Monday, June 2, 2008

Cold Medication Use in Young Children Dangerous

Cough and cold medication use in young children has been linked to a significant number of adverse effects and several deaths, leading the FDA to recommend against their use for children less than two years old. Despite these concerns about safety and efficacy, there has been little research on patterns of cough and cold medication use in very young children. Now, a new study from the Emergency Medicine Network (www.emnet-usa.org) led by Katherine O’Donnell, M.D. of Children’s Hospital Boston reveals important new statistics about medication use in children under the age of two.


According to the study, 1-in-3 children under the age of two with bronchiolitis (a lower respiratory tract infection associated with runny nose, cough, wheezing and/or difficulty breathing) had received over-the-counter cough and cold medicines in the week prior to visiting an emergency department.


This study identifies rates and predictors of cough and cold medication use prior to the manufacturer recall of and FDA recommendations against use of these medications in children younger than two years of age.


“After the recall and labeling changes, it will be important to monitor for potential ongoing use of these medicines in young children and observe if parents or physicians are turning to other therapies in place of these medications,” says O’Donnell.


Given these findings and the fact that non-concentrated cough and cold formulations remain available for over-the-counter use, the authors encourage physicians to counsel all parents of young children about these ineffective and potentially dangerous medications.


While the study did not identify a specific high-risk demographic group for targeted educational interventions, factors including daycare attendance, second-hand smoke exposure, recent antibiotic use and presence of wheezing were associated with increased use of cough and cold medications. Children less than a year old, as well as those with a history of hospitalization, were less likely to use these medications.

Improving Doctor-Child Communication

Study finds kids who use touch pad device are more likely to share critical info with doctor

Technology may be the key to identifying high-risk behaviors among adolescents. Injury risk, depressive symptoms and drug and alcohol use are the leading causes of adolescent morbidity and mortality; yet pediatricians often lack the time to screen for these behavioral concerns. That paradox of care is the motivation behind a new study, published in the June issue of Pediatrics, which found adolescents who participated in computerized screening with real-time results were more likely to be identified as having a problem by their pediatrician than adolescents whose screening results were delayed.

The study, conducted by researchers at the Center for Innovation in Pediatric Practices in The Research Institute at Nationwide Children’s Hospital, compared the results of 878 primary care patients, ages 11 to 20 years, who participated in a unique, computerized behavioral screening system between June 1, 2005 and February 20, 2006 called “Health eTouch.” Developed by researchers at Nationwide Children’s, Health eTouch is a Web application, presented to patients on secure wireless Web tablets with 10-inch touch screen displays. Questions vary based on the user’s age and reported behaviors and are drawn from existing publicly available validated measures.

Study participants took part in Health eTouch screening in the waiting rooms of the urban clinics they attended. These clinics were randomly assigned to have pediatricians either receive screening results just prior to face-to-face encounters with patients – “Immediate Results” condition – or two to three business days later – “Delayed Results” condition. When provided with the screening results, pediatricians were able to view a summary of patient responses to screening questions, as well as a list of flagged responses thought to be indicative of high-risk behaviors and an overall positive or negative rating for various behavioral concerns tested during the screening process.

After participating in Health eTouch, 59 percent of respondents screened positive for at least one of the following behavioral concerns: injury risk behaviors, significant depressive symptoms or substance use. Of those youths who screened positive and whose results were provided to pediatricians just prior to their consultation, 68 percent were identified as having a problem by their pediatrician, while only 52 percent of youths whose results were delayed were identified as having a problem by their pediatrician.

“Routine behavioral screening, although critical in identifying and addressing high-risk behaviors, often does not occur or is limited due to the time constraints and competing demands facing primary care physicians,” said Kelly Kelleher, MD, a principal investigator for the Center for Innovation in Pediatric Practices in The Research Institute at Nationwide Children’s and a faculty member at The Ohio State University College of Medicine. “Our research has found that recent advances in information technology, such as the Health eTouch system, and the immediate reporting of computerized screening results may help overcome barriers to behavioral screening.”

Direct data entry by youths in waiting rooms and automated scoring and printing programs minimize staff time necessary for screening, scoring, reporting and filing results. Also, past research has shown adults and adolescents are more willing to disclose sensitive information to a computer than to a clinician.

Low vitamin D levels common in children

Low vitamin D levels appear common in healthy children

Many healthy infants and toddlers may have low levels of vitamin D, and about one-third of those appear to have some evidence of reduced bone mineral content on X-rays, according to a report in the June issue of Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals.

Reports of a resurgence of vitamin D deficiency and rickets, the resulting bone-weakening disease, have emerged in several states, according to background information in the article. Vitamin D deficiency also appears to be high in other countries, including Greece, China, Canada and England.

Catherine M. Gordon, M.D., M.Sc., and colleagues at Children's Hospital Boston, studied 380 healthy children ages 8 months to 24 months who visited a primary care center for a physical examination between 2005 and 2007. Parents filled out a questionnaire regarding their nutritional intake and that of their children, and also reported on the use of vitamin D and other supplements, time spent outdoors, socioeconomic status and education level.

Among the 365 children for whom blood samples were available, 12.1 percent (44) had vitamin D deficiency, defined as 20 nanograms per milliliter of blood or less, and 40 percent (146) had levels below the accepted optimal level of 30 nanograms per milliliter. Breastfed infants who did not receive vitamin D and toddlers who drank less milk were at higher risk of deficiency (for each cup of milk toddlers drank per day, blood vitamin D level increased by 2.9 nanograms per milliliter).

Forty children of the 44 with vitamin D deficiency underwent X-rays of the wrist and knee. Thirteen (32.5 percent) had evidence of bone mineral loss, and three (7.5 percent) exhibited changes to their bones suggestive of rickets.

"Only one child had signs of rickets on physical examination," the authors write. "Thus, these infants and toddlers had a sub-clinical deficiency that could make detection of this issue particularly problematic in routine clinical practice, as a child's vitamin D status is not typically evaluated as part of routine care."

The data suggest that infants should receive vitamin D supplements while breastfeeding and raise the question of whether some children, including those with established risk factors for vitamin D deficiency, should receive regular measurements of blood vitamin D levels. "Given the potential benefits of vitamin D on bone and other tissues, and growing data supporting its immunomodulatory and antiproliferative effects, the current findings support recommendations advocating for vitamin D supplementation for all young children," they conclude.


Editorial: Additional Information Needed About Risks of Low Vitamin D Levels

"The results of this study suggest that a vitamin D level is not a good screening test for rickets in asymptomatic children; 92.5 percent of those with hypovitaminosis [low levels of] D, as defined by Gordon et al, had no evidence of rickets on radiograph [X-ray]," writes James A. Taylor, M.D., of the University of Washington, Seattle, in an accompanying editorial.

"Future research is needed to determine whether infants and toddlers with vitamin D levels of 20 nanograms per milliliter or lower are at significant short- or long-term risk for other bone disease or different conditions," Dr. Taylor writes. "Pending this research, the recommendations by Gordon et al that all young children should receive vitamin D supplementation and that children with risk factors should have periodic vitamin D levels obtained may be premature.

Drinking 100% juice OK

Drinking juice not associated with being overweight in children

Children who drink 100-percent juice are no more likely to be overweight and may have a better overall nutrient intake than children who do not drink juice, according to a report in the June issue of Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals.

Increasing numbers of Americans, including children, are overweight or obese, according to background information in the article. Food-consumption patterns may play a role in children's weight gain. Drinking juice has been associated with overweight and obesity in some studies but not in others.

Theresa A. Nicklas, Dr.P.H., of Baylor College of Medicine, Houston, and colleagues analyzed data from a group of 3,618 children age 2 to 11 who participated in the National Health and Nutrition Examination Survey (NHANES) between 1999 and 2002. During in-home interviews, the children were weighed and measured, and they or their parents reported the types of foods and drinks they consumed.

On average, the children drank 4.1 fluid ounces of juice per day, which contributed an average of 58 calories to their diet. There was no association between drinking juice and being overweight. Children who drank juice had significantly higher intakes of calories, carbohydrates, vitamins C and B6, potassium, riboflavin, magnesium, iron and folate and significantly lower intakes of total fat, saturated fat, discretionary fat and added sugar.

Children who drank juice also ate more whole fruit than those who did not drink juice. "It is not clear why some children drink more fruit juice and what the association is with increased intake of fruit in these individuals," the authors write. "Taste and availability are two generally recognized factors in increased intake of fruit and vegetables; usual food intake, subjective norms, parenting style and visual benefits of eating fruit and vegetables are others."

Overall, children drank less juice than the daily maximum amounts recommended by the American Academy of Pediatrics—4 to 6 ounces for children 1 to 6 years old and 8 to 12 ounces for children and teens 7 to 18 years old. Children age 2 to 3 drank the most juice—an average of 6 ounces per day.

"One-hundred–percent juice consumption was associated with better nutrient intake than in the non-consumption group and was not associated with weight status or the likelihood of being overweight in children 2 to 11 years of age," the authors conclude.