Friday, April 24, 2015

Does Extremely Preterm Outcome Hinge on the Intensity of Perinatal Care Provided?

      We often read that investing resources into the tiniest of preterm babies may not be cost-effective given the mortality risk as well as the neurodevelopmental disability that can occur in the extremely preterm infant. Yet maybe the more intensive care resources we provide, the better the outcomes?  That opinion is substantiated by Serenius et al. (doi:10.1542/peds.2014-2988) as they describe some interesting findings using a national prospective study of more than 800 fetuses alive at the time a mother was admitted for delivery.  To our surprise, being proactive and increasing the intensity of perinatal care does result in some pretty impressive risk-reduction in these ELBW infants. So what should we conclude about the use of proactive care in this high risk population of infants.   
      Doctor Cody Arnold and Doctor Eric Eichenwald weigh in with an accompanying commentary that sheds further light on the findings in this study (doi: 10.1542/peds.2015-0536) Maybe the cost is outweighed by the benefit—but we’d love to know your thoughts about how much is too much when it comes to trying to provide whatever it takes to help an extremely preterm baby? 
     Share your opinion on the findings in this study by responding to our blog, writing an e-letter or post your comments on our Facebook or Twitter sites.

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Wednesday, April 22, 2015

Perinatal Transmission of Hepatitis B: What Factors Increase Risk of Transmission Despite Immunoprophylaxis?

      We have made such great strides  immunoprophylactically treating infants born to mothers who are hepatitis B surface antigen  (HBsAg)positive to the point where 95% of perinatal hepatitis B viral (HBV) infections are prevented—but some still occur.   Thus the question is which infants are most likely to be at risk of getting HBV infection despite immunoprophylaxis?  This week Schillie et al. (doi:10.1542/peds.2014-3213) answer that question using some prospectively collected data from several Hepatitis B prevention programs from 2007 to 2013 to identify risk factors for perinatal transmission.  The authors looked at maternal demographics, lab results, infant birth weight and gestational age, and the immunotherapy used from an analysis of almost 18,000 mother-infant pairs.  
      In this study only 1.1% of babies acquired HBV infection from their mothers despite the vast majority of these babies having gotten immunoprophylaxis.  Just what factors increase a baby’s risk of infection?  Some include younger maternal age, maternal viral load, and maternal hep e antigen positivity—but there are even more to be concerned about. Helping to make sense of the findings of this study and to share some thoughts on how to do even more to reduce the perinatal transmission of this virus is an accompanying commentary by Dr. Ravi Jhaveri (doi:10.1542/peds.2015-0360).   
       Hopefully you’re now so hepped up from this description of the study—you’ll link to the article and commentary and learn which of your patients are at highest.

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Tuesday, April 21, 2015

A Bitter Pill to Swallow: What Does the Pediatric Literature Say About Effective Pill-Swallowing Interventions?

By: Lewis First, MD, MS; Editor-in-Chief  

      Every one of us that sees patients comes across a child who will not take the
Amanda Mills
medicine we prescribe or recommend—perhaps due to taste, perhaps because they cannot take a pill easily, or perhaps just to be oppositional.  We also often make recommendations to try to get children to be better at taking their medicine—but what is the evidence that what we recommend works? 

      Patel et al. (doi:10.1542/peds.2014-2114) dose out the results of a systematic review on this topic this week in our journal.  The authors look at studies over a 27 year span and sadly only find 4 cohort studies and one case series—all of which recommended a method found successful in that individual study. The fact that there may be limited generalizability of a particular intervention studied, or some potential bias in wanting an assessment to work are but some of the limitations identified in this interesting review.  So what method do you recommend? 
      Is it discussed in this study?  We want to hear from you on this review and any tricks you have found (evidence-based or anecdotal) that you can share with us by responding to this blog, sending us an e-letter or posting on our Facebook and Twitter pages.  

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Monday, April 20, 2015

A Guiding Hand in Pediatric Psychiatry: The Massachusetts Child Psychiatry Project in Action

By: Joann Schulte  DO, MPH; Editorial Board Member
      It should come as no surprise that the mental health care needs of children and adolescents has increased more than that of adults during the period 1995-20101.  The responsibility for dealing with that increase seems to fall more and more  on primary care pediatricians.. The reasons are multiple: a shortage of child mental health specialists; mental health problems are more complex; and the use of psychotropic medications by primary care pediatricians due to the lack of child psychiatrist availability is increasing.
      So what’s a pediatrician to do when you want to consult a psychiatrist or other mental health specialist and they are not readily available? You create a program that enables primary care providers to consult with mental health practitioners in their region about diagnostic issues and use of psychotropic medication.  One such program, the Massachusetts Child Psychiatry Access Project is described in a new study being published this month by Van Cleave et al. (doi:10.1542/peds.2014-0720) in Pediatrics.
      The Massachusetts program (between 2005 and 2011) enrolled 285 practices whose providers called for advice a mean of 5.2 times per 1000 patients per year and saw calls steadily increase as seen in the figure below from the article.
Calls per month to all MCPAP sites by PCPs, May 2005-July 2011
       Calls most frequently concerned medication/evaluation questions and most commonly referred to  patients with diagnoses of ADHD and anxiety.  The researchers found that 46% of the time the call resulted in a referral back to the primary care provider and another 42% of calls led to an evaluation by a psychiatrist or to a care coordinator to identify appropriate resources for the patient.
      The demand for mental health services by pediatric patients is increasing and the evaluation of this project in Massachusetts suggests the use of a consulting service was of help to practicing pediatricians. Having somebody in the mental health world who is accessible by phone and can listen and provide appropriate advice to a practicing pediatrician is important if we are going to help our patients with their mental health needs.

1.  Olfson M et al. National trends in the mental health care of children, adolescents and adults by office-based physicians. JAMA Psychiatry 2014; 7(1):81-90

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Friday, April 17, 2015

Parenting Worldwide: Health and Development in Low and Middle Income Countries

By: Lydia Furman, MD,  Assistant Editor

          This article was a surprise in that, of all the places to conduct a randomized control trial of a parenting intervention, I did not expect one in Pakistan, implemented by Lady Health Workers. (community health workers) Dr. Yousafzai et al. (doi: 10.1542/peds.2014-2335) certainly deserve kudos for their perseverance in conducting this randomized controlled trial (RCT) in a low-income, low-resource region, and for their rigorous study design, in which assessment was conducted by an independent surveillance team. Traditionally we think of the most relevant child health issues in developing countries as nutrition-related infant and child mortality and morbidity, infectious diseases, and availability of basic needs. The authors open our eyes to the pressing need for parenting interventions 
in low and middle income countries. 
          Many of us are familiar with the pioneering work of Dr. Olds in this country in the use of home visits to decrease infant and child mortality and improve maternal and child mental health (e.g. Olds et al. JAMA Pediatric 2014; Kitzman et al. Arch Pediatr Adolesc Med 2010); home visits with focused programming have also been shown to reduce unintentional childhood injuries (Kendrick et al. Cochrane Database Syst Rev 2013). This US data may not be directly translatable to low and middle income countries, and certainly this work by Yousafzai et al. brings a new and welcome look at the emotional and developmental needs of infants and children along with their parents in developing countries.
           The study is a secondary analysis of an RCT, with the primary outcomes of childhood cognition, language and motor development reported recently in Lancet (Yousafzai et al. Lancet 2014). Study design involved a cluster trial with a 2x2 factorial design in which new interventions were piggybacked onto an already existing Lady Health Worker Program serving this impoverished region. The new interventions were “Responsive Stimulation,” in which the health workers helped parents observe and respond to their child’s emotional signals through play and communications interactions; modelling improved opportunities to support child development; and “Enhanced Nutrition,” in which “responsive feeding messages” were emphasized and a multiple micronutrient powder was provided for children ages 6-24 months. Thus, in addition to the routine programming, the 4 groups were: 1- “Responsive Stimulation” alone, 2- “Enhanced Nutrition” alone, 3- both new interventions, and 4- neither of the new interventions.  Assessment included a 5 minute play observation by an independent observer, questionnaires completed by the mother, an assessment using the HOME survey (Home Observation for Measurement of the Environment, Caldwell and Bradley, 1984), and maternal depression as measured by validated questionnaire.
           All this good effort was not for naught, and by 24 months of age, statistically significant benefits with moderate to large effect sizes were reported for the “Responsive Stimulation” intervention, with small to modest effect sizes reported for the “Enhanced Nutrition” intervention: mother-child interaction and care environment benefited from each intervention with an additive effect of both. Not all outcomes, however, were improved, and the pattern of change was interesting and not completely predictable- a review of the the well done graphics and tables is worth the time. Perhaps most interesting to me is that there was less impact on maternal depression than expected by the authors; this may not actually be so surprising in that the new intervention did not directly target maternal mental health or (as the authors note) address underlying risk factors such as domestic violence. A key message here, given the increasing body of research showing a major impact of maternal depression on child health and development (e.g. Barker et al Depress Anxiety 2011), may be that maternal depression among women in low and middle income countries is a critical area for focused intervention in and of itself. 

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