Sunday, March 23, 2014

Breastfeeding Past Two Years Linked to Infant Tooth Decay

By Kathleen Raven
March 17, 2014
NEW YORK (Reuters Health) - Breastfeeding is credited with a long list of benefits, but one downside of extended and intensive breastfeeding may be a higher risk of cavities in baby's first teeth, according to a new study.
The more frequently a mother breastfed her child beyond the age of 24 months during the day, the greater the child's risk of severe early tooth decay, researchers found.
Benjamin Chaffee of the University of California, San Francisco led the study as a doctoral student at the University of California at Berkeley. He and his team looked at a possible link between longer-term breastfeeding and the risk of tooth decay and cavities in a survey of 458 babies in low-income families in the city of Porto Alegre, Brazil.
Because the study lasted more than one year, most babies were consuming various kinds of solid food and liquids in addition to breast milk.
The World Health Organization (WHO) recommends that babies are fed breast milk exclusively for the first six months of their lives, with solid foods added to the diet at that point. However, the WHO also recommends continued breastfeeding up to age two and beyond, the authors note.
For the study, the researchers checked in on babies when they were about six, 12 and 38 months old. At six months, the study team gathered data on the number of breast milk bottles the baby drank the day before and any other liquids, like juice.
At the 12-month mark, parents reported whether they fed their babies any of 29 specific foods, including fruits, vegetables, beans, organ meat, candy chips, chocolate milk, cookies, honey, soft drinks or sweet biscuits.
Two trained dentists examined all of the babies at each of the visits.
Nearly half of the children had consumed a prepared infant formula drink by age six months, the researchers reported February 19 online in the Annals of Epidemiology, but very few still drank formula by age one.
The researchers found that about 40% of children who were breastfed between ages six and 24 months had some tooth decay by the end of the study. For babies breastfed for longer than two years and frequently, that number rose to 48%.
"Our study does not suggest that breastfeeding causes caries," Chaffee told Reuters Health.
It is possible that breast milk in conjunction with excess refined sugar in modern foods may be contributing to the greater tooth decay seen in babies breastfed the longest and most often, the authors speculate in their report.
More research is needed to determine what's going on, but the findings are in keeping with professional dental guidelines that suggest avoiding on-demand breastfeeding after tooth eruption, they write.
"There are two aspects of breastfeeding - the actual human milk, which has some, but very little, ability to promote tooth decay," said William Bowen, professor emeritus in the Center for Oral Biology at the University of Rochester Medical Center in New York.
"The second is the physical aspect of breastfeeding, or even bottle-feeding, and that's where the problem arrives," he said.
Bowen was not involved in the new study.
When a baby sucks on a mother's breast or from a bottle, the baby's teeth are sealed off from saliva in the mouth. This physical barrier prevents the saliva from breaking down bacteria, and increases the chances of tooth decay, Bowen said.
Even though participants in the study came from poor backgrounds, "bad habits can form at any socioeconomic level," Bowen told Reuters Health.
About 16% of babies in the U.S. were still exclusively breastfed at age six months last year, according to the National Center for Chronic Disease Prevention and Health Promotion.
The good news, Bowen said, is that it's very easy to clean an infant's teeth.
A simple wipe in the mouth with a water-dampened cloth or Q-tip can effectively remove food before the baby's first teeth, he said, adding: "It's important to get the excess food out of the mouth."
One not-so-good habit is allowing infants to stay on a mother's nipple throughout the night, Bowen said. This usually means very little saliva circulates in the baby's mouth, which can increase the risk of decay.
The primary caregiver of the baby should also maintain good dental health because the bacteria that cause tooth decay in a baby usually come from the primary caregiver, Bowen explained.
The American Academy of Pediatric Dentistry recommends that parents take their child for a first dental visit when the first tooth appears, or no later than the first birthday.
Brushing teeth might help, Chaffee said, The study researchers collected data on tooth brushing habits, but did not investigate a specific link between cleaning teeth after the last feeding and caries.
"But anything that removes carbohydrates and sugars from the oral cavity should help prevent too decay," Chaffee said.
Ann Epidemiol 2014.

Limit Food Allergy Panels, AAP Says in Choosing Wisely List

Larry Hand
March 18, 2014

The American Academy of Pediatrics (AAP) has released its second list of common tests and treatments to question as part of the Choosing Wisely initiative.
The AAP also announced on March 17 the launch of an online learning module pediatricians can use to help with 2 items on its first Choosing Wisely list, released in February 2013. The module is designed to avoid use of antibiotics for viral respiratory illnesses and the use of unnecessary computed tomography scans.
"The AAP strongly supports partnerships and tools that improve the quality of care for patients," AAP President James M. Perrin, MD, said in a news release. "Pediatricians want the best possible tests and treatments for their patients, and they want them to be used appropriately. This is particularly important when treating children, because they are still growing and developing."
The new evidence-based recommendations are:
  • "Don't prescribe high-dose dexamethasone (0.5mg/kg per day) for the prevention or treatment of bronchopulmonary dysplasia in the pre-term infant.
  • Don't perform screening panels for food allergies without previous consideration of medical history.
  • Avoid using acid blockers and motility agents such as metoclopramide (generic) for physiologic gastroesophageal reflux...that is effortless, painless, and not affecting growth. Do not use medication in the so-called 'happy-spitter.'
  • Avoid the use of surveillance cultures for the screening and treatment of asymptomatic bacteruria.
  • Infant home apnea monitors should not be routinely used to prevent Sudden Infant Death Syndrome."
The AAP's complete list of Choosing Wisely recommendations is available online. The first 5 recommendations are:
  • "Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
  • Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under four years of age.
  • Computed tomography (CT) scans are not necessary in the immediate evaluation of minor head injuries; clinical observation/Pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is indicated.
  • Neuroimaging (CT, [magnetic resonance imaging]) is not necessary in a child with simple febrile seizure.
  • [CT] scans are not necessary in the routine evaluation of abdominal pain."
Choosing Wisely was launched in 2012 by the American Board of Internal Medicine. A national campaign, Choosing Wisely involves more than 50 medical specialty societies identifying common medical tests and treatments that may not be necessary or of benefit to patients.

Supplement May Reduce Diarrhea Burden in Preschoolers

Larry Hand
March 17, 2014
Daily doses of live bacterial supplementation may reduce the occurrence and duration of diarrhea and respiratory tract infection (RTI) in preschool children, as well as lower the costs of treatment, according to a study published online March 17 inPediatrics.
Pedro Gutierrez-Castrellon, MD, DSc, from the National Perinatology Institute, Mexico City, Mexico, and colleagues conducted a randomized, double-blind, placebo-controlled trial at 4 day care centers near the institute between April 2011 and June 2012.
A computer-generated randomization placed 336 healthy children aged 6 to 36 months who were born at term (≥36 weeks' gestation) and who had similar socioeconomic characteristics in 2 equal-number groups. Half the children (168) received Lactobacillus reuteri DSM 17938 (1 × 108 colony-forming unit) and half (168) received placebo once a day for 12 weeks. All of the children completed the study with no breached protocols, the researchers report.
Parents gave the dropper doses on first feedings in the morning, and researchers assessed compliance on the basis of empty bottles returned and parent-kept diaries. Researchers instructed parents on how to monitor daily the stool consistency of their children and to report any respiratory symptoms. Confirmed RTI cases led to hospitalized or outpatient care.
L reuteri supplementation helped reduce the number of days with diarrhea per child from 0.96 (0.2) to 0.32 (0.1; P = .03) during the trial and from 1.1 to 0.5 (P = .01) during a 12-week follow-up period.
In addition, the researchers report that 99 episodes of diarrhea occurred among the L reuteri group compared with 152 episodes among the placebo group (P = .01). Diarrhea lasted an average of 1.6 ± 0.9 days in the L reuteri group and 2.7 ± 1.1 days in the placebo group (P = .02).
L reuteri supplementation helped reduce the number of days with RTI per child from 4.6 (1.8) to 1.5 (0.6; P = .01) during the trial and from 4.4 (1.1) to 2.1 (0.8; P = .01) during follow-up.
L reuteri supplementation also helped significantly reduce the number of days of school absences (P = .03), the number of healthcare visits (P = .04), and the number of days of antibiotic use (P = .04) during the trial and in follow-up. In a cost–benefit analysis, the first such analysis they are aware of, the researchers found that L reuteri supplementation also helped reduce healthcare costs.
"The prophylactic use of L reuteri was associated with a reduction of $36 US dollars (USD) for each case of diarrhea and $37 USD for each case of RTI," the researchers write. They calculated the incremental cost effectiveness ratio at −35.7 for diarrhea and −37.4 for RTI.
"This study adds independent support to previously published evidence that can now be used in systematic reviews to establish evidence-based recommendations for the use of L reuteri DSM 17938 in the prevention of infectious diseases in day care Centers," the researchers conclude.
This research was supported by GioGaia AB, Stockholm, Sweden, who supplied the L reuteri and placebo products used in the trial. The authors have disclosed no relevant financial relationships.
Pediatrics. Published online March 17, 2014. Abstract

Friday, February 14, 2014

Varicella Vaccine Works Well Over Time

April 03, 2013
By David Douglas
NEW YORK (Reuters Health) Apr 03 - Since its introduction in the mid-1990s, varicella vaccine has reduced the average incidence of chickenpox by as much as tenfold, according to researchers.
The vaccine was licensed in the US in 1995 for children at least 12 months old. In 2006, a second dose was recommended.
For a study reported Monday in Pediatrics, Dr. Roger Baxter of the Kaiser Permanente Vaccine Study Center, Oakland, California and colleagues tracked 7,585 children vaccinated in 1995 when they were in their second year of life. This group included 2826 youngsters who received a second dose between 2006 and 2009. All were members of the Kaiser Permanente Northern California health delivery system.
The study showed "the long-lasting effectiveness of varicella vaccine, and the benefit of the second dose," Dr. Baxter told Reuters Health by email.
More than 97% of the children enrolled completed the study. Overall, over 14 years, the average incidence of varicella was 15.9 per 1000 person-years, nine- to tenfold lower than in the prevaccine era.
Annual vaccine effectiveness ranged from 73% to 80% in the first two years of the study to 80% to 90% in the last 10 years. Effectiveness did not seem to wane.
Most cases of varicella were mild and occurred early after vaccination, at which time varicella virus zoster was still widely circulating. No child developed varicella after a second dose. In addition, herpes zoster cases were mild and rates were lower in the vaccine era than earlier (relative risk, 0.61).
The investigators concluded, "Varicella vaccine was effective at preventing chicken pox, and no evidence of waning protection was noted over a 14-year period. One dose provided excellent protection against moderate to severe disease, and most cases occurred shortly after the cohort was vaccinated."
SOURCE:  Pediatrics 2013.

    Daily Sunscreen May Prevent Skin Aging

    June 04, 2013

    By Genevra Pittman
    NEW YORK (Reuters Health) Jun 04 - Using sunscreen every day may help protect against aging skin, according to a new study from Australia.
    Although the benefits of sunscreen are well know when it comes to preventing sunburns and lowering skin cancer risks, researchers said rigorous studies were lacking on how sunscreen use affects photoaging.
    Still, one dermatologist who wasn't involved in the new study said the findings just reinforce what skin doctors already know and tell their patients.
    "If you ask most dermatologists... they'll tell you the two things they recommend for people who really want to avoid photoaging are, don't smoke and use sunscreen," said Dr. Alan Boyd, from Vanderbilt University Medical Center in Nashville.
    "There are definitely a diminished number of people who have pre-cancerous (skin) changes if they are regular users of sunscreen," he told Reuters Health. "It's not too much of a leap to assume the signs and features of photoaging would follow hand in hand."
    For the new study, Dr. Adele Green from the Queensland Institute of Medical Research and her colleagues analyzed data from 903 adults younger than 55 who were followed between 1992 and 1996.
    Half of them were told to put sunscreen of SPF 15 or greater on their head, neck, arms and hands every morning, and to reapply when necessary. The others used sunscreen according to their own discretion.
    At the start and end of the study, the researchers measured photoaging using the skin on the back of each person's left hand. They found that over four years, there were no detectable changes in the skin condition of people who were told to use sunscreen daily, once other sun-related factors were taken into account.
    Australians in that group were 24% less likely to show any increased aging - clinical changes that might not be visible to the naked eye - than those who decided on their own when to wear sunscreen, Dr. Green and her colleagues reported June 3 online in the Annals of Internal Medicine.
    Beta carotene, which was also given to some of the participants, did not seem to have any protective effect on skin aging, however.
    Photoaging happens after long-term exposure to ultraviolet radiation, which penetrates the skin and can cause collagen to break down and DNA to mutate, said Dr. Brundha Balaraman, a dermatology researcher from the Washington University School of Medicine in St. Louis.
    "This study effectively shows that daily sunscreen can reduce the signs of photoaging and photodamage," Dr. Balaraman, who also wasn't part of the research team, told Reuters Health in an email.
    "I believe that daily use of broad-spectrum sunscreens with frequent reapplications may have more profound measurable effects on photoaging," she added. "But the key to prevention is to develop these healthy sun-protective habits at a young age."

    Ultrasound Poor Screen in Kids With Fever, UTI

    Veronica Hackethal, MD
    February 10, 2014
    Renal and bladder ultrasound (RBUS) is a poor screening tool for genitourinary (GU) abnormalities identifiable on voiding cystourethrogram (VCUG) after febrile urinary tract infections (UTIs) in children, according to a study published online February 10 in Pediatrics.
    "Neither positive nor negative ultrasounds reliably identify or rule out [genitourinary] abnormalities," write Caleb P. Nelson, MD, MPH, from the Department of Urology, Boston Children’s Hospital, Harvard Medical School, Massachusetts, and colleagues. "Ultrasound and VCUG provide different, but complementary, information."
    American Academy of Pediatrics (AAP) 2011 guidelines advise RBUS to screen for GU abnormalities in children aged 2 to 24 months with index cases of febrile UTIs, according to the authors, with VCUG used for confirming abnormalities suggestive of high-grade vesicoureteral reflux (VUR) or obstructive uropathy or after a second febrile UTI. The implication of these guidelines, the authors point out, is that a normal RBUS rules out clinically significant GU pathology.
    The researchers looked at 3995 medical records between January 1, 2006, and December 31, 2010, in which VCUG and RBUS were conducted on the same day and then selected only those with UTI as an indication for imaging. They excluded records with postnatal GU imaging or prenatal GU abnormalities. They then placed both RBUS and VCUG into 4 categories each, based on GU abnormality type, with VUR graded on the 5-point international grading system. They also assigned diagnostic criteria thresholds for positive tests, ranging in severity from relaxed to stringent.
    The researchers identified 2259 children younger than 60 months whose indication for imaging was UTI. RBUS was normal in 75%, but VCUG indicated 41.7% had evidence for any VUR, 20.9% had VUR greater than grade 2, and 2.7% had VUR higher than grade 3. Among those with a first febrile UTI, these percentages were 47.5%, 26.9%, and 2.6%, respectively. Depending on threshold, RBUS had a sensitivity ranging from 5% (specificity, 97%) to 28% (specificity, 77%), with the sensitivity of VUR higher than grade 3 ranging from 18% (specificity, 97%) to 55% (specificity, 77%).
    There were 1203 children aged 2 to 24 months who received imaging after an initial febrile UTI. The positive predictive value of RBUS in this group was 37% to 47% for VUR higher than grade 2 and 13% to 24% for VUR higher than grade 3, with negative predictive values ranging from 72% to 74% (VUR higher than grade 2) and 95% to 96% (VUR higher than grade 3).
    Limitations include possible misdiagnosis relating to the study's retrospective nature. In addition, the initial radiologist review was unblinded and not confirmed by independent review. To minimize verification bias, only patients with RBUS and VCUG on the same day were selected, which could have introduced selection bias if foregoing a second test was based on the first test's results.
    "A negative RBUS does not rule out significant GU pathology (particularly VUR grades III and higher)," the authors conclude, "whereas a positive RBUS is a poor predictor."
    In an independent commentary, Stephen M. Downs, MD, from Children’s Health Services Research, Indiana University School of Medicine, Indianapolis, commends this study for being the largest and most well-conducted of its kind.
    However, although noting that this study's results are valid and consistent with past studies, and agreeing that RBUS is a "lousy screen for VUR," Dr. Downs ultimately supports the AAP guidelines. He points out that the guidelines actually suggest watchful waiting, rather than RBUS, to screen for high-grade VUR, with VCUG recommended only after the second UTI. Early RBUS is recommended for identifying parenchymal damage and obstructive uropathy associated with infection, he explains. Children with VUR are likely to have another UTI, he continues, and most (about 90%) will never have another UTI and would be unnecessarily exposed to the discomfort, cost, and radiation of VCUG.
    "Readers should know that the RBUS recommended by the AAP guideline does serve a critical role in the evaluation of young children who have a first febrile UTI," Dr. Downs argues, "but it is watchful waiting that screens for VUR."
    The authors and Dr. Downs have disclosed no relevant financial relationships.
    Pediatrics. Published online February 10, 2014. Abstract

    Dexamethasone Tames Acute Asthma in Kids, With Less Vomiting

    Diedtra Henderson
    February 10, 2014
    Giving children with acute asthma flare-ups 1 or 2 doses of dexamethasone in the emergency department (ED) provides equivalent relief to a 5-day course of prednisone while reducing the chance of triggering vomiting, according to a meta-analysis by Grant E. Keeney, MD, from the Department of Pediatrics, Medical College of Wisconsin, Milwaukee, and colleagues, who published the results of their analysis online February 10 in Pediatrics.

    Some 6 million children in the United States suffer from asthma, a chronic inflammatory disease that accounts for 2% of all ambulatory care and ED visits by pediatric patients, the authors write. Oral prednisone, which tamps down inflammation and decreases mucus production, is the cornerstone of treatment for acute asthma exacerbations, but the remedy exacts a cost: vomiting.
    The authors sought to determine whether dexamethasone might provide the same therapeutic benefit with fewer doses and less vomiting than is associated with a 5-day course of oral prednisone or prednisolone. Searching PubMed, the researchers identified 667 articles describing randomized clinical trials comparing the medicines of interest; they included 6 trials in the meta-analysis.
    Each study was performed in the ED and enrolled from 15 to 272 patients, 63.5% of whom were boys. Dexamethasone was given as a single dose, either orally or intramuscularly, in 4 studies and was given as multiple doses in 2 studies. There was no statistically significant difference between the 2 therapies when it came to relapses to the clinic, ED, or hospitalization.
    "Significantly fewer patients receiving dexamethasone vomited in the ED or at home after discharge. This finding has clinical significance for improving patient and parental satisfaction," according to the authors.
    "This is a huge win for those of us in emergency medicine and, more importantly, for the families we take care of, when you consider that asthma is the most common chronic disease of children," Stephen J. Teach, MD, MPH, associate chief of the Division of Emergency Medicine at Children's National Medical Center in Washington, DC, told Medscape Medical News.
    According to Dr. Teach, the facility handles 1% of ED visits made by children in the country for asthma. Practitioners recognized that if prednisone was given as early as possible during a significant asthma flare-up, it cut down on emergency admissions, and children missed less school.
    "It was big breakthrough," he told Medscape Medical News. However, "prednisone is a terrible medication to take. It tastes awful. It's hard to mask it.... When it hits the stomach, it's an irritant. Kids throw it up all the time. It became this wonderful–terrible thing."
    Dexamethasone's noxious taste, in contrast, can be masked with cherry syrup. Large-volume EDs already have begun to make the shift.
    "There's really no difference, and it's more patient-centered," said Dr. Teach, who was not involved in the current study. "Kids take it better. They take fewer doses.... All of the available data suggest there is no difference in short-term outcomes."
    The authors note that their results were based on studies based in the ED, making it unclear whether they apply to the ambulatory clinic setting.
    "Based on our findings, emergency physicians should consider single or 2-dose dexamethasone regimens over 5-day prednisone/prednisolone regimens for the treatment of acute asthma exacerbations," the authors conclude.

    Thursday, February 13, 2014

    The 2014 Child/Teen Immunization Schedule: Changes You Should Know

    William T. Basco, Jr., MD, MS
    February 03, 2014extracts 

    Hepatitis A Vaccine Changes

    Hepatitis A vaccine is routinely given at 12-23 months of age, but the previous footnotes were not specific as to which older children are considered "high risk" and therefore should receive the vaccine. The new footnotes provide clearer recommendations. Those specific recommendations now include children who may travel to countries that have a high or intermediate degree of endemic infection. Other recommended populations that might be cared for by pediatric providers include males who have sex with other males, users of illicit drugs (injectable or not), and patients with clotting factor disorders or chronic liver disease.

    Human Papillomavirus Vaccine Changes

    There are no global changes to the recommendations for human papillomavirus (HPV) vaccine. For pediatric providers, however, it is worth remembering that only the quadrivalent HPV vaccine is recommended for boys, whereas either the bivalent or quadrivalent HPV vaccine can be used for girls.  The third dose should be administered at least 12 weeks after the second dose and at least 24 weeks after the first dose.

    Meningococcal Vaccine Changes

    There is no change to the recommendation that 11- to 12-year olds should universally receive the vaccine and that a booster should be administered at 16 years of age. Changes in the meningococcal vaccine recommendations are mostly limited to expanded indications for the quadrivalent conjugate meningococcal vaccine MenACWY-CRM (meningococcal groups A, C, and Y and W-135 oligosaccharide diphtheria CRM197 conjugate vaccine; Menveo®) among younger children considered at high risk for meningococcal disease.
    It is probably also worth reminding pediatric providers that certain older children should receive the meningococcal vaccine. Indicated populations include those with complement deficiencies or anatomical or functional asplenia, as well as children traveling to areas in Africa where meningitis is endemic or those undertaking the Hajj. Specific catch-up recommendations for children with high-risk conditions are also provided and require accessing additional CDC documents.

    Pneumococcal Vaccine Changes

    First, one of the most interesting changes is the addition of a clear statement about when pneumococcal polysaccharide vaccine (PPSV23) should be given relative to pneumococcal conjugate vaccine (PCV13): The footnotes state clearly that children in need of PPSV23 should receive the recommended PCV13 doses before receiving PPSV23. The PPSV23 dose should also be given at least 8 weeks after completion of PCV13series or catch-up. That sequencing was often probably the case for most children who received the polysaccharide vaccine, but there needs to be a continual emphasis on trying to complete the PCV13 series for all children before considering who should receive PPSV23.
    Second, it is worth emphasizing that we are still seeing some children < 59 months of age who received pneumococcal vaccination as PCV7. Providers should ensure that children who received part of their pneumococcal vaccination as PCV7 receive the appropriate PCV13 follow-up doses. 
    The footnotes also contain details on which children should receive PPSV23. For children 24 through 71 months of age, several chronic conditions indicate a need for PPSV23, including chronic cardiac disease; chronic lung disease; diabetes mellitus; cerebrospinal fluid leak; cochlear implants; sickle cell disease and other hemoglobinopathies; other asplenia; or immune suppression, including from HIV, renal failure, or receipt of immunosuppressive drugs.
    Of all the indicated populations in a pediatric practice, the most prevalent is probably asthmatics who have received systemic steroids. That is a group of personal interest to me as a researcher, and one that we probably underemphasize for receipt of PPSV23.
    Finally, the footnotes expand upon the description of who should receive a second dose of PPSV23 vaccine after age 5 years; it is worth noting that children with diabetes, chronic heart, lung, and liver disease are not among that group. The recommendation for a second PPSV23 dose is confined to those with immune-compromising conditions, now listed in the footnotes.

    Tdap Vaccine Changes

    In regard to Tdap, additional clarifications are provided in the footnotes. The universal recommendation that everyone 11 years of age or older receive at least 1 Tdap vaccination is still present. However, there is no current recommendation for further booster doses with Tdap, except among pregnant women. Pregnant women should receive Tdap with each pregnancy, preferably during the 27- to 36-week gestational age period.
    A previous recommendation that warrants emphasis is the recommendation that Tdap be used for any child older than 7 years who needs a tetanus booster as part of wound management or as the first dose of a catch-up series, provided that they did not already receive a Tdap booster. They should not receive a second Tdap booster, however, if they have received one after age 7 years. As a reminder, this section also contains detailed recommendations for how to handle an older child who inadvertently receives DTaP and how this might affect the decision to later boost with Tdap.
    For all vaccines, additional detail on indicated populations or indications for travelers can be found at the ACIP's vaccine-specific site.