Posted On: May 30, 2012

Surviving the Drowning Season

We’re on the cusp of summer, and, unfortunately, on the brink of the drowning season.

According to the Centers for Disease Control and Prevention (CDC), drowning is a leading cause of death worldwide, and the highest rates are among children. In the U.S., drowning is the leading cause of “injury death” among children ages 1 to 4. At least half of those victims drowned in swimming pools.

Drowning death rates are higher than the rates for all other causes of death in young children except for congenital disorders.

From 2005 to 2009, nearly 6,000 people were treated annually in U.S. emergency rooms for nonfatal misadventures in the water. More than half were children younger than 4, and more than 17 in 100 were children from 5 to 14. (Among people older than 15, more than 1 in 5 water accidents were associated with alcohol use.) Half of all those emergency patients required hospitalization or were transferred to another facility for further care.

To prevent drowning, all parents and children should learn survival swimming skills—the ability to right oneself after falling into water, to swim a short distance and float or tread water. In addition:

  • The swimming environment should be protected by lifeguards, and pools should have fencing on four sides that separates the pool from the house and yard.

  • Avoid consuming alcohol when swimming, boating, water-skiing or supervising children.

  • All boaters and weaker swimmers should wear life jackets.

  • Caregivers/supervisors should be trained in cardiopulmonary resuscitation.

For additional information about drowning risk factors and prevention strategies, visit the CDC’s website about water-related injuries.

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Posted On: May 24, 2012

Kids Join the High Blood Pressure Club

Childhood is generally the time when we begin establishing the bad habits—eating poorly, overeating, being sedentary—that later come back to haunt us in the form of diabetes, heart disease and a higher risk of cancer.

But the American Academy of Pediatrics (AAP) has determined that for youngsters, it’s almost never too early to be screened for high blood pressure.

A large—no pun intended—-part of the concern is that one-third of children and teenagers are overweight or obese. The forecast is grim—as much as half the population, researchers say, could be obese by 2030.

As noted above, obesity invites myriad health problems, including high blood pressure. According to a story on NPR, pediatricians are seeing the roots of these diseases in kids as young as 3.

Diagnosing hypertension (or high blood pressure) in kids is more complicated than for adults. The numbers rendered when the nurse applies the cuff to an adult arm are pretty clear—if they’re higher than 140 over 90, you’re at risk. But those values vary for children according to their age, gender and height.

So doctors must not only measure a child’s blood pressure, but compare it to standards of normalcy for children with the same traits as the patient. What’s normal for an 8-year-old girl isn’t what’s normal for a 15-year-old boy.

Sometimes pediatricians neglect to measure their patients’ blood pressure. The NPR story noted that among children eventually diagnosed with high blood pressure, only about 1 in 4 had it recorded in his or her chart. As a parent, you should insist on this simple, painless procedure.

And even if the notation is made, if the doctor fails to consult the varying standards, a high reading might not be recognized. So after the reading is taken on your child, ask what is deemed normal for a kid like yours. Don’t accept a response such as “he’s fine,” or “there’s nothing to worry about here.” Get the values and ask how they will change as your child grows. This not only reinforces your participation in your children’s care, it models how they should manage their health care as adults.

The risk of not diagnosing high blood pressure early is setting up a child for premature problems. We recently reported about the wisdom of testing children for high cholesterol for the same reasons. People as young as 20 or 30 can suffer a stroke that results from hypertension that might have been recognized sooner.

One estimate counts 2,000 children and teens among people who suffer strokes every year as a result of high blood pressure.

But unlike many adults, children don’t necessarily require medication to control hypertension. Simple lifestyle changes generally bring positive change in their health profile. As usual, reducing high-fat foods and high-sugar drinks, and increasing activity make a big difference. And, because kids have higher metabolism, they’re better at losing weight.

Most high blood pressure in children is found during routine medical exams. According to the AAP, these symptoms also can indicate hypertension:

  • headache;

  • dizziness;

  • shortness of breath;

  • visual disturbances;

  • fatigue.

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Posted On: May 17, 2012

Drug Labels Still Leave Pediatricians Playing a Guessing Game

Nearly 50 years ago, Dr. Harry Shirkey coined the phrase "therapeutic orphan" to describe children who took prescription medicine. Because drug studies among a pediatric population were complicated and offered little financial return for pharmaceutical companies, no one really knew how drugs developed for adults would affect children who took them. Providers prescribed them based on their best guess about how to tailor an adult dose to a child.

In 1997, Congress passed the Food and Drug Administration Modernization Act (FDAMA). It offered incentives for pediatric drug development in the form of additional marketing exclusivity. Progress has been made in drug research among children, and drug labeling for these patients has improved.

But not enough.

According to a recent study published in the Journal of the American Medical Association, (JAMA) not even half of drug labels have information on safety and proper dosing for kids. More than 500 drug labels were evaluated.

According a Reuters story about the new study, drugs still pass the FDA approval process and make it to market without much research on how they should be given to children for the best treatment and least harm.

Pediatric research remains difficult—the number of children with a given disease usually is lower than that of adults, and the ethical concerns are thornier because minors can’t provide informed consent.

The JAMA study looked at hundreds of drugs that treated a range of problems from high blood pressure to allergies.

Labels were deemed “adequate” to use in children if they included how effective the drug is, if it’s safe in younger children and teens and enumerated doses of children of different ages.

Two hundred thirty-one drugs were adequately labeled and 29 others carried dosing for some younger age groups, but not all. Still, slightly more than half of all labels lacked useful pediatric information. Even after tossing the results of drugs that were irrelevant to kids (prostate cancer treatments, for example), 44 in 100 labels offered no information for young patients.

Some newer drugs, those approved by the FDA between 2002 and 2008, also lacked safety and dosing information for kids. But the good news is that drugs commonly prescribed for children—asthma meds and vaccines, for example—often undergo rigorous testing.

Still, kids get cancer, arthritis, and they suffer lung and heart disease; studies on how drugs to treat them react in children often fall by the wayside. And the “how much and at what cost” treatment guessing game continues.

Prescribing medications to children that have not been labeled for them is an off-label use (doctors are allowed to prescribe them, but drug companies may not market them for an unapproved use). That might result in benefit, no therapeutic effect or harm (adverse reactions). (To learn more about medication errors, link here.)

Doctors uncertain about a drug’s effect in a kid might be reluctant to prescribe it off-label, and that could deprive the patient of a real benefit.

If a child receiving an unlabeled drug therapy doesn’t respond well, is that because the drug just didn’t work? Was the dosing incorrect? If there are side effects, do they denote a marker of the drug itself, or of an incorrect dose?

The researchers concluded, “Labeling with pediatric information in only 46 percent of products is still insufficient. Legislation to increase pediatric clinical trials and require the resulting information be added to labeling is necessary. The current legislation expires in 2012 without reauthorization.”

That lapse is not acceptable. Contact your congressional representatives to appeal for completion of a process that has shown benefit but is not finished.

And if your child is prescribed a drug lacking information about appropriate doses for certain age groups, and possible side effects, ask your doctor and pharmacist for more information. If they’re uncertain, because there’s no science to inform them, ask if there are alternative therapies.

Children should not be guinea pigs.

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Posted On: May 10, 2012

Teens Who Develop Diabetes Have a Stark Future

Youth often confers health benefits not available to adults. One example is metabolism—when you’re young, you burn calories faster than when you’ve stopped growing and age (among other factors) imposes a more sedentary existence. Another example is bone regeneration—younger folks build bone better and faster than their elders, and generally are not at risk of osteoporosis, a degenerative bone disorder.

But a new study signals that one dread disorder—diabetes—is as ominous for youngsters as it is for adults. A study and companion editorial in the New England Journal of Medicine made clear that if a teenager develops Type 2 diabetes, he or she will struggle for life to control it.

The problem is obesity. Thanks to poor diet and insufficient exercise, too many teenagers are overweight, concluded the largest federally funded study ever to examine how to treat diabetes in teens. (Earlier studies primarily focused on adults.)

Most diabetes drugs aren't approved for youths. So the key for kids is to prevent the disease, not to treat it.

As a story in the Associated Press pointed out, in earlier generations, doctors seldom saw children with Type 2 diabetes. (Type 1 diabetes, formerly called “juvenile diabetes,” presents earlier, and is attributed to both genetic risk and external factors, such as diet or an infection.)

One-third of U.S. children and teens are overweight or obese. They are at higher risk of developing Type 2 diabetes, in which the body either fails to make enough insulin or to use it efficiently to metabolize sugar from food.

Treatment for Type 2 diabetes usually is metformin, a drug to lower blood sugar. If that doesn’t control the problem, other drugs and daily insulin shots may be required. The risks of long-term blood sugar problems include blindness, nerve damage, kidney failure, limb amputation, heart attack and stroke.

Read more about diabetes and its standards of care here.

The study tested how to manage blood sugar in teens newly diagnosed with diabetes. Half of the nearly 700 subjects failed within a few years; 1 in 5 suffered serious complications.

The study subjects had their blood sugar normalized with metformin, then were given either metformin alone, metformin plus diet and exercise counseling or metformin plus a second drug, Avandia. After nearly four years, half of the metformin-only group failed to maintain blood sugar control. The group on two drugs did a little better, but not much different from those in the lifestyle group.

Because Avandia has been linked to a higher risk of heart attacks in adults (which became known after the study began), it’s not recommended for teens.

The NEJM editorial, by Dr. David Allen, called the study’s message “stark”: “[T]omorrow and beyond, public-policy approaches — sufficient economic incentives to produce and purchase healthy foods and to build safe environments that require physical movement — and not simply the prescription of more and better pills will be necessary to stem the epidemic of Type 2 diabetes and its associated morbidity.”

Yes, the problem is social. But it’s also individual. Parents must establish healthful eating habits early in life, and ensure that their children exercise their bodies as well as their minds. Those are the earliest, easiest and best interventions to prevent the insidious disease that robs so many people of so much, and many of them too soon.

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Posted On: May 4, 2012

Less Radiation Is Good Medicine for Diagnosing Appendicitis

Appendicitis often presents as an emergency, and whether you’re old or young, the belly pain can be extreme. Typically, it’s diagnosed using a CT scan, and a new study indicates that this evaluation should be performed differently for adults and for children.

As published in the New England Journal of Medicine, the research shows that exposure to the radiation in a CT scan is of concern particularly for children and young adults. Such scans can employ different levels of radiation, and it appears that low-dose CT scans are just as effective in diagnosing appendicitis in teens and young adults as standard doses.

Because the effects of radiation exposure can be dire—an increased risk of cancer, primarily—the lower the dose the better. (See our article, “Radiation Overdose Injuries”.) But these lower levels haven’t been accepted widely, according to analysis of the NEJM study by MedPage Today, because of the quality of the images rendered was suspect.

So the researchers conducted a randomized trial of 879 patients ages 15 to 44 suspected of having appendicitis. About half received a low-dose CT scan and half received the standard-dose scan.

About 4 in 10 patients in each group had an appendectomy after the scan. Afterward, it was determined that six patients in each group did not have inflammation, and had undergone the operation unnecessarily.

The difference between the two groups was so negligible that using the low-dose CT instead of the standard dose would have resulted in only one additional unnecessary operation in 330 patients. That risk, researchers noted, is favorably weighed against the potentially higher cancer risk with the standard dose.

"However, it is highly debatable whether the radiation levels used in our two groups can actually induce cancer and whether use of the low dose instead of the standard dose can actually reduce the carcinogenic risk," they added.

The rate of perforated appendix, which indicates that the diagnosis was delayed, also was similar between the two dosage groups.

The welcome performance of the lower dose scan was attributed to superior imaging capability of modern equipment and the fact that it’s fairly simple to interpret CT images of an appendix.

Cells that divide rapidly are more susceptible to cancer. Because the active growth of children signifies rapid cell turnover; because gastrointestinal tract cells continually turn over; and because children have a longer life span and are therefore more vulnerable to all forms of radiation exposure for a longer period, it just makes sense to limit their radiation exposure when you can.

If your child’s doctor prescribes a CT scan to diagnose possible appendicitis, request a low-dose procedure. And if it’s prescribed for other diagnostic reasons, discuss the options. Sometimes, care providers embrace the more-is-more solution out of habit, and that’s not always the best medicine.

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