Tuesday, November 25, 2014

The Pneumococcal Vaccine: Rates of Pneumonia and Sinusitis Before, After Implementation

By: Lewis First, MD, MS; Editor-in-Chief 
Sneeze photo by Anna Gutermuth via Flickr

I don’t think many of us would argue with the benefits of the pneumococcal vaccine in reducing rates of pneumococcal bacteremia and sepsis—but what about other manifestations of this infection—i.e. pneumonia and sinusitis?

Lindstrand et al. (doi: 10.1542/peds.2013-4177) performed a population-based study in Sweden of all hospitalizations pre- and post-introduction of the pneumococcal vaccines (PCV 7 and PCV 13) to look at hospitalizations for these two disorders. Their results are dramatic (in a very positive sense)!

If you had any doubt as to the effectiveness of immunizing against pneumococcus, this study being early released this week will do a “doubt-ectomy”—and hopefully not just for health care professionals but for families who may be less convinced about the need to vaccinate their children.

The study makes some sharp points about the reduction in hospitalizations that can be attributed to the administration of this vaccine—but read it for yourself and see what I mean.

Monday, November 24, 2014

Postnatal Growth Following Prenatal Lead Exposure and Calcium Intake

By: Assistant Editor Lydia Furman, MD

Photo by F. Lamiot via Wikimedia Commons (edited)
Lead is a ubiquitous environmental toxin, with well appreciated deleterious effects on the neurodevelopment of young children. But what do we know about the physical growth of lead-exposed infants and children? Dr. Hong and colleagues prospectively examine the effect of maternal lead levels during early and late pregnancy on postnatal growth at birth and at 6, 12 and 24 months (doi: 10.1542./peds.2014-1658).

Lead does cross the placenta, so prenatal exposure clearly has potential to reach the developing fetus; however there is limited evidence to date of any impact on postnatal growth beyond the neonatal period (Schell et al, Am J Human Bio, 2009).

Certainly no lead level is considered “safe.” With a new focus on primary prevention, the CDC has established 5.0 micrograms/dL or greater as the lead level that identifies children who are in the highest 2.5 percent of US children based on the National Health and Nutrition Examination survey (NHANES) data on blood lead levels in children.

Previously the CDC used a “level of concern” of 10 micrograms/dL; however it became clear that even at these “low” levels there were negative effects on neurodevelopment as assessed at 24 months with the Bayley Scales of Infant Development (Tellez-Rojo et al, Pediatrics, 2006), on intelligence as assessed at age 6 years (Canfield et al, New England Journal of Medicine, 2003 and Jusko et al, Environmental Health Perspectives, 2007), and on reading readiness at kindergarten entry (McLaine et al, Pediatrics, 2013). With the new population-based 2.5 percentile level of 5.0 micrograms/dL, clinicians, public health departments and parents hope to have the opportunity to intervene earlier and prevent deleterious effects.

But with less than 5.0 micrograms/dL as a non-actionable level for children, any direct effect of prenatal lead levels higher than this on child growth would be surprising. Hong and colleagues studied a cohort of 1,150 pregnant women whose mean lead level of 1.25 micrograms/dL was actually much lower.  Their unexpected results are a call to action for public health servants, policy makers and child advocates.

The authors further asked whether dietary intake of calcium has any impact on lead’s effects, and measured women’s diets carefully using dietary interviewers and 24 hour recall. Mothers’ mean daily calcium intake at study entry was 541 mg/24 hours; when pregnancy dietary intake of calcium was below the mean, this intensified the negative effect of maternal lead levels on infant growth, particularly birth weight.

The authors make a convincing case for biological plausibility of both the interrelationship between maternal dietary calcium intake during pregnancy and maternal blood lead levels, and the consequent demonstrated effect on infant growth. This article sets the stage for additional public health work, both to promote increased dietary calcium during pregnancy, and to continue the fight to reduce exposure of mothers and children to environmental toxins, including lead.

Friday, November 21, 2014

How Teens Are Using the Internet to Learn About Sex

By: Editorial Board Member Joann Schulte, DO, MPH

Public domain photo via Pixabay
The way adolescents learn about sex is changing since the Internet has become a standard way for
people to seek information.

A new study published this month in Pediatrics (doi: 10.1542/ peds.2014-0592) explores the ways Dutch adolescents’ use of Internet sites shaped their perceptions of their body images and sexual self-perceptions.

Researchers at Utrecht University in the Netherlands and Boston Children’s Hospital explored how often teenagers looked at sexually explicit Internet material (pornography) and social networking sites.

The researchers examined the use of such sites among 1,132 Dutch children who were enrolled in the 7th through 10th grades. Ms. Suzan Doornwaard and her colleagues examined four groups of students over six-month intervals and assessed their behaviors using a computerized questionnaire that the students completed during school hours.

The researchers found boys visited pornography sites occasionally and that their use increased over time. Social networking sites were used daily and commonly by both boys and girls. Dutch researchers also reported that the adolescents who had higher initial use of sex-related online behavior or rapidly increased use were more likely to have less satisfaction with their own, actual sexual experiences. Additionally, the study's authors noted that adolescents who didn't have private access to the web and more parental rules on internet use were more likely to be involved in sex-related behavior online.

The study provides some initial, limited guidance for parents and suggests that parental guidance on Internet use for adolescents is a smart idea. Knowing where and what adolescents look at online and discussing it with them seem to be smart parenting strategies.

Thursday, November 20, 2014

Hospice and Palliative Care Competencies: Their Growth and Development

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

In this era of training across the continuum using competency-based outcomes, the question arises as to whether competencies exist for all pediatric subspecialties.

This week, the field of Pediatric Hospice and Palliative Medicine (HPM) is sharing their first attempt at defining competencies for this specialty in a special article written by Klick et al. (doi: 10.1542/peds. 2014-0748).

The authors reflect the work of a group of HPM clinician-educators who came together, and using a defined methodology shared in this article, were able to provide us with the first set of pediatric HPM competencies.

Hopefully these will not just be implemented for those specializing in the field, but will be milestones defined for achievement for those early in their medical student or residency training needing introduction to baseline competencies in pediatric hospice and palliative care medicine.

How familiar are you with these HPM competencies as a practicing pediatrician? The best way to find out is to read this special article and learn more.

Related Reading:

Wednesday, November 19, 2014

The Duration of Nasal Shedding by Rhinovirus—What It Is and I(s-not)!

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

Human rhinovirus-14. Photo by US Dept. of Energy.
Parents often tell us that their young child’s nose is always running. We like to say that if a child’s feet smell and her nose runs—it probably means she is upside down. But since this situation is unusual, the more common reason for rhinorrhea is a viral upper respiratory infection often caused by a strain of rhinovirus.

So just how long does rhinovirus hang around in a child’s nose? Or is it possible that children get different strains of rhinovirus mimicking a long-lasting strain?

Loeffelholz et al. (doi: 10.1542/peds. 2014-2132) set out to perform a longitudinal study of infants in their first year of life by collecting monthly nasopharyngeal samples as well as additional samples when upper respiratory infections occurred. They then ran the samples via reverse-transcription polymerase chain reaction (PCR) to look at nucleotide sequences for the strain of rhinovirus detected.

Researchers studies over 2,000 specimens from approximately 350 babies. What is most remarkable is that they identified more than 300 different rhinovirus infections involving upwards of 175 strains. Fewer than 10 infectious events represented prolonged infection more than 30 days long (i.e. found in two sequential monthly samples).

Before you start working up your patients for an immune dysfunction because their upper respiratory symptoms seem persistent, read this article. It may enable you to focus more on good URI preventive strategies of hand-washing, avoidance of second hand smoke exposure, and coughing and sneezing into an elbow rather than a hand—as time better spent than ordering a myriad of tests and cultures reflecting the spread of viral infections in otherwise healthy hosts.

The information in this article may be well worth sharing with families to avert the need for further laboratory testing and unnecessary use of antibiotics—but don’t take my word for it, you can be in the know (or in the nose) yourself if you give this study some attention.

Related Reading: 

Tuesday, November 18, 2014

Otitis Media and Antibiotic Selection: Does Race Play a Role in What Drug Is Chosen?

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

Photo by Eden, Janine, and Jim via Flickr
Although the AAP’s guidelines on otitis media (OM) (doi:10.1542/peds.2012-3488) frown on automatic usage of antibiotics given the high incidence of viral infections for this disorder, there are circumstances in which an antibiotic is indicated. Though the guidelines make clear recommendations on what drug to use as first line for antibiotic treatment of otitis, variations in frequency of diagnosing otitis as well as in antimicrobial treatment regimen used do exist.

To gain a better understanding of these variations and their significance, Fleming-Dutra et al. (doi: 10.1542/peds.2014-1781) used national survey data to examine OM visits between black and non-black children and then compared amoxicillin prescription with broader spectrum antibiotic use, also by race, to determine if race was an independent factor in antibiotic selection.

While the number of OM visits per 1,000 children seen in the outpatient setting were not different in terms of race, the choice of antibiotics in this study revealed that black children were receiving amoxicillin more than broad-spectrum antimicrobials compared to white children, even when controlling for confounders in a multivariate analysis.

So what does this mean? Given the dangers of antibiotic overuse, are we providing better care to black children by limiting their antibiotics to amoxicillin, or are we discriminating against them by not offering broad-spectrum agents that we give to non-black patients?

There are many questions raised by this study and to help answer them, we have called upon infectious disease expert and one of our associate editors Dr. Charles Woods and his colleague Dr. Faye Jones (doi:10.1542/peds.2014-3056) to provide an important commentary to accompany this thought-provoking article.

Both the article and commentary are worth hearing about, and better yet reading about—so please do so and share your thoughts on the findings by responding to this blog, or via an eLetter, or commenting on Facebook or Twitter.

Related Reading:

Monday, November 17, 2014

The Challenges of Practicing Pediatrics in China

Pediatrics Assistant Editor Lydia Furman, MD, shares her perspective on a forthcoming article from our December issue. The full version of the article is available now to subscribers here, and on December 1, 2014, an extract will be freely available to all.


Chinese flag. Public domain photo via Wikimedia Commons
More than a decade ago, Shugerman and colleagues examined determinants of satisfaction among pediatricians in the US (Shugerman et al Pediatr 2001). They compared general and subspecialty pediatricians and internists and family practitioners, and found that “despite lower incomes, general pediatricians reported the highest levels of satisfaction and the least job stress of all physician groups…” and “[Pediatricians] were least likely to endorse symptoms of burnout or job stress.”

This finding likely makes good sense to many of us, and more recent work underscores this finding, with more than half of pediatricians describing themselves as “very satisfied” with their careers (Schmidt et al Health Care Manag 2014). These studies did not, and we would not expect them to, ask about personal safety and violence on the job; the focus of surveys is on burnout, job satisfaction, aspects of daily life such as patient volume and acuity, and hours worked. In general, we do not expect to fear for our physical safety while serving as pediatricians, with limited exception perhaps for those serving in uniquely high-risk environments.

Our good fortune is precisely our blind spot. The courageous Pediatrics article by Xu and colleagues (doi: 10.1542/peds.2014-1377) about the extraordinary and frightening circumstances of pediatricians in mainland China is a showstopper.

Perhaps there are knowledgeable colleagues among us who have friends or family in China who are aware that it may be physically dangerous to practice pediatrics in mainland China, but this shocking (and I believe the word is appropriate) underbelly to medical practice is not widely appreciated. Xu et al. describe instances of physical violence directed against pediatricians, with an increasing rate of medical violence unchecked by the courts or the government.

As fewer medical school graduates choose pediatrics or apply for pediatric jobs in mainland China, the wait time for patient care and the number of patients the remaining pediatricians see has risen dramatically, with each practicing doctor responsible for 80-100 visits per day (even up to 150 per day). Most US pediatricians cannot imagine this workload, and would rapidly change jobs or negotiate for better pay and better hours, citing not just personal exhaustion but patient safety as mandating a change.

Chinese pediatricians do not have ability to increase their pay, and unlike physicians in other specialties, do not have the option to perform procedures or prescribe medications that will supplement their incomes to a tolerable level. Per Xu et al., pediatricians are fleeing their jobs and the job market, with no resolution in sight and no solutions in the pipeline to prevent, improve or change working conditions.

What is our role as fellow pediatricians? What is our government’s role? Do we have any options? Shouldn’t children in every corner of the globe have the same access to health care as in the US? Shouldn’t our colleagues in every corner of the globe have the opportunity to practice medicine in a safe working environment? This brief piece raises issues many of us did not even know needed to be confronted.