Pediatrics

Clinicians who have attempted to perform an in-office procedure on infants or young children will recognize the difficulties that arise from the developmental inability to cooperate with procedures.¹ Potential problems mentioned in the literature include but are not limited to anxiety, which is identified in all age groups of patients undergoing dermatologic procedures²; limitation of pain control³; and poor outcomes due to movement by the patient.¹ In one author’s experience (N.B.S.), anxious and scared children can potentially cause injury to themselves, parents/guardians, and health care professionals by flailing and kicking; children are flexible and can wriggle out of even fine grips, and some children, especially toddlers, can be strong.

The usage of topical anesthetics can only give superficial anesthesia. They can ostensibly reduce pain and are useful for anesthesia of curettage, but their use is limited in infants and young children by the minimal amount of drug that is safe for application, as risks of absorption include methemoglobinemia and seizure activity, and especially by lack of cooperation by the child.⁴ Infiltrative anesthesia is needed for adequate pain control in addition to a topical anesthetic for many procedures.³

General anesthesia seems to be the best alternative due to associated amnesia of the events occurring including pain; immobilization and ability to produce more accurate biopsy sampling; better immobilization leading to superior cosmetic results; and reduced risk to patients, parents/guardians, and health care professionals from a flailing child. In the field of pediatric dermatology, general anesthesia often is used for excision of larger lesions and cosmetic repairs. Operating room privileges are not always easy to obtain, but many pediatric dermatologists take advantage of outpatient surgical centers associated with their medical center. A retrospective review of 226 children receiving 681 procedures at a single institution documented low rates of complications.¹

If it was that easy, most children would be anesthetized with general anesthesia. However, there are risks associated with general anesthesia. Parents/guardians often will do what they can to avoid risk and may therefore refuse general anesthesia, but it is not completely avoidable in complicated skin disease. Despite the risks, the benefit is present in a major anomaly correction such as a cleft palate in a 6-month-old but may not be there for the treatment of a wart. When procedures are nonessential or may be conducted without anesthesia, avoidance of general anesthesia is reasonable and a combination of topical and local infiltrative anesthesia can help. In the American Academy of Dermatology guidelines on in-office anesthesia, Kouba et al⁵ states: “Topical agents are recommended as a first-line method of anesthesia for the repair of dermal lacerations in children and for other minor dermatologic procedures, including curettage. For skin biopsy, excision, or other cases where topical agents alone are insufficient, adjunctive use of topical anesthesia to lessen the discomfort of infiltrative anesthetic should be considered.”

A new controversy recently has emerged concerning the potential risks of anesthesia on neurocognitive development in infants and young children. These concerns regardingthe labeling changes of anesthetic and sedation drugs by the US Food and Drug Administration (FDA) in December 2016 specifically focused on these risks in children younger than 3 years with prolonged (>3 hours) and repeated exposures; however, this kind of exposure is unlikely with standard pediatric dermatologic procedures.^6-9

There is compelling evidence from animal studies that exposure to all anesthetic agents in clinical use induces neurotoxicity and long-term adverse neurobehavioral deficits; however, whether these findings are applicable in human infants is unknown.^6-9 Most of the studies in humans showing adverse outcomes have been retrospective observational studies subject to multiple sources of bias. Two recent large clinical studies—the GAS (General Anaesthesia compared to Spinal anaesthesia) trial¹⁰ and the PANDA (Pediatric Anesthesia and Neurodevelopment Assessment) study¹¹—have shown no evidence of abnormal neurocognitive effects with a single brief exposure before 3 years of age (PANDA) or during infancy (GAS) in otherwise-healthy children.^10,11

It is important to note that the FDA labeling change warning specifically stated that “[c]onsistent with animal studies, recent human data suggest that a single, relatively short exposure to general anesthetic and sedation drugs in infants or toddlers is unlikely to have negative effects on behavior or learning.” Moreover, the FDA emphasized that “Surgeries or procedures in children younger than 3 years should not be delayed or avoided when medically necessary.”¹² Taking these points into consideration, we should offer our patients in-office care when possible and postpone elective procedures when advisable but proceed when necessary for our patients’ physical and emotional health.

Clinicians who have attempted to perform an in-office procedure on infants or young children will recognize the difficulties that arise from the developmental inability to cooperate with procedures.¹ Potential problems mentioned in the literature include but are not limited to anxiety, which is identified in all age groups of patients undergoing dermatologic procedures²; limitation of pain control³; and poor outcomes due to movement by the patient.¹ In one author’s experience (N.B.S.), anxious and scared children can potentially cause injury to themselves, parents/guardians, and health care professionals by flailing and kicking; children are flexible and can wriggle out of even fine grips, and some children, especially toddlers, can be strong.

The usage of topical anesthetics can only give superficial anesthesia. They can ostensibly reduce pain and are useful for anesthesia of curettage, but their use is limited in infants and young children by the minimal amount of drug that is safe for application, as risks of absorption include methemoglobinemia and seizure activity, and especially by lack of cooperation by the child.⁴ Infiltrative anesthesia is needed for adequate pain control in addition to a topical anesthetic for many procedures.³

General anesthesia seems to be the best alternative due to associated amnesia of the events occurring including pain; immobilization and ability to produce more accurate biopsy sampling; better immobilization leading to superior cosmetic results; and reduced risk to patients, parents/guardians, and health care professionals from a flailing child. In the field of pediatric dermatology, general anesthesia often is used for excision of larger lesions and cosmetic repairs. Operating room privileges are not always easy to obtain, but many pediatric dermatologists take advantage of outpatient surgical centers associated with their medical center. A retrospective review of 226 children receiving 681 procedures at a single institution documented low rates of complications.¹

If it was that easy, most children would be anesthetized with general anesthesia. However, there are risks associated with general anesthesia. Parents/guardians often will do what they can to avoid risk and may therefore refuse general anesthesia, but it is not completely avoidable in complicated skin disease. Despite the risks, the benefit is present in a major anomaly correction such as a cleft palate in a 6-month-old but may not be there for the treatment of a wart. When procedures are nonessential or may be conducted without anesthesia, avoidance of general anesthesia is reasonable and a combination of topical and local infiltrative anesthesia can help. In the American Academy of Dermatology guidelines on in-office anesthesia, Kouba et al⁵ states: “Topical agents are recommended as a first-line method of anesthesia for the repair of dermal lacerations in children and for other minor dermatologic procedures, including curettage. For skin biopsy, excision, or other cases where topical agents alone are insufficient, adjunctive use of topical anesthesia to lessen the discomfort of infiltrative anesthetic should be considered.”

A new controversy recently has emerged concerning the potential risks of anesthesia on neurocognitive development in infants and young children. These concerns regardingthe labeling changes of anesthetic and sedation drugs by the US Food and Drug Administration (FDA) in December 2016 specifically focused on these risks in children younger than 3 years with prolonged (>3 hours) and repeated exposures; however, this kind of exposure is unlikely with standard pediatric dermatologic procedures.^6-9

There is compelling evidence from animal studies that exposure to all anesthetic agents in clinical use induces neurotoxicity and long-term adverse neurobehavioral deficits; however, whether these findings are applicable in human infants is unknown.^6-9 Most of the studies in humans showing adverse outcomes have been retrospective observational studies subject to multiple sources of bias. Two recent large clinical studies—the GAS (General Anaesthesia compared to Spinal anaesthesia) trial¹⁰ and the PANDA (Pediatric Anesthesia and Neurodevelopment Assessment) study¹¹—have shown no evidence of abnormal neurocognitive effects with a single brief exposure before 3 years of age (PANDA) or during infancy (GAS) in otherwise-healthy children.^10,11

It is important to note that the FDA labeling change warning specifically stated that “[c]onsistent with animal studies, recent human data suggest that a single, relatively short exposure to general anesthetic and sedation drugs in infants or toddlers is unlikely to have negative effects on behavior or learning.” Moreover, the FDA emphasized that “Surgeries or procedures in children younger than 3 years should not be delayed or avoided when medically necessary.”¹² Taking these points into consideration, we should offer our patients in-office care when possible and postpone elective procedures when advisable but proceed when necessary for our patients’ physical and emotional health.

Clinicians who have attempted to perform an in-office procedure on infants or young children will recognize the difficulties that arise from the developmental inability to cooperate with procedures.¹ Potential problems mentioned in the literature include but are not limited to anxiety, which is identified in all age groups of patients undergoing dermatologic procedures²; limitation of pain control³; and poor outcomes due to movement by the patient.¹ In one author’s experience (N.B.S.), anxious and scared children can potentially cause injury to themselves, parents/guardians, and health care professionals by flailing and kicking; children are flexible and can wriggle out of even fine grips, and some children, especially toddlers, can be strong.

The usage of topical anesthetics can only give superficial anesthesia. They can ostensibly reduce pain and are useful for anesthesia of curettage, but their use is limited in infants and young children by the minimal amount of drug that is safe for application, as risks of absorption include methemoglobinemia and seizure activity, and especially by lack of cooperation by the child.⁴ Infiltrative anesthesia is needed for adequate pain control in addition to a topical anesthetic for many procedures.³

General anesthesia seems to be the best alternative due to associated amnesia of the events occurring including pain; immobilization and ability to produce more accurate biopsy sampling; better immobilization leading to superior cosmetic results; and reduced risk to patients, parents/guardians, and health care professionals from a flailing child. In the field of pediatric dermatology, general anesthesia often is used for excision of larger lesions and cosmetic repairs. Operating room privileges are not always easy to obtain, but many pediatric dermatologists take advantage of outpatient surgical centers associated with their medical center. A retrospective review of 226 children receiving 681 procedures at a single institution documented low rates of complications.¹

If it was that easy, most children would be anesthetized with general anesthesia. However, there are risks associated with general anesthesia. Parents/guardians often will do what they can to avoid risk and may therefore refuse general anesthesia, but it is not completely avoidable in complicated skin disease. Despite the risks, the benefit is present in a major anomaly correction such as a cleft palate in a 6-month-old but may not be there for the treatment of a wart. When procedures are nonessential or may be conducted without anesthesia, avoidance of general anesthesia is reasonable and a combination of topical and local infiltrative anesthesia can help. In the American Academy of Dermatology guidelines on in-office anesthesia, Kouba et al⁵ states: “Topical agents are recommended as a first-line method of anesthesia for the repair of dermal lacerations in children and for other minor dermatologic procedures, including curettage. For skin biopsy, excision, or other cases where topical agents alone are insufficient, adjunctive use of topical anesthesia to lessen the discomfort of infiltrative anesthetic should be considered.”

A new controversy recently has emerged concerning the potential risks of anesthesia on neurocognitive development in infants and young children. These concerns regardingthe labeling changes of anesthetic and sedation drugs by the US Food and Drug Administration (FDA) in December 2016 specifically focused on these risks in children younger than 3 years with prolonged (>3 hours) and repeated exposures; however, this kind of exposure is unlikely with standard pediatric dermatologic procedures.^6-9

There is compelling evidence from animal studies that exposure to all anesthetic agents in clinical use induces neurotoxicity and long-term adverse neurobehavioral deficits; however, whether these findings are applicable in human infants is unknown.^6-9 Most of the studies in humans showing adverse outcomes have been retrospective observational studies subject to multiple sources of bias. Two recent large clinical studies—the GAS (General Anaesthesia compared to Spinal anaesthesia) trial¹⁰ and the PANDA (Pediatric Anesthesia and Neurodevelopment Assessment) study¹¹—have shown no evidence of abnormal neurocognitive effects with a single brief exposure before 3 years of age (PANDA) or during infancy (GAS) in otherwise-healthy children.^10,11

It is important to note that the FDA labeling change warning specifically stated that “[c]onsistent with animal studies, recent human data suggest that a single, relatively short exposure to general anesthetic and sedation drugs in infants or toddlers is unlikely to have negative effects on behavior or learning.” Moreover, the FDA emphasized that “Surgeries or procedures in children younger than 3 years should not be delayed or avoided when medically necessary.”¹² Taking these points into consideration, we should offer our patients in-office care when possible and postpone elective procedures when advisable but proceed when necessary for our patients’ physical and emotional health.

Results from two new studies suggest that genetic testing early in the diagnostic pathway may allow for earlier and more precise diagnoses in early-life epilepsies and a range of other childhood-onset disorders, and potentially limit costs associated with a long diagnostic course.

Both papers, published online July 31 in JAMA Pediatrics, showed the diagnostic yield of genetic testing approaches, including whole-exome sequencing (WES), to be high.

The results also argue for the incorporation of genetic testing into the first diagnostic assessments; not limiting it to severe presentations only; and for broad testing methods to be employed in lieu of narrower ones.

Results from two new studies suggest that genetic testing early in the diagnostic pathway may allow for earlier and more precise diagnoses in early-life epilepsies and a range of other childhood-onset disorders, and potentially limit costs associated with a long diagnostic course.

Both papers, published online July 31 in JAMA Pediatrics, showed the diagnostic yield of genetic testing approaches, including whole-exome sequencing (WES), to be high.

The results also argue for the incorporation of genetic testing into the first diagnostic assessments; not limiting it to severe presentations only; and for broad testing methods to be employed in lieu of narrower ones.

Results from two new studies suggest that genetic testing early in the diagnostic pathway may allow for earlier and more precise diagnoses in early-life epilepsies and a range of other childhood-onset disorders, and potentially limit costs associated with a long diagnostic course.

Both papers, published online July 31 in JAMA Pediatrics, showed the diagnostic yield of genetic testing approaches, including whole-exome sequencing (WES), to be high.

The results also argue for the incorporation of genetic testing into the first diagnostic assessments; not limiting it to severe presentations only; and for broad testing methods to be employed in lieu of narrower ones.

Photo by Aurimas Rimsa

Researchers say they have published the most extensive data ever collected on childhood cancer in sub-Saharan Africa.

On the African continent, only South Africa operates a childhood cancer registry on the national level.

Researchers brought together data from 16 of the smaller, local registries, collecting this information for the first time and presenting it in an accessible format.

The data were published in ecancermedicalscience.

Examining the data in context allowed the researchers to notice trends in cancer incidence. For example, they found that, in Blantyre, Malawi’s second-largest city, the cumulative risk of a child developing Burkitt lymphoma is 2 in every thousand.

The researchers called this incidence “remarkable” and noted that the global research community is largely unaware of this.

“Everything starts with awareness,” said study author Cristina Stefan, global clinical leader of oncology for Roche Diagnostics International Ltd of Switzerland and director of the African Medical Research and Innovation Institute.

“It is highly necessary to publicize these data, which, at the moment, represent the best image of the malignant disease in children in the respective regions.”

The researchers also noted that factors such as the prevalence of malaria and the Epstein-Barr virus contribute to the unique epidemiology of childhood cancer in Africa.

“Our colleagues can learn that the patterns and distribution of cancers in Africa are totally different from Europe, and there is a need for further research into the roles of factors such as genetic predispositions and the influence of infections and other comorbidities in the evolution of cancer,” Dr Stefan said.

“We have learned many universal lessons about data collection as we prepared this work. Our hope is that the publication of this monograph will open the forums for future discussions and that the work will be referenced for the better understanding of cancer in children in Africa and used to improve outcomes for children affected there.”

Photo by Aurimas Rimsa

Researchers say they have published the most extensive data ever collected on childhood cancer in sub-Saharan Africa.

On the African continent, only South Africa operates a childhood cancer registry on the national level.

Researchers brought together data from 16 of the smaller, local registries, collecting this information for the first time and presenting it in an accessible format.

The data were published in ecancermedicalscience.

Examining the data in context allowed the researchers to notice trends in cancer incidence. For example, they found that, in Blantyre, Malawi’s second-largest city, the cumulative risk of a child developing Burkitt lymphoma is 2 in every thousand.

The researchers called this incidence “remarkable” and noted that the global research community is largely unaware of this.

“Everything starts with awareness,” said study author Cristina Stefan, global clinical leader of oncology for Roche Diagnostics International Ltd of Switzerland and director of the African Medical Research and Innovation Institute.

“It is highly necessary to publicize these data, which, at the moment, represent the best image of the malignant disease in children in the respective regions.”

The researchers also noted that factors such as the prevalence of malaria and the Epstein-Barr virus contribute to the unique epidemiology of childhood cancer in Africa.

“Our colleagues can learn that the patterns and distribution of cancers in Africa are totally different from Europe, and there is a need for further research into the roles of factors such as genetic predispositions and the influence of infections and other comorbidities in the evolution of cancer,” Dr Stefan said.

“We have learned many universal lessons about data collection as we prepared this work. Our hope is that the publication of this monograph will open the forums for future discussions and that the work will be referenced for the better understanding of cancer in children in Africa and used to improve outcomes for children affected there.”

Photo by Aurimas Rimsa

Researchers say they have published the most extensive data ever collected on childhood cancer in sub-Saharan Africa.

On the African continent, only South Africa operates a childhood cancer registry on the national level.

Researchers brought together data from 16 of the smaller, local registries, collecting this information for the first time and presenting it in an accessible format.

The data were published in ecancermedicalscience.

Examining the data in context allowed the researchers to notice trends in cancer incidence. For example, they found that, in Blantyre, Malawi’s second-largest city, the cumulative risk of a child developing Burkitt lymphoma is 2 in every thousand.

The researchers called this incidence “remarkable” and noted that the global research community is largely unaware of this.

“Everything starts with awareness,” said study author Cristina Stefan, global clinical leader of oncology for Roche Diagnostics International Ltd of Switzerland and director of the African Medical Research and Innovation Institute.

“It is highly necessary to publicize these data, which, at the moment, represent the best image of the malignant disease in children in the respective regions.”

The researchers also noted that factors such as the prevalence of malaria and the Epstein-Barr virus contribute to the unique epidemiology of childhood cancer in Africa.

“Our colleagues can learn that the patterns and distribution of cancers in Africa are totally different from Europe, and there is a need for further research into the roles of factors such as genetic predispositions and the influence of infections and other comorbidities in the evolution of cancer,” Dr Stefan said.

“We have learned many universal lessons about data collection as we prepared this work. Our hope is that the publication of this monograph will open the forums for future discussions and that the work will be referenced for the better understanding of cancer in children in Africa and used to improve outcomes for children affected there.”

Photo by Rhoda Baer

The American Society of Clinical Oncology (ASCO) has updated its clinical practice guidelines on the use of antiemetics in cancer patients.

The update, published in the Journal of Clinical Oncology, provides new evidence-based information on the appropriate use of olanzapine, NK1 receptor antagonists, and dexamethasone.

“The adverse impact of inadequately controlled nausea and vomiting on patients’ quality of life is well documented,” said Paul J. Hesketh, MD, co-chair of the ASCO expert panel that updated the guidelines.

“By following the ASCO antiemetics guideline, clinicians have the opportunity to improve patients’ quality of life by minimizing treatment-induced emesis.”

To update ASCO’s guidelines on antiemetics, the expert panel conducted a systematic review of the medical literature published between November 2009 and June 2016. The panel included members with expertise in medical oncology, radiation oncology, nursing, pharmacy, and health services research, as well as a patient representative.

“Tremendous progress has been realized over the last 25 years in the prevention of chemotherapy-induced nausea and vomiting with the introduction of new classes of antiemetic agents,” said Mark G. Kris, MD, co-chair of the expert panel that updated the guidelines.

“The full benefit of these treatment advances will only be realized, however, if evidence-based guidelines are fully implemented.”

Key recommendations in the updated guidelines include:

For adults receiving chemotherapy with a high risk for nausea and vomiting (eg, cisplatin or the combination of cyclophosphamide and an anthracycline), olanzapine should be added to standard antiemetic regimens (the combination of a 5-HT3 receptor antagonist, an NK1 receptor antagonist, and dexamethasone). Olanzapine also helps individuals who experience symptoms despite receiving medicines to prevent vomiting before chemotherapy is given.

For adults receiving carboplatin-based chemotherapy or high-dose chemotherapy and children receiving chemotherapy with a high risk for nausea and vomiting, an NK1 receptor antagonist should be added to the standard antiemetic regimen (the combination of 5-HT3 receptor antagonist and dexamethasone).

Dexamethasone treatment can be limited to the day of chemotherapy administration in patients receiving an anthracycline and cyclophosphamide.

Dronabinol and nabilone, cannabinoids approved by the US Food and Drug Administration, can be used to treat nausea and vomiting that is resistant to standard antiemetic therapies. Evidence remains insufficient to recommend medical marijuana for either prevention or treatment of nausea and vomiting in patients with cancer receiving chemotherapy or radiation therapy.

Photo by Rhoda Baer

The American Society of Clinical Oncology (ASCO) has updated its clinical practice guidelines on the use of antiemetics in cancer patients.

The update, published in the Journal of Clinical Oncology, provides new evidence-based information on the appropriate use of olanzapine, NK1 receptor antagonists, and dexamethasone.

“The adverse impact of inadequately controlled nausea and vomiting on patients’ quality of life is well documented,” said Paul J. Hesketh, MD, co-chair of the ASCO expert panel that updated the guidelines.

“By following the ASCO antiemetics guideline, clinicians have the opportunity to improve patients’ quality of life by minimizing treatment-induced emesis.”

To update ASCO’s guidelines on antiemetics, the expert panel conducted a systematic review of the medical literature published between November 2009 and June 2016. The panel included members with expertise in medical oncology, radiation oncology, nursing, pharmacy, and health services research, as well as a patient representative.

“Tremendous progress has been realized over the last 25 years in the prevention of chemotherapy-induced nausea and vomiting with the introduction of new classes of antiemetic agents,” said Mark G. Kris, MD, co-chair of the expert panel that updated the guidelines.

“The full benefit of these treatment advances will only be realized, however, if evidence-based guidelines are fully implemented.”

Key recommendations in the updated guidelines include:

For adults receiving chemotherapy with a high risk for nausea and vomiting (eg, cisplatin or the combination of cyclophosphamide and an anthracycline), olanzapine should be added to standard antiemetic regimens (the combination of a 5-HT3 receptor antagonist, an NK1 receptor antagonist, and dexamethasone). Olanzapine also helps individuals who experience symptoms despite receiving medicines to prevent vomiting before chemotherapy is given.

For adults receiving carboplatin-based chemotherapy or high-dose chemotherapy and children receiving chemotherapy with a high risk for nausea and vomiting, an NK1 receptor antagonist should be added to the standard antiemetic regimen (the combination of 5-HT3 receptor antagonist and dexamethasone).

Dexamethasone treatment can be limited to the day of chemotherapy administration in patients receiving an anthracycline and cyclophosphamide.

Dronabinol and nabilone, cannabinoids approved by the US Food and Drug Administration, can be used to treat nausea and vomiting that is resistant to standard antiemetic therapies. Evidence remains insufficient to recommend medical marijuana for either prevention or treatment of nausea and vomiting in patients with cancer receiving chemotherapy or radiation therapy.

Photo by Rhoda Baer

The American Society of Clinical Oncology (ASCO) has updated its clinical practice guidelines on the use of antiemetics in cancer patients.

The update, published in the Journal of Clinical Oncology, provides new evidence-based information on the appropriate use of olanzapine, NK1 receptor antagonists, and dexamethasone.

“The adverse impact of inadequately controlled nausea and vomiting on patients’ quality of life is well documented,” said Paul J. Hesketh, MD, co-chair of the ASCO expert panel that updated the guidelines.

“By following the ASCO antiemetics guideline, clinicians have the opportunity to improve patients’ quality of life by minimizing treatment-induced emesis.”

To update ASCO’s guidelines on antiemetics, the expert panel conducted a systematic review of the medical literature published between November 2009 and June 2016. The panel included members with expertise in medical oncology, radiation oncology, nursing, pharmacy, and health services research, as well as a patient representative.

“Tremendous progress has been realized over the last 25 years in the prevention of chemotherapy-induced nausea and vomiting with the introduction of new classes of antiemetic agents,” said Mark G. Kris, MD, co-chair of the expert panel that updated the guidelines.

“The full benefit of these treatment advances will only be realized, however, if evidence-based guidelines are fully implemented.”

Key recommendations in the updated guidelines include:

For adults receiving chemotherapy with a high risk for nausea and vomiting (eg, cisplatin or the combination of cyclophosphamide and an anthracycline), olanzapine should be added to standard antiemetic regimens (the combination of a 5-HT3 receptor antagonist, an NK1 receptor antagonist, and dexamethasone). Olanzapine also helps individuals who experience symptoms despite receiving medicines to prevent vomiting before chemotherapy is given.

For adults receiving carboplatin-based chemotherapy or high-dose chemotherapy and children receiving chemotherapy with a high risk for nausea and vomiting, an NK1 receptor antagonist should be added to the standard antiemetic regimen (the combination of 5-HT3 receptor antagonist and dexamethasone).

Dexamethasone treatment can be limited to the day of chemotherapy administration in patients receiving an anthracycline and cyclophosphamide.

Dronabinol and nabilone, cannabinoids approved by the US Food and Drug Administration, can be used to treat nausea and vomiting that is resistant to standard antiemetic therapies. Evidence remains insufficient to recommend medical marijuana for either prevention or treatment of nausea and vomiting in patients with cancer receiving chemotherapy or radiation therapy.

MADRID – Ninety-two percent of Spanish children sickened during the first-ever outbreak of enterovirus-associated brain stem encephalitis in western Europe survived with no long-term sequelae, Nuria Worner, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

“We think that aggressive treatments should be restricted to those patients with important neurologic involvement,” declared Dr. Worner of Vall d’Hebron University Hospital in Barcelona. “We can say that no patients with milder involvement and without warning signs during the first 24 hours after onset of neurologic involvement went on to develop fulminant symptoms.”

Notable outbreaks of enterovirus A71 (EV-A71)-associated brain stem encephalitis occurred in Southeast Asia, Australia, and China in the late 1990s.

Dr. Worner reported on 196 children treated for laboratory-confirmed EV-A71–associated brain stem encephalitis at 16 Spanish hospitals in April-December 2016. Their median age was 25 months, 57% were male, and a median of 2 days of symptoms of mild viral illness transpired before neurologic symptoms arose. Prior to presenting to a hospital, 21% of the children had been diagnosed with hand-foot-and-mouth disease, and 13% with herpangina.

Initial preadmission symptoms included fever in 94% of cases, sleepiness in 86%, ataxia in 75%, tremor in 47%, myoclonus in 40%, and a rash in 26%.

Fifty-five percent of the children had EV RNA isolated from both throat and feces, 26% from the throat only, and 19% only from their feces. Eighty-seven percent of serotyped EV were EV-A71.

Ninety percent of children underwent lumbar puncture. Particularly noteworthy was the finding that EV was detected in the cerebrospinal fluid of a mere 3% of patients, although pleocytosis was present in 84%.

Brain MRI showed brain stem encephalitis along with myelitis in 50% of patients, brain stem myelitis without encephalitis in 29%, myelitis elsewhere in 2%, and normal findings in 19%.

Ground zero for the outbreak was Barcelona and the surrounding region of Catalonia; indeed, 130 of the 196 (66%) affected children came from there. The Catalan health department and pediatric infectious disease specialists quickly created standardized case severity definitions and treatment recommendations; they distributed them nationally.

Mild EV-A71–associated brain stem disease was defined as two or more of the following: tremor, myoclonus, mild ataxia, and/or significant drowsiness. The recommendation in these mild cases was for no treatment other than supportive care and careful in-hospital monitoring.

Patients with moderate involvement had to meet the definition for mild disease plus more pronounced ataxia or bulbar motor neuron involvement marked by slurred speech, drooling, dysphagia, apnea, abolition of the gag reflex, and/or an abnormal respiratory pattern. Moderately affected patients received two doses of intravenous immunoglobulin (IVIG), each dosed at 1 g/kg per 24 hours. Admission to the pediatric ICU was individualized for patients with moderate EV-A71–associated brain stem encephalitis.

Severe disease was categorized as bulbar motor neuron involvement plus neurogenic cardiorespiratory failure. Those patients were uniformly admitted to a pediatric ICU and given the two doses of IVIG. The need for systemic steroids was determined on an individual basis.

Forty percent of patients received IVIG and systemic steroids, 24% received IVIG only, 2% systemic steroids only, and 34% received no treatment other than supportive care.

Twenty-six percent of children were admitted to a pediatric ICU for a median stay of 3.5 days. Nine percent of children were placed on mechanical ventilation.

As the disease evolved, the most frequent neurologic complications included slurred speech in 15% of children, abnormal breathing pattern in 11%, seizures in 10%, acute flaccid paralysis in 9%, and cardiorespiratory failure with pulmonary edema in 9%, all occurring within the first hours after hospital admission.

The median hospital length of stay for the full study population was 6 days. The survival rate was 99.5%, with the sole death being due to cardiorespiratory failure.

With 1-6 months of follow-up since the acute episode of EV-A71–associated brain stem encephalitis, the long-term sequelae included two cases of limb paresis and two cases of paresis of a cranial nerve, one child with residual seizures, and one with hypoxic-ischemic encephalopathy.

Asked why the fatality rate in the Spanish outbreak was so much lower than in the earlier Australasian outbreaks, Dr. Worner cited Catalan physicians’ quick recognition of what was underway – and, more importantly, a difference in the EV-A71 viral subgenotype. Most of the most severe cases in Asia and Australia involved the C-4 subgenotype, while in Spain, the predominant subgenotype involved in the outbreak was C-1.

As for the curious finding that EV was detectable in the cerebrospinal fluid of a mere 3% of the Spanish children, she said the explanation is unknown. The two main possibilities are that the CNS symptoms were due to a parenchymal brain infection rather than to EV-A71 infection of meningeal tissue. Alternatively, the CNS involvement may have been a manifestation of an immunologic response to the infection, rather than being due to the virus itself.

Dr. Worner reported having no financial conflicts of interest.

bjancin@frontlinemedcom.com

MADRID – Ninety-two percent of Spanish children sickened during the first-ever outbreak of enterovirus-associated brain stem encephalitis in western Europe survived with no long-term sequelae, Nuria Worner, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

“We think that aggressive treatments should be restricted to those patients with important neurologic involvement,” declared Dr. Worner of Vall d’Hebron University Hospital in Barcelona. “We can say that no patients with milder involvement and without warning signs during the first 24 hours after onset of neurologic involvement went on to develop fulminant symptoms.”

Notable outbreaks of enterovirus A71 (EV-A71)-associated brain stem encephalitis occurred in Southeast Asia, Australia, and China in the late 1990s.

Dr. Worner reported on 196 children treated for laboratory-confirmed EV-A71–associated brain stem encephalitis at 16 Spanish hospitals in April-December 2016. Their median age was 25 months, 57% were male, and a median of 2 days of symptoms of mild viral illness transpired before neurologic symptoms arose. Prior to presenting to a hospital, 21% of the children had been diagnosed with hand-foot-and-mouth disease, and 13% with herpangina.

Initial preadmission symptoms included fever in 94% of cases, sleepiness in 86%, ataxia in 75%, tremor in 47%, myoclonus in 40%, and a rash in 26%.

Fifty-five percent of the children had EV RNA isolated from both throat and feces, 26% from the throat only, and 19% only from their feces. Eighty-seven percent of serotyped EV were EV-A71.

Ninety percent of children underwent lumbar puncture. Particularly noteworthy was the finding that EV was detected in the cerebrospinal fluid of a mere 3% of patients, although pleocytosis was present in 84%.

Brain MRI showed brain stem encephalitis along with myelitis in 50% of patients, brain stem myelitis without encephalitis in 29%, myelitis elsewhere in 2%, and normal findings in 19%.

Ground zero for the outbreak was Barcelona and the surrounding region of Catalonia; indeed, 130 of the 196 (66%) affected children came from there. The Catalan health department and pediatric infectious disease specialists quickly created standardized case severity definitions and treatment recommendations; they distributed them nationally.

Mild EV-A71–associated brain stem disease was defined as two or more of the following: tremor, myoclonus, mild ataxia, and/or significant drowsiness. The recommendation in these mild cases was for no treatment other than supportive care and careful in-hospital monitoring.

Patients with moderate involvement had to meet the definition for mild disease plus more pronounced ataxia or bulbar motor neuron involvement marked by slurred speech, drooling, dysphagia, apnea, abolition of the gag reflex, and/or an abnormal respiratory pattern. Moderately affected patients received two doses of intravenous immunoglobulin (IVIG), each dosed at 1 g/kg per 24 hours. Admission to the pediatric ICU was individualized for patients with moderate EV-A71–associated brain stem encephalitis.

Severe disease was categorized as bulbar motor neuron involvement plus neurogenic cardiorespiratory failure. Those patients were uniformly admitted to a pediatric ICU and given the two doses of IVIG. The need for systemic steroids was determined on an individual basis.

Forty percent of patients received IVIG and systemic steroids, 24% received IVIG only, 2% systemic steroids only, and 34% received no treatment other than supportive care.

Twenty-six percent of children were admitted to a pediatric ICU for a median stay of 3.5 days. Nine percent of children were placed on mechanical ventilation.

As the disease evolved, the most frequent neurologic complications included slurred speech in 15% of children, abnormal breathing pattern in 11%, seizures in 10%, acute flaccid paralysis in 9%, and cardiorespiratory failure with pulmonary edema in 9%, all occurring within the first hours after hospital admission.

The median hospital length of stay for the full study population was 6 days. The survival rate was 99.5%, with the sole death being due to cardiorespiratory failure.

With 1-6 months of follow-up since the acute episode of EV-A71–associated brain stem encephalitis, the long-term sequelae included two cases of limb paresis and two cases of paresis of a cranial nerve, one child with residual seizures, and one with hypoxic-ischemic encephalopathy.

Asked why the fatality rate in the Spanish outbreak was so much lower than in the earlier Australasian outbreaks, Dr. Worner cited Catalan physicians’ quick recognition of what was underway – and, more importantly, a difference in the EV-A71 viral subgenotype. Most of the most severe cases in Asia and Australia involved the C-4 subgenotype, while in Spain, the predominant subgenotype involved in the outbreak was C-1.

As for the curious finding that EV was detectable in the cerebrospinal fluid of a mere 3% of the Spanish children, she said the explanation is unknown. The two main possibilities are that the CNS symptoms were due to a parenchymal brain infection rather than to EV-A71 infection of meningeal tissue. Alternatively, the CNS involvement may have been a manifestation of an immunologic response to the infection, rather than being due to the virus itself.

Dr. Worner reported having no financial conflicts of interest.

bjancin@frontlinemedcom.com

MADRID – Ninety-two percent of Spanish children sickened during the first-ever outbreak of enterovirus-associated brain stem encephalitis in western Europe survived with no long-term sequelae, Nuria Worner, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

“We think that aggressive treatments should be restricted to those patients with important neurologic involvement,” declared Dr. Worner of Vall d’Hebron University Hospital in Barcelona. “We can say that no patients with milder involvement and without warning signs during the first 24 hours after onset of neurologic involvement went on to develop fulminant symptoms.”

Notable outbreaks of enterovirus A71 (EV-A71)-associated brain stem encephalitis occurred in Southeast Asia, Australia, and China in the late 1990s.

Dr. Worner reported on 196 children treated for laboratory-confirmed EV-A71–associated brain stem encephalitis at 16 Spanish hospitals in April-December 2016. Their median age was 25 months, 57% were male, and a median of 2 days of symptoms of mild viral illness transpired before neurologic symptoms arose. Prior to presenting to a hospital, 21% of the children had been diagnosed with hand-foot-and-mouth disease, and 13% with herpangina.

Initial preadmission symptoms included fever in 94% of cases, sleepiness in 86%, ataxia in 75%, tremor in 47%, myoclonus in 40%, and a rash in 26%.

Fifty-five percent of the children had EV RNA isolated from both throat and feces, 26% from the throat only, and 19% only from their feces. Eighty-seven percent of serotyped EV were EV-A71.

Ninety percent of children underwent lumbar puncture. Particularly noteworthy was the finding that EV was detected in the cerebrospinal fluid of a mere 3% of patients, although pleocytosis was present in 84%.

Brain MRI showed brain stem encephalitis along with myelitis in 50% of patients, brain stem myelitis without encephalitis in 29%, myelitis elsewhere in 2%, and normal findings in 19%.

Ground zero for the outbreak was Barcelona and the surrounding region of Catalonia; indeed, 130 of the 196 (66%) affected children came from there. The Catalan health department and pediatric infectious disease specialists quickly created standardized case severity definitions and treatment recommendations; they distributed them nationally.

Mild EV-A71–associated brain stem disease was defined as two or more of the following: tremor, myoclonus, mild ataxia, and/or significant drowsiness. The recommendation in these mild cases was for no treatment other than supportive care and careful in-hospital monitoring.

Patients with moderate involvement had to meet the definition for mild disease plus more pronounced ataxia or bulbar motor neuron involvement marked by slurred speech, drooling, dysphagia, apnea, abolition of the gag reflex, and/or an abnormal respiratory pattern. Moderately affected patients received two doses of intravenous immunoglobulin (IVIG), each dosed at 1 g/kg per 24 hours. Admission to the pediatric ICU was individualized for patients with moderate EV-A71–associated brain stem encephalitis.

Severe disease was categorized as bulbar motor neuron involvement plus neurogenic cardiorespiratory failure. Those patients were uniformly admitted to a pediatric ICU and given the two doses of IVIG. The need for systemic steroids was determined on an individual basis.

Forty percent of patients received IVIG and systemic steroids, 24% received IVIG only, 2% systemic steroids only, and 34% received no treatment other than supportive care.

Twenty-six percent of children were admitted to a pediatric ICU for a median stay of 3.5 days. Nine percent of children were placed on mechanical ventilation.

As the disease evolved, the most frequent neurologic complications included slurred speech in 15% of children, abnormal breathing pattern in 11%, seizures in 10%, acute flaccid paralysis in 9%, and cardiorespiratory failure with pulmonary edema in 9%, all occurring within the first hours after hospital admission.

The median hospital length of stay for the full study population was 6 days. The survival rate was 99.5%, with the sole death being due to cardiorespiratory failure.

With 1-6 months of follow-up since the acute episode of EV-A71–associated brain stem encephalitis, the long-term sequelae included two cases of limb paresis and two cases of paresis of a cranial nerve, one child with residual seizures, and one with hypoxic-ischemic encephalopathy.

Asked why the fatality rate in the Spanish outbreak was so much lower than in the earlier Australasian outbreaks, Dr. Worner cited Catalan physicians’ quick recognition of what was underway – and, more importantly, a difference in the EV-A71 viral subgenotype. Most of the most severe cases in Asia and Australia involved the C-4 subgenotype, while in Spain, the predominant subgenotype involved in the outbreak was C-1.

As for the curious finding that EV was detectable in the cerebrospinal fluid of a mere 3% of the Spanish children, she said the explanation is unknown. The two main possibilities are that the CNS symptoms were due to a parenchymal brain infection rather than to EV-A71 infection of meningeal tissue. Alternatively, the CNS involvement may have been a manifestation of an immunologic response to the infection, rather than being due to the virus itself.

Dr. Worner reported having no financial conflicts of interest.

bjancin@frontlinemedcom.com

Exposure to clindamycin and doxycycline during the first trimester may be associated with an increased risk of organ-specific malformations such as ventricular/atrial septal defect, new research suggests.

In a population-based cohort study in 139,938 liveborn singletons, there was an 81% increased risk of ventricular/septal defect (adjusted odds ratio, 1.81) associated with clindamycin exposure during the first trimester, compared with no exposure. Similarly, there was a 67% greater risk of musculoskeletal system malformations (aOR, 1.67) associated with clindamycin exposure (Br J Clin Pharmacol. 2017 Jul 19. doi: 10.1111/bcp.13364).

Kathy Scarbeck/Frontline Medical News

Exposure to clindamycin and doxycycline during the first trimester may be associated with an increased risk of organ-specific malformations such as ventricular/atrial septal defect, new research suggests.

In a population-based cohort study in 139,938 liveborn singletons, there was an 81% increased risk of ventricular/septal defect (adjusted odds ratio, 1.81) associated with clindamycin exposure during the first trimester, compared with no exposure. Similarly, there was a 67% greater risk of musculoskeletal system malformations (aOR, 1.67) associated with clindamycin exposure (Br J Clin Pharmacol. 2017 Jul 19. doi: 10.1111/bcp.13364).

Kathy Scarbeck/Frontline Medical News

Exposure to clindamycin and doxycycline during the first trimester may be associated with an increased risk of organ-specific malformations such as ventricular/atrial septal defect, new research suggests.

In a population-based cohort study in 139,938 liveborn singletons, there was an 81% increased risk of ventricular/septal defect (adjusted odds ratio, 1.81) associated with clindamycin exposure during the first trimester, compared with no exposure. Similarly, there was a 67% greater risk of musculoskeletal system malformations (aOR, 1.67) associated with clindamycin exposure (Br J Clin Pharmacol. 2017 Jul 19. doi: 10.1111/bcp.13364).

Kathy Scarbeck/Frontline Medical News

Prompt, symptomatic, multidisciplinary treatment is the best way to curtail the symptoms of pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric syndrome associated with streptococcal infection (PANDAS), according to new guidelines.

Clinicians should tailor treatment to symptoms, wrote Margo Thienemann, MD, of Stanford (Calif.) University and her coauthors in the clinical management section of the guidelines. For example, children with mild psychiatric symptoms might only need cognitive-behavioral therapy (CBT), while more severe symptoms can merit a slow up-titration of psychoactive medications.

Prompt, symptomatic, multidisciplinary treatment is the best way to curtail the symptoms of pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric syndrome associated with streptococcal infection (PANDAS), according to new guidelines.

Clinicians should tailor treatment to symptoms, wrote Margo Thienemann, MD, of Stanford (Calif.) University and her coauthors in the clinical management section of the guidelines. For example, children with mild psychiatric symptoms might only need cognitive-behavioral therapy (CBT), while more severe symptoms can merit a slow up-titration of psychoactive medications.

Prompt, symptomatic, multidisciplinary treatment is the best way to curtail the symptoms of pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric syndrome associated with streptococcal infection (PANDAS), according to new guidelines.

Clinicians should tailor treatment to symptoms, wrote Margo Thienemann, MD, of Stanford (Calif.) University and her coauthors in the clinical management section of the guidelines. For example, children with mild psychiatric symptoms might only need cognitive-behavioral therapy (CBT), while more severe symptoms can merit a slow up-titration of psychoactive medications.

CHICAGO – Bone marrow transplantation is evolving as a promising treatment for patients with the most severe forms of epidermolysis bullosa.

“Is this a cure? It’s not,” Dr. Jakub Tolar, MD, PhD, said at the World Congress of Pediatric Dermatology. “It is, however, a path toward understanding how we can treat this grave disorder in a systemic way.”

Courtesy Gabriella McCann

dbrunk@frontlinemedcom.com

CHICAGO – Bone marrow transplantation is evolving as a promising treatment for patients with the most severe forms of epidermolysis bullosa.

“Is this a cure? It’s not,” Dr. Jakub Tolar, MD, PhD, said at the World Congress of Pediatric Dermatology. “It is, however, a path toward understanding how we can treat this grave disorder in a systemic way.”

Courtesy Gabriella McCann

dbrunk@frontlinemedcom.com

CHICAGO – Bone marrow transplantation is evolving as a promising treatment for patients with the most severe forms of epidermolysis bullosa.

“Is this a cure? It’s not,” Dr. Jakub Tolar, MD, PhD, said at the World Congress of Pediatric Dermatology. “It is, however, a path toward understanding how we can treat this grave disorder in a systemic way.”

Courtesy Gabriella McCann

dbrunk@frontlinemedcom.com

As a physician or a patient, you probably have noticed that the quality of health care is better when there is a continuous relationship between the physician and the patient. Discontinuity can make doctor-patient communication less fluid, but familiarity can breed comfort and confidence. Patients often complain when they see a different physician at every visit. And physicians know they are less efficient when they are seeing a patient they have never seen before.

Tomwang112/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

As a physician or a patient, you probably have noticed that the quality of health care is better when there is a continuous relationship between the physician and the patient. Discontinuity can make doctor-patient communication less fluid, but familiarity can breed comfort and confidence. Patients often complain when they see a different physician at every visit. And physicians know they are less efficient when they are seeing a patient they have never seen before.

Tomwang112/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

As a physician or a patient, you probably have noticed that the quality of health care is better when there is a continuous relationship between the physician and the patient. Discontinuity can make doctor-patient communication less fluid, but familiarity can breed comfort and confidence. Patients often complain when they see a different physician at every visit. And physicians know they are less efficient when they are seeing a patient they have never seen before.

Tomwang112/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.

NASHVILLE, TENN. – Pediatric endocrinologist Cassandra Brady, MD, caught the attention of her audience at Pediatric Hospital Medicine when she mentioned that children presenting with new-onset diabetes rarely spend more than 2 days at Vanderbilt University’s children’s hospital, even if they present in diabetic ketoacidosis.

In many places, children with new-onset diabetes spend quite a bit longer in the hospital – even if they are medically stable and feeling fine – for diabetes education.

That’s not the case at Vanderbilt, where Dr. Brady is an assistant professor. Once kids are stabilized, they and their parents undergo a 3-hour crash course – sometimes even in the PICU – on diabetes survival skills, and then they’re sent home with insulin. They learn the finer points about carbohydrate counting and tight glucose control at subsequent outpatient visits.

More and more payers are probably going to push for that model, Dr. Brady noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

For those interested in making the transition to outpatient eduction, she explained in an interview exactly how Vanderbilt’s been doing it safely for years.

aotto@frontlinemedcom.com

NASHVILLE, TENN. – Pediatric endocrinologist Cassandra Brady, MD, caught the attention of her audience at Pediatric Hospital Medicine when she mentioned that children presenting with new-onset diabetes rarely spend more than 2 days at Vanderbilt University’s children’s hospital, even if they present in diabetic ketoacidosis.

In many places, children with new-onset diabetes spend quite a bit longer in the hospital – even if they are medically stable and feeling fine – for diabetes education.

That’s not the case at Vanderbilt, where Dr. Brady is an assistant professor. Once kids are stabilized, they and their parents undergo a 3-hour crash course – sometimes even in the PICU – on diabetes survival skills, and then they’re sent home with insulin. They learn the finer points about carbohydrate counting and tight glucose control at subsequent outpatient visits.

More and more payers are probably going to push for that model, Dr. Brady noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

For those interested in making the transition to outpatient eduction, she explained in an interview exactly how Vanderbilt’s been doing it safely for years.

aotto@frontlinemedcom.com

NASHVILLE, TENN. – Pediatric endocrinologist Cassandra Brady, MD, caught the attention of her audience at Pediatric Hospital Medicine when she mentioned that children presenting with new-onset diabetes rarely spend more than 2 days at Vanderbilt University’s children’s hospital, even if they present in diabetic ketoacidosis.

In many places, children with new-onset diabetes spend quite a bit longer in the hospital – even if they are medically stable and feeling fine – for diabetes education.

That’s not the case at Vanderbilt, where Dr. Brady is an assistant professor. Once kids are stabilized, they and their parents undergo a 3-hour crash course – sometimes even in the PICU – on diabetes survival skills, and then they’re sent home with insulin. They learn the finer points about carbohydrate counting and tight glucose control at subsequent outpatient visits.

More and more payers are probably going to push for that model, Dr. Brady noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

For those interested in making the transition to outpatient eduction, she explained in an interview exactly how Vanderbilt’s been doing it safely for years.

aotto@frontlinemedcom.com