Pre- and postnatal thimerosal exposure was not linked with neuropsychological deficits.
In 1999, the AAP and the U.S. Public Health Service suggested that vaccine manufacturers remove thimerosal preservatives from vaccines to minimize potential mercury toxicity to the developing brain. In this study, investigators examined pre- and postnatal mercury exposure and neuropsychological outcomes in 1047 children at age 7 to 10 years at four HMOs.
Data were collected from complete vaccination records, maternal interviews, and 3-hour neuropsychological assessments of 42 motor and developmental tasks. Estimates of mercury exposure included mothers’ pre- and postnatal exposure to immunoglobulin and vaccines and prenatal fish consumption. Overall, no consistent association was found between pre- or postnatal thimerosal exposure and neuropsychological outcome. A few positive and negative sex-specific associations were noted.
Comment: These results are reassuring for parents whose children were immunized before thimerosal was removed from vaccines. The small potpourri of associations probably reflects the large number of outcomes examined, because no plausible biologic explanation exists for both positive and negative effects. This study did not address a link between thimerosal and autism, but those findings will be reported by the CDC in a separate study. For now, we can reassure parents that mercury has been removed from vaccines, that no clear adverse outcomes have been associated with thimerosal exposure, and that we will continue to assess vaccine safety.
— Peggy Sue Weintrub, MD
Published in Journal Watch Pediatrics and Adolescent Medicine September 26, 2007
Citation(s):
Thompson WW et al. Early thimerosal exposure and neuropsychological outcomes at 7 to 10 years. N Engl J Med 2007 Sep 27; 357:1281.
Showing posts with label pediatrics. Show all posts
Showing posts with label pediatrics. Show all posts
Tuesday, October 23, 2007
Wednesday, September 19, 2007
Steroids Have No Benefit for Bronchiolitis
A multicenter trial shows no benefit over placebo.
Bronchiolitis is the most common reason for hospitalization of infants in the U.S., and the possible role for steroid treatment has been hotly debated. To assess the efficacy of dexamethasone, researchers conducted a randomized, double-blind, placebo-controlled trial in infants aged 2 to 12 months at 20 emergency departments during three respiratory virus seasons. Inclusion criteria included first episode of wheezing and an ED diagnosis of moderate-to-severe bronchiolitis (defined as a Respiratory Distress Assessment Instrument [RDAI] score 6).
Of 8686 infants screened, 93% were excluded because of prior wheezing (41% of excluded cases), an RDAI score <6 (25%), or other reasons. Overall, 600 infants were randomized to receive either a single dose of dexamethasone (1 mg/kg up to a maximum of 12 mg) or placebo. All other care was at the discretion of the attending physician. Most patients received bronchodilators.
There were no differences between the dexamethasone and placebo groups in admission rates (the primary outcome), respiratory status 4 hours after treatment, hospital length of stay, or readmission rates. The findings remained the same in infants who were positive or negative for respiratory syncytial virus and in those with and without eczema or a family history of asthma.
Comment: This properly sized, well-designed study should end the use of steroids in children with bronchiolitis. If steroids did have an effect, the inclusion of only patients with moderate-to-severe disease should have favored them by eliminating the mild cases from which recovery is virtually ensured, regardless of treatment. Similarly, the exclusion of patients with prior episodes of wheezing, which might represent asthma, makes this a clean decision: First episode of wheezing means no steroids, period.
— J. Stephen Bohan, MD, MS, FACP, FACEP
Published in Journal Watch Emergency Medicine July 25, 2007
Citation(s):
Corneli HM et al. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med 2007 Jul 26; 357:331-9.
Bronchiolitis is the most common reason for hospitalization of infants in the U.S., and the possible role for steroid treatment has been hotly debated. To assess the efficacy of dexamethasone, researchers conducted a randomized, double-blind, placebo-controlled trial in infants aged 2 to 12 months at 20 emergency departments during three respiratory virus seasons. Inclusion criteria included first episode of wheezing and an ED diagnosis of moderate-to-severe bronchiolitis (defined as a Respiratory Distress Assessment Instrument [RDAI] score 6).
Of 8686 infants screened, 93% were excluded because of prior wheezing (41% of excluded cases), an RDAI score <6 (25%), or other reasons. Overall, 600 infants were randomized to receive either a single dose of dexamethasone (1 mg/kg up to a maximum of 12 mg) or placebo. All other care was at the discretion of the attending physician. Most patients received bronchodilators.
There were no differences between the dexamethasone and placebo groups in admission rates (the primary outcome), respiratory status 4 hours after treatment, hospital length of stay, or readmission rates. The findings remained the same in infants who were positive or negative for respiratory syncytial virus and in those with and without eczema or a family history of asthma.
Comment: This properly sized, well-designed study should end the use of steroids in children with bronchiolitis. If steroids did have an effect, the inclusion of only patients with moderate-to-severe disease should have favored them by eliminating the mild cases from which recovery is virtually ensured, regardless of treatment. Similarly, the exclusion of patients with prior episodes of wheezing, which might represent asthma, makes this a clean decision: First episode of wheezing means no steroids, period.
— J. Stephen Bohan, MD, MS, FACP, FACEP
Published in Journal Watch Emergency Medicine July 25, 2007
Citation(s):
Corneli HM et al. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med 2007 Jul 26; 357:331-9.
Antibiotic Prophylaxis Does Not Lower Rate of Recurrent UTI in Children
In fact, prophylaxis is associated with increased risk for resistant urinary tract infection.
The 1999 American Academy of Pediatrics practice guideline recommends that children with a first urinary tract infection (UTI) undergo imaging to determine the presence and grade of vesicoureteral reflux, which is found in 30% to 40% of children with UTI. The guideline recommends that children with vesicoureteral reflux be given daily antibiotic prophylaxis to suppress recurrent UTI and, theoretically, to prevent renal scarring, but there is scant scientific support for this stance. Therefore, investigators sought to identify risk factors for recurrent UTI and resistant UTI and to assess the value of antibiotic prophylaxis against recurrent UTI in a cohort study of children 6 years or younger.
Among nearly 75,000 children seen at 27 primary care pediatric practices from 2001 to 2006, the incidence of first UTI was 0.7%, the rate of recurrent UTI was 12%, and the cumulative incidence of UTI was 4.2% per person-year. Factors that increased the risk for recurrent UTI were white race (hazard ratio, 1.97); age 3–4 years (HR, 2.75); age 4–5 years (HR, 2.47); and grade 4–5 vesicoureteral reflux (HR, 4.38). Antibiotic prophylaxis was not associated with lower risk of recurrent UTI (HR, 1.01) but was a risk factor for antibiotic resistance among children with recurrent UTI (HR, 7.50).
Comment: This is the first large cohort study to determine the incidence of and risk factors for recurrent UTI in children. The noteworthy discovery that antibiotic prophylaxis does not help prevent recurrent UTI and that, in fact, it leads to an increase in resistant strains in recurrent UTI episodes strikes down conventional dogma. For children 6 years old with primary or recurrent UTI, treat the primary disease, but do not initiate or recommend daily antibiotic prophylaxis.
— John A. Marx, MD, FAAEM, FACEP
Published in Journal Watch Emergency Medicine July 27, 2007
Citation(s):
Conway PH et al. Recurrent urinary tract infections in children: Risk factors and association with prophylactic antimicrobials. JAMA 2007 Jul 11; 298:179-86.
The 1999 American Academy of Pediatrics practice guideline recommends that children with a first urinary tract infection (UTI) undergo imaging to determine the presence and grade of vesicoureteral reflux, which is found in 30% to 40% of children with UTI. The guideline recommends that children with vesicoureteral reflux be given daily antibiotic prophylaxis to suppress recurrent UTI and, theoretically, to prevent renal scarring, but there is scant scientific support for this stance. Therefore, investigators sought to identify risk factors for recurrent UTI and resistant UTI and to assess the value of antibiotic prophylaxis against recurrent UTI in a cohort study of children 6 years or younger.
Among nearly 75,000 children seen at 27 primary care pediatric practices from 2001 to 2006, the incidence of first UTI was 0.7%, the rate of recurrent UTI was 12%, and the cumulative incidence of UTI was 4.2% per person-year. Factors that increased the risk for recurrent UTI were white race (hazard ratio, 1.97); age 3–4 years (HR, 2.75); age 4–5 years (HR, 2.47); and grade 4–5 vesicoureteral reflux (HR, 4.38). Antibiotic prophylaxis was not associated with lower risk of recurrent UTI (HR, 1.01) but was a risk factor for antibiotic resistance among children with recurrent UTI (HR, 7.50).
Comment: This is the first large cohort study to determine the incidence of and risk factors for recurrent UTI in children. The noteworthy discovery that antibiotic prophylaxis does not help prevent recurrent UTI and that, in fact, it leads to an increase in resistant strains in recurrent UTI episodes strikes down conventional dogma. For children 6 years old with primary or recurrent UTI, treat the primary disease, but do not initiate or recommend daily antibiotic prophylaxis.
— John A. Marx, MD, FAAEM, FACEP
Published in Journal Watch Emergency Medicine July 27, 2007
Citation(s):
Conway PH et al. Recurrent urinary tract infections in children: Risk factors and association with prophylactic antimicrobials. JAMA 2007 Jul 11; 298:179-86.
Wednesday, July 11, 2007
Prophylaxis Not Associated with Lower Recurrence of UTIs in Children
The use of antimicrobial prophylaxis after a first childhood urinary tract infection is not associated with lower rates of recurrence — and in fact is associated with an increased risk for resistant infections, according to a JAMA study.
Researchers followed some 600 children under age 6 with first episodes of UTI for over a year to examine the characteristics that would predict recurrent infections. They found that white race, age 3 to 5 years, and grade 4 to 5 vesicoureteral reflux were all factors associated with increased risk for recurrence. Antimicrobial prophylaxis had no effect on recurrence risk, but among children in whom infection recurred, prophylaxis was associated with an increased risk for resistant infections.
The authors suggest that clinicians "discuss the risks and unclear benefits of prophylaxis with families ... after a first UTI."
Full text:
http://jama.ama-assn.org/cgi/content/full/298/2/179
Researchers followed some 600 children under age 6 with first episodes of UTI for over a year to examine the characteristics that would predict recurrent infections. They found that white race, age 3 to 5 years, and grade 4 to 5 vesicoureteral reflux were all factors associated with increased risk for recurrence. Antimicrobial prophylaxis had no effect on recurrence risk, but among children in whom infection recurred, prophylaxis was associated with an increased risk for resistant infections.
The authors suggest that clinicians "discuss the risks and unclear benefits of prophylaxis with families ... after a first UTI."
Full text:
http://jama.ama-assn.org/cgi/content/full/298/2/179
Sunday, June 24, 2007
Lab Screening in Children with Suspected Inflammatory Bowel Disease
When clinical suspicion is high, normal screening lab values have limited value.
Primary care clinicians often perform screening laboratory tests when they suspect that a child might have inflammatory bowel disease (IBD). Investigators evaluated the screening utility of hemoglobin values, platelet counts, erythrocyte sedimentation rate (ESR), and albumin levels using prospectively collected data from a multisite registry of 526 children (mean age, 11.6 years) who were newly diagnosed with IBD (392 with Crohn disease; 134 with ulcerative colitis).
All four tests were normal in 30% of children with mild disease (21% of patients with Crohn disease and 54% of those with ulcerative colitis), compared with only 4% of children with moderate or severe IBD. Of the four tests, ESR was the least likely to be normal (defined as <20 mm/hour), regardless of disease severity. For example, among children with moderate or severe IBD, 18% had normal ESRs, 24% had normal hemoglobin levels, 43% had normal platelet counts, and 50% had normal albumin levels. Hematochezia was the most common presenting feature in children with mild IBD.
Comment: These results indicate that the four IBD screening tests assessed have limited value. I wish the authors had performed more sophisticated analyses, such as calculating sensitivity for different combinations of laboratory values, because early identification of children with IBD is important. The authors note that new laboratory markers, such as antibodies against neutrophils or microbial antigens, and antiglycan antibodies, might hold greater promise.
— Howard Bauchner, MD
Published in Journal Watch Pediatrics and Adolescent Medicine June 13, 2007
Citation(s):
Mack DR et al. Laboratory values for children with newly diagnosed inflammatory bowel disease. Pediatrics 2007 Jun; 119:1113-9.
Primary care clinicians often perform screening laboratory tests when they suspect that a child might have inflammatory bowel disease (IBD). Investigators evaluated the screening utility of hemoglobin values, platelet counts, erythrocyte sedimentation rate (ESR), and albumin levels using prospectively collected data from a multisite registry of 526 children (mean age, 11.6 years) who were newly diagnosed with IBD (392 with Crohn disease; 134 with ulcerative colitis).
All four tests were normal in 30% of children with mild disease (21% of patients with Crohn disease and 54% of those with ulcerative colitis), compared with only 4% of children with moderate or severe IBD. Of the four tests, ESR was the least likely to be normal (defined as <20 mm/hour), regardless of disease severity. For example, among children with moderate or severe IBD, 18% had normal ESRs, 24% had normal hemoglobin levels, 43% had normal platelet counts, and 50% had normal albumin levels. Hematochezia was the most common presenting feature in children with mild IBD.
Comment: These results indicate that the four IBD screening tests assessed have limited value. I wish the authors had performed more sophisticated analyses, such as calculating sensitivity for different combinations of laboratory values, because early identification of children with IBD is important. The authors note that new laboratory markers, such as antibodies against neutrophils or microbial antigens, and antiglycan antibodies, might hold greater promise.
— Howard Bauchner, MD
Published in Journal Watch Pediatrics and Adolescent Medicine June 13, 2007
Citation(s):
Mack DR et al. Laboratory values for children with newly diagnosed inflammatory bowel disease. Pediatrics 2007 Jun; 119:1113-9.
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