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AHA: Limit children’s added sugar intake to 25 g/day
The American Heart Association has set its sights on the high levels of sugar in children’s diets, recommending that consumption of added sugars be limited to 25 grams or less per day to minimize the increased risk of cardiovascular disease, according to a scientific statement published Aug. 22 in Circulation.
“In part because of the lack of clarity and consensus on how much sugar is considered safe for children, sugars remain a commonly added ingredient in foods and drinks, and overall consumption by children and adults remains high,” wrote Miriam B. Vos, MD, of Emory University, Atlanta, and her coauthors.
The group conducted a literature search of the available evidence on sugar intake and its effects on blood pressure, lipids, insulin resistance and diabetes mellitus, nonalcoholic fatty liver disease, and obesity. They also used dietary data from the 2009-2012 National Health and Nutrition Examination Survey (NHANES) to estimate added sugar consumption (Circulation 2016 Aug 22. doi: 10.1161/cir.0000000000000439).
The NHANES data revealed that on average, 2- to 5-year-olds consume 53.3 g of added sugar, defined as all sugars used as ingredients in processed and prepared foods, eaten separately or added to foods at the table, per day; 6- to 11-year-olds consume 78.7 grams a day; and 12- to 19-year-olds consume 92.9 grams per day.
The writing group found there was evidence supporting links between added sugars and increased energy intake, adiposity, central adiposity, and dyslipidemia, which are all known risk factors for cardiovascular disease. They also found that added sugars were particularly harmful when introduced during infancy.
In particular, they found that consumption of sugar-sweetened beverages was strongly associated with an increased risk of obesity across all ages, and there was also a clear dose-response relationship between increased sugar consumption and increased cardiovascular risk.
Based on this, they recommended that children and adolescents drink no more than one 8-oz. sugar-sweetened beverage per week, and limit their overall added sugar intake to 25 g (around 6 teaspoons) or less per day, while added sugars should be avoided entirely for children aged under 2 years.
The group also identified significant gaps in the literature around certain issues such as whether there is a lower threshold for added sugars below which there is no negative impact on cardiovascular health, whether added sugars in food are better or worse than added sugars in drinks, and whether the sugars in 100% fruit juice have biological and cardiovascular effects in children that are similar to those of added sugars in sugar-sweetened beverages.
“Although added sugars can mostly likely be safely consumed in low amounts as part of a healthy diet, little research has been done to establish a threshold between adverse effects and health, making this an important future research topic,” wrote Dr. Vos and her colleagues.
One author reported a consultancy to the Milk Processor Education Program, and another reported having advised the Sugar Board. No other conflicts of interest were declared.
The American Heart Association has set its sights on the high levels of sugar in children’s diets, recommending that consumption of added sugars be limited to 25 grams or less per day to minimize the increased risk of cardiovascular disease, according to a scientific statement published Aug. 22 in Circulation.
“In part because of the lack of clarity and consensus on how much sugar is considered safe for children, sugars remain a commonly added ingredient in foods and drinks, and overall consumption by children and adults remains high,” wrote Miriam B. Vos, MD, of Emory University, Atlanta, and her coauthors.
The group conducted a literature search of the available evidence on sugar intake and its effects on blood pressure, lipids, insulin resistance and diabetes mellitus, nonalcoholic fatty liver disease, and obesity. They also used dietary data from the 2009-2012 National Health and Nutrition Examination Survey (NHANES) to estimate added sugar consumption (Circulation 2016 Aug 22. doi: 10.1161/cir.0000000000000439).
The NHANES data revealed that on average, 2- to 5-year-olds consume 53.3 g of added sugar, defined as all sugars used as ingredients in processed and prepared foods, eaten separately or added to foods at the table, per day; 6- to 11-year-olds consume 78.7 grams a day; and 12- to 19-year-olds consume 92.9 grams per day.
The writing group found there was evidence supporting links between added sugars and increased energy intake, adiposity, central adiposity, and dyslipidemia, which are all known risk factors for cardiovascular disease. They also found that added sugars were particularly harmful when introduced during infancy.
In particular, they found that consumption of sugar-sweetened beverages was strongly associated with an increased risk of obesity across all ages, and there was also a clear dose-response relationship between increased sugar consumption and increased cardiovascular risk.
Based on this, they recommended that children and adolescents drink no more than one 8-oz. sugar-sweetened beverage per week, and limit their overall added sugar intake to 25 g (around 6 teaspoons) or less per day, while added sugars should be avoided entirely for children aged under 2 years.
The group also identified significant gaps in the literature around certain issues such as whether there is a lower threshold for added sugars below which there is no negative impact on cardiovascular health, whether added sugars in food are better or worse than added sugars in drinks, and whether the sugars in 100% fruit juice have biological and cardiovascular effects in children that are similar to those of added sugars in sugar-sweetened beverages.
“Although added sugars can mostly likely be safely consumed in low amounts as part of a healthy diet, little research has been done to establish a threshold between adverse effects and health, making this an important future research topic,” wrote Dr. Vos and her colleagues.
One author reported a consultancy to the Milk Processor Education Program, and another reported having advised the Sugar Board. No other conflicts of interest were declared.
The American Heart Association has set its sights on the high levels of sugar in children’s diets, recommending that consumption of added sugars be limited to 25 grams or less per day to minimize the increased risk of cardiovascular disease, according to a scientific statement published Aug. 22 in Circulation.
“In part because of the lack of clarity and consensus on how much sugar is considered safe for children, sugars remain a commonly added ingredient in foods and drinks, and overall consumption by children and adults remains high,” wrote Miriam B. Vos, MD, of Emory University, Atlanta, and her coauthors.
The group conducted a literature search of the available evidence on sugar intake and its effects on blood pressure, lipids, insulin resistance and diabetes mellitus, nonalcoholic fatty liver disease, and obesity. They also used dietary data from the 2009-2012 National Health and Nutrition Examination Survey (NHANES) to estimate added sugar consumption (Circulation 2016 Aug 22. doi: 10.1161/cir.0000000000000439).
The NHANES data revealed that on average, 2- to 5-year-olds consume 53.3 g of added sugar, defined as all sugars used as ingredients in processed and prepared foods, eaten separately or added to foods at the table, per day; 6- to 11-year-olds consume 78.7 grams a day; and 12- to 19-year-olds consume 92.9 grams per day.
The writing group found there was evidence supporting links between added sugars and increased energy intake, adiposity, central adiposity, and dyslipidemia, which are all known risk factors for cardiovascular disease. They also found that added sugars were particularly harmful when introduced during infancy.
In particular, they found that consumption of sugar-sweetened beverages was strongly associated with an increased risk of obesity across all ages, and there was also a clear dose-response relationship between increased sugar consumption and increased cardiovascular risk.
Based on this, they recommended that children and adolescents drink no more than one 8-oz. sugar-sweetened beverage per week, and limit their overall added sugar intake to 25 g (around 6 teaspoons) or less per day, while added sugars should be avoided entirely for children aged under 2 years.
The group also identified significant gaps in the literature around certain issues such as whether there is a lower threshold for added sugars below which there is no negative impact on cardiovascular health, whether added sugars in food are better or worse than added sugars in drinks, and whether the sugars in 100% fruit juice have biological and cardiovascular effects in children that are similar to those of added sugars in sugar-sweetened beverages.
“Although added sugars can mostly likely be safely consumed in low amounts as part of a healthy diet, little research has been done to establish a threshold between adverse effects and health, making this an important future research topic,” wrote Dr. Vos and her colleagues.
One author reported a consultancy to the Milk Processor Education Program, and another reported having advised the Sugar Board. No other conflicts of interest were declared.
FROM CIRCULATION
Key clinical point: The American Heart Association has recommended that children consume no more than 25 grams of added sugar per day and that added sugars be avoided altogether for children aged under 2 years to limit the consequences for cardiovascular health.
Major finding: On average, American children consume 80 grams of added sugar per day, and increased added sugar consumption is associated with increased adiposity, central adiposity, and dyslipidemia.
Data source: Scientific statement from the American Heart Association.
Disclosures: One author reported a consultancy to the Milk Processor Education Program, and another reported having advised the Sugar Board. No other conflicts of interest were declared.
FASD diagnostic guidelines updated at key time
A newly published set of clinical guidelines for the diagnosis of fetal alcohol spectrum disorder (FASD), the first such update to the guidelines since 2005, will help health care providers better diagnose children exposed to alcohol during gestation.
“These new guidelines will be a valuable resource for clinicians to accurately diagnose infants and children who were affected by alcohol exposure before birth,” George F. Koob, PhD, director of the National Institute on Alcohol Abuse and Alcoholism, said in a statement. “They represent the most data-driven diagnostic criteria for fetal alcohol syndrome and fetal alcohol spectrum disorder produced to date.”
The guidelines call for a multidisciplinary approach to FASD diagnosis, which would require children suspected of FASD to be evaluated by either a pediatrician or a clinical geneticist/dysmorphologist, along with undergoing a neuropsychological and behavioral assessment. Children also should be assessed by speech pathologists, occupational therapists, physical therapists, audiologists, psychiatrists, and ophthalmologists on a case-by-case basis, if needed (Pediatrics. 2016;138[2]:e20154256).
“[FASD], the umbrella term for the range of disabilities that can result from prenatal alcohol exposure, represents the leading cause of preventable developmental disabilities in the world,” according to an NIH statement. “As a result of alcohol exposure in the womb, children can have lower IQ, restricted growth resulting in shorter height/lower weight, small head size, a characteristic pattern of facial deformities, and behavioral issues such as attention deficit, poor impulse control, and the inability to regulate mood/behavior.”
As a first step outlined in the diagnostic algorithm in the guidelines, the mothers should be assessed to determine how much prenatal alcohol was consumed; there is a table with a definition of documented prenatal alcohol exposure as it applies to the four definitions. The guidelines stress that no amount of alcohol consumption during pregnancy can be considered safe; therefore, the amount and frequency of alcohol consumption, along with any possible drug use, is critical to determining the severity of FASD in the child.
The four diagnostic categories into which FASD has been divided have not been changed in the update, although the criteria for each have been updated. These four categories, which were created by the Institute of Medicine in 1996, are: fetal alcohol syndrome (FAS), which applies to the most severely affected children; partial FAS (PFAS), which applies to children who display some, but not all, of the full spectrum of FAS characteristics; alcohol-related neurodevelopmental disorder (ARND), which applies to children who have no physical signs of FAS but do display cognitive or behavioral impairment; and alcohol-related birth defects (ARBD), which applies to children with no FAS symptoms aside from a physical malformation brought on by prenatal alcohol consumption.
“These four diagnostic categories remain the most apt descriptors of the range of disabilities observed within the continuum of FASD,” guidelines coauthor Kenneth R. Warren, MD, said in a statement. “We have refined the guidelines to reflect our collective expertise gained through the evaluation of more than 10,000 children in domestic and international venues.”
There is an extensive chart in the guidelines article documenting the updated criteria for the four diagnostic criteria.
After determining maternal alcohol consumption during pregnancy, characteristic structural features should be evaluated in the child. Typical physical signs of FASD include short palpebral fissures, a smooth philtrum, and a vermilion border of the upper lip that may be thinner than normal, along with midface hypoplasia. There is a new lip/philtrum guide for the white population, incorporating a 45-degree view in the guidelines.
From there, neurodevelopmental assessments and neuropsychological evaluations should be conducted to identify any cognitive impairments, keeping in mind that these will progress as the child ages. Finally, a multidisciplinary case conference should be held to discuss whether or not FASD should be diagnosed or not.
“These updated guidelines reflect consensus among a large and experienced cadre of FASD investigators in the fields of dysmorphology, epidemiology, neurology, psychology, developmental/ behavioral pediatrics, and educational diagnostics,” wrote the authors of the guidelines, led by H. Eugene Hoyme, MD of the University of South Dakota in Sioux Falls. “The improved specificity of these guidelines will aid clinicians in assignment of more accurate diagnoses of alcohol-exposed infants and children, thereby leading to more widespread early intervention and improved prevention efforts.”
The authors reported no relevant financial disclosures.
These updated diagnostic guidelines for fetal alcohol spectrum disorders (FASD) are being published and made available to clinicians at a very important time in the history of research on this disorder.
With National Institutes of Health–National Institute on Alcohol Abuse and Alcoholism support, a multidisciplinary group of investigators under the Collaboration to Establish Fetal Alcohol Spectrum Disorders Prevalence (CoFASP) is now compiling the first regionally based prevalence estimates for the disorders in the United States, which are thought to be on the order of 2%-5% of first grade children in the general population. These estimates exceed that of other common developmental disabilities such as autism spectrum disorders, and highlight the tremendous importance of this public health issue.
|
Dr. Christina D. Chambers |
The updated diagnostic guidelines expand upon the previous criteria published more than 10 years ago by Hoyme et al. Now on the basis of experience with evaluating more than 10,000 children in the United States, the authors’ consensus guidelines add more detailed information about the type and severity of neurobehavioral deficits commonly seen in alcohol-affected children, specify the quantity and frequency of alcohol reported by the mother that can be used to help define prenatal alcohol exposure, and incorporate emerging biomarkers of exposure that do not rely solely on maternal report, among other improvements and clarifications.
One of the major barriers to identification of FASD-affected children is pediatricians’ lack of confidence in their ability to recognize affected children. This set of guidelines should improve the ability of clinicians to better identify those children who may be affected by alcohol and might otherwise be misdiagnosed or not diagnosed at all, and can help standardize the pediatrician’s approach to doing this.
Christina Chambers, PhD, MPH, a professor of pediatrics at University of California, San Diego, and director of clinical research for the department of pediatrics at UCSD and Rady Children’s Hospital, commented in an interview. She is also a coauthor of, and helped to develop, the guidelines. Dr. Chambers said she had no relevant financial disclosures.
These updated diagnostic guidelines for fetal alcohol spectrum disorders (FASD) are being published and made available to clinicians at a very important time in the history of research on this disorder.
With National Institutes of Health–National Institute on Alcohol Abuse and Alcoholism support, a multidisciplinary group of investigators under the Collaboration to Establish Fetal Alcohol Spectrum Disorders Prevalence (CoFASP) is now compiling the first regionally based prevalence estimates for the disorders in the United States, which are thought to be on the order of 2%-5% of first grade children in the general population. These estimates exceed that of other common developmental disabilities such as autism spectrum disorders, and highlight the tremendous importance of this public health issue.
|
|
Dr. Christina D. Chambers |
The updated diagnostic guidelines expand upon the previous criteria published more than 10 years ago by Hoyme et al. Now on the basis of experience with evaluating more than 10,000 children in the United States, the authors’ consensus guidelines add more detailed information about the type and severity of neurobehavioral deficits commonly seen in alcohol-affected children, specify the quantity and frequency of alcohol reported by the mother that can be used to help define prenatal alcohol exposure, and incorporate emerging biomarkers of exposure that do not rely solely on maternal report, among other improvements and clarifications.
One of the major barriers to identification of FASD-affected children is pediatricians’ lack of confidence in their ability to recognize affected children. This set of guidelines should improve the ability of clinicians to better identify those children who may be affected by alcohol and might otherwise be misdiagnosed or not diagnosed at all, and can help standardize the pediatrician’s approach to doing this.
Christina Chambers, PhD, MPH, a professor of pediatrics at University of California, San Diego, and director of clinical research for the department of pediatrics at UCSD and Rady Children’s Hospital, commented in an interview. She is also a coauthor of, and helped to develop, the guidelines. Dr. Chambers said she had no relevant financial disclosures.
These updated diagnostic guidelines for fetal alcohol spectrum disorders (FASD) are being published and made available to clinicians at a very important time in the history of research on this disorder.
With National Institutes of Health–National Institute on Alcohol Abuse and Alcoholism support, a multidisciplinary group of investigators under the Collaboration to Establish Fetal Alcohol Spectrum Disorders Prevalence (CoFASP) is now compiling the first regionally based prevalence estimates for the disorders in the United States, which are thought to be on the order of 2%-5% of first grade children in the general population. These estimates exceed that of other common developmental disabilities such as autism spectrum disorders, and highlight the tremendous importance of this public health issue.
|
|
Dr. Christina D. Chambers |
The updated diagnostic guidelines expand upon the previous criteria published more than 10 years ago by Hoyme et al. Now on the basis of experience with evaluating more than 10,000 children in the United States, the authors’ consensus guidelines add more detailed information about the type and severity of neurobehavioral deficits commonly seen in alcohol-affected children, specify the quantity and frequency of alcohol reported by the mother that can be used to help define prenatal alcohol exposure, and incorporate emerging biomarkers of exposure that do not rely solely on maternal report, among other improvements and clarifications.
One of the major barriers to identification of FASD-affected children is pediatricians’ lack of confidence in their ability to recognize affected children. This set of guidelines should improve the ability of clinicians to better identify those children who may be affected by alcohol and might otherwise be misdiagnosed or not diagnosed at all, and can help standardize the pediatrician’s approach to doing this.
Christina Chambers, PhD, MPH, a professor of pediatrics at University of California, San Diego, and director of clinical research for the department of pediatrics at UCSD and Rady Children’s Hospital, commented in an interview. She is also a coauthor of, and helped to develop, the guidelines. Dr. Chambers said she had no relevant financial disclosures.
A newly published set of clinical guidelines for the diagnosis of fetal alcohol spectrum disorder (FASD), the first such update to the guidelines since 2005, will help health care providers better diagnose children exposed to alcohol during gestation.
“These new guidelines will be a valuable resource for clinicians to accurately diagnose infants and children who were affected by alcohol exposure before birth,” George F. Koob, PhD, director of the National Institute on Alcohol Abuse and Alcoholism, said in a statement. “They represent the most data-driven diagnostic criteria for fetal alcohol syndrome and fetal alcohol spectrum disorder produced to date.”
The guidelines call for a multidisciplinary approach to FASD diagnosis, which would require children suspected of FASD to be evaluated by either a pediatrician or a clinical geneticist/dysmorphologist, along with undergoing a neuropsychological and behavioral assessment. Children also should be assessed by speech pathologists, occupational therapists, physical therapists, audiologists, psychiatrists, and ophthalmologists on a case-by-case basis, if needed (Pediatrics. 2016;138[2]:e20154256).
“[FASD], the umbrella term for the range of disabilities that can result from prenatal alcohol exposure, represents the leading cause of preventable developmental disabilities in the world,” according to an NIH statement. “As a result of alcohol exposure in the womb, children can have lower IQ, restricted growth resulting in shorter height/lower weight, small head size, a characteristic pattern of facial deformities, and behavioral issues such as attention deficit, poor impulse control, and the inability to regulate mood/behavior.”
As a first step outlined in the diagnostic algorithm in the guidelines, the mothers should be assessed to determine how much prenatal alcohol was consumed; there is a table with a definition of documented prenatal alcohol exposure as it applies to the four definitions. The guidelines stress that no amount of alcohol consumption during pregnancy can be considered safe; therefore, the amount and frequency of alcohol consumption, along with any possible drug use, is critical to determining the severity of FASD in the child.
The four diagnostic categories into which FASD has been divided have not been changed in the update, although the criteria for each have been updated. These four categories, which were created by the Institute of Medicine in 1996, are: fetal alcohol syndrome (FAS), which applies to the most severely affected children; partial FAS (PFAS), which applies to children who display some, but not all, of the full spectrum of FAS characteristics; alcohol-related neurodevelopmental disorder (ARND), which applies to children who have no physical signs of FAS but do display cognitive or behavioral impairment; and alcohol-related birth defects (ARBD), which applies to children with no FAS symptoms aside from a physical malformation brought on by prenatal alcohol consumption.
“These four diagnostic categories remain the most apt descriptors of the range of disabilities observed within the continuum of FASD,” guidelines coauthor Kenneth R. Warren, MD, said in a statement. “We have refined the guidelines to reflect our collective expertise gained through the evaluation of more than 10,000 children in domestic and international venues.”
There is an extensive chart in the guidelines article documenting the updated criteria for the four diagnostic criteria.
After determining maternal alcohol consumption during pregnancy, characteristic structural features should be evaluated in the child. Typical physical signs of FASD include short palpebral fissures, a smooth philtrum, and a vermilion border of the upper lip that may be thinner than normal, along with midface hypoplasia. There is a new lip/philtrum guide for the white population, incorporating a 45-degree view in the guidelines.
From there, neurodevelopmental assessments and neuropsychological evaluations should be conducted to identify any cognitive impairments, keeping in mind that these will progress as the child ages. Finally, a multidisciplinary case conference should be held to discuss whether or not FASD should be diagnosed or not.
“These updated guidelines reflect consensus among a large and experienced cadre of FASD investigators in the fields of dysmorphology, epidemiology, neurology, psychology, developmental/ behavioral pediatrics, and educational diagnostics,” wrote the authors of the guidelines, led by H. Eugene Hoyme, MD of the University of South Dakota in Sioux Falls. “The improved specificity of these guidelines will aid clinicians in assignment of more accurate diagnoses of alcohol-exposed infants and children, thereby leading to more widespread early intervention and improved prevention efforts.”
The authors reported no relevant financial disclosures.
A newly published set of clinical guidelines for the diagnosis of fetal alcohol spectrum disorder (FASD), the first such update to the guidelines since 2005, will help health care providers better diagnose children exposed to alcohol during gestation.
“These new guidelines will be a valuable resource for clinicians to accurately diagnose infants and children who were affected by alcohol exposure before birth,” George F. Koob, PhD, director of the National Institute on Alcohol Abuse and Alcoholism, said in a statement. “They represent the most data-driven diagnostic criteria for fetal alcohol syndrome and fetal alcohol spectrum disorder produced to date.”
The guidelines call for a multidisciplinary approach to FASD diagnosis, which would require children suspected of FASD to be evaluated by either a pediatrician or a clinical geneticist/dysmorphologist, along with undergoing a neuropsychological and behavioral assessment. Children also should be assessed by speech pathologists, occupational therapists, physical therapists, audiologists, psychiatrists, and ophthalmologists on a case-by-case basis, if needed (Pediatrics. 2016;138[2]:e20154256).
“[FASD], the umbrella term for the range of disabilities that can result from prenatal alcohol exposure, represents the leading cause of preventable developmental disabilities in the world,” according to an NIH statement. “As a result of alcohol exposure in the womb, children can have lower IQ, restricted growth resulting in shorter height/lower weight, small head size, a characteristic pattern of facial deformities, and behavioral issues such as attention deficit, poor impulse control, and the inability to regulate mood/behavior.”
As a first step outlined in the diagnostic algorithm in the guidelines, the mothers should be assessed to determine how much prenatal alcohol was consumed; there is a table with a definition of documented prenatal alcohol exposure as it applies to the four definitions. The guidelines stress that no amount of alcohol consumption during pregnancy can be considered safe; therefore, the amount and frequency of alcohol consumption, along with any possible drug use, is critical to determining the severity of FASD in the child.
The four diagnostic categories into which FASD has been divided have not been changed in the update, although the criteria for each have been updated. These four categories, which were created by the Institute of Medicine in 1996, are: fetal alcohol syndrome (FAS), which applies to the most severely affected children; partial FAS (PFAS), which applies to children who display some, but not all, of the full spectrum of FAS characteristics; alcohol-related neurodevelopmental disorder (ARND), which applies to children who have no physical signs of FAS but do display cognitive or behavioral impairment; and alcohol-related birth defects (ARBD), which applies to children with no FAS symptoms aside from a physical malformation brought on by prenatal alcohol consumption.
“These four diagnostic categories remain the most apt descriptors of the range of disabilities observed within the continuum of FASD,” guidelines coauthor Kenneth R. Warren, MD, said in a statement. “We have refined the guidelines to reflect our collective expertise gained through the evaluation of more than 10,000 children in domestic and international venues.”
There is an extensive chart in the guidelines article documenting the updated criteria for the four diagnostic criteria.
After determining maternal alcohol consumption during pregnancy, characteristic structural features should be evaluated in the child. Typical physical signs of FASD include short palpebral fissures, a smooth philtrum, and a vermilion border of the upper lip that may be thinner than normal, along with midface hypoplasia. There is a new lip/philtrum guide for the white population, incorporating a 45-degree view in the guidelines.
From there, neurodevelopmental assessments and neuropsychological evaluations should be conducted to identify any cognitive impairments, keeping in mind that these will progress as the child ages. Finally, a multidisciplinary case conference should be held to discuss whether or not FASD should be diagnosed or not.
“These updated guidelines reflect consensus among a large and experienced cadre of FASD investigators in the fields of dysmorphology, epidemiology, neurology, psychology, developmental/ behavioral pediatrics, and educational diagnostics,” wrote the authors of the guidelines, led by H. Eugene Hoyme, MD of the University of South Dakota in Sioux Falls. “The improved specificity of these guidelines will aid clinicians in assignment of more accurate diagnoses of alcohol-exposed infants and children, thereby leading to more widespread early intervention and improved prevention efforts.”
The authors reported no relevant financial disclosures.
FROM PEDIATRICS
CDC updates diagnostic guidelines for congenital Zika virus infection
All infants who either exhibit abnormal clinical or neuroimaging findings consistent with possible Zika infection, or who exhibit normal phenotypes but are born to mothers who are positive for Zika virus infection during pregnancy, should undergo laboratory testing for the virus, according to updated diagnostic guidance from the CDC.
All infants should undergo a comprehensive physical exam at birth, as well as a neurologic examination, postnatal head ultrasound, and standard hearing tests to determine any phenotypic signs of congenital Zika infections (MMWR. ePub: 2016 Aug 19. doi: 10.15585/mmwr.mm6533e2).
Laboratory samples should be collected within 2 days of birth. Molecular testing should be done via a real-time reverse transcription–polymerase chain reaction (rRT-PCR), while serologic testing should be carried out via IgM. If the former test is positive, then the infant is Zika positive; however, if the rRT-PCR is negative but the IgM is positive, then the conclusion can only be a “probable” congenital Zika infection.
For infants with laboratory-confirmed or probable congenital Zika infection, the CDC recommends outpatient management and follow-up. For those who are found negative for Zika despite having other symptoms consistent with infection, the CDC advises continued evaluation to determine the cause of any congenital anomalies.
If an infant has no overt symptoms of Zika virus but is found to have laboratory-confirmed or probable Zika, they should be given routine newborn care along with auditory brainstem response (ABR) testing and an opthalmology examination within 1 month of birth. Infants with no overt signs of Zika and a lab-confirmed negative result can resume standard newborn care with no additional monitoring.
Outpatient care should begin with clear establishment of a medical home, followed by monitoring the child’s growth and developmental screenings at every well child visit, according to the CDC. Vision screening should be repeated at all well child visits; ABR should be repeated 4-6 months after initial testing.
“Use a standardized, validated developmental screening tool at 9 months as currently recommended, or earlier for any parental or provider concerns,” according to lead author Kate Russell, MD, of the CDC’s Epidemic Intelligence Service, and her coauthors.
Cranial ultrasound should be performed on all infants, regardless of how normal any prenatal cranial ultrasounds were. Previously, the CDC advised that if a third trimester prenatal cranial ultrasound showed no abnormalities, a postnatal cranial ultrasound was not needed.
The CDC continues to advise that a multidisciplinary approach be taken to evaluation, diagnosis, and potential treatment of infants with congenital Zika virus infection.
“Because the types of services needed to care for infants with congenital Zika syndrome are complex, CDC recommends coordinated care through a multidisciplinary team and established medical home,” according to the guidance. “As a critical component of patient care and early identification of any delays, families should be empowered to be active participants in their child’s monitoring and care.”
All infants who either exhibit abnormal clinical or neuroimaging findings consistent with possible Zika infection, or who exhibit normal phenotypes but are born to mothers who are positive for Zika virus infection during pregnancy, should undergo laboratory testing for the virus, according to updated diagnostic guidance from the CDC.
All infants should undergo a comprehensive physical exam at birth, as well as a neurologic examination, postnatal head ultrasound, and standard hearing tests to determine any phenotypic signs of congenital Zika infections (MMWR. ePub: 2016 Aug 19. doi: 10.15585/mmwr.mm6533e2).
Laboratory samples should be collected within 2 days of birth. Molecular testing should be done via a real-time reverse transcription–polymerase chain reaction (rRT-PCR), while serologic testing should be carried out via IgM. If the former test is positive, then the infant is Zika positive; however, if the rRT-PCR is negative but the IgM is positive, then the conclusion can only be a “probable” congenital Zika infection.
For infants with laboratory-confirmed or probable congenital Zika infection, the CDC recommends outpatient management and follow-up. For those who are found negative for Zika despite having other symptoms consistent with infection, the CDC advises continued evaluation to determine the cause of any congenital anomalies.
If an infant has no overt symptoms of Zika virus but is found to have laboratory-confirmed or probable Zika, they should be given routine newborn care along with auditory brainstem response (ABR) testing and an opthalmology examination within 1 month of birth. Infants with no overt signs of Zika and a lab-confirmed negative result can resume standard newborn care with no additional monitoring.
Outpatient care should begin with clear establishment of a medical home, followed by monitoring the child’s growth and developmental screenings at every well child visit, according to the CDC. Vision screening should be repeated at all well child visits; ABR should be repeated 4-6 months after initial testing.
“Use a standardized, validated developmental screening tool at 9 months as currently recommended, or earlier for any parental or provider concerns,” according to lead author Kate Russell, MD, of the CDC’s Epidemic Intelligence Service, and her coauthors.
Cranial ultrasound should be performed on all infants, regardless of how normal any prenatal cranial ultrasounds were. Previously, the CDC advised that if a third trimester prenatal cranial ultrasound showed no abnormalities, a postnatal cranial ultrasound was not needed.
The CDC continues to advise that a multidisciplinary approach be taken to evaluation, diagnosis, and potential treatment of infants with congenital Zika virus infection.
“Because the types of services needed to care for infants with congenital Zika syndrome are complex, CDC recommends coordinated care through a multidisciplinary team and established medical home,” according to the guidance. “As a critical component of patient care and early identification of any delays, families should be empowered to be active participants in their child’s monitoring and care.”
All infants who either exhibit abnormal clinical or neuroimaging findings consistent with possible Zika infection, or who exhibit normal phenotypes but are born to mothers who are positive for Zika virus infection during pregnancy, should undergo laboratory testing for the virus, according to updated diagnostic guidance from the CDC.
All infants should undergo a comprehensive physical exam at birth, as well as a neurologic examination, postnatal head ultrasound, and standard hearing tests to determine any phenotypic signs of congenital Zika infections (MMWR. ePub: 2016 Aug 19. doi: 10.15585/mmwr.mm6533e2).
Laboratory samples should be collected within 2 days of birth. Molecular testing should be done via a real-time reverse transcription–polymerase chain reaction (rRT-PCR), while serologic testing should be carried out via IgM. If the former test is positive, then the infant is Zika positive; however, if the rRT-PCR is negative but the IgM is positive, then the conclusion can only be a “probable” congenital Zika infection.
For infants with laboratory-confirmed or probable congenital Zika infection, the CDC recommends outpatient management and follow-up. For those who are found negative for Zika despite having other symptoms consistent with infection, the CDC advises continued evaluation to determine the cause of any congenital anomalies.
If an infant has no overt symptoms of Zika virus but is found to have laboratory-confirmed or probable Zika, they should be given routine newborn care along with auditory brainstem response (ABR) testing and an opthalmology examination within 1 month of birth. Infants with no overt signs of Zika and a lab-confirmed negative result can resume standard newborn care with no additional monitoring.
Outpatient care should begin with clear establishment of a medical home, followed by monitoring the child’s growth and developmental screenings at every well child visit, according to the CDC. Vision screening should be repeated at all well child visits; ABR should be repeated 4-6 months after initial testing.
“Use a standardized, validated developmental screening tool at 9 months as currently recommended, or earlier for any parental or provider concerns,” according to lead author Kate Russell, MD, of the CDC’s Epidemic Intelligence Service, and her coauthors.
Cranial ultrasound should be performed on all infants, regardless of how normal any prenatal cranial ultrasounds were. Previously, the CDC advised that if a third trimester prenatal cranial ultrasound showed no abnormalities, a postnatal cranial ultrasound was not needed.
The CDC continues to advise that a multidisciplinary approach be taken to evaluation, diagnosis, and potential treatment of infants with congenital Zika virus infection.
“Because the types of services needed to care for infants with congenital Zika syndrome are complex, CDC recommends coordinated care through a multidisciplinary team and established medical home,” according to the guidance. “As a critical component of patient care and early identification of any delays, families should be empowered to be active participants in their child’s monitoring and care.”
FROM MMWR
Can anesthesia in infants affect IQ scores?
About 10,000 newborns receive general anesthesia for congenital heart defects every year, and the more exposure they have to inhaled anesthetic agents, the greater effect it may have on their neurologic development, investigators at Children’s Hospital of Philadelphia reported in a study of newborns with hypoplastic left heart syndrome.
While previous studies have linked worse neurodevelopment to patient factors like prematurity and genetics, this is the first study to show a consistent relationship between neurodevelopment outcomes and modifiable factors during cardiac surgery in infants, Laura K. Diaz, MD, and her colleagues reported in the August issue of the Journal of Thoracic and Cardiovascular Surgery (J Thorac Cardiovasc Surg. 2016;152:482-9).
They studied 96 patients with hypoplastic left heart syndrome (HLHS) or similar syndromes who received volatile anesthetic agents (VAA) at their institution from 1998 to 2003. The patients underwent a battery of neurodevelopmental tests between the ages of 4 and 5 years that included full-scale IQ (FSIQ), verbal IQ (VIQ), performance IQ (PIQ), and processing speed.
“This study provides evidence that in children undergoing staged reconstructive surgery for HLHS, increasing cumulative exposure to VAAs beginning in infancy is associated with worse performance for FSIQ and VIQ, suggesting that VAA exposure may be a modifiable risk factor for adverse neurodevelopment outcomes,” Dr. Diaz and her colleagues wrote.
While survival has improved significantly in recent years for infants with hypoplastic left heart syndrome, physicians have harbored concerns that these children encounter neurodevelopmental issues later on. Dr. Diaz and her colleagues acknowledged that previous studies have shown factors, such as the use of cardiopulmonary bypass (CPB) and hospital length of stay, that could affect neurodevelopment in these children, but the findings have been inconsistent. Instead, those studies have shown such patient-specific factors as birth weight, ethnicity, and hereditary disorders were strong determinants of neurodevelopment in infants who have cardiac surgery, Dr. Diaz and her coauthors pointed out.
Their own previous study of patients with single-ventricle congenital heart disease concurred with the findings of those other studies, but it did not evaluate exposure to anesthesia (J. Thorac. Cardiovasc. Surg. 2014;147:1276-82). That was the focus of their current study.
Among the study group, 94 patients had an initial operation with CPB in their first 30 days of life. All 96 infants in the study group had additional operations, whether cardiac or noncardiac. The study tracked all anesthetic exposures up until the neurodevelopment evaluation in February 2008. All but 2 patients had initial VAA exposure at less than 1 year of age, and 45 at less than 1 month of age. Deep hypothermic circulatory arrest was used uniformly for aortic arch reconstruction.
The study used four different generalized linear models to evaluate anesthesia exposure and neurodevelopment.
For both FSIQ and PIQ, total minimum alveolar concentration hours were deemed to be statistically significant factors for lower scores. For PIQ, birth weight and length of postoperative hospital stay were statistically significant. For processing speed, gestational age and length of hospital stay were statistically significant.
Dr. Diaz and her colleagues said their findings are preliminary and do not justify a change in practice. “Prospective randomized, controlled multicenter clinical trials are indicated to continue to clarify the effects of early and repetitive exposure to VAA in this and other pediatric populations,” the study authors concluded.
Dr. Diaz and the study authors had no financial relationships to disclose.
The study by Dr. Diaz and her colleagues makes all the more clear the need for a prospective randomized trial on the effect inhaled anesthetic agents in infants can have on their neurologic development, Richard A. Jonas, MD, of Children’s National Heart Institute, Children’s National Medical Center, Washington, said in his invited commentary (J. Thorac. Cardiovasc. Surg. 2016;152:490).
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Dr. Richard A. Jonas |
However, besides the study limitations that Dr. Diaz and her colleagues pointed out in their study, another “problem” Dr. Jonas noted with the study subjects was that they had staged reconstruction for hypoplastic left heart syndrome. “Not only is this group of patients at risk for prenatal effects of their abnormal in utero circulation, but in addition, they all underwent additional cardiac or noncardiac procedures after their initial cardiac surgery,” he said. These factors, along with some degree of cyanosis in their formative years, may help explain why this study is an outlier in that it did not implicate nonoperative factors that other studies implicated, Dr. Jonas said.
Nonetheless, the study is “an important contribution that adds further evidence to the observation that volatile agents can affect neurodevelopmental outcome,” Dr. Jonas said. Hence the need for a prospective randomized trial.
Dr. Jonas had no financial relationships to disclose.
The study by Dr. Diaz and her colleagues makes all the more clear the need for a prospective randomized trial on the effect inhaled anesthetic agents in infants can have on their neurologic development, Richard A. Jonas, MD, of Children’s National Heart Institute, Children’s National Medical Center, Washington, said in his invited commentary (J. Thorac. Cardiovasc. Surg. 2016;152:490).
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Dr. Richard A. Jonas |
However, besides the study limitations that Dr. Diaz and her colleagues pointed out in their study, another “problem” Dr. Jonas noted with the study subjects was that they had staged reconstruction for hypoplastic left heart syndrome. “Not only is this group of patients at risk for prenatal effects of their abnormal in utero circulation, but in addition, they all underwent additional cardiac or noncardiac procedures after their initial cardiac surgery,” he said. These factors, along with some degree of cyanosis in their formative years, may help explain why this study is an outlier in that it did not implicate nonoperative factors that other studies implicated, Dr. Jonas said.
Nonetheless, the study is “an important contribution that adds further evidence to the observation that volatile agents can affect neurodevelopmental outcome,” Dr. Jonas said. Hence the need for a prospective randomized trial.
Dr. Jonas had no financial relationships to disclose.
The study by Dr. Diaz and her colleagues makes all the more clear the need for a prospective randomized trial on the effect inhaled anesthetic agents in infants can have on their neurologic development, Richard A. Jonas, MD, of Children’s National Heart Institute, Children’s National Medical Center, Washington, said in his invited commentary (J. Thorac. Cardiovasc. Surg. 2016;152:490).
|
|
Dr. Richard A. Jonas |
However, besides the study limitations that Dr. Diaz and her colleagues pointed out in their study, another “problem” Dr. Jonas noted with the study subjects was that they had staged reconstruction for hypoplastic left heart syndrome. “Not only is this group of patients at risk for prenatal effects of their abnormal in utero circulation, but in addition, they all underwent additional cardiac or noncardiac procedures after their initial cardiac surgery,” he said. These factors, along with some degree of cyanosis in their formative years, may help explain why this study is an outlier in that it did not implicate nonoperative factors that other studies implicated, Dr. Jonas said.
Nonetheless, the study is “an important contribution that adds further evidence to the observation that volatile agents can affect neurodevelopmental outcome,” Dr. Jonas said. Hence the need for a prospective randomized trial.
Dr. Jonas had no financial relationships to disclose.
About 10,000 newborns receive general anesthesia for congenital heart defects every year, and the more exposure they have to inhaled anesthetic agents, the greater effect it may have on their neurologic development, investigators at Children’s Hospital of Philadelphia reported in a study of newborns with hypoplastic left heart syndrome.
While previous studies have linked worse neurodevelopment to patient factors like prematurity and genetics, this is the first study to show a consistent relationship between neurodevelopment outcomes and modifiable factors during cardiac surgery in infants, Laura K. Diaz, MD, and her colleagues reported in the August issue of the Journal of Thoracic and Cardiovascular Surgery (J Thorac Cardiovasc Surg. 2016;152:482-9).
They studied 96 patients with hypoplastic left heart syndrome (HLHS) or similar syndromes who received volatile anesthetic agents (VAA) at their institution from 1998 to 2003. The patients underwent a battery of neurodevelopmental tests between the ages of 4 and 5 years that included full-scale IQ (FSIQ), verbal IQ (VIQ), performance IQ (PIQ), and processing speed.
“This study provides evidence that in children undergoing staged reconstructive surgery for HLHS, increasing cumulative exposure to VAAs beginning in infancy is associated with worse performance for FSIQ and VIQ, suggesting that VAA exposure may be a modifiable risk factor for adverse neurodevelopment outcomes,” Dr. Diaz and her colleagues wrote.
While survival has improved significantly in recent years for infants with hypoplastic left heart syndrome, physicians have harbored concerns that these children encounter neurodevelopmental issues later on. Dr. Diaz and her colleagues acknowledged that previous studies have shown factors, such as the use of cardiopulmonary bypass (CPB) and hospital length of stay, that could affect neurodevelopment in these children, but the findings have been inconsistent. Instead, those studies have shown such patient-specific factors as birth weight, ethnicity, and hereditary disorders were strong determinants of neurodevelopment in infants who have cardiac surgery, Dr. Diaz and her coauthors pointed out.
Their own previous study of patients with single-ventricle congenital heart disease concurred with the findings of those other studies, but it did not evaluate exposure to anesthesia (J. Thorac. Cardiovasc. Surg. 2014;147:1276-82). That was the focus of their current study.
Among the study group, 94 patients had an initial operation with CPB in their first 30 days of life. All 96 infants in the study group had additional operations, whether cardiac or noncardiac. The study tracked all anesthetic exposures up until the neurodevelopment evaluation in February 2008. All but 2 patients had initial VAA exposure at less than 1 year of age, and 45 at less than 1 month of age. Deep hypothermic circulatory arrest was used uniformly for aortic arch reconstruction.
The study used four different generalized linear models to evaluate anesthesia exposure and neurodevelopment.
For both FSIQ and PIQ, total minimum alveolar concentration hours were deemed to be statistically significant factors for lower scores. For PIQ, birth weight and length of postoperative hospital stay were statistically significant. For processing speed, gestational age and length of hospital stay were statistically significant.
Dr. Diaz and her colleagues said their findings are preliminary and do not justify a change in practice. “Prospective randomized, controlled multicenter clinical trials are indicated to continue to clarify the effects of early and repetitive exposure to VAA in this and other pediatric populations,” the study authors concluded.
Dr. Diaz and the study authors had no financial relationships to disclose.
About 10,000 newborns receive general anesthesia for congenital heart defects every year, and the more exposure they have to inhaled anesthetic agents, the greater effect it may have on their neurologic development, investigators at Children’s Hospital of Philadelphia reported in a study of newborns with hypoplastic left heart syndrome.
While previous studies have linked worse neurodevelopment to patient factors like prematurity and genetics, this is the first study to show a consistent relationship between neurodevelopment outcomes and modifiable factors during cardiac surgery in infants, Laura K. Diaz, MD, and her colleagues reported in the August issue of the Journal of Thoracic and Cardiovascular Surgery (J Thorac Cardiovasc Surg. 2016;152:482-9).
They studied 96 patients with hypoplastic left heart syndrome (HLHS) or similar syndromes who received volatile anesthetic agents (VAA) at their institution from 1998 to 2003. The patients underwent a battery of neurodevelopmental tests between the ages of 4 and 5 years that included full-scale IQ (FSIQ), verbal IQ (VIQ), performance IQ (PIQ), and processing speed.
“This study provides evidence that in children undergoing staged reconstructive surgery for HLHS, increasing cumulative exposure to VAAs beginning in infancy is associated with worse performance for FSIQ and VIQ, suggesting that VAA exposure may be a modifiable risk factor for adverse neurodevelopment outcomes,” Dr. Diaz and her colleagues wrote.
While survival has improved significantly in recent years for infants with hypoplastic left heart syndrome, physicians have harbored concerns that these children encounter neurodevelopmental issues later on. Dr. Diaz and her colleagues acknowledged that previous studies have shown factors, such as the use of cardiopulmonary bypass (CPB) and hospital length of stay, that could affect neurodevelopment in these children, but the findings have been inconsistent. Instead, those studies have shown such patient-specific factors as birth weight, ethnicity, and hereditary disorders were strong determinants of neurodevelopment in infants who have cardiac surgery, Dr. Diaz and her coauthors pointed out.
Their own previous study of patients with single-ventricle congenital heart disease concurred with the findings of those other studies, but it did not evaluate exposure to anesthesia (J. Thorac. Cardiovasc. Surg. 2014;147:1276-82). That was the focus of their current study.
Among the study group, 94 patients had an initial operation with CPB in their first 30 days of life. All 96 infants in the study group had additional operations, whether cardiac or noncardiac. The study tracked all anesthetic exposures up until the neurodevelopment evaluation in February 2008. All but 2 patients had initial VAA exposure at less than 1 year of age, and 45 at less than 1 month of age. Deep hypothermic circulatory arrest was used uniformly for aortic arch reconstruction.
The study used four different generalized linear models to evaluate anesthesia exposure and neurodevelopment.
For both FSIQ and PIQ, total minimum alveolar concentration hours were deemed to be statistically significant factors for lower scores. For PIQ, birth weight and length of postoperative hospital stay were statistically significant. For processing speed, gestational age and length of hospital stay were statistically significant.
Dr. Diaz and her colleagues said their findings are preliminary and do not justify a change in practice. “Prospective randomized, controlled multicenter clinical trials are indicated to continue to clarify the effects of early and repetitive exposure to VAA in this and other pediatric populations,” the study authors concluded.
Dr. Diaz and the study authors had no financial relationships to disclose.
FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
Key clinical point: Volatile inhaled anesthesia may affect neurodevelopment in infants with hypoplastic left heart syndrome.
Major finding: Different generalized linear models determined an association between minimum alveolar concentration hours and hospital length of stay with lower IQ scores and processing speed.
Data source: Meta-analysis reviewed a subgroup of 96 patients with hypoplastic left heart syndrome who had neurodevelopmental testing at a single center between 1998 and 2003.
Disclosures: The authors have no financial relationships to disclose.
Autism follow-up screening by PCPs yields high accuracy
Primary care providers can effectively conduct the follow-up interview after a positive screening on the Modified Checklist for Autism in Toddlers (M-CHAT) without missing cases or flagging too many false positives, suggests a recent study.
“The online M-CHAT/F [M-CHAT Follow-up Interview] enabled PCPs [primary care providers] to clarify positive parent responses to M-CHAT items during well-child visits, rather than requiring another visit or call by a trained interviewer,” wrote Raymond Sturner, MD, of Johns Hopkins University, Baltimore, and his colleagues.
“This study found that the performance of the M-CHAT/F by a PCP was equivalent to one administered by trained Kennedy Krieger Institute Center for Autism and Related Disorders staff,” they wrote (Pediatrics. 2016 Aug 19. doi: 10.1542/peds.2015-3036). “This report is the first demonstrating feasibility of administration of the M-CHAT/F during the time of well-child visit in community practices.”
The authors recruited 47 primary care providers at 22 clinics in Maryland to complete an M-CHAT/F during children’s 18- and 24-month routine visits if their initial M-CHAT yielded a positive screening. Each family was then contacted again for an M-CHAT/F conducted by a trained research assistant from the Kennedy Krieger Institute Center for Autism and Related Disorders.
The PCPs volunteered for the study and primarily had suburban practices, with just 18% rural and 9% urban practices. Just under a third of children at the practices were insured by Medicaid, and the demographic breakdown included 39% white, 33% African-American, 16% Asian, and 8% Hispanic.
Of the 5,071 children screened (mean age, 23 months), 6.7% had a positive screen. Of the 197 M-CHAT/Fs the PCPs completed, 99 children then underwent a full autism spectrum disorder (ASD) diagnostic evaluation, including administration of the Autism Diagnostic Observation Schedule and the Mullen Scales of Early Learning.
PCPs and research assistants agreed 86.6% of the time on the result of the M-CHAT/F screening, with statistically equivalent positive predictive value (PPV), sensitivity, specificity, and overall accuracy. The research assistants’ PPV was 0.84, and the PCPs’ PPV was 0.88. The PPV for any developmental delay diagnosis was similarly equivalent between the research assistants and PCPs.
Dr. Sturner and his associates noted that the findings confirm “previous studies showing that most children with false-positive screens have developmental difficulties of a degree that would make them eligible for early intervention. Some children with false-positive screens had atypical features not meeting criteria for ASD.”
The National Institutes of Mental Health funded the research. Dr. Sturner is director of Total Child Health (TCH), a for-profit subsidiary of the Center for Promotion of Child Development through Primary Care, which conducted the study. Barbara Howard, MD, is president of TCH. Tanya Morrel, PhD, is an employee of and stockholder in TCH, and Paul Bergmann has consulted for the company. The remaining authors had no relevant disclosures.
Primary care providers can effectively conduct the follow-up interview after a positive screening on the Modified Checklist for Autism in Toddlers (M-CHAT) without missing cases or flagging too many false positives, suggests a recent study.
“The online M-CHAT/F [M-CHAT Follow-up Interview] enabled PCPs [primary care providers] to clarify positive parent responses to M-CHAT items during well-child visits, rather than requiring another visit or call by a trained interviewer,” wrote Raymond Sturner, MD, of Johns Hopkins University, Baltimore, and his colleagues.
“This study found that the performance of the M-CHAT/F by a PCP was equivalent to one administered by trained Kennedy Krieger Institute Center for Autism and Related Disorders staff,” they wrote (Pediatrics. 2016 Aug 19. doi: 10.1542/peds.2015-3036). “This report is the first demonstrating feasibility of administration of the M-CHAT/F during the time of well-child visit in community practices.”
The authors recruited 47 primary care providers at 22 clinics in Maryland to complete an M-CHAT/F during children’s 18- and 24-month routine visits if their initial M-CHAT yielded a positive screening. Each family was then contacted again for an M-CHAT/F conducted by a trained research assistant from the Kennedy Krieger Institute Center for Autism and Related Disorders.
The PCPs volunteered for the study and primarily had suburban practices, with just 18% rural and 9% urban practices. Just under a third of children at the practices were insured by Medicaid, and the demographic breakdown included 39% white, 33% African-American, 16% Asian, and 8% Hispanic.
Of the 5,071 children screened (mean age, 23 months), 6.7% had a positive screen. Of the 197 M-CHAT/Fs the PCPs completed, 99 children then underwent a full autism spectrum disorder (ASD) diagnostic evaluation, including administration of the Autism Diagnostic Observation Schedule and the Mullen Scales of Early Learning.
PCPs and research assistants agreed 86.6% of the time on the result of the M-CHAT/F screening, with statistically equivalent positive predictive value (PPV), sensitivity, specificity, and overall accuracy. The research assistants’ PPV was 0.84, and the PCPs’ PPV was 0.88. The PPV for any developmental delay diagnosis was similarly equivalent between the research assistants and PCPs.
Dr. Sturner and his associates noted that the findings confirm “previous studies showing that most children with false-positive screens have developmental difficulties of a degree that would make them eligible for early intervention. Some children with false-positive screens had atypical features not meeting criteria for ASD.”
The National Institutes of Mental Health funded the research. Dr. Sturner is director of Total Child Health (TCH), a for-profit subsidiary of the Center for Promotion of Child Development through Primary Care, which conducted the study. Barbara Howard, MD, is president of TCH. Tanya Morrel, PhD, is an employee of and stockholder in TCH, and Paul Bergmann has consulted for the company. The remaining authors had no relevant disclosures.
Primary care providers can effectively conduct the follow-up interview after a positive screening on the Modified Checklist for Autism in Toddlers (M-CHAT) without missing cases or flagging too many false positives, suggests a recent study.
“The online M-CHAT/F [M-CHAT Follow-up Interview] enabled PCPs [primary care providers] to clarify positive parent responses to M-CHAT items during well-child visits, rather than requiring another visit or call by a trained interviewer,” wrote Raymond Sturner, MD, of Johns Hopkins University, Baltimore, and his colleagues.
“This study found that the performance of the M-CHAT/F by a PCP was equivalent to one administered by trained Kennedy Krieger Institute Center for Autism and Related Disorders staff,” they wrote (Pediatrics. 2016 Aug 19. doi: 10.1542/peds.2015-3036). “This report is the first demonstrating feasibility of administration of the M-CHAT/F during the time of well-child visit in community practices.”
The authors recruited 47 primary care providers at 22 clinics in Maryland to complete an M-CHAT/F during children’s 18- and 24-month routine visits if their initial M-CHAT yielded a positive screening. Each family was then contacted again for an M-CHAT/F conducted by a trained research assistant from the Kennedy Krieger Institute Center for Autism and Related Disorders.
The PCPs volunteered for the study and primarily had suburban practices, with just 18% rural and 9% urban practices. Just under a third of children at the practices were insured by Medicaid, and the demographic breakdown included 39% white, 33% African-American, 16% Asian, and 8% Hispanic.
Of the 5,071 children screened (mean age, 23 months), 6.7% had a positive screen. Of the 197 M-CHAT/Fs the PCPs completed, 99 children then underwent a full autism spectrum disorder (ASD) diagnostic evaluation, including administration of the Autism Diagnostic Observation Schedule and the Mullen Scales of Early Learning.
PCPs and research assistants agreed 86.6% of the time on the result of the M-CHAT/F screening, with statistically equivalent positive predictive value (PPV), sensitivity, specificity, and overall accuracy. The research assistants’ PPV was 0.84, and the PCPs’ PPV was 0.88. The PPV for any developmental delay diagnosis was similarly equivalent between the research assistants and PCPs.
Dr. Sturner and his associates noted that the findings confirm “previous studies showing that most children with false-positive screens have developmental difficulties of a degree that would make them eligible for early intervention. Some children with false-positive screens had atypical features not meeting criteria for ASD.”
The National Institutes of Mental Health funded the research. Dr. Sturner is director of Total Child Health (TCH), a for-profit subsidiary of the Center for Promotion of Child Development through Primary Care, which conducted the study. Barbara Howard, MD, is president of TCH. Tanya Morrel, PhD, is an employee of and stockholder in TCH, and Paul Bergmann has consulted for the company. The remaining authors had no relevant disclosures.
FROM PEDIATRICS
Key clinical point: Primary care providers can conduct the M-CHAT/F following a positive M-CHAT screening for autism spectrum disorders.
Major finding: Primary care providers and trained interviewers agreed 86.6% of the time on the screening results of the M-CHAT/F for ASDs.
Data source: A cohort study of 5,071 children, mean age 23 months, screened with the M-CHAT, and a subsequent 197 children screened with the M-CHAT/F in 22 Maryland primary care practices.
Disclosures: The National Institutes of Mental Health funded the research. Dr. Sturner is director of Total Child Health (TCH), a for-profit subsidiary of the Center for Promotion of Child Development through Primary Care, which conducted the study. Barbara Howard, MD, is president of TCH. Tanya Morrel, PhD, is an employee of and stockholder in TCH, and Paul Bergmann has consulted for the company. The remaining authors had no relevant disclosures.
Clean-catch urine method effective in young infants
Urine samples from a noninvasive clean-catch method have no significantly greater contamination rate than do those from urethral catheterization, making clean catch a quick, effective option to attempt before catheterization, a recent study found.
The clean-catch method uses a standard bladder stimulation technique and was most successful in infants less than 90 days old.
“Because the use of urethral catheterization is an invasive method that could be associated with adverse events in up to 20% of children, our findings support the use of the clean-catch urine standardized stimulation technique as an alternative to invasive methods to obtain a urine specimen,” wrote Mélanie Labrosse, MD, PhD, and her associates at the University of Montreal (Pediatrics. 2016 Aug 19. doi: 10.1542/peds.2016-0573). “However, until further studies on proportion and predictive factors of contamination become available, it would be more cautious to perform invasive methods in children who appear ill, who have a positive urinalysis, or before beginning antibiotics.”
The clean-catch method involved providing the infants an opportunity to feed over 20 minutes, after which a practitioner cleaned the genitals and the parent then held the infant by the armpits. Female infants’ hips were flexed and male infants’ legs dangled.
“Examiners then alternated between bladder stimulation maneuvers, which consisted of gentle tapping in the suprapubic area at a frequency of 100 taps per minute for 30 seconds, and lumbar paravertebral massage maneuvers for 30 seconds,” the authors wrote. “These two stimulation maneuvers were repeated until micturition began or for a maximum of 300 seconds.”
The researchers attempted the clean-catch technique with 126 infants under 6 months old. About half were boys, a quarter of whom were circumcised, and the whole sample had a median age of 55 days. The procedure took a median 45 seconds and was effective in 49% of the children (at least 1 mL of urine collected within 5 minutes).
The procedure was more likely to be effective in infants under 3 months old, with three times greater odds of success for those aged 30-59 days and four times greater odds of success for those aged 0-29 days and those aged 60-89 days (odds ratio 3.2, 4.3, and 4.4, respectively). Only 26% of the children aged 91-180 days yielded a successful clean-catch sample, compared with 61% of infants under 30 days and 54% of infants under 90 days old. UTI was present in 11 (9%) children.
Likelihood of a successful clean-catch sample was not affected by infant sex, low oral intake, or recent urination (within an hour).
While 16% of the clean catches were contaminated, this rate was not statistically different from the 6% of contaminated samples among those undergoing the invasive method.
The authors suggested using the clean-catch technique as a first attempt in two situations: ruling out UTI in children aged 2-6 months and in children under 6 months who need a urinalysis in which urine typically would be obtained noninvasively.
“In addition, trying the CCU procedure instead of using a collection bag seems reasonable, considering the wait time associated with this technique and the logistics involved in changing the bag every 30 minutes,” the authors noted.
They reported having no disclosures. No external funding source was noted in the study.
Urine samples from a noninvasive clean-catch method have no significantly greater contamination rate than do those from urethral catheterization, making clean catch a quick, effective option to attempt before catheterization, a recent study found.
The clean-catch method uses a standard bladder stimulation technique and was most successful in infants less than 90 days old.
“Because the use of urethral catheterization is an invasive method that could be associated with adverse events in up to 20% of children, our findings support the use of the clean-catch urine standardized stimulation technique as an alternative to invasive methods to obtain a urine specimen,” wrote Mélanie Labrosse, MD, PhD, and her associates at the University of Montreal (Pediatrics. 2016 Aug 19. doi: 10.1542/peds.2016-0573). “However, until further studies on proportion and predictive factors of contamination become available, it would be more cautious to perform invasive methods in children who appear ill, who have a positive urinalysis, or before beginning antibiotics.”
The clean-catch method involved providing the infants an opportunity to feed over 20 minutes, after which a practitioner cleaned the genitals and the parent then held the infant by the armpits. Female infants’ hips were flexed and male infants’ legs dangled.
“Examiners then alternated between bladder stimulation maneuvers, which consisted of gentle tapping in the suprapubic area at a frequency of 100 taps per minute for 30 seconds, and lumbar paravertebral massage maneuvers for 30 seconds,” the authors wrote. “These two stimulation maneuvers were repeated until micturition began or for a maximum of 300 seconds.”
The researchers attempted the clean-catch technique with 126 infants under 6 months old. About half were boys, a quarter of whom were circumcised, and the whole sample had a median age of 55 days. The procedure took a median 45 seconds and was effective in 49% of the children (at least 1 mL of urine collected within 5 minutes).
The procedure was more likely to be effective in infants under 3 months old, with three times greater odds of success for those aged 30-59 days and four times greater odds of success for those aged 0-29 days and those aged 60-89 days (odds ratio 3.2, 4.3, and 4.4, respectively). Only 26% of the children aged 91-180 days yielded a successful clean-catch sample, compared with 61% of infants under 30 days and 54% of infants under 90 days old. UTI was present in 11 (9%) children.
Likelihood of a successful clean-catch sample was not affected by infant sex, low oral intake, or recent urination (within an hour).
While 16% of the clean catches were contaminated, this rate was not statistically different from the 6% of contaminated samples among those undergoing the invasive method.
The authors suggested using the clean-catch technique as a first attempt in two situations: ruling out UTI in children aged 2-6 months and in children under 6 months who need a urinalysis in which urine typically would be obtained noninvasively.
“In addition, trying the CCU procedure instead of using a collection bag seems reasonable, considering the wait time associated with this technique and the logistics involved in changing the bag every 30 minutes,” the authors noted.
They reported having no disclosures. No external funding source was noted in the study.
Urine samples from a noninvasive clean-catch method have no significantly greater contamination rate than do those from urethral catheterization, making clean catch a quick, effective option to attempt before catheterization, a recent study found.
The clean-catch method uses a standard bladder stimulation technique and was most successful in infants less than 90 days old.
“Because the use of urethral catheterization is an invasive method that could be associated with adverse events in up to 20% of children, our findings support the use of the clean-catch urine standardized stimulation technique as an alternative to invasive methods to obtain a urine specimen,” wrote Mélanie Labrosse, MD, PhD, and her associates at the University of Montreal (Pediatrics. 2016 Aug 19. doi: 10.1542/peds.2016-0573). “However, until further studies on proportion and predictive factors of contamination become available, it would be more cautious to perform invasive methods in children who appear ill, who have a positive urinalysis, or before beginning antibiotics.”
The clean-catch method involved providing the infants an opportunity to feed over 20 minutes, after which a practitioner cleaned the genitals and the parent then held the infant by the armpits. Female infants’ hips were flexed and male infants’ legs dangled.
“Examiners then alternated between bladder stimulation maneuvers, which consisted of gentle tapping in the suprapubic area at a frequency of 100 taps per minute for 30 seconds, and lumbar paravertebral massage maneuvers for 30 seconds,” the authors wrote. “These two stimulation maneuvers were repeated until micturition began or for a maximum of 300 seconds.”
The researchers attempted the clean-catch technique with 126 infants under 6 months old. About half were boys, a quarter of whom were circumcised, and the whole sample had a median age of 55 days. The procedure took a median 45 seconds and was effective in 49% of the children (at least 1 mL of urine collected within 5 minutes).
The procedure was more likely to be effective in infants under 3 months old, with three times greater odds of success for those aged 30-59 days and four times greater odds of success for those aged 0-29 days and those aged 60-89 days (odds ratio 3.2, 4.3, and 4.4, respectively). Only 26% of the children aged 91-180 days yielded a successful clean-catch sample, compared with 61% of infants under 30 days and 54% of infants under 90 days old. UTI was present in 11 (9%) children.
Likelihood of a successful clean-catch sample was not affected by infant sex, low oral intake, or recent urination (within an hour).
While 16% of the clean catches were contaminated, this rate was not statistically different from the 6% of contaminated samples among those undergoing the invasive method.
The authors suggested using the clean-catch technique as a first attempt in two situations: ruling out UTI in children aged 2-6 months and in children under 6 months who need a urinalysis in which urine typically would be obtained noninvasively.
“In addition, trying the CCU procedure instead of using a collection bag seems reasonable, considering the wait time associated with this technique and the logistics involved in changing the bag every 30 minutes,” the authors noted.
They reported having no disclosures. No external funding source was noted in the study.
FROM PEDIATRICS
Key clinical point: A noninvasive clean-catch urine sample method can be effective in infants under 90 days old.
Major finding: Forty-nine percent of infants under 6 months old produced a successful clean catch; odds of success were 3-4 times greater in infants under 90 days.
Data source: A prospective cohort study of 126 infants under 6 months old in a Montreal pediatric emergency department between May and October 2015.
Disclosures: The authors reported having no disclosures. No external funding source was noted in the study.
Pertussis often goes undiagnosed, especially in adults
A majority of pertussis cases in the United States may go undetected in people under the age of 50, particularly in adults, results of a retrospective database cohort study suggest.
“The incidence of pertussis in adolescents and adults is very difficult to quantify,” wrote Chi-Chang Chen, MD, of IMS Health, Plymouth Meeting, Pa., and associates. Symptoms may be misdiagnosed as other respiratory illnesses, infected individuals may not seek treatment, and pertussis may not be considered as a possible diagnosis in adults, they noted.
To project the possible range of pertussis incidence in this population, the investigator used three different models to analyze information from private insurance and laboratory databases as well as data from the Centers for Disease Control and Prevention for a 6-year period. The first method, which used medical claims for ICD-9 diagnosed pertussis, found an annual incidence rate of 9/100,000 population. The second used a proxy pertussis model that was based on symptoms that could indicate undiagnosed pertussis, showing an incidence rate of 21/100,000. The third method used pathogen data to estimate the fraction of cough illness statistically attributable to pertussis, resulting in an incidence rate of 649/100,000 population, which is 58-93 times higher than the ICD-9 estimated incidence.
These estimates “highlight the need for improved preventive measures – such as increased vaccination – against pertussis,” the investigators said, noting that immunization recommendations for additional age groups and research involving strategies to reduce waning immunity after vaccination should be considered.
The study was funded by GlaxoSmithKline Vaccines.
Read the full study in Human Vaccines & Immunotherapeutics (2016 May. doi: 10.1080/21645515.2016.1186313).
A majority of pertussis cases in the United States may go undetected in people under the age of 50, particularly in adults, results of a retrospective database cohort study suggest.
“The incidence of pertussis in adolescents and adults is very difficult to quantify,” wrote Chi-Chang Chen, MD, of IMS Health, Plymouth Meeting, Pa., and associates. Symptoms may be misdiagnosed as other respiratory illnesses, infected individuals may not seek treatment, and pertussis may not be considered as a possible diagnosis in adults, they noted.
To project the possible range of pertussis incidence in this population, the investigator used three different models to analyze information from private insurance and laboratory databases as well as data from the Centers for Disease Control and Prevention for a 6-year period. The first method, which used medical claims for ICD-9 diagnosed pertussis, found an annual incidence rate of 9/100,000 population. The second used a proxy pertussis model that was based on symptoms that could indicate undiagnosed pertussis, showing an incidence rate of 21/100,000. The third method used pathogen data to estimate the fraction of cough illness statistically attributable to pertussis, resulting in an incidence rate of 649/100,000 population, which is 58-93 times higher than the ICD-9 estimated incidence.
These estimates “highlight the need for improved preventive measures – such as increased vaccination – against pertussis,” the investigators said, noting that immunization recommendations for additional age groups and research involving strategies to reduce waning immunity after vaccination should be considered.
The study was funded by GlaxoSmithKline Vaccines.
Read the full study in Human Vaccines & Immunotherapeutics (2016 May. doi: 10.1080/21645515.2016.1186313).
A majority of pertussis cases in the United States may go undetected in people under the age of 50, particularly in adults, results of a retrospective database cohort study suggest.
“The incidence of pertussis in adolescents and adults is very difficult to quantify,” wrote Chi-Chang Chen, MD, of IMS Health, Plymouth Meeting, Pa., and associates. Symptoms may be misdiagnosed as other respiratory illnesses, infected individuals may not seek treatment, and pertussis may not be considered as a possible diagnosis in adults, they noted.
To project the possible range of pertussis incidence in this population, the investigator used three different models to analyze information from private insurance and laboratory databases as well as data from the Centers for Disease Control and Prevention for a 6-year period. The first method, which used medical claims for ICD-9 diagnosed pertussis, found an annual incidence rate of 9/100,000 population. The second used a proxy pertussis model that was based on symptoms that could indicate undiagnosed pertussis, showing an incidence rate of 21/100,000. The third method used pathogen data to estimate the fraction of cough illness statistically attributable to pertussis, resulting in an incidence rate of 649/100,000 population, which is 58-93 times higher than the ICD-9 estimated incidence.
These estimates “highlight the need for improved preventive measures – such as increased vaccination – against pertussis,” the investigators said, noting that immunization recommendations for additional age groups and research involving strategies to reduce waning immunity after vaccination should be considered.
The study was funded by GlaxoSmithKline Vaccines.
Read the full study in Human Vaccines & Immunotherapeutics (2016 May. doi: 10.1080/21645515.2016.1186313).
FROM HUMAN VACCINES & IMMUNOTHERAPEUTICS
DEET and picaridin safely protect against insect bites
BOSTON – Insect repellents containing DEET or picaridin are safe when used properly, and are important for bite protection in children, according to Mercedes E. Gonzalez, MD.
Insect bite reactions are common in children aged 2-10 years, and the emergence of Zika virus raises new concerns about the dangers of mosquito bites, in particular; the World Health Organization has declared Zika-related effects – namely microcephaly and Guillain-Barré syndrome – to be a “public health emergency of international concern.”
In children, illness associated with Zika virus is generally mild, but can include fever, rash, conjunctivitis, and/or arthralgia, Dr. Gonzalez said at the American Academy of Dermatology summer meeting.
DEET, used since 1957, is effective against mosquitoes, black flies, ticks, mites, and land leeches. It works by forming a vapor barrier that deters insects from coming into contact with the skin. The barrier extends about 4 cm from the skin. DEET can also be used on clothing but may cause damage to spandex, rayon, acetate, and leather, and can dissolve plastic and vinyl.
Although it is available in concentrations of 5%-100%, concentrations of 10%-35% provide adequate protection in most situations, said Dr. Gonzalez of the University of Miami.
Animal studies using large doses have shown that DEET is not a specific neurotoxin, and while there have been case reports of central nervous system toxicity in humans, there is no link to DEET dose or mechanistic pathway. Reported deaths have involved intentional ingestion and overuse or incorrect use of products, she said.
In fact, safety concerns are so minimal that the Environmental Protection Agency removed labels indicating caution in children, and the American Academy of Pediatrics recommends the use of DEET for preventing insect bites in children older than age 2 months, and in pregnant and lactating women.
One DEET safety concern, however, is flammability. Both DEET and the aerosol vehicle used in some DEET-containing products, are flammable, so caution is warranted, she said. Occlusion following use of DEET should also be avoided as it can increase absorption, and the product should be washed off after use.
Picaridin is another insect repellent that, like DEET, forms a vapor barrier to deter insects from getting close to the skin and biting, and can be used on both the skin and clothing, but it does not damage plastics or fabrics.
It has similar efficacy as DEET, and has a number of advantages over DEET in that it is odorless and does not feel sticky or greasy when applied. It has not been reported to cause any serious toxicity or mutagenesis.
Picaridin – which is effective against mosquitoes, dog and deer ticks, chiggers, and flies – has been used in Australia since 1998, and in the United States since 2005. That year, the Centers for Disease Control and Prevention recommended that it be used to protect against West Nile virus, and the World Health Organization said it was the best agent for preventing malaria, Dr. Gonzalez noted.
“So when [patients] ask about the best insect repellent, for most situations I do recommend DEET or picaridin, at 10%-25% for DEET, or 7%-15% for picaridin,” she said. She encourages people to read labels, noting that the EPA is encouraging the use of “repellency awareness” labels on insect repellents to inform the consumer whether it prevents against mosquitoes and/or ticks, and for how long.
It helps to provide specific recommendations, providing pictures and circling those that are recommended. Selling the products in the office is also a good idea to make sure patients “leave with the right product,” she said.
Also, advise patients about what to avoid, such as products that contain blends of natural plant oils, which have been shown to be ineffective, providing less than an hour of protection, she said.
Dr. Gonzalez also advises against the use of combination insect repellent/sunscreen products. One reason is that sunscreen needs frequent reapplication, while insect repellent does not. Further, studies have demonstrated that using sunscreen over insect repellent dramatically increases the percutaneous absorption of DEET, and reduces the SPF of the sunscreen. If both are needed, sunscreen should be applied first to reduce transdermal penetration of the active insect repellent ingredient, and should be reapplied every 2 hours, she said.
“Proper insect repellent use is just one part of protection,” she added.
Other measures that should be encouraged include the use of protective clothing, such as light cotton long sleeves and pants; avoidance of clothing with bright colors or flowery prints; avoidance of scented soaps, perfumes, or hair spray; removal of mosquito habitats by eliminating any standing water, covering gaps in doors, using screens and nets; and, if possible, staying indoors at sunrise, sunset, and early evening when mosquitoes are most active.
Dr. Gonzalez noted that many free resources are available online, including a tool at the epa.gov site that helps in selection of an appropriate product for one’s specific needs.
Dr. Gonzalez reported serving as a speaker and/or advisory board member and receiving honoraria from Pierre Fabre Dermatologie, Anacor Pharmaceuticals, Encore Dermatology, and PuraCap Pharmaceutical.
BOSTON – Insect repellents containing DEET or picaridin are safe when used properly, and are important for bite protection in children, according to Mercedes E. Gonzalez, MD.
Insect bite reactions are common in children aged 2-10 years, and the emergence of Zika virus raises new concerns about the dangers of mosquito bites, in particular; the World Health Organization has declared Zika-related effects – namely microcephaly and Guillain-Barré syndrome – to be a “public health emergency of international concern.”
In children, illness associated with Zika virus is generally mild, but can include fever, rash, conjunctivitis, and/or arthralgia, Dr. Gonzalez said at the American Academy of Dermatology summer meeting.
DEET, used since 1957, is effective against mosquitoes, black flies, ticks, mites, and land leeches. It works by forming a vapor barrier that deters insects from coming into contact with the skin. The barrier extends about 4 cm from the skin. DEET can also be used on clothing but may cause damage to spandex, rayon, acetate, and leather, and can dissolve plastic and vinyl.
Although it is available in concentrations of 5%-100%, concentrations of 10%-35% provide adequate protection in most situations, said Dr. Gonzalez of the University of Miami.
Animal studies using large doses have shown that DEET is not a specific neurotoxin, and while there have been case reports of central nervous system toxicity in humans, there is no link to DEET dose or mechanistic pathway. Reported deaths have involved intentional ingestion and overuse or incorrect use of products, she said.
In fact, safety concerns are so minimal that the Environmental Protection Agency removed labels indicating caution in children, and the American Academy of Pediatrics recommends the use of DEET for preventing insect bites in children older than age 2 months, and in pregnant and lactating women.
One DEET safety concern, however, is flammability. Both DEET and the aerosol vehicle used in some DEET-containing products, are flammable, so caution is warranted, she said. Occlusion following use of DEET should also be avoided as it can increase absorption, and the product should be washed off after use.
Picaridin is another insect repellent that, like DEET, forms a vapor barrier to deter insects from getting close to the skin and biting, and can be used on both the skin and clothing, but it does not damage plastics or fabrics.
It has similar efficacy as DEET, and has a number of advantages over DEET in that it is odorless and does not feel sticky or greasy when applied. It has not been reported to cause any serious toxicity or mutagenesis.
Picaridin – which is effective against mosquitoes, dog and deer ticks, chiggers, and flies – has been used in Australia since 1998, and in the United States since 2005. That year, the Centers for Disease Control and Prevention recommended that it be used to protect against West Nile virus, and the World Health Organization said it was the best agent for preventing malaria, Dr. Gonzalez noted.
“So when [patients] ask about the best insect repellent, for most situations I do recommend DEET or picaridin, at 10%-25% for DEET, or 7%-15% for picaridin,” she said. She encourages people to read labels, noting that the EPA is encouraging the use of “repellency awareness” labels on insect repellents to inform the consumer whether it prevents against mosquitoes and/or ticks, and for how long.
It helps to provide specific recommendations, providing pictures and circling those that are recommended. Selling the products in the office is also a good idea to make sure patients “leave with the right product,” she said.
Also, advise patients about what to avoid, such as products that contain blends of natural plant oils, which have been shown to be ineffective, providing less than an hour of protection, she said.
Dr. Gonzalez also advises against the use of combination insect repellent/sunscreen products. One reason is that sunscreen needs frequent reapplication, while insect repellent does not. Further, studies have demonstrated that using sunscreen over insect repellent dramatically increases the percutaneous absorption of DEET, and reduces the SPF of the sunscreen. If both are needed, sunscreen should be applied first to reduce transdermal penetration of the active insect repellent ingredient, and should be reapplied every 2 hours, she said.
“Proper insect repellent use is just one part of protection,” she added.
Other measures that should be encouraged include the use of protective clothing, such as light cotton long sleeves and pants; avoidance of clothing with bright colors or flowery prints; avoidance of scented soaps, perfumes, or hair spray; removal of mosquito habitats by eliminating any standing water, covering gaps in doors, using screens and nets; and, if possible, staying indoors at sunrise, sunset, and early evening when mosquitoes are most active.
Dr. Gonzalez noted that many free resources are available online, including a tool at the epa.gov site that helps in selection of an appropriate product for one’s specific needs.
Dr. Gonzalez reported serving as a speaker and/or advisory board member and receiving honoraria from Pierre Fabre Dermatologie, Anacor Pharmaceuticals, Encore Dermatology, and PuraCap Pharmaceutical.
BOSTON – Insect repellents containing DEET or picaridin are safe when used properly, and are important for bite protection in children, according to Mercedes E. Gonzalez, MD.
Insect bite reactions are common in children aged 2-10 years, and the emergence of Zika virus raises new concerns about the dangers of mosquito bites, in particular; the World Health Organization has declared Zika-related effects – namely microcephaly and Guillain-Barré syndrome – to be a “public health emergency of international concern.”
In children, illness associated with Zika virus is generally mild, but can include fever, rash, conjunctivitis, and/or arthralgia, Dr. Gonzalez said at the American Academy of Dermatology summer meeting.
DEET, used since 1957, is effective against mosquitoes, black flies, ticks, mites, and land leeches. It works by forming a vapor barrier that deters insects from coming into contact with the skin. The barrier extends about 4 cm from the skin. DEET can also be used on clothing but may cause damage to spandex, rayon, acetate, and leather, and can dissolve plastic and vinyl.
Although it is available in concentrations of 5%-100%, concentrations of 10%-35% provide adequate protection in most situations, said Dr. Gonzalez of the University of Miami.
Animal studies using large doses have shown that DEET is not a specific neurotoxin, and while there have been case reports of central nervous system toxicity in humans, there is no link to DEET dose or mechanistic pathway. Reported deaths have involved intentional ingestion and overuse or incorrect use of products, she said.
In fact, safety concerns are so minimal that the Environmental Protection Agency removed labels indicating caution in children, and the American Academy of Pediatrics recommends the use of DEET for preventing insect bites in children older than age 2 months, and in pregnant and lactating women.
One DEET safety concern, however, is flammability. Both DEET and the aerosol vehicle used in some DEET-containing products, are flammable, so caution is warranted, she said. Occlusion following use of DEET should also be avoided as it can increase absorption, and the product should be washed off after use.
Picaridin is another insect repellent that, like DEET, forms a vapor barrier to deter insects from getting close to the skin and biting, and can be used on both the skin and clothing, but it does not damage plastics or fabrics.
It has similar efficacy as DEET, and has a number of advantages over DEET in that it is odorless and does not feel sticky or greasy when applied. It has not been reported to cause any serious toxicity or mutagenesis.
Picaridin – which is effective against mosquitoes, dog and deer ticks, chiggers, and flies – has been used in Australia since 1998, and in the United States since 2005. That year, the Centers for Disease Control and Prevention recommended that it be used to protect against West Nile virus, and the World Health Organization said it was the best agent for preventing malaria, Dr. Gonzalez noted.
“So when [patients] ask about the best insect repellent, for most situations I do recommend DEET or picaridin, at 10%-25% for DEET, or 7%-15% for picaridin,” she said. She encourages people to read labels, noting that the EPA is encouraging the use of “repellency awareness” labels on insect repellents to inform the consumer whether it prevents against mosquitoes and/or ticks, and for how long.
It helps to provide specific recommendations, providing pictures and circling those that are recommended. Selling the products in the office is also a good idea to make sure patients “leave with the right product,” she said.
Also, advise patients about what to avoid, such as products that contain blends of natural plant oils, which have been shown to be ineffective, providing less than an hour of protection, she said.
Dr. Gonzalez also advises against the use of combination insect repellent/sunscreen products. One reason is that sunscreen needs frequent reapplication, while insect repellent does not. Further, studies have demonstrated that using sunscreen over insect repellent dramatically increases the percutaneous absorption of DEET, and reduces the SPF of the sunscreen. If both are needed, sunscreen should be applied first to reduce transdermal penetration of the active insect repellent ingredient, and should be reapplied every 2 hours, she said.
“Proper insect repellent use is just one part of protection,” she added.
Other measures that should be encouraged include the use of protective clothing, such as light cotton long sleeves and pants; avoidance of clothing with bright colors or flowery prints; avoidance of scented soaps, perfumes, or hair spray; removal of mosquito habitats by eliminating any standing water, covering gaps in doors, using screens and nets; and, if possible, staying indoors at sunrise, sunset, and early evening when mosquitoes are most active.
Dr. Gonzalez noted that many free resources are available online, including a tool at the epa.gov site that helps in selection of an appropriate product for one’s specific needs.
Dr. Gonzalez reported serving as a speaker and/or advisory board member and receiving honoraria from Pierre Fabre Dermatologie, Anacor Pharmaceuticals, Encore Dermatology, and PuraCap Pharmaceutical.
EXPERT ANALYSIS FROM AAD SUMMER ACADEMY 2016
Acetaminophen doesn’t exacerbate asthma in young children
As-needed use of acetaminophen for fever or pain does not exacerbate mild persistent asthma in young children, according to a report published online August 18 in the New England Journal of Medicine.
In a prospective, randomized, double-blind clinical trial performed at 18 U.S. medical centers, neither acetaminophen nor ibuprofen raised the rate of exacerbations or impaired asthma control among 300 children aged 1-5 years. This result refutes those of observational and post hoc data that linked acetaminophen to increased asthma exacerbations, daily symptoms, and need for bronchodilators in children and adults. Those findings “have led to much controversy and even alarm,” with some physicians recommending that acetaminophen be completely avoided in children with asthma until more safety data became available, said William J. Sheehan, MD, of the division of allergy and immunology, Boston Children’s Hospital and Harvard Medical School, Boston, and his associates.
The investigators performed this 2-year study to obtain such safety data. The children (median age, 40 months) were randomly assigned to receive either liquid acetaminophen (150 patients) or matching liquid ibuprofen (150 patients) as needed for pain, fever, or discomfort and were followed for 46 weeks. All the participants received standard asthma-control therapies including inhaled glucocorticoids, oral leukotriene-receptor antagonists, and as-needed inhaled glucocorticoids.
The primary outcome – the mean number of asthma exacerbations – was 0.81 in the acetaminophen group and 0.87 in the ibuprofen group, a nonsignificant difference. The rate of exacerbations also did not differ between acetaminophen and ibuprofen in the subgroup of 226 children who completed the entire trial or in the subgroup of 200 who received a study medication for pain or fever at least once during follow-up, Dr. Sheehan and his associates said (N Engl J Med. 2016 Aug 18. doi: 10.1056/NEJMoa1515990).
There also were no significant differences between the two study groups in time to first asthma exacerbation, percentage of days of good asthma control (85.8% vs. 86.8% of days), use of rescue albuterol (2.8 vs. 3.0 inhalations per week), or unscheduled health care visits for asthma (0.75 vs. 0.76 visits). No between-group differences occurred regarding adverse events or serious adverse events.
Some experts have suggested that the observational studies reporting a link between acetaminophen and asthma exacerbations may have been flawed by “confounding by indication,” because children with asthma have more symptomatic respiratory infections than do those without asthma and use more acetaminophen for fever and malaise. “We [also] observed that greater use of antipyretic, analgesic medications was associated with more apparent respiratory illnesses and that the reported respiratory illnesses were associated with asthma exacerbations.
“However, we found no evidence that acetaminophen, when used during periods of respiratory illness, was associated with a higher risk of asthma exacerbations or other asthma-related complications than was ibuprofen,” Dr. Sheehan and his associates wrote.
This study was funded by the National Institutes of Health and the National Heart, Lung, and Blood Institute. Dr. Sheehan reported having no relevant financial disclosures; his associates reported numerous ties to industry sources.
The findings of Sheehan et al. should reassure clinicians and parents who care for young children taking asthma-controlling medications that the use of acetaminophen in usual, as-needed doses will not worsen the condition.
Acetaminophen and ibuprofen can be used similarly in situations for which they are indicated.
Augusto A. Litonjua, MD, is in the Channing Division of Network Medicine, Brigham and Women’s Hospital, and at Harvard Medical School, both in Boston. Dr. Litonjua made these remarks in an editorial accompanying Dr. Sheehan’s report (N Engl J Med. 2016 Aug 18. doi: 10.1056/NEJMe1607629). He reported receiving personal fees from UpToDate, Springer Humana Press, and AstraZeneca outside this editorial.
The findings of Sheehan et al. should reassure clinicians and parents who care for young children taking asthma-controlling medications that the use of acetaminophen in usual, as-needed doses will not worsen the condition.
Acetaminophen and ibuprofen can be used similarly in situations for which they are indicated.
Augusto A. Litonjua, MD, is in the Channing Division of Network Medicine, Brigham and Women’s Hospital, and at Harvard Medical School, both in Boston. Dr. Litonjua made these remarks in an editorial accompanying Dr. Sheehan’s report (N Engl J Med. 2016 Aug 18. doi: 10.1056/NEJMe1607629). He reported receiving personal fees from UpToDate, Springer Humana Press, and AstraZeneca outside this editorial.
The findings of Sheehan et al. should reassure clinicians and parents who care for young children taking asthma-controlling medications that the use of acetaminophen in usual, as-needed doses will not worsen the condition.
Acetaminophen and ibuprofen can be used similarly in situations for which they are indicated.
Augusto A. Litonjua, MD, is in the Channing Division of Network Medicine, Brigham and Women’s Hospital, and at Harvard Medical School, both in Boston. Dr. Litonjua made these remarks in an editorial accompanying Dr. Sheehan’s report (N Engl J Med. 2016 Aug 18. doi: 10.1056/NEJMe1607629). He reported receiving personal fees from UpToDate, Springer Humana Press, and AstraZeneca outside this editorial.
As-needed use of acetaminophen for fever or pain does not exacerbate mild persistent asthma in young children, according to a report published online August 18 in the New England Journal of Medicine.
In a prospective, randomized, double-blind clinical trial performed at 18 U.S. medical centers, neither acetaminophen nor ibuprofen raised the rate of exacerbations or impaired asthma control among 300 children aged 1-5 years. This result refutes those of observational and post hoc data that linked acetaminophen to increased asthma exacerbations, daily symptoms, and need for bronchodilators in children and adults. Those findings “have led to much controversy and even alarm,” with some physicians recommending that acetaminophen be completely avoided in children with asthma until more safety data became available, said William J. Sheehan, MD, of the division of allergy and immunology, Boston Children’s Hospital and Harvard Medical School, Boston, and his associates.
The investigators performed this 2-year study to obtain such safety data. The children (median age, 40 months) were randomly assigned to receive either liquid acetaminophen (150 patients) or matching liquid ibuprofen (150 patients) as needed for pain, fever, or discomfort and were followed for 46 weeks. All the participants received standard asthma-control therapies including inhaled glucocorticoids, oral leukotriene-receptor antagonists, and as-needed inhaled glucocorticoids.
The primary outcome – the mean number of asthma exacerbations – was 0.81 in the acetaminophen group and 0.87 in the ibuprofen group, a nonsignificant difference. The rate of exacerbations also did not differ between acetaminophen and ibuprofen in the subgroup of 226 children who completed the entire trial or in the subgroup of 200 who received a study medication for pain or fever at least once during follow-up, Dr. Sheehan and his associates said (N Engl J Med. 2016 Aug 18. doi: 10.1056/NEJMoa1515990).
There also were no significant differences between the two study groups in time to first asthma exacerbation, percentage of days of good asthma control (85.8% vs. 86.8% of days), use of rescue albuterol (2.8 vs. 3.0 inhalations per week), or unscheduled health care visits for asthma (0.75 vs. 0.76 visits). No between-group differences occurred regarding adverse events or serious adverse events.
Some experts have suggested that the observational studies reporting a link between acetaminophen and asthma exacerbations may have been flawed by “confounding by indication,” because children with asthma have more symptomatic respiratory infections than do those without asthma and use more acetaminophen for fever and malaise. “We [also] observed that greater use of antipyretic, analgesic medications was associated with more apparent respiratory illnesses and that the reported respiratory illnesses were associated with asthma exacerbations.
“However, we found no evidence that acetaminophen, when used during periods of respiratory illness, was associated with a higher risk of asthma exacerbations or other asthma-related complications than was ibuprofen,” Dr. Sheehan and his associates wrote.
This study was funded by the National Institutes of Health and the National Heart, Lung, and Blood Institute. Dr. Sheehan reported having no relevant financial disclosures; his associates reported numerous ties to industry sources.
As-needed use of acetaminophen for fever or pain does not exacerbate mild persistent asthma in young children, according to a report published online August 18 in the New England Journal of Medicine.
In a prospective, randomized, double-blind clinical trial performed at 18 U.S. medical centers, neither acetaminophen nor ibuprofen raised the rate of exacerbations or impaired asthma control among 300 children aged 1-5 years. This result refutes those of observational and post hoc data that linked acetaminophen to increased asthma exacerbations, daily symptoms, and need for bronchodilators in children and adults. Those findings “have led to much controversy and even alarm,” with some physicians recommending that acetaminophen be completely avoided in children with asthma until more safety data became available, said William J. Sheehan, MD, of the division of allergy and immunology, Boston Children’s Hospital and Harvard Medical School, Boston, and his associates.
The investigators performed this 2-year study to obtain such safety data. The children (median age, 40 months) were randomly assigned to receive either liquid acetaminophen (150 patients) or matching liquid ibuprofen (150 patients) as needed for pain, fever, or discomfort and were followed for 46 weeks. All the participants received standard asthma-control therapies including inhaled glucocorticoids, oral leukotriene-receptor antagonists, and as-needed inhaled glucocorticoids.
The primary outcome – the mean number of asthma exacerbations – was 0.81 in the acetaminophen group and 0.87 in the ibuprofen group, a nonsignificant difference. The rate of exacerbations also did not differ between acetaminophen and ibuprofen in the subgroup of 226 children who completed the entire trial or in the subgroup of 200 who received a study medication for pain or fever at least once during follow-up, Dr. Sheehan and his associates said (N Engl J Med. 2016 Aug 18. doi: 10.1056/NEJMoa1515990).
There also were no significant differences between the two study groups in time to first asthma exacerbation, percentage of days of good asthma control (85.8% vs. 86.8% of days), use of rescue albuterol (2.8 vs. 3.0 inhalations per week), or unscheduled health care visits for asthma (0.75 vs. 0.76 visits). No between-group differences occurred regarding adverse events or serious adverse events.
Some experts have suggested that the observational studies reporting a link between acetaminophen and asthma exacerbations may have been flawed by “confounding by indication,” because children with asthma have more symptomatic respiratory infections than do those without asthma and use more acetaminophen for fever and malaise. “We [also] observed that greater use of antipyretic, analgesic medications was associated with more apparent respiratory illnesses and that the reported respiratory illnesses were associated with asthma exacerbations.
“However, we found no evidence that acetaminophen, when used during periods of respiratory illness, was associated with a higher risk of asthma exacerbations or other asthma-related complications than was ibuprofen,” Dr. Sheehan and his associates wrote.
This study was funded by the National Institutes of Health and the National Heart, Lung, and Blood Institute. Dr. Sheehan reported having no relevant financial disclosures; his associates reported numerous ties to industry sources.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point: Using acetaminophen for fever or pain doesn’t exacerbate mild persistent asthma in young children.
Major finding: The mean number of asthma exacerbations was 0.81 in the acetaminophen group and 0.87 in the ibuprofen group, a nonsignificant difference.
Data source: A 2-year multicenter, double-blind, randomized clinical trial involving 300 children aged 1-5 years.
Disclosures: This study was funded by the National Institutes of Health and the National Heart, Lung, and Blood Institute. Dr. Sheehan reported having no relevant financial disclosures; his associates reported numerous ties to industry sources.
Pilot program helps children better understand food allergies
Elementary school students had improved attitudes toward food allergies and felt more confident in taking action during a food allergy emergency after completing an education program on the subject, results of a pilot study in Japan suggest.
At present there is no standard school curriculum for children regarding food allergy, wrote Dr. Kiwako Yamamoto-Hanada of the National Center for Child Health and Development, Tokyo, and associates, so they developed such a program consisting of two 60-minute sessions. A total of 36 elementary school children, 8 of whom had a history of food allergies, filled out questionnaires before and after participating in the program.
After completing the program, 79% of the students stated that it should be included in the school curriculum. Students also demonstrated improved knowledge about food allergies, with a greater percentage knowing what an EpiPen is (100% vs. 0%), understanding that food allergy is related to death (100% vs. 43%), and feeling confident that they could take immediate action if they saw a food allergy emergency (61% vs. 4%). “This is the first report to find that a [food allergy] program for elementary schoolchildren was well tolerated and that perceptions and attitudes toward [food allergies] improved,” the investigators wrote.
The authors stated that they had no financial conflicts of interest.
Read the full story here: http://dx.doi.org/10.1016/j.anai.2016.06.018
Elementary school students had improved attitudes toward food allergies and felt more confident in taking action during a food allergy emergency after completing an education program on the subject, results of a pilot study in Japan suggest.
At present there is no standard school curriculum for children regarding food allergy, wrote Dr. Kiwako Yamamoto-Hanada of the National Center for Child Health and Development, Tokyo, and associates, so they developed such a program consisting of two 60-minute sessions. A total of 36 elementary school children, 8 of whom had a history of food allergies, filled out questionnaires before and after participating in the program.
After completing the program, 79% of the students stated that it should be included in the school curriculum. Students also demonstrated improved knowledge about food allergies, with a greater percentage knowing what an EpiPen is (100% vs. 0%), understanding that food allergy is related to death (100% vs. 43%), and feeling confident that they could take immediate action if they saw a food allergy emergency (61% vs. 4%). “This is the first report to find that a [food allergy] program for elementary schoolchildren was well tolerated and that perceptions and attitudes toward [food allergies] improved,” the investigators wrote.
The authors stated that they had no financial conflicts of interest.
Read the full story here: http://dx.doi.org/10.1016/j.anai.2016.06.018
Elementary school students had improved attitudes toward food allergies and felt more confident in taking action during a food allergy emergency after completing an education program on the subject, results of a pilot study in Japan suggest.
At present there is no standard school curriculum for children regarding food allergy, wrote Dr. Kiwako Yamamoto-Hanada of the National Center for Child Health and Development, Tokyo, and associates, so they developed such a program consisting of two 60-minute sessions. A total of 36 elementary school children, 8 of whom had a history of food allergies, filled out questionnaires before and after participating in the program.
After completing the program, 79% of the students stated that it should be included in the school curriculum. Students also demonstrated improved knowledge about food allergies, with a greater percentage knowing what an EpiPen is (100% vs. 0%), understanding that food allergy is related to death (100% vs. 43%), and feeling confident that they could take immediate action if they saw a food allergy emergency (61% vs. 4%). “This is the first report to find that a [food allergy] program for elementary schoolchildren was well tolerated and that perceptions and attitudes toward [food allergies] improved,” the investigators wrote.
The authors stated that they had no financial conflicts of interest.
Read the full story here: http://dx.doi.org/10.1016/j.anai.2016.06.018
FROM ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY