Pediatrics

 

MADRID – Ninety-five percent of cases of enterovirus and parechovirus meningitis in infants younger than 90 days old in the United Kingdom and Ireland were diagnosed through lumbar puncture and identification of the virus in the CSF by PCR, Seilesh Kadambari, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

“We recommend that routine testing of CSF for enterovirus and parechovirus in febrile infants should be promoted, even in the absence of pleocytosis,” said Dr. Kadambari of John Radcliffe Hospital in Oxford, England.

He presented highlights of a comprehensive prospective observational surveillance study conducted across the United Kingdom and Ireland to assess the burden of enterovirus and parechovirus meningitis in infants younger than 90 days old.

This active enhanced prospective surveillance study was undertaken because an earlier retrospective study concluded that the rate of viral meningitis across all pediatric and adult age groups had increased rapidly during a recent 10-year period in the United Kingdom and Ireland. Infants younger than 3 months of age were especially hard hit by enterovirus, which accounted in the earlier study for 92% of all viral meningitis cases in that age group. Dr. Kadambari and his coinvestigators decided to take a closer prospective look at the sub-3-month age group because it’s such an important time neurodevelopmentally.

During the 13-month period of June 2014 to June 2015, 710 patients younger than 90 days old were hospitalized for enterovirus or parechovirus meningitis across the United Kingdom and Republic of Ireland. Ninety-five percent were due to enterovirus. Only 6% of affected infants were born prematurely.

“One of the take-home messages for me from the study was that 12% of enterovirus cases and 23% of parechovirus meningitis cases required admission to an ICU setting,” the pediatrician observed.

Among the infants admitted to a pediatric ICU, half of those with enterovirus meningitis and all those with parechovirus meningitis required intubation and mechanical ventilation. One-fifth of the enterovirus meningitis patients in pediatric ICUs required inotropic support for cardiovascular stabilization, as did all young infants with parechovirus meningitis.

Among the 710 patients, the three most common clinical presenting features were fever, irritability, and reduced feeding, present in 85%, 66%, and 54%, respectively.

Upon physical examination, two noteworthy common findings were signs of shock, present in 27% of infants with enterovirus meningitis and 43% with parechovirus meningitis, and respiratory distress, seen in 12% and 26%, respectively.

None of the 710 infants had a secondary bacterial infection. “That has implications for antimicrobial stewardship programs,” according to Dr. Kadambari.

The majority of infants had a normal CSF WBC count and a normal-range C-reactive protein level.

“Raised inflammatory markers were not a common feature in our cohort,” he noted.

Two infants died: one of a massive pulmonary hemorrhage and the other as a result of septic shock. Of the remaining 708 patients, however, 699 (98.7%) were discharged without significant neurologic impairment. Seven infants with enterovirus meningitis and two with parechovirus meningitis were discharged with severe delay, including cases of fine motor and gross motor delay, visual abnormalities, and a single case of severe cardiac dysfunction requiring discharge on an ACE inhibitor.

This surveillance study was a collaboration between St. George’s University of London and Public Health England. Dr. Kadambari reported having no financial conflicts.

Future studies need to examine long-term neurodevelopmental outcomes in affected young infants out to age 24 months, he said.

bjancin@frontlinemedcom.com

 

MADRID – Ninety-five percent of cases of enterovirus and parechovirus meningitis in infants younger than 90 days old in the United Kingdom and Ireland were diagnosed through lumbar puncture and identification of the virus in the CSF by PCR, Seilesh Kadambari, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

“We recommend that routine testing of CSF for enterovirus and parechovirus in febrile infants should be promoted, even in the absence of pleocytosis,” said Dr. Kadambari of John Radcliffe Hospital in Oxford, England.

He presented highlights of a comprehensive prospective observational surveillance study conducted across the United Kingdom and Ireland to assess the burden of enterovirus and parechovirus meningitis in infants younger than 90 days old.

This active enhanced prospective surveillance study was undertaken because an earlier retrospective study concluded that the rate of viral meningitis across all pediatric and adult age groups had increased rapidly during a recent 10-year period in the United Kingdom and Ireland. Infants younger than 3 months of age were especially hard hit by enterovirus, which accounted in the earlier study for 92% of all viral meningitis cases in that age group. Dr. Kadambari and his coinvestigators decided to take a closer prospective look at the sub-3-month age group because it’s such an important time neurodevelopmentally.

During the 13-month period of June 2014 to June 2015, 710 patients younger than 90 days old were hospitalized for enterovirus or parechovirus meningitis across the United Kingdom and Republic of Ireland. Ninety-five percent were due to enterovirus. Only 6% of affected infants were born prematurely.

“One of the take-home messages for me from the study was that 12% of enterovirus cases and 23% of parechovirus meningitis cases required admission to an ICU setting,” the pediatrician observed.

Among the infants admitted to a pediatric ICU, half of those with enterovirus meningitis and all those with parechovirus meningitis required intubation and mechanical ventilation. One-fifth of the enterovirus meningitis patients in pediatric ICUs required inotropic support for cardiovascular stabilization, as did all young infants with parechovirus meningitis.

Among the 710 patients, the three most common clinical presenting features were fever, irritability, and reduced feeding, present in 85%, 66%, and 54%, respectively.

Upon physical examination, two noteworthy common findings were signs of shock, present in 27% of infants with enterovirus meningitis and 43% with parechovirus meningitis, and respiratory distress, seen in 12% and 26%, respectively.

None of the 710 infants had a secondary bacterial infection. “That has implications for antimicrobial stewardship programs,” according to Dr. Kadambari.

The majority of infants had a normal CSF WBC count and a normal-range C-reactive protein level.

“Raised inflammatory markers were not a common feature in our cohort,” he noted.

Two infants died: one of a massive pulmonary hemorrhage and the other as a result of septic shock. Of the remaining 708 patients, however, 699 (98.7%) were discharged without significant neurologic impairment. Seven infants with enterovirus meningitis and two with parechovirus meningitis were discharged with severe delay, including cases of fine motor and gross motor delay, visual abnormalities, and a single case of severe cardiac dysfunction requiring discharge on an ACE inhibitor.

This surveillance study was a collaboration between St. George’s University of London and Public Health England. Dr. Kadambari reported having no financial conflicts.

Future studies need to examine long-term neurodevelopmental outcomes in affected young infants out to age 24 months, he said.

bjancin@frontlinemedcom.com

 

MADRID – Ninety-five percent of cases of enterovirus and parechovirus meningitis in infants younger than 90 days old in the United Kingdom and Ireland were diagnosed through lumbar puncture and identification of the virus in the CSF by PCR, Seilesh Kadambari, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

“We recommend that routine testing of CSF for enterovirus and parechovirus in febrile infants should be promoted, even in the absence of pleocytosis,” said Dr. Kadambari of John Radcliffe Hospital in Oxford, England.

He presented highlights of a comprehensive prospective observational surveillance study conducted across the United Kingdom and Ireland to assess the burden of enterovirus and parechovirus meningitis in infants younger than 90 days old.

This active enhanced prospective surveillance study was undertaken because an earlier retrospective study concluded that the rate of viral meningitis across all pediatric and adult age groups had increased rapidly during a recent 10-year period in the United Kingdom and Ireland. Infants younger than 3 months of age were especially hard hit by enterovirus, which accounted in the earlier study for 92% of all viral meningitis cases in that age group. Dr. Kadambari and his coinvestigators decided to take a closer prospective look at the sub-3-month age group because it’s such an important time neurodevelopmentally.

During the 13-month period of June 2014 to June 2015, 710 patients younger than 90 days old were hospitalized for enterovirus or parechovirus meningitis across the United Kingdom and Republic of Ireland. Ninety-five percent were due to enterovirus. Only 6% of affected infants were born prematurely.

“One of the take-home messages for me from the study was that 12% of enterovirus cases and 23% of parechovirus meningitis cases required admission to an ICU setting,” the pediatrician observed.

Among the infants admitted to a pediatric ICU, half of those with enterovirus meningitis and all those with parechovirus meningitis required intubation and mechanical ventilation. One-fifth of the enterovirus meningitis patients in pediatric ICUs required inotropic support for cardiovascular stabilization, as did all young infants with parechovirus meningitis.

Among the 710 patients, the three most common clinical presenting features were fever, irritability, and reduced feeding, present in 85%, 66%, and 54%, respectively.

Upon physical examination, two noteworthy common findings were signs of shock, present in 27% of infants with enterovirus meningitis and 43% with parechovirus meningitis, and respiratory distress, seen in 12% and 26%, respectively.

None of the 710 infants had a secondary bacterial infection. “That has implications for antimicrobial stewardship programs,” according to Dr. Kadambari.

The majority of infants had a normal CSF WBC count and a normal-range C-reactive protein level.

“Raised inflammatory markers were not a common feature in our cohort,” he noted.

Two infants died: one of a massive pulmonary hemorrhage and the other as a result of septic shock. Of the remaining 708 patients, however, 699 (98.7%) were discharged without significant neurologic impairment. Seven infants with enterovirus meningitis and two with parechovirus meningitis were discharged with severe delay, including cases of fine motor and gross motor delay, visual abnormalities, and a single case of severe cardiac dysfunction requiring discharge on an ACE inhibitor.

This surveillance study was a collaboration between St. George’s University of London and Public Health England. Dr. Kadambari reported having no financial conflicts.

Future studies need to examine long-term neurodevelopmental outcomes in affected young infants out to age 24 months, he said.

bjancin@frontlinemedcom.com

 

The U.S. Food and Drug Administration has approved perampanel (Fycompa) for monotherapy treatment of partial-onset seizures (POS) in patients aged 12 years or older as of July 27. It was approved in 2012 for adjunctive use for POS and primary, generalized tonic-clonic seizures in patients aged 12 years or older.

Three clinical trials showed improvement in seizure control for the patients with POS taking perampanel, compared with placebo.

Courtesy Wikimedia Commons/FitzColinGerald/Creative Commons License

The FDA approved the supplemental new drug application pertaining to this use filed by Eisai, the manufacturer of perampanel. The U.S. Drug Enforcement Agency has designated the drug a Schedule III federally controlled substance, since it can be abused and can lead to dependence. Perampanel also has a risk of causing psychiatric problems.

The drug is available in tablets from 2 mg to 12 mg and as an oral suspension formulation. It is taken once daily.

“Approximately one-third of people living with epilepsy have seizures that are not adequately controlled,” said Robert T. Wechsler, MD, PhD, medical director of the Idaho Comprehensive Epilepsy Center, in Eisai’s press release. “Having a new monotherapy option for partial-onset seizures that is once a day gives physicians and patients an effective treatment option that has the potential to make a difference in patients’ lives.”

dwatson@frontlinemedcom.com

 

The U.S. Food and Drug Administration has approved perampanel (Fycompa) for monotherapy treatment of partial-onset seizures (POS) in patients aged 12 years or older as of July 27. It was approved in 2012 for adjunctive use for POS and primary, generalized tonic-clonic seizures in patients aged 12 years or older.

Three clinical trials showed improvement in seizure control for the patients with POS taking perampanel, compared with placebo.

Courtesy Wikimedia Commons/FitzColinGerald/Creative Commons License

The FDA approved the supplemental new drug application pertaining to this use filed by Eisai, the manufacturer of perampanel. The U.S. Drug Enforcement Agency has designated the drug a Schedule III federally controlled substance, since it can be abused and can lead to dependence. Perampanel also has a risk of causing psychiatric problems.

The drug is available in tablets from 2 mg to 12 mg and as an oral suspension formulation. It is taken once daily.

“Approximately one-third of people living with epilepsy have seizures that are not adequately controlled,” said Robert T. Wechsler, MD, PhD, medical director of the Idaho Comprehensive Epilepsy Center, in Eisai’s press release. “Having a new monotherapy option for partial-onset seizures that is once a day gives physicians and patients an effective treatment option that has the potential to make a difference in patients’ lives.”

dwatson@frontlinemedcom.com

 

The U.S. Food and Drug Administration has approved perampanel (Fycompa) for monotherapy treatment of partial-onset seizures (POS) in patients aged 12 years or older as of July 27. It was approved in 2012 for adjunctive use for POS and primary, generalized tonic-clonic seizures in patients aged 12 years or older.

Three clinical trials showed improvement in seizure control for the patients with POS taking perampanel, compared with placebo.

Courtesy Wikimedia Commons/FitzColinGerald/Creative Commons License

The FDA approved the supplemental new drug application pertaining to this use filed by Eisai, the manufacturer of perampanel. The U.S. Drug Enforcement Agency has designated the drug a Schedule III federally controlled substance, since it can be abused and can lead to dependence. Perampanel also has a risk of causing psychiatric problems.

The drug is available in tablets from 2 mg to 12 mg and as an oral suspension formulation. It is taken once daily.

“Approximately one-third of people living with epilepsy have seizures that are not adequately controlled,” said Robert T. Wechsler, MD, PhD, medical director of the Idaho Comprehensive Epilepsy Center, in Eisai’s press release. “Having a new monotherapy option for partial-onset seizures that is once a day gives physicians and patients an effective treatment option that has the potential to make a difference in patients’ lives.”

dwatson@frontlinemedcom.com

 

In the Journal of Child and Adolescent Psychopharmacology’s July 2017 issue, a group of respected individuals representing diverse expertise published “guidelines” to support clinical management of pediatric acute-onset neuropsychiatric syndrome (PANS) and its subclass PANDAS (those associated with streptococcal infection). PANS represents an enigmatic clinical syndrome that includes abrupt onset of obsessive-compulsive disorder (OCD) or eating restriction in combination with anxiety, attention deficit, hyperkinesia, emotional lability, irritability, aggressive or oppositional behavior, or academic decline. Neurologic findings also may be present; these are most often motor or vocal tics, but choreiform movements of the finger (repetitive motions that are rapid, jerky, and involuntary), deteriorating penmanship, sleep disruptions, or urinary frequency also may be present. The clinical course most often is relapsing and remitting with overall improvement over months or years.

CDC/ Melissa Brower

These events are often, but not universally, associated with infections, both for the initial clinical presentation as well as the subsequent exacerbations. A spectrum of inciting infections, most often upper respiratory tract disease including rhinitis, sinusitis, and pharyngitis, are reported as precipitating events. Group A streptococcal (GAS) infection has been most commonly identified. The evidence for GAS includes retrospective studies of increases in antistreptolysin O (ASO), anti-DNAse B (ADB), or anticarbohydrate-specific antibody titers associated with OCD or tic exacerbations; epidemiologic studies linking GAS infections in the prior 3 months with OCD and tic disorders; and animal studies demonstrating neuropsychiatric changes after GAS immunizations. Other infectious agents, specifically Mycoplasma pneumoniae, influenza viruses, Lyme borreliosis, and sinus infections, also are suspected triggers for PANS. Definitive proof, however, of a causal relationship between infection and PANS or PANDAS remains lacking.

The PANS/PANDAS consortium made specific recommendations for the management of patients with this clinically diagnosed syndrome (J Child Adolesc Psychopharmacol. 2017 Apr 7. doi: 10.1089/cap.2016.0151).

Specific recommendations include:

1. Searching for a coexisting infectious etiology with history, exam, and appropriate laboratory testing (including ASO and ADB antibodies), and, when present, treating accordingly. Even in the absence of definitive evidence of GAS infection, they recommend an initial course of antimicrobial therapy such as that given to patients with rheumatic fever.

2. For children with PANDAS (PANS with either culture or serologic evidence of GAS), consider instituting long-term streptococcal prophylaxis. The data on its value is mixed; however, most studies find more than 40% (and as many as 75%) of exacerbations are associated with GAS, and at least one study reports a reduction in neuropsychiatric exacerbations in children on penicillin or azithromycin prophylaxis for a 1-year period. Such decisions should be individualized: In children with strong evidence of exacerbations linked to GAS, there was thought to be greater likelihood of benefit, while, in those with no evidence for prior GAS infection, the potential for benefit was thought to be insufficient to justify prophylaxis. Furthermore, the optimal duration of prophylaxis is unknown. The guidelines recommend up to 2 years, but individualization is appropriate since severe cases may warrant prolonged prophylaxis.

3. In children who present with PANDAS and a positive throat culture for GAS, follow-up should be the same as that given for rheumatic fever, with reculture at 2-7 days and retreatment if there is persistence of GAS.

4. Vigilance for GAS infection in family members is appropriate, including obtaining throat cultures from persons with pharyngitis and treating them promptly when results are positive.

5. When GAS infection is not identified, the clinician should search for alternative infectious agents, such as Mycoplasma pneumoniae (using polymerase chain reaction on throat or nasopharyngeal swab), influenza virus, or alternative infections such as sinusitis, and treat accordingly.

6. Children with PANS and PANDAS should be immunized according to Advisory Committee of Immunization Practices recommendations, which includes annual influenza immunization. The committee reported that symptom flares after immunization were uncommon, brief, and manageable with NSAIDs.

7. The committee suggested that optimization of serum vitamin D levels among children with PANS and PANDAS could be of benefit, despite limited evidence. The committee members recommended treating children with PANS/PANDAS with vitamin D₃ as needed to maintain serum 25-hydroxy vitamin D levels above 30 ng/mL. No benefit for adenotonsillectomy was identified. The committee recommended that tonsillectomy and/or adenoidectomy should limited to those with traditional indications (sleep apnea, failure to thrive, and abnormally large tonsils, etc.). The committee also found no evidence to suggest that probiotics modulate this condition.

These guidelines come with an important caveat. They represent a practical clinical approach for the management of infection in the context of PANS or PANDAS and rely heavily on the clinical experience of the members of the PANS/PANDAS Consortium. They provide criteria for the retrospective diagnosis of GAS infection and recommend treatment of GAS in all patients with newly diagnosed PANS. The suggested guidelines are supported by limited data and recognize that further prospective study of the mechanistic link between infection and PANS, clarification of the risk factors for development of PANS, and definitive study of the risks and benefits of antimicrobial prophylaxis are needed.

The consortium also has published two accompanying guidelines that address psychiatric (J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0145) and immunomodulatory management (J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0148) in the same issue of the Journal of Child and Adolescent Psychopharmacology.

 

Proposed criteria for documenting GAS infection in PANS pediatric patients

These are the criteria proposed by the consortium for documentation of active or prior GAS infection in children with PANS:

• A rise in serial antibody level, regardless of rapid test or culture result. This definition does not require clinical pharyngitis.
• Acute pharyngitis with a positive GAS throat culture, with or without a rising antibody level.
• Pharyngitis with characteristic palatal petechiae.
• Pharyngitis with a characteristic scarlatiniform rash.
• Pharyngitis without a throat swab or serology, but intimate (usually household) exposure to a proven GAS case.
• Asymptomatic pharyngeal colonization documented after an intimate exposure.
• Asymptomatic pharyngeal colonization after a negative throat swab documented within the prior 3-4 months.
• Single ASO or ADB antibody level within 6 months after the initial onset of neuropsychiatric symptoms may be accepted as positive if it is more than 95th percentile, using the laboratory’s normal standard for children of comparable age, or provisionally ASO greater than or equal to 1:480 or ADB greater than or equal to 1:1280.
• Both ASO and ADB are elevated at more than 80% percentile for age in the same serum sample within 6 months after the initial onset of neuropsychiatric symptoms.
• Culture-documented streptococcal dermatitis.

Source: J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0151.

Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. Dr. Pelton said he had no relevant financial disclosures. Email him at pdnews@frontlinemedcom.com.

 

In the Journal of Child and Adolescent Psychopharmacology’s July 2017 issue, a group of respected individuals representing diverse expertise published “guidelines” to support clinical management of pediatric acute-onset neuropsychiatric syndrome (PANS) and its subclass PANDAS (those associated with streptococcal infection). PANS represents an enigmatic clinical syndrome that includes abrupt onset of obsessive-compulsive disorder (OCD) or eating restriction in combination with anxiety, attention deficit, hyperkinesia, emotional lability, irritability, aggressive or oppositional behavior, or academic decline. Neurologic findings also may be present; these are most often motor or vocal tics, but choreiform movements of the finger (repetitive motions that are rapid, jerky, and involuntary), deteriorating penmanship, sleep disruptions, or urinary frequency also may be present. The clinical course most often is relapsing and remitting with overall improvement over months or years.

CDC/ Melissa Brower

These events are often, but not universally, associated with infections, both for the initial clinical presentation as well as the subsequent exacerbations. A spectrum of inciting infections, most often upper respiratory tract disease including rhinitis, sinusitis, and pharyngitis, are reported as precipitating events. Group A streptococcal (GAS) infection has been most commonly identified. The evidence for GAS includes retrospective studies of increases in antistreptolysin O (ASO), anti-DNAse B (ADB), or anticarbohydrate-specific antibody titers associated with OCD or tic exacerbations; epidemiologic studies linking GAS infections in the prior 3 months with OCD and tic disorders; and animal studies demonstrating neuropsychiatric changes after GAS immunizations. Other infectious agents, specifically Mycoplasma pneumoniae, influenza viruses, Lyme borreliosis, and sinus infections, also are suspected triggers for PANS. Definitive proof, however, of a causal relationship between infection and PANS or PANDAS remains lacking.

The PANS/PANDAS consortium made specific recommendations for the management of patients with this clinically diagnosed syndrome (J Child Adolesc Psychopharmacol. 2017 Apr 7. doi: 10.1089/cap.2016.0151).

Specific recommendations include:

1. Searching for a coexisting infectious etiology with history, exam, and appropriate laboratory testing (including ASO and ADB antibodies), and, when present, treating accordingly. Even in the absence of definitive evidence of GAS infection, they recommend an initial course of antimicrobial therapy such as that given to patients with rheumatic fever.

2. For children with PANDAS (PANS with either culture or serologic evidence of GAS), consider instituting long-term streptococcal prophylaxis. The data on its value is mixed; however, most studies find more than 40% (and as many as 75%) of exacerbations are associated with GAS, and at least one study reports a reduction in neuropsychiatric exacerbations in children on penicillin or azithromycin prophylaxis for a 1-year period. Such decisions should be individualized: In children with strong evidence of exacerbations linked to GAS, there was thought to be greater likelihood of benefit, while, in those with no evidence for prior GAS infection, the potential for benefit was thought to be insufficient to justify prophylaxis. Furthermore, the optimal duration of prophylaxis is unknown. The guidelines recommend up to 2 years, but individualization is appropriate since severe cases may warrant prolonged prophylaxis.

3. In children who present with PANDAS and a positive throat culture for GAS, follow-up should be the same as that given for rheumatic fever, with reculture at 2-7 days and retreatment if there is persistence of GAS.

4. Vigilance for GAS infection in family members is appropriate, including obtaining throat cultures from persons with pharyngitis and treating them promptly when results are positive.

5. When GAS infection is not identified, the clinician should search for alternative infectious agents, such as Mycoplasma pneumoniae (using polymerase chain reaction on throat or nasopharyngeal swab), influenza virus, or alternative infections such as sinusitis, and treat accordingly.

6. Children with PANS and PANDAS should be immunized according to Advisory Committee of Immunization Practices recommendations, which includes annual influenza immunization. The committee reported that symptom flares after immunization were uncommon, brief, and manageable with NSAIDs.

7. The committee suggested that optimization of serum vitamin D levels among children with PANS and PANDAS could be of benefit, despite limited evidence. The committee members recommended treating children with PANS/PANDAS with vitamin D₃ as needed to maintain serum 25-hydroxy vitamin D levels above 30 ng/mL. No benefit for adenotonsillectomy was identified. The committee recommended that tonsillectomy and/or adenoidectomy should limited to those with traditional indications (sleep apnea, failure to thrive, and abnormally large tonsils, etc.). The committee also found no evidence to suggest that probiotics modulate this condition.

These guidelines come with an important caveat. They represent a practical clinical approach for the management of infection in the context of PANS or PANDAS and rely heavily on the clinical experience of the members of the PANS/PANDAS Consortium. They provide criteria for the retrospective diagnosis of GAS infection and recommend treatment of GAS in all patients with newly diagnosed PANS. The suggested guidelines are supported by limited data and recognize that further prospective study of the mechanistic link between infection and PANS, clarification of the risk factors for development of PANS, and definitive study of the risks and benefits of antimicrobial prophylaxis are needed.

The consortium also has published two accompanying guidelines that address psychiatric (J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0145) and immunomodulatory management (J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0148) in the same issue of the Journal of Child and Adolescent Psychopharmacology.

 

Proposed criteria for documenting GAS infection in PANS pediatric patients

These are the criteria proposed by the consortium for documentation of active or prior GAS infection in children with PANS:

• A rise in serial antibody level, regardless of rapid test or culture result. This definition does not require clinical pharyngitis.
• Acute pharyngitis with a positive GAS throat culture, with or without a rising antibody level.
• Pharyngitis with characteristic palatal petechiae.
• Pharyngitis with a characteristic scarlatiniform rash.
• Pharyngitis without a throat swab or serology, but intimate (usually household) exposure to a proven GAS case.
• Asymptomatic pharyngeal colonization documented after an intimate exposure.
• Asymptomatic pharyngeal colonization after a negative throat swab documented within the prior 3-4 months.
• Single ASO or ADB antibody level within 6 months after the initial onset of neuropsychiatric symptoms may be accepted as positive if it is more than 95th percentile, using the laboratory’s normal standard for children of comparable age, or provisionally ASO greater than or equal to 1:480 or ADB greater than or equal to 1:1280.
• Both ASO and ADB are elevated at more than 80% percentile for age in the same serum sample within 6 months after the initial onset of neuropsychiatric symptoms.
• Culture-documented streptococcal dermatitis.

Source: J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0151.

Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. Dr. Pelton said he had no relevant financial disclosures. Email him at pdnews@frontlinemedcom.com.

 

In the Journal of Child and Adolescent Psychopharmacology’s July 2017 issue, a group of respected individuals representing diverse expertise published “guidelines” to support clinical management of pediatric acute-onset neuropsychiatric syndrome (PANS) and its subclass PANDAS (those associated with streptococcal infection). PANS represents an enigmatic clinical syndrome that includes abrupt onset of obsessive-compulsive disorder (OCD) or eating restriction in combination with anxiety, attention deficit, hyperkinesia, emotional lability, irritability, aggressive or oppositional behavior, or academic decline. Neurologic findings also may be present; these are most often motor or vocal tics, but choreiform movements of the finger (repetitive motions that are rapid, jerky, and involuntary), deteriorating penmanship, sleep disruptions, or urinary frequency also may be present. The clinical course most often is relapsing and remitting with overall improvement over months or years.

CDC/ Melissa Brower

These events are often, but not universally, associated with infections, both for the initial clinical presentation as well as the subsequent exacerbations. A spectrum of inciting infections, most often upper respiratory tract disease including rhinitis, sinusitis, and pharyngitis, are reported as precipitating events. Group A streptococcal (GAS) infection has been most commonly identified. The evidence for GAS includes retrospective studies of increases in antistreptolysin O (ASO), anti-DNAse B (ADB), or anticarbohydrate-specific antibody titers associated with OCD or tic exacerbations; epidemiologic studies linking GAS infections in the prior 3 months with OCD and tic disorders; and animal studies demonstrating neuropsychiatric changes after GAS immunizations. Other infectious agents, specifically Mycoplasma pneumoniae, influenza viruses, Lyme borreliosis, and sinus infections, also are suspected triggers for PANS. Definitive proof, however, of a causal relationship between infection and PANS or PANDAS remains lacking.

The PANS/PANDAS consortium made specific recommendations for the management of patients with this clinically diagnosed syndrome (J Child Adolesc Psychopharmacol. 2017 Apr 7. doi: 10.1089/cap.2016.0151).

Specific recommendations include:

1. Searching for a coexisting infectious etiology with history, exam, and appropriate laboratory testing (including ASO and ADB antibodies), and, when present, treating accordingly. Even in the absence of definitive evidence of GAS infection, they recommend an initial course of antimicrobial therapy such as that given to patients with rheumatic fever.

2. For children with PANDAS (PANS with either culture or serologic evidence of GAS), consider instituting long-term streptococcal prophylaxis. The data on its value is mixed; however, most studies find more than 40% (and as many as 75%) of exacerbations are associated with GAS, and at least one study reports a reduction in neuropsychiatric exacerbations in children on penicillin or azithromycin prophylaxis for a 1-year period. Such decisions should be individualized: In children with strong evidence of exacerbations linked to GAS, there was thought to be greater likelihood of benefit, while, in those with no evidence for prior GAS infection, the potential for benefit was thought to be insufficient to justify prophylaxis. Furthermore, the optimal duration of prophylaxis is unknown. The guidelines recommend up to 2 years, but individualization is appropriate since severe cases may warrant prolonged prophylaxis.

3. In children who present with PANDAS and a positive throat culture for GAS, follow-up should be the same as that given for rheumatic fever, with reculture at 2-7 days and retreatment if there is persistence of GAS.

4. Vigilance for GAS infection in family members is appropriate, including obtaining throat cultures from persons with pharyngitis and treating them promptly when results are positive.

5. When GAS infection is not identified, the clinician should search for alternative infectious agents, such as Mycoplasma pneumoniae (using polymerase chain reaction on throat or nasopharyngeal swab), influenza virus, or alternative infections such as sinusitis, and treat accordingly.

6. Children with PANS and PANDAS should be immunized according to Advisory Committee of Immunization Practices recommendations, which includes annual influenza immunization. The committee reported that symptom flares after immunization were uncommon, brief, and manageable with NSAIDs.

7. The committee suggested that optimization of serum vitamin D levels among children with PANS and PANDAS could be of benefit, despite limited evidence. The committee members recommended treating children with PANS/PANDAS with vitamin D₃ as needed to maintain serum 25-hydroxy vitamin D levels above 30 ng/mL. No benefit for adenotonsillectomy was identified. The committee recommended that tonsillectomy and/or adenoidectomy should limited to those with traditional indications (sleep apnea, failure to thrive, and abnormally large tonsils, etc.). The committee also found no evidence to suggest that probiotics modulate this condition.

These guidelines come with an important caveat. They represent a practical clinical approach for the management of infection in the context of PANS or PANDAS and rely heavily on the clinical experience of the members of the PANS/PANDAS Consortium. They provide criteria for the retrospective diagnosis of GAS infection and recommend treatment of GAS in all patients with newly diagnosed PANS. The suggested guidelines are supported by limited data and recognize that further prospective study of the mechanistic link between infection and PANS, clarification of the risk factors for development of PANS, and definitive study of the risks and benefits of antimicrobial prophylaxis are needed.

The consortium also has published two accompanying guidelines that address psychiatric (J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0145) and immunomodulatory management (J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0148) in the same issue of the Journal of Child and Adolescent Psychopharmacology.

 

Proposed criteria for documenting GAS infection in PANS pediatric patients

These are the criteria proposed by the consortium for documentation of active or prior GAS infection in children with PANS:

• A rise in serial antibody level, regardless of rapid test or culture result. This definition does not require clinical pharyngitis.
• Acute pharyngitis with a positive GAS throat culture, with or without a rising antibody level.
• Pharyngitis with characteristic palatal petechiae.
• Pharyngitis with a characteristic scarlatiniform rash.
• Pharyngitis without a throat swab or serology, but intimate (usually household) exposure to a proven GAS case.
• Asymptomatic pharyngeal colonization documented after an intimate exposure.
• Asymptomatic pharyngeal colonization after a negative throat swab documented within the prior 3-4 months.
• Single ASO or ADB antibody level within 6 months after the initial onset of neuropsychiatric symptoms may be accepted as positive if it is more than 95th percentile, using the laboratory’s normal standard for children of comparable age, or provisionally ASO greater than or equal to 1:480 or ADB greater than or equal to 1:1280.
• Both ASO and ADB are elevated at more than 80% percentile for age in the same serum sample within 6 months after the initial onset of neuropsychiatric symptoms.
• Culture-documented streptococcal dermatitis.

Source: J Child Adolesc Psychopharmacol. 2017. doi: 10.1089/cap.2016.0151.

Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. Dr. Pelton said he had no relevant financial disclosures. Email him at pdnews@frontlinemedcom.com.

 

JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.

Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.¹ For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.

Design Pics/Thinkstock

As a provider, I recognize that spirituality and faith are important pieces of many people’s identities, yet I often feel ill equipped to discuss these issues openly with patients. For many of my sexual and gender minority patients and families, I find myself searching for tools to help navigate the relationship between spirituality/faith and identity. Thankfully, there are an increasing number of resources to help gender minority youth and family members handle some of these complex topics of spirituality/faith. Below are some suggestions for key messages to communicate to patients and families when these questions arise, as well as resources for patients and families.^2-5

• Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
• LGBT people exist in almost every faith group across the country.
• Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
• Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
• While every religion has different teachings, almost all religions advocate love and compassion.
• Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
• Remember this is your journey. You get to decide the path and the pace.
• Recognize that this may involve working for change within your community or it may mean leaving it.
• Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.

An increasing number of states and cities are outlawing conversion therapy. Most major professional medical organizations including the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry oppose conversion therapy.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Spirituality resources

• LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
• Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
• LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
• HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith

 

References

1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).

2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)

3. Pediatrics. 2013 Jul;132(1):198-203.

4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)

5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.

 

JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.

Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.¹ For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.

Design Pics/Thinkstock

As a provider, I recognize that spirituality and faith are important pieces of many people’s identities, yet I often feel ill equipped to discuss these issues openly with patients. For many of my sexual and gender minority patients and families, I find myself searching for tools to help navigate the relationship between spirituality/faith and identity. Thankfully, there are an increasing number of resources to help gender minority youth and family members handle some of these complex topics of spirituality/faith. Below are some suggestions for key messages to communicate to patients and families when these questions arise, as well as resources for patients and families.^2-5

• Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
• LGBT people exist in almost every faith group across the country.
• Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
• Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
• While every religion has different teachings, almost all religions advocate love and compassion.
• Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
• Remember this is your journey. You get to decide the path and the pace.
• Recognize that this may involve working for change within your community or it may mean leaving it.
• Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.

An increasing number of states and cities are outlawing conversion therapy. Most major professional medical organizations including the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry oppose conversion therapy.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Spirituality resources

• LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
• Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
• LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
• HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith

 

References

1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).

2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)

3. Pediatrics. 2013 Jul;132(1):198-203.

4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)

5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.

 

JB is a 15-year-old female who presents to your office for a wellness check. Mom is concerned because she has seemed more depressed and withdrawn over the past few months. During the confidential portion of your visit, JB discloses that, while she has had boyfriends in the past, she is realizing that she is romantically and sexually attracted to females. Many members of her religious faith, which she is strongly connected to, believe that homosexuality is a sin. She has been secretly researching therapies to help her “not be gay” and asks you for advice.

Adolescence is a time of rapid growth and development. Two important developmental tasks of adolescence are to establish key aspects of identity and identify meaningful moral standards, values, and belief systems.¹ For some LGBTQ adolescents, these tasks can become more complicated when the value system or religious faith in which they were raised views homosexuality or gender nonconformity as a sin.

Design Pics/Thinkstock

As a provider, I recognize that spirituality and faith are important pieces of many people’s identities, yet I often feel ill equipped to discuss these issues openly with patients. For many of my sexual and gender minority patients and families, I find myself searching for tools to help navigate the relationship between spirituality/faith and identity. Thankfully, there are an increasing number of resources to help gender minority youth and family members handle some of these complex topics of spirituality/faith. Below are some suggestions for key messages to communicate to patients and families when these questions arise, as well as resources for patients and families.^2-5

• Identifying as lesbian, gay, bisexual, or transgender is normal, just different.
• LGBT people exist in almost every faith group across the country.
• Many religious groups have wrestled with homosexuality, gender identity, and religion and decided to be more welcoming to LGBT communities.
• Within most faiths, there are many interpretations of religious texts, such as the Bible and the Koran, on all issues, including homosexuality.
• While every religion has different teachings, almost all religions advocate love and compassion.
• Clergy and other faith leaders can be a source of support. However, every faith community is different and may not always be supportive. Safely investigate your individual community’s approach. You have the right to question and explore your faith, sexuality, and/or gender identity and reconcile these in a way that is true to you.
• Remember this is your journey. You get to decide the path and the pace.
• Recognize that this may involve working for change within your community or it may mean leaving it.
• Referral for “conversion” or “reparative therapy” is never indicated. Such therapy is not effective and may be harmful to LGBTQ individuals by increasing internalized stigma, distress, and depression.

An increasing number of states and cities are outlawing conversion therapy. Most major professional medical organizations including the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry oppose conversion therapy.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus. She has no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

Spirituality resources

• LGBTQ and Religion: Your Relationship with Religion is Completely Up to You, the FAQ Page by the Trevor Project, a national organization that provides crisis intervention and suicide prevention resources to LGBTQ young people ages 13-24 years. www.thetrevorproject.org/pages/lgbtq-and-religion
• Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality, a resource from PFLAG (Parents, Families, and Friends of Lesbians and Gays). www.pflag.org/sites/default/files/Faith%20In%20Our%20Families.pdf
• LGBT Center UNC Chapel Hill: Religion and Spirituality, a page with a link to nondenominational and denomination-specific resources with various religious and spiritual communities’ beliefs regarding faith and LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual). lgbtq.unc.edu/resources/exploring-identities/religion-and-spirituality
• HRC: Explore Religion and Faith, a Human Rights Campaign page containing links to resources on religion and faith. It also has links to the Coming Home Series, guides aimed at those who hope to lead their faith communities toward a more welcoming stance and those seeking a path back to beloved traditions. www.hrc.org/explore/topic/religion-faith

 

References

1. Raising teens: A synthesis or research and a foundation for action. (Boston: Center for Health Communication, Harvard School of Public Health, 2001).

2. Faith in Our Families: Parents, Families and Friends Talk About Religion and Homosexuality (Washington, D.C.: Parents, Families and Friends of Lesbians and Gays, 1997)

3. Pediatrics. 2013 Jul;132(1):198-203.

4. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. (Washington, D.C.: National Academies Press, 2011)

5. Coming Home: To Faith, to Spirit, to Self. Pamphlet by the Human Rights Campaign.

 

CHICAGO – Multiple laser and light options are available to treat children with infantile hemangiomas, port wine birthmarks, and angiofibromas, according to Kristen M. Kelly, MD.

“Combination treatments with procedures and medications can improve treatment in many cases,” Dr. Kelly said at the World Congress of Pediatric Dermatology.

Dr. Kelly, professor of dermatology and surgery at the University of California, Irvine, said that the use of lasers and other light sources for infantile hemangiomas has dramatically decreased since propranolol, timolol, and other beta-blockers have become available. Most children are candidates for beta-blocker therapy, she said, but for those who are not, the pulsed dye laser (PDL) may be a good option. She also considers using the PDL for ulcerated lesions. “Of course concern comes up, because lasers can sometimes cause ulcerations, so you have to be aware of that,” she said.

In her clinical opinion, the PDL is a good adjunct to beta-blocker treatment when a superficial component to infantile hemangioma exists. It allows you to achieve more complete removal, she noted, and can decrease the time required for beta-blocker therapy. PDLs also are good for when there is recurrence as a beta-blocker is tapered or stopped, and for treating residua such as redness or textural changes that may be left after beta-blocker therapy.

“For the more proliferative phase of infantile hemangiomas, I’ll use a larger spot size: 10-12 mm, and short pulse durations: 0.45 to 1.5 milliseconds, and low energies,” Dr. Kelly said. “I would start with an energy of 5 or 5.5 J/cm². I may creep that up a little with time, but I don’t feel that you need to use very high energies. For lesions that are starting to involute, you could consider higher energies.”

Consider the combination of PDL and propranolol for patients who have a superficial component, for ulcerated lesions, or for rapidly progressing lesions that are not responding to your treatment. “You can also use the combination of PDL and timolol,” she said. “Starting treatment can avoid the need for reconstruction later.”

Dr. Kelly then discussed her approach to treating port wine birthmarks. She almost exclusively uses the PDL and the 755-nm Alexandrite lasers for these lesions. “For some of the resistant lesions, I’ll consider some of the combined treatments, like the combined 1064/532 nm system,” she said. “If I have really young patients, I use the PDL almost exclusively. I find the Alexandrite laser useful when I have thicker lesions that have hypertrophied.”

For optimal effect, she recommends treating lesions as early as possible and increasing chromophore target by placing patients with facial lesions in the Trendelenburg position during treatment sessions. Her preferred PDL parameters are a wavelength of 585 nm or 595 nm with a pulse duration of 0.45 to 1.5 milliseconds for the vast majority of lesions. “I try to vary the pulse duration over time, so if I’m getting a great result with 0.45 milliseconds, I’ll do that a couple of times,” Dr. Kelly said. “Once I feel I’ve reached a plateau, I might change to 1.5 milliseconds, or consider doing a second pass.”

Whenever possible she uses larger spot sizes and chooses the level of energy based on the type of lesion she’s treating. “I think it’s important to look for an endpoint,” she said. “I like to see deep purpura but I don’t like to see gray, because I feel that’s where you’re going to get epidermal injury or [there is] the chance for scarring and dyspigmentation, which can be permanent in some patients.”

Patients with port wine birthmarks require 3-15 treatments or more, typically 4 weeks apart. “Some people do 2- or 3-week intervals; that’s something to consider,” Dr. Kelly said. “In a darker-skinned patient with hyperpigmentation, I will use longer intervals, especially on an extremity that may take a little longer to heal.”

Alternative treatments are being studied, including the use of lasers in combination with antiangiogenic agents. “Rapamycin has been looked at most extensively, and it’s been shown to have a significant benefit,” she said.

According to Dr. Kelly, a new device for treating port wine birthmarks is being developed that combines pulse dye laser, Nd:YAG, and radiofrequency. “The potential advantage of this is that when we use the PDL alone, we probably cannot get very deep into those vessels,” she said. “The combination of the PDL and radiofrequency may allow us to more completely coagulate these vessels and get better response.”

Dr. Kelly closed her presentation by discussing angiofibromas, disfiguring skin lesions that are associated with tuberous sclerosis and have a fairly rapid recurrence. Topical and/or oral rapamycin are treatment options, but so are laser and light sources. She cited approaches published by Roy Geronemus MD, of the Laser and Skin Surgery Center of New York, and his associates, which included PDL treatment with a 10-mm spot size delivered at 7.5 J/cm² with a pulse duration of 1.5 ms, and dynamic cooling spray duration of 30 ms (Lasers Surg Med 2013;45:555-7). This was followed by ablative fractional resurfacing with a 15-mm spot size at 70 mJ per pulse and 40% coverage. Other treatment options for angiofibromas include pinpoint electrosurgery to papular, fibrotic lesions and topical rapamycin ointment twice a day.

Dr. Kelly disclosed having drugs or devices donated by Light Sciences Oncology, Solta Medical, Cynosure, Syneron Candela, and Novartis. She is a consultant for MundiPharma, Allergan, and Syneron Candela, and has received research funding from the American Society of Laser Medicine and Surgery, the National Institutes of Health, the Sturge-Weber Foundation, and the UC Irvine Institute of Clinical and Translational Science.
 

 

dbrunk@frontlinemedcom.com

 

CHICAGO – Multiple laser and light options are available to treat children with infantile hemangiomas, port wine birthmarks, and angiofibromas, according to Kristen M. Kelly, MD.

“Combination treatments with procedures and medications can improve treatment in many cases,” Dr. Kelly said at the World Congress of Pediatric Dermatology.

Dr. Kelly, professor of dermatology and surgery at the University of California, Irvine, said that the use of lasers and other light sources for infantile hemangiomas has dramatically decreased since propranolol, timolol, and other beta-blockers have become available. Most children are candidates for beta-blocker therapy, she said, but for those who are not, the pulsed dye laser (PDL) may be a good option. She also considers using the PDL for ulcerated lesions. “Of course concern comes up, because lasers can sometimes cause ulcerations, so you have to be aware of that,” she said.

In her clinical opinion, the PDL is a good adjunct to beta-blocker treatment when a superficial component to infantile hemangioma exists. It allows you to achieve more complete removal, she noted, and can decrease the time required for beta-blocker therapy. PDLs also are good for when there is recurrence as a beta-blocker is tapered or stopped, and for treating residua such as redness or textural changes that may be left after beta-blocker therapy.

“For the more proliferative phase of infantile hemangiomas, I’ll use a larger spot size: 10-12 mm, and short pulse durations: 0.45 to 1.5 milliseconds, and low energies,” Dr. Kelly said. “I would start with an energy of 5 or 5.5 J/cm². I may creep that up a little with time, but I don’t feel that you need to use very high energies. For lesions that are starting to involute, you could consider higher energies.”

Consider the combination of PDL and propranolol for patients who have a superficial component, for ulcerated lesions, or for rapidly progressing lesions that are not responding to your treatment. “You can also use the combination of PDL and timolol,” she said. “Starting treatment can avoid the need for reconstruction later.”

Dr. Kelly then discussed her approach to treating port wine birthmarks. She almost exclusively uses the PDL and the 755-nm Alexandrite lasers for these lesions. “For some of the resistant lesions, I’ll consider some of the combined treatments, like the combined 1064/532 nm system,” she said. “If I have really young patients, I use the PDL almost exclusively. I find the Alexandrite laser useful when I have thicker lesions that have hypertrophied.”

For optimal effect, she recommends treating lesions as early as possible and increasing chromophore target by placing patients with facial lesions in the Trendelenburg position during treatment sessions. Her preferred PDL parameters are a wavelength of 585 nm or 595 nm with a pulse duration of 0.45 to 1.5 milliseconds for the vast majority of lesions. “I try to vary the pulse duration over time, so if I’m getting a great result with 0.45 milliseconds, I’ll do that a couple of times,” Dr. Kelly said. “Once I feel I’ve reached a plateau, I might change to 1.5 milliseconds, or consider doing a second pass.”

Whenever possible she uses larger spot sizes and chooses the level of energy based on the type of lesion she’s treating. “I think it’s important to look for an endpoint,” she said. “I like to see deep purpura but I don’t like to see gray, because I feel that’s where you’re going to get epidermal injury or [there is] the chance for scarring and dyspigmentation, which can be permanent in some patients.”

Patients with port wine birthmarks require 3-15 treatments or more, typically 4 weeks apart. “Some people do 2- or 3-week intervals; that’s something to consider,” Dr. Kelly said. “In a darker-skinned patient with hyperpigmentation, I will use longer intervals, especially on an extremity that may take a little longer to heal.”

Alternative treatments are being studied, including the use of lasers in combination with antiangiogenic agents. “Rapamycin has been looked at most extensively, and it’s been shown to have a significant benefit,” she said.

According to Dr. Kelly, a new device for treating port wine birthmarks is being developed that combines pulse dye laser, Nd:YAG, and radiofrequency. “The potential advantage of this is that when we use the PDL alone, we probably cannot get very deep into those vessels,” she said. “The combination of the PDL and radiofrequency may allow us to more completely coagulate these vessels and get better response.”

Dr. Kelly closed her presentation by discussing angiofibromas, disfiguring skin lesions that are associated with tuberous sclerosis and have a fairly rapid recurrence. Topical and/or oral rapamycin are treatment options, but so are laser and light sources. She cited approaches published by Roy Geronemus MD, of the Laser and Skin Surgery Center of New York, and his associates, which included PDL treatment with a 10-mm spot size delivered at 7.5 J/cm² with a pulse duration of 1.5 ms, and dynamic cooling spray duration of 30 ms (Lasers Surg Med 2013;45:555-7). This was followed by ablative fractional resurfacing with a 15-mm spot size at 70 mJ per pulse and 40% coverage. Other treatment options for angiofibromas include pinpoint electrosurgery to papular, fibrotic lesions and topical rapamycin ointment twice a day.

Dr. Kelly disclosed having drugs or devices donated by Light Sciences Oncology, Solta Medical, Cynosure, Syneron Candela, and Novartis. She is a consultant for MundiPharma, Allergan, and Syneron Candela, and has received research funding from the American Society of Laser Medicine and Surgery, the National Institutes of Health, the Sturge-Weber Foundation, and the UC Irvine Institute of Clinical and Translational Science.
 

 

dbrunk@frontlinemedcom.com

 

CHICAGO – Multiple laser and light options are available to treat children with infantile hemangiomas, port wine birthmarks, and angiofibromas, according to Kristen M. Kelly, MD.

“Combination treatments with procedures and medications can improve treatment in many cases,” Dr. Kelly said at the World Congress of Pediatric Dermatology.

Dr. Kelly, professor of dermatology and surgery at the University of California, Irvine, said that the use of lasers and other light sources for infantile hemangiomas has dramatically decreased since propranolol, timolol, and other beta-blockers have become available. Most children are candidates for beta-blocker therapy, she said, but for those who are not, the pulsed dye laser (PDL) may be a good option. She also considers using the PDL for ulcerated lesions. “Of course concern comes up, because lasers can sometimes cause ulcerations, so you have to be aware of that,” she said.

In her clinical opinion, the PDL is a good adjunct to beta-blocker treatment when a superficial component to infantile hemangioma exists. It allows you to achieve more complete removal, she noted, and can decrease the time required for beta-blocker therapy. PDLs also are good for when there is recurrence as a beta-blocker is tapered or stopped, and for treating residua such as redness or textural changes that may be left after beta-blocker therapy.

“For the more proliferative phase of infantile hemangiomas, I’ll use a larger spot size: 10-12 mm, and short pulse durations: 0.45 to 1.5 milliseconds, and low energies,” Dr. Kelly said. “I would start with an energy of 5 or 5.5 J/cm². I may creep that up a little with time, but I don’t feel that you need to use very high energies. For lesions that are starting to involute, you could consider higher energies.”

Consider the combination of PDL and propranolol for patients who have a superficial component, for ulcerated lesions, or for rapidly progressing lesions that are not responding to your treatment. “You can also use the combination of PDL and timolol,” she said. “Starting treatment can avoid the need for reconstruction later.”

Dr. Kelly then discussed her approach to treating port wine birthmarks. She almost exclusively uses the PDL and the 755-nm Alexandrite lasers for these lesions. “For some of the resistant lesions, I’ll consider some of the combined treatments, like the combined 1064/532 nm system,” she said. “If I have really young patients, I use the PDL almost exclusively. I find the Alexandrite laser useful when I have thicker lesions that have hypertrophied.”

For optimal effect, she recommends treating lesions as early as possible and increasing chromophore target by placing patients with facial lesions in the Trendelenburg position during treatment sessions. Her preferred PDL parameters are a wavelength of 585 nm or 595 nm with a pulse duration of 0.45 to 1.5 milliseconds for the vast majority of lesions. “I try to vary the pulse duration over time, so if I’m getting a great result with 0.45 milliseconds, I’ll do that a couple of times,” Dr. Kelly said. “Once I feel I’ve reached a plateau, I might change to 1.5 milliseconds, or consider doing a second pass.”

Whenever possible she uses larger spot sizes and chooses the level of energy based on the type of lesion she’s treating. “I think it’s important to look for an endpoint,” she said. “I like to see deep purpura but I don’t like to see gray, because I feel that’s where you’re going to get epidermal injury or [there is] the chance for scarring and dyspigmentation, which can be permanent in some patients.”

Patients with port wine birthmarks require 3-15 treatments or more, typically 4 weeks apart. “Some people do 2- or 3-week intervals; that’s something to consider,” Dr. Kelly said. “In a darker-skinned patient with hyperpigmentation, I will use longer intervals, especially on an extremity that may take a little longer to heal.”

Alternative treatments are being studied, including the use of lasers in combination with antiangiogenic agents. “Rapamycin has been looked at most extensively, and it’s been shown to have a significant benefit,” she said.

According to Dr. Kelly, a new device for treating port wine birthmarks is being developed that combines pulse dye laser, Nd:YAG, and radiofrequency. “The potential advantage of this is that when we use the PDL alone, we probably cannot get very deep into those vessels,” she said. “The combination of the PDL and radiofrequency may allow us to more completely coagulate these vessels and get better response.”

Dr. Kelly closed her presentation by discussing angiofibromas, disfiguring skin lesions that are associated with tuberous sclerosis and have a fairly rapid recurrence. Topical and/or oral rapamycin are treatment options, but so are laser and light sources. She cited approaches published by Roy Geronemus MD, of the Laser and Skin Surgery Center of New York, and his associates, which included PDL treatment with a 10-mm spot size delivered at 7.5 J/cm² with a pulse duration of 1.5 ms, and dynamic cooling spray duration of 30 ms (Lasers Surg Med 2013;45:555-7). This was followed by ablative fractional resurfacing with a 15-mm spot size at 70 mJ per pulse and 40% coverage. Other treatment options for angiofibromas include pinpoint electrosurgery to papular, fibrotic lesions and topical rapamycin ointment twice a day.

Dr. Kelly disclosed having drugs or devices donated by Light Sciences Oncology, Solta Medical, Cynosure, Syneron Candela, and Novartis. She is a consultant for MundiPharma, Allergan, and Syneron Candela, and has received research funding from the American Society of Laser Medicine and Surgery, the National Institutes of Health, the Sturge-Weber Foundation, and the UC Irvine Institute of Clinical and Translational Science.
 

 

dbrunk@frontlinemedcom.com

 

SAN FRANCISCO – Maladaptive perfectionism contributes to and is a risk factor for many common psychiatric disorders in children and adolescents, panelists said at the annual conference of the Anxiety and Depression Association of America.

“Perfectionism isn’t a disorder, it’s a personality style. Some of the kids who come in don’t meet criteria for any psychiatric disorder, they just have this personality style that really warrants treatment, because it is getting in the way of their living happy and productive lives. But I would say most of the time we see overlap with DSM Axis I disorders,” said Deborah Ledley, PhD, a clinical psychologist at the Children’s and Adult Center for OCD and Anxiety in Plymouth Meeting, Pa.

Bruce Jancin/Frontline Medical News

At this specialty clinic, most who are perfectionists also meet diagnostic criteria for generalized anxiety disorder. Perfectionism and obsessive-compulsive disorder (OCD) is another common combination.

“Basically, when people present with multiple disorders and underlying perfectionism, it might actually be more effective to target the perfectionism, rather than treating each disorder sequentially,” according to Dr. Ledley. “Do we really need to treat social anxiety and panic disorder, and a subclinical eating disorder, or can we say, ‘This person is a perfectionist – let us treat that and see if we can remit all those disorders.’”

That strategy often has proved successful for Dr. Ledley and her fellow panelist Lynne Siqueland, PhD, who also practices at the center. Both specialize in cognitive-behavioral therapy (CBT). They were quick to note that there are essentially no published studies on CBT for pediatric perfectionism. Nonetheless, they have found CBT to be quite effective in clinical practice, with the caveat that the standard, full-speed-ahead, 12-sessions-and-we’re done manualized approach to CBT as often applied to anxiety disorders, depression, and other CBT-amenable disorders will not work for perfectionistic youths.

“Perfectionists are often quite guarded and wary of treatment. We have found that jumping to therapy immediately can be a mistake,” Dr. Siqueland said. “We’ve learned the hard way that the most important part of treatment is you have to woo these people – carefully, slowly, addressing things that matter to them – because they don’t want to change, especially if perfectionism is working for them. The process of assessment must go beyond labeling or assigning a diagnosis. We need to get to know these kids and earn their trust. So we start with long conversations about life and values, and what’s working and not working for them.”

Dr. Ledley agreed. “We are not rushing with these patients,” she said. “This is so different from the way we are with an OCD patient, for example. When I have an OCD patient, I have the initial session with the parents, then an assessment session with the kid, then in the next session, I do some psychoeducation, and in the session after that, I’m doing exposures, because I work fast. Working with perfectionist kids is different: I have to earn their trust. I tell them a lot of stories about patients I’ve worked with who are just like them.”
 

How to spot maladaptive perfectionism

When the therapists meet with the parents for the first time – generally without the kids present – what they hear over and over again is, “My child is wound like a spring.” These are generally children who excel at everything: school, sports, music lessons, and other activities. And they are stressed out.

“These are the kids who are working on their Beethoven at age 8, trying to master the Moonlight Sonata. But the parents say the child is too hard on himself, freaking out over a grade less than 100% on a small quiz,” Dr. Ledley observed.

Sometimes, though, perfectionism backfires even in grade school, and the parents’ concern is not that their child is super accomplished yet not enjoying it, but rather that their kid has great potential and never gets anything done because of procrastination or an inability to hand in work that is less than perfect.

Dr. Ledley said when she first meets a perfectionist child, she typically sees a kid who looks perfect, has impeccable manners, and is mature beyond their years.

“They’re invested in coming across as successful in every way. They definitely do not let their guard down when you first meet them. But with these kids who look so perfect, we feel that there’s this fragility and fear, and delicacy lurking just below the surface. It’s almost like they’re afraid they’re going to break because they’re so held together,” according to the psychologist.

Once trust has been established and the youth has drawn up a requested list of the pros and cons of their perfectionism, Dr. Siqueland said, she hears a familiar refrain: “No freedom, no fun, no choice, no time for friends, tired all the time, and no sleep. That’s the usual list of the kids.”

The notion that hard-driving parents typically are at fault for pushing their child into perfectionism is a misconception.

“In our practice, I would say it’s self-induced perfectionism in 75% of cases,” according to Dr. Siqueland.
 

 

Treatment tips

After spending considerable time establishing rapport with a perfectionist youth, Dr. Ledley and Dr. Siqueland emphasize three key messages:

1. While on the surface your perfectionist strategy makes sense, enabling you to bask in positive feedback from teachers, coaches, friends, and in some cases your parents, it simply can’t be kept up long term.

“To the ones who really want to go to college and med school, I just say, ‘It’s not going to work there. You’ll not survive college. Or maybe college, but certainly not med school. So are you going to fix it now or fix it later? If you want med school as a goal, let’s help you get there,’ ” Dr. Siqueland said.

2. Therapy is not about changing your values.

“They fear that, if they don’t push and sacrifice, they’re going to be average, or even a slacker – and slacker might be worse than average,” Dr. Siqueland continued.

“We tell them it’s OK to have a drive for excellence, to go after your dream, and to take pride in good work well done. These are your values, and that’s great. We are not in the business of turning you into a slacker,” Dr. Ledley added.

3. Perfectionism takes away choices.

Therapy is all about helping you to live your life rather than having anxiety order you around. You can learn to have freedom, fun, choice, and sleep while in most cases doing as well as or better than before on your grades.

For clinicians who are inexperienced in addressing perfectionism in youth, Dr. Ledley and Dr. Siqueland recommended as a useful primer “The Perfectionism Workbook for Teens” (Oakland, Calif.: New Harbinger Publications, 2016).

They reported having no financial conflicts of interest.

bjancin@frontlinemedcom.com

 

SAN FRANCISCO – Maladaptive perfectionism contributes to and is a risk factor for many common psychiatric disorders in children and adolescents, panelists said at the annual conference of the Anxiety and Depression Association of America.

“Perfectionism isn’t a disorder, it’s a personality style. Some of the kids who come in don’t meet criteria for any psychiatric disorder, they just have this personality style that really warrants treatment, because it is getting in the way of their living happy and productive lives. But I would say most of the time we see overlap with DSM Axis I disorders,” said Deborah Ledley, PhD, a clinical psychologist at the Children’s and Adult Center for OCD and Anxiety in Plymouth Meeting, Pa.

Bruce Jancin/Frontline Medical News

At this specialty clinic, most who are perfectionists also meet diagnostic criteria for generalized anxiety disorder. Perfectionism and obsessive-compulsive disorder (OCD) is another common combination.

“Basically, when people present with multiple disorders and underlying perfectionism, it might actually be more effective to target the perfectionism, rather than treating each disorder sequentially,” according to Dr. Ledley. “Do we really need to treat social anxiety and panic disorder, and a subclinical eating disorder, or can we say, ‘This person is a perfectionist – let us treat that and see if we can remit all those disorders.’”

That strategy often has proved successful for Dr. Ledley and her fellow panelist Lynne Siqueland, PhD, who also practices at the center. Both specialize in cognitive-behavioral therapy (CBT). They were quick to note that there are essentially no published studies on CBT for pediatric perfectionism. Nonetheless, they have found CBT to be quite effective in clinical practice, with the caveat that the standard, full-speed-ahead, 12-sessions-and-we’re done manualized approach to CBT as often applied to anxiety disorders, depression, and other CBT-amenable disorders will not work for perfectionistic youths.

“Perfectionists are often quite guarded and wary of treatment. We have found that jumping to therapy immediately can be a mistake,” Dr. Siqueland said. “We’ve learned the hard way that the most important part of treatment is you have to woo these people – carefully, slowly, addressing things that matter to them – because they don’t want to change, especially if perfectionism is working for them. The process of assessment must go beyond labeling or assigning a diagnosis. We need to get to know these kids and earn their trust. So we start with long conversations about life and values, and what’s working and not working for them.”

Dr. Ledley agreed. “We are not rushing with these patients,” she said. “This is so different from the way we are with an OCD patient, for example. When I have an OCD patient, I have the initial session with the parents, then an assessment session with the kid, then in the next session, I do some psychoeducation, and in the session after that, I’m doing exposures, because I work fast. Working with perfectionist kids is different: I have to earn their trust. I tell them a lot of stories about patients I’ve worked with who are just like them.”
 

How to spot maladaptive perfectionism

When the therapists meet with the parents for the first time – generally without the kids present – what they hear over and over again is, “My child is wound like a spring.” These are generally children who excel at everything: school, sports, music lessons, and other activities. And they are stressed out.

“These are the kids who are working on their Beethoven at age 8, trying to master the Moonlight Sonata. But the parents say the child is too hard on himself, freaking out over a grade less than 100% on a small quiz,” Dr. Ledley observed.

Sometimes, though, perfectionism backfires even in grade school, and the parents’ concern is not that their child is super accomplished yet not enjoying it, but rather that their kid has great potential and never gets anything done because of procrastination or an inability to hand in work that is less than perfect.

Dr. Ledley said when she first meets a perfectionist child, she typically sees a kid who looks perfect, has impeccable manners, and is mature beyond their years.

“They’re invested in coming across as successful in every way. They definitely do not let their guard down when you first meet them. But with these kids who look so perfect, we feel that there’s this fragility and fear, and delicacy lurking just below the surface. It’s almost like they’re afraid they’re going to break because they’re so held together,” according to the psychologist.

Once trust has been established and the youth has drawn up a requested list of the pros and cons of their perfectionism, Dr. Siqueland said, she hears a familiar refrain: “No freedom, no fun, no choice, no time for friends, tired all the time, and no sleep. That’s the usual list of the kids.”

The notion that hard-driving parents typically are at fault for pushing their child into perfectionism is a misconception.

“In our practice, I would say it’s self-induced perfectionism in 75% of cases,” according to Dr. Siqueland.
 

 

Treatment tips

After spending considerable time establishing rapport with a perfectionist youth, Dr. Ledley and Dr. Siqueland emphasize three key messages:

1. While on the surface your perfectionist strategy makes sense, enabling you to bask in positive feedback from teachers, coaches, friends, and in some cases your parents, it simply can’t be kept up long term.

“To the ones who really want to go to college and med school, I just say, ‘It’s not going to work there. You’ll not survive college. Or maybe college, but certainly not med school. So are you going to fix it now or fix it later? If you want med school as a goal, let’s help you get there,’ ” Dr. Siqueland said.

2. Therapy is not about changing your values.

“They fear that, if they don’t push and sacrifice, they’re going to be average, or even a slacker – and slacker might be worse than average,” Dr. Siqueland continued.

“We tell them it’s OK to have a drive for excellence, to go after your dream, and to take pride in good work well done. These are your values, and that’s great. We are not in the business of turning you into a slacker,” Dr. Ledley added.

3. Perfectionism takes away choices.

Therapy is all about helping you to live your life rather than having anxiety order you around. You can learn to have freedom, fun, choice, and sleep while in most cases doing as well as or better than before on your grades.

For clinicians who are inexperienced in addressing perfectionism in youth, Dr. Ledley and Dr. Siqueland recommended as a useful primer “The Perfectionism Workbook for Teens” (Oakland, Calif.: New Harbinger Publications, 2016).

They reported having no financial conflicts of interest.

bjancin@frontlinemedcom.com

 

SAN FRANCISCO – Maladaptive perfectionism contributes to and is a risk factor for many common psychiatric disorders in children and adolescents, panelists said at the annual conference of the Anxiety and Depression Association of America.

“Perfectionism isn’t a disorder, it’s a personality style. Some of the kids who come in don’t meet criteria for any psychiatric disorder, they just have this personality style that really warrants treatment, because it is getting in the way of their living happy and productive lives. But I would say most of the time we see overlap with DSM Axis I disorders,” said Deborah Ledley, PhD, a clinical psychologist at the Children’s and Adult Center for OCD and Anxiety in Plymouth Meeting, Pa.

Bruce Jancin/Frontline Medical News

At this specialty clinic, most who are perfectionists also meet diagnostic criteria for generalized anxiety disorder. Perfectionism and obsessive-compulsive disorder (OCD) is another common combination.

“Basically, when people present with multiple disorders and underlying perfectionism, it might actually be more effective to target the perfectionism, rather than treating each disorder sequentially,” according to Dr. Ledley. “Do we really need to treat social anxiety and panic disorder, and a subclinical eating disorder, or can we say, ‘This person is a perfectionist – let us treat that and see if we can remit all those disorders.’”

That strategy often has proved successful for Dr. Ledley and her fellow panelist Lynne Siqueland, PhD, who also practices at the center. Both specialize in cognitive-behavioral therapy (CBT). They were quick to note that there are essentially no published studies on CBT for pediatric perfectionism. Nonetheless, they have found CBT to be quite effective in clinical practice, with the caveat that the standard, full-speed-ahead, 12-sessions-and-we’re done manualized approach to CBT as often applied to anxiety disorders, depression, and other CBT-amenable disorders will not work for perfectionistic youths.

“Perfectionists are often quite guarded and wary of treatment. We have found that jumping to therapy immediately can be a mistake,” Dr. Siqueland said. “We’ve learned the hard way that the most important part of treatment is you have to woo these people – carefully, slowly, addressing things that matter to them – because they don’t want to change, especially if perfectionism is working for them. The process of assessment must go beyond labeling or assigning a diagnosis. We need to get to know these kids and earn their trust. So we start with long conversations about life and values, and what’s working and not working for them.”

Dr. Ledley agreed. “We are not rushing with these patients,” she said. “This is so different from the way we are with an OCD patient, for example. When I have an OCD patient, I have the initial session with the parents, then an assessment session with the kid, then in the next session, I do some psychoeducation, and in the session after that, I’m doing exposures, because I work fast. Working with perfectionist kids is different: I have to earn their trust. I tell them a lot of stories about patients I’ve worked with who are just like them.”
 

How to spot maladaptive perfectionism

When the therapists meet with the parents for the first time – generally without the kids present – what they hear over and over again is, “My child is wound like a spring.” These are generally children who excel at everything: school, sports, music lessons, and other activities. And they are stressed out.

“These are the kids who are working on their Beethoven at age 8, trying to master the Moonlight Sonata. But the parents say the child is too hard on himself, freaking out over a grade less than 100% on a small quiz,” Dr. Ledley observed.

Sometimes, though, perfectionism backfires even in grade school, and the parents’ concern is not that their child is super accomplished yet not enjoying it, but rather that their kid has great potential and never gets anything done because of procrastination or an inability to hand in work that is less than perfect.

Dr. Ledley said when she first meets a perfectionist child, she typically sees a kid who looks perfect, has impeccable manners, and is mature beyond their years.

“They’re invested in coming across as successful in every way. They definitely do not let their guard down when you first meet them. But with these kids who look so perfect, we feel that there’s this fragility and fear, and delicacy lurking just below the surface. It’s almost like they’re afraid they’re going to break because they’re so held together,” according to the psychologist.

Once trust has been established and the youth has drawn up a requested list of the pros and cons of their perfectionism, Dr. Siqueland said, she hears a familiar refrain: “No freedom, no fun, no choice, no time for friends, tired all the time, and no sleep. That’s the usual list of the kids.”

The notion that hard-driving parents typically are at fault for pushing their child into perfectionism is a misconception.

“In our practice, I would say it’s self-induced perfectionism in 75% of cases,” according to Dr. Siqueland.
 

 

Treatment tips

After spending considerable time establishing rapport with a perfectionist youth, Dr. Ledley and Dr. Siqueland emphasize three key messages:

1. While on the surface your perfectionist strategy makes sense, enabling you to bask in positive feedback from teachers, coaches, friends, and in some cases your parents, it simply can’t be kept up long term.

“To the ones who really want to go to college and med school, I just say, ‘It’s not going to work there. You’ll not survive college. Or maybe college, but certainly not med school. So are you going to fix it now or fix it later? If you want med school as a goal, let’s help you get there,’ ” Dr. Siqueland said.

2. Therapy is not about changing your values.

“They fear that, if they don’t push and sacrifice, they’re going to be average, or even a slacker – and slacker might be worse than average,” Dr. Siqueland continued.

“We tell them it’s OK to have a drive for excellence, to go after your dream, and to take pride in good work well done. These are your values, and that’s great. We are not in the business of turning you into a slacker,” Dr. Ledley added.

3. Perfectionism takes away choices.

Therapy is all about helping you to live your life rather than having anxiety order you around. You can learn to have freedom, fun, choice, and sleep while in most cases doing as well as or better than before on your grades.

For clinicians who are inexperienced in addressing perfectionism in youth, Dr. Ledley and Dr. Siqueland recommended as a useful primer “The Perfectionism Workbook for Teens” (Oakland, Calif.: New Harbinger Publications, 2016).

They reported having no financial conflicts of interest.

bjancin@frontlinemedcom.com

 

CHICAGO – True complications in pediatric dermatologic surgery probably aren’t that frequent, but no solid data on the topic exist in the medical literature.

“An appropriate and thorough perioperative evaluation and planning may limit complications,” Harper N. Price, MD, said at the World Congress of Pediatric Dermatology.

Dr. Price, chief of the division of pediatric dermatology at Phoenix Children’s Hospital, shared general approaches to managing pain, infection, and suture reactions in children who are undergoing dermatologic procedures.

The first step is to make the child comfortable in the office or operating room (OR) setting; this can include approaching children slowly unless you know them well. “Sit at their level, because coming up very fast and being over ... them is intimidating,” she advised. “Make sure you include the child in the conversation you’re having; it elicits more trust and belief in what’s going to happen. You want to explain what’s going to happen in a friendly manner. I think sometimes we have residents who are new to pediatrics that come in and say, ‘We’re going to cut this out,’ and the next thing you know, the child’s in tears. Describe what the procedure is going to be like in words that they can understand, and whatever you do, do not lie about what’s going to happen.”

Dr. Price also makes it a point to cover surgical trays before they’re wheeled in. “They don’t need to see needles and sharp objects,” she said. “Even afterward, bloody gauze can be scary to kids.” Positioning the patient properly also is important. “We’ll wrap young children up in a swaddle,” she said. “In my opinion, you should not be forcefully restraining an older child. They need to cooperate and it needs to be a safe procedure, otherwise, you should consider doing it in the operating room. I never enlist a parent to hold or restrain a child.”

One key to managing pain during dermatologic procedures in children comes down to anticipation: What kinds of distractions might the child need? What preoperative analgesia will be required? What postoperative pain medications should be used? “We know that certain procedures in children might be more painful, such as nail procedures, ablative laser procedures, and large excisions with extensive undermining,” Dr. Price said. “Pain is subjective and differs from child to child in the way it’s experienced, so you need to consider the child’s age, coping style, and temperament, and what their history of pain is like. We know that inadequate pain control in children has a negative impact and a negative implication on their future health care interventions, as well as their reactions to further pain.”

Parental involvement can sometimes help. “I like a parent to stay in the room if I’m doing a procedure in the office, as long as they agree to stay seated,” she said. “It may make your office staff more anxious, and it may make parents more anxious, too, so it’s something to think about.” There is some evidence that having a parent present during an in-office procedure increases parental satisfaction as well.

In an effort to minimize pain and anxiety before in-office procedures, Dr. Price and her associates at Phoenix Children’s Hospital often use instant ice packs. “They get cold really fast, they’re cheap, and you don’t have to run to a refrigerator to get ice,” she said. Other beneficial measures include topical anesthetics and breathing techniques, such as having the child blow on a pinwheel, blow bubbles, or perform diaphragmatic breathing. Using distractions – stuffed animals, picture books, or video games on a tablet – can also help. “If the child is going to the OR, using preoperative midazolam can help relax the child, especially if they’re having repeated procedures,” Dr. Price said. Oral sucrose solution in infants, especially in young infants, provides about 5-8 minutes of temporary analgesia and can be placed on their pacifier or their tongue, she added, noting that ethyl chloride spray can also be helpful prior to injections.

During the procedure itself, counter-stimulatory methods can be helpful; this can include handheld devices that use a combination of vibration, ice, and distraction methods. “Buffer your lidocaine and don’t inject cold lidocaine; that hurts a lot more,” she recommended. “Inject slowly; inject deep. If you have a painful procedure and you’re in an OR setting where you give Marcaine [bupivacaine], put that in at the end of the procedure for short-term postoperative pain relief.” After the procedure, it’s better not to apologize for causing pain or if the procedure didn’t go well. “Give positive incentives like stickers and stuffed animals, and use a dressing wrap with bright colors,” she said. “We often doctor up stuffed animals in the OR so when [the children] wake up, they have something fun to look at.”

Postoperatively, the best way to prevent pain is to recommend limited physical activity. “Children become active quickly after a procedure, and then they hurt,” Dr. Price said. “For extremity wounds, consider ice and elevation. I like bulky dressings to prevent trauma, to remind the families that they’ve had a procedure done. They can usually keep them on for several days.”

Surgical site infections are uncommon, but if they do occur, it’s usually between postoperative days 4 and 10. “The biggest indicator of an infection in my opinion is pain,” she said. “If they’re having a lot of pain, I would be concerned. Causes may be the presence of bacteria on the skin or mucosa or improper wound care at home.”

The risk factors for surgical site infections in children are not well defined in dermatologic surgery, Dr. Price added, “but we know that if you’re going to be operating in the diaper area, that’s a place where you’re going to have a high risk of infection. Preoperative hair removal – if you shave the scalp before surgery creating small nicks – could [introduce] bacteria. And it’s likely that the overall health of the patient may impact their risk of infection. You want to know the difference between normal wound healing and an infection. Culture it. If you’re worried, you may want to start empiric antibiotics. If you have a severe infection, something with necrosis, fluctuance, or dehiscence, you might want to consider partially opening that wound and letting it drain and heal in by secondary intention.”

Measures to prevent postoperative infections include perioperative counseling to restrict excessive activity to prevent trauma, bleeding, and dehiscence; use of bulky dressings, and explicit wound care instructions. “My nurse calls [the patient’s family] the day after a procedure, and I usually have them come in for a wound check, even if there are no sutures to remove, just to make sure things look OK,” she said.

Suture reactions are another potential complication of dermatologic surgery in children. The incidence is unknown, but suture reactions usually occur around 6 weeks postoperatively and tend to happen more often in older children. “Excessive reactions, while uncommon, can lead to an increased risk of dehiscence, infection, and delayed healing,” Dr. Price said. Small caliber monofilament sutures are less reactive than large caliber, multifilament sutures, she added, while synthetic and nonabsorbable sutures are less reactive than natural materials such as silk and surgical gut. Dr. Price favors using poliglecaprone, polyglactin 910, and polypropylene.

Tips for minimizing suture reactions include the following: Use the smallest caliber suture appropriate for the wound; avoid buried sutures too close to the surface of the skin; use a smaller caliber suture at the end of excisions, where there tends to be less tension; and keep knots small and flat at the apexes of excision. “Manage suture reactions with reassurance,” she said. “The nice thing is that these often heal fine without any delay. When possible, remove the offending suture material. A lot of times, I’ll use sterile forceps. At home, I’ll have [parents] massage the area with warm compresses to try to extrude the suture. But, if you wait long enough, it usually comes out.”

Dr. Price reported having no financial disclosures.

dbrunk@frontlinemedcom.com

 

CHICAGO – True complications in pediatric dermatologic surgery probably aren’t that frequent, but no solid data on the topic exist in the medical literature.

“An appropriate and thorough perioperative evaluation and planning may limit complications,” Harper N. Price, MD, said at the World Congress of Pediatric Dermatology.

Dr. Price, chief of the division of pediatric dermatology at Phoenix Children’s Hospital, shared general approaches to managing pain, infection, and suture reactions in children who are undergoing dermatologic procedures.

The first step is to make the child comfortable in the office or operating room (OR) setting; this can include approaching children slowly unless you know them well. “Sit at their level, because coming up very fast and being over ... them is intimidating,” she advised. “Make sure you include the child in the conversation you’re having; it elicits more trust and belief in what’s going to happen. You want to explain what’s going to happen in a friendly manner. I think sometimes we have residents who are new to pediatrics that come in and say, ‘We’re going to cut this out,’ and the next thing you know, the child’s in tears. Describe what the procedure is going to be like in words that they can understand, and whatever you do, do not lie about what’s going to happen.”

Dr. Price also makes it a point to cover surgical trays before they’re wheeled in. “They don’t need to see needles and sharp objects,” she said. “Even afterward, bloody gauze can be scary to kids.” Positioning the patient properly also is important. “We’ll wrap young children up in a swaddle,” she said. “In my opinion, you should not be forcefully restraining an older child. They need to cooperate and it needs to be a safe procedure, otherwise, you should consider doing it in the operating room. I never enlist a parent to hold or restrain a child.”

One key to managing pain during dermatologic procedures in children comes down to anticipation: What kinds of distractions might the child need? What preoperative analgesia will be required? What postoperative pain medications should be used? “We know that certain procedures in children might be more painful, such as nail procedures, ablative laser procedures, and large excisions with extensive undermining,” Dr. Price said. “Pain is subjective and differs from child to child in the way it’s experienced, so you need to consider the child’s age, coping style, and temperament, and what their history of pain is like. We know that inadequate pain control in children has a negative impact and a negative implication on their future health care interventions, as well as their reactions to further pain.”

Parental involvement can sometimes help. “I like a parent to stay in the room if I’m doing a procedure in the office, as long as they agree to stay seated,” she said. “It may make your office staff more anxious, and it may make parents more anxious, too, so it’s something to think about.” There is some evidence that having a parent present during an in-office procedure increases parental satisfaction as well.

In an effort to minimize pain and anxiety before in-office procedures, Dr. Price and her associates at Phoenix Children’s Hospital often use instant ice packs. “They get cold really fast, they’re cheap, and you don’t have to run to a refrigerator to get ice,” she said. Other beneficial measures include topical anesthetics and breathing techniques, such as having the child blow on a pinwheel, blow bubbles, or perform diaphragmatic breathing. Using distractions – stuffed animals, picture books, or video games on a tablet – can also help. “If the child is going to the OR, using preoperative midazolam can help relax the child, especially if they’re having repeated procedures,” Dr. Price said. Oral sucrose solution in infants, especially in young infants, provides about 5-8 minutes of temporary analgesia and can be placed on their pacifier or their tongue, she added, noting that ethyl chloride spray can also be helpful prior to injections.

During the procedure itself, counter-stimulatory methods can be helpful; this can include handheld devices that use a combination of vibration, ice, and distraction methods. “Buffer your lidocaine and don’t inject cold lidocaine; that hurts a lot more,” she recommended. “Inject slowly; inject deep. If you have a painful procedure and you’re in an OR setting where you give Marcaine [bupivacaine], put that in at the end of the procedure for short-term postoperative pain relief.” After the procedure, it’s better not to apologize for causing pain or if the procedure didn’t go well. “Give positive incentives like stickers and stuffed animals, and use a dressing wrap with bright colors,” she said. “We often doctor up stuffed animals in the OR so when [the children] wake up, they have something fun to look at.”

Postoperatively, the best way to prevent pain is to recommend limited physical activity. “Children become active quickly after a procedure, and then they hurt,” Dr. Price said. “For extremity wounds, consider ice and elevation. I like bulky dressings to prevent trauma, to remind the families that they’ve had a procedure done. They can usually keep them on for several days.”

Surgical site infections are uncommon, but if they do occur, it’s usually between postoperative days 4 and 10. “The biggest indicator of an infection in my opinion is pain,” she said. “If they’re having a lot of pain, I would be concerned. Causes may be the presence of bacteria on the skin or mucosa or improper wound care at home.”

The risk factors for surgical site infections in children are not well defined in dermatologic surgery, Dr. Price added, “but we know that if you’re going to be operating in the diaper area, that’s a place where you’re going to have a high risk of infection. Preoperative hair removal – if you shave the scalp before surgery creating small nicks – could [introduce] bacteria. And it’s likely that the overall health of the patient may impact their risk of infection. You want to know the difference between normal wound healing and an infection. Culture it. If you’re worried, you may want to start empiric antibiotics. If you have a severe infection, something with necrosis, fluctuance, or dehiscence, you might want to consider partially opening that wound and letting it drain and heal in by secondary intention.”

Measures to prevent postoperative infections include perioperative counseling to restrict excessive activity to prevent trauma, bleeding, and dehiscence; use of bulky dressings, and explicit wound care instructions. “My nurse calls [the patient’s family] the day after a procedure, and I usually have them come in for a wound check, even if there are no sutures to remove, just to make sure things look OK,” she said.

Suture reactions are another potential complication of dermatologic surgery in children. The incidence is unknown, but suture reactions usually occur around 6 weeks postoperatively and tend to happen more often in older children. “Excessive reactions, while uncommon, can lead to an increased risk of dehiscence, infection, and delayed healing,” Dr. Price said. Small caliber monofilament sutures are less reactive than large caliber, multifilament sutures, she added, while synthetic and nonabsorbable sutures are less reactive than natural materials such as silk and surgical gut. Dr. Price favors using poliglecaprone, polyglactin 910, and polypropylene.

Tips for minimizing suture reactions include the following: Use the smallest caliber suture appropriate for the wound; avoid buried sutures too close to the surface of the skin; use a smaller caliber suture at the end of excisions, where there tends to be less tension; and keep knots small and flat at the apexes of excision. “Manage suture reactions with reassurance,” she said. “The nice thing is that these often heal fine without any delay. When possible, remove the offending suture material. A lot of times, I’ll use sterile forceps. At home, I’ll have [parents] massage the area with warm compresses to try to extrude the suture. But, if you wait long enough, it usually comes out.”

Dr. Price reported having no financial disclosures.

dbrunk@frontlinemedcom.com

 

CHICAGO – True complications in pediatric dermatologic surgery probably aren’t that frequent, but no solid data on the topic exist in the medical literature.

“An appropriate and thorough perioperative evaluation and planning may limit complications,” Harper N. Price, MD, said at the World Congress of Pediatric Dermatology.

Dr. Price, chief of the division of pediatric dermatology at Phoenix Children’s Hospital, shared general approaches to managing pain, infection, and suture reactions in children who are undergoing dermatologic procedures.

The first step is to make the child comfortable in the office or operating room (OR) setting; this can include approaching children slowly unless you know them well. “Sit at their level, because coming up very fast and being over ... them is intimidating,” she advised. “Make sure you include the child in the conversation you’re having; it elicits more trust and belief in what’s going to happen. You want to explain what’s going to happen in a friendly manner. I think sometimes we have residents who are new to pediatrics that come in and say, ‘We’re going to cut this out,’ and the next thing you know, the child’s in tears. Describe what the procedure is going to be like in words that they can understand, and whatever you do, do not lie about what’s going to happen.”

Dr. Price also makes it a point to cover surgical trays before they’re wheeled in. “They don’t need to see needles and sharp objects,” she said. “Even afterward, bloody gauze can be scary to kids.” Positioning the patient properly also is important. “We’ll wrap young children up in a swaddle,” she said. “In my opinion, you should not be forcefully restraining an older child. They need to cooperate and it needs to be a safe procedure, otherwise, you should consider doing it in the operating room. I never enlist a parent to hold or restrain a child.”

One key to managing pain during dermatologic procedures in children comes down to anticipation: What kinds of distractions might the child need? What preoperative analgesia will be required? What postoperative pain medications should be used? “We know that certain procedures in children might be more painful, such as nail procedures, ablative laser procedures, and large excisions with extensive undermining,” Dr. Price said. “Pain is subjective and differs from child to child in the way it’s experienced, so you need to consider the child’s age, coping style, and temperament, and what their history of pain is like. We know that inadequate pain control in children has a negative impact and a negative implication on their future health care interventions, as well as their reactions to further pain.”

Parental involvement can sometimes help. “I like a parent to stay in the room if I’m doing a procedure in the office, as long as they agree to stay seated,” she said. “It may make your office staff more anxious, and it may make parents more anxious, too, so it’s something to think about.” There is some evidence that having a parent present during an in-office procedure increases parental satisfaction as well.

In an effort to minimize pain and anxiety before in-office procedures, Dr. Price and her associates at Phoenix Children’s Hospital often use instant ice packs. “They get cold really fast, they’re cheap, and you don’t have to run to a refrigerator to get ice,” she said. Other beneficial measures include topical anesthetics and breathing techniques, such as having the child blow on a pinwheel, blow bubbles, or perform diaphragmatic breathing. Using distractions – stuffed animals, picture books, or video games on a tablet – can also help. “If the child is going to the OR, using preoperative midazolam can help relax the child, especially if they’re having repeated procedures,” Dr. Price said. Oral sucrose solution in infants, especially in young infants, provides about 5-8 minutes of temporary analgesia and can be placed on their pacifier or their tongue, she added, noting that ethyl chloride spray can also be helpful prior to injections.

During the procedure itself, counter-stimulatory methods can be helpful; this can include handheld devices that use a combination of vibration, ice, and distraction methods. “Buffer your lidocaine and don’t inject cold lidocaine; that hurts a lot more,” she recommended. “Inject slowly; inject deep. If you have a painful procedure and you’re in an OR setting where you give Marcaine [bupivacaine], put that in at the end of the procedure for short-term postoperative pain relief.” After the procedure, it’s better not to apologize for causing pain or if the procedure didn’t go well. “Give positive incentives like stickers and stuffed animals, and use a dressing wrap with bright colors,” she said. “We often doctor up stuffed animals in the OR so when [the children] wake up, they have something fun to look at.”

Postoperatively, the best way to prevent pain is to recommend limited physical activity. “Children become active quickly after a procedure, and then they hurt,” Dr. Price said. “For extremity wounds, consider ice and elevation. I like bulky dressings to prevent trauma, to remind the families that they’ve had a procedure done. They can usually keep them on for several days.”

Surgical site infections are uncommon, but if they do occur, it’s usually between postoperative days 4 and 10. “The biggest indicator of an infection in my opinion is pain,” she said. “If they’re having a lot of pain, I would be concerned. Causes may be the presence of bacteria on the skin or mucosa or improper wound care at home.”

The risk factors for surgical site infections in children are not well defined in dermatologic surgery, Dr. Price added, “but we know that if you’re going to be operating in the diaper area, that’s a place where you’re going to have a high risk of infection. Preoperative hair removal – if you shave the scalp before surgery creating small nicks – could [introduce] bacteria. And it’s likely that the overall health of the patient may impact their risk of infection. You want to know the difference between normal wound healing and an infection. Culture it. If you’re worried, you may want to start empiric antibiotics. If you have a severe infection, something with necrosis, fluctuance, or dehiscence, you might want to consider partially opening that wound and letting it drain and heal in by secondary intention.”

Measures to prevent postoperative infections include perioperative counseling to restrict excessive activity to prevent trauma, bleeding, and dehiscence; use of bulky dressings, and explicit wound care instructions. “My nurse calls [the patient’s family] the day after a procedure, and I usually have them come in for a wound check, even if there are no sutures to remove, just to make sure things look OK,” she said.

Suture reactions are another potential complication of dermatologic surgery in children. The incidence is unknown, but suture reactions usually occur around 6 weeks postoperatively and tend to happen more often in older children. “Excessive reactions, while uncommon, can lead to an increased risk of dehiscence, infection, and delayed healing,” Dr. Price said. Small caliber monofilament sutures are less reactive than large caliber, multifilament sutures, she added, while synthetic and nonabsorbable sutures are less reactive than natural materials such as silk and surgical gut. Dr. Price favors using poliglecaprone, polyglactin 910, and polypropylene.

Tips for minimizing suture reactions include the following: Use the smallest caliber suture appropriate for the wound; avoid buried sutures too close to the surface of the skin; use a smaller caliber suture at the end of excisions, where there tends to be less tension; and keep knots small and flat at the apexes of excision. “Manage suture reactions with reassurance,” she said. “The nice thing is that these often heal fine without any delay. When possible, remove the offending suture material. A lot of times, I’ll use sterile forceps. At home, I’ll have [parents] massage the area with warm compresses to try to extrude the suture. But, if you wait long enough, it usually comes out.”

Dr. Price reported having no financial disclosures.

dbrunk@frontlinemedcom.com

 

CHICAGO – Sometimes, the skin can provide the first clues that a patient has been exposed to a drug product that has been adulterated or an over-the-counter product illegally sold in this country that contains a prescription medication, according to pediatric dermatologist Scott Norton, MD.

Speaking at the World Congress of Pediatric Dermatology, he reviewed some of the reactions associated with exposure to counterfeit drugs, contraband drugs, as well as products, misrepresented as drugs that do not include any active pharmaceutical ingredients. The worldwide market for these products is a “hugely profitable industry,” and the scope of the problem should not be underestimated, said Dr. Norton, chief of dermatology at Children’s National Health System, Washington.

Children's Hospital

Examples include completely fraudulent formulations, from fake vaccines being distributed in China and Nigeria and counterfeit antimalarials in Cambodia to “contraceptive” pills in Brazil that contain no contraceptive ingredients. In addition, many Asian so-called herbal remedies are actually adulterated with corticosteroids, antibiotics, and other prescription medications. Another issue, he noted, is that substandard medications might contain too much or too little of the active ingredient listed on the label, including adulterated vehicles or fillers. In other cases, they may be contaminated, as happened with the CNS-injectable steroids that caused serious fungal infections and deaths in the United States.

It’s particularly important to have a high index of suspicion for such products given an increasingly mobile worldwide population. Today, patients and their family members who travel out of the country – and even local shopkeepers – may bring in these sorts of products from outside the United States, many of which would require a prescription in the United States.

In the United States, there have been several reports of a mysterious fixed drug eruption in patients reported to have taken Baczol, a cold and flu remedy available over the counter in El Salvador for upper respiratory infections. Two of the ingredients listed on the Baczol label are sulfamethoxazole and trimethoprim, two prescription antibiotics. After determining that two Salvadoran American children with a suspected fixed drug eruption had taken a Baczol product, Dr. Norton, with the aid of medical students, was able to find Baczol containing trimethoprim-sulfamethoxazole for sale over the counter in more than one-third of the shops visited in the greater Washington area (MMWR Morb Mortal Wkly Rep. 2013 Nov 22;62[46]:914-6). Eventually, the Food and Drug Administration issued a consumer alert regarding certain Baczol products containing these ingredients, but Dr. Norton said he is still concerned about the possibility for more grave hypersensitivity reactions to these sulfa antibiotics in the Salvadoran product.

CDC, MMWR https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6246a2.htm#fig

In the United States, children treated with adulterated preparations for atopic dermatitis may present with striae and other dermatologic stigmata of potent topical steroid use in areas of atopy; for example, one such preparation was found to contain clobetasol. In a commentary recently published online in JAMA Dermatology, Hongfu Xie, MD, and two other Chinese dermatologists described the pervasive presence of topical steroids in Chinese cosmetic preparations (JAMA Dermatol. 2017 Jul 5. doi: 10.1001/jamadermatol.2017.1615).

Sometimes, said Dr. Norton, the problem lies in the lack of an expected ingredient. He and his team at Children’s National Health System helped solve a medical mystery involving a skin ailment in very premature infants with cholestasis. An interdisciplinary team was convened after the neonatal intensive care unit at the hospital saw its third infant with severe blistering and erosions in an acral, perianal, and perioral pattern that did not respond to empiric treatment for herpes simplex virus and staphylococcal infection – a pattern reminiscent of zinc deficiency dermatitis. Dietitians reported that there was a nationwide shortage of sterile injectable zinc, so total parenteral nutrition was being formulated without zinc. All three of the premature infants were receiving total parenteral nutrition and were so premature that they had insufficient zinc stores. The problem was identified and corrected (MMWR 2014 Jan. 17;63[02];35-7).

A more pervasive issue, which has global significance, pertains to counterfeit vaccines prepared with absolutely no vaccine components, often made in China or Nigeria with high-quality and sophisticated packaging, said Dr. Norton.

Keeping a lid on counterfeit drugs is challenging since there are so many potential entry points into the supply chain, Dr. Norton pointed out. Weak points include mislabeled raw ingredients, packaging, storage, transportation, repackaging, and distribution. The proliferation of online pharmacies also makes regulation more difficult.

There is some international cooperation to detect and combat drug counterfeiting and adulteration: For example, Interpol, the International Coalition of Medicines Regulatory Authorities, the Pharmaceutical Security Institute, and even the United Nations are developing cooperative strategies to combat the problem.

In the meantime, he emphasized that physicians must maintain a high index of suspicion and keep in mind that the first signs of adulterated drugs or prescription drugs available OTC may appear on the skin.

Dr. Norton reported no conflicts of interest.

 

koakes@frontlinemedcom.com

On Twitter @karioakes

 

CHICAGO – Sometimes, the skin can provide the first clues that a patient has been exposed to a drug product that has been adulterated or an over-the-counter product illegally sold in this country that contains a prescription medication, according to pediatric dermatologist Scott Norton, MD.

Speaking at the World Congress of Pediatric Dermatology, he reviewed some of the reactions associated with exposure to counterfeit drugs, contraband drugs, as well as products, misrepresented as drugs that do not include any active pharmaceutical ingredients. The worldwide market for these products is a “hugely profitable industry,” and the scope of the problem should not be underestimated, said Dr. Norton, chief of dermatology at Children’s National Health System, Washington.

Children's Hospital

Examples include completely fraudulent formulations, from fake vaccines being distributed in China and Nigeria and counterfeit antimalarials in Cambodia to “contraceptive” pills in Brazil that contain no contraceptive ingredients. In addition, many Asian so-called herbal remedies are actually adulterated with corticosteroids, antibiotics, and other prescription medications. Another issue, he noted, is that substandard medications might contain too much or too little of the active ingredient listed on the label, including adulterated vehicles or fillers. In other cases, they may be contaminated, as happened with the CNS-injectable steroids that caused serious fungal infections and deaths in the United States.

It’s particularly important to have a high index of suspicion for such products given an increasingly mobile worldwide population. Today, patients and their family members who travel out of the country – and even local shopkeepers – may bring in these sorts of products from outside the United States, many of which would require a prescription in the United States.

In the United States, there have been several reports of a mysterious fixed drug eruption in patients reported to have taken Baczol, a cold and flu remedy available over the counter in El Salvador for upper respiratory infections. Two of the ingredients listed on the Baczol label are sulfamethoxazole and trimethoprim, two prescription antibiotics. After determining that two Salvadoran American children with a suspected fixed drug eruption had taken a Baczol product, Dr. Norton, with the aid of medical students, was able to find Baczol containing trimethoprim-sulfamethoxazole for sale over the counter in more than one-third of the shops visited in the greater Washington area (MMWR Morb Mortal Wkly Rep. 2013 Nov 22;62[46]:914-6). Eventually, the Food and Drug Administration issued a consumer alert regarding certain Baczol products containing these ingredients, but Dr. Norton said he is still concerned about the possibility for more grave hypersensitivity reactions to these sulfa antibiotics in the Salvadoran product.

CDC, MMWR https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6246a2.htm#fig

In the United States, children treated with adulterated preparations for atopic dermatitis may present with striae and other dermatologic stigmata of potent topical steroid use in areas of atopy; for example, one such preparation was found to contain clobetasol. In a commentary recently published online in JAMA Dermatology, Hongfu Xie, MD, and two other Chinese dermatologists described the pervasive presence of topical steroids in Chinese cosmetic preparations (JAMA Dermatol. 2017 Jul 5. doi: 10.1001/jamadermatol.2017.1615).

Sometimes, said Dr. Norton, the problem lies in the lack of an expected ingredient. He and his team at Children’s National Health System helped solve a medical mystery involving a skin ailment in very premature infants with cholestasis. An interdisciplinary team was convened after the neonatal intensive care unit at the hospital saw its third infant with severe blistering and erosions in an acral, perianal, and perioral pattern that did not respond to empiric treatment for herpes simplex virus and staphylococcal infection – a pattern reminiscent of zinc deficiency dermatitis. Dietitians reported that there was a nationwide shortage of sterile injectable zinc, so total parenteral nutrition was being formulated without zinc. All three of the premature infants were receiving total parenteral nutrition and were so premature that they had insufficient zinc stores. The problem was identified and corrected (MMWR 2014 Jan. 17;63[02];35-7).

A more pervasive issue, which has global significance, pertains to counterfeit vaccines prepared with absolutely no vaccine components, often made in China or Nigeria with high-quality and sophisticated packaging, said Dr. Norton.

Keeping a lid on counterfeit drugs is challenging since there are so many potential entry points into the supply chain, Dr. Norton pointed out. Weak points include mislabeled raw ingredients, packaging, storage, transportation, repackaging, and distribution. The proliferation of online pharmacies also makes regulation more difficult.

There is some international cooperation to detect and combat drug counterfeiting and adulteration: For example, Interpol, the International Coalition of Medicines Regulatory Authorities, the Pharmaceutical Security Institute, and even the United Nations are developing cooperative strategies to combat the problem.

In the meantime, he emphasized that physicians must maintain a high index of suspicion and keep in mind that the first signs of adulterated drugs or prescription drugs available OTC may appear on the skin.

Dr. Norton reported no conflicts of interest.

 

koakes@frontlinemedcom.com

On Twitter @karioakes

 

CHICAGO – Sometimes, the skin can provide the first clues that a patient has been exposed to a drug product that has been adulterated or an over-the-counter product illegally sold in this country that contains a prescription medication, according to pediatric dermatologist Scott Norton, MD.

Speaking at the World Congress of Pediatric Dermatology, he reviewed some of the reactions associated with exposure to counterfeit drugs, contraband drugs, as well as products, misrepresented as drugs that do not include any active pharmaceutical ingredients. The worldwide market for these products is a “hugely profitable industry,” and the scope of the problem should not be underestimated, said Dr. Norton, chief of dermatology at Children’s National Health System, Washington.

Children's Hospital

Examples include completely fraudulent formulations, from fake vaccines being distributed in China and Nigeria and counterfeit antimalarials in Cambodia to “contraceptive” pills in Brazil that contain no contraceptive ingredients. In addition, many Asian so-called herbal remedies are actually adulterated with corticosteroids, antibiotics, and other prescription medications. Another issue, he noted, is that substandard medications might contain too much or too little of the active ingredient listed on the label, including adulterated vehicles or fillers. In other cases, they may be contaminated, as happened with the CNS-injectable steroids that caused serious fungal infections and deaths in the United States.

It’s particularly important to have a high index of suspicion for such products given an increasingly mobile worldwide population. Today, patients and their family members who travel out of the country – and even local shopkeepers – may bring in these sorts of products from outside the United States, many of which would require a prescription in the United States.

In the United States, there have been several reports of a mysterious fixed drug eruption in patients reported to have taken Baczol, a cold and flu remedy available over the counter in El Salvador for upper respiratory infections. Two of the ingredients listed on the Baczol label are sulfamethoxazole and trimethoprim, two prescription antibiotics. After determining that two Salvadoran American children with a suspected fixed drug eruption had taken a Baczol product, Dr. Norton, with the aid of medical students, was able to find Baczol containing trimethoprim-sulfamethoxazole for sale over the counter in more than one-third of the shops visited in the greater Washington area (MMWR Morb Mortal Wkly Rep. 2013 Nov 22;62[46]:914-6). Eventually, the Food and Drug Administration issued a consumer alert regarding certain Baczol products containing these ingredients, but Dr. Norton said he is still concerned about the possibility for more grave hypersensitivity reactions to these sulfa antibiotics in the Salvadoran product.

CDC, MMWR https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6246a2.htm#fig

In the United States, children treated with adulterated preparations for atopic dermatitis may present with striae and other dermatologic stigmata of potent topical steroid use in areas of atopy; for example, one such preparation was found to contain clobetasol. In a commentary recently published online in JAMA Dermatology, Hongfu Xie, MD, and two other Chinese dermatologists described the pervasive presence of topical steroids in Chinese cosmetic preparations (JAMA Dermatol. 2017 Jul 5. doi: 10.1001/jamadermatol.2017.1615).

Sometimes, said Dr. Norton, the problem lies in the lack of an expected ingredient. He and his team at Children’s National Health System helped solve a medical mystery involving a skin ailment in very premature infants with cholestasis. An interdisciplinary team was convened after the neonatal intensive care unit at the hospital saw its third infant with severe blistering and erosions in an acral, perianal, and perioral pattern that did not respond to empiric treatment for herpes simplex virus and staphylococcal infection – a pattern reminiscent of zinc deficiency dermatitis. Dietitians reported that there was a nationwide shortage of sterile injectable zinc, so total parenteral nutrition was being formulated without zinc. All three of the premature infants were receiving total parenteral nutrition and were so premature that they had insufficient zinc stores. The problem was identified and corrected (MMWR 2014 Jan. 17;63[02];35-7).

A more pervasive issue, which has global significance, pertains to counterfeit vaccines prepared with absolutely no vaccine components, often made in China or Nigeria with high-quality and sophisticated packaging, said Dr. Norton.

Keeping a lid on counterfeit drugs is challenging since there are so many potential entry points into the supply chain, Dr. Norton pointed out. Weak points include mislabeled raw ingredients, packaging, storage, transportation, repackaging, and distribution. The proliferation of online pharmacies also makes regulation more difficult.

There is some international cooperation to detect and combat drug counterfeiting and adulteration: For example, Interpol, the International Coalition of Medicines Regulatory Authorities, the Pharmaceutical Security Institute, and even the United Nations are developing cooperative strategies to combat the problem.

In the meantime, he emphasized that physicians must maintain a high index of suspicion and keep in mind that the first signs of adulterated drugs or prescription drugs available OTC may appear on the skin.

Dr. Norton reported no conflicts of interest.

 

koakes@frontlinemedcom.com

On Twitter @karioakes

 

Mobile health interventions targeting mothers of healthy newborns significantly improved safe sleep practices, compared with controls, in a randomized trial of 1,600 mothers published online July 25 in JAMA.

Despite the success of the Back to Sleep campaign in reducing rates of sudden infant death syndrome, approximately 3,500 infant deaths due to SIDS, accidental suffocation, or strangulation in bed occurred in 2014, wrote Rachel Y. Moon, MD, of the University of Virginia, Charlottesville, and her colleagues (JAMA. 2017;318:351-9).

Halfpoint/thinkstock

In the Social Media and Risk-Reduction Training (SMART) study to assess the effectiveness of mobile intervention on safe sleep practices, the researchers randomized 1,600 mothers affiliated with 16 hospitals nationwide to four groups: breastfeeding nursing quality intervention (NQI) and breastfeeding mobile health intervention (mHealth); safe sleep NQI, and breastfeeding mHealth; breastfeeding NQI and safe sleep mHealth; or safe sleep NQI and safe sleep mHealth. The mHealth intervention consisted of daily messages and videos for the first 11 days and then every 3-4 days for 60 days; the content was about safe sleep for infants (intervention) or about breastfeeding (control).

A total of 1,263 mothers completed the study, and mothers who received the mobile messages about safe sleep were significantly more likely than those who received the control messages to engage in safe sleep practices, including placing babies on their backs (89% vs. 80%), sharing a room without cosleeping (83% vs. 70%), avoiding the use of soft bedding (79% vs. 68%), and use of pacifiers (69% vs. 60%). The initial nursing quality intervention alone had no significant impact on any of the safe sleep practices, the researchers noted.

The results were limited by several factors, including the 21% lost to follow up and lack of data on adverse events and clinical outcomes, the researchers said. However, the results suggest that mobile messages could be cost effective and easily implemented by hospitals.

“Furthermore, because the rates of opening and viewing messages in this study were consistently higher than 50%, and almost all adults now have cell phones or email access, it is likely that this type of intervention would be feasible and well received by parents,” Dr. Moon and her associates added. “Whether widespread implementation is feasible or if it reduces sudden and unexpected infant death rates remains to be studied.”

“The messages and videos were timed to address challenges and questions that arise at specific time points; therefore, providing this additional information to parents at critical times may have been important in assuaging concerns about adherence to recommended practices. Furthermore, receiving frequent videos and email or text messages may have served as a virtual support system for mothers, reinforcing safe parental practices,” Dr. Moon and her associates noted.

The researchers had no financial conflicts to disclose. The study was supported in part by the National Institute of Child Health and Human Development and by the CJ Foundation for SIDS.

 

Mobile health interventions targeting mothers of healthy newborns significantly improved safe sleep practices, compared with controls, in a randomized trial of 1,600 mothers published online July 25 in JAMA.

Despite the success of the Back to Sleep campaign in reducing rates of sudden infant death syndrome, approximately 3,500 infant deaths due to SIDS, accidental suffocation, or strangulation in bed occurred in 2014, wrote Rachel Y. Moon, MD, of the University of Virginia, Charlottesville, and her colleagues (JAMA. 2017;318:351-9).

Halfpoint/thinkstock

In the Social Media and Risk-Reduction Training (SMART) study to assess the effectiveness of mobile intervention on safe sleep practices, the researchers randomized 1,600 mothers affiliated with 16 hospitals nationwide to four groups: breastfeeding nursing quality intervention (NQI) and breastfeeding mobile health intervention (mHealth); safe sleep NQI, and breastfeeding mHealth; breastfeeding NQI and safe sleep mHealth; or safe sleep NQI and safe sleep mHealth. The mHealth intervention consisted of daily messages and videos for the first 11 days and then every 3-4 days for 60 days; the content was about safe sleep for infants (intervention) or about breastfeeding (control).

A total of 1,263 mothers completed the study, and mothers who received the mobile messages about safe sleep were significantly more likely than those who received the control messages to engage in safe sleep practices, including placing babies on their backs (89% vs. 80%), sharing a room without cosleeping (83% vs. 70%), avoiding the use of soft bedding (79% vs. 68%), and use of pacifiers (69% vs. 60%). The initial nursing quality intervention alone had no significant impact on any of the safe sleep practices, the researchers noted.

The results were limited by several factors, including the 21% lost to follow up and lack of data on adverse events and clinical outcomes, the researchers said. However, the results suggest that mobile messages could be cost effective and easily implemented by hospitals.

“Furthermore, because the rates of opening and viewing messages in this study were consistently higher than 50%, and almost all adults now have cell phones or email access, it is likely that this type of intervention would be feasible and well received by parents,” Dr. Moon and her associates added. “Whether widespread implementation is feasible or if it reduces sudden and unexpected infant death rates remains to be studied.”

“The messages and videos were timed to address challenges and questions that arise at specific time points; therefore, providing this additional information to parents at critical times may have been important in assuaging concerns about adherence to recommended practices. Furthermore, receiving frequent videos and email or text messages may have served as a virtual support system for mothers, reinforcing safe parental practices,” Dr. Moon and her associates noted.

The researchers had no financial conflicts to disclose. The study was supported in part by the National Institute of Child Health and Human Development and by the CJ Foundation for SIDS.

 

Mobile health interventions targeting mothers of healthy newborns significantly improved safe sleep practices, compared with controls, in a randomized trial of 1,600 mothers published online July 25 in JAMA.

Despite the success of the Back to Sleep campaign in reducing rates of sudden infant death syndrome, approximately 3,500 infant deaths due to SIDS, accidental suffocation, or strangulation in bed occurred in 2014, wrote Rachel Y. Moon, MD, of the University of Virginia, Charlottesville, and her colleagues (JAMA. 2017;318:351-9).

Halfpoint/thinkstock

In the Social Media and Risk-Reduction Training (SMART) study to assess the effectiveness of mobile intervention on safe sleep practices, the researchers randomized 1,600 mothers affiliated with 16 hospitals nationwide to four groups: breastfeeding nursing quality intervention (NQI) and breastfeeding mobile health intervention (mHealth); safe sleep NQI, and breastfeeding mHealth; breastfeeding NQI and safe sleep mHealth; or safe sleep NQI and safe sleep mHealth. The mHealth intervention consisted of daily messages and videos for the first 11 days and then every 3-4 days for 60 days; the content was about safe sleep for infants (intervention) or about breastfeeding (control).

A total of 1,263 mothers completed the study, and mothers who received the mobile messages about safe sleep were significantly more likely than those who received the control messages to engage in safe sleep practices, including placing babies on their backs (89% vs. 80%), sharing a room without cosleeping (83% vs. 70%), avoiding the use of soft bedding (79% vs. 68%), and use of pacifiers (69% vs. 60%). The initial nursing quality intervention alone had no significant impact on any of the safe sleep practices, the researchers noted.

The results were limited by several factors, including the 21% lost to follow up and lack of data on adverse events and clinical outcomes, the researchers said. However, the results suggest that mobile messages could be cost effective and easily implemented by hospitals.

“Furthermore, because the rates of opening and viewing messages in this study were consistently higher than 50%, and almost all adults now have cell phones or email access, it is likely that this type of intervention would be feasible and well received by parents,” Dr. Moon and her associates added. “Whether widespread implementation is feasible or if it reduces sudden and unexpected infant death rates remains to be studied.”

“The messages and videos were timed to address challenges and questions that arise at specific time points; therefore, providing this additional information to parents at critical times may have been important in assuaging concerns about adherence to recommended practices. Furthermore, receiving frequent videos and email or text messages may have served as a virtual support system for mothers, reinforcing safe parental practices,” Dr. Moon and her associates noted.

The researchers had no financial conflicts to disclose. The study was supported in part by the National Institute of Child Health and Human Development and by the CJ Foundation for SIDS.