Thursday, October 30, 2014

For Treating Empyema, Which Is Better—Urokinase Drainage or Video-Assisted Thoracoscopy?

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

Video-assisted thoracoscopy.
Image by Cancer Research UK  via Wikimedia Commons.
Every once in a while we have a patient who develops a parapneumonic effusion of pus (otherwise known as an empyema) as a complication of an acute bacterial pneumonia. When this happens, treatment might involve a chest tube and when that fails, the use of thoracoscopy.

Recently however, the addition of urokinase to enzymatically break apart the empyema has been suggested to make the chest-tube drainage method more effective—but is it as effective as video-assisted thoracoscopy (VATS)?

Marhuenda et al. (doi:10.1542/peds.2013-3935) approached this question by performing a prospective randomized multicenter clinical trial in children younger than 15 years old with empyema that required intervention.

The results indicate that urokinase plus drainage may be just as effective as VATS, but if you want to see for yourself, scope out this study and discuss it with your local pediatric surgeons to see if they agree the two treatments are similar. Be sure to share what you learn with us by leaving a comment here on the blog, sharing an eLetter on our journal’s website or visiting us on Facebook or Twitter.

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Wednesday, October 29, 2014

Association Between Perinatal Complications and Accelerated Aging at Midlife

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

Public domain photo via Pixabay
We certainly have published myriads of studies noting the role of perinatal complications increasing risks for morbidity and mortality in early childhood—but what about later in life?

Can a perinatal stressful event lead to earlier aging processes in adulthood?

It’s a fascinating hypothesis that Shalev et al. (doi:10.1542/peds.2014-1669) set out to study looking at leucocyte telomere length and perceived facial age of a prospective cohort of more than 1,000 adults who have been studied since birth for 38 years. In this study, even when controlling for potential confounders, authors found an association between perinatal maternal and infant complications and subsequent aging indicators.

Just why or how this might occur is discussed by the authors and also in a thought-provoking commentary by Dr. Alan Guttmacher, director of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), and Dr. Tonse Raju (medical program officer for the NICHD) (doi:10.1542/peds.2014-2646) that also warrants your consideration.

The idea that perinatal programming can influence how we age is a fascinating concept—but it’s even more fascinating when this study begins to show this to be true. Clearly we will need even more research in the months and years ahead to better identify the mechanisms at play that promote accelerated aging as a result of perinatal complications.

Tuesday, October 28, 2014

College Health Services Handling Students with Chronic Illness: Are They Ready, Willing, and Able?

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

Queen's College quad.  Photo by Queen's College via Flickr.
If you are practicing in a town or city where there is a college or university, have you investigated what the college health service can provide for students with a chronic medical condition like asthma or diabetes? Do you know if these health services reach out to these students or perhaps coordinate care with your office when the care gets complex? If so, how common is it for college health services to identify, support and provide care for chronically ill students?

Lemly et al. (doi:10.1542/peds.2014-1304) tackle these questions by sharing the results of a national survey of medical directors of 200 college health services in regard to their preparedness to identify and manage care for teens and young adults with diabetes, asthma, and depression. The results will likely surprise you or perhaps even make you curious enough to visit your local college health service to get a better idea of what they do offer and whether you need to link more closely with them if services are not what you expect.

The good news is the majority of these centers are well-prepared to manage acute exacerbations although the findings for identification of students and chronic management of their underlying illnesses are not as reassuring.

And if you want some additional insight into what this study shows, don’t miss the accompanying commentary by Dr. Terry Bravender (doi:10.1542/peds.2014-2645), adolescent specialist. As you transition your patients with chronic illness off to college, investigating or alerting the college health service about your patient will ease the transition—and if you aren’t in contact with those services, this article may change that going forward.

What’s been your experience with a college health service, and if you work in a college health service, what’s been your experience with referring pediatricians sending you the information you need to optimize care? Share your thoughts by responding to this blog, via an eLetter, or on Facebook or Twitter.

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Monday, October 27, 2014

Why You Should be Thinking About Fetal Alcohol Spectrum Disorders in Your Practice

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

Diagnosing someone with a fetal alcohol spectrum disorder (FASD) is easier said than done. The findings can be subtle and might be easily missed unless you uncover clues in the family history or are aware of the constellation of dysmorphology findings that can be associated with this disorder.

Sometimes there is a sense that a fetal alcohol spectrum disorder is a rarer entity than it actually is—and thus you need not worry about missing something unlikely to occur. Alternatively, you may figure it will eventually declare itself anyway if a child develops progressive development delay or another less subtle finding prompting a more careful diagnostic approach.

Yet the prevalence of fetal alcohol spectrum disorders appears to be more common than we might hope—at least according to a representative sample of children examined at ages 6 to 7 in the Midwest US as studied by May et al. (doi:10.1542/peds.2013-3319).

Figure showing final estimate of FASD prevalence in a Midwestern US city.
Copyright 2014 © American Academy of Pediatrics. Used with permission.

The researchers selected their sample simply on the basis of their being below the 25th percentile for height, weight, and head circumference. This interesting study also includes a discussion of the risk factors that might point you towards diagnosing this disorder sooner.

If you need a refresher on ways to identify fetal alcohol syndrome so you can diagnose and implement early intervention services sooner rather than later, this is the study for you.

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Friday, October 24, 2014

Sociodemographic Differences and Infant Dietary Patterns

Pediatrics Editorial Board Member Joann Schulte, DO, MPH, shares her expert perspective on a new article from our November issue. To learn more about Dr. Schulte, check out her bio on our Contributors page.

By: Joann Schulte, DO, MPH

Jarred baby food. Photo by Parenting Patch via Wikimedia Commons
You are what you eat, and the diet for infants is supposed to be exclusively breast milk for the first six months of life. But what about the transition to solid foods in the second half of the first year? What dietary patterns are associated with adequate growth and not obesity? This infant feeding topic is an important one in a country where obesity and diabetes are common and emerge early.

New research published this month in Pediatrics (doi: 10.1542/peds.2014-1045) explores infants’ second six months of life and finds the transition to a different diet is important with regards to an infant’s growth, weight gain and obesity. Dr. Xiaozphong Wen and his colleagues at the State University of New York Buffalo did a secondary data analysis of the US Center for Disease Control and Prevention and the US Food and Drug Administration’s jointly funded and administered Infant Feeding Practices Study data to examine dietary patterns of infants as their parents started their transition to solid foods.

The Buffalo researchers analyzed a subsample of 1,555 infants followed from 2005 to 2007 and looked at four dietary patterns and growth, identified based on 18 foods typically eaten by US infants. The 18 foods included formula, breast milk, juices, cereal, fruits, vegetables, meats, seafood, peanuts/nut products and sweet foods.

At six months of age, the four patterns were “high sugar/fat/protein”, “infants guideline solids”, “formula”, and “high dairy/ regular cereal.” At 12 months, the four patterns were “high sugar/fat/protein”, “infant guideline solids”, “formula/baby cereal” and “high dairy”.

Mothers supplied the dietary histories, reporting what their infants were fed in the prior week. Nine surveys were done, spanning the transitions in feeding patterns from three months to 12 months.The researchers calculated sex- and age-specific length-for-age Z scores and BMI Z scores to examine infants’ growth and a correlation with each diet.

At six months of age, “high sugar/fat/protein” and “high dairy/regular cereal” were associated with infants being shorter and fatter. The authors concluded that the “infant guideline solids” with breastfeeding was a promising, healthy diet for infants.

The study is an important one because it provides information that can guide physicians and parents in selecting a diet that will help children grow without being coming obese. The right diets can shape children’s health as adults and offer a way to control diabetes and other conditions related to obesity.

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Prenatal & Newborn Screening for Critical Congenital Heart Disease

Pediatrics Editorial Board Member Beth Tarini, MD, MS, shares her expert perspective on a new article from our November issue. 

By: Beth Tarini, MD, MS
Public Domain Photo via Pixabay

Critical Congenital Heart Disease (CCHD) is a group of life-threatening heart defects for which timely detection and intervention can save newborns’ lives. To this end, many states across the US have implemented mandatory pulse oximetry screening of newborns in order to identify and treat infants with CCHDs before they become symptomatic.

A study by Johnson et al. in the November issue of Pediatrics (doi: 10.1542/peds.2014-1461) demonstrates that pulse oximetry screening for CCHD may have a low yield in a tertiary care birth center. Not surprisingly, this occurred because most of the infants with CCHDs born at the center were diagnosed by a fetal echocardiograph. In contrast, newborns referred to the tertiary care center from an outside birth center for treatment of a CCHD were more often diagnosed after birth – either based on pulse oximetry or clinical symptoms.

What should we do with this information? The authors point out that “improving access to and training in fetal echocardiography should also improve detection of these conditions.”  While this statement is technically true, it is impracticable. A total of 15 percent of women in the US do not receive adequate prenatal care, while 6 percent of US women either began prenatal care in the third trimester or did not receive any prenatal care

For these women, post-natal pulse oximetry remains their best hope for detecting CCHD in their newborns. For those women who do receive prenatal care, we would need to invest a significant amount of resources (e.g., training, manpower, equipment) to ensure that they all received prenatal ultrasounds of the same quality received by women at well-resourced tertiary care centers.

Even if we lived in a world where resources and funding were limitless, we must still be mindful that technology –whether an expensive fetal ultrasound or a simple pulse oximetry– is not infallible. In this study, an infant with CCHD had a normal fetal cardiac examination (i.e., no fetal echocardiography was performed) and a normal pulse-oximetry screening. This infant was only detected after symptoms prompted a clinical evaluation, reminding us that amidst all of this technology, a clinician’s watchful eye still has value for the patient.

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Thursday, October 23, 2014

Discussing Weight-Management With Latino Families in the Pediatrician's Office

Pediatrics Editorial Board Member Terrill Bravender MD, MPH, shares his expert perspective on a new article from our December issue. To learn more about Dr. Bravender and his work in adolescent medicine, check out his bio on our Contributors page.

By: Terrill Bravender, MD, MPH

"What's on your plate?"  USDA nutrition initiative  in Spanish.
Photo by the USDA via Flickr
The long-term health implications of childhood obesity are clear: type 2 diabetes, sleep apnea,
orthopedic complications, hypertension and other cardiovascular conditions among others. It is also clear that one component of the public health approach to childhood obesity is involvement of the primary care physician. It is important for primary care providers to review growth charts, identify children who are overweight or obese, screen for medical complications, and develop intervention plans for these children.

Latino children have particularly high rates of obesity, and non-English-speaking and immigrant Latino children have poorer health care access compared to US-born English-speaking Latino children. But once Latino children come into the doctor’s office, what kind of care do they receive? While physicians’ use of body-mass index (BMI) growth charts and identification of obese children has improved over the past 10 years, has it improved for Latino children? And once obese Latino children are identified, what kind of counseling do they receive?

These are the questions asked (and answered) by Dr. Christy Turer and colleagues in the December issue of Pediatrics (doi: 10.1542/peds.2014-1282). The researchers at University of Texas Southwestern Medical Center video/audio taped encounters between physicians and 26 Latino families with overweight or obese children between the ages of 6 and 12.

While it was encouraging that 81 percent of families were told of their child’s overweight status, only about half were helped to develop a weight management plan. Concerningly (but not surprisingly), language barriers played an important role. A number of physicians in the study were Spanish-proficient, so the non-English speaking status of the patients did not play much of a role.

However, language incongruency did play a role: for instance, when physicians and families did not speak the same language, using a growth chart to illustrate the child’s weight status was only used 13 percent of the time; when they spoke the same language, the growth chart was used 83 percent of the time.

The global increases in childhood obesity rates have many social and environmental causes, and the problem will continue to require a multifaceted approach. Identification of at risk children and office-based counseling is one small part, but the least we can do as physicians is to systematize our approach, and work to provide the highest level of care to all of our patients regardless of language status. This is a challenge for sure, but one that certainly can be met.

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