Digital Edition - Contemporary Pediatrics

Transcription

CONTEMPORARY PEDIATRICS JUNE 2016 VOL. 33 NO. 06
Contemporary
ZIKA
SPECIAL
REPORT
A GO-TO GLUTEN GUIDE
PEDIATRICS
JUNE 2016
VOL. 33 | NO. 06
Expert Clinical Advice for Today’s Pediatrician
ContemporaryPediatrics.com
A GO-TO
HYPOGLYCEMIA GUIDELINES
GLUTEN GUIDE
5 BABY STEPS TO BETTER NUTRITION
FAQS, SCREENING, & COUNSELING
PROBIOTICS FOR C. DIFFICILE
+
HYPOGLYCEMIA
GUIDELINES
ZIKA SPECIAL REPORT
5 baby steps to
better nutrition
Probiotics for
C. difficile VIDEO
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
Harlan R Gephart, MD
Jane A Oski, MD, MPH
Clinical Professor of Pediatrics,
University of Washington School of
Medicine, Seattle, Washington
Department of Pediatrics, Tuba City
Regional Health Care Corporation,
Tuba City, Arizona
W Christopher Golden, MD
Andrew J Schuman, MD
Assistant Professor of Pediatrics
(Neonatology), Johns Hopkins
University School of Medicine, and
Medical Director, Full Term Nursery,
Johns Hopkins Hospital, Baltimore,
Maryland
Section Editor for Peds v2.0,
Adjunct Assistant Professor
of Pediatrics, Geisel School of
Medicine at Dartmouth, Lebanon,
New Hampshire
physician
contributing editors
Michael G Burke, MD
Bernard A Cohen, MD
Donna Hallas, PhD, CPNP,
PNP-BC, PMHS, FAANP
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
Clinical Professor, New York
University (NYU) College of
Nursing, and Coordinator, Pediatric
Nurse Practitioner Program, New
York, New York
OUR MISSION
Office- and hospital-based pediatricians and nurse practitioners use Contemporary Pediatrics’ timely, trusted, and
practical information to enhance their day-to-day care of children. We advance pediatric providers’ professional development through
in-depth, peer-reviewed clinical and practice management articles, case studies, and news and trends coverage.
content
Section Editor for Journal
Club, Chairman, Department of
Pediatrics, Saint Agnes Hospital,
Baltimore, Maryland
Section Editor for Dermcase,
Professor of Pediatrics and
Dermatology, Johns Hopkins
University School of Medicine,
Baltimore, Maryland
founding editor
Frank A Oski, MD
NANCY BITTEKER
DIANE CARPENTERI
REPRINTS
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KATHRYN FOXHALL & MARIAN FREEDMAN
Contributing Editors
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Contemporary
PEDIATRICS
June
2016
VOL. 33 NO. 6
clinical feature
18 Gluten-free diet: Not for all children
A gluten-free diet for most healthy children actually can be less healthy, but for kids
diagnosed with celiac disease, a gluten-free diet is definitive and lifelong treatment.
Mary Beth Nierengarten, MA. Reviewed by John Snyder, MD, FAAP.
clinical feature
clinical feature
22 Hypoglycemia guidelines:
AAP vs PES
27 5 baby steps
to better nutrition
The American Academy of Pediatrics and the
Pediatric Endocrine Society advance different
plasma glucose values for hypoglycemia.
Teaching patients these simple
strategies will empower them to
make better choices about what they
eat and take control of their health.
John Jesitus. Reviewed by
Paul S Thornton, MD, and David Adamkin, MD
INTER@ACTIVE: MORE ON NUTRITION
NEW to Contemporary Pediatrics! Check out the first 2 of
our new evidence-based Medical Minute video series with
Bobby Lazzara, MD. This month? A recent study shows
psyllium holds promise in treating kids with IBS. PLUS!
Learn probiotics’ positive impact on Clostridium difficileassociated diarrhea.
special report
14 Zika virus: Top
mosquito repellent
recommendations
Contemporary Pediatrics asked pediatric
and dermatology experts to share
recommendations for insect repellents
to prevent mosquito bites that might
spread the Zika virus.
Lisette Hilton
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6
13 puzzler
departments
HYPOTHERMIA AND EMESIS
IN A NEWBORN
9 EYE ON WASHINGTON
Mike T Wei, BS, MS4; Nistana A Spigland, MD;
Cori M Green, MD, MS
11 JOURNAL CLUB
34 peds v2.0
MOC REFORM: ONE YEAR LATER
Here’s how the American Board of
Pediatrics is transforming MOC and
what further changes lie ahead.
CMS Medicaid mandates are now final.
in addition
4 EDITORIAL ADVISORY BOARD
41 ADVERTISING INDEX
Andrew J Schuman, MD, FAAP
40 dermcase
VESICULAR RASH IN AN INFANT
WITH ECZEMA
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IMAGE CREDIT: GE T T Y IMAGES / HERO IMAGES
8
Pat F Bass III, MD, MS, MPH
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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
NOW ON A PHONE NEAR YOU
e’ve teamed with
clinical technology
leader Bobby Lazzara,
MD, to take your CP user
experience to the small screen.
Check out our new short, phonefriendly videos as Dr. Lazzara highlights
2-minute takeaways on pediatric trials
you’ll want to know about.
Dr. Lazzara was trained as a
cardiothoracic surgeon and holds board
certifications in general surgery, critical
care medicine, and cardiothoracic
surgery. His formal training included
experience in general and pediatric
cardiac surgery, and he maintains
a running dialog on pediatric issues
with his brother, Anthony Lazzara, MD,
founder of Villa La Paz Foundation, a
hospital and refuge for ill and destitute
children in Peru.
Dr. Bobby was an early adopter of
technology in the service of physician
learning, receiving a Smithsonian
Computer World Award for performing
the world’s first cardiac surgery
over the Internet in 1998. As founder
of Virtual Operating Room, LLC,
and MDiTV, Inc., he pioneered live
streaming and video on demand for
W
Video Exclusives from Contemporary Pediatrics
The latest way we’re speeding you innovative data
that may inform your treatment practices.
medical education, including the first
transmission of live surgery to mobile
devices in 2009.
As creator and producer of the
Medical News Minute, he now focuses
on harnessing the power of video to
deliver physicians and healthcare
professionals the latest in clinical trial
data and treatment innovations.
He completed his undergraduate and
master’s degrees at Tulane University,
WE WANT TO HEAR FROM YOU
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As always, turn to Contemporary
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J U N E 2 016
EYE ON
washington
BY KATHRYN FOXHALL
CONTEMPORARYPEDIATRICS.COM/EOW
FOR MORE NEWS
@CONTEMPEDS
Update: Medicaid mandates are now final
I
n late April, the Centers for
Medicare and Medicaid Services
(CMS) published the final rules
for remaking Medicaid managed
care, starting a huge reform process that will impact the majority of
Medicaid recipients. (“CMS proposes Medicaid program change,” Contemporary Pediatrics, April 2016.)
The rules, proposed in fairly
similar form a year ago, set new
mandates for the states to develop
rules for managed care plans serving Medicaid recipients.
That’s big, because as of 2013,
46 million—almost three-fourths—
of Medicaid beneficiaries had all or
part of their benefits in managed
care, according to the CMS. The
Government Accountability Office
in December said that as of fiscal
2013, 39 states were using comprehensive, risk-based managed care in
their Medicaid programs.
Even Medicaid experts are still
combing through the 1230 pages of
explanations and responses to public comments and (at the end of the
document) the 200 pages of actual
rules. The regulations cover a large
number of topics including what
information should go to patients,
how to ensure provider networks
are adequate to take care of patients,
and what enrollment protections
should be available patients.
Joseph Zickafoose, MD, a senior
researcher at the Mathematica
Policy Research group and a practicing pediatrician, said that as
far as he has analyzed the rules, “I
think that CMS worked hard and
probably did a good job at trying to
strike the balance” between federal
regulatory authority and state ownership of the Medicaid program.
“What these rules really do is
direct the states to get more specific about certain things that they
haven’t had to be specific about in
the past,” he notes. This is only the
beginning because states will now
begin to set their own rules based
on the regulations, with some of the
implementation beginning almost
immediately and other parts coming in over several years.
Information to
consumers
“The rule is going to require
more consumer information than
we have ever had before,” says Kelly
Whitener, associate professor at
the Georgetown University Health
Policy Institute Center for Children
and Families, Washington, DC.
That will be very important in helping consumers to understand their
plans, she notes.
Among other things, the rules
require that managed care plans frequently update provider directories
and post them on the plan’s website,
“which will ensure managed care
plans are actively monitoring the
status of their contracted providers.”
Prov ider directories are to
include information such as the provider’s group/site affiliation, website
URL and physical accessibility for
enrollees with physical disabilities,
and the plan’s formularies.
The CMS says the rules will permit both states and managed care
plans to use a variety of electronic
communication methods while
requiring that beneficiaries also be
able to get the information by paper
for free. Plans must provide information “in each state’s prevalent
languages explaining the availability of oral interpretation services or
written translations, if requested.”
CORRECTION
Contempora
PEDIATRryICS
Expert Clini
cal Advice
for Today’s
In the Eye on Washington article that
appeared in the May 2016 edition of
Contemporary Pediatrics, the headline
“Pediatric drug voucher program
renewed” should have read: “Pediatric
drug voucher program moves through
Congress.”
J U N E 2 016
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Pediatricia
n
PEDS V2.0
MAY 2016
VOL. 33 | NO.
05
WHAT’S
NEW IN
BABY TECH
Contemporary
Pediat
PARENTING
&ReacPEDIA
hing grads TRICS
of Google
U.
rics.com
TOP SEARC
HES
Safe sleep
Living life onli
ne
Kids on planes
9
eye on washington
Enrollment
Insurance Program (CHIP) to
ensure that patients don’t have to
“The importance of rapid enrolldo inordinate travel. The providers
ment and access to a network procovered by these standards include
vider can hardly be overstated,”
primary and specialty care as well
says Sara Rosenbaum, a national
as behavioral health for both adult
expert on Medicaid, in an analysis
and pediatric patients, and “OB/
of the rules in a HealthAffairs blog.
GYN, pediatric dental, hospital, and
She explains, “The rule allows
pharmacy providers if these providstates to use a passive enrollment
ers’ services are covered under the
approach in which beneficiaries are
managed care contract.”
assigned to plans through a proIt’s important that the CMS
cess that simultaneously provides
has
called for standards for pedia period of time ‘for the enrollee to
atric providers specifically, says
make an active choice of delivery
Zickafoose, but providers should
system’ or select a different plan.”
remember these new reguZickafoose explains that
lations don’t set specific
families are offered the
FAST FACT
standards: “They tell
opportunity to pick a
By 2013, 46 million
states that the states
managed care plan and
Medicaid
need to set standards.”
a primary care provider,
beneficiaries had
Whitener points out
but many times they
their benefits in
managed
care.
there is an extended
don’t and get assigned to
period for the network adeboth a plan and primary
quacy standard to be worked
care provider.
out
at
the state level. That allows
In these new rules, he notes, if
time, she notes, for stakeholders
states do that assigning they need
including pediatricians to reach out
to take into account the needs of
to states and managed care plans to
the child and the family, for exampush for better standards.
ple, trying to preserve an existing patient provider relationship.
Zickafoose says that suggests to him
Medical loss ratio
that states should try to assign those
The regulations’ provision that
kids to a plan that allows them to go
probably has received the most
to a doctor they have seen before.
attention is the medical loss ratio
(MLR). Under the rules, the managed care plans must develop rates
Network adequacy
that “would reasonably achieve a
There has been concern about
medical loss ratio standard . . . of at
whether plans provide adequate
least 85% for the rate year,” Rosennetworks to serve patients. Zickafbaum states. That would mean that
oose says that for the first time these
at least 85% of funds would be spent
regulations are requiring states to
on claims and quality improvement
have rules for the types and numactivities rather than on adminisbers of providers in a network.
trative expenses.
Under the new mandates, the
The CMS says Medicaid and
states will develop their travel time
CHIP are the only coverage proand distance standards for mangrams in which an MLR standard
aged care and the Children’s Health
10
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does not apply to managed care
plans, although some states have
their own or similar measures of
health plans’ administrative expenditures and profits.
Family planning
As Rosenbaum notes, under the
rules, “Plans must specifically demonstrate a sufficient family planning network (although enrollees
have the right to seek family planning services from the provider of
their choice, regardless of network
status).”
In an e-mail, Jamie Poslosky,
director of t he American
Academy of Pediatrics’ Division
of Advocacy Communications,
says the regulations “could have
gone further in requiring plans
to cover all [US Food and Drug
Administration]-approved contraceptive drugs/devices and services
without prior authorization, but it
did give states welcome guidance
about what services they can and
cannot restrict.”
Posting of contracts
Whitener of Georgetown points
out that for the first time the rules
require that the managed care contracts be posted on the state website. That will be “really important”
in helping research and advocacy
groups understand what is happening, she says. Currently, the documents must be obtained through
a Freedom of Information Act
request, she says.
Links to the CMS discussion
and the final rule (found at the end
of the document), summary fact
sheets, and the timeline for implementation dates are available at
www.medicaid.gov.
journal club
BY MARIAN FREEDMAN
COMMENTARY BY MICHAEL G BURKE, MD
CONTEMPORARYPEDIATRICS
Parent mentors get uninsured kids insured
C
ompared with traditional
Medicaid/Children’s Health
Insurance Program (CHIP)
outreach, the use of parent
mentors (PMs) raises rates
of insured minority children and
improves healthcare access along
with providing other benefits—
including cost effectiveness—a new
study shows.
Investigators conducted a yearlong trial in Dallas, Texas, communities with high proportions of
low-income, minority families with
uninsured children. The 237 parent participants, all of whom were
Latino or African American, were
assigned to either the group with
which PMs engaged (via home visits
and phone/e-mail/texts) or the control group. The PMs were parents
with 1 or more children covered by
Medicaid/CHIP who participated in
2-day training sessions that enabled
them to assist families with insurance applications, retaining coverage, medical homes, and social
needs. Those in the control group
were given access to standard-ofcare outreach/enrollment by Texas
Medicaid/CHIP and were subject to
a campaign to raise CHIP/Medicaid
awareness that included bilingual
advertisements, websites with application links and order forms, and
daycare-center outreach.
In the PM group, 95% of children obtained insurance compared
with 68% of controls. The PM intervention also insured children more
quickly and was more effective in
renewing coverage. In addition,
PMs were associated with improving access to medical and dental
commentary
This is a great program! It provides a model for a cost-effective means of
enrolling the 4 million insurance-eligible, uninsured children in the United
States. Keep in mind that the parent mentors described here are not health
professionals. They are essentially peers with just 2 days of training who step
in to act like an experienced family member invested in getting children the
healthcare they need. In the year of the study, these role models visited each
of their assigned families a mean of almost 20 times and made more than
160 phone/text/e-mail contacts. The results, including the cost savings, are
impressive. —Michael G Burke, MD
Too little sleep is tied to teenagers’
injury-related risk behaviors
High school students who report
sleeping 7 hours or less on an average school night are significantly
more likely than their peers who
sleep up to 9 hours a night to engage
care, reducing out-of-pocket costs,
achieving parental satisfaction
and quality of care, and sustaining insurance after the intervention
ended. Controls had higher total
costs than the PM group for emergency department visits, hospitalizations, intensive care unit stays,
and wage loss and other costs of caring for sick children. Investigators
calculated that PMs, who received
$53 per child per month and followed up to 10 families at a time,
saved $6045 per year per child
insured (Flores G, et al. Pediatrics.
2016;137[4]:e20153519).
in several injury-related risk behaviors: infrequent bicycle helmet use;
infrequent seatbelt use; riding with
a driver who has been drinking;
drinking and driving; and texting
J U N E 2 016
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while driving.
An analysis of risk data from
50,370 high school students in
the national Youth Risk Behavior
Surveys in 2007, 2009, 2011, or 2013
found that 3 of these behaviors—
infrequent seatbelt use, riding with
a driver who has been drinking,
and drinking and driving—also
11
journal club
were more likely for students who
reported sleeping 10 or more hours
compared with 9 hours on an average school night.
A full 68.8% of respondents
reported getting 7 hours or less
sleep on an average school night:
4 hours or less, 6.3%; 5 hours, 10.5%;
6 hours, 21.9%; or 7 hours, 30.1%.
Another 23.5% reported 8 hours
sleep, 5.8% reported 9 hours, and
1.8%, 10 or more hours. Girls were
more likely than boys to report
insufficient sleep. The overall percentage of those reporting insufficient sleep ranged from 59.7% of
students in the 9th grade to 76.6% of
those in the 12th grade. Prevalence
of insufficient sleep was lowest for
American Indian/Alaska Native
students (60.3%) and highest for
Asian students (75.7%).
O vera l l, 86.1% of students
reported infrequent bicycle helmet use in the past 30 days; 8.7%
reported infrequent seatbelt use;
26% reported riding with a driver
who had been drinking at least
once; 8.9% reported drinking and
driving; and 30.3% reported texting
while driving (Wheaton AG, et al.
MMWR Morb Mortal Wkly Rep.
2016;65[13]:337-341).
commentary
Although cause and effect aren’t clearly established here, this study suggests that teenagers are not just more likely to be
injured because of fatigue and drowsiness leading to falling asleep at the wheel, but that they also may be too sleepy to be
smart. Tired teenagers may be making high-risk choices that their well-rested peers avoid. —Michael G Burke, MD
Predicting hyperbilirubinemia in babies
Newborn babies are more likely to
develop jaundice requiring treatment if
they have significant hemolysis contributing to their bilirubin levels (ie, bruising, ABO blood group incompatibility,
glucose-6-phosphate dehydrogenase
[G6PD] deficiency). To detect hemolysis and predict hyperbilirubinemia
(HB), investigators tested a bedside endtidal carbon monoxide concentration
(ETCOc) monitor in conjunction with
hour-of-life stratified bilirubins.
A total of 79 infants—gestational age
≥35 weeks, birth weight ≥2000 g, and
postnatal age >6 hours and <6 days—
underwent up to 4 ETCOc measurements
a day for up to 4 days of life in conjunction
with total bilirubin (TB) measurements.
Investigators followed these infants for
30 to 35 days after birth for clinical outcomes and results from laboratory tests
and determined the relationship between
ETCOc and risk for HB.
Infants with ETCOc ≥2.5 ppm were
at high risk of neonatal HB; those with
ETCOc between 1.5 ppm and 2.5 ppm
were at moderate risk; and those with
≤1.5 ppm were at low risk. Of the 31 infants
whose TB was >75th percentile, 23% had
ETCOc ≤1.5 ppm and 77% had ETCOc
>1.5 ppm, suggesting that the highest-risk
babies have the highest degree of hemolysis (Bhutani VK, et al. Acta Paediatrica.
2016;105[5]:e189-e194).
commentary
To understand this article, you need to reach all the way back to biochemistry class to
remember that breakdown of a molecule of heme leads to production of 1 molecule of
bilirubin and 1 molecule of carbon monoxide. By using both bilirubin level by hour of life
and ETCOc, the researchers propose that we will be able to more accurately predict which
babies will likely need treatment for their jaundice. —Michael G Burke, MD
12
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also of
note
Do you really want to
supersize that baby?
Bottle size is significantly
associated with the
volume of formula
an infant consumes,
according to a study—
conducted via parental
questionnaire—in
378 2-month-old infants
who were exclusively
formula fed. Infants who
were fed with bottles with
a capacity of 6 ounces
or more consumed about
4 ounces more formula
each day than infants fed
using bottles that were
smaller than 6 ounces
(33.3 oz vs 29.8 oz,
respectively)—a daily
80-kcal difference (Wood
CT, et al. Acad Pediatr.
2016;16[3]:254-259). puzzler
S FIGURE 1 Abdominal X-ray shows gaseous
distension of stomach and enlarged duodenal bulb
(double bubble). There is only minimal distal gas in
the left lower quadrant and paucity of bowel gas.
S FIGURE 2 Upper gastrointestinal series demonstrates
a dilated first portion of the duodenum and no contrast
beyond the duodenal bulb.
Hypothermia and emesis
in a newborn
MIKE T WEI, BS, MS4; NISTANA A SPIGLAND, MD;
CORI M GREEN, MD, MS
THE CASE
The patient, a 7-day-old, small-for-gestational-age (SGA) female (birth weight,
2.21 kg), born by vaginal delivery at 37 weeks to a G1P0 mother, presented to
IMAGE CREDIT/AUTHOR SUPPLIED
the pediatric emergency department (ED) for hypothermia and emesis at the
recommendation of her pediatrician. The neonate’s delivery was complicated
by maternal and newborn fever, and she received antibiotics for 48 hours.
Ultimately, her blood cultures were negative. Otherwise, she did well in the
nursery and was discharged at 2 days of age. FOR MORE ON THIS CASE, TURN TO PAGE 31.
J U N E 2 016
|
13
SPECIAL REPORT
Zika
Virus
Zika virus:
Top mosquito repellent
recommendations
LISETTE HILTON
Ms Hilton is a medical
writer who has covered
health and medicine for
25 years. She resides in
Boca Raton, Florida. She
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.
14
Contemporary Pediatrics asked pediatric and dermatology
experts to share recommendations for insect repellents to
prevent mosquito bites that might spread the Zika virus.
and dermatology experts to share their best
With summer here and concern growing
patient recommendations for insect repelabout the spread of the Zika virus to the
lents. This article summarizes what they
United States, pediatricians might notice
had to say.
more patients inquiring about how to
Since it was developed in 1957, DEET
safely repel mosquitoes and their diseasehas demonstrated that it is the best
inducing bites.
insect repellent humans have ever
The Centers for Disease Control
invented, says Tucson, Arizonaand Prevention (CDC) is urging
FAST FACT
based dermatologist Ronald G.
everyone to take steps to preSince 1957, DEET
Wheeland, MD.
vent mosquito bites with such
has demonstrated
“In a 20% to 50% concenthings as appropriate clothing
that it is the best
tration,
it is effective and safe,
and Environmental Protection
insect repellent
according to the US Agency
A genc y (E PA)-re g i s tere d
ever invented.
for Toxic Substances and Disease
insect repellents. The repellents,
Registry. In addition, use of long
according to the CDC, should have
sleeves and pants will help reduce the inci1 of the following active ingredients: DEET
dence of mosquito bites,” Wheeland says.
(N,N-diethyl-meta-toluamide); picaridin
Tina S. Alster, MD, director, Washington
(2-[2-hydroxyethyl]-1-piperidinecarboxInstitute of Dermatologic Laser Surgery,
ylic acid 1-methylpropylester); IR3535
Washington, DC, says that according to
(3-[N-acetyl-N-butyl]-aminoproprionic
Consumer Reports, the most effective prodacid ethyl ester); or oil of lemon eucalyptus
ucts against the Aedes species mosquito
(para-menthane-3.8-diol).
that spreads the virus are Sawyer Picaridin
Contemporary Pediatrics asked pediatric
|
J U N E 2 016
special report
TABLE
RECOMMENDED INSECT REPELLENTS
The products listed below are those recommended by the pediatric experts contacted for this report augmented by those
products rated by Consumer Reports for repelling insects, especially mosquitoes and ticks. Discuss use of any insecticide with the
child’s pediatrician prior to application.
BRAND AND MODEL
ACTIVE INGREDIENTS
All-Terrain Kids Herbal Armor
Oil of soybean, 11.5%; oil of citronella, 10.0%; oil of peppermint, 2.0%; oil of cedar,
1.5%; oil of lemongrass, 1.0%; oil of geranium, 0.05%
Avon Skin-So-Soft Bug Guard Plus
Picaridin
Picaridin, 10%
Avon Skin-So-Soft Original Bath Oil
None stated
Ben’s 30% DEET Tick and Insect
Wilderness Formulaa
DEET, 30%
Burt’s Bees Herbal
Castor oil, 10%; rosemary oil, 3.77%; lemongrass oil, 2.83%; cedar oil, 0.94%;
peppermint oil, 0.76%; citronella oil, 0.57%; clove oil, 0.38%; geranium oil, 0.19%
California Baby Natural Bug Blend
Pure essential oils of cymbopogon nardus (citronella grass), 5%; cymbopogon
schoenanthus (lemongrass), 0.5%; Cedrus atlantica (cedar), 0.5%
Coleman SkinSmart
IR3535, 20%
Cutter Natural
Geraniol, 5%; soybean oil, 2%; sodium lauryl sulfate, 0.4%; potassium sorbate,
0.1%
Cutter Skinsations
DEET, 7%
EcoSmart Organicb
Geraniol, 1.0%; rosemary oil, 0.5%; cinnamon oil, 0.5%; lemongrass oil, 0.5%
HOMS Bite Blocker BioUD Mini Trigger
2-undecanone (CAS #112-12-9), 7.75%
Natrapel 8-Hour
Picaridin, 20%
OFF! Deep Woods VIII
DEET, 25%
OFF! FamilyCare Insect Repellent I (Smooth
and Dry)
DEET, 15%
OFF! FamilyCare Insect Repellent II (Clean
Feel)
Picaridin, 5%
Repel Lemon Eucalyptusa
Oil of lemon eucalyptus, 30.0% (approximately 65% para-menthane-3.8-diol)
Repel Scented Family
DEET, 15%
Sawyer Picaridina
Picaridin, 20%
a
Indicates a top 3-rated product for repelling Aedus and Culex mosquitoes and ticks according to Consumer Reports.
Does not contain certified organic ingredients.
Abbreviations: CAS, Chemical Abstract Service; DEET, N,N-diethyl-meta-toluamide;
IR3535, 3-(N-acetyl-N-butyl)-aminopropionic acid ethyl ester.
b
Adapted from: Consumer Reports. Insect repellent ratings. Available at:
http://www.consumerreports.org/cro/health/beauty-personal-care/insect-repellent/insect-repellentratings/ratings-overview.htm. Accessed May 16, 2016.
J U N E 2 016
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15
special report
PROTECT KIDS FROM INSECT BITES
} Ensure that children’s clothing covers their arms and legs.
} Cover cribs, strollers, and baby carriers with mosquito netting.
} Treat kids’ clothing and gear with permethrin.
} Use only EPA-registered, pediatrician-recommended insect repellents.
} Do not use insect repellents on babies aged <2 months.
} Do not use products with lemon eucalyptus oil or para-menthane-diol on
children aged <3 years.
} Do not apply insect repellent onto a child’s hands, eyes, mouth, or cut or
irritated skin.
Abbreviation: EPA, Environmental Protection Agency.
From Centers for Disease Control and Prevention. Available at: www.cdc.gov/zika/prevention/.
Accessed May 27, 2016.
considering going to an infested
Insect Repellent (Sawyer; Safety
area, they can purchase hats with
Harbor, Florida), containing 20%
netting on them and clothing that
picaridin; Ben’s 30% DEET Tick
is long sleeved in advance. During
and Insect Wilderness Formula
the night, they should sleep in beds
(Tender Corporation; Littleton, New
that have netting around them.
Hampshire); and Repel Lemon
One particularly effective
Euc a ly pt u s (Spec t r u m
tool is to spray clothing
Bra nds; Midd leton,
FAST FACT
with DEET-containing
W i s c on s i n), w h i c h
Biting insects are
repellent. This allows
most attracted
contains 65% parato where carbon
for better control of
menthane-3.8-diol).
dioxide
is
being
bugs
and potential Zika
“ T hese produc ts
emitted.
vectors.”
provided protection for
Sandy Tsao, MD, assisabout 8 hours and were as
tant professor, Harvard Medical
effective as products with higher
School, Boston, Massachusetts, and
chemical concentrations,” Alster
a dermatologist at the Dermatology
says.
Laser and Cosmetic Center at
Dermatologist Joel Schlessinger,
Massachusetts General Hospital,
MD, president of LovelySkin.com,
Boston, says DEET is her go-to recsays that although DEET is very
ommendation for repelling mosquiimportant for protection, the use
toes. Tsao says she uses OFF! Deep
of barrier clothing and nets in the
Woods, but there are other OFF!
home (particularly around the bed
products, such as Off! FamilyCare
area) are essential.
Smooth and Dry and Off! Skintastic
“Mosquito repellent will never
FamilyCare Insect Repellent, that
be completely effective and, for
are less concentrated.
that reason, it is imperative to
“DEET is seen as one of the most
put other roadblocks between the
effective products for repelling
mosquito and you,” Schlessinger
insects, but the concern is that it can
says. “If any of your patients are
16
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J U N E 2 016
be neurotoxic,” Tsao says. She recommends that parents discuss with
their child’s pediatrician his or her
recommended products to minimize insect bites prior to any insecticide application. The pediatrician
may recommend a specific brand of
insecticide or recommend alternate
skin protective measures other than
insecticide use to minimize any
potential insecticide adverse effects.
Tsao also recommends permethrin clothing treatment that lasts
for 6 washes. Using these products,
which impregnate clothing with
insect repellent, could lead to less
need for DEET and other insecticides, she says.
“Biting insects, including mosquitoes, are most attracted to where
carbon dioxide is being emitted, so
your face and ears are prime targets for a bite,” Tsao says. “As well,
insects tend to gravitate to areas of
heavy sweat.” She recommends that
patients apply the insecticide to any
areas of exposed skin—making sure
to not forget the ankles, feet, hands,
and scalp.
Medina, Ohio, dermatologist
Helen M. Torok, MD, says she has
trepidation about recommending
DEET, but will talk to patients about
DEET if asked about mosquito
repellents. “Of those [patients] that
are also uncomfortable with DEET,
then I recommend the lemoneucalyptus products,” she says.
Elaine C. Siegfried, MD, professor of pediatrics and dermatology,
Saint Louis University, Missouri,
says she defers to CDC recommendations for Zika prevention. “For
children with sensitive skin, treat
clothing and gear with permethrin
or purchase permethrin-treated
items,” she says. FLARE FREE AND LOVING IT
4
EUCERIN® ECZEMA RELIEF BODY CREME HELPED
OUT OF 5 CHILDREN STAY FLARE FREE FOR 6 MONTHS1*
Eucerin Eczema Relief Body Creme relieves dry,
itchy skin and provides hydration for patients
with eczema-prone skin1—in a light, fast-absorbing
daily formula
SKIN PROTECTANT
*Subjects applying daily Eucerin® Eczema Relief Body Creme demonstrated a statistically significant
difference (P =0.006) in the prevention of eczema flares compared with control group subjects.1
Reference: 1. Weber TM, Samarin F, Babcock MJ, Filbry A, Rippke F. Steroid-free over-the-counter
eczema skin care formulations reduce risk of flare, prolong time to flare, and reduce eczema symptoms
in pediatric subjects with atopic dermatitis. J Drugs Dermatol. 2015;14(5):478-485.
©2016 Beiersdorf Inc.
Trust Eucerin.
Over 100 years committed
to skin science.
CLINICAL FEATURE
Gluten-free
Diet
Gluten-free diet:
Not for all children
MARY BETH NIERENGARTEN, MA. REVIEWED BY JOHN SNYDER, MD, FAAP.
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
anothing to disclose in
of this article.
18
A gluten-free diet for most healthy children actually can
be less healthy, but for kids who have been diagnosed
with celiac disease, a gluten-free diet is definitive and
lifelong treatment.
The popularity of gluten-free diets continSuch a diet, however, is not for all chilues to grow as people increasingly turn to
dren and actually can be less healthy
diet as a way to manage copious symptoms
for otherwise healthy children because
from gastrointestinal disturbances, which
of the reduced nutritional benefits and
can range from headaches to skin rashes,
often-enhanced sugar and fat content of
behavioral problems, and psychological
gluten-free diets if not monitored carefully.
difficulties. Data from the NPD Group
Along with the lack of supplementation
Dieting Monitor, which regularly tracks
of vitamins and minerals in most glutendieting and nutrition-related issues,
free foods, gluten-free diets often are
show a steady increase in the permore expensive for families.
FAST
FACT
centage of American adults who
For children diagnosed with
26% of adults
say they are cutting down or
celiac disease, the role of a gluaged 18 to
trying to avoid gluten in their
ten-free diet as definitive ther49 years cut down
diets. As of 2012, 30% of Amerapy is well established. Other
or avoid gluten
ican adults aged older than
conditions as well warrant concompletely.1,2
50 years and 26% of adults aged
sideration of this diet in children,
18 to 49 years claimed to be cutting
including wheat allergy and gluten
down or avoiding gluten completely.1,2
sensitivity. Other children with gastrointestinal symptoms with no obvious cause
For parents who are trying to provide
also may benefit, as perhaps subgroups of
the healthiest environment for their chilchildren with autism spectrum disorder
dren, the media-hyped benefits of a gluten(ASD).
free diet may help steer them to placing
To help pediatricians navigate through
their child on a gluten-free diet in the belief
the morass of information emerging on
that it will provide symptom relief, prevent
gluten-free diets, John Snyder, MD, FAAP,
celiac disease, or just be healthier.3
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J U N E 2 016
clinical feature
1
DIFFERENTIAL DIAGNOSIS OF CELIAC DISEASE,
WHEAT ALLERGY, AND GLUTEN SENSITIVITY
CELIAC DISEASE
WHEAT ALLERGY
GLUTEN SENSITIVITY
Time to onset of
symptoms after
gluten exposure
Weeks to years
Minutes to hours
Hours to days
Screening
} Recommended tests for diagnosis
} Diagnosis includes:
} Diagnosis includes:
include:
1) Quantitative IgA and
2) IgA anti-tTG antibody (IgA antiendomysial antibody for children
with autoimmune disease).
} Diagnosis confirmed by endoscopy
and biopsies.
1) Double blind food
challenge;
2) Skin tests; and
3) IgE serology.
1) Negative immune-allergy
tests to wheat;
2) Negative celiac disease
serology in IgA-competent
person;
3) Negative duodenal
histopathology; and
4) Symptom resolution on a
gluten-free diet.
Pathogenesis/
HLA
Autoimmune condition (both innate and
adaptive immunity). Almost all cases are
in the HLA-DQ2 or 8 region.
Allergic immune
response/no association
to HLA
Possible innate immunity/no
association to HLA
Autoantibodies
and enteropathy
Almost always present
Always absent
Always absent
Abbreviations: HLA, human leukocyte antigen; IgA, immunoglobulin A; IgE, immunoglobulin E; tTG, tissue transglutaminase antibody.
From Snyder J4; Fasano A, et al7; Pietzak M.8
professor of pediatrics and chief,
Division of Gastroenterolog y,
Hepatolog y, and Nutrition, at
Children’s National Health System
in Washington, DC, spoke on indications for a gluten-free diet in
children and key issues to keep in
mind when talking to parents and
children about a gluten-free diet in
his presentation “The gluten-free
diet—not for everyone?” at the
American Academy of Pediatrics
2015 National Conference and
Exhibition, Washington, DC.4
Definition of and
indications for a
gluten-free diet
Gluten is a complex of water-insoluble proteins found in wheat, rye,
barley, and crossbreed grains such
as wheat-rye (ie, triticale).4,5 The
2 main proteins found in gluten are
gliadins and glutenins, and they
provide dough with its elasticity,
shape, and chewy texture.
A g luten-f re e produc t , a s
defined by the US Food and Drug
Administration (FDA), is a food
that is inherently free of gluten or
one that contains no ingredient that
is: 1) a gluten-containing grain such
as spelt wheat; 2) derived from a
grain in which the gluten has not
been removed such as wheat flour;
or 3) derived from a good in which
gluten has been removed but greater
than 20 parts per million (ppm) of
gluten remain in the product.4,6
Indications for considering a
gluten-free diet in a child include,
most importantly, the diagnosis of
J U N E 2 016
|
celiac disease for which a gluten-free
diet is definitive treatment. Along
with celiac disease, the other 2 primary conditions for which a glutenfree diet should be considered are
wheat allergy and gluten sensitivity.
Because the symptoms of all these
conditions are similar, and may
include chronic diarrhea, weight
loss, and abdominal distension, a
thoughtful approach to making the
diagnosis is critical (Table 1).4,7,8
To make the accurate diagnosis
for celiac disease, Snyder highlighted
the importance of using the recommended screening tests to measure
quantitative immunoglobulin A
(IgA) level and the IgA anti-tissue
transglutaminase (tTG) antibody
level for celiac disease followed by
endoscopic intestinal biopsy of the
19
clinical feature
small intestine in patients with
symptoms and positive screening
serology (Table 1).4,7,8 If celiac disease is not found, consideration of
a wheat allergy or gluten sensitivity
can then be considered.
It is particularly important to
accurately diagnose children with
celiac disease because these children, unlike those diagnosed with
a wheat allergy or gluten sensitivity,
are at increased risk of a number
of other comorbidities, including
the development of other autoimmune diseases, and increased risk
of cancer later in life if they do not
carefully follow a gluten-free diet
(Table 2).8
Other situations in which pediatricians may consider a gluten-free
diet are for children with ASD and
those with chronic problems with
no obvious cause, according to
Snyder. Although the recent consensus report on gastrointestinal
disorders in persons with ASD
found no definitive data on specific
patterns of gastrointestinal abnormalities in these people or efficacy
in any specific diet, the report does
specify that the data did not look
at whether subgroups of patients
may benefit from such diets. For
patients who try a restricted diet,
the report recommends professional
supervision, including the input of
an experienced dietitian, to prevent
nutritional inadequacies.9 Before
the trial is undertaken, the child
should be tested for celiac disease.
For children who present with
chronic problems with no obvious
cause, Snyder said that a trial of
dietary therapy is often considered
after celiac disease has been ruled
out. For these children and all children who go on a gluten-free diet, he
20
IMPORTANCE OF DIFFERENTIATING
CELIAC DISEASE FROM WHEAT ALLERGY
OR GLUTEN SENSITIVITY
2
Nutritional deficiencies
Persons with celiac disease are at risk of severe
intestinal damage caused by the immune system
attacking normal tissue in response to eating gluten.
This can result in malabsorption of food and nutritional
deficiencies that in turn can lead to morbidities such as
iron deficiency anemia and osteoporosis.
Development of other
autoimmune conditions
Persons with celiac disease are at risk of developing
other autoimmune conditions.
Risk of malignancies
Persons with celiac disease are at increased
risk of developing certain types of cancers (eg,
gastrointestinal cancers, particularly T cell
enteropathy lymphoma).
Increased mortality
Persons with celiac disease have a 2-fold to 4-fold
increased risk of mortality at any age compared with
the general population if they do not follow a glutenfree diet.
Familial risk
Persons with a first[- and second]-degree relative with
celiac disease are at higher risk of developing it.
From Pietzak M.8
LIMITATIONS OF A GLUTEN-FREE DIET
3
Can be nutritionally
lacking (it does not have
to be)
} Micronutrients and macronutrients can be
imbalanced.
} Gluten-free grains often are not enriched with
vitamins and minerals; can be low in thiamin,
riboflavin, niacin, folate, iron, and dietary fiber.
} Gluten-free processed foods can be higher in
saturated fats than comparable gluten-containing
foods.
Can be expensive
} Gluten-free foods often cost more.
Compliance
} Often difficult for children to follow a diet that is
more restrictive than their peers.
} Can be difficult to determine if a food is gluten-free
because gluten is hidden in many foods.
3
From Reilly NR ; Snyder J.
4
emphasized the need to work with
a dietitian experienced in using
the gluten-free diet to ensure a balanced, healthy diet.
|
J U N E 2 016
Eating a gluten-free
diet: Involve a dietitian
For children who are placed on a
gluten-free diet, involving a dietitian
clinical feature
ONLINE RESOURCES FOR
PEDIATRICIANS AND FAMILIES
} Children’s National Health System:
Celiac disease program
Information for children with celiac
disease, including gluten-free recipes,
celiac disease-friendly restaurants.
bit.ly/childrens-national-celiac
} One Medical Group:
10 apps to keep you gluten-free
bit.ly/gluten-free-apps
} Academy of Nutrition and Dietetics:
Kids eat right
Apps with information to help maintain
a gluten-free diet.
Helpful apps: “Is That Gluten Free?”
and “Find Me Gluten Free” and more.
Information on nutrition and eating for
children, videos, recipes.
bit.ly/kids-eat-right
} North American Society for Pediatric
Gastroenterology, Hepatology, and
Nutrition (NASPGHAN):
GI Kids: Celiac disease
Information on managing celiac
disease in children.
Links to resources on gluten-free diet
for families (in English and Spanish).
bit.ly/NASPGHAN-celiac
} American Academy of Pediatrics:
HealthyChildren.org: Gluten-free food
labeling
Information on the FDA’s final rule on
defining gluten-free food labeling with
links to additional information.
bit.ly/AAP-gluten-free-labeling
found in them because of contamination with gluten during transportation, storage, and processing.11
In addition to talking to patients
and guiding them in food choices to
reduce or avoid eating diets too low
in nutrients, pediatricians working
with dietitians can address other
potential limitations of gluten-free
diets such as cost and issues of
adherence (Table 3).3,4 Adhering to
a gluten-free diet can be costly, and
for many children may affect their
psychosocial well-being because of
the restrictions of the diet that may
lead to social isolation.1,12
As with any therapy, follow-up
visits with children on a gluten-free
diet are important to ensure adherence to the diet as well as to evaluate
symptoms and monitor for complications. Pediatricians, working with
dietitians, can help improve adherence by ongoing education and support to families.12
Summary
Abbreviation: FDA, Food and Drug Administration.
From Snyder J.4
increased saturated fat and sugar
is highly recommended. “Involve a
content,10,11 which can lead to obedietitian since gluten-free foods can
be deficient in macronutrients and
sity, new-onset insulin resistance,
micronutrients and are often not
and metabolic syndrome.3
enriched with vitamins and minerAlong with ensuring proper
als,” emphasized Snyder.
nutrition, involvement of a
The need to ensure that
dietitian can help with
FAST
FACT
children on a gluten-free
choosing foods that are
Children on glutendiet receive sufficient
gluten-free. Because
free diets may lack
nutrients is highlighted
even small amounts of
certain vitamins,
by studies show ing
gluten can be harmful,
minerals, and
that these children may
particularly for children
dietary fiber.10,11
be getting low amounts
on definitive treatment
of important vitamins and
for celiac disease, working
minerals as well as dietary fiber.
with a trained professional can help
Along with the lack of nutrient foridentify safe foods. For example,
tification in gluten-free products,
although oats are safe for most peomany of these products also have
ple, trace amounts of gluten may be
J U N E 2 016
|
With the increasing popularity of
gluten-free diets, questions of who
actually may benefit from this type
of diet need some answers. Prior to
initiating a gluten-free diet, all children need to be tested for celiac disease. If diagnosed, a gluten-free diet
is required as definitive and lifelong
treatment. Other conditions that
warrant a gluten-free diet include
wheat allergy and gluten sensitivity. For all children, education on
adhering to a healthy, balanced diet
is needed, and involving a dietitian
is integral to their care.
For answers to frequently asked
questions about gluten-free
diets, go to ContemporaryPediatrics.com/
FAQs-gluten-free-diet.
21
CLINICAL FEATURE
Hypoglycemia
Guidelines
Hypoglycemia
guidelines: AAP vs PES
JOHN JESITUS. REVIEWED BY PAUL S THORNTON, MD, AND DAVID ADAMKIN, MD.
Mr Jesitus is a medical
writer based in Colorado.
He has nothing to disclose
in regard to affiliations with
of this article. Dr Thornton
and Dr Adamkin also report
no conflicts of interest.
The American Academy of Pediatrics (AAP) and the
Pediatric Endocrine Society (PES) advance different
plasma glucose values for hypoglycemia in children.
The topic of hypoglycemia in neonates and
children has generated significant debate of
late, with the American Academy of Pediatrics (AAP) and the Pediatric Endocrine
Society (PES) having advanced apparently
conf licting guidelines.1,2 To avoid overscreening of healthy infants and children
without discharging babies who may have
glucose-regulation problems beyond the
first days of life, the community pediatrician is perhaps best served by observing the
AAP’s approach for the first 48 hours, with
increased vigilance consistent with the PES
approach thereafter.3
Introduction
The disconnect between the 2 societies’
guidelines comes as little surprise, considering the paucity of evidence regarding clinically significant levels of neonatal
hypoglycemia (NH) and the lack of consensus regarding a specific level to define
hypoglycemia in the first 2 days of life.4
In reviewing NH studies to date,
22
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J U N E 2 016
confounding factors such as variable definitions of hypoglycemia and lack of control groups make it impossible to define a
specific plasma glucose (PG) concentration
or duration that can predict permanent
neurologic injury in high-risk infants.5-7
Although it is known that symptoms and
long-term neurological damage occur
within a range of low PG values of varying
duration and severity,1 it is also critically
important to remember that factors such
as the presence of the alternative brain
fuels beta-hydroxybutyrate (BOHB) and
lactate, as well as hypoxia or ischemia, can
affect whether brain injury will occur in
conjunction with hypoglycemia.2
Hypoglycemia is defined as a glucose
concentration low enough to cause signs
or symptoms of impaired brain function
(neuroglycopenia).8 Various authors have
noted that the generally adopted PG concentration historically used to define NH
for all infants, <47 mg/dL, lacks rigorous
scientific justification.
clinical feature
1
SCREENING AND MANAGEMENT OF POSTNATAL
GLUCOSE IN AT-RISK INFANTS: AAP
WHICH INFANTS
WHEN
WHAT
THRESHOLD
INTERVENTION
Symptomatic
<48 h
Any screening value
<40 mg/dL
IV glucosea
Asymptomatic
0-4 h (Feed in first h, screen
glucose 30 min later)
Initial screening
<25 mg/dL
Feed infant, recheck glucose in
1h
A subsequent
screening
<25 mg/dL
IV glucosea
25-40 mg/dL
Refeed, IV glucose as needed
Initial screening
<35 mg/dL
Feed infant, recheck in 1 h
Subsequent
screening
<35 mg/dL
IV glucose
35-45 mg/dL
Refeed, IV glucose as needed
<45 mg/dL
IV glucose
≥45 mg/dL
Discharge when infant can
maintain this level before routine
feeding
≥60 mg/dL
Discharge when infant can
maintain this level before routine
feeding
4-24 h (Continue feeds q
2-3 h; screen before each
feeding)
24-48 h
Any infants treated 48-96 h
intravenously
Any screening value
Any screening value
a
Glucose dose: 200 mg/kg (dextrose 10% at 2 mL/kg) mini-bolus and/or IV infusion at 5-8 mg/kg/min (80-100 mL/kg/d). AAP’s general target glucose range is 40-50 mg/dL.
Abbreviations: AAP, American Academy of Pediatrics; IV, intravenous.
From: Committee on Fetus and Newborn, et al.1
Who, when, how?
To help determine which infants to
screen, at what intervals, and what
glucose levels to target during the
first 48 hours of life, the AAP examined whether specific ranges of PG
levels have been associated with
neurodevelopmental harm in longterm follow-up studies (Table 11). 3
Recommended values for intervention are somewhat arbitrary, the
AAP concedes, but designed to provide a margin of safety above glucose concentrations associated with
clinical signs.
T h e PE S g u i d e l i n e s d i ffer in that they expand the list of
whom to screen and recommend
that the target for treatment in
these at-risk babies is 50 mg/dL
if being treated by feeding and
70 mg/dL if treated by intravenous
(IV) glucose (Table 2).2
To help physicians recognize
hypoglycemic disorders that persist beyond 48 hours and prevent
brain damage in at-risk infants, the
PES analyzed mean glucose levels
found in newborns in establishing
its guidelines, while also broadening
the list of at-risk infants.2
When diagnosing hypoglycemia,
the PES highlights the following
issues:
} One should use only PG concentrations determined by a clinical
laboratory method (not a pointof-care analyzer);
} Whole-blood glucose values are
approximately 15% lower than
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|
PG concentrations; and
} Red-cell glycolysis occurring
during sample processing delays
can cut glucose concentration by
up to 6 mg/dL hourly.
Signs and symptoms
Clinical signs of NH—ranging
from cyanosis to seizures—are
nonspecific and common to sick
neonates. Other symptoms may
include jitteriness, apneic episodes, tachypnea, lethargy, poor
feeding, and weak crying.
Who’s at risk?
The AAP and PES guidelines concur that infants at highest risk for
NH include those who are:
} Late preterm (34-36 weeks);
23
clinical feature
2
HYPOGLYCEMIA EVALUATION
AND INVESTIGATIONS IN INFANTS
AND CHILDREN: PES
PATIENT
STRATEGY
STRENGTH OF
SUPPORTING EVIDENCE
Children able to
communicate
symptoms
Evaluate and treat only those
in whom Whipple’s triad is
documented:
Recommended
(Grade 1++++)
} Symptoms and/or signs of
hypoglycemia;
} A documented low PG
concentration; and
} Relief of signs/symptoms
when PG is restored to
normal.
Evaluate and manage
only those whose PG
concentrations are
documented by laboratory
quality assays to be below
the normal threshold for
neurogenic responses
(<60 mg/dL).
Suggested
Neonates suspected
to be at high risk
for persistent
hypoglycemia disorder
Screen and manage glucose
for the first 48 h of life, then
evaluate for etiology when
infant is ≥48 h old (after the
normal period of transitional
neonatal hypoglycemia has
passed).
Suggested
Infants and children
with persistent
hypoglycemic disorders
Investigate to diagnose
underlying mechanism of the
disorder.
Recommended
(Grade 1++++)
Infants and younger
children unable to
reliably communicate
symptoms
(Grade 2+++0)
Workup/investigation
(Grade 2++00)
Abbreviation: PES, Pediatric Endocrine Society; PG, plasma glucose.
From: Thornton PS, et al.2
} Small for gestational age;
} Large for gestational age;
} Infants of diabetic mothers.
Babies at increased risk for persistent hypoglycemia (lasting beyond
the first 2 days of life) also include
those with the following characteristics, says the PES:
} Postmature delivery;
} Family history of genetic forms
of hy p o g l yc e m i a (s u c h a s
24
congenital hyperinsulinism or
hypopituitarism);
} Congenital syndromes (such as
Beckwith-Wiedemann);
} Abnormal physical features (such
as midline facial deformations,
microphallus); and
} Perinatal stress (birth asphyxia/
ischemia, cesarean delivery,
maternal preeclampsia/eclampsia or hypertension, meconium
|
aspiration syndrome, erythroblastosis fetalis, polycythemia,
hypothermia).
Both guidelines agree that only
infants who show clinical manifestations or who are otherwise
known to be at risk require blood
glucose measurements.1,2 In such
cases, the AAP recommends measuring plasma or blood glucose
concentration as soon as possible
(point of care)—in minutes, not
hours—while keeping in mind that
breastfed term infants have lower
PG concentrations but higher concentrations of ketone bodies than do
formula-fed infants.9,10 These higher
ketone concentrations may allow
breastfed infants to tolerate lower
plasma glucose concentrations
without showing NH symptoms.
J U N E 2 016
For children with confirmed persistent hypoglycemia or those needing
IV glucose to treat hypoglycemia,
say PES guidelines, workup/investigation should include (Table 32):
Thorough history. Include timing of episode, in context of food,
birth weight, gestational age, and
family history.
Physical exam. Seek evidence
of hypopituitarism, glycogenosis,
adrenal insufficiency, or BeckwithWiedemann syndrome.
Specimen or “critical sample.”
Whenever possible, obtain at
time of spontaneous presentation
of hypoglycemia <50 mg/dL after
48 hours of life and before treatment that might alter intermediary metabolites and hormone levels
is given. Readily available assays
for PG, insulin, BOHB, and lactate
are useful for distinguishing categories of hypoglycemia disorders.
clinical feature
3
POSTNATAL GLUCOSE TREATMENT
TARGETS: PES
High-risk newborns without a suspected
congenital hypoglycemia disorder
Neonates with suspected congenital
hypoglycemia disorder and those requiring
IV glucose to treat hypoglycemia
0-48 h
>50 mg/dL
>48 h
>60 mg/dL
Any time
>70 mg/dL
The PES set the above thresholds based on the following observations about the
impact of specific glucose concentrations in adults:
55-65 mg/dL
Brain glucose utilization becomes limited.
50-55 mg/dL
Neurogenic symptoms (palpitations, tremor, anxiety, sweat,
hunger, paresthesia) perceived.
<50 mg/dL
Discussion
Cognitive function impaired (neuroglycopenia, characterized by
confusion, seizures, coma).
Abbreviations: IV, intravenous; PES, Pediatric Endocrine Society.
From: Thornton PS, et al.2
Consider reserving extra plasma for
tests such as plasma cortisol, growth
hormone, or free fatty acids.
Provocative fasting test. If a
spontaneous episode of glucose
<50 mg/dL does not occur in a
patient in whom workup is warranted, a 6-hour fast should be performed. Additionally, if the patient is
unable to maintain PG >60 mg/dL,
then further consideration of a
persistent hypoglycemic disorder
should be entertained.
Managing persistent
hypoglycemia
Neonates with persistent hypoglycemia: Because recurrent PG levels of 50 mg/dL to 70 mg/dL can
blunt awareness of hypoglycemia
and impair hepatic glucose release
(ie, hypoglycemia-associated autonomic failure),11 PES treatment
targets aim to maintain PG concentration within the normal range of
70 mg/dL to 100 mg/dL. For defects
in glycogen metabolism and gluconeogenesis, maintaining such a
PG concentration prevents metabolic acidosis and growth failure;
for hyperinsulinism, it can prevent
recurrent hypoglycemia, which
raises the risk of subsequent hypoglycemic episodes. For any hypoglycemia disorder, base long-term
therapy on the specific disorder’s
etiology, consulting with a physician experienced in diagnosing and
managing pediatric hypoglycemia.
High-risk neonates without a
suspected congenital hypoglycemia disorder: The PES committee’s
consensus was that during the first
48 hours of life, a safe target for such
an infant should be near the mean
for healthy newborns on the first
day of life, and above the threshold for neuroglycopenic symptoms
(>50 mg/dL). After 48 hours of age,
the committee raised the glucose
target (>60 mg/dL) above the threshold for neurogenic symptoms and
J U N E 2 016
|
near the target for older infants and
children because hypoglycemia that
persists beyond the first 48 hours
(and particularly beyond the first
week) increases the concern for an
underlying hypoglycemia disorder.
Absent evidence regarding shortterm or long-term consequences of
different treatment targets, the PES
committee focused on physiology,
etiology, and mechanism, balancing
the risks and benefits of interventions in setting these targets.
The apparent conflict between the
AAP and PES recommendations
stems from philosophical and methodological differences. Experts concur that within an hour or 2 of birth,
PG concentrations in normal neonates temporarily drop by up to
30 mg/dL,1,2 a phenomenon known
as transitional neonatal hypoglycemia (TNH).12 However, questions such as what this natural nadir
means, how to respond to PG concentrations during the first 2 days
of life, and whether newborn brains
are more or less susceptible to
hypoglycemic injury have sparked
controversy.13-15
A PES committee reviewed available data regarding metabolic fuel
and hormonal responses during
this period in normal newborns and
determined that TNH most closely
resembles known genetic forms
of congenital hyperinsulinism.12
During this mild form of hyperinsulinism, mean PG threshold for insulin suppression is approximately
55 mg/dL to 65 mg/dL shortly after
birth and rises to approximately
80 mg/dL to 85 mg/dL—the mean
level found in older infants, children, and adults—by age 72 hours,
25
clinical feature
as the glucose-stimulated insulin
secretion mechanism matures.16,17
The difficulty in distinguishing
TNH from a suspected persistent
hypoglycemic disorder during an
infant’s first 48 hours supports the
PES’ suggestion to delay any diagnostic evaluation until 2 to 3 days
after birth.2
In a recent reexamination of
the mechanism and implications
of TNH, the PES reviewed the
major metabolic fuel and hormonal
responses to hypoglycemia in neonates.12 Considering published data
from normal newborns during this
phase, Stanley and colleagues rea-
necessary for postnatal survival
(such as enhancing oxidative fat
metabolism, stimulating appetite).20
An alternate explanation advanced
by the PES is that this lower threshold for insulin secretion is essential for in utero fetal nutrition and
growth, and that persistence of this
lower set point of insulin secretion
is caused by peripartum stress. In
126 term-appropriate for gestational
age neonates, the lowest glucose
values (<30 mg/dL) appeared to be
especially associated with peripartum stresses (fetal distress, birth
asphyxia, low Apgar scores) and low
weight-versus-length ratios, consis-
The apparent conflict between the AAP and PES
recommendations stems from philosophical and
methodological differences.
soned that mean responses most
likely reflected the responses of normal newborns.
Additionally, the PES found
the PG concentrations of normal
newborns during the transitional
period to be “remarkably stable
and relatively unaffected by the
timing of initial feeding or interval between feedings.” However,
Adamkin believes feeding will
affect infants with lower levels of
glucose.4 Studies published between
1950 and 1992 show mean PG levels
of approximately 57 mg/dL across
fasting times that ranged from
8 to 24 hours.18,19 These data led the
PES to conclude that TNH appears
to be a regulated process in normal
newborns.
Researchers have speculated that
this dip in glucose levels might
stimulate physiological processes
26
tent with fetal growth restriction. By
72 hours, only 0.5% of these babies
will have persistent glucose values
<50 mg/dL.21
Perinatal stress has been associated with hyperinsulinemic hypoglycemia that may persist until
6 months of age.22,23 These factors
explain why the PES considers
birth asphyxia, ischemia, and other
stressors to put infants at risk of
hypoglycemia, although the AAP
counters that routinely screening
such patients would be burdensome
and produce many enigmatic readings in asymptomatic infants.3
In setting its thresholds, the AAP
focused instead on the lower ranges
of glucose concentrations found in
fetuses and asymptomatic infants17,24
in suggesting a bottom line of
<25 mg/dL and actionable levels of
25 mg/dL to 40 mg/dL during an
|
J U N E 2 016
infant’s first 4 hours of life. From
4 to 24 hours, the AAP’s lower range
is <35 mg/dL, with actionable values
of 35 mg/dL to 45 mg/dL.
T he neu rodevelopmenta l
approach that underlies the AAP
thresholds is hardly free of controversy. For starters, the 1988 study25
that resulted in widespread adoption of 47 mg/dL as the threshold
for NH in all infants had methodological flaws, and focused not on
hypoglycemia but on feeding patterns of low-birth-weight babies.1
Subsequent studies in various newborn populations—including a follow-up study showing less dramatic
impact when these infants were
aged 7 or 8 years26 —have yielded
conflicting results. Recent reviews
have revealed a dearth of highquality data regarding the relationship between early glucose levels
and neurodevelopmental outcome,
especially in late-preterm and newborn infants with risk factors.27 It
should be noted that any study that
looks only at glucose levels without examining all the brain fuels
including oxygen and blood flow is
flawed.
The AAP authors conclude that
sticking with this group’s recently
reratified 2011 recommendations,
“along with enhanced vigilance to
identify persistent hypoglycemia
symptoms after 48 hours, might be
the best compromise” to prevent
overscreening and overtreatment
while still committing to diagnosing persistent hypoglycemia after
the transitional period, but before
infants are discharged home.3
For references, go to
hypoglycemia-guidelines
CLINICAL FEATURE
Nutrition
Strategies
5 baby steps to
better nutrition
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
of this article.
Teaching patients these simple yet specific strategies for
better nutrition will empower them to make better choices
about what they eat and take control of their health.
control of their eating.
Patients often want to make big changes
Here are 5 small strategies that will
to improve their health. However, there
make
significant nutritional improvements
often is a disconnect between wanting to
for the pediatric patient.
make a change and the ability to carry
1. Switch from soft drinks to water.
the change through and make it a habit.
Sugar-sweetened beverages are a main
Rather, the patients that are successful in
source of extra calories for the pediatric
improving their nutrition are those who
population. These beverages include not
make small but sustainable changes and
only soft drinks, but also specialty coffee
maintain those changes over time.
drinks, fruit juices, sports drinks, energy
The difficulty in change often frusdrinks, and vitamin water drinks.
trates clinicians and discourages
Although soda consumption has
them from making interventions
FAST FACT
decreased over the last 10 years,
at all. Physicians sometimes
Sugar-sweetened
consumption of the other
lack self-efficacy to deliver
beverages are a
drinks has been on the rise.
behavioral interventions, or
main source of
These drinks add a significant
they may not have signifiextra calories for
children.
amount of calories to the avercant experience with deliverage American diet.1
ing nutritional counseling in their
practice. This article seeks to give the
Consumption of sugar-sweetened
pediatrician a number of focused, spedrinks places children at risk for a number
cific, and brief strategies that can be impleof poor outcomes including elevated blood
mented in a busy office practice to achieve
glucose levels, diabetes mellitus, oversustainable, long-term nutritional change
weight or obesity, metabolic syndrome,
and help patients make better day-to-day
and cardiovascular disease as an adult.1
decisions by empowering them to take
Sugary drinks have very few dietary
J U N E 2 016
|
27
clinical feature
or other benefits for the pediatric
patient, and they are associated
with the aforementioned impacts
on overall health. As a result, the
pediatrician should consider recommending that caregivers eliminate
sugar-sweetened beverages as much
as possible from their children’s
diet. Instead, children and adolescents should be encouraged to drink
water. Developing this habit at an
early age will significantly reduce
wasted calories for the pediatric
patient over his or her lifetime. If
parents do not offer these drinks in
their home, their children will have
significantly reduced access to these
extra, empty calories.
When beverages other than
water are consumed, zero-calorie
in a dose-dependent manner. The
Physicians’ Health Study and the
Nurses’ Health Study both demonstrated that consumption of more
whole grain foods was associated
with lower weight compared with
those who consumed fewer wholegrain foods at all follow-up points.3
Increased intake of whole grains
additionally has been associated
with decreased risk of high cholesterol, diabetes, heart disease, and
cancer.
The US Department of Health
and Human Services recommends
that whole grains make up at
least half of all grains consumed.4
However, fewer than half of all
American meet this goal.
Pediatric patients can increase
When beverages other than water are
consumed, zero- or low-calorie drinks or
skim milk are good recommendations.
drinks, low-calorie drinks, or skim
milk are good recommendations.
Additionally, children should eat
fruit rather than drink fruit juice or
other fruit beverages. If fruit juice is
to be consumed, it is recommended
that children aged 1 to 6 years limit
their intake to 4 oz. to 6 oz. per day,
and for children aged 7 to 18 years,
8 oz. to 12 oz. (2 servings) per day.2
2 . C ho o s e w hole g r a i n s .
Increased intake of whole grains is
inversely associated with a number of different parameters associated with obesity such as body
mass index, waist-to-hip ratio, and
waist circumference. Lower abdominal fat has been associated with
increased intake of whole grains
28
intake of whole grains by eating
more brown rice, oatmeal, whole
oats, bulgur (cracked wheat), popcorn, whole rye, graham flour, pearl
barley, whole wheat, and whole
grain corn.
Also, referral to a nutritionist is
another strategy for the pediatrician
to improve consumption of whole
grains and other dietary interventions. Physicians generally underrefer to ancillary services, but many
physicians also do not feel skilled in
dietary counseling.
Some simple substitutions to
recommend to parents are to
buy whole-wheat bread, pasta,
and crackers instead of the versions made with white f lour.
|
J U N E 2 016
Whole-wheat products retain vitamins and other nutrients that are
lost during the bleaching process
to make white flour. Additionally,
the whole-wheat versions contain
more fiber. Although some patients
complain that the taste, texture, and
feel of whole-grain products are different, many patients come to like
them over time, especially if parents do not offer the white-f lour
versions.
Encourage parents to experiment with different grains. There
is a plethora of commercially available products that allow increased
intake of grains without a lot of sacrifice. However, parents need to be
mindful of words on labels such
as wheat, stoned wheat, enriched
wheat, or 7-grain. These may not be
whole grains although they give the
appearance of being so.
Try offering the following suggestions during meals or snacks to
increase the amount of different
grains over time and slowly introduce as snacks or pastas. Here are
some suggestions of whole grains
for each part of the day:
} Breakfast: Whole-wheat cereals,
whole-grain muffins, or oatmeal.
} Lunch: Whole-grain bread for
sandw iches or whole-grain
crackers to accompany soup.
} Dinner: Brown or wild rice as
a side instead of white rice or
whole-grain pasta.
} Snacks: Unbuttered popcorn or
whole-grain crackers.
3. Always eat breakfast. Eating
breakfast has been associated with
decreased risk of overweight and
obesity. 5 Breakfast eaters have a
higher consumption of fiber, calcium, vitamins A and C, and other
nutrients as well as being more likely
clinical feature
} Fresh fruit; and
} Dry cereal.
RESOURCES FOR PEDIATRICIANS
AND FAMILIES
American Heart Association (AHA):
Dietary Recommendations for Healthy Children
} bit.ly/AHA-diet-recommendations-kids
Centers for Disease Control and Prevention (CDC):
CDC Guide to Strategies for Reducing the Consumption of
Sugar-Sweetened Beverages
} bit.ly/CDC-reduce-sugar-beverages
US Department of Agriculture (USDA). ChooseMyPlate.gov:
Choose my plate: 10 tips to a great plate
English:
} bit.ly/USDA-choose-my-plate-10-tips-eng
Spanish:
} bit.ly/USDA-choose-my-plate-10-tips-sp
US Department of Agriculture (USDA):
Dietary Guidelines for Americans 2015-2020, 8th edition
} bit.ly/USDA-diet-guidelines-2015
US Department of Health and Human Services (USDHHS). Dietary
guidelines 2015-2020:
Appendix 7. Nutritional Goals for Age-Sex Groups Based on Dietary
Reference Intakes and Dietary Guidelines Recommendations
} bit.ly/USDHHS-nutrition-goals-2015
US Department of Health and Human Services, Office of Disease
Prevention and Health Promotion (ODPHP): health.gov:
Toolkits and Resources
} bit.ly/ODPHP-diet-guidelines-2015-tools
to meet general nutrition recommendations compared with breakfast skippers.6 Eating breakfast is
also associated with better school
attendance, grades, performance,
and test scores.7,8
As children get older, they are
more likely to skip breakfast. More
than 95% of children aged 5 years
and younger eat breakfast daily,
although this number decreases to
87% among 6- to 11-year-olds and
69% in children aged 12 years and
older.9 Encourage parents to be good
role models for their children and
not skip breakfast. If children are
already overweight or obese, eating a good breakfast is an invaluable asset in helping patients control
weight gain.
Healthy breakfast options that
are quick for parents include:
} A bowl of whole-grain cereal
topped with low-fat milk or
yogurt, and fruit;
} Granola bars;
} Breakfast bars;
} Dried fruit;
J U N E 2 016
|
4. Avoid processed foods.
Although patients will never be
totally able to avoid processed foods,
they should be encouraged to choose
unprocessed foods when available.
Processed foods are energy dense
with a high calorie per unit weight.
They are often high in added sugars,
sodium, and fat, and low in fiber
and whole grains as well. A better choice is a natural food with a
higher content of water. For example, a fresh apple is a better choice
than applesauce or some sort of
apple snack that comes in a bag.
S ome com mon food s t hat
patients think are healthy and often
do not consider processed can turn
what seems to be a healthy food
choice into a poorer, unhealthy one.
For example, the cereal industry spends a lot of time, effort, and
money convincing parents that
their products are a great way for
kids to start their day. However,
examining the label of many popular cereal boxes reveals ingredients
such as artificial sugars, artificial
dyes, sodium, partially hydrogenated oils, trans fats, and butylated
hydroxyanisole (BHA), a product in embalming f luid. Mixing
rolled oats, sunflower seeds, sliced
almonds, chopped pecans, and raisins or a dried fruit of choice is a
much healthier option. Mixing granola, steel cut oats, and millet is
another homemade cereal that is
much healthier than the more processed, off-the-shelf versions.
Salad dressing can easily turn a
healthy meal idea into a processed
calorie feast that is not so healthy. A
quick glance at salad dressing labels
marketed as “all natural” and “lite”
29
clinical feature
reveals ingredients such as maltodextrin, sodium benzoate, calcium
disodium ethylenediaminetetraacetic acid (EDTA), modified food
starches, monosodium glutamate,
corn syrup, autolyzed yeast extract,
sodium chloride, and xanthum
gum. Instead, suggest trying oil
and vinegar with a little Dijon mustard and garlic mixed in. Another
healthier option is to mix Greek
yogurt, yellow mustard, raw honey,
and lemon juice.
Ketchup, tortilla chips, pasta
sauce, soup, flavored yogurt, granola bars, and energy bars are just
a few of the other foods that may
suggest one is eating healthy, but
the label may reveal something different. However, all these items,
with a quick Internet search, can
be made from more natural and
healthy ingredients easily at home.
These unprocessed versions are
much healthier and contain significantly fewer processed ingredients. Patients can be instructed to
read a label and if they have trouble
pronouncing or do not recognize
a large number of the ingredients,
there is a good chance the product
is highly processed, and the parent
might be better advised to consider
an alternative option.
5. Avoid junk food. If parents choose not to buy junk food,
children simply will have significantly fewer opportunities to eat
these calorie-rich, low-nutritionalquality foods. Although efforts
to ba n ju n k food f rom t he
Supplemental Nutrition Assistance
Program (SNAP), as was successful for alcohol and cigarettes,
have failed, it is estimated that
changes in the program could
significantly improve diets of the
30
1 in 7 Americans that receive food
assistance. One pilot project that
has yet to be implemented found
that fruit and vegetable consumption increased by 25% when SNAP
recipients were incentivized with
30 cents for every dollar used to purchase fruits and vegetables.10
In addition to providing patient
education on these topics, pediatricians can advocate for policies
that improve the likelihood that
patients will make better food
choices. Because so many people
in the United States receive food
assistance, most grocery chains and
convenience stores want to participate. Few stores opt out of programs
such as SNAP or Women, Infants,
and Children (WIC). In 2009, the
measuring eating habits, calorie
intake, or exercise, self-tracking
demonstrates benefits across a wide
range of desired activities. When
patients record both what and how
much they eat, they generally eat
less and lose more weight compared
with those who do not self-track the
activity.14 With some activities such
as exercise, patients tend not only to
perform the desired activity more,
but they also seem to get greater
enjoyment from that activity.
With self-tracking, a patient
can set smaller waypoints on the
way to achieving a bigger goal.
Measurement allows patients to not
be overwhelmed by a larger goal,
and allows them to see where they
are on the path to achievement.
Studies have demonstrated that doubling
shelf space for fruits and vegetables
increased consumption by 30% to 60%.12,13
WIC program increased the types of
foods stores were required to stock in
order to participate. Nearly all stores
participated, and milk, whole grain,
and fruit consumption increased.11
Similarly, studies have demonstrated that simply doubling shelf
space for fruits and vegetables
increased consumption by 30% to
60%.12,13 The SNAP or WIC mandates for certain amounts of shelf
space for fruits, vegetables, and other
healthy, nutritionally desirable foods
will likely improve consumption of
these items for people beyond participants in food assistance programs.11
Finally, there is a saying in business that “You cannot change what
you do not measure.” Whether
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J U N E 2 016
Small incremental changes in
eating habits and purchasing decisions can make a big difference
in the nutritional state of children
and adolescents. The pediatrician
has an opportunity to counsel in
the office as well as participate in
local and national advocacy related
to food assistance programs and
food programs in public schools.
Finally, advocating for patients to
measure and record aspects of their
nutritional habits is likely to lead
to improvements in what patients
consume.
5-steps-to-nutrition
puzzler
CONTINUED FROM PAGE 13
HYPOTHERMIA AND EMESIS IN A NEWBORN
After discharge, the baby was
breastfeeding without emesis,
and although she was thought to
be sleepy (by mother’s report), she
did wake for feeds. At baseline, she
breastfed for 5 to 10 minutes every
3 to 4 hours, but starting at age 5 days
she was having greater difficulty
latching. Furthermore, she became
lethargic and developed nonbilious,
nonbloody, nonprojectile emesis
with each feed.
The neonate maintained continued daily bowel movements.
Simultaneously, she had decreased
urine output, with 2 small wet diapers the night prior to admission.
The morning of admission, the
patient was taken to her pediatrician, who noted a rectal temperature of lower than 36°C, along with
emesis with feeding trial.
Physical exam
In the pediatric ED, the patient
weighed 2.20 kg and had a rectal
temperature of 35.8°C, heart rate
of 138 beats per minute, respiratory
rate of 32 breaths per minute, and
a blood pressure of 77/51 mm Hg.
Physical exam revealed an active
and alert neonate in no apparent distress; her abdomen was soft,
nontender, nondistended, and
without hepatosplenomegaly. The
remainder of the examination was
noncontributory.
Differential diagnosis
The patient presented with 2 primary symptoms, both of which
have unique differential diagnoses. Hypothermia in a newborn
is concerning for many possible
conditions (Table 11,2). Although
1 DIFFERENTIAL DIAGNOSIS OF HYPOTHERMIA
DIAGNOSIS
CHARACTERISTIC FINDINGS
Cold exposure
} History pointing toward difficulty with swaddling infant;
neonate being outside in cold weather without adequate
protection; or not dressing neonate in adequate levels of
clothing.
} May demonstrate signs of abuse.
} History of maternal GBS colonization; premature
Infection
rupture of membranes; preterm rupture of membranes;
prematurity; prolonged rupture of membranes; maternal
UTI; chorioamnionitis.
} Presentation dependent on the causative agent
and source. Nonspecific signs include pulmonary
hypertension, hypoxemia, decreased cardiac output,
or signs of overt shock. Metabolic signs include
hypoglycemia/hyperglycemia, jaundice, or metabolic
acidosis. Signs of meningitis or temperature instability
may also be seen.
} Very unlikely in a newborn; would most likely be from
Ingestions
abuse. History of ingestion of poison or drugs.
Metabolic
derangements/
Endocrinopathies
} Laboratory findings demonstrating electrolyte
abnormalities, hypothyroidism (high TSH, low T 3 /T4),
abnormal urine findings, abnormal newborn screen.
} Patient may demonstrate nonspecific findings such as
fatigue and hypoactivity or hyperactivity.
Abbreviations: GBS, group B streptococcus; T3, triiodothyronine; T4, thyroxine; TSH, thyroid-stimulating
hormone; UTI, urinary tract infection.
From Mandt MJ, et al1; Fein DM, et al.2
the definition is controversial,
the World Health Organization
(in 1997) categorized hypothermia as an unintentional temperature drop below 36.5°C and further
divided hypothermia into 3 stages:
cold stress (36.0°C-36.4°C), moderate hypothermia (32.0°C-35.9°C),
and severe hypothermia (<32.0°C).3
Neonates are at higher risk of developing hypothermia because of their
large surface-to-mass ratio, lack of
subcutaneous tissue, and poorly
developed thermoregulation. Hypothermia may occur secondary to
environmental exposure, infections
J U N E 2 016
|
(sepsis, meningitis), metabolic/
endocrine disorders, drugs, central
nervous system dysfunction, shock,
burns, or iatrogenic causes.2
The initial concern in this neonate with hypothermia was a serious
bacterial infection, which should
be highly considered until proven
otherwise. The patient’s concurrent
lethargy and emesis in the context of peripartum maternal fever
could have been consistent with an
undertreated infection or late-onset
infection. Although lower on the
differential, metabolic derangement
was considered given the patient’s
31
puzzler
2
DIFFERENTIAL DIAGNOSIS OF EMESIS
DIAGNOSIS
CHARACTERISTIC FINDINGS
Gastroesophageal reflux
Effortless regurgitation (“happy spitter”).
Gastroesophageal reflux
disease
Neonate may demonstrate fussiness, irritability, or
feeding aversion.
Food protein-induced
enteropathy
Colitis with bloody stooling, diarrhea, and failure to
thrive.
Pyloric stenosis
Typically 3-6 wk neonate with postprandial
nonbilious. nonbloody projectile vomiting;
demanding feeding after (“hungry spitter”).
Physical exam may demonstrate “olive-like” mass in
the right upper quadrant.
Laboratory exam may show hypochloremic
metabolic alkalosis.
Adrenal insufficiency
Similar presentation to pyloric stenosis.
May demonstrate hyponatremia and hyperkalemic
acidosis.
Intestinal obstruction
(intestinal atresia,
Hirschsprung disease,
malrotation with/without
volvulus, intussusception)
May demonstrate bilious and prolonged vomiting
(>12 h). Neonate may have abdominal distension
and tenderness.
Hematemesis or hematochezia may be present as
well.
From Fein DM, et al2; Zenel JA4; Nazarey P, et al.5
emesis, which would lead to electrolyte imbalance and nutritional
deficiency, ultimately resulting in
hypothermia. The lack of history of
cold exposure and ingestions made
these diagnoses less likely in this
neonate.
Emesis in the newborn also can
be attributed to a myriad of pathologies. Primary diagnoses include
gastroesophageal ref lux/gastroesophageal reflux disease, feeding
intolerance, obstruction, necrotizing enterocolitis, metabolic disorders, milk-protein intolerance, and
infections (urinary tract infection or
meningitis; Table 22,4,5).6 Given the
hypothermia and history of peripartum maternal fever, infection
32
was the top diagnosis in the differential. Suspicion for a primary gastrointestinal etiology was initially
lower on the differential because
the newborn presented with normal
stooling and intermittent spit-up.
Laboratory tests
Workup for infectious etiology
revealed normal urinalysis, complete blood count, and comprehensive metabolic panel. A respiratory
viral panel was negative, and a bloody
lumbar puncture was significant
for elevated protein (839 mg/dL).
At 48 hours into the evaluation,
all cultures and the herpes simplex virus polymerase chain reaction test were negative. Antibiotics
|
J U N E 2 016
were discontinued but emesis persisted. During the first 24 hours in
the hospital, the patient had 6 episodes of nonbilious, nonbloody
emesis described as “spit-up.” She
was started on ranitidine with little
relief.
Throughout the hospital course,
emesis occurred either immediately
after feeds or within 30 minutes,
varying in quantity between 10 mL
and 40 mL. The patient continued to
have bowel movements and a benign
abdominal exam. However, given
the emesis, nasoduodenal (ND) tube
placement was attempted on day
2 of the admission. This procedure
was unsuccessful and an abdominal
X-ray at the time of placement demonstrated the ND tube tip within
the region of the stomach along
with gaseous distension of the stomach and an enlarged duodenal bulb
(double bubble; Figure 1). The X-ray
also showed minimal distal gas in
the bowel in the left lower quadrant
and an overall paucity of bowel gas.
While awaiting further imaging in
the radiology suite, the patient had
her first episode of bilious vomiting.
Upper gastrointestinal (GI) series
demonstrated dilatation of the first
portion of the duodenum without
contrast beyond the duodenal bulb
(Figure 2).
Given these findings, intestinal
obstruction became the leading
diagnosis, although the patient’s
hy pothermia could have been
explained by being SGA at birth
(with resultant impaired thermoregulation), or by infection.4,5
Diagnosis
Pediatric surgery was consulted.
The patient underwent an exploratory laparotomy that revealed an
puzzler
annular pancreas with duodenal stenosis above the level of the common
bile duct, as well as malrotation. No
ischemic bowel changes were noted.
Discussion
O vera l l, congenita l duodena l
obstruction affects 1 in 2500 to 1 in
10,000 live births.7 In 1980, Kiernan
and colleagues published a seminal
review of annular pancreas, which
encompassed 266 literature reports
and 15 operations at the Mayo
Clinic between 1957 and 1976.8 In
this series, 51.5% of cases of annular pancreas occurred in children,
that led to the more traditionally
seen emesis pattern.9,10
Clinical presentation of different medical conditions often can be
subtle in newborns. The presentation of gastrointestinal obstruction
is clear when a patient presents with
early projectile and/or bilious vomiting combined with absent flatus
or bowel movements. However, as in
this case, the clinical picture can be
obscured when a neonate presents
with nonbilious emesis, and complicated further by hypothermia and
lethargy, suggesting an infectious
etiology until proven otherwise.
This case underscores the importance
of having a high index of suspicion for
neonatal bowel obstruction.
and almost all neonates presented
unable to swallow secretions or by
vomiting feedings, usually with first
feed.4,5,8 This finding is supported
by a review by Chen and associates
from records at the Children’s Hospital of Zhejiang University School
of Medicine, China.7 Among the
287 neonates identified in their
facility with duodenal obstruction,
86.06% presented with vomiting
and 83.81% with bilious vomiting.
However, the patient in this case
had an atypical presentation, with
hypothermia occurring later in the
first week of life and nonbilious
vomiting that appeared more characteristic of spit-up. Interestingly,
the patient developed bilious vomiting while in the radiology suite.
Because the lesion was above the
level of the common bile duct, likely
there was an accumulation of bile
This case underscores the importance of having a high index of suspicion for neonatal bowel obstruction,
particularly in babies presenting
with vomiting (regardless of the
character or timing) and systemic
signs of illness. Additionally, pediatricians should have a low threshold
for ordering abdominal imaging in
neonates presenting with emesis. If
an abdominal X-ray demonstrates
a pattern of general gas paucity, clinicians should perform additional
radiographic imaging (such as an
upper GI series or abdominal sonogram) to evaluate for a possible
bowel obstruction.
Patient outcome
The patient underwent an uncomplicated duodenoduodenostomy
and was safely discharged 20 days
after the surgery.
J U N E 2 016
|
Mr Wei is a fourth-year medical student
at Weill Cornell Medicine, New YorkPresbyterian Hospital, New York City, New
York. Dr Spigland is professor of Clinical
Surgery, Weill Cornell Medicine, and chief,
Division of Pediatric Surgery and Pediatric
Trauma, New York-Presbyterian Hospital,
Cornell Campus. Dr Green is assistant
professor of Pediatrics, Weill Cornell
Medicine, New York-Presbyterian Hospital,
New York City. The authors have 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.
REFERENCES
1. Mandt MJ, Grubenhoff JA. Emergencies and
injuries. In: Hay WW Jr, Levin MJ, Deterding RR,
Abzug MJ, Sondheimer JM. Current Diagnosis
and Treatment: Pediatrics. 21st ed. New York, NY:
McGraw-Hill Companies; 2012:351-352.
2. Fein DM, Avner JR. The febrile or septic-appearing neonate. In: Schafermeyer RW, Tenenbein M,
Macias CG, Sharleff GQ, Yamamoto LG. Strange and
Schafermeyer’s Pediatric Emergency Medicine. 4th
ed. New York, NY: McGraw-Hill Education; 2015:5-7.
3. Kumar V, Shearer JC, Kumar A, Darmstadt GL.
Neonatal hypothermia in low resource settings: a
review. J Perinatol. 2009;29(6):401-412.
4. Zenel JA. Examination of the newborn infant. In:
Rudolph CD, Rudolph AM, Lister GE, First LR, Gershon
AA. Rudolph’s Pediatrics. 22nd ed. New York, NY:
5. Nazarey P, Sato TT. Gastrointestinal obstruction. In:
Rudolph CD, Rudolph AM, Lister GE, First LR, Gershon
AA. Rudolph’s Pediatrics. 22nd ed. New York, NY:
6. Parashette KR, Croffie J. Vomiting. Pediatr Rev.
2013;34(7):307-319.
7. Chen QJ, Gao ZG, Tou JF, et al. Congenital duodenal
obstruction in neonates: a decade’s experience from
one center. World J Pediatr. 2014;10(3):238-244.
8. Kiernan PD, ReMine SG, Kiernan PC, ReMine WH.
Annular pancreas: Mayo Clinic experience from 1957
to 1976 with review of the literature. Arch Surg.
1980;115(1):46-50.
9. Merianos DJ, Schwab CW II. Pediatric surgery. In:
Atluri P, Karakousis GC, Porrett PM, Kaiser LR. The
Surgical Review: An Integrated Basic and Clinical
Science Study Guide. 3rd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2009:382-393.
10. Hackam DJ, Grikscheit T, Wang K, Upperman JS,
Ford HR. Pediatric surgery. In: Brunicardi FC, Anderson
DK, Billiar TR, et al. Schwartz’s Principles of Surgery.
10th ed. New York, NY: McGraw-Hill Companies;
2014;chap 39. C O N T E M P O R A RY P E D I AT R I C S . C O M
33
peds v2.0
ANDREW J SCHUMAN, MD
SECTION EDITOR
MOC reform: One year later
This article reports the latest developments in the
process of reform for the American Board of Pediatrics’
Maintenance of Certification (MOC) requirements,
what transformations already have occurred, and what
changes still lie ahead.
It’s been over a year since the American Board of Pediatrics (ABP)
announced its intentions to overhaul
the maintenance of certification
(MOC) process. In this reportorial article, I’ll bring you up-to-date
with current MOC requirements
and the changes likely to occur over
the next year. In addition, I’ll provide some updates regarding several
developments that pertain to MOC
opposition.
MOC circa 2016
In 2010, the American Board of
Medical Specialties (ABMS) and
its member boards changed the
model of certification to today’s
model that is based on continuous
“maintenance” of certification. As
a consequence, in 2010, the ABP
began issuing certificates with no
end dates. Pediatricians were listed
either as “participating in MOC” on
the ABP website or “not participating in MOC.” According to current
data provided by the ABP website,
as of December 2015, approximately
34
34% of the pediatrician workforce
has a permanent certificate and
53% of pediatricians have time-limited certificates. These numbers are
essentially unchanged from 2013.
Of note is that about 14% of pediatricians have let their ABP certificates lapse, which represents a small
increase from 11% in 2013 (Figure).
The situation that ultimately
caused many of the member boards
of the ABMS to consider a “gentler” approach to MOC involved a
directive imposed on membership
by the American Board of Internal
Medicine (ABIM) in 2014. In that
year, the ABIM mandated that
member physicians participate in
MOC every 2 years. Additionally,
grandfathered ABIM physicians
began to be listed as “certified, not
meeting MOC requirements” on the
ABIM website if they didn’t register
for continuous MOC.
In response to written protests
from over 20,000 internists, the
ABIM issued an “apology” letter
that indicated that the ABIM would
|
J U N E 2 016
suspend several of its Part 4 requirements and change the language
reporting a diplomate’s MOC status
on its website. The letter also indicated that the ABIM will update the
MOC written exam to make it more
relevant to current practice.
This event led to the development
of an alternative board (more on
this later) as well as the expectation
among other physicians that their
own boards would begin embracing
“reform.”
Changes in ABP MOC
Over the past year, the ABP began to
solicit feedback from member pediatricians and expressed its intention to make MOC requirements
less rigorous and more relevant to
pediatric practice. The 2016 annual
report from the ABP was recently
published, and it includes much
information regarding what transformations already have occurred
and what is likely to happen to the
10-year recertification exam (MOC
Part 3).
Firstly, in response to discussions surrounding the quality
assurance (QA) projects required
for Part 4, the ABP now provides
full 40 credits for pediatric practices that have achieved National
Center for Quality Assurance
pediatrics v2.0
GENERAL PEDIATRICS DIPLOMATES (ALL):
DISTRIBUTION OF CERTIFICATE TYPE
Diplomates who achieved their certificates before 1989 were awarded permanent
certificates. Beginning in 1989, diplomates were issued time-limited certificates. In
2010, the American Board of Pediatrics began issuing certificates with no end dates.
Diplomates holding time-limited certificates or certificates with no end dates must meet
the requirements of Maintenance of Certification to keep their certification active. Data
include all diplomates ever certified, regardless of age, as of December 31, 2015.
54.7
48.8
32.1 33.5
12.9
Permanent
Time-limited/
no end date
US/Canadian medical
school graduate
17.2
Lapsed
0.3 0.4
Revoked
International medical
school graduate
From American Board of Pediatrics. Workforce data, 2015-2016. Available at: https://www.abp.org/sites/
abp/files/pdf/workforcebook.pdf. Accessed May 5, 2016.
(NCQA), patient-centered medical home (PCMH) status. Many
practices have sought this certification (see “Home sweet ‘medical
home’” (Contemporary Pediatrics,
November 2013). Achieving PCMH
status assures patients (and insurance companies) that practices have
met or surpassed quality benchmarks. This enables certified practices to prove eligibility for quality
payment incentives offered by
many accountable care organizations and insurance companies. It
should be noted, however, that the
ABP only provides MOC Part 4
credit for PCMH certification via
NCQA, which is just one of several
organizations that provide PCMH
certification. These include URAC
(formerly the Utilization Review
Ac c re d it at ion C om m i s sion),
the Joint Commission, and the
Accreditation Association for
Ambulatory Health Care.
The ABP also provides MOC
credit for participation in state or
national quality initiatives. For
example, the American Academy
of Pediatrics (AAP) Division of
Chapter Quality includes several
ongoing quality projects involving asthma care, attention-deficit/
hyperactivity disorder diagnosis
and management, immunizations,
and mental health and adolescent
J U N E 2 016
|
substance abuse. Now MOC Part 4
credit is also granted for small practices that design and pursue their
own QA projects, such as undertaking a project to improve rates
of handwashing among providers
and staff.
A new exam format
In May 2015, the ABP convened a
conference to discuss converting
the 10-year exam to one that is a
complete departure from the existing format. The new testing concept
is that pediatricians will be given
questions on a regular ongoing
basis, perhaps monthly via the Internet, and be allowed to research the
topic before submit ting t heir
answers. In the view of the ABP,
by changing to this format, pediatricians will utilize these questions either to gain new knowledge
or reinforce present understanding.
The idea was based on a pilot program developed by the American
Board of Anesthesiology (ABA).
In 2015, 1400 ABA members
participated in a Maintenance of
Certification Assessment (MOCA)
pilot. Participants received 1 multiple choice question via e-mail once
a week. Once accessed, they had a
limited amount of time to answer.
They received feedback immediately indicating whether the answer
was correct and a brief discussion,
including references. If answered
incorrectly, they would receive
follow-up questions on the same
subject weeks or months later. The
ABA has subsequently replaced its
current system with a redesigned
MOCA 2.0 program that went into
effect in January of this year.
According to a recent blog posted
by ABP President and CEO David
35
pediatrics v2.0
G. Nichols, MD, provisional features of the ABP version of the
MOCA exam will include the following (subject to change):
} Diplomates will establish a practice profile when registering for
MOCA, so that the content can
be weighted to suit the type of
practice.
} Diplomates may receive 1 to 3 multiple choice questions per week.
} The amount of time allowed for
the answer may vary depending on the complexity of the
question.
} Online resources or books may
be used, but because each question is timed, the diplomate will
need to judge carefully whether
to invest time in searching
through a resource.
} A feedback page will pop up after
submitting the answer.
} A randomization protocol will
minimize the likelihood that any
2 diplomates receive the same
questions during a given time
period.
HOW TO OBTAIN MOC CREDITS
As discussed in the Peds v2.0 article “Improve your practice with
behavior evaluation and management portals” (Contemporary
Pediatrics, February 2016), if a practice enrolls in either CHADIS or
mehealth for attention-deficit/hyperactivity disorder (ADHD) and uses
these portals for evaluation and management of ADHD, developmental
screening, and depression and anxiety screens, practices are eligible for
MOC Part 4 credits.
The CHADIS program (bit.ly/CHADIS) currently offers 3 MOC Part 4
modules, while mehealth for ADHD (bit.ly/mehealth-for-ADHD) offers 1
module. Each module provides 25 MOC Part 4 credits.
Abbreviations: CHADIS, Child Health and Development Interactive System; MOC, maintenance
of certification.
decisions based on the response
patterns. Those who successfully
participate will meet standards
for Part 3 of MOC.
An ABP MOCA pilot (MOCAPeds [Maintenance of Certification
Assessment for Pediatrics]) will
be launched next year. Interested
pediatricians should visit the ABP
website (www.abp.org) to find out
more about the program and consider participating in focus groups
A MOCA pilot (MOCA-Peds [Maintenance
of Certification Assessment for
Pediatrics]) will be launched next year.
} Flexibility will allow diplomates
to decide when to respond based
on their schedule and time availability. Test security provisions
may vary depending on whether
the diplomate chooses to answer
questions during the week they
are delivered or wait to answer a
batch of questions.
} If MOCA is ultimately adopted,
the ABP will make pass/fail
36
regarding the MOCA pilot.
this alternative board to hospitals
and insurance companies as well
as to other physicians. The NBPAS
requires previous board certification and participation in yearly
continuing medical education, and
membership costs only $169 every
2 years. As of this writing, the
NBPAS has enrolled more than
3000 members and is accepted by
26 hospitals nationwide.
Many pediatricians continue to
express their opposition to MOC.
Interested pediatricians should view
the many anti-MOC blogs available
on the Rebel.MD website. Last year,
several pediatricians developed the
Peds4MOCreform.org website to
express their opposition to MOC.
So far, their site has garnered more
than 6500 signatures supporting
MOC reform.
More nays
There are many physicians opposed
to the MOC certification.
Cardiologist Paul Teirstein, MD,
has started an alternative board
of medical specialties called the
National Board of Physicians and
Surgeons (NBPAS) and is encouraging interested physicians to promote
|
J U N E 2 016
First anti-MOC laws
The state legislature of Oklahoma
unanimously passed a law that
went into effect on April 12, 2016,
making it illegal for medical facilities to make MOC a requirement
for medical practice.
The law states: “Nothing in the
pediatrics v2.0
SAMPLE MOC PART 3
PILOT EXAM QUESTION
QUESTION
A 16-year-old girl has a fever and
rash. Her symptoms began abruptly
today with fever, headache,
myalgias, and nausea. She
now has a petechial rash on her
extremities that spares her palms
and soles. She is hypotensive and
tachycardic. A complete blood
count reveals thrombocytopenia
and leukopenia.
Which of the following is the most
likely diagnosis?
A. Infectious mononucleosis
B. Infective endocarditis
C. Meningococcemia
D. Rocky Mountain spotted fever
E. Toxic shock syndrome
ANSWER
The correct answer is:
C – Meningococcemia.
KEY LEARNING OBJECTIVE
Differential diagnosis of fever and
rash
REFERENCE(S)
American Academy of Pediatrics.
Meningococcal infections. In:
Kimberlin DW, Brady MT, Jackson
MA, Long SS, eds. Red Book:
2015 Report of the Committee
on Infectious Diseases. 30th ed.
Elk Grove Village, IL: American
Academy of Pediatrics; 2015:547.
Rocky Mountain spotted fever.
In: Kimberlin DW, Brady MT,
Jackson MA, Long SS, eds. Red
Book: 2015 Report of the Committee
Staphylococcal infections. In:
Kimberlin DW, Brady MT, Jackson
MA, Long SS, eds. Red Book:
2015 Report of the Committee
RATIONALE
Fever with accompanying rash
is a common presentation in
pediatric offices and emergency
departments. Many causes
are benign and self-limited, but
the physician must be able to
recognize emergencies with this
presentation. Rocky Mountain
spotted fever, meningococcemia,
and toxic shock syndrome may
all present with fever, malaise,
headache, nausea, hypotension/
shock, and thrombocytopenia.
The onset of symptoms is abrupt
with meningococcemia. Although
the rash may originally appear as
macular, it may quickly progress
to petechia/purpura. A complete
blood count may show leukopenia in
addition to thrombocytopenia. Rocky
Mountain spotted fever can have
a similar presentation, although
typically the rash occurs 3 to 4 days
following the fever and is more likely
to involve the palms and soles. The
rash of toxic shock syndrome is
diffuse and may resemble a sunburn.
Conjunctivae may also be involved.
REFERENCE
If you’d like to provide feedback on
this question, click here to let us
know.
Abbreviation: MOC, Maintenance of
Certification.
Provided by American Board of Pediatrics.
J U N E 2 016
Oklahoma Allopathic Medical and
Surgical Licensure and Supervision
Act shall be construed to require a
physician to secure a Maintenance
of Certification (MOC) as a condition of licensure, reimbursement,
employment, or admitting privileges at a hospital in this state.”
Other states such as Michigan
and Missouri have similar laws
currently under consideration. In
addition, in early April, Kentucky
governor Matt Bevin signed SB17
into law. This bill is the first state
law to be passed and signed that
makes it illegal to require specialty
medical board certification or
MOC as a requirement for practicing medicine in the state.
There are also 19 state medical societies that have officially
expressed opposition to MOC. These
are California, Florida, Georgia,
Indiana, Iowa, Massachusetts,
Michigan, New Jersey, New York,
North Carolina, Ohio, Oklahoma,
Pennsylvania, South Carolina,
Texas, Virginia, Washington, West
Virginia, and Wisconsin.
To be continued
This concludes the reportorial
update on MOC reform and opposition. Just because I have not
expressed my opinion does not
mean that you should not express
yours. Has the ABP done enough,
or should it do more? Please contact
the editors of Contemporary Pediatrics to tell them what you think of
these ABP MOC changes.
Send your comments to
[email protected]
|
37
CONTINUED FROM PAGE 40
dermcase
Etiology
Hand, foot, and mouth disease has
been classically associated with the
enterovirus coxsackievirus A16
(CVA16) and enterovirus 71 (EV71)
in North America. It presents with
vesicles and erosions on the hard
palate and vesicles with a red to
hemorrhagic border on the hands,
feet, and occasionally buttocks. A
novel presentation with widespread
symmetric involvement of the arms,
legs, diaper area, and mid-face has
been reported with increasing frequency over the last 5 years and has
become the new norm (Figure).
In children with atopic dermatitis, the enteroviral exanthema is
often exacerbated in areas affected
ECZEMA COXSACKIUM
months have been observed with
the CVA6 virus strain.4,5 As with
other enteroviruses, CVA6 is spread
through fecal-oral transmission.
Clinical manifestations
Eczema coxsackium presents with
uniform, clustered, 2-mm to 4-mm
vesiculobullous and erosive lesions
in regions previously affected
by atopic dermatitis, resembling
eczema herpeticum. The eruption
may consist solely of small vesicles
that often evolve into hemorrhagic
crusts or conf luent hemorrhagic
bullae. In addition to areas affected
by eczema, CVA6 has a tendency to
trigger lesions in regions affected
by other trauma such as diaper der-
Eczema coxsackium presents with
uniform, clustered, 2-mm to 4-mm
vesiculobullous and erosive lesions.
by eczema. This presentation,
termed “eczema coxsackium,” was
reported as early as 1968 to be associated with CVA16.1 Since 2008,
eczema coxsackium and the more
widespread eruption in children
without eczema have been linked
to both CVA16 and, more recently,
to coxsackievirus A6 (CVA6). 2,3
Coxsackievirus A6 is more often
associated w it h disseminated
lesions, including perioral and buttock lesions, than the CVA16 virus.
Eczema coxsackium is most commonly observed among preschoolers in the summer through late fall.
However, adult cases and increasing
reports of cases in the fall and winter
38
matitis and burns, or in a GianottiCrosti–type distribution.
Unlike with eczema herpeticum,
CVA6-associated skin findings
are not usually linked with fever,
decreased appetite, or decreased
activity. Rarely, children become
dehydrated because of decreased
oral intake. Many parents report
a brief history of fever or diarrhea
during the week before appearance
of the exanthema. 6 Rare, serious
complications including aseptic
meningitis have been reported.7
Onychomadesis, Beau’s lines, and
desquamation of the palms and
soles may develop 1 to 3 weeks after
resolution of the rash, which may
|
J U N E 2 016
persist for 2 to 3 weeks.6-8
Differential diagnosis
The differential diagnosis includes
eczema herpeticum, varicella, contact dermatitis, and blistering drug
reactions. Diagnosis can be made
based on history, presence of systemic symptoms, and reversetranscription polymerase chain
reaction assay from vesicular fluid,
throat swabs, or stool samples.
Management
Eczema coxsackium is managed
with supportive care. Aggressive use
of moisturizer for managing underlying eczema is recommended. Lowpotency topical steroids are used for
managing itch. Isolation from other
children is not necessary.
Outcome
The patient continued to eat and
drink normally, and his exanthem
crusted over and healed over the
next 2 weeks.
Ms Vandiver is a third-year medical student
at Johns Hopkins University School of
Medicine, Baltimore, Maryland. Dr Cohen,
section editor for Dermcase, is professor of
pediatrics and dermatology, Johns Hopkins
University School of Medicine, Baltimore.
The author and section editor have 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. Vignettes are based on real cases
that have been modified to allow the author
and section editor to focus on key teaching
points. Images also may be edited or
substituted for teaching purposes.
dermcase-0615
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*Directly Esteriﬁed Fatty Isethionate.
Dove and NutriumMoisture are Registered Trademarks.
© 2016 Unilever
dermcase
BERNARD A COHEN, MD
SECTION EDITOR
W FIGURE Vesicular
rash on the patient’s
elbow.
Vesicular rash in an infant
with eczema
AMY VANDIVER, BA, MS3; BERNARD A COHEN, MD
The parents of a healthy 6-month-old boy with eczema bring him to the office
for evaluation of a rapidly progressive rash on his arms, legs, face, and back.
He had a low-grade fever and loose stools for 2 days last week. FOR MORE ON THIS CASE,
TURN TO PAGE 38.
DERMCASE
diagnosis
40
ECZEMA COXSACKIUM
|
J U N E 2 016
IMAGE CREDIT/AUTHOR SUPPLIED
THE CASE
careers
A r i zo n a
idaho
ARIZONA
Great family and golf community. Full-time Pediatrician BC/BE to join
well established Pediatric practice in Tucson, Az. Competitive salary
with excellent benefit package, including bonus compensation.
Send CV to [email protected]
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Outdoor | Direct Mail | Print Advertising
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Live in the
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If adventure is what you are looking for, this is the right place for you!
Idaho’s Treasure Valley offers it all. Hiking, skiing, fishing, whitewater
rafting, and more, all within an hour of our multi-specialty group
based in Nampa. Boise, Idaho’s capital, and largest city is just minutes
away. Saltzer Medical Group, the largest and oldest physician-owned
multi-specialty group in the state of Idaho is seeking a pediatric
physician. A favorable malpractice climate, shareholder status after
three successful years of employment and affordable housing makes
this an ideal practice location. Position is in Nampa, call is 1:5.
Nurse triage services are available for after hours call. A competitive
compensation package with guarantee and incentive is being offered
to the right individual. For immediate consideration, Contact Vicki
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Additional information about our group can be viewed
on our website at www.saltzermed.com.
Reach your target audience.
Our audience.
Contact me today to place your ad.
Joanna Shippoli
Account Manager
440-891-2615
[email protected]
Advertising Index
BAYER
Claritin�� 7
www.claritin.ca
UNILEVER
Dove�� 39
www.dove.us
BEIERSDORF
Eucerin Eczema�� 17
www.eucerinus.com
C B FLEET
Pedia-Lax�� 5
www.pedia-lax.com
J u n e 2 016
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Digital Edition - Contemporary Pediatrics

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