clinical feature - Contemporary Pediatrics

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CONTEMPORARY PEDIATRICS MARCH 2016 VOL. 33 NO. 03
Contemporary
JOURNAL CLUB
ANNUAL TOP 10
MARCH 2016
PEDIATRICS
VOL. 33 | NO. 03
Expert Clinical Advice for Today’s Pediatrician
RETHINKING ASTHMA: ENGAGING TOP TOOLS & TECHNIQUES
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1.Bahorski J, Repasky T, Ranner D, Fields A, Jackson M, Moultry L, Pierce K, Sandell M (Tallahassee Memorial
Healthcare). Temperature measurement in pediatrics: a comparison of the rectal method versus the temporal
artery method. In Press, Corrected Proof, Available online 24 February 2011, Journal of Pediatric Nursing (2011).
2.Batra P, Goyal S. Comparison of rectal, axillary, tympanic, and temporal artery thermometry in the pediatric emergency room. Pediatr Emerg Care. 2013
Jan;29(1):63-6. doi: 10.1097/PEC.0b013e31827b5427.
3.Batra P, Saha A, Faridi MM. Thermometry in children. J Emerg Trauma Shock. 2012 Jul;5(3):246-9.
4.Carr EA, Wilmoth ML, Eliades AB, Baker PJ, Shelestak D, Heisroth KL, Stoner KH (Akron Children’s Hospital). Comparison of Temporal Artery to Rectal
Temperature Measurements in Children Up to 24 Months, Journal of Pediatric Nursing, In Press, [Epub ahead of print], Jan 25, 2010.
5.Gunawan M, Soetjiningsih I ( Udayana University, Sanglah Hospital, Denpasar, Indonesia). Comparison of the accuracy of body temperature measurements
with temporal artery thermometer and axillary mercury thermometer in term newborns. Paediatr Indones, Vol. 50, No. 2, March 2010.
6.Kemp, C. (2013). Temporal artery thermometers may rival rectal thermometers in ED. AAP News, 34(4).
7.Reynolds M, et al. Are temporal artery temperatures accurate enough to replace rectal temperature measurement in pediatric ED patients? J Emerg Nurs.
2012 Nov 8. pii: S0099-1767(12)00329-7. doi: 10.1016/j.jen.2012.07.007. [Epub ahead of print]
8.Titus MO, Hulsey T, Heckman J, Losek JD (Medical University of South Carolina and Children’s Hospital). Temporal artery thermometry utilization in pediatric
emergency care. Clinical Pediatrics, Mar 2009; vol. 48: pp. 190 - 193.
Accuracy Proven for All Ages (Studies including premature neonates to infants
younger than 3 months)
1.Batra P, Saha A, Faridi MM. Thermometry in children. J Emerg Trauma Shock. 2012 Jul;5(3):246-9.
2.Burdjalov et al. Non-Invasive infrared temperature assessment of the temporal artery for core temperature determination in premature neonates.
American Pediatric Society and the Society for Pediatric Research, 5/1/2001
3.Carr et al. Comparison of Temporal Artery to Rectal Temperature Measurements in Children Up to 24 Months, J of Ped Nursing (2011) 26, 179–185
4.Gunawan et al. Comparison of the accuracy of body temperature measurements with temporal artery thermometer and axillary mercury thermometer
in term newborns. Paediatr Indones, 50 (2) 2010.
5.Haddad et al. Comparison of temporal artery and axillary temperatures in healthy newborns.
JOGNN, 41, 383-388; 2012.
For more information and
access to clinical studies:
6.Lee et al. Accuracy of temporal artery thermometry in neonatal intensive care infants.
Adv Neonatal Care, 11(1) 62-70, 2011.
7.Reynolds M, et al. Are temporal artery temperatures accurate enough to replace rectal
temperature measurement in pediatric ED patients? J Emerg Nurs. 2012 Nov 8.
pii: S0099-1767(12)00329-7. doi: 10.1016/j.jen.2012.07.007. [Epub ahead of print]
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CONTEMPORARY PEDIATRICS MARCH 2016 VOL. 33 NO. 03
Contemporary
JOURNAL CLUB
ANNUAL TOP 10
PEDIATRICS
MARCH 2016
VOL. 33 | NO. 03
Expert Clinical Advice for Today’s Pediatrician
ContemporaryPediatrics.com
RETHINKING ASTHMA: ENGAGING TOP TOOLS & TECHNIQUES
RETHINKING
ASTHMA
SPIROMETRY WORKSHOP
Engaging top tools & techniques
OBSTRUCTIVE SLEEP APNEA IN KIDS
Spirometry
workshop
JOURNAL CLUB ANNUAL TOP 10
Obstructive
sleep apnea
in kids
Contemporary
editorial advisory board
PEDIATRICS
Gary L Freed, MD, MPH
Michael S Jellinek, MD
Scott A Shipman, MD, MPH
Director, Division of General
Pediatrics, Professor of Pediatrics
and Health Management and
Policy, and Director, Child Health
Evaluation and Research (CHEAR)
Unit, University of Michigan Health
Systems, Ann Arbor, Michigan
Professor of Psychiatry and of
Pediatrics, Harvard Medical School,
Boston, and Chief Executive
Officer, Community Network,
Lahey Health System, Burlington,
Massachusetts
Director of Primary Care Initiatives
and Workforce Analysis,
Association of American Medical
Colleges, Washington, DC, and
Assistant Professor of Pediatrics,
Dartmouth Institute for Health
Policy and Clinical Practice, Geisel
School of Medicine at Dartmouth,
Lebanon, New Hampshire
Jane A Oski, MD, MPH
Harlan R Gephart, MD
Department of Pediatrics, Tuba City
Regional Health Care Corporation,
Tuba City, Arizona
Clinical Professor of Pediatrics,
University of Washington School of
Medicine, Seattle, Washington
Andrew J Schuman, MD
W Christopher Golden, MD
physician
contributing editors
Section Editor for Peds v2.0,
Adjunct Assistant Professor
of Pediatrics, Geisel School of
Medicine at Dartmouth, Lebanon,
New Hampshire
Assistant Professor of Pediatrics
(Neonatology), Johns Hopkins
University School of Medicine, and
Medical Director, Full Term Nursery,
Johns Hopkins Hospital, Baltimore,
Maryland
Michael G Burke, MD
Section Editor for Journal
Club, Chairman, Department of
Pediatrics, Saint Agnes Hospital,
Baltimore, Maryland
Steven M Selbst, MD
Professor of Pediatrics, Vice Chair
for Education, Director, Pediatric
Residency Program, Sidney Kimmel
Medical College at Thomas
Jefferson University, Philadelphia,
Pennsylvania, and Attending
Physician, Pediatric Emergency
Medicine, Nemours/Alfred I duPont
Hospital for Children, Wilmington,
Delaware
Veronica L Gunn, MD, MPH
Medical Director, Community
Services for Children’s Hospital
and Health System, Milwaukee,
Wisconsin
Donna Hallas, PhD, CPNP,
PNP-BC, PMHS, FAANP
Bernard A Cohen, MD
Section Editor for Dermcase,
Professor of Pediatrics and
Dermatology, Johns Hopkins
University School of Medicine,
Baltimore, Maryland
Clinical Professor, New York
University (NYU) College of
Nursing, and Coordinator, Pediatric
Nurse Practitioner Program, New
York, New York
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Contemporary
PEDIATRICS
March
2016
VOL. 33 NO. 3
clinical features
14 Rethinking asthma: Prevention & management
Pediatricians should target lung function as well as lifestyle, diet, and obesity
as contributing factors for pediatric asthma and provide interventions that will
improve patients’ compliance with treatment regimens.
Pat F Bass III, MD, MS, MPH
20 Spirometry establishes asthma control in children
Here’s a quick primer on the use of the spirometer in children with asthma and
guidance for incorporating this tool into the clinical setting.
Mary Beth Nierengarten, MA
26 Obstructive sleep apnea syndrome in kids
A co-author of the recent Childhood Adenotonsillectomy Trial study discusses
key issues for diagnosing and treating kids with OSAS as well as current
American Academy of Pediatrics clinical practice guidelines for OSAS.
Mary Beth Nierengarten, MA. Reviewed by Carol M Rosen, MD.
13 puzzler
44 dermcase
TODDLER WITH BLISTERING
ACRODERMAL RASH
UNUSUAL SKIN LESION IN A
TEENAGED BOY
Cindy Luu, MD; Jane OH, MD;
Minnelly Luu, MD; Brittney DeClerck, MD
Jacqueline Michel, DO; Kathryn
Wheeler, MD; Jaclyn Otero, MD;
Kristina Carswell, MD; Molly Posa MD;
Maria N Kelly, MD
CLINICAL THERMOMETRY: AN
UPDATE AND REVIEW
Dr. Schuman reviews what’s new in
tools for determining one of the body’s
most vital signs.
Andrew J Schuman, MD, FAAP
Contemporary Pediatrics (Print ISSN: 8750-0507, Digital ISSN: 2150-6345)
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4 EDITORIAL ADVISORY BOARD
45 ADVERTISING INDEX
departments
9 EYE ON WASHINGTON
Why the jump in SSI benefits for kids?
Do you have a manuscript to submit
to Contemporary Pediatrics?
10 JOURNAL CLUB
E-mail [email protected]
for submission guidelines.
Dr. Burke’s top 10 list for the last year
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GE T T Y IMAGES/ALLEN DONIKOWSKI
37 peds v2.0
in addition
inter ctive
JOI N US A ND JOIN IN W IT H YOU R P E D IATR IC PEERS AT C ON TEM POR A RYPED IATR IC S.C OM
‘NOTE BLOAT’ PART 2 Readers (Still) React
Our Editorial Board Advisor (and Tech Guru) Dr Andrew Schuman’s January 2016
Peds v2.0 column (“Expediting medical documentation”) is still resonating.
Contemporary
L PEDIATRICS
PRACTICA
THE
PEARLS FROM
4
TRENCHES: PART
S
PEDIATRIC
p
JANUARY 201601
VOL. 33 | NO.
First, David Notrica, MD,
from Phoenix, AZ, runs
the numbers for us:
’s Pediatrician
Advice for Today
Expert Clinical
For example: (Minutes) x (complexity
of diagnoses factor) + (office expense of
a new patient) 30 minutes x 1.2 = 36
minutes + new patient overhead costs
(converted to + 5 minutes) = 42 minutes
eds v2
D .0
SECON
Expediting medic
SENS
doE
cumentation al
THE
Dr Schuman, I enjoyed your article.
EHRs should have been an amazing
advance for doctors and patients.
Instead they became a scaffold to
improve billing. As much as I hate
the thought of doctors becoming
hourly (minutely) employees, it would
lead to cleaner documentation. With
a little adjustment, physicians could
indeed take back medicine.
s.com
ContemporaryPediatric
ANDREW J SCHUMA
N, MD
SECTION EDITOR
Dr Schuman lays out
his plan for a more
meaningful
way to document
medical encounters
and eliminate
“note bloat,” thereby
ensuring that physicia
appropriately compen
ns are
sated by governm
ent and
insurance compan
ies.
Early loss
detection &
intervention
TREATMENT OF OME y
Autoinflation stud
impression of the
patient’s medical problems and
communicate our
plan for treatment
and further evaluation to those
who will read our
note. The EHR
note ensures continuity of care for
When the editors
our patients.
at Contemp oworkshop at the
rary Pediatrics invited
If you read the
American
Peds v2.0 article
me to launch
“Level 4 office-vis
of Pediatrics National Academy
this section in 2012,
it coding” from
I had no idea
Conference
February 2013, you
and Exhibition in
how much fun
I would have writOctober last year
know that coding office visits is
(see “Best tech for
ing it, and that
based on
our readers would
pediatrics 2015,”
ical decision making” the “medContemporary Pediatrics
actually find the
topics interestin
, December
involved,
g.
the nature of the
2015), pediatricia
Like most of you,
ns told me that their
presenting probI work in a clinic.
lem, and the number
EHRs were too hard
I enjoy treating
my patients, and
to use, with the
of problems
addressed at the
majority of attendees
there is not a day
visit. Unless you
that goes by that
reporting that
I
assign a time designatio
they are unable
need to navigate
to complete their
obstacles imposed
n with your
note, to justify
office notes during
by insurance companie
a 99214
their regular
s, governmust include numerou visit you
hours. Many, if
ment reforms,
not most, were freand my electroni
s
elements
c
in your note to
quently taking at
health record (EHR).
ensure payment
least an hour’s work
If there were to
as
a level 4 visit. Thus,
home with them.
be a theme for this
This is no way to
year’s Peds v2.0,
a level 4 history includes at
care for patients
it would be “taking
or ensure
least 4 history
back the pracof
present illness
life for medical providers! a quality
tice of pediatrics
(HPI) elements;
” for ourselves and
at
least 1 item from
our patients. Yes,
the past medical
there will be lots
history (a medicatio
Our current
of tech articles this
n list or allergy
year because this
list qualifies), social
documentatio
leopard will never
history, or famchange his digin
system
ily history; and
. . . is designed
tal spots. However,
at least a 2-system
to justify
let’s begin our
review of systems
of coding for insurance the level
recovery of medical
(ROS). The level
practice by discompany
4 physical exam
reimbursement
cussing alternativ
requires examinarather than facilie ways of docution of 5 to 7 systems,
tating documen
menting office visits.
tation of the office
including the
patient’s vital signs.
visit. The purpose
When I conducted
of the office note
my last tech
should be to convey
As every provider
knows, when
our clinical
a note is reviewed
36
CONTEMPO
we glance at the
RARYP EDI
AT R
ICS.COM
|
JANUARY
2 016
YOU ARE NOW ON EHR
SYSTEM NUMBER . . .
#1
66%
21%
#2
I hope your article gets legs and
moves things forward.
John Montgomery, MD,
hailing from Columbus,
IN, responds with a tech
tip of his own:
#3
7%
DO NOT
KNOW
6%
SOURCE: Contemporary Pediatrics Annual Issues
& Attitudes Survey, 2015
Andrew, this is a great article. I
agree that EMR documentation is
very time consuming and drains
enjoyment from practice. I have
found that the 2 EMR programs I have
used do not time-stamp well. And
as you know, you may be in and out
of a room several times (like with an
asthma patient getting treatments)
or if you are not open to the exam
screen in EMR, it is not recording
When I run across a useful set of
text, I “copy it” and then add it to
my list. As an example, this last
week, I got a letter on a patient
from a Peds urologist. He gave good
parent instructions on vulvovaginitis
treatment, so I added it to my list.
[Now I can just] type “fuvaginitis”
for “follow-up vaginitis” . . . it types
[out the entire parent instruction list I
had entered]. That list took a couple
seconds. I will be watching for more
of your posts. Thanks.
time as with patient.
I depend heavily on a program
called “Typinator.” I have over 400
macros that range from one
word to many sentences. Some
are just typo fixers like correcting
“adn” to “and.” I would not be able
to practice without this. (Especially
in light of a serious hand injury last
year resulting in loss of use of my
middle finger on nondominant hand).
Jay A. Bernstein, MD,
FAAP, of Rockville, MD,
sees it this way:
I am fortunate to be at the end of my
career in pediatrics. Having seen the
metamorphosis of medical practice
over the years, my conclusion [is]
that physicians in general, and
pediatricians in particular, are
followers and weak minded in
terms of their own value. As one
who has yet to be convinced
of the benefits of any of the
technology-driven issues you
cite, I have maintained a
successful non-EHR practice
and hope to be able to finish up
that way. It is not difficult to justify
levels of service in written notes.
Those who complain about it have
only themselves to blame. They have
accepted a new system on blind faith
without being asked to meaningfully
contribute to its construction.
Want to have your say? We’re a click away at [email protected]
Part of the
8
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EYE ON
washington
BY KATHRYN FOXHALL
CONTEMPORARYPEDIATRICS.COM/EOW
FOR MORE NEWS
@CONTEMPEDS
Why the jump in SSI benefits for kids?
T
he number of children on
Supplemental Security Income (SSI) disability has
surged in recent years, and
even after much discussion
over the last 5 years, people are still
trying to determine all the reasons.
Some are asking whether we are doing the best we can for the children
involved.
In addition, the fact that the
percentage of children getting SSI
differs greatly by state and even by
county has people wondering.
Much of the discussion began
w it h a s er ie s i n t he B o s to n
Globe in 2010 called “The Other
Welfare,” which indicated that
once families begin getting the
checks, it’s hard to give up the
money; that getting the checks
creates a mindset that the child is
disabled; that sometimes teenagers avoid getting jobs so as not to
lose the funding; and that some
families believe a child must be
on medication to qualify.
A recent report from the National
Academy of Medicine (NAM) says
that for more than 1.3 million lowincome children with severe disability, “the Supplemental Security
Income program offers a vital
source of financial support.”
To be eligible, children must
be in low-income households.
Most current child recipients are
in households below 200% of the
federal poverty level. In 2014, the
maximum SSI benefit was $721
per month, according to a brief by
Mathematica Policy Research staff.
From 1998 to 2013, SSI child caseloads grew by 45% and the ratio of
children on SSI increased by 45% up
to 1.8% of all children, according to
Mathematica.
I n 2 012 , t he G over n ment
Accountability Office, a branch of
Congress, found that 65% of child
SSI recipients are awarded these
disability benefits for “mental
over the 10 years ending in 2013,
the percentage of low-income
household children allowed SSI
for mental disorders had actually
decreased. However, the total percentage of children in poverty had
increased, so more children with
mental disorders had become eligible for the program. About 22%
of these children had a diagnosis
of ADHD and another 21% had
autistic disorder and other perva-
About .31% of US children receive SSI
benefits for speech and language disorders,
and the total number has tripled in the
past decade. —National Academy of Medicine
impairment.” The 3 most prevalent primary mental impairments
of those children in 2011 were
attention-deficit/hyperactivity disorder (ADHD), speech and language delays, and autism.
Last year, at the request of the
Social Security Administration,
a NA M commit tee looked at
mental impairments other than
speech and language problems. In
its report “Mental Disorders and
Disabilities Among Low-Income
Children,” the committee stressed,
first off, that there is limited information about the trends in mental
disorder rates and the disabilities associated with them in children in general, but it found that
M A R C H 2 016
|
sive developmental disorders.
Another NAM committee looked
at speech and language issues separately. In a January 2016 report titled
“Speech and Language Disorders
in Children: Implications for the
Social Security Administration’s
Supplemental Security Income
Program,” the committee said that
currently about .31% of US children
receive SSI benefits for speech and
language disorders, and the total
number has tripled in the past
decade.
Surveys have found an increase
in speech and language disorders
in children in the general population. The National Survey of
CONTINUED ON
PAGE 43
9
journal club
BY MARIAN FREEDMAN
COMMENTARY BY MICHAEL G BURKE, MD
CONTEMPORARYPEDIATRICS
Two sides to bariatric surgery for teens
T
hree years after undergoing bariatric surgery, obese
adolescents had lost significant weight and improved
their cardiometabolic health
and weight-related quality of life,
according to a prospective study in
242 teenagers. However, some participants also developed micronutrient deficiencies during the 3-year
period and needed additional abdominal procedures.
Of total participants, most (67%)
under went Rou x-en-Y gastric
bypass, with 28% having sleeve gastrectomy and 6% adjustable gastric
banding. (Because so few participants had adjustable gastric banding,
investigators did not include results
for this group in their analysis.)
The adolescents ranged in age from
13 to 19 years and had a mean body
mass index (BMI) of 53 before the
procedure; 98% had a BMI higher
than 40. After collecting baseline
data for all participants, investigators evaluated changes in body
weight, coexisting conditions, and
other data periodically for 3 years
after the procedure.
At 3 years postsurgery, 26% of
participants were no longer obese.
Participants overall had a mean
weight loss of 27%; for those who
underwent gastric bypass, this figure was 28%, and for those who had
sleeve gastrectomy, 26%. Among
participants who underwent gastric bypass, 89% had at least a 10%
reduction in BMI; for sleeve gastrectomy this figure was 85%. At the
end of the study, only 2% of participants who underwent gastric bypass
and 4% of those who had sleeve gastrectomy weighed more than they
had at baseline.
Surgery also led to related health
improvements, with remission of
several comorbidities in those who
had these conditions at baseline:
remission of type 2 diabetes in 95%;
abnormal kidney function in 86%;
commentary
Surgical intervention as treatment for obesity is not for everyone. However, for
this group of severely obese teenagers, these interventions may be the best that
we have to offer, and earlier may be better. Hypertension and diabetes mellitus
resolved more often in these adolescents than in similar populations of obese
adults who had bariatric surgery for longstanding obesity. —Michael G Burke, MD
Mindfulness instruction relieves
mental/behavioral health problems
Mindfulness instruction improved
psychological functioning and
reduced post t rau mat ic st ress
10
prediabetes in 76%; elevated blood
pressure in 74%; and dyslipidemia
in 66%. Weight-related quality of
life also improved, as assessed by
the Impact of Weight on Quality
of Life-Kids instrument that measures how weight affects a child’s
physical comfort, body esteem,
social life, and family relations.
On the negative side, 57% of
participants had low ferritin levels
at 3 years postsurgery compared
with 5% at baseline. The proportion of participants with deficiencies of vitamin B12 or vitamin A
also increased over time. In addition, 13% of participants underwent
1 or more additional intra-abdominal procedures, all but 3 of which
were related to the prior bariatric
surgery (Inge TH, et al. N Engl J
Med. 2016;374[2]:113-123).
symptoms in low-income, minority middle school students, a trial
in 2 Baltimore City Public Schools
|
M A R C H 2 016
showed. The 300 5th-grade to
8th-grade participants—almost
all African Americans and eligible
for free lunches—were assigned to
either a mindfulness-based stress
reduction (MBSR) program or to a
CONTINUED ON
PAGE 12
journal club
Top 10 list
for the last year
Machine
It’s that time again! Here is Dr. Michael Burke’s
selection of the 10 best articles he’s reviewed for
Journal Club in the last 12 months. The summaries
of these articles and Dr. Burke’s commentaries are
listed chronologically by publication date as they
appeared in Contemporary Pediatrics. To read the
complete summaries and commentaries, go to
ContemporaryPediatrics.com/Journal-Club.
1 2 3 4 5 6 7 8 9 Cesarean delivery raises infants’ risk of RSV
hospitalization. Kristensen K, et al. Pediatr Infect
Dis J. 2015;34(2):145-148 (May 2015)
Study finding turns peanut-allergy avoidance
strategy on its head. Du Toit G, et al. N Engl J Med.
2015;372(9):803-813 (May 2015)
Automated EMR alert helps clinicians pay attention
to elevated BP. Brady TM, et al. Clin Pediatr.
2015;54(7):667-675 (July 2015)
Physician-provided oral health services reduce
caries in kindergarteners. Kranz AM, et al.
Pediatrics. 2015;136(1):107-114 (September 2015)
4 behavior targets help prevent obesity. Cloutier MM,
et al. J Pediatr. 2015;167(2):372-377 (October 2015)
Why do pediatricians work when sick? Szymczak
JE, et al. JAMA Pediatr. 2015;169(9):815-821
(November 2015)
A place for acupuncture in NAS treatment? Raith
W, et al. Pediatrics. 2015;136(5):876-884
(January 2016)
E-cigarette use likely leads to future cigarette
use. Primack BA, et al. JAMA Pediatr.
2015;169(11):1018-1023 (January 2016)
Is it okay to return to school the day after 1 strep
throat treatment? Schwartz RH, et al. Pediatr Infect
Dis J. 2015;34(12):1302-1304
(February 2016)
10
Toddlers’ media use goes way beyond TV.
Kabali HK, et al. Pediatrics. 2015;136(6):1044-1050
(February 2016)
Medical waste removal has cost physicians thousands of dollars
over the year with the charges going up every year and their
business having nothing to show for their expense. There is
now a cost-effective, professionally recognized alternative.
The Medical Waste Machine system replaces an expensive,
ongoing medical waste removal cost, which increases regularly
and incurs a cost to the doctors forever. The system can save
small and large businesses up to 80% yearly.
The Medical Waste Machine system improves the liability
situation because there are no sharps (needles and syringes,
lancets, blades, broken glass carpules, etc.) and other medical
waste onsite due to the sterilization process that converts the
medical waste to ordinary waste immediately.
Also, the system makes an important environmental contribution
because the waste going to the landfill is not only reduced in
volume by an average of 75% but is sterile as well.
Due to the monoply that has occured in the medical waste
removal industry, prices are increasing considerably and
regularly. By saving physicians money, eliminating their liability,
which they are responsible forever (from cradle to grave),
eliminating their paperwork and improving the environment, the
Medical Waste Machine offers an unequivocal number of
advantages over medical waste carriers and mail back services.
For more information:
Dr Burke, section editor for Journal Club, is chairman of the
Department of Pediatrics at Saint Agnes Hospital, Baltimore,
Maryland.
Telephone: 508-358-8099
Fax: 508-358-2131
E-Mail: [email protected]
www.medicalinnovationsinc.com
journal club
CONTINUED FROM
PAGE 10
health education program (Healthy
Topics [HT]) that focused on overall student wellness.
The MBSR program consists of:
material related to mindfulness,
meditation, yoga, and mind/body
connection; mindfulness meditations, mindful yoga, and body
awareness; and group discussion
about applying mindfulness to
everyday situations. In the HT control program, students learn about
topics, such as nutrition, exercise,
body systems, adolescence, and
puberty.
At baseline and after completion of the 12-week programs,
investigators compared mindfulness, psychological symptoms,
mood and emotion regulation, coping, and posttraumatic symptoms
in the 2 groups. The MBSR participants showed lower levels of both
depressive symptoms and posttraumatic symptoms (Sibinga EM, et al.
Pediatrics. 2016;137[1]:e20152532).
commentary
This was a carefully planned and implemented in-school program that required buy-in from teachers and school administrators,
all of whom must constantly juggle competing demands. However, the results showed that the juggling was worthwhile. Middle
school children who underwent mindfulness training emerged with skills to help them safely navigate high school and the
neighborhoods where they live. —Michael G Burke, MD AD keeping your patient awake?
Melatonin might help!
A nightly 3-mg dose of melatonin can
help children with atopic dermatitis (AD)
fall asleep more quickly and reduce the
severity of their AD. This was the finding
of an 8-week trial in Taiwan in 48 youngsters with AD aged from 1 to 18 years.
Pa r t icipa nts were div ided into
2 groups, 1 of which received melatonin for 4 weeks and then a placebo for
another 4 weeks. The second group did
the reverse, taking a nightly placebo first
and then crossing over to melatonin.
Investigators assessed AD severity on the
first and last day of the 2 treatment periods, using the Scoring Atopic Dermatitis
(SCORAD) index, and used questionnaires to evaluate subjective symptoms.
Melatonin shortened by 21.4 minutes how long it took participants to
fall asleep, compared with placebo. In
addition, after melatonin treatment, the
SCORAD index decreased by 9.1 (on
a best-to-worst scale of 0 to 103) compared with the score after taking placebo.
(These 2 melatonin-related improvements did not correlate with one another,
however.) Patients themselves thought
that melatonin improved their sleep and
their AD (Chang YS, et al. JAMA Pediatr.
2016;170[1]:35-42).
commentary
All the patients in this study had both AD and a sleep problem involving either delayed sleep
initiation or disrupted sleep on 3 or more nights per week for 3 months prior to the study.
It may be that sleeplessness leads to more awareness of itching, more scratching, and
worsened AD. If so, improved sleep might explain improved AD. Or, it may be that antiinflammatory properties of melatonin decrease itching, which leads to less scratching and
improved AD. Bedtime melatonin may be worth a try! —Michael G Burke, MD 12
|
M A R C H 2 016
also of
note
Infant mortality rates can
be affected by changes
in cigarette taxes and
prices. An analysis of
the relationship between
changes in cigarette taxes
and prices over time and
infant mortality rates found
that higher cigarette taxes
are strongly associated
with decreases in infant
mortality. Using data for all
states from 1999 to 2010,
researchers found that for
every dollar in increased
taxes on cigarettes, infant
deaths decreased by
0.19 per 1000 live births—a
potential annual reduction
of 750 US infant deaths, or
an average of 2 averted
deaths each day. This
association was strongest
among non-Hispanic
African Americans (Patrick
SW, et al. Pediatrics.
2016;137[1]:e20152901). puzzler
Toddler with
blistering
acrodermal
rash
CINDY LUU, MD, PGY3
JANE OH, MD
MINNELLY LUU, MD
BRITTNEY DECLERCK, MD
S FIGURE 1 Erythematous papules and plaques covering the patient’s
perineal, acrodermal, and facial areas, as well as alopecia.
THE CASE
The anxious parents of a previously healthy, 19-month-old boy bring the
child to the emergency department (ED) for evaluation of progressive rash
IMAGE CREDIT/AUTHOR SUPPLIED
that began 4 months ago. The skin eruption started as small blisters on his
knees, which became tense and ruptured, eventually evolving to red-pink
scaly plaques. Over the next few months, the boy developed similar lesions on
his hands, elbows, neck, perineal area, and face, with sparing of the mucous
membranes. FOR MORE ON THIS CASE, TURN TO PAGE 33.
M A R C H 2 016
|
13
CLINICAL FEATURE
Rethinking
Asthma
Rethinking asthma
Prevention & management
PAT F BASS III, MD, MS, MPH
Dr Bass is chief medical
information officer and
associate professor of
medicine and of pediatrics,
Louisiana State University
Health Sciences Center–
Shreveport. The author
has nothing to disclose in
regard to affiliations with
or financial interests in
any organizations that may
have an interest in any part
of this article.
Pediatricians should target lung function as well as
lifestyle, diet, and obesity as contributing factors for
pediatric asthma and examine interventions that will
improve patients’ compliance with treatment regimens.
function in a dose-dependent manner.4
Despite significant advances in asthma
research and care, the burden of asthma
Adult studies have demonstrated that
remains high. On a daily basis, asthma
weight loss can, in fact, improve lung funcleads to: 68,000 missed school days or worktion.5 As a result, office interventions tardays; 36,000 asthma attacks and
geting activity levels may impact
4800 emergency department
asthma or its severity. Further,
visits; 1250 hospital admisthis evidence demonstrates
sions; and 11 deaths.1 This
additional benefit of the
pediatrician targeting
article will review a numNumber of ED visits
healthy weight loss and
ber of different aspects of
due to asthma by kids
maintenance beyond traasthma care that impact
under age 15 in 2010.
ditional cardiovascular
the pediatrician.
Source: American Lung
and endocrine targets that
Association. 2014.
are well known.
Lifestyle, obesity,
640,000
and asthma
A link between lifestyle, obesity and asthma has been discussed in
the medical literature for some time.2,3 In
1 long-term study, decreased levels of
physical activity and increased screen
time were associated with obesity. In turn,
obesity in the 4th to 6th grades was associated with asthma and decreased lung
14
|
M A R C H 2 016
Outcomes of asthma
in pediatrics
Control of asthma in the pediatric years
has a tremendous impact on the patient
in adulthood. In the Melbourne Asthma
study that examines the natural history
of asthma, results demonstrate that lung
function as well as clinical outcomes
clinical feature
are predicted by asthma severity
in childhood. 6 Poorly controlled
asthma in childhood can result in
significant respiratory morbidity
into adulthood, and poor control in
childhood represents a significant
risk of morbidity as children transition into their adult lives.
Diagnosing asthma
severity: FeNO
Fractional exhaled nitric oxide
(FeNO) is a relatively recent, pointof-care diagnostic tool used to
identify T-helper cell type 2 (Th2)driven a llergic inf lammation,
which is present in up to 80% of
children and 50% of adult asthma
patients.7 Elevated FeNO levels are
indicative of airway inflammation
that is likely to respond to inhaled
steroids. Additionally, FeNO-based
management of asthma symptoms
is associated with less asthma exacerbations compared with management based on clinical parameters
alone.
However, what is considered a
meaningful difference in FeNO
measurement still is under debate,
and not all experts believe FeNO
is useful in managing pediatric
asthma. It also should be noted that
use of FeNo is limited in patients
with asthma phenotypes not characterized by inflammation. There
is 1 FeNO measurement device
approved by the US Food and Drug
Administration (FDA) and available for use in clinical practice—the
Nioxx Vero.7
Yellow-zone asthma
management
The 2007 Expert Panel Report
3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma8
recommends a short course of oral
corticosteroids if increased doses of
a short-acting beta agonist (SABA)
do not lead to improved control of
asthma symptoms. A recent practice
guideline, Management of acute loss
of asthma control in the yellow zone:
a practice parameter,9 provides additional treatment options based on
research published since the 2007
report.
Montelukast and
neuropsychiatric
events
Many parents like the ease and
simplicity of montelukast or other
leukotriene inhibitors compared
with an asthma inhaler. Although
labeling was added in 2009 outlining risk for neuropsychiatric
events, the FDA Pediatric Advisory
Committee (PAC) recently rec-
13.8 million
NUMBER OF SCHOOL DAYS KIDS WITH ASTHMA MISSED IN 2013
Source: Centers for Disease Control and Prevention.
The repor t emphasizes t he
importance of quick relief, but discourages scheduled SABA as the
only treatment because this strategy fails to prevent progression
into the red zone consistently.9 The
guideline offers several options
including:
1. Increase inhaled steroid doses by
4-fold by increasing either the
frequency or dose of medication.
2. Dynamic dosing in which the
patient uses his/her controller
medication each time the SABA
is used. In this way, the amount
of steroids received is in proportion to the severity of the asthma
symptoms.
These enhanced yellow-zone
strategies should be continued for
14 days to ensure symptoms resolve
and lung function improves.9 The
guideline emphasizes that the
strategies be tailored to the individual patient and that clinicians
make changes to the action plan
based on how well it performs with
each episode of poor control.
M A R C H 2 016
|
ommended strategies to increase
awareness with health providers
and parents.10
Montelukast was discussed as
part of a routine PAC pediatric
safety review in September 2014.11
Public testimony by parents outlined that although the FDA has
attempted to communicate these
risks to clinicians, many are not
aware of or fail to communicate
this risk to parents.
T he pre s c r i bi n g i n for m ation for montelukast includes the
following:10
“Neuropsychiatric events have
been repor ted in adu lt, adolescent, and pediatric patients
ta k ing [montelukast sodium].
Postmarketing reports with [montelu kast sodium] use include
agitation, aggressive behavior or
hostility, anxiousness, depression, disorientation, disturbance
in attention, dream abnormalities,
hallucinations, insomnia, irritability, memory impairment, restlessness, somnambulism, suicidal
15
clinical feature
thinking and behavior (including
suicide), and tremor. The clinical details of some postmarketing
reports involving [montelukast
sodium] appear consistent with a
drug-induced effect.”
In the very young pediatric
patient who is not able to fully
communicate (montelukast is
approved in children aged as young
as 6 months), detection of these
adverse effects can be very difficult.
Similarly, some of these adverse
effects can be easily attributable by
a parent or pediatrician as part of
adolescence in older children. As
a result, it is only increased awareness that can identify this problem.
Providers should educate parents
and then follow up specifically
after starting therapy.11
The most common adverse
effects of montelukast are not
serious and symptoms generally
resolve with cessation of treatment.
New drugs for asthma
For the longest time, Xolair has
been t he on ly biolog ic ava i lable for patients with poorly controlled moderate-to-severe asthma.
Importantly, long-term followup studies (median follow-up of
5 years) have now demonstrated
rates of cancer are similar between
patients treated with Xolair and
those not receiving Xolair. There
are now other biologic options
available to the pediatrician.3
Mepolizumab, a monoclonal
anti-IL-5 antibody, was recently
approved by the FDA as an add-on
therapy for patients aged 12 years
and older with severe asthma.12
Administered via injection once
per month, the drug lowers eosinophil levels. Studies demonstrated
16
decreased hospitalization and
decreased steroid use but not
WHAT’S THE SINGLE
BIGGEST BARRIER YOU
SEE TO GOOD ASTHMA
SYMPTOM CONTROL IN
YOUR PATIENTS?
50
%
Noncompliance
with treatment
5%
Difficulty of
medication
delivery
devices
10
%
Environmental
triggers out of
your control
34%
Insufficient
caregiver
support
Source: Contemporary Pediatrics online poll.
March 2016.
improvements in lung function.2,3
Headache, injection-site reactions, back pain, and weakness
were common adverse effects in
clinical trials.12 Less-common but
Diet and asthma
There has been a great deal of interest and research in recent years into
diet and patterns of asthma. Current evidence points to a “Mediterranean diet” decreasing asthma risk
while a “Western diet” increases
risk. The Western diet (increased
amounts of refined grains and saturated fats with low amounts of fruits
and vegetables) is proinflammatory
and increases risk of asthma while
the Mediterranean diet (limited
amounts of refined grains and saturated fats but increased amounts
of fruits and vegetables) is antii n f la m mator y a nd de c re a s e s
asthma risk. However, evidence for
specific anti-inf lammatory foods
is still lacking to the point that the
supplementation can be recommended. 2 This has led to multiple
studies looking at the relationship
between specific foods or supplements and how they might be
related to or treat asthma.
Previous evidence has noted
increases in allergic disease and
asthma in places where vitamin
D is deficient, and more severe
exacerbations of asthma with
exposure to a trigger such as a
viral respiratory tract infection.13
However, the Vitamin D Add-on
Poor control [of asthma] in childhood
represents a significant risk of morbidity as
children transition into their adult lives.
serious adverse effects included
swelling of the face, mouth, and
tongue; dizziness; hives; breathing
problems; and rash. Herpes zoster
infections also can occur.
|
M A R C H 2 016
Therapy Enhances Corticosteroid
Responsiveness in Asthma (VIDA)
trial failed to demonstrate more
rapid tapering of inhaled steroids
CONTINUED ON
PAGE 19
For bacterial conjunctivitis in children as young as 12 months –
Unleash power against
pathogens of concern.
1
1
1
1 drop
3x
a day
4 to 12 hours apart
For 7 days
Indication
BESIVANCE® (besifloxacin ophthalmic suspension) 0.6% is a quinolone antimicrobial indicated for the treatment of
bacterial conjunctivitis caused by susceptible isolates of the following bacteria: Aerococcus viridans*, CDC coryneform
group G, Corynebacterium pseudodiphtheriticum*, Corynebacterium striatum*, Haemophilus influenzae, Moraxella
catarrhalis*, Moraxella lacunata*, Pseudomonas aeruginosa*, Staphylococcus aureus, Staphylococcus epidermidis,
Staphylococcus hominis*, Staphylococcus lugdunensis*, Staphylococcus warneri*, Streptococcus mitis group, Streptococcus
oralis, Streptococcus pneumoniae, Streptococcus salivarius*
* Efficacy for this organism was studied in fewer than 10 infections.
Important Safety Information about BESIVANCE®
BESIVANCE® is for topical ophthalmic use only, and should not be injected subconjunctivally, nor should it be introduced directly
into the anterior chamber of the eye.
As with other anti-infectives, prolonged use of BESIVANCE® may result in overgrowth of non-susceptible organisms, including
fungi. If super-infection occurs, discontinue use and institute alternative therapy.
Patients should not wear contact lenses if they have signs or symptoms of bacterial conjunctivitis or during the course of
therapy with BESIVANCE®.
The most common adverse event reported in 2% of patients treated with BESIVANCE® was conjunctival redness. Other adverse
events reported in patients receiving BESIVANCE® occurring in approximately 1-2% of patients included: blurred vision, eye pain,
eye irritation, eye pruritus and headache.
BESIVANCE® is not intended to be administered systemically. Quinolones administered systemically have been associated with
hypersensitivity reactions, even following a single dose. Patients should be advised to discontinue use immediately and contact
their physician at the first sign of a rash or allergic reaction.
Safety and effectiveness in infants below one year of age have not been established.
Please see brief summary of Prescribing Information on adjacent page.
Reference: 1. BESIVANCE® Prescribing Information, September 2012.
Besivance is a trademark of Bausch & Lomb Incorporated or its affiliates.
© 2015 Bausch & Lomb Incorporated. All rights reserved. US/BES/15/0011
BRIEF SUMMARY OF PRESCRIBING INFORMATION
This Brief Summary does not include all the information needed to use Besivance
safely and effectively. See full prescribing information for Besivance.
Besivance (besifloxacin ophthalmic suspension) 0.6%
Sterile topical ophthalmic drops
Initial U.S. Approval: 2009
1
INDICATIONS AND USAGE
Besivance® (besifloxacin ophthalmic suspension) 0.6%, is indicated for the treatment of
bacterial conjunctivitis caused by susceptible isolates of the following bacteria:
Aerococcus viridans*, CDC coryneform group G, Corynebacterium pseudodiphtheriticum*,
Corynebacterium striatum*, Haemophilus influenzae, Moraxella catarrhalis*, Moraxella
lacunata*, Pseudomonas aeruginosa*, Staphylococcus aureus, Staphylococcus
epidermidis, Staphylococcus hominis*, Staphylococcus lugdunensis*, Staphylococcus
warneri*, Streptococcus mitis group, Streptococcus oralis, Streptococcus pneumoniae,
Streptococcus salivarius*
*Efficacy for this organism was studied in fewer than 10 infections.
2
DOSAGE AND ADMINISTRATION
Invert closed bottle and shake once before use.
Instill one drop in the affected eye(s) 3 times a day, four to twelve hours apart for 7 days.
4
CONTRAINDICATIONS
None
5
WARNINGS AND PRECAUTIONS
5.1
Topical Ophthalmic Use Only NOT FOR INJECTION INTO THE EYE.
Besivance is for topical ophthalmic use only, and should not be injected subconjunctivally,
nor should it be introduced directly into the anterior chamber of the eye.
5.2
Growth of Resistant Organisms with Prolonged Use As with other anti-infectives, prolonged use of Besivance (besifloxacin ophthalmic suspension) 0.6% may result
in overgrowth of non-susceptible organisms, including fungi. If super-infection occurs,
discontinue use and institute alternative therapy. Whenever clinical judgment dictates, the
patient should be examined with the aid of magnification, such as slit-lamp biomicroscopy, and, where appropriate, fluorescein staining.
5.3
Avoidance of Contact Lenses Patients should not wear contact lenses if they
have signs or symptoms of bacterial conjunctivitis or during the course of therapy with
Besivance.
6
ADVERSE REACTIONS
Because clinical trials are conducted under widely varying conditions, adverse reaction
rates observed in one clinical trial of a drug cannot be directly compared with the rates
in the clinical trials of the same or another drug and may not reflect the rates observed in
practice.
The data described below reflect exposure to Besivance in approximately 1,000 patients
between 1 and 98 years old with clinical signs and symptoms of bacterial conjunctivitis.
The most frequently reported ocular adverse reaction was conjunctival redness, reported
in approximately 2% of patients.
Other adverse reactions reported in patients receiving Besivance occuring in approximately
1-2% of patients included: blurred vision, eye pain, eye irritation, eye pruritus and headache.
8
USE IN SPECIFIC POPULATIONS
8.1
Pregnancy Pregnancy Category C. Oral doses of besifloxacin up to
1000 mg/kg/day were not associated with visceral or skeletal malformations in rat pups
in a study of embryo-fetal development, although this dose was associated with maternal
toxicity (reduced body weight gain and food consumption) and maternal mortality. Increased post-implantation loss, decreased fetal body weights, and decreased fetal ossification were also observed. At this dose, the mean Cmax in the rat dams was approximately
20 mcg/mL, >45,000 times the mean plasma concentrations measured in humans.
The No Observed Adverse Effect Level (NOAEL) for this embryo-fetal development study
was 100 mg/kg/day (Cmax, 5 mcg/mL, >11,000 times the mean plasma concentrations
measured in humans).
In a prenatal and postnatal development study in rats, the NOAELs for both fetal and
maternal toxicity were also 100 mg/kg/day. At 1000 mg/kg/day, the pups weighed
significantly less than controls and had a reduced neonatal survival rate. Attainment of
developmental landmarks and sexual maturation were delayed, although surviving pups
from this dose group that were reared to maturity did not demonstrate deficits in behavior,
including activity, learning and memory, and their reproductive capacity appeared normal.
Since there are no adequate and well-controlled studies in pregnant women, Besivance
should be used during pregnancy only if the potential benefit justifies the potential risk to
the fetus.
8.3
Nursing Mothers Besifloxacin has not been measured in human milk, although
it can be presumed to be excreted in human milk. Caution should be exercised when
Besivance is administered to a nursing mother.
8.4
Pediatric Use The safety and effectiveness of Besivance® in infants below one
year of age have not been established. The efficacy of Besivance in treating bacterial
conjunctivitis in pediatric patients one year or older has been demonstrated in controlled
clinical trials [see CLINICAL STUDIES (14)].
There is no evidence that the ophthalmic administration of quinolones has any effect on
weight bearing joints, even though systemic administration of some quinolones has been
shown to cause arthropathy in immature animals.
8.5
Geriatric Use No overall differences in safety and effectiveness have been
observed between elderly and younger patients.
12
CLINICAL PHARMACOLOGY
12.1 Mechanism of Action Besifloxacin is a fluoroquinolone antibacterial [see CLINICAL PHARMACOLOGY (12.4)].
12.3 Pharmacokinetics Plasma concentrations of besifloxacin were measured in adult
patients with suspected bacterial conjunctivitis who received Besivance bilaterally three
times a day (16 doses total). Following the first and last dose, the maximum plasma besifloxacin concentration in each patient was less than 1.3 ng/mL. The mean besifloxacin
Cmax was 0.37 ng/mL on day 1 and 0.43 ng/mL on day 6. The average elimination half-life
of besifloxacin in plasma following multiple dosing was estimated to be 7 hours.
12.
Microbiology
Besifloxacin is an 8-chloro fluoroquinolone with a N-1 cyclopropyl group. The compound
has activity against Gram-positive and Gram-negative bacteria due to the inhibition of
both bacterial DNA gyrase and topoisomerase IV. DNA gyrase is an essential enzyme
required for replication, transcription and repair of bacterial DNA. Topoisomerase IV is an
essential enzyme required for partitioning of the chromosomal DNA during bacterial cell
division. Besifloxacin is bactericidal with minimum bactericidal concentrations (MBCs)
generally within one dilution of the minimum inhibitory concentrations (MICs).
The mechanism of action of fluoroquinolones, including besifloxacin, is different from that
of aminoglycoside, macrolide, and β-lactam antibiotics. Therefore, besifloxacin may be
active against pathogens that are resistant to these antibiotics and these antibiotics may
be active against pathogens that are resistant to besifloxacin. In vitro studies demonstrated
cross-resistance between besifloxacin and some fluoroquinolones.
In vitro resistance to besifloxacin develops via multiple-step mutations and occurs
at a general frequency of < 3.3 x 10-10 for Staphylococcus aureus and < 7 x 10-10 for
Streptococcus pneumoniae.
Besifloxacin has been shown to be active against most isolates of the following bacteria
both in vitro and in conjunctival infections treated in clinical trials as described in the
INDICATIONS AND USAGE section:
Aerococcus viridans*, CDC coryneform group G,
Corynebacterium pseudodiphtheriticum*, C. striatum*, Haemophilus influenzae, Moraxella
catarrhalis*, M. lacunata*, Pseudomonas aeruginosa*, Staphylococcus aureus, S.
epidermidis, S. hominis*, S. lugdunensis*, S. warneri*, Streptococcus mitis group, S. oralis,
S. pneumoniae, S. salivarius*
*Efficacy for this organism was studied in fewer than 10 infections.
13
NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Long-term studies in
animals to determine the carcinogenic potential of besifloxacin have not been performed.
No in vitro mutagenic activity of besifloxacin was observed in an Ames test (up to 3.33 mcg/
plate) on bacterial tester strains Salmonella typhimurium TA98, TA100, TA1535, TA1537
and Escherichia coli WP2uvrA. However, it was mutagenic in S. typhimurium strain TA102
and E. coli strain WP2(pKM101). Positive responses in these strains have been observed
with other quinolones and are likely related to topoisomerase inhibition.
Besifloxacin induced chromosomal aberrations in CHO cells in vitro and it was positive in an
in vivo mouse micronucleus assay at oral doses × 1500 mg/kg. Besifloxacin did not induce
unscheduled DNA synthesis in hepatocytes cultured from rats given the test compound up
to 2,000 mg/kg by the oral route. In a fertility and early embryonic development study in
rats, besifloxacin did not impair the fertility of male or female rats at oral doses of up to
500 mg/kg/day. This is over 10,000 times higher than the recommended total daily human
ophthalmic dose.
14
CLINICAL STUDIES
In a randomized, double-masked, vehicle controlled, multicenter clinical trial, in which
patients 1-98 years of age were dosed 3 times a day for 5 days, Besivance was superior to
its vehicle in patients with bacterial conjunctivitis. Clinical resolution was achieved in 45%
(90/198) for the Besivance treated group versus 33% (63/191) for the vehicle treated group
(difference 12%, 95% CI 3% - 22%). Microbiological outcomes demonstrated a statistically
significant eradication rate for causative pathogens of 91% (181/198) for the Besivance
treated group versus 60% (114/191) for the vehicle treated group (difference 31%, 95%
CI 23% - 40%). Microbiologic eradication does not always correlate with clinical outcome
in anti-infective trials.
17
PATIENT COUNSELING INFORMATION
Patients should be advised to avoid contaminating the applicator tip with material from the
eye, fingers or other source.
Although Besivance is not intended to be administered systemically, quinolones
administered systemically have been associated with hypersensitivity reactions, even
following a single dose. Patients should be advised to discontinue use immediately and
contact their physician at the first sign of a rash or allergic reaction.
Patients should be told that although it is common to feel better early in the course of
the therapy, the medication should be taken exactly as directed. Skipping doses or not
completing the full course of therapy may (1) decrease the effectiveness of the immediate
treatment and (2) increase the likelihood that bacteria will develop resistance and will not
be treatable by Besivance or other antibacterial drugs in the future.
Patients should be advised not to wear contact lenses if they have signs or symptoms of
bacterial conjunctivitis or during the course of therapy with Besivance.
Patients should be advised to thoroughly wash hands prior to using Besivance.
Patients should be instructed to invert closed bottle (upside down) and shake once before
each use. Remove cap with bottle still in the inverted position. Tilt head back, and with
bottle inverted, gently squeeze bottle to instill one drop into the affected eye(s).
Manufactured by: Bausch & Lomb Incorporated
Tampa, Florida 33637
Besivance® is a registered trademark of Bausch & Lomb Incorporated.
©Bausch & Lomb Incorporated
U.S. Patent Nos. 6,685,958; 6,699,492; 5,447,926
†DuraSite is a trademark of InSite Vision Incorporated
US/BES/15/0019
Based on 9142605(flat)-9142705(folded)
clinical feature
CONTINUED FROM
PAGE 16
general diets (eg, Mediterranean
diet) or should researchers continue to go down a path examining
specific components looking for
some sort of magic bullet? There
is at least some evidence that trying to encourage better diets may
asthma costs.19
Research recently began looking at whether today’s increasingly
“plugged-in” society might help
improve asthma control. One study
looked at more than 1000 children
in the Kaiser Permanente Colorado
or improved asthma control when
vitamin D-deficient patients were
supplemented or given a placebo.14
Despite a n i ma l models of
vitamin A deficiency being significantly associated with airway
inf lammation and evidence of
vitamin A deficiency being proinflammatory in adults, there is little
evidence to support if vitamin A
impacts asthma.15 In the Danish
ESTIMATED ANNUAL COST OF TREATING ASTHMA
National Birth Cohort,16 maternal
vitamin A intake did not impact
IN KIDS AGED YOUNGER THAN 18 YEARS
Source: Weiss KB, et al. Journal of Allergy and Clinical Immunology. 2000.
asthma in the first 7 years of life.
Other studies have failed to demhave an impact. In a Spanish study,
health maintenance organization
onstrate any impact on the develchildren who ate an overall highand the impact of speech recogniopment or treatment of asthma
antioxidant diet were less likely
tion on asthma adherence.19
with vitamin A supplementation in
16,17
to experience an asthma episode
early life.
Speech recognition phone calls
compared
with
children
consumwere made to intervention parents
Although the results for vitamin
ing lower levels of antioxidants.18
when inhaled steroid refills were
C supplementation are more promdue or overdue.19 Although adherising, the evidence still appears
Future research hopefully will
insufficient to make a recomprovide an answer, but there is a
ence overall in both the intervenmendation that supplementation
definite benefit from a reasonable
tion arm and the standard care
improves asthma.15
diet that encourages weight loss in
arm was poor, adherence was 25%
the obese and overweight or maingreater in the intervention group as
Similarly, there is not enough
tenance of a healthy weight.
measured by a possession ratio over
current evidence to suggest that
24 months. Interestingly, urgent
vitamin E supplementation in
care visits did not differ between
pregnancy prevents respiratory
Improving adherence
the 2 groups. Low-cost intervendisease in early childhood despite
Depending on what one reads and
tions such as the one described
animal models that support the
how one defines adherence, com15
have the potential for significant
concept. Recent randompliance ranges somewhere
improvements in adherence and
between 22% and 78%.
ized trials also have
subsequent asthma control and
Adherence is poor in
not demonstrated a
FAST FACT
The death rate
potential cost savings.
asthmatic patients
positive impact of
from
asthma
among
In another adherence study, the
for a nu mber of
supplementat ion
African American
target was adolescents and deliverdifferent reasons
with vitamin E on
children is 500% higher
ing messages to their ever-present
including parenasthma.
than in white children.
smartphones to help improve comtal concern about
Like with studies
Source:Akinbami LJ, et al.
pliance.20 Using a web-based appliadverse effects, the
in cancer and other
Ambul Pediatr. 2002.
complexity of asthma
diseases that appear
cation, patients sign up and request
regimens, cost, and a
a menable to d iet a r y
med reminder delivery messages.
whole host of other factors.
intervention, research appears
In addition to improvements in
Interventions that can improve
to be at a crossroads in regard
adherence, improvements in selfadherence will likely improve
to diet and its association with
efficacy and quality of life also
C O N T I N U E D O N PAGE 32
a st h ma cont rol a nd decrea se
asthma. Is it better to look at more
$3.2 billion
M A R C H 2 016
|
19
CLINICAL FEATURE
Spirometry
Workshop
Spirometry
establishes asthma
control in children
MARY BETH NIERENGARTEN, MA
Ms Nierengarten, a medical
writer in Minneapolis,
Minnesota, has more
than 25 years of medical
writing experience,
authoring articles for
a number of online
and print publications,
including various Lancet
supplements, and
Medscape. She has
nothing to disclose in
of this article.
20
Good asthma control in children begins with an accurate
diagnosis and uses spirometry to control patients’
symptoms and monitor their lung function. This article
provides pediatricians with a quick primer on the use of
the spirometer in children with asthma and guidance for
incorporating this tool into the clinic setting.
As one of the most common chronic diseases in childhood, asthma affects millions
of children in the United States.1 Data from
the 2012 National Health Interview Survey show that 6.8 million children aged
younger than 18 years (9% of all children)
have asthma and 10 million (14%) have
been diagnosed at one time with asthma.2
Broken down by race and socioeconomic conditions, the numbers get worse.
Among non-Hispanic black children, 16%
have asthma and 22% have ever been diagnosed with it. Among children in poor
families, 13% have asthma and 19% have
received a diagnosis at one time. The worst
rates are for children in fair to poor health,
|
M A R C H 2 016
with 37% of children with asthma and 40%
receiving a diagnosis at one time.2
These numbers highlight the many
children with asthma who require ongoing management so that they can achieve
and maintain good asthma control. To
provide these children with the best care,
pediatricians and other healthcare providers who have them as patients need to
become educated on and facile in using a
tool that is critical to the accurate diagnosis
of asthma and asthma control. That tool is
spirometry.
“The goal of caring for children with
asthma is to ensure their disease is well
controlled, and that boils down to both
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clinical feature
DIAGNOSIS OF ASTHMA
1
Detailed
medical history
Suggested items to include:
} Symptoms
} Patterns of symptoms
} Precipitating and/or aggravating factors
} Development of disease and treatment
} Family history
} Social history
} History of exacerbations
to guide them when using it in the
clinic. The information provided
debunks several myths about spirometry that may interfere with its
more widespread use. Among these
myths are that spirometry can’t be
used in children; spirometry takes a
long time to administer and can only
be performed by respiratory therapists; and the curves and numbers
generated from spirometry are difficult to interpret.
} Impact of asthma on patient and family
} Assessment of patient’s and family’s perceptions of disease
Physical
examination
Examination focuses on:
} Upper respiratory tract: increased nasal secretion, mucosal
swelling, and/or nasal polyp
} Chest: wheezing during normal breathing or prolonged
phase of forced exhalation, hyperexpansion of thorax, use of
accessory muscles, appearance of hunched shoulders, chest
deformity. Key symptoms include wheezing; history of cough
(especially at night), recurrent wheeze, difficulty breathing, or
chest tightness; worsening symptoms with exercising, viral
infection, inhaling allergens or irritants, weather changes,
strong emotional expression, stress, or menstrual cycle; and
symptoms worsen or occur at night, waking patient.a
} Skin: atopic dermatitis, eczema
Spirometry
Can demonstrate obstruction and assess reversibility
} Recommended in children aged >5 yearsb
a
Lack of wheezing and normal chest exam do not exclude asthma.
Although guidelines recommend children be aged ≥5 years before using spirometry, some aged as young as
3 years are able to use it well enough to get useful information. Very young children can get frustrated with
the machine and should wait until they are older to use it.
Adapted from National Institutes of Health. National Heart, Lung, and Blood Institute.1
b
controlling their symptoms and
objectively measuring lung function
with spirometry,” says John Kelso,
MD, from the Division of Allergy,
Asthma and Immunology, Scripps
Clinic, San Diego, California.
For the past 10 years, Kelso, who
also is a clinical professor of pediatrics at the University of California,
San Diego School of Medicine, has
conducted a workshop on spirometry at the American Academy of
Pediatrics (AAP) annual meeting.
The workshop provides information
22
on the latest guidelines for the recommended use of spirometry to
diagnose and monitor asthma in
children, as well as instructions on
how to use and interpret the findings of spirometry and incorporate
this tool into office flow.
This article summarizes the workshop Kelso gave at the most recent
AAP annual meeting in October 2015
in Washington, DC, with an eye to
providing pediatricians with a quick
primer on spirometry and some
useful and accessible information
|
M A R C H 2 016
Symptoms and
spirometry: twin
components of
diagnosis and
monitoring
Referring to the most recent national
guidelines for the diagnosis and management of asthma by the National
Heart, Lung, and Blood Institute,
National Asthma Education and
Prevention Program Expert Panel
Report 3 (EPR3), Kelso highlighted
the recommendation for including
spirometry in a comprehensive evaluation of asthma that also includes
physical examination and a detailed
medical history.1 Table 1 lists these
3 main components of a thorough
clinical evaluation of a child with
suspected asthma.
Spirometry is specifically needed
to provide an objective measure of
pulmonary function, because subjective measures such as patient perceptions of airf low obstructions,
medical history, and physical examination are not reliable for assessing
lung status or adequate to rule out
other potential conditions (Table 2).1
According to the guidelines, diagnosing asthma with spirometry is
recommended over measuring peak
f low meters because of the wide
variability in peak flow meters and
clinical feature
2
OTHER CONDITIONS TO RULE OUT:
MAKING THE DIFFERENTIAL DIAGNOSIS
Upper airway
diseases
} Allergic rhinitis
Large airway
obstructions
} Foreign body in trachea or bronchus
} Allergic sinusitis
} Vocal cord dysfunction
} Vascular rings or laryngeal webs
} Laryngotracheomalacia, tracheal stenosis, or
bronchostenosis
} Enlarged lymph nodes or tumor
Small airway
obstructions
} Viral or obliterative bronchiolitis
} Cystic fibrosis
How spirometry works
} Bronchopulmonary dysplasia
} Heart disease
Other causes
} Recurrent cough (not attributed to asthma)
} Aspiration from dysfunction of swallowing mechanism or
gastroesophageal reflux
Adapted from National Institutes of Health. National Heart, Lung, and Blood Institute.1
3
CRITERIA TO EVALUATE PROPER
PERFORMANCE OF SPIROMETRY
Peak
Does each effort, as demonstrated by flow-volume curve, have
a sharp initial peak?
Finish
Does each effort extend all the way down to baseline at the
end?
Reproducible
Are at least 2 of the efforts superimposable?
From John Kelso, MD.
reference values.
Once a child is diagnosed with
asthma, the guidelines also recommend the use of spirometry to
measure pulmonary function at
1-month to 6-month intervals, as
well as ongoing monitoring over the
patient’s lifetime to detect the potential for and rate of decline of pulmonary function over time.1 Such
lifetime monitoring is needed to
determine if the goals of treatment
suggest that his or her asthma is
well controlled,” he said. “However,
[his/her] spirometry may be abnormal and in that case it is important
to intensify treatment because the
abnormal spirometry may indicate
underlying inflammation that, if
not adequately treated, may lead to
airway remodeling.”
The reverse is also true. “If a child
has a normal spirometry but needs
to take albuterol frequently, that
child needs to have [his/her] treatment intensified,” Kelso added.
are being met or if and when adjustments are needed.
Ongoing spirometry along with
symptom assessment for evaluating asthma control is needed, said
Kelso. This is because of the discrepancy that often occurs between
what symptoms suggest and what
information obtained from spirometry reveals.
“For example, a child may rarely
need to use albuterol, which may
M A R C H 2 016
|
Spirometry is a pulmonary function test that measures the airflow
and volume during forced expiration into a spirometer. To use it, the
child inhales completely to total
lung capacity (TLC), seals his or her
mouth over a mouthpiece, and then
forcefully exhales the air and continues to blow until no more air can be
expelled (residual volume). The volume of air expelled in this maneuver
is the forced vital capacity (FVC).
To obtain accurate assessment
of pulmonary function, correct use
of the spirometer is essential. Table
3 lists criteria for assessing whether
the child is performing the test well
enough (ie, expending maximal
effort) to provide accurate results.
Of critical importance is for the child
to exert maximal effort in blowing into the spirometer. If the child
exhales too weakly, quits too soon, or
the efforts are not reproducible, the
results will not be accurate.
Although technically blowing out
for 6 seconds or more is required
to ensure all air is exhaled, Kelso
explained that a shorter effort of
6 seconds or less is acceptable in
children. To ensure an adequate
23
clinical feature
4
ABNORMAL SPIROMETRY READING
APPEARANCE ON
SPIROMETRY
CHARACTERISTICS
Obstructive lung
disease
(eg, asthma)
} Obstruction to airflow
} Trouble getting air out
} PFT: decreased FEV1 /FVC, decreased
Flow-volume
curve is
“scooped”
FEV1, maybe decreased FVC (FEV1
decreased out of proportion to FVC)
Restrictive lung
disease
(eg, pulmonary
fibrosis)
} Restriction to full inhalation
} Trouble getting air in
} PFT: normal or increased FEV1 /FVC,
Small triangle
on flow-volume
curve
decreased FEV1, decreased FVC (FEV1
and FVC decreased proportionally)
Abbreviations: FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity;
PFT, pulmonary function test.
From John Kelso, MD.
5 USEFUL FEATURES OF A SPIROMETER
} Inclusion of “incentive” screens for children to motivate them to blow
as hard as they can (eg, simulate blowing candles on a birthday cake)
} A standard printer attached to spirometer to print out reports or
interface directly with electronic medical record
} Reports customized to print out only the parameters of interest.
} Ability to print dates and results of spirometry from previous visits on
same report
} Ability to print “pre-” vs “post-” bronchodilator reports
24
Clinics that care for children with
asthma should have spirometry
available because it improves their
care, emphasized Kelso. He cited
several features that are particularly
useful, which are listed in Table 5.
Although he said there is some
upfront cost in obtaining the
machine and a learning curve in
using it, the advantages of having
a spirometer far outweigh either of
these potential downsides. Included
in the cost are the machine (~$2000),
3-liter calibration syringe (~$300),
filters (~$2 each), and a dedicated
computer/printer. He emphasized
that these upfront costs are recouped
by the reimbursement for the test.
In terms of a learning curve,
Kelso emphasized that with some
experience the test is easy to interpret for both assessing if the child
is using it to maximal effort and
whether the results are normal or
abnormal. He also emphasized that
spirometry can be incorporated in
the clinical setting or office flow to
be done easily and quickly.
Conclusion
From John Kelso, MD
result, the child must do at least
2 to 3 maximal efforts that are
reproducible and provide results
(f low-volume curves) that are
superimposable.
Once the criteria are met, meaning that the child has exerted
maximal effort in blowing into the
spirometer at least 2 times with
reproducible results, the results of
the spirometer will reveal if the test
is normal or abnormal. If abnormal,
the test will show what the patterns
Incorporating
spirometry in the clinic
of abnormality are; that is, whether
or not these indicate obstructive
lung disease or restrictive lung disease (Table 4).
For children with indications
of asthma, which is obstructive
lung disease, Kelso said he typically gives the child albuterol, waits
10 minutes, and then repeats the
spirometry. This is to see if there is
an increase in the spirometry and
how much of the asthma is acutely
reversible with the bronchodilator.
|
M A R C H 2 016
Good asthma control starts with
an accurate diagnosis, and an accurate diagnosis includes spirometry. Ongoing monitoring of asthma
control also requires spirometry. To
provide the best care for children
with asthma, clinics should invest
in a spirometer to give the most
accurate information on which
to base diagnostic and treatment
decisions.
For references, go to
ContemporaryPediatrics.com/
spirometry-workshop
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CLINICAL FEATURE
Pediatric
OSAS
Obstructive sleep
apnea syndrome
in kids
MARY BETH NIERENGARTEN, MA. REVIEWED BY CAROL M ROSEN, MD.
Ms Nierengarten, a medical
writer in Minneapolis,
Minnesota, has more
than 25 years of medical
writing experience,
authoring articles for
a number of online
and print publications,
including various Lancet
supplements, and
Medscape. She has
nothing to disclose in
of this article.
26
A co-author of the recent Childhood Adenotonsillectomy
Trial study discusses key developments for diagnosing and
treating kids with obstructive sleep apnea syndrome (OSAS)
as well as current AAP clinical practice guidelines for OSAS.
with attention, behavior, and learning,
Among the clinical syndromes that fall
as well as worsening of any underlying
under the umbrella of sleep disordered
comorbidities including obesity, asthma,
breathing (SDB), obstructive sleep apnea
or psychological distress such as anxiety
syndrome (OSAS) that affects the upper
or depression. Thus, early diagnosis and
airway is the most common and occurs in
treatment is critical for preventing longabout 1% to 5% of children.1 Other more
term morbidity.2
rare SDB clinical problems occur in
children with brain and respiGiven that OSAS is the most
FAST
FACT
ratory control deficits (central
prevalent form of SDB and
Obstructive sleep
sleep apnea and/or hypoventhe one most likely to be
apnea syndrome
tilation disorder) or in those
encountered in clinical pracoccurs in about
who have abnormalities of
tice, this article focuses only
1% to 5% of
their spinal cord, nerves, muson this type of SDB. In 2012,
children.1
cles, lungs, or chest wall that
t he A merica n Academy of
interfere with sufficient breathing
Pediatrics (AAP) published cliniduring sleep.
cal practice guidelines on the diagnosis
For all children with SDB, chroniand management of childhood obstruccally disrupted sleep places them at
tive sleep apnea syndrome.1,3 Since the
increased risk of developing problems
publication of those guidelines, important
|
M A R C H 2 016
clinical feature
new findings from the Childhood
Adenotonsillectomy Trial (CHAT)
have been published that provide
more insight into the expected benefits of adenotonsillectomy for children with mild-to-moderate OSAS,
as well as on the natural history of
milder OSAS.4
In this inter view, Carol L .
Rosen, MD, professor of Pediatrics,
J.S. Rube Endowed Chair in Pedia-
will be taken from that presentation,
as well as recommendations made
in the most recent AAP guidelines
(Table 1).1
Between 1 in 20 to 1 in 100 children suffer from OSAS, which is
between 1% and 5% of children.
Prevalence increases in African
A merica n chi ld ren a nd lowincome children, with further evidence showing some disparities in
The peak age of developing pediatric
OSAS is between 2 years and 8 years,
and it occurs before puberty with the
same prevalence in boys and girls.
tric Sleep Medicine, Division of
Pediatric Pulmonology, Allergy/
Immunology, and Sleep Medicine,
Case Western Reserve University
School of Medicine, Cleveland,
Ohio, discusses key issues of
screening, diagnosing, and treating children with OSAS based on
her experience and how that experience is guided primarily by the
current AAP practice guideline.
As a coauthor of the more recent
CHAT study, she also highlights the
evolution of current thinking about
childhood OSAS, management
options, and unanswered questions
going forward.
Q. As discussed, this article
focuses on children with
obstructive sleep apnea. Let’s start
by talking about the prevalence of
pediatric OSAS.
Dr. Rosen: I just gave a talk on this
subject to pediatrician colleagues
and residents, so some of the answers
to this question and the following
health outcomes and a differential
response to therapy for these children. Years ago, we reported that
African Americans were less likely
to have undergone an adenotonsillectomy. Yet, in those who did, these
children were 4 times more likely to
have OSAS in the years following
that surgery. In the CHAT study,
African American children with
OSA were less likely to normalize
after surgery.4
The peak age of developing
pediatric OSAS is between 2 years
and 8 years, and it occurs before
puberty with the same prevalence
in boys and girls. Genetics play
a role, with children in families
with a history of OSAS at 2-fold to
4-fold increased risk of developing
it. Obesity is also a risk factor for
OSAS in children, but it is not as
powerful a risk factor in children
compared with adults. (However,
obesity in the teenaged years is
linked to a 5-fold risk for developing OSAS compared with nonobese
M A R C H 2 016
|
teenagers.) In children, obesity is a
risk factor for incomplete response
to adenotonsillectomy, and if children are already overweight before
adenotonsillectomy, they are at
increased risk for becoming overweight after that surgery.4,5
Q. What are the causes of
OSAS in children and who are
most at risk?
Dr. Rosen: The number 1, 2, and 3
cause is adenotonsillar hypertrophy;
that is to say, the main cause or “tipover” for children is having enlarged
tonsils and adenoids. Other lessfrequent causes include craniofacial
or genetic factors, neuromuscular
disorders, or obesity.
So, enlarged tonsils/adenoids are
commonly found in children who
develop OSAS. Other risk factors
include the presence of comorbidities (ie, asthma, allergies), perinatal
influences (former premature babies
have 3 times the risk of developing OSA),6 living in disadvantaged
neighborhoods,7 and exposure to
irritants such as environmental
tobacco smoke,8 infectious agents,
and being sleep deprived.
Finally, children with specific
medical conditions are at increased
risk, including those with Down
syndrome, Prader-Willi syndrome,
achondroplasia, Pierre Robin anomalad, sickle cell anemia,9 craniosynostosis, spina bifida, and Hunter
disease.
Q. What are the signs and
symptoms of OSAS in children?
Dr. Rosen: The most common
symptom of OSAS in children is
snoring. That is why I often use
t he description “snoring and
CONTINUED ON
PAGE 30
27
clinical feature
1
AAP CLINICAL PRACTICE GUIDELINE:
KEY ACTION STATEMENTS (RECOMMENDATIONS)
STATEMENT 1:
Screening for OSAS
} Clinicians should ask during each healthcare visit whether a child snores.
} Clinicians need to do a more focused evaluation in children who snore, or who present with
signs and symptoms of OSAS.
STATEMENT 2A:
Polysomnography
For children who regularly snore or present with signs and symptoms of OSAS, clinicians should:
} Obtain a polysomnogram, or
} Refer child to a specialist (sleep or otolaryngologist) for a more extensive evaluation.
STATEMENT 2B:
Alternative testing
STATEMENT 3:
Adenotonsillectomy
Clinicians may order alternative diagnostic tests if polysomnography is not available, including
nocturnal video recording or oximetry, daytime nap polysomnography, or ambulatory
polysomnography.
Adenotonsillectomy should be the first line of treatment for children:
} Diagnosed with OSAS,
} Having adenotonsillar hypertrophy on clinical exam, and
} In whom surgery is not contraindicated.
Consider other treatments (see Statement 6) in children diagnosed with OSAS but without
adenotonsillar hypertrophy.
For obese children with varying degrees of adenotonsillar hypertrophy, use clinical judgement
to assess the benefits of adenotonsillectomy compared with alternative treatments.
STATEMENT 4:
High-risk patients
undergoing
adenotonsillectomy
Need to monitor high-risk patient undergoing adenotonsillectomy as in patients after surgery.
STATEMENT 5:
Reevaluation
Patients with persistent signs and symptoms of OSAS after treatment should be clinically
reassessed to determine if further treatment is needed.
STATEMENT 5B:
Reevaluation of high-risk
patients
High-risk patients, including those with a significantly abnormal baseline polysomnogram, with
sequelae of OSAS, who are obese, or who remain symptomatic after treatment should be:
} Reevaluated with an objective test for persistent OSAS after adenotonsillectomy, or
} Referred to a sleep specialist.
STATEMENT 6:
CPAP
Patients should be referred for CPAP management if symptoms/signs or objective evidence of
OSAS persists (regardless of whether adenotonsillectomy was performed or not).
STATEMENT 7:
Weight loss
Recommend weight loss as well as other therapy in obese or overweight children with OSAS.
STATEMENT 8:
Intranasal corticosteroids
Prescribe topical intranasal corticosteroids for:
} Children with mild OSAS in whom adenotonsillectomy is contraindicated, or
} Children with mild postoperative OSA.
Abbreviations: AAP, American Academy of Pediatrics; CPAP, continuous positive airway pressure; OSAS, obstructive sleep apnea syndrome.
From Marcus CL, et al.1
28
|
M A R C H 2 016
clinical feature
2 SYMPTOMS AND SIGNS OF OSAS IN CHILDREN
History
} Frequent snoring (at least 3
} Sleeping either in a seated
nights/wk)
position or with neck
hyperextended
} Labored breathing during
} Headaches when waking up
sleep
} Gasps, snorting, observed
} Cyanosis
episodes of apnea
} Sleepiness during the day
} Sleep enuresis, particularly
} Attention-deficit/
secondary enuresis (ie,
after at least 6 months of
continence)
Physical
examination
hyperactivity disorder
} Problems with learning
} Tonsillar hypertrophy
} Hypertension
} Adenoidal facies
} Micrognathia/Retrognathia
} Overweight or underweight
} Failure to thrive
} High-arched palate
Abbreviation: OSAS, obstructive sleep apnea syndrome.
From Marcus CL, et al.1
CONTINUED FROM
PAGE 27
obstructive sleep apnea” when
referring to OSAS in children.
About 10% of children habitually
snore, that is, snore more than
3 nights a week, but not all children
have OSAS.
The AAP guidelines provide a
list of additional signs and symptoms1 of OSAS beyond just snoring
(Table 2). When taking a history of
a child, it can be challenging to recognize OSAS because parents may
not report some of the most common
symptoms, such as snoring, difficult breathing, observed apnea and
arousals, and any changes in daytime sleepiness. The clinical evaluation during wakefulness (history
and physical examination) has only
a 50-50 chance for predicting OSAS.
Some children have lots of symptoms and enlarged tonsils, but only
minimal findings when an overnight diagnostic test is performed.
On the other hand, some children
30
may have minimal symptoms and
mildly enlarged tonsils, but will show
significant OSAS when overnight
diagnostic testing is performed.
Q. What are the current
recommendations for screening
and diagnosis?
Dr. Rosen: As highlighted in the
guidelines (Table 1, Statement 1),1
clinicians should screen all chil-
signs and symptoms and family
history of OSAS. The Sleep-Related
Breathing Disorders Scale of the
Pediatric Sleep Questionnaire
(PSQ), by Chervin and colleagues,
is a well-validated symptom inventory and popular screening tool.10
It should be noted, however, that
the PSQ is not perfect at correctly
identifying OSAS. In the CHAT
study, this screening tool was “positive” in about 75% of snoring children who had OSAS diagnosed by
overnight sleep study.4
For diagnosing OSAS in children,
the AAP guideline provides a couple of options (Table 1, Statement
2A and 2B).1 For children who snore
on a regular basis or present with
signs/symptoms of OSAS (Table 2),1
the guidelines recommend a sleep
study (which measures the severity
of sleep apnea by using the apnea
hypopnea index [AHI] measure) or
referring the child to a specialist
(such as a sleep specialist or otolaryngologist) for more extensive
evaluation. Alternatively, clinicians
can order tests other than a sleep
study (Table 1, Statement 2B).1
There are a couple of challenges
to diagnosis. Tonsil size does not
Obstructive sleep apnea in children
is a distinct disorder from the condition
that occurs in adults.
Source: Tauman R, et al. Expert Rev Resp Med. 2011.
dren at every health encounter
for snoring because snoring is the
most common symptom. If the
child snores, then the pediatrician
should “do more,” checking into
other potentially OSAS-related
|
M A R C H 2 016
predict OSAS severity and there
is poor correlation between snoring, the AHI measured on the sleep
study, and daytime dysfunction.
Some children may have a lot of
daytime problems believed to be
clinical feature
(CPAP), which is the standard treatbreathing in children. This indiment for adults with OSAS, the
vidual may be a sleep medicine spestandard first-line treatment for
cialist or other specialist, including
children with enlarged tonsils and
otolaryngologists.
adenoids is adenotonsillectomy that
has about an 80% cure rate (Table
Does OSAS affect children
What would you further
1, Statement 3).1 If the child already
differently than adults? If so, how?
highlight as important for
Dr. Rosen: Yes, there are several difpediatricians to know about OSAS
has had an adenotonsillectomy, then
ferences. In adults, OSAS is much
in children?
CPAP is the next line of therapy and
more common in men than women.
Dr. Rosen: I would highlight the
can be effective. However, impleIn children before puberty,
CHAT study, which was a ranmentation and adherence are
there’s no difference in
domized, controlled trial in which
problematic, especially in
FAST
FACT
prevalence between girls
children with mild-to-moderate
children with limited
Clinicians
and boys. In adults,
OSAS were randomized to surgery
ability to cooperate or in
should screen all
the peak age for OSAS
or watchful waiting and supportteenagers who are oppochildren at every
is midlife, whereas
ive care. After 7 months followsitional.
Parent
superhealth visit for
in children it peaks
ing surgery or watchful waiting,
vision and commitment
snoring.1
between ages 2 years
the children were reassessed for
are key. Although nonsurand 8 years. The presentOSAS.
gical CPAP can be an altering symptoms also differ in that for
The study found no differences
native treatment in children with
children the main complaints are
between the 2 groups in terms
enlarged tonsils and adenoids, it is
snoring and behavioral or learnof the primary outcome, which
much harder to deliver and tolerate
ing problems, whereas for adults
looked at attention/executive and
than effective CPAP therapy when
cognitive functioning. 5 Children
the chief complaint is daytime
the tonsils and adenoids are blocking
sleepiness.
the upper airway.
who did undergo surgery, however,
There are also different patterns
Other treatments for specific
reported significant improvements
of breathing. Adults have more
children may include denta l/
in global behaviors, generic and
specific discreet airway collapses,
orthodontic devices, specialized
disease-specific quality of life, and
whereas children are more likely to
have partial collapses because they
are better at keeping their airway
For every increment in BMI of 1 kg/m2
open than adults. This may explain
beyond the mean BMI for age and gender,
why children don’t necessarily have
the risk of OSAS increased by 12%.
as much daytime sleepiness as adults
Source: Arens R, et al. J Appl Physiol. 2010.
because they are better at staying
asleep during their partial airway
collapse compared with adults who
regularly wake up when their airaggressive surgeries, positional
symptoms of OSAS such as snoring
ways collapse completely. However,
therapy, or weight loss.
and sleepiness. In the early surgery
the clinical picture of obese children
group, most of these children (79%)
with OSAS may be more similar to
also had a normal polysomnograWhen should a pediatrician
adults with OSAS.
phy 6 months later compared with
refer a child with OSAS to a sleep
only 46% of the kids in the watchspecialist?
ful waiting group.
Dr. Rosen: That is clearly stated in
What is the standard
In the surgery group, finding
the guidelines (Table 1, Statements 1
treatment for OSAS in children?
a normal sleep study 6 months
and 2).1 The guidelines recommend
Dr. Rosen: Unlike the use of conlater is similar to previous studies
tinuous positive airway pressure
referral to a specialist in sleep and
related to OSAS, but only low AHI
during overnight testing. Other
children with a high AHI may have
only minimal daytime problems.
Q.
Q.
Q.
Q.
M A R C H 2 016
|
31
clinical feature
suggesting an 80% to 85% “cure
rate” for OSAS af ter surger y.
On the other hand, the finding that almost one-half of the
children who did not have surgery had a normal sleep study
option in children with milder
OSAS and fewer symptoms.
However, there are still many
unanswered questions about what
the best practices are with regard
to how to best treat children who
Symptoms of OSAS are often subtle,
and therefore not always immediately
recognized by parents.
Source: Tauman R, et al. Expert Rev Resp Med. 2011.
7 months later was somewhat of
a surprise. Children with milder
OSAS and less obesity, and who
were non-African American, were
more likely to “normalize” their
sleep studies. However, normalization of the sleep study doesn’t
mean that symptoms got better.11
Nevertheless, watchful waiting
may be a reasonable management
snore. The interesting thing about
the CHAT study is that nearly
half the children who met criteria
for study participation (ie, candidates for surgery) based on clinical
assessments that indicated OSAS
actually had normal sleep studies
without OSAS, and therefore were
not eligible for enrollment in the
CHAT study.
T he Nat iona l Inst it utes of
Health (NIH) is sponsoring a new
multisite clinical trial called the
Pediatric Adenotonsillectomy for
Snoring (PATS) trial that begins
this spring. The trial will look at
children with mild SDB (that is,
children who snore but don’t have
OSAS) and examine whether tonsillectomy and adenoectomy will
change outcomes in this group.
It will assess the effect of early
adenotonsillectomy on behavior,
vigilance, OSAS symptoms and
quality of life, and healthcare use.
It will also identify factors that
moderate a child’s response to surgery, including age, race, asthma,
tobacco exposure, and socioeconomic status.
pediatric-OSAS
Rethinking asthma
CONTINUED FROM
PAGE 19
were seen.
There are a number of different smartphone applications offering free (Medisafe [www.medisafe.
com/]; MedActionPlan [w w w.
medactionplan.com/]; MyMeds
[http://my-meds.com]) and paid
(Rx Remind Me [https://itunes.
apple.com/us/app/rx-remind-me/
id972766049?mt=8]) apps and plans
that allow one to enter a medication
to receive text or e-mail reminders. For some patients, this type of
reminder system may significantly
32
improve compliance and potential
control.20
Immunotherapy
Despite being used in clinica l
practice for more than 100 years,
immunotherapy remains underused in clinical practice related
to asthma. 21 As healthcare moves
toward more personalized medicine, immunotherapy holds great
promise—identification of specific subsets of patients that will
be ident i f ied f rom a speci f ic
therapy.
|
M A R C H 2 016
Increasingly, available molecular diagnosis tools will allow for
better identification of patients
who will benefit from particular
immunotherapies. As an example,
2 recent studies have demonstrated
decreased need for inhaled steroids
among patients sensitized to house
dust mites and started on a targeted oral immunotherapy.22,23
rethinking-asthma
puzzler TODDLER WITH BLISTERING ACRODERMAL RASH
CONTINUED FROM PAGE 13
History and physical
The child was evaluated at multiple
clinics and treated with topical steroids and antifungal creams without improvement. Two weeks prior
to this visit, he developed a tactile fever with increased blistering.
He was treated with a 7-day course
of oral antibiotics without change
in the rash. The parents also noted
recent thinning of the boy’s hair.
The patient was of appropriate
size and meeting his developmental milestones. He had traveled to
Mexico 3 weeks after onset of the
knee rash, at which point he developed mild diarrhea that resolved
without treatment. He was exclusively breastfed until aged 2 months,
at which time he was transitioned
to full formula. He began eating
solids at age 4 months, and continued formula feeding through age
14 months. At the time of presentation, he was eating a full and varied
diet. His 3 siblings are healthy.
On examination, the patient
appeared alert and well-nourished
(Figure 1). He had erythematous,
superficially eroded, and crusted
papules and plaques on the periorbital, perinasal, and perioral skin
as well as on his cheeks, ears, posterior scalp, dorsal hands, dorsal feet,
elbows, and knees. A few plaques
were noted on the antecubital fossae, forearms, and trunk. Confluent,
beefy-red eroded plaques with polycyclic borders covered his penis,
scrotum, perineum, inguinal folds,
medial thighs, and gluteal cleft.
Multiple smaller, erythematous,
eroded papules were present at the
margin of these lesions. His hair was
diffusely thin. No lymphadenopathy
was appreciated. Neurologic exam
was unremarkable.
Pertinent laboratory data included
a hemoglobin of 10.8 g/dL (normal:
10.5-13.5 g/dL); mean cell volume,
83.5 fL (normal: 70-86 fL); albumin,
4.3 g/dL (normal: 3.4-4.2 g/dL); alkaline phosphatase, 83 U/L (normal:
115-460 U/L); and C-reactive protein,
3.0 mg/dL (normal: 0.0-0.9 mg/dL).
Blood cultures returned negative, and
a punch biopsy of the thigh was performed by the Dermatology service.
Other testing included a wound culture and herpes simplex virus (HSV)
polymerase chain reaction (PCR).
Differential diagnosis
The differential diagnosis for this
child presenting with chronic, diffuse, eroded, and scaly red papules
and plaques is broad and includes
infectious etiologies, autoimmune
disorders, drug reactions, and nutritional deficiencies (Table).
Infectious etiologies that can
cause rash, particularly in the intertriginous areas, include erythrasma,
erysipelas, cellulitis, bullous impetigo, staphylococcal scalded skin
syndrome (SSSS), and cutaneous
candidiasis. Erythrasma, which typically affects adolescents and adults,
is a superficial skin infection caused
by the skin flora Corynebacterium,
and it presents with macerated,
scaly plaques in the axillae, groin,
and between the toes. Erysipelas
involves the upper dermis, while
cellulitis involves the deeper dermis. In distinguishing between the
2 rashes, erysipelas has a clear line
of demarcation with affected tissue
and is associated more with systemic symptoms of fever and chills. M A R C H 2 016
|
TABLE
DIFFERENTIAL
DIAGNOSIS FOR
ACRODERMAL
RASH
INFECTIOUS
} Erythrasma
} Erysipelas
} Cellulitis
} Cutaneous candidiasis
} Bullous impetigo
} Staphylococcal scalded
skin syndrome
IMMUNE
} Linear IgA bullous
dermatosis
} Bullous pemphigoid
} Atopic dermatitis
} Seborrheic dermatitis
} Psoriasis
} Allergic/irritant contact
dermatitis
} Primary
immunodeficiencies (eg,
Wiskott-Aldrich syndrome)
NUTRITIONAL DEFICIENCIES
} Zinc
} Essential fatty acids
} Biotin (vitamin B7)
} Niacin (vitamin B3)
} Protein
OTHER
} Epidermolysis bullosa
} Drug reaction
} Toxic epidermal necrolysis
} Stevens-Johnson syndrome
Abbreviation: IgA, immunoglobulin A.
Exfoliative toxins elaborated by
Staphylococcus aureus cause a range
of skin lesions by binding to and
disrupting adhesion molecules high
33
puzzler
in the epidermis. In bullous impetigo, which usually occurs in older
children and adults who have antibodies to the toxins and can readily
clear them in their kidneys, patients
can develop localized lesions. The
eruption begins as small red papules
that progress to vesicles surrounded
by erythema, then into expanding
flaccid bullae with clear yellow fluid
and central crusts.
In SSSS, which occurs in younger
children who lack antibodies and
patients with renal failure who cannot clear the antibody-bound toxin,
toxins disseminate to the same epidermal adhesion molecules resulting in total body erythema and
generalized superficial sloughing of
the skin. Patients are usually febrile
with diffuse blanching erythema,
and f laccid bullae and erosions
develop first over areas with the most
frictional trauma (feet, hands, buttocks, flexural surfaces) 1 to 2 days
later. Gentle pressure to the skin by
the examining finger results in a
Nikolsky sign or skin sloughing.
Candida infections often occur
as a secondary infection in patients
with chronic seborrheic dermatitis
or contact irritant dermatitis. They
tend to manifest as erythematous,
macerated plaques/erosions with
fine scaling and satellite lesions,
which can occur in the inguinal
folds, axillae, scrotum, and intergluteal folds. However, given this
patient’s lack of response to antifungals, antibiotics, and topicals,
there was a greater concern for an
underlying systemic process triggering his rash.
Immune etiologies that can
present with diffuse red scaly rash
include atopic dermatitis, psoriasis, and seborrheic dermatitis. The
34
infantile form of atopic dermatitis presents with pruritic, red scaly
lesions on the extensor surfaces of
the arms, legs, face, and scalp, with
sparing of the diaper area, which
makes it unlikely in this patient.
Psoriasis presents with symmetrically distributed cutaneous plaques
with sharply defined margins and
a silver scale, while seborrheic dermatitis is characterized by well-
Finally, various nutritional deficiencies that can result in skin
fragility, rash, hair loss, impaired
immune function, and delayed
developmental growth should be
considered, including deficiencies
in essential fatty acids, biotin, niacin, or zinc. Biotin is essential in
carbohydrate and fatty acid metabolism. Symptoms of deficiency may
include mental status changes,
Nutritional deficiencies that can
result in skin fragility, rash, hair loss,
impaired immune function, and delayed
developmental growth should be considered.
demarcated erythematous papules
and greasy yellow scales, usually
around the scalp, ear, midface,
and intertriginous areas, particularly the diaper. Both processes are
not consistent with the patient’s
presentation. Other etiologies to consider
include junctional disorders that
disrupt the integrity of the dermal
keratinocytes such as epidermolysis
bullosa, or drug reactions causing
toxic epidermal necrolysis (TEN)
or Stevens-Johnson syndrome (SJS).
In epidermolysis bullosa, genetically mediated defects in cell adhesion molecules in the epidermis,
epidermal-dermal junction, or in
the dermis result in blistering and
erosions/ulcerations in areas of
friction-induced trauma. In some
variants, the mucous membranes
are also involved in these chronic
disorders. Although the patient did
have drug exposure with antibiotics,
there was no mucosal involvement,
which excludes SJS and TEN.
|
M A R C H 2 016
myalgias, anorexia, nausea, and red
scaly dermatitis of the extremities.
Both the rashes seen in biotin and
essential fatty acid deficiency can
result in skin changes similar to
that of zinc deficiency. The patient’s
varied diet made this an unlikely
cause. Niacin deficiency can result
in pellagra, a triad of photosensitive
dermatitis in sun-exposed areas,
diarrhea, and dementia. Given the
patient’s rash in the perineal area,
this also was unlikely.
The rash associated with zinc
deficiency, secondary to a zinc-deficient diet, chronic zinc loss in the
gastrointestinal tract, or acrodermatitis enteropathica (AE), presents
with erythematous scaly plaques
and/or erosions on the extensor surfaces of the extremities and periorificial areas, and hair loss, which
occurred in this patient. In time,
children with zinc deficiency also
stop gaining weight and become
fussy. Any gastrointestinal disorder resulting in malabsorption (eg,
puzzler
cystic fibrosis [CF]) and secondary
zinc deficiency can result in similar
symptoms, and needs to be distinguished from AE.
Diagnosis
The patient’s zinc level returned
low at 26 μg/dL. The punch biopsy
showed epidermal hyperplasia,
spongiosis, keratinocyte vacuolization, upper epidermal necrosis,
and significant neutrophilic exocytosis with occasional clusters of
gram-positive cocci in the stratum
corneum consistent with necrolytic migratory erythema seen in
nutritional deficiency and superimposed bacterial infection. The HSV
PCR remained negative, and wound
culture returned positive for methicillin-sensitive S aureus and Corynebacterium sp. Patient outcome
The patient was discharged home on
oral clindamycin and topical mupirocin, and initiated on zinc acetate
supplementation at 1.7 mg/kg/day.
One month later, his rash had
improved, but he continued to
develop intermittent new vesicles.
His zinc level was rechecked and
remained low at less than 16 μg/dL.
Zinc supplementation was increased
to 4 mg/kg/day, which resulted in
resolution of the rash and a normal serum zinc level after 1 month.
With follow-up over the succeeding months, his alopecia began to
resolve and no further lesions were
noted (Figure 2).
Discussion
Acrodermatitis enteropathica is a
rare inherited form of zinc deficiency, characterized by diarrhea,
alopecia, acral dermatitis, and
S FIGURE 2 Resolution of prior lesions, resulting in postinflammatory
hyperpigmentation, as well as improvement in alopecia.
“dementia” (irritability). It is caused
by an autosomal recessive defect in
the SLC39A4 gene, which impairs
intestinal zinc absorption.1 Studies have shown that human breast
milk compared with formula has a
relatively high concentration of zinc
because of greater bioavailability
from the high-citrate, lactoferrin,
and low-phosphorus environment,
as well as the presence of a zinc
transporter protein that facilitates
absorption. These factors often
compensate for an affected child’s
M A R C H 2 016
|
poor absorption. Breast milk zinc
levels start declining around age
6 months and no longer compensate adequately. 2 In patients who
develop these characteristic symptoms upon weaning from breast
milk, it is best to consider a diagnosis of AE. It is atypical in this patient
that his symptoms developed over a
year from weaning off breast milk.
Rarely breast milk is low in zinc,
and full-term babies of affected
mothers will present with zinc-deficiency symptoms at 1 month of age.
35
puzzler
Because zinc is not concentrated in
babies until the last month of gestation, symptoms will develop sooner
in premature infants. In patients
who develop symptoms while on
breast milk, it is important to consider malabsorption syndromes in
the differential, such as CF.
Zinc acts like a metal component
of an activating cofactor for many
enzymatic systems in the body,
including alkaline phosphatase,
carbonic anhydrase, or dehydrogenases. 3 Accordingly, this patient’s
relatively low level of alkaline phosphatase was an important early
clue to his diagnosis of zinc deficiency. Zinc also plays a vital role
in wound healing and growth, and
it is involved in immune responses
to infection.4 Ten percent to 40% of
dietary zinc is absorbed in the small
bowel, but absorption can be inhibited by other factors in the bowel
such as the presence of fiber, iron,
or other heavy metals. Sixty percent
of zinc is loosely bound to albumin, while 30% is bound tightly to
macroglobulins. Normal zinc levels
range from 70 μg/dL to 120 μg/dL.
Zinc is mostly bound intracellularly
to metalloproteins, with primary
stores in the liver and kidney.5
Clinical manifestations of zinc
deficiency commonly include an
erythematous and vesiculobullous
dermatitis; alopecia; ophthalmic
disorders including photophobia;
anorexia; diarrhea; growth retardation; delayed sexual maturation; impaired taste or smell;
hypogonadism; neuropsychiatric
manifestations; anemia; and frequent infections with poor wound
healing.3 The rash associated with
low zinc levels typically presents
with erythematous scaly plaques,
36
which can develop into vesicular,
bullous, or pustular lesions with
subsequent desquamation, particularly in areas where the skin
turns over most quickly (intertriginous and periorificial areas).
Characteristic locations include
the extensor extremities, the anogenital skin, and the periorificial
area of the face. Other cutaneous
stigmata include angular cheilitis,
of elemental zinc) are generally required. 8 Symptoms should
resolve within 1 month of appropriate supplementation, as was seen
in this patient. In patients whose
symptoms do not respond within
1 month of initiation of therapy, it
is important to consider the therapeutic level of treatment versus
another underlying cause, such as
malabsorption syndromes (eg, CF).
The child in this case demonstrated
alopecia with perioral and acral
distribution of rash, as well as lab data
supporting zinc deficiency.
paronychia, and generalized alopecia. Skin lesions often become
secondarily infected with bacterial
or fungal infections.3
Sy mptomat ic low levels of
zinc also may be associated with
impaired intestinal absorption
(Crohn disease, CF); increased urinary excretion (renal tubular defect
in sickle cell disease, nephrotic syndrome); decreased binding capacity
(hypoalbuminemia secondary to
liver disease); or iatrogenic causes
(inadequate supplementation in
total parenteral nutrition [TPN]dependent patients, those with
decreased i nta ke, or premature infants whose nutritional
demands are greater than maternal supply).6,7 For zinc deficiency
related to dietary intake, supplementation with 1-2 mg/kg/day
of elemental zinc is generally
suff icient; for def icits related
to impaired zinc absor pt ion, higher replacement
dos e s (a rou nd 3 mg / k g /d ay
|
M A R C H 2 016
These syndromes will only partially
improve with supplementation, and
will require addressing the primary
defect, such as the utility of pancreatic enzyme replacement in CF.
The child in this case demonstrated alopecia with perioral
and acral distribution of rash,
as well as lab data supporting
zinc deficiency that was determined to be of unknown etiology because symptoms developed
almost a year after weaning off
breast milk. He also lacked clinical
symptoms such as failure to thrive
or frequent infections. Although the
etiology of the patient’s zinc deficiency continues to be evaluated at
this time, he had substantial clinical improvement once his zinc level
returned to normal.
For references and authors’
biographies, go to
puzzler-0316
peds v2.0
ANDREW J SCHUMAN, MD
SECTION EDITOR
Clinical thermometry
An update and review
Thermometry has come a long way since 1592 when
Galileo first fashioned a crude thermometer to measure
temperature. In this month’s article, Dr. Schuman
reviews what’s new in tools for determining one of the
body’s most vital signs.
When I opened my first practice in
1986, I was intrigued by an advertisement in Contemporary Pediatrics that caught my attention, and
days later I was the proud owner of
a FirstTemp tympanic thermometer. The manufacturer (Intelligent
Medical Systems; Carlsbad, California) promised the device’s measurements were as accurate as oral and
rectal temperatures taken with glass
thermometers. I was initially skeptical of this high-tech thermometer, but within weeks it proved to be
a very popular device among staff,
providers, and patients. The reason
it was successful was that it required
little patient cooperation and took
temperatures in seconds, and it produced measurements comparable
to those obtained with our digital
oral and rectal thermometers. This
month’s Peds v2.0 provides an overview of the history of clinical thermometry and reviews some of the
thermometers that are currently
available for home and office use.
A brief history of
clinical thermometry
Early physicians recognized that illness often was associated with fever,
but it took centuries for scientists to
develop the means to actually measure body temperature. Although
Galileo in 1592 was the first to fashion a crude thermometer, it was
another Italian scientist, Santorio
Santorio, who was the first to take
oral temperatures in 1625.1 His thermoscope, as it was called, was large
and cumbersome, and took hours to
perform a single measurement.
It was not until the mid-1800s
that the German physician Carl
Wunderlich developed a footlong thermometer that could take
clinical temperatures.1 In 1868, he
published his data of more than
1 million axillary readings from
M A R C H 2 016
|
Kinsa Smart Thermometer
Accurate temperatures can quickly
be included in EHRs. See page 40.
more than 25,000 patients. He determined that there was a diurnal variation in daily body temperatures
ranging from 97.3°F in the morning
to 99.5°F in the evening. He also
originated the standard of 98.6°F
as “normal body temperature” that
we use today. His readings took
20 minutes to perform, and for anyone but the most patient of physicians, this was not a practical device.
It was a contemporary of Carl
Wunderlich, Thomas Clifford
Allbutt, an Englishman, who introduced the first portable 6-inch thermometer in 1866 that could record
a temperature in 5 minutes.1 His
37
pediatrics v2.0
Thermofocus 01500A3 is an
easy-to-use, noncontact, infrared
forehead thermometer. See page 40.
Fever and children
Before the Haemophilus influenzae
type b vaccine first became available
in 1985 and the first pediatric conjugate pneumococcal vaccine became
available in 2000, pediatricians routinely encountered severe illnesses
in patients that included meningitis,
septic arthritis, osteomyelitis, and
sepsis. These were so common that
blood cultures and spinal taps were
routine office procedures. Before
the introduction of the H influenzae and pneumococcal vaccines, 3%
of young febrile children without a
focus of infection had positive blood
cultures for H influenzae, Streptococcus pneumoniae, or Neisseria meningitides. Six percent of those patients
positive for pneumococcus also were
discovered to have meningitis, while
up to 20% of positive blood cultures
for H influenzae were associated with
meningitis.2,3 Today, the incidence of
occult bacteremia is 0.5%, and we
rarely perform blood cultures or spinal taps in the workup of infections,
except in febrile young infants.4 The
38
key point is that just 2 decades ago in
the last century, parents and pediatricians were alerted to the possibility of severe pediatric illness by the
presence of fever, and they were comforted by its absence. Today, documentation of a fever alerts physicians
regarding the cause of the associated
symptoms. In most situations, there
is an infectious cause with rheumatologic illnesses, malignancy-related
fevers, and period fevers being much
less common.5
Identification of fever in young
infants is very important with most
protocols identifying “fever” as a rectal
temperature of 100.4°F or higher.
Fever in young infants
Even today, when an infant in the
first 2 month of life presents with
fever, we proceed to evaluate that
child for sepsis, meningitis, pneumonia, or a urinary tract infection.
In most circumstances, this warrants admission of young infants for
empiric antibiotic therapy pending
results of cultures. Therefore, identification of fever in young infants is
very important with most protocols
identifying “fever” as a rectal temperature of 100.4°F or higher.
Studies have repeatedly shown
that parents overdiagnose fever
|
M A R C H 2 016
temperature, as well as recommend
a thermometer for home use and
recommend an age-dependent site
for temperature measurement.
Tympanic temperatures:
Reliable or not?
Fever and its measurement was a
popular topic in the pediatric literature during the 1980s through 2000
when infrared “tympanic” thermometers (the FirstTemp was introduced in 1984) became available,
and pediatricians published study
after study comparing this device’s
measurement to those taken by more
thermometer could be transported
in a pocket. Subsequently, temperature measurement became a routine vital sign. (You can view one of
Allbutt’s thermometers by visiting
https://museumofhstm.wordpress.
com/2012/08/31/allbutts-clinicalthermometer/.) Allbutt eventually
received a knighthood for his achievement and service to medicine.
when they rely on touch alone.
There are also a wide variety of
home thermometers available for
use in infants including pacifier
thermometers, forehead thermometers, ear thermometers, and digital thermometers that can be used
either orally or rectally. When parents report an elevated temperature
in a young infant above the threshold of 100.4°F degrees, it often is
followed by the recommendation
for the parent to take the baby to the
emergency department for a septic workup. Emergency department
physicians, erring on the side of caution, often will do this workup if the
infant has no fever on arrival, and
even when an antipyretic has not
been given. It is therefore important
for pediatricians to instruct new
parents regarding how to take a
pediatrics v2.0
traditional means. The tympanic
membrane was an attractive site for
temperature measurement because
of its shared blood supply with the
hypothalamus, the body’s thermoregulatory center. Many arguments
ensued regarding the appropriateness of the use of tympanic thermometers in clinical practice, with
some studies showing good correlation and others showing poor correlation between temperatures taken
from the ear canal and oral, axillary,
and rectal sites.6,7
Many other companies introduced their own ear thermometers. All the devices had 1 thing
in common: They did not really
measure temperatures of the tympanic membrane, but measured the
temperature of the ear canal. To
present measurements with which
physicians were more familiar, all
these devices added a “fudge factor,”
called an “offset,” to the actual ear
canal measurement to present an
equivalent oral or rectal temperature. Although these temperatures
were not influenced by the presence
of cerumen or otitis media, measurements were affected by the size
of the ear canal and how deep the
probe could be inserted comfortably. Overall, because of their speed
and ease of use, ear thermometers
became an office staple to screen
children aged older than 2 years for
the presence or absence of fever.
Temporal artery
thermometry
It was Exergen (Watertown, Massachusetts) that introduced the next
innovation in infrared temperature
measurement. Forehead temperatures have been taken by concerned
mothers since the dawn of time,
HOW TO TAKE A TAT-2000C
OR TAT-5000 MEASUREMENT
} Slide the thermometer straight across the forehead (mid-
line), and not down the side of the face. Hold down the
button when you do so. You will hear a series of audible
clicks as the device records higher temperature readings.
} It is preferable to hold the instrument sideways.
Approaching your patient with the instrument straight
up and down could be somewhat intimidating.
} Finish the measure by touching the device behind the ear. This
TAT-2000C
lets the device display accurate readings when the patient is perspiring.
When making the measurement behind the ear, tuck the thermometer
under the ear lobe in the soft conical depression on the neck just below
the mastoid. Take your finger off the button to display the reading.
An excellent animated in-service video can be viewed at www.exergen.
com/ww/index.htm. It features the voice of Exergen’s chief clinical scientist (and the device inventor’s wife), Mary Beth Pompei.
From: Exergen Corp.8
and Francesco Pompei, the founder
and chief executive officer of Exergen, suspected that the superficial
branch of the temporal artery was
an ideal site for reliable and reproducible temperature measurement.
Exergen introduced its clinical temporal artery thermometer, the TAT5000, in 2000. Now nearly 16 years
later, the company has sold more
than 400,000 devices and the thermometer is being used by over half
of pediatric practices in the United
States.
The device measures the patient’s
core body temperature, which is
about 1°F or 0.5°C higher than oral
readings. The TAT-5000 thermometer uses dual scanners, one that
measures ambient environmental temperature and another that
gauges the arterial temperature of
M A R C H 2 016
|
TAT-5000
the patient’s skin. The thermometer records over 1000 readings per
second, producing an audible click
as the device registers a higher reading. After taking 3000 readings, an
internal “heat balance” algorithm
determines the arterial temperature, which is displayed on the unit’s
LED screen. Best of all, although
the thermometer lists for over $400,
Exergen frequently puts the device
on sale for $200. One reason the
device is so popular in the medical
community is that it carries a lifetime warranty.
Parents also can purchase a home
forehead thermometer manufactured by Exergen for less than $30.
This is the Exergen consumer TAT2000C. It uses the same technology
39
pediatrics v2.0
Home thermometers
If you view the thermometers available for home use displayed at any
pharmacy, you will see a wide variety of thermometers for taking temperatures on children. Consumer
sites such as Consumer Search
(www.consumersearch.com/digital-thermometers/best-temporalthermometers) list thermometers
that they recommend for home
use. These include the Kinsa Smart
Thermometer (New York, New
York) that I reviewed in “What’s
new in ‘connected’ medical
devices” that appeared
Caregiver
Noncontact
infrared device
also measures
temps of objects like
heated baby bottles.
40
TEMPORAL
ARTERY THRESHOLD
MEASUREMENTS
FOR FEVER BY AGE
TABLE
AGE
UPPER RANGE OF NORMAL
TEMPERATURE
0-2 mo
100.7°F (38.1°C)
3-47 mo
100.3°F (37.9°C)
4-9 yr
100.1°F (37.8°C)
10-18 yr
100.1°F (37.8°C)
From: Exergen Corp.8
in the November 2015 issue of Contemporary Pediatrics. Other Consumer Search favorite models
include the Vicks V934 digital thermometer (Kaz Inc; Southborough,
Massachusetts) for rectal temps; the
Braun Thermoscan 5 (Kronberg,
Germany) for ear temperatures;
and the Exergen TAT-2000C for
forehead temperatures. Please note
that pacifier thermometers should
be avoided because they are not
believed to be accurate.
Newest clinical
thermometers
The latest innovation in clinical
thermometry is the noncontact,
infrared forehead thermometer.
One model sold for use in pandemics (eg, Ebola, influenza) is the Thermofocus 01500A3, manufactured
by Tecnimed (Varese, Italy). It is
placed a few inches from the center of the forehead and positioned
so that 2 beams of light emanating
from the device overlap. A button
is depressed and the temperature is
displayed seconds later. Tecnimed
states that the device’s reading is as
accurate as an axillary temperature.
|
M A R C H 2 016
The Thermofocus can store up to
9 measurements, and it sells for
about $80 on Amazon.com.
Thermomedics (Delray Beach,
Florida) released its Caregiver
clinical-grade, noncontact infrared
thermometer last year. The device
is very rugged, and takes a measurement when placed 0.5 inches
to 2 inches from the forehead. It
can store up to 30 readings. Like
the Thermofocus, the Caregiver can
be used to measure environmental
objects (eg, heated baby formula in
a bottle) as well. The Caregiver sells
for $357 and comes with a 2-year
warranty, with a lifetime warranty
optional. According to the manufacturer, the device displays a reading that should be interpreted as an
oral temperature.
Note that I’m not aware of any
peer-reviewed articles evaluating
noncontact, clinical-grade thermometers such as the Caregiver and
the Thermofocus. I’ve used both
devices in my clinic on dozens of
children, both febrile and afebrile,
and I have found the readings to
closely correlate with temperatures
taken by our TAT-5000.
In conclusion
As clinicians, we often take our
tools for granted. We are able to
record one of our most important
vital signs because of the efforts of
scientists and physicians centuries
ago. Our readings are displayed in
seconds, but it remains up to the
pediatrician to determine the cause,
treatment, and consequences of the
illness associated with the fever.
thermometry
as the TAT-5000, but it can store up
to 8 temperatures, has an illuminated screen, and can be silenced so
it doesn’t wake a child. The device
has a warranty of 1 year. Exergen
worked with Dr. Keith Powell and
15 pediatric practices affiliated with
the Children’s Hospital Medical
Center of Akron, Ohio, to establish a normal upper limit of measurements for its temporal artery
thermometers. Powell recorded
2300 temperatures from children to
determine the “threshold” for fever
as displayed in the Table.8
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dermcase
Discussion
Also known as Becker melanosis or
Becker pigmentary hamartoma, a
Becker nevus (BN) is an acquired
benign hamartoma. Although the
exact cause is unknown, BN has been
described in both sporadic and familial cases by a paradominant mode
of inheritance.1-3 It occurs at an incidence of 0.5% in adolescent males
with a 6:1 male predominance. 2
Approximately half of BN cases begin
to develop before age 10 years.
It is hypothesized that these nevi
have an increased number of androgen receptors, which can explain
the typical history of onset around
puberty and hypertrichosis of the
nevus.2 The nevi most commonly
occur unilaterally on the shoulder or
back. Lesions can appear as a macule or plaque and can be smooth or
verrucous textured; range in color
from skin colored to brown; and
vary from 1 cm to many centimeters
in size. They are generally irregularly shaped but well demarcated.
Becker nevi typically last for a
BECKER NEVUS
are not limited to, tinea versicolor,
eczema, acne vulgaris, acanthosis
nigricans, neurofibromatosis type 1,
hypoplasia of the ipsilateral breast,
scoliosis, lumbar spina bifida, and
pectus carinatum.1-3
Becker nevus syndrome occurs
when there are associated cutaneous, muscular, or skeletal abnormalities or unilateral breast hypoplasia
in addition to the nevus.1-3 Not surprisingly, acanthosis nigricans was
appreciated during this patient’s
physical exam, and he has a past
medical history of eczema.
Diagnosis is usually made by history and physical examination in a
patient who has a hyperpigmented
patch with hypertrichosis on the
shoulder or back. Differential diagnosis includes café au lait spots, postinf lammatory hyperpigmentation,
congenital melanocytic nevus, and
plexiform neurofibroma 1 (Table).2
Congenital smooth muscle hamartoma is actually the newborn equivalent of a BN with similar clinical
and histological findings at birth.
Reassurance should be provided that
Becker nevus represents a benign entity
and malignant conversion has not been
demonstrated.
lifetime, but many fade with time.
They are benign and have not been
reported associated with malignant
transformation.2 Although a BN can
be an isolated cutaneous finding,
many associated cutaneous, muscular, and skeletal anomalies have
been reported. These include, but
42
Histopathology shows epidermal
papillomatosis, horn cysts, acanthosis, and hyperkeratosis. Often there
are increased numbers of thickened
smooth muscle bundles that connect to hair follicles.1,2 There are no
nevomelanocytes present, helping to
distinguish this from a congenital
|
M A R C H 2 016
TABLE
DIFFERENTIAL
DIAGNOSIS FOR
BECKER NEVUS
Café au lait spots
} Congenital melanocytic
nevus
Plexiform neurofibroma
Congenital smooth muscle
hamartoma
Postinflammatory
hyperpigmentation
From Shou-Mei Kane K. et al.2
nevomelanocytic nevus.2 Although
the basal cell keratinocytes are filled
with melanin, there is no increase in
the number of melanocytes present.
Because of the association with
rare muscular, skeletal, and cutaneous abnormalities, further evaluation should be considered when a
patient is diagnosed with a BN.1,2
Biopsies are performed on occasion
to rule out other etiologies. Because
the lesions are benign, no treatment
is required. However, for irritation
or cosmetic reasons, laser therapy
can be used to remove hair and
lighten the lesions. Newer studies
have revealed that using low-fluence
high-repetition-rate diode lasers
(808-801 nm) can provide significant
hair reduction at 6 and 12 months
posttreatment providing substantial
aesthetic improvement of the lesion.4
There also have been reports of
the use of topical flutamide therapy for 8 weeks to treat the hyperpigmentation in the lesion. 5 With
dermcase
this treatment, no change in the
pigmentation of the surrounding
skin outside the nevus was reported.
However, there was no observed
improvement in the hypertrichosis. Spironolactone also has been
reported as a treatment for a case
of BN with ipsilateral breast hypoplasia.6 In this report, the patient
had enlargement of the hypoplastic
breast after 1 month of taking spironolactone. Both cases help to support the association with increased
androgen receptors in BN.5,6
Conclusion
Becker nevi are more common than
appreciated because of underreporting. It is imperative that clinical practitioners accurately identify this skin
lesion in order to reassure the patient
and family; recognize associated
cutaneous, muscular, and skeletal
anomalies; and refer appropriately to
subspecialists if needed. Patients typically present with complaints related
to hypertrichosis and hyperpigmentation. Although the lesions can be
quite large and cosmetically concerning, reassurance should be provided that BN represents a benign
entity and malignant conversion has
not been demonstrated. A variety of
therapeutic interventions for BN are
available; however, these are primarily for cosmetic improvement only.
Patient follow-up
The patient was referred to pediatric dermatology who confirmed the
diagnosis of BN. Dermatology educated the family on this diagnosis and
confirmed that no other associated
anomalies were present on his physical examination. Because the patient
was not concerned with the hyperpigmentation or hypertrichosis, no
treatment was recommended at this
time. Dermatology recommended
follow-up annually for surveillance of
the lesion and routine skin checks.
Dr Michel is a pediatric resident, University
of Florida College of Medicine, Gainesville.
Drs Wheeler, Otero, Carswell, and Posa are
assistant professors of Pediatrics, Division
of General Academic Pediatrics, Department
of Pediatrics, University of Florida College
of Medicine. Dr Kelly is clinical associate
professor of Pediatrics, Division of General
Academic Pediatrics, Department of
Pediatrics, University of Florida College
of Medicine. Dr Cohen, section editor for
Dermcase, is professor of pediatrics and
dermatology, Johns Hopkins University
School of Medicine, Baltimore, Maryland.
The authors and section editor have nothing
to disclose in regard to affiliations with or
financial interests in any organizations that
may have an interest in this article.
dermcase-0316
eye on washington
CONTINUED FROM
PAGE 9
Children’s Health, done by telephone by the National Center for
Health Statistics, showed the percentage of children with these
disorders increased from 3.8% to
4.8% of the child population from
2007 to 2011, and, says the panel, the
trends in annual SSI initial allowances parallel the overall increases
in these disorders in the child
population.
There are no studies on why the
increase in the population is happening, said the committee, but it
noted that studies on autism spectrum disorder and ADHD say causes
of the increases in those disorders
include awareness of developmental
disorders, more availability of early
intervention and special education,
and changes in definition.
The 2 NAM reports did not
investigate the cause of the stateby-state variation in the percentages of children receiving SSI. The
Mathematica report found that
in 2013, “There was a pattern of
larger SSI-child population ratios in
Northeastern and Southern states,
suggesting regional concentration
in caseload growth, [although]
some states in these regions (such
as New Jersey) had SSI-child population ratios below 1.5%.” Seven
states, mostly in the South, had
M A R C H 2 016
|
ratios above 2.5%. The percentage
of children on SSI in 2013 varied
from .6% in Hawaii, North Dakota,
and Utah to 3.3% in Louisiana and
Mississippi.
The NAM Mental Disorders and
Disabilities report said investigations are also needed on improving evaluation of impairment and
disability in children and on the
effects of child SSI benefits on family income and work.
Both NAM reports are available for download at no cost at
iom.nationalacademies.org. Search
under “Reports” for SSI. The mental
disorders report also features an
in-depth review of how SSI works.
43
dermcase
BERNARD A COHEN, MD
SECTION EDITOR
W The patient
presents with a large
hyperpigmented patch
on his chest with
well-demarcated
borders and increased
hair growth throughout.
Unusual skin lesion
in a teenaged boy
JACQUELINE C MICHEL, DO; KATHRYN WHEELER, MD; JACLYN OTERO, MD;
KRISTINA CARSWELL, MD; MOLLY POSA, MD; MARIA N KELLY, MD
The mother of a healthy 15-year-old boy brings him to the office for evaluation
of a darkening hairy patch on his left upper chest and shoulder. The patch is
not symptomatic, and it first appeared as a subtle, poorly defined brown area
when he was aged 10 years. FOR MORE ON THIS CASE, TURN TO PAGE 42.
DERMCASE
diagnosis
44
BECKER NEVUS
|
M A R C H 2 016
THE CASE
careers
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M A R C H 2 016
|
45

clinical feature - Contemporary Pediatrics

Transcription

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