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Maternal Child Health ‹ Child Health Notes ‹ April 09
IHS Child Health Notes"It doesn’t matter if the cat is black or white as long as it catches mice." - Deng Hsaio P’ing 1904-1997 This is a page for sharing "what works" as seen in the published literature as well as what is done at sites that care for American Indian/Alaskan Native children. If you have any suggestions, comments or questions please contact Steve Holve, MD, Chief Clinical Consultant in Pediatrics at steve.holve@tchealth.org April 2009Quote of the month"We believe that the death of a child is a tragedy, but the death
of a child from a preventable cause is an injustice." Articles of Interest A short course of oral prednisolone is widely used to treat preschool children with viral induced wheezing but evidence is contradictory if this is effective. The authors conducted a randomized controlled clinical trial of a five day course of oral prednisolone for children ages 10 months to 6 years with wheezing associated with a viral URI. There was no significant difference in hospitalization, respiratory symptom scores, albuterol use or symptoms at 7 days. Preemptive use of high-dose fluticasone for virus-induced wheezing in young
children The authors examined the utility and safety of high dose pre-emptive fluticasone in reducing the severity of recurrent wheezing in preschool children. This was a randomized controlled trial using fluticasone 750ug BID versus placebo at the onset of URI symptoms and continued for a maximum of 10 days. The use of high dose fluticasone decreased the use of rescue oral corticosteroids versus the placebo group (8% compared to 18%) a 50% reduction. However, the fluticasone group had smaller mean gains in height over 1 year though there was no difference in basal cortisol levels or bone density. Editorial Comment Preschool children get 6 – 10 URIs each year and 30% of preschool children will wheeze with intercurrent viral illnesses. While the disease is usually mild and self-limited viral induced wheezing creates much distress for parents and children and the use of considerable medical resources. The treatment for viral induced wheezing has been the same as that used for asthma. Even in the face of evidence that shows that such treatments have little effect most physicians use inhaled bronchodilators and oral steroids for all patients with viral induced wheezing in the hope that there is a subgroup with atopic disease that will benefit. At present our ability to predict which wheezing preschoolers have atopic disease is poor. What should we do for children who wheeze only with colds? Inhaled bronchodilators may be of benefit. Oral steroids are best reserved for those ill enough to be hospitalized or those with atopic disease. The use of leukotriene antagonists and inhaled corticosteroids requires further study. At present the side effects of high dose fluticasone appear to outweigh the small benefits and can not be routinely recommended. Infectious Disease Updates Reason starts to prevail in the “Vaccines and Autism Debate” Two occurrences in the past 3 weeks suggest that reasonable people are beginning to prevail in the unsubstantiated claim that vaccines cause autism. In February, the US Court on Federal Claims in the Omnibus Autism Proceeding found that there was no association between vaccines and autism. The following website contains a review of this decision: http://www.cdc.gov/Features/AutismDecision/ The March 2, 2009 edition of NEWSWEEK Magazine contained a balanced article, “Anatomy of a Scare” that outlines the unscientific bias in the Wakefield 1998 Lancet article that claim that measles vaccine virus infected the guts of children and leaked neurotoxic compounds into the brain leading to autism. Most providers aren’t aware of the rest of the Wakefield story: 10 of the 13 original authors retracted the article’s conclusion, Wakefield’s financial incentive has come into scrutiny and every study conducted to test Wakefield’s MMR hypothesis has found “no evidence that MMR vaccination is associated with autism”. The article can be read online at http://www.newseek.com/id/185853/output/print Hopefully this ruling and article will help to turn the tide of negative press about vaccines. In 2008, parental refusal of vaccines resulted in the largest number of measles cases in the US, 131 cases, in 15 years. Recent literature on American Indian/Alaskan Native Health Kvigne VL, Leonardson GR, Borzelleca J, Neff-Smith M, Welty TK. Characteristics
of children whose siblings have fetal alcohol syndrome or incomplete fetal alcohol
syndrome. Pediatrics. 2009 Mar;123(3):e526-33. Fetal alcohol syndrome (FAS) continues to be a prevalent, and preventable cause of mental retardation in the United States. Rates of FAS are higher among American Indians and Alaska Natives than the general population. The prevalence of FAS in native populations is well above other ethnicities. Rates of FAS range from 9.8 per 1,000 live births among southwestern Indians, to 5.6 per 1,000 in Alaska, and 2.5 per 1,000 in Arizona.1 In the Northern Plains American Indians, the prevalence of FAS was estimated at 8.5 children per 1000 live births in 1993.2 Among American Indian and Alaska Native populations, FAS is a common diagnosis. In this study, the authors conducted two retrospective case control studies of Northern Plains Native American Children with FAS and incomplete FAS to characterize children born before and after a child diagnosed with FAS or incomplete FAS. The aim of the study was to define factors or characteristics in older siblings of FAS children that might predict FAS in subsequent children. The results of the study show that siblings born just before children with FAS and incomplete FAS had more facial dysmorphology, growth delay, central nervous system impairment, maternal alcohol history, prenatal alcohol exposure, and were more often diagnosed with FAS by physicians compared to controls. Both sibling groups born just after children with FAS and incomplete FAS had more facial dysmorphology, growth delay, and central nervous system impairment than the control siblings as well. On average before and after siblings of a child with FAS met 2.0 FAS criteria while before and after siblings of a child with incomplete FAS met 1.2 FAS criteria. Before siblings of a child with FAS had significantly greater growth delay than before siblings of a child with incomplete FAS and controls. Maternal alcohol use during pregnancy decreased in mothers with children with FAS and incomplete FAS. 64.1% of mothers of children with FAS used alcohol in the before sibling pregnancy while 46.7% of mothers of children with incomplete FAS used alcohol in the before sibling pregnancy. The percentages of mothers using alcohol during after sibling pregnancies reduced in both groups (45% of mothers with children with FAS and 40.9% of mothers with children with incomplete FAS). This study is not without limitations. This is a retrospective chart review study in which mothers were not interviewed and children were not examined. In defining predictive factors or characteristics of children with FAS, authors had to rely on provider documentation in the medical record. Because the before siblings had certain identifiable characteristics of FAS, the authors concluded that predicting subsequent FAS at risk pregnancies is possible. The authors recommended that medical providers receive additional training to recognize features of Fetal Alcohol Spectrum Disorders and that they ‘screen and intervene with all pregnant women who drink alcohol during pregnancy.” References:
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