be applied once daily to clean, dry skin, but they may need to be applied less frequently if irritation occurs. Skin irritation with peeling and redness may be associated with the early use of topical retinoids. The use of mild, nondrying cleansers and noncomedogenic moisturizers may help reduce this irritation. Alternate-day dosing may be used if irritation persists. Topical retinoids thin the stratum corneum, and they have been associated with sun sensitivity. Instruct patients about sun protection. Also see Sunscreens and Photoprotection. Topical antibiotics are mainly used for their role against Propionibacterium acnes. They may also have anti-inflammatory properties. Topical antibiotics are not comedolytic, and bacterial resistance may develop to any of these agents. The development of resistance is lessened if topical antibiotics are used in combination with benzoyl peroxide.[18] Commonly prescribed topical antibiotics for acne vulgaris include erythromycin and clindamycin alone or in combination with benzoyl peroxide. Clindamycin and erythromycin are available in a variety of topical agents. They may be applied once or twice a day. Gels and solutions may be more irritating than creams or lotions. Clindamycin has maintained better efficacy than erythromycin. Benzoyl peroxide products are also effective against P acnes, and bacterial resistance to benzoyl peroxide has not been reported.[19] Benzoyl peroxide products are available over the counter and by prescription in a variety of topical forms, including soaps, washes, lotions, creams, and gels. Benzoyl peroxide products may be used once or twice a day. These agents may occasionally cause a true allergic contact dermatitis. More often, an irritant contact dermatitis develops, especially if used with tretinoin or when accompanied by aggressive washing methods. If intensive erythema and pruritus develop, a patch test with benzoyl peroxide is indicated to rule out allergic contact dermatitis. Systemic treatments Systemic antibiotics are a mainstay in the treatment of acne vulgaris. These agents have anti-inflammatory properties, and they are effective against P acnes. The tetracycline group of antibiotics is commonly prescribed for acne. The more lipophilic antibiotics, such as doxycycline and minocycline, are generally more effective than tetracycline. Greater efficacy may also be due to less P acnes resistance to minocycline. However, P acnes resistance is becoming more common with all classes of antibiotics currently used to treat acne vulgaris.[20]P acnes resistance to erythromycin has greatly reduced its usefulness in the treatment of acne. Subantimicrobial therapy or concurrent treatment with topical benzoyl peroxide may reduce the emergence of resistant strains. Although continued use of systemic tetracycline group antibiotics was believed to result in colonization with tetracycline-resistant Staphylococcus aureus, this does not appear to be true. A study by Fanelli et al found that S aureus remained sensitive to tetracycline even after prolonged use of that antibiotic for acne. This has significant ramifications when considering efforts to control the spread of methicillin-resistant S aureus (MRSA) because tetracycline group antibiotics are currently one of the primary options for outpatient treatment of MRSA.[21] Other antibiotics, including trimethoprim alone or in combination with sulfamethoxazole, and azithromycin, reportedly are helpful.[22, 23] Some hormonal therapies may be effective in the treatment of acne vulgaris. Oral contraceptives increase sex hormone–binding globulin, resulting in an overall decrease in circulating free testosterone. Combination birth control pills have shown efficacy in the treatment of acne vulgaris.[24, 25, 26, 27] Spironolactone may also be used in the treatment of acne vulgaris.[28] Spironolactone binds the androgen receptor and reduces androgen production. Adverse effects include dizziness, breast tenderness, and dysmenorrhea. Dysmenorrhea may be lessened by coadministration with an oral contraceptive. Periodic evaluation of blood pressure and potassium levels is appropriate. Pregnancy must be avoided while taking spironolactone because of the risk of feminization of the male fetus. Isotretinoin is a systemic retinoid that is highly effective in the treatment of severe, recalcitrant acne vulgaris. Isotretinoin causes normalization of epidermal differentiation, depresses sebum excretion by 70%, is anti-inflammatory, and even reduces the presence of P acnes. Isotretinoin therapy should be initiated at a dose of 0.5 mg/kg/d for 4 weeks and increased as tolerated until a cumulative dose of 120-150 mg/kg is achieved. Coadministration with steroids at the onset of therapy may be useful in severe cases to prevent initial worsening. Some patients may respond to doses lower than the standard recommendation dosages. A lower dose (0.25-0.4 mg/kg/d) may be as effective as the higher dose given for the same time period and with greater patient satisfaction. Lower intermittant dosing schedules (1 week out of each month) are not as effective.[29] Isotretinoin is a teratogen, and pregnancy must be avoided. Contraception counseling is mandatory, and 2 negative pregnancy test results are required prior to the initiation of therapy in women of childbearing potential. The baseline laboratory examination should also include cholesterol and triglyceride assessment, hepatic transaminase levels, and a CBC count. Pregnancy tests and laboratory examinations should be repeated monthly during treatment. Acne can be a very depressing situation. It freezes personality development in the adolescent stage and may create hostility, anger, and antisocial behavior. Associated mood changes and depression have also been reported during treatment. Isotretinoin may heighten feelings of depression and suicidal thoughts.[30] Do not administer isotretinoin to a depressed or suicidal teenager. Although a cause-and-effect relationship has not been established, patients should be informed of this potential effect and must sign a consent form acknowledging they are aware of this potential risk.[31, 32] A US Food and Drug Administration–mandated registry is now in place for all individuals prescribing, dispensing, or taking isotretinoin. For more information on this registry, see iPLEDGE. This registry aims to further decrease the risk of pregnancy and other unwanted and potentially dangerous adverse effects during a course of isotretinoin therapy. While using isotretinoin, the patient is considered at high risk for abnormal healing and the development of excessive granulation tissue following procedures. Many dermatologists delay elective procedures, such as dermabrasion or laser resurfacing (eg, with carbon dioxide laser or erbium:YAG laser), for up to 1 year after completion of therapy. Other procedures to be avoided during therapy include tattoos, piercings, leg waxing, and other epilation procedures. Note the images below. Acne with reactive hyperpigmentation; before treatAcne with reactive hyperpigmentation; before treatment. Acne with reactive hyperpigmentation; after treatmAcne with reactive hyperpigmentation; after treatment. A summary of the American Academy of Dermatology treatment guidelines, Guidelines of care for acne vulgaris management, may be of interest.[33] Also see the Medscape Acne Resource Center.

Kids' Urinary Infections Usually Not a Kidney Risk

From Reuters Health Information By Amy Norton NEW YORK (Reuters Health) Oct 12 - Most children with recurrent urinary tract infections (UTIs) are not at increased risk of chronic kidney disease later in life, a new meta-analysis suggests. "If there is no structural abnormalities in the kidney ultrasound after the first UTI, the parents should not be worried at all" about the risk of chronic kidney disease, said lead researcher Dr. Jarmo Salo of the University of Oulu in Finland. Recurrent UTIs in young children have been seen as a possible risk factor for chronic kidney disease later in life, especially in cases with vesicoureteral reflux (VUR). But the idea that repeat UTIs and VUR are risk factors for chronic kidney disease is not universally accepted -- nor is the practice of testing children for VUR when they have a urinary tract infection. For the new study, reported October 10th in Pediatrics, researchers pooled data from 10 studies, with 1,576 patients, that either looked at the history of childhood UTIs in people with chronic kidney disease, or that followed children with UTIs to monitor their renal function. They also reviewed the records of all 366 patients who were treated for chronic kidney disease at their hospital over one year. The 10 studies showed no evidence that childhood UTIs -- even along with VUR -- were the main cause of chronic kidney disease, according to the researchers. And of the kidney disease patients who did have a history of childhood UTIs, all also had structural abnormalities in their kidneys. Similarly, of the 366 patients at their center, the researchers found that only three had repeat childhood UTIs that might have contributed to their chronic kidney disease -- and all had structural abnormalities in the kidneys that would be detectable on ultrasound. Dr. Salo told Reuters Health in an email that doctors in Finland no longer "actively" look for VUR because there's evidence that it is a "normal phenomenon," and that treating it does not prevent long-term kidney damage. "We suggest that the (x-ray) imaging studies are not necessary if the child has structurally normal kidneys in ultrasound," Dr. Salo said. But a pediatric urologist not involved in the study cautioned against making a "sweeping" recommendation against VUR testing. "The good news for parents is yes, the chances of your child developing kidney disease will be very low," said Dr. Hiep T. Nguyen of Children's Hospital Boston. However, he told Reuters Health, repeat UTIs in young children (generally younger than 5) are not the same as those in older kids or adults. And some of those children are at increased risk for kidney damage -- particularly if they have more-severe, high-grade VUR. What's more, Dr. Nguyen said, there is evidence that finding and treating high-grade VUR with low-dose antibiotics and period testing to see whether reflux has resolved may prevent kidney damage. Nguyen said that a young child with a UTI should have an ultrasound "at a minimum" to look for structural abnormalities in the kidneys.Dr. Salo agreed. But the area of controversy is in testing for VUR. Essentially, Dr. Nguyen said, pediatricians are increasingly moving away from recommending VUR testing for children with urinary tract infections. Pediatricians, he noted, see a lot of children with UTIs, and most of those kids will have no long-term kidney disease as a result. But urology specialists see the people with chronic kidney disease, and they are apt to see the value in testing for VUR so that kids with reflux can be treated. "We are looking from two different viewpoints," Dr. Nguyen said. VUR has a strong genetic component, and researchers are working on gene tests -- where a child will just have to "spit in a cup," Dr. Nguyen said -- that could help pinpoint the kids with UTIs who would be the best candidates for VUR testing. For now, the decision to do VUR testing is basically case-by-case. Dr. John Gearhart, director of pediatric urology at Johns Hopkins Children's Center in Baltimore, said the current findings "should reassure mothers and fathers." But he agreed that there are cases where testing for VUR is appropriate: if there's a family history of the condition, for example, or if a young child has more than one urinary infection that includes fever. Testing for VUR does involve radiation, albeit as low a dose as possible, Dr. Gearhart noted in an interview. So limiting the number of children who have it is important. There can also be side effects from the low-dose antibiotics given to children with VUR -- such as stomach upset, diarrhea and yeast infections. There is an ongoing North American clinical trial looking at whether giving antibiotics to young children with mild to moderate VUR prevents kidney scarring, which could eventually lead to chronic kidney disease. That, according to Dr. Gearhart, should give more insights into whether it is helpful to give all children with VUR preventive antibiotics. SOURCE: Pediatrics 2011.

Easy 2-Step Screening Tool Detects Underage Drinking

From Medscape Medical News > Psychiatry Yael Waknine October 14, 2011 — A new tool to screen children and teenagers for alcohol was introduced today by the National Institutes of Health National Institute on Alcohol Abuse and Alcoholism. "Routine screening and intervention for alcohol use in young people is critical to preventing the constellation of problems associated with adolescent drinking," said Howard Koh, MD, MPH, in a National Institutes of Health news release. The new screening tool offers "an opportunity to engage young patients before it is too late." Dr. Koh is assistant secretary for health at the US Department of Health and Human Services. The screening tool was developed in collaboration with the American Academy of Pediatrics Committee on Substance Abuse, clinical researchers, and health practitioners. A simple, fast, and effective early-detection test that is easily managed by busy practitioners, the tool consists of 2 basic questions: one to quantify a patient's use of alcohol in the past year, and the other to inquire about friends' consumption of alcohol as a predictor of future use. "People who start drinking before the age of 15 are much more likely to have alcohol problems later in life than those who begin drinking at age 21 or older," noted Pamela S. Hyde, administrator of the Department of Health and Human Services' Substance Abuse and Mental Health Services Administration. "By helping clinicians identify underage drinking early, this simple and straightforward tool will help young people avoid behaviors that prevent them from achieving their full potential." In addition to the 2-question screen, the guide includes a chart to determine the risk for adverse consequences based on age and the level of alcohol consumption. Options for follow-up range from a motivational discussion regarding the medical implications of alcohol abuse to referrals for additional treatment. "Clinicians who care for young people are well aware of the many harms caused by underage drinking," said Sharon Levy, MD, MPH. "The guide takes much of the mystery out of intervening with young patients who are drinking, allowing clinicians to proceed within a clinical framework of low, moderate, or high risk. It will enable pediatricians and other clinicians who care for young people to easily incorporate alcohol screening across the care spectrum, from annual visits to urgent care." Dr. Levi serves as chair of the American Academy of Pediatrics' Committee on Substance Abuse and assistant professor of pediatrics at Harvard Medical School in Boston, Massachusetts.

Most Shy Children Do Not Suffer From Social Phobia

From Medscape Medical News > Psychiatry Fran Lowry October 19, 2011 — Many children describe themselves as being shy, but only 1 in 10 may actually have social phobia, a disabling psychiatric disorder that goes beyond normal human shyness, new research shows. Debate has recently surfaced over whether the diagnostic term social phobia "medicalizes" normal human shyness, resulting in unnecessary treatment, especially in youth, senior author Kathleen R. Merikangas, PhD, from the National Institute of Mental Health, Bethesda, Maryland, told Medscape Medical News. "We wanted to examine the prevalence of shyness and social phobia, and the only way we really get to know about the scope of these problems is by going after the general population," she said. The study was published online October 17 in Pediatrics. Disabling Disorder Dr. Merikangas and colleagues collected household and school data from across the United States to garner a nationally representative sample of adolescents aged 13 to 18 years and create the National Comorbidity Survey–Adolescent Supplement, a face-to-face survey. The data in the survey included 10,123 adolescents and 6000 parents. Participants were asked about a variety of mental disorders, including social phobia. "Social phobia is a very disabling psychiatric disorder. It interferes with a person's social life, their educational activities and success in school, and limits outside activities. Those affected feel uncomfortable to the point where they avoid contact with others or speaking out in class, and this is where we draw the threshold between a normal trait and disorder," said Dr. Merikangas. The researchers found that almost half of the adolescents (46.7%) rated themselves as shy, and that about 62.4% of parents reported that their teenagers were shy. "It's almost like a normative trait to describe yourself, or for the parents to describe their kids, as being shy. It's just like saying someone has blue eyes or brown eyes, or they are extroverted or introverted. Shyness is one of those, and it's a normal human trait," Dr. Merikangas said. Increases With Age The study also found that of the children who report themselves as shy, 12% had social phobia, or substantial impairment from their shyness. In addition, the rate of social phobia increased with the age of the children. For 13-year-olds, the rate was 6.3%; for 15- to 16-year-olds, it was 9.6%; and at age 17 to 18 years, it was 10.4%. Social phobia is treatable, Dr. Merikangas emphasized. "Parents of children who have social phobia can modify their child's environment; help them to have gradual exposure to the things that exacerbate their social phobia. Behavioral and exposure therapy, similar to fear-of-flying programs that some of the airlines put on, can help," she said. The education system could also help these children, she added. "If the education system were to recognize it, more teachers may be less harsh in grading kids who don't raise their hand in class, or who don't talk in class. If they are aware of social phobia, they may help them, rather than punish them." Gateway Disorder Commenting on the study for Medscape Medical News, Anne Marie Albano, PhD, from Columbia University and the New York State Psychiatric Institute, New York City, said: "I think it's a critical study. It has quantified and clarified what we have known in psychiatry, which is that shyness is a normally distributed trait that is not a clinical syndrome, and it is distinct from social phobia or social anxiety disorder, which is disabling." Dr. Albano agreed that there is much that can be done for kids with social phobia. "There are highly effective treatments in cognitive behavioral therapy that teach them skills for managing the anxiety and making their way into the social world they need to live in," she said. For those who develop more impairment in functioning, the combination of medication and psychotherapy is effective, she added. "One of the big things about social phobia that we know is it's a gateway disorder. It usually occurs first, and it's a gateway to depression and substance abuse, so it's critical that we get kids help for this and not dismiss it as a normal personality trait," she said. This study was supported by the Intramural Research Program of the National Institute of Mental Health. Dr. Merikangas and Dr. Albano have reported no relevant financial relationships. Pediatrics. Published online October 17, 2011. Abstract

Cell Phones and Brain Tumors: No Link, But Is Study Flawed?

From Medscape Medical News > Oncology Roxanne Nelson October 21, 2011 — The latest study on cancer and cell phones — the largest to date — has found no evidence of an overall increase in brain tumors or any cancers over an 18-year period. However, a group of experts says that the study is seriously flawed, and declares that it should be "condemned as misleading spin." The study was published online October 20 in BMJ, and the fierce rebuttal comes from Updated Results The study is an update of a nationwide Danish study that compared the cancer risk for all 420,095 Danish cell-phone subscribers with that for nonusers from 1982 to 1995, with follow-up to 1996 (J Natl Cancer Inst. 2001;93:203-207) and then 2002 (J Natl Cancer Inst. 2006;98:1707-1713). This study has found no evidence of any increased risk for brain or central nervous system (CNS) tumors or any cancer among cell-phone subscribers, and the latest results — which now span a period of 18 years — confirm this finding of no evidence. The researchers, led by Patrizia Frei, PhD, a postdoctoral research fellow from the Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, extended the follow-up of the Danish cohort to 2007, and focused on CNS tumors in 358,403 cell-phone subscribers. Overall, 10,729 CNS tumors occurred from 1990 to 2007 in 5111 men and 5618 women. The incidence rate ratio for CNS tumors was consistently close to 1 in women and men, both overall and when stratified. However, when analyzed by morphologic subtype of intracranial CNS tumor, there was a slight but nonsignificantly elevated incidence rate ratio of glioma in men (1.08; 95% confidence interval [CI], 0.96 to 1.22). The ratio was highest in the shortest-term users (1 to 4 years); after 5 years of use, the numbers were only slightly elevated. For other and unspecified types intracranial tumors of the CNS, incidence rate ratios were nonsignificantly higher in both men (1.12; 95% CI, 0.95 to 1.33) and women (1.19; 95% CI, 0.85 to 1.67), but the authors did not see a "clear indication of a dose–response effect." The authors note that this "extended follow-up allowed us to investigate effects in people who had used [cell] phones for 10 years or more, and this long-term use was not associated with higher risks of cancer." However, they point out that because "a small to moderate increase in risk for subgroups of heavy users or after even longer induction periods than 10 to 15 years cannot be ruled out, further studies with large study populations, where the potential for misclassification of exposure and selection bias is minimized, are warranted." More Research Needed? The study has 2 important methodologic advantages over most other studies, write Anders Ahlbom, PhD, and Maria Feychting, MD, PhD, both from the Karolinska Institute in Stockholm, Sweden, in an accompanying editorial. First, "it was based on a computerized cohort that was followed passively in registries, so it avoided the need to contact people," they point out. Thus, the problems of nonresponse and selection bias, which have been an issue in other studies, were eliminated. Second, the researchers used digitized subscriber data that were obtained from the operators, rather than from retrospective questionnaires or interviews with users. "This circumvented the recall bias that is present in other studies," the editorialists write, although they point out that "having a [cell] phone subscription is not equivalent to using a [cell] phone and, conversely, some users will be nonsubscribers." Although the study used a Danish cohort, the editorialists point out that in Sweden, where handheld cell phones were introduced almost 25 years ago, the incidence rates for glioma have not risen since 1970. The use of cell phones has spread quickly, and 87% of people 16 to 75 years of age were using them in 2002. The proportion that has been using them for 10 or even 15 years must have been substantial, note Drs. Ahlbom and Feychting. Thus, "the absence of a trend in the incidence of brain tumors in national statistics is reassuring." The research that has been conducted evaluating the safety of cell phones is now extensive, and "the question is how much more research is needed," they write. "Continued monitoring of health registers and prospective cohorts is warranted, but more case–control or other studies with built in selection and recall bias are not needed," the editorialists conclude. Fierce Rebuttal However, a group of experts from several countries have joined together and issued a fierce rebuttal of this study in a document posted on, a health education and advocacy group based in the United States. "This seriously flawed study misleads the public and decision makers about the safety of [cell] phone use. I consider that their claims are worthless," Denis L. Henshaw, PhD, emeritus professor of human radiation effects, University of Bristol, United Kingdom, states in the document. "From the way it was set up originally, this deeply flawed study was designed to fail to find an increased risk of brain tumors tied [to] cell phone use. In order for any study of a relatively rare disease like brain tumors to find a change in risk, millions must be followed for decades. By extending an earlier analysis on the same group of cell phone users, this new report provides unsurprising, biased, and misleading conclusions," explains Devra Davis, PhD, MPH, cancer epidemiologist and president of Environmental Health Trust, in the document. A serious concern about this study is the choice of individuals in the control group, the group of experts asserts. The Danish researchers compared the rates of brain tumors that occurred from 1990 to 2007 in those who began using cell phones after 1987 with the rates in those who were nonsubscribers when the study started. "This understates risk, because most of those who began as 'nonsubscribers' to cell phone service (i.e., the 'controls' at the time the cohort was collected) became cell phone users later on, and accumulated almost as many years (on average per person) as the 'exposed' subscribers. Hence, the comparison to the population not contained in the subscriber sample is a comparison between 2 exposed groups. When Michael Kundi and colleagues from the Medical University of Vienna mathematically corrected for this concern in an earlier report from this Danish study, they found a significantly increased risk for brain tumors," the group writes. This concern about the control group is raised in the editorial, which describes it as a "weakness" of the study. The misclassification of subscribers and nonsubscribers "would dilute any association between [cell-]phone use and cancer risk, and this is important for a negative study like the current one," they note. "However, for long-term users, this misclassification would have only a small effect: long-term users who did not hold personal subscriptions would make up a small proportion of the reference population," they assert. In their rebuttal, the experts declare that this updated Danish study "in fact did find increased risk, even though the study is currently being promoted to the media as if it did not." "Statistical significance tests are tools used in science to help understand the chance that a finding is real. In fact, the article reports a significant increased risk of a very rare form of glioma of the cerebral ventricle based on 8 cases (2.58; 95% CI,1.08 to 6.10), but the authors chose to make no mention of this significant finding. In this instance, despite the small number, the finding is significant," they write. "The authors reject all other findings of borderline significance completely. In a study of relatively rare diseases, such as brain tumors, the failure to obtain statistical significance should not be confused with a lack of public health importance. In fact, most of the reported numbers of brain tumors in this article give estimated risks where the result goes from below 1 (a negative result meaning no increased risk), to above 1 (a positive result indicating in some instances a doubled or greater risk)," they add. "All of the few well-designed case–control studies of this issue have found significantly increased risk. Thus, these borderline findings of increased risk may well signal an important association," they add. In the document, Alasdair Philips, an expert in electromagnetic health from Powerwatch in the United Kingdom, says: "This study only looks at 7% of the Danish population who had a personal cell-phone subscription for at least 1 year during the period 1987 to 1995. It ignores corporate subscribers (the heaviest users then), and the researchers have no data at all on cell-phone use since 1995, so the extra 86% of the population who started to use a cell phone since 1996 were left in the 'nonsubscriber' part of the population. This study uses seriously flawed data to make a flawed analysis and should be condemned as misleading spin." A Mixed Bag Previous studies on the link between cell phones and cancer have come to various conclusions. Approximately 30 epidemiologic studies have attempted to evaluate a possible association between cell-phone use and the risk for brain and salivary gland tumors. There have also been a number of experimental studies involving cell cultures and animal models. One meta-analysis found evidence linking cell-phone use to an increased risk for tumors, whereas another study showed that cell-phone use for as little as 50 minutes at a time appears to affect brain glucose metabolism in the region closest to the phone's antenna. Yet another study pointed to evidence that exposure to cell phones prenatally and early in life increases a child's risk of developing behavioral problems. Conversely, a recent study reported that children and adolescents who use cell phones do not appear to be at a higher risk for brain cancer. In 2009, a Scandinavian study failed to find substantial changes in brain tumor incidence among adults 5 to 10 years after the use of cell phones sharply increased. Results from the 13-country INTERPHONE project, the largest study ever conducted on cell-phone use and cancer risk, reported no increase in risk for glioma or meningioma with the use of cell phones. However, there were suggestions of an increased risk for glioma in people with the highest levels of exposure. Some countries have begun to take measures to limit cell-phone exposure in children. In June, the World Health Organization's International Agency for Research on Cancer announced that radiofrequency electromagnetic fields have been classified as possibly carcinogenic to humans (group 2B) on the basis of an increased risk for glioma that some studies have associated with the use of wireless phones. This study was funded by the Danish Strategic Research Council to cover costs for data linkage. The authors and editorialists have disclosed no relevant financial relationships. BMJ. Published online October 20, 2011. Abstract, Editorial

Wednesday, October 19, 2011

Contrasting Views on Treatment of Children Dying From Cancer

From Medscape Medical News > Oncology Roxanne Nelson October 19, 2011 — Despite significant improvements in cure rates, childhood cancer can follow an unpredictable course. In some cases, the disease will progress or recur and ultimately lead to death. A new study has found that parents and healthcare professionals might not always see eye to eye when it comes to end-of-life care for a child. A study published online October 17 in CMAJ found that, compared with healthcare providers, parents strongly favored aggressive treatment in the palliative phase of care. Parents also ranked hope as a more important factor when making treatment-related decisions. Hope and the child's quality of life tied for the highest ranking in importance for parents; these were followed by increased survival time. Healthcare professionals, however, ranked quality of life as the most important factor, followed by increased survival time. The researchers observed that parents favored the use of chemotherapy more than healthcare professionals (54.5% vs 15.6%; P < .0001). "Information about the quality of life and length of life is important, but we don't know a lot about these parameters in real life," said lead author Lillian Sung, MD, PhD, a pediatric oncologist at the Hospital for Sick Children in Toronto, Ontario, Canada. "These should be research parameters." For example, in some cases, chemotherapy can improve quality of life, she explained in an interview. Healthcare professionals also need to speak more explicitly with parents about end-of-life care and explain what the choices are and what can be expected, she continued. "We need more communication and more honest dialogue." Hope is a good coping mechanism. "We also need to let parents know that we appreciate where they're coming from, and that we don't want to take away hope," said Dr. Sung. "Hope is a good coping mechanism, but the nature of that hope may change in the trajectory of illness." At the outset, a parent's hope might be for a cure, but as the illness progresses, that hope changes to wanting more time and a better quality of time; finally, it might evolve to hoping for a peaceful death, she explained. "We need to work with parents and provide guidance," Dr. Sung explained. "We also shouldn't assume that just because parents are hopeful that they don't understand what's going on." Child's Input In a commentary accompanying the study, Caprice Knapp, PhD, and Kelly Komatz, MD, both from the University of Florida, Gainesville, note that this study is important because it highlights "the incongruity between the preferences of parents and those of healthcare workers." "It may be that this incongruity masks a greater concern: miscommunication or unrealistic expectations," they write, pointing out that a key finding of research recently published by the Center to Advance Palliative Care was that most physicians do not understand the scope of palliative care. "If there is a basic misunderstanding of terminology, definitions, and messages associated with end-of-life care, then incongruity of preferences might be expected," the editorialists note. The researchers highlight the importance of hope in the pediatric palliative setting and the difficulty in balancing "hope for a cure with hope for the comfort and dignity of the child." This study is important because of its design and rigor, the editorialists explain. Even though only 77 interviews were completed, that is "an impressive number that should be acknowledged," they write, adding that evidence in pediatric palliative care is limited by small sample sizes, and that the authors should be "commended for consistently doing their study over 4 years." However, an important limitation of the study is that the children's preferences were not obtained, Drs. Knapp and Komatz write. Not including that information "fails to recognize that decision-making is triadic, not dyadic." "Without this information, it is unclear whether families or healthcare workers drive incongruity," they note. Dr. Sung agrees that the child's input is very important, and notes that parents did rate their child's opinion as being very important in making this type of decision. Depending on the child's maturity and cognitive ability, it is important to include them in these discussions. It is very rare that clinicians speak to the children, said Dr. Sung. "By talking to them, it may facilitate their comfort and allow them to express their own feelings. There is great value in what the children have to say." Chemotherapy and Importance of Hope Choosing between palliative chemotherapy and supportive care alone is one of the most important and difficult decisions in pediatric oncology. The goal of this study was to compare the strength of preference between parents and healthcare professionals for supportive care alone and palliative chemotherapy, the researchers explain. Prior to beginning the study, Dr. Sung and colleagues held a focus group with 12 parents of children who had died of cancer. From this, they identified the range of factors that parents consider important when choosing between supportive care and palliative chemotherapy. The focus group also tested the visual aids and the interview scripts that were going to be used in the study to help ensure that the potential for causing additional distress to the participants would be minimized. A total of 77 parents of children whose cancer had no reasonable chance of being cured and 128 healthcare professionals in pediatric oncology were involved in the study. Interviews were conducted with both parents and providers, and visual analogue scales were used to help respondents illustrate the anticipated level of the child's quality of life, the expected duration of survival, and the probability of cure (for healthcare personnel only). The participants were then asked about their preference for treatment options, given these baseline attributes, reported which factors might affect this decision, and ranked all identified factors in order of importance. Overall, parents and healthcare professionals had similar viewpoints when making end-of-life decisions, although parents focused more on the importance of hope. In addition, as a group, healthcare providers tended to regard supportive care alone more positively than parents. This indicates, the authors note, that parents and healthcare professionals generally have different underlying attitudes about end-of-life care. These differences might, in part, "contribute to the apparent conflict between professionals and parents when tensions emerge during the palliative phase of care," they write. Despite the importance that parents placed on the child's quality of life, they still reported that they would accept chemotherapy if it reduced both quality of life and survival time. This finding, the authors note, shows the complexity of decision-making, and that it is "possible that hope for a cure is such an important factor that it may override considerations of the child's quality of life and survival time." The study was supported by the Canadian Cancer Society. Dr. Sung is supported by the Canadian Institutes of Health Research through a New Investigator Award. The other authors and the editorialists have disclosed no relevant financial relationships. CMAJ. Published online October 17, 2011. Abstract, Abstract

Tuesday, October 18, 2011

Kids and Heat: Making Exercise Safe

From Medscape Pediatrics An Expert Interview With Michael F. Bergeron, PhD Laurie Scudder, DNP, NP; Michael F. Bergeron, PhD Editor's Note: The American Academy of Pediatrics (AAP) Council on Sports Medicine and Fitness and the Council on School Health recently issued a policy statement titled "Climatic Heat Stress and Exercising Children and Adolescents". In a revision of a previous statement issued in 2000, this new policy statement relies on recent evidence to provide guidance to support clinicians in providing advice to children, teens, parents, coaches, and others that allows for safe participation in outdoor sports and exercise in a range of adverse climatic conditions including high heat and humidity. Laurie Scudder, DNP, NP, spoke with Michael F. Bergeron PhD, lead author of the policy statement; Director, National Institute for Athletic Health & Performance at Sanford Health ; and Professor, Department of Pediatrics at The University of South Dakota, about this policy and implications for clinicians. Medscape: Dr. Bergeron, the AAP policy statement is supported by a number of recent studies that compared body temperature regulation, exercise tolerance, and cardiovascular responses between similarly fit children and adults exposed to equally intensive exercise and environmental conditions and concluded that, assuming appropriate preventive measures are undertaken, children and adults tolerate these conditions equally well. Could you expand briefly on some of these key studies and findings? Dr. Bergeron: The earlier policy on this topic was based on physiologic and anatomic characteristics of children that had been thought to impair thermoregulatory ability, particularly during exercise in the heat. One of these factors was a reported low exercise economy; that is, there has been a concern that kids expend a much higher amount of energy during physical activity and consequently would produce more heat for a given level of exercise. However, at the same relative exercise intensity (commensurate with body size), there are no differences between children and adults. Second, children up to about 13 years of age have a much higher ratio of body surface area to their mass. That was thought to put them at a temperature regulation disadvantage, suggesting that they potentially could gain more heat from the sun and such. And children do have a lower sweating capacity up until the later teenage years. Some of the early evidence also suggested that their cardiovascular capacities including cardiac output were lower than adults. Collectively, all of that set the stage for a perspective that kids would be at a much higher risk for poorer physical performance and heat-related illness during physical activities in hot climates. However, more recent research, both my own and that of a number of others, does not support this notion. The more current research has done a better job in more directly comparing identical relative exercise intensities in the same environments with equal levels of hydration in adults and kids. Also, these studies do not support the contention that there is a maturational disadvantage during exercise in the heat. Therefore, the AAP Council on Sports Medicine and Fitness and the Council on School Health wanted to make the point in the new policy statement that the evidence does not suggest or support that children and adolescents are at any kind of thermoregulatory or cardiovascular disadvantage. Kids were also thought to not be able to adapt to the heat as well as adults. Again, more recent research does not support that. Of note, most of the research conducted in this area has been done with children 8 years of age and older. There is not a lot of research on temperature regulation with children younger than 8 years. Accordingly, there may be some differences in those earlier ages. However, when we're talking about sports and exertional heat illness, it is usually children and adolescents in the later elementary school into middle and high school years who are typically participating in these activities. Again, are there temperature regulatory differences in younger children? There may be, but that is not the population in the policy statement toward whom we're really directing the attention. The new policy focuses on the factors that do indeed put kids at risk. Although children are not at a maturational disadvantage for increased risk from exercise in the heat, there are a host of modifiable factors that do lead to higher risk when exercising in the heat. Medscape: As you noted, the new policy stresses that heat-related illnesses such as heat cramps, exhaustion, and stroke are caused by known, preventable risk factors. What are the biggest risk factors for incurring heat illnesses during sports? Dr. Bergeron: There are certainly a number of things that can increase risk. The environment itself, being hot, causes body temperature to go up even if you're not doing anything. When you exercise, your body produces a lot of heat. Normally there are a number of ways that the body gets rid of that heat, the primary mechanism being sweating. Additionally, a breeze can very effectively contribute to a convective heat loss. The hotter it is, the more heat that your body will be producing, especially during intense exercise. The more humid it is, the more that you're going to sweat and the less effective that sweat is in releasing the energy or heat from the body because, in order for sweat to be effective in regulating temperature, it needs to evaporate. The more water in the air, the less evaporation, and you see that as sweat beads up on your skin or just rolls off to the ground. Hot and humid conditions that include intense solar radiation and a lack of a breeze are the worst conditions. Hazy, hot, humid, and still days are common, even in the late summer and early fall in some regions. When you look at what primarily causes kids to have problems, it usually comes down to doing too much for too long in too hot of an environment. Sometimes this occurs before a child or adolescent is acclimated to the heat. However, if you work young athletes hard enough and long enough in an extreme environment, even those who are used to these summer conditions are going to have problems. Also, kids typically do not tend to be well hydrated before, during, and after activities in the heat, especially with multiple same-day practice sessions or competitions and tournament scenarios. Insufficient recovery time and recovery nutrition are often important contributing problems, too. There are a host of other factors. Preseason practice starts in the late summer. Kids may have spent a lot of time indoors and are not used to the outdoor weather. They may also not be well rested, and are often not fit enough and prepared for the intensity, duration, and type of activities that they jump right into. This sets up a "perfect storm" for all the kids who are not acclimated and well prepared physically, nutritionally, restwise, or fitnesswise. Then you place this very motivated group of kids on a team with a motivated coach. This enthusiasm and sense of urgency to get these kids ready in a short amount of time, when they are not as prepared to tolerate the practices as coaches and parents think they are, readily prompts a number of risks and problems. Of course, you also have kids who don't want to quit or show "weakness". There are certainly a lot of factors. However, it usually boils down to doing too much, too long, too hard, in too hot of an environment. Medscape: The statement indicates that although most children can indeed exercise safely in the heat if the right precautions are taken and modifications are made, certain ones should be, at least temporarily, restricted from exercise in excessive heat including those with recent illnesses, diabetes insipidus, type 2 diabetes, obesity, cystic fibrosis, hyperthyroid conditions, or any acute or chronic condition that affects water-electrolyte balance or thermoregulation. All of these make intuitive sense. The document also noted that kids with sickle cell trait merit specific concern because exertional sickling may contribute to heat intolerance and related clinical problems. Can you discuss this a bit more? What specific recommendations would you make for this group of children? Dr. Bergeron: Sickle cell trait, of course, is different from sickle cell disease because most of the hemoglobin for those with sickle cell trait is normal, with anywhere from 30% to 40% having the sickle characteristic. By and large, routine physical activity, whether it's sports or playing, is not associated with any notable signs or symptoms. Accordingly, there are no restrictions for these children and adolescents, and these kids may not ever be aware that they potentially might have a problem. However, more and more, epidemiologic studies, case studies, and other research has found that exercise that is high enough in intensity and conducted in sufficient thermal stress can cause an effect similar to what might happen at altitude. A certain amount of measurable red blood cell sickling can cause potential occlusion at the small microvessels. This would also prompt a widespread immune system response that begins an entire cascade of events in the blood and vessels, via cell adhesion molecule activity and other changes that create the potential for localized vascular dysfunction prompting full blockage or restricted blood flow and consequent problems. It is not totally clear whether the exertional rhabdomyolysis often associated with sickle cell trait and intense, repeated exercise is the result of the activity level being too high or whether sickle cell trait was the primary independent contributing factor. The National Collegiate Athletic Association is now considering a proposal to require screening of all of their athletes, although this is still a contentious issue. The current thinking is that those with sickle cell trait should more deliberately build up their training; self-pace; and avoid high-intensity, repeated activities, especially at the end of a practice. If those athletes with sickle cell trait exhibit a problem, then they should indeed promptly stop and get assessed. Sickle cell trait warrants concern, particularly when these kids are exercising hard and repeatedly in a hot environment. Otherwise, most activities are going to be just fine. Medscape: Can you speak to other risk factors that may put kids at risk for excessive heat retention or poor thermoregulation, such as uniforms? Dr. Bergeron: Uniforms and protective equipment are barriers to heat dissipation, whether it's a helmet, shoulder or leg pads, sleeves, or pants. All prevent heat from being dissipated and create a heavier metabolic and thermal load. It is harder work just to carry all that extra padding and the uniform, so metabolically, there is a greater demand. There are many other factors that are worth talking about. As the new policy statement from the AAP makes clear, you really need to look at everything including education, awareness, and preparation. It is the responsibility of coaches, parents, and the athletes themselves to be sure that they're ready and that they understand the risks and the signs and symptoms of a heat-related problem. It really comes down to monitoring and paying attention. We must recognize when children are having difficulty and get them off the field and promptly and properly attended to. It should also be appreciated that people with developing heat-related illness are often the worst ones to judge if they are having serious problems. Affected kids need to stop when they often don't want to because they don't want to be seen as weaker. However, these kids are also often not even capable of assessing themselves. It is incumbent on all involved, including the other players, to recognize and respond to developing problems. Of course, the adults involved need to ensure that sufficient preparatory steps are taken and emergency procedures are in place and practiced in order to reduce the risk for catastrophic outcomes. There is a lot of attention on hydration, as there should be. Hydration is integral to safety and performance in any athletic activity, especially in the heat. However, you can be pretty well hydrated and still get into trouble. So hydration is not the only answer. There is also concern about the high-caffeine energy drinks that kids have been using with more frequency recently. These may cause an increase in fluid loss or even mask fatigue and allow kids to push themselves too hard. I am often asked, "When is it unsafe to exercise, that is, at what temperature should kids not go out there?" It is really a sliding scale, with risk increasing as the number of risk factors increases. Then the urgency for some kind of offsetting action becomes greater. However, it is not the same for everybody and not the same for all conditions. It is important to assess both the athletes and the conditions with which you are dealing and appropriately and sufficiently accommodate for that. The main point of the AAP statement is to recognize that you can do a lot out in the heat and in a lot of environmental circumstances, as long as you make the appropriate adjustments. Medscape: That is a good segue to my next question. The AAP statement emphasizes the importance of preconditioning, suggesting that this process of acclimatization include graduated exposure over 10-14 days to increasing environmental temperatures as well as increased intensity and duration of physical activity. In your experience, is this time frame generally provided? Are there more specific guidelines available to describe this process? Dr. Bergeron: As I indicated earlier, preseason sports activities often focus on accomplishing a lot in a short amount of time with a high level of enthusiasm and motivation. Coaches and players often have a sense of urgency that they only have 2 weeks or so to prepare for the season and therefore must push. In the case of football, exertional heatstroke deaths most often occur in the first few days. Again, it goes back to doing too much, too long, too hard, and too soon. What coaches, parents, and the kids themselves need to realize is that they are not professional athletes and are typically not conditioning year-round. The kids are probably not as conditioned as they think they are, and coaches want them to be. Even those who live in a warm environment may be spending a lot of time indoors. They begin the season likely not used to exercising in hot conditions with high intensity and long duration, especially in a uniform. It really makes a lot of sense to give kids a chance to adapt, not only to the environment, but to the intensity, duration, and uniforms. If you give kids a chance to progressively adapt, they not only will be safer, but these young athletes will perform better too! In someone fully unacclimatized to the heat, it can take 10 days to 2 weeks for the body to adapt by increasing blood volume, so that exercise causes less cardiac stress and increasing sweating ability. With exercise-heat acclimatization, the body also conserves electrolytes, primarily sodium and chloride, to improve fluid retention. These are adaptations that happen over a period of time. Although 2 weeks is ideal, progressing through those first few days more sensibly can really make a big difference. Medscape: The statement does not specifically address parents. What recommendations should a healthcare professional provide to parents and teens about readiness for hot weather sports? Dr. Bergeron: Preconditioning is important and something that needs to be done over a long period of time. When you look at the preseason period, whether it's football or soccer, the notion is that there are 2-3 weeks to get athletes in shape. The body does not adapt that quickly. Conditioning and fitness cannot be changed in a very short amount of time. However, an athlete can get fatigued and be seriously hurt in a very short amount of time. True changes, ie, measurable changes in fitness and conditioning, take a long period of time. Parents, kids, and coaches need to recognize that you are not going to make substantial gains in fitness and athletic capacity in 2-3 weeks. If you try to, you're just going to put these kids at risk for some kind of injury or maybe worse. Being rested, well fed, and well hydrated places athletes in a better state to tolerate the heat. Some research also has shown that being sleep deprived increases vulnerability to the heat. Kids can't be staying up late and ignoring meals. The discussion really needs to be that: If you're going to play sports, you need to have some kind of plan so that you're not just sitting idly and waiting for the season and then you go. It needs to be a balanced, multifaceted, long-term physical activity conditioning and recovery plan that helps prepare for that. However, it is also important to realize that these kids are playing sports primarily for fun, the socialization, and, hopefully, health. They are not professional athletes. If you work them like professional athletes, there will be consequences. They are primarily students and sports are a part-time activity. Unfortunately, a lot of parents, coaches, and sports academies have taken on more of a professional development model, which overlooks sufficient progressive adaptation, rest, and recovery -- and the fact that these kids are student athletes! Athletes, coaches, administrators, and parents must understand the real and more realistic objective. Medscape: The policy includes specific hydration recommendations, suggesting that 9- to 12-year-old children consume 100-250 mL every 20 minutes and that teens drink up to 1.0-1.5 L/hr during physical activity in the heat. Although water is usually sufficient, exercise of longer duration -- more than an hour or so or repeated same-day sessions -- may warrant use of electrolyte solutions. Is this true for children of all ages? What about younger kids? Are beverages containing carbohydrates warranted in some situations? Dr. Bergeron: It's difficult to give a hard-and-fast answer to that. If you're not going to be exercising very long and you're just going to be exercising once a day and you're having normal meals, then drinking water as you feel you need it during those activities and more if it's hotter is going to be just fine for even older kids. However, for the longer you go, the harder you go, and the hotter it is, the proportional value of something else besides water is going to increase. In other words, you're going to be expending more energy, whether it's because of high intensity, long duration, repeated bouts, or because the heat itself is causing you to use carbohydrates at a greater rate. Maybe then you're not going to get enough energy and electrolytes from meals alone. This happens with a lot of kids in tournament scenarios who are playing multiple times each day during a weekend event. They don't have time for sufficient meals between competitions. In these kinds of situations, there is likely an advantage of having some kind of carbohydrate-electrolyte drink. What does a child or adolescent need during physical activity from a nutrition perspective? They certainly need water. As they go longer and harder, they need some kind of carbohydrate, whether they're taking that in as a food snack or in a sport drink. As you get older, the volume of sweat is greater and the amount of electrolytes, primarily sodium and chloride, lost from sweat become greater too. I would say that replacing electrolytes from sweating is not generally of primary importance in somebody up to about 12-13 years of age. However, by 14-15 years of age, when the sweat rate is higher and the concentration of electrolytes is greater, salt loss is a larger issue. Parents will often note that their kids never had a problem with electrolyte deficits and muscle cramping at a younger age but do experience more problems at 14 or 15 years of age. Accordingly, they need to pay a little bit more attention to water and sodium loss through sweating, especially the more times they play and the more times they're exercising for longer durations. Again, it depends on the situation: the recovery time and meal opportunities; the duration of the activity; and how many times you're doing it on the same day. You need to get your nutrition in there one way or the other. If you can't do it with meals, you need to be thinking about something else. Medscape: The statement also emphasizes the importance of trained personnel and facilities capable of treating heat illness being readily available. This may not always be the case in lower-resource communities. Can you expand on this? What specific types of facilities should be available? An emergency action plan with clearly written protocols is also recommended. Are there resources to assist schools and communities with development of these plans? Dr. Bergeron: Part of the effectiveness of cooling is early recognition. So the first step is to recognize that there's a problem and promptly respond. If an athlete is believed to be overheated, then he or she should be immediately stopped and taken out of the sun and heat. If there is an opportunity for getting indoors into air-conditioning or in the shade, that should be done. Rehydrate if possible. If it appears that athlete children or adolescents have crossed the threshold to exertional heatstroke because their body temperature is elevated, this is an emergency. Although checking body temperature is not always feasible, if the affected youth is showing central nervous system changes or collapses, then having something like a wading pool or tub filled with water and ice available can save a life. Promptly submerging most of the body in cold water or rotating cold wet towels and fanning are not expensive solutions. This just requires forethought and having and promptly implementing a plan. That is what is spelled out in the policy statement: You need to have an emergency action plan in place. It doesn't have to be extensive. It would be nice if you had an athletic trainer on-site. Unfortunately, a lot of schools don't have that luxury. However, you at least need to have people learn the signs and symptoms of heat illness and have a sense of urgency when they see evolving heat illness; it's a lot easier to catch it early. You can always put athletes back in a game, but once they collapse with exertional heatstroke, there's no do over. Now you're dealing with a medical emergency. Again, having the education and awareness to recognize an emergency and the forethought to have on-site some kind of simple, rapid cooling system available, such as a wading pool and some water and ice, can save a life. Medscape: Are there resources available for schools and communities that don't have a trainer available and wish to develop emergency action plans? Dr. Bergeron: There are a number of resources. The American College of Sports Medicine (ACSM) has a 2007 position statement on Exertional Heat Illness During Training and Competition. It includes a lot of information about the physiology and recognition of problems with heat. They outline suggested equipment and supplies for treating heat-related illnesses, what should be on hand, and how to treat athletes should they have problems. The National Athletic Trainers' Association has a number of guidelines, too. A 2010 paper outlined the prevention, recognition, and treatment of a number of problems and describes simply the equipment that should be on hand.[1] Medscape: You also served as lead author for the ACSM's 2005 consensus statement on heat stress and injury risk in youth football players. Are there any notable differences between these 2 recommendations? Dr. Bergeron: There are not many differences. The ACSM youth statement was specific to youth and high school football. Therefore, the recommendations are very specific to the football preseason period. That is one of the only, if not the only, sports-specific guidelines for reducing risk in the heat of which I'm aware. However, as we said in the AAP policy statement, you can apply those guidelines as a template for other sports. The whole idea is that the foundation of what we recommended with the ACSM in 2005 is the same foundation in the AAP statement. You need to be educated and prepared. Athletes need to acclimate and progress slowly. Adults need to monitor and respond. The bottom line is very similar. Medscape: Are there any other key elements of this new statement that you would like to emphasize? Dr. Bergeron: Although these guidelines provide more latitude, they are not intended to downplay the challenge or the health threat of environmental heat stress and exercise in the heat. The main point is worth reiterating: Risk can be substantially reduced if modifiable factors are appreciated and appropriately addressed. If the workload is adjusted and these recommendations followed, most, if not all, exertional heat-related problems would be averted. The statement should provide some degree of comfort that sports and exercise can be fun and safe even in the summertime. Again, it's not that you don't recognize that there can be challenges and problems, but we don't always have to shut everything down. Kids never play themselves to death. It's really the scenarios and circumstances that adults create and inflict on them that cause problems. References