Wednesday, April 1, 2015

Antibiotic Usage in Infancy and Being Overweight: Weighing in on an Unexpected Association

By: Lewis First, MD, MS; Editor-in-Chief  
     How often have you considered that antibiotics given in infancy might predispose your patient to being overweight by age 2 years?  We certainly did not until we read the study by Saari et al. (doi: 10.1542/peds.2014-3407) and realized that the intestinal microbiome might be the culprit responsible for such an association. 
     The authors studied a population-based cohort of approximately 6 thousand boys and a similar number of girls in the first 24 months of life and looked at antibiotic purchase data as well as body mass index and height at 2 years of age. Since antibiotics can change the human microbiome, especially in infancy, doing so may trigger additional weight gain. 
      Why this happens is the subject of a provocative discussion section of this study, making this article well worth your attention. 

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Tuesday, March 31, 2015

Being PROS at Motivational Interviewing to Combat Being Overweight in Childhood

By: Lewis First, MD, MS; Editor-in-Chief  
      Motivational interviewing (MI) is a patient-centered counseling style by which you work with a patient to facilitate behavioral change through their recognizing their internal desire to change.  It is used for a variety of behavioral disorders by psychologists. 
      This week we publish a fascinating study by Resnicow et al. ( doi: 10.1542/peds.2014-1880) involving a randomized controlled trial performed by pediatric providers and registered dieticians of children in 42 practices enrolled in the AAP’s Pediatric Research in Office Settings (PROS) Network. Overweight children ages 2-8 were randomized to get (1) usual care, (2) four provider trained MI sessions to parents of an index child and (3), four provider trained MI sessions  plus 6 more MI sessions with a registered dietician with outcome being BMI measured at a two-year follow-up. 
     Without spoiling the richness of the data contained in this study, suffice it say that the groups that received MI showed much more impressive reductions in BMI than the group who got routine care.  Before everyone cheers (and cheering is well deserved here), one still needs to ponder whether this study can be generalized to all of us. Fortunately obesity researcher Dr. Cara Ebbeling (doi: 10.1542/peds.2015-0495) offers a commentary on this study that provides further insight as to what we can learn from it. 
     One thing is certain—before your patients can benefit from an MI approach to losing weight, you would need to learn MI, and perhaps hire dieticians if you don’t have some available to you also facile in MI, —which might not be affordable despite the reduction in up-the-road health care costs due to the weight reduction achieved. 
      Would you or registered dieticians in your community or practice be willing to learn motivational interviewing if it can lead to weight reduction in your overweight patients? Why or why not?  Share your thoughts with us as a response to this blog, via an e-letter or via our Facebook or Twitter sites.

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Monday, March 30, 2015

Follow-up Studies of Preterm and Late Preterm Infant Neurocognitive Performance Continue To Develop

By: Lewis First, MD, MS; Editor-in-Chief  
     Our readers tell us they learn a lot reading the studies we publish on long-term follow-up of infants born early particularly in terms of their neurodevelopment. Well this week we don’t want to disappoint our readers and therefore bring you three studies of interest in the area of cognitive development of preterm, and late preterm infants. 
      The first study by Burnett et al. (doi: 10.1542/peds.2014-3188) focuses on extremely preterm (less than 28 weeks) and extremely low birth weight (less than1000 g) infants in terms of their executive function, not just in infancy and toddlerhood but into adolescence. 
     Sadly, poor performance in executive function tasks seen early in life carries on into the teen years, and while some aspects of executive function improve over time, a number of aspects do not, suggesting the need to intervene sooner than later to try to further develop executive function skills over time.
      A second study by Heinonen et al. (doi: 10.1542/peds.2014-3556) looks at late preterm infants and follows their neurocognitive performance not just into adolescence, but into late adulthood. The authors traced a cohort of more than 900 men and women born in Finland in 1934-44 who were assessed  as adults with a battery of tests to identify signs of Alzheimer disease and believe it or not, those who were identified as late-preterm had a higher risk of showing neurocognitive impairment.  Interestingly enough however, those who were able to pursue higher education did not show such findings. 
     Finally there is a third study by Schonhaut et al. (doi:10.1542/peds.2014-1957)  that looks at developmental impairment relative to gestational age in moderate, late preterm and early term infants and once again, there is an inverse association between gestational age and developmental delay.
     There are a lot of interesting comments one can make about the findings in all three studies, and at the same time, one has to be amazed that cohorts of infants are now being followed not just into early childhood but through adolescence and into adulthood without major losses to follow-up.  As a result, we are learning more and more about the developmental outcomes associated with being born early.   
     To help make even more sense of these types of studies and what we can do to perhaps improve developmental outcomes in these patients, Dr. Betty Vohr (doi: 10.1542/peds.2015-0227) offers her perspective in a very interesting commentary.  Read all three studies and the commentary and then see what develops in regard to interventional strategies to improve developmental outcomes in these infants born preterm.

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Friday, March 27, 2015

Pimecrolimus Does More than Just Skin the Surface When It Comes to Treating Atopic Dermatitis

By: Lewis First, MD, MS; Editor-in-Chief  
While our first line of treatment for moderate to severe atopic dermatitis in a child usually involves the use of a topical corticosteroid, steroids, especially the more potent ones, may also have some side effects. As a result, some parents of infants may be concerned about using topical steroids, reducing compliance with this mode of therapy.  Fortunately, other therapies have entered the treatment market, offering non-steroidal immunomodulatory effects to reduce the degree of inflammation—but how safe and effective are these drugs? 
Sigurgeirsson et al. (doi: 10.1542/peds.2014-1990) opted to answer this question by studying one immunomodulatory drug—pimecrolimus—in a 5-year randomized controlled open-label trial comparing this drug to mild to moderate topical corticosteroids, using one or the other until the flare resolved and reusing the same medication when a flare recurred.  While short-term topical steroids were also added to pimecrolimus for more severe disease flares in that group, the results are nonetheless very impressive.  The infants who received pimecrolimus had substantially less need for topical steroids during flares than the other group who used them exclusively for flares and the number and quality of adverse events in both groups were minimal and nonsubstantial. Most importantly, there was no change in humoral or cellular immunity in either group.
If you are faced with the need for long-term management of an infant or young child with atopic dermatitis, this study may make the use of pimecrolimus a more rash-ional choice than you may have considered and perhaps move it into first-line treatment for mild to moderate atopic dermatitis in our patients.  So are you using pimecrolimus as your first line?  Share your responses with us either via this blog, an e-letter or our Facebook or Twitter sites.

Related Links:

  •        Vitamin D Deficiency Rickets in an Adolescent With Severe Atopic Dermatitis
  •         Grand Rounds: Nutrient Supplementation and Atopic Dermatitis