Wednesday, February 25, 2015

Washing the Dishes: A New Way to Reduce the Risk of Allergy!

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

          We hear more and more in the news about the role of the hygiene hypothesis resulting in less allergic symptoms.  As a refresher, this hypothesis suggests that early microbial exposure triggers early immune stimulation that results in immunologic tolerance compared to later exposures that result in allergy and infection from a more inflammatory versus tolerant immune response. 
With that in mind, Hesselmar at al. (doi:10.1542/peds.2014-2968) decided to study the common practice of washing dishes to see if the washing dishes by hand (and thus exposing oneself to many more microbes than letting a dishwasher do the washing) resulted in less risk of allergy in those children.  The investigators collected data on more than 1000 children age 7-8 years in Sweden and asked them whether their families washed dishes and whether they had signs and symptoms of asthma, eczema, or allergic rhinitis as compared to those families who used a dishwasher.
To our surprise (perhaps yours as well), the families who do hand dishwashing showed much less allergic disease in their children compared to those who used the dishwasher.  So—does hand dishwashing mean more microbes to generate immunotolerance at an early age of exposure or not?  Is there another explanation for what the authors of this study show nicely in this study? 
Drs. Laurence Cheng and Michael Cabana (doi:10.1542/peds.2014-3911) have added an accompanying commentary to this study to try to clean up your concerns about whether or not to buy in or wash away your belief in the hygiene hypothesis.  Both the study and commentary dish out some provocative information and opinion, and we welcome your input as well. Just respond directly to this blog, or send us an e-letter or simply comment on our Facebook or Twitter page.

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Tuesday, February 24, 2015

Herpes Zoster in Children after Varicella Infection: How Frequently Does It Occur and to Whom?

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

          Since the start of the varicella vaccine, we have seen a reduction in the incidence and prevalence of this viral infection, but varicella continues to occur and herpes zoster remains a potential complication to those who experience this viral illness. But how common is zoster in children pre-and post the start of the varicella vaccine, and is it more common in those children who had medically diagnosed chickenpox than those who did not?
So many questions and yet Drs. Wen and Liu (doi: 10.1542/peds.2013-4037) have collected more than 27,000 children with varicella from a national database between 2000 and 2006 and another 25,000 vaccinated but without symptomatic varicella and monitored these cohorts for the development of zoster for several years.  The results represent the first population-based data regarding the incidence of zoster in children as captured in the study we are releasing this week. 
The good news is that the vaccine is clearly having an effect on decreasing the incidence of zoster in those who are vaccinated, although cases still occur.  If you need some nice evidence to demonstrate yet another reason to administer the varicella vaccine, this article may be just what you the doctor ordered.

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Monday, February 23, 2015

Teen Sleep Duration over Two Decades: A Study That May Keep You Awake!

          There are so many studies in our journal and others noting the importance of good sleep hygiene and pointing out the problems that occur when sleep is curtailed in children and adolescents, and yet this week we offer a different longitudinal perspective on sleep studies. 
Keyes et al. (doi: 10.1542/peds.2014-2707) share their analysis of historical shifts in adolescent sleep time over 20 years using national survey data of more than 272,000 teens from 27 years of birth cohorts.  Teens in each cohort were asked if they were getting at least 7 hours of sleep and if the amount of sleep they were getting was adequate or not.  The authors share trends indicating that adolescent sleep has been declining over the last 20 years with girls not doing as well as boys in getting adequate sleep.  There are also lots of misperceptions noted between teens feeling they are getting adequate sleep relative to what they are actually getting especially for underrepresented minorities and teens with lower socioeconomic status. 
If you aren’t talking sleep hygiene with your teen patients, this study is nothing to snore at—and should energize  you to make this more of a priority in your anticipatory guidance discussions during health maintenance visits with adolescents in your practice.  Stay up a few minutes later tonight—and read this study to learn more.

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Friday, February 20, 2015

Improving the Quality of Pain Relief in Sickle Cell Disease

Editorial Board Member Joann Schulte, DO, MPH  
Studies of emergency providers have found that negative attitudes toward sickle cell patients interfere with the adherence to national guidelines from the NIH and the American Pain Society. A related article in Blood1 suggested that textbooks used in hematology, internal medicine and emergency medicine didn’t provide adequate information about the treatment or prevention of vaso-occulsive crisis. (VOC) The pain associated with VOC is one of the most common reasons for emergency room visits by patients with sickle cell disease (SCD). 

An article published this month in Pediatrics offers an approach that might favorably impact the therapy of sickle cell patients. Mathias et. al (doi:10.1542/peds.2014-2874) evaluated time to opioids (TTO) in a cohort of Dallas children with SCD.  Among a group of 177 children seen during calendar years 2008-2010, 414 visits to emergency rooms were reported, resulting in admissions 53% of the time.  The median TTO was 86 minutes among admitted children and 87 minutes among those not admitted.  A multivariate analysis of outcomes found that faster TTO was associated with greater improvement of pain scores, decrease in time in the emergency room and increased amount of opioids administered intravenously.  The authors suggest that TTO should serve as a measure of quality of care and now aim for a goal of starting opioids in less than 60 minutes for SCD patients in pain. 

Providing pain relief promptly for SCD patients is an important goal.  Earlier studies have found SCD patients and their families are often dissatisfied with the delays in care.  This Dallas study suggests that TTO is a quality measure that merits consideration and implementation in practice settings where children with sickle cell are seen.  The study was only done in one center, but other studies have found that implementation of a clinical pathway can improve the care given to sickle cell patients.   It’s an area that deserves more attention from pediatricians and hematologists who take care of patients with sickle cell disease.

  1. Solomon LR. Treatment and prevention of pain due to vaso-occlusive crises in adults with sickle cell disease: an educational void. Blood 2008;111:997-1003