Agave Syrup, Placebo, Both Better Than Nothing for Kids' Cough

By Anne Harding

October 28, 2014

NEW YORK (Reuters Health) - Agave nectar - or placebo - are better than nothing for nighttime coughs in infants and toddlers, according to new findings published online October 27 in JAMA Pediatrics.

"For a condition that we don't have any other good treatment, especially for babies under age one, placebo seems to make a difference, and if there's a safe alternative that could make parents feel better and perhaps reduce unnecessary antibiotic prescribing that's something to consider," Dr. Ian Paul of Penn State College of Medicine in Hershey, the first author of the study, told Reuters Health in a telephone interview.

The US Food and Drug Administration has warned against the use of over-the-counter cough and cold medicines in children younger than 2, based on safety concerns and the fact that there is no proof of their efficacy, the researchers note in their report.

In 2007, Dr. Paul and his colleagues showed that honey was more effective than dextromethorphan or no treatment for nocturnal cough and sleep problems related to upper respiratory tract infection. However, they note, children younger than a year old should not be given honey, due to the risk of botulism.

Agave nectar has similar properties to honey, but with no known botulism risk, the researchers add. To investigate whether it might be helpful for treating cough, the researchers randomly assigned 125 children 2 to 47 months old presenting with non-specific cough for seven days or less to a dose of agave nectar, placebo, or no treatment 30 minutes before bedtime.

Parents completed a survey about their child's symptoms the night before the child enrolled in the study, and then on the subsequent night when the child was given agave, placebo or no treatment.

In each study group, the researchers found, parents rated all symptoms significantly improved in the second survey. For each symptom, improvements in the agave group and the placebo group were significantly better than for the no treatment group, aside from cough bothersomeness.

The researchers used pasteurized agave nectar with natural grape flavoring from Zarbee's, Inc., while the placebo consisted of grape-flavored water with caramel coloring.

"You can get plain agave nectar at pretty much every supermarket now," Dr. Paul said. "What made me think to try it in our study was I saw it in the supermarket."

Based on the findings, he added, pediatricians can think about advising parents to try agave nectar for children with cough. "It's something they can consider, as an alternative to telling parents to do nothing." The treatment "appears harmless," Dr. Paul said, and may make both parents and babies feel better.

Up to 38% of visits to primary care pediatricians by children one to five years old involve cough and cold, Dr. James A. Taylor and Dr. Douglas J. Opel of the University of Washington in Seattle note in an editorial accompanying the study. "These can be frustrating encounters for health care professionals because of the perception that the clinician has nothing to offer beyond reassurance," they add.

"If a placebo is of low cost, has no or minimal adverse effects, and the parent or patient is not deceived about the nature of the treatment," they write, "it seems largely irrelevant whether or not the benefit from a clinical encounter is because of a clinician's recommendation for the use of an evidence-based treatment or from a placebo effect."

They conclude: "As investigators such as Paul and colleagues continue to evaluate pharmacologic treatments, perhaps we should also conduct research designed to identify other components of care (e.g., communication techniques and nonspecific treatments) that improve outcomes after visits to clinicians by children with cold symptoms, even if the improvement is simply caused by a placebo effect, as broadly characterized."

AAP Updates Guidelines on Bronchiolitis in Young Children

Laurie Barclay, MD

October 27, 2014

Management of bronchiolitis in children aged 1 to 23 months no longer requires testing for specific viruses or a trial dose of a bronchodilator, according to new guidelines issued by the American Academy of Pediatrics (AAP) and published online October 27 in Pediatrics.

According to a comprehensive evidence review, the new AAP guideline on diagnosing, treating, and preventing bronchiolitis updates their previous recommendations published in 2006. It targets pediatricians, family physicians, emergency medicine specialists, hospitalists, nurse practitioners, and physician assistants who care for children.

Bronchiolitis is the most common cause of hospitalization among infants younger than 1 year. The new guideline emphasizes that only supportive care, including oxygen and hydration, is strongly recommended for young children with bronchiolitis.

"Bronchiolitis is a disorder commonly caused by viral lower respiratory tract infection in infants," write Shawn L. Ralston, MD, and colleagues from the AAP. "Bronchiolitis is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, and increased mucus production. Signs and symptoms typically begin with rhinitis and cough, which may progress to tachypnea, wheezing, rales, use of accessory muscles, and/or nasal flaring."

Changes from the 2006 guideline include that testing for specific viruses is no longer needed, because multiple viruses may cause bronchiolitis. Routine radiographic or laboratory studies are also unnecessary, and clinicians should diagnose bronchiolitis and assess its severity on the basis of history and physical examination.

The AAP also no longer recommends a trial dose of a bronchodilator, such as albuterol or salbutamol, because evidence to date shows that bronchodilators are ineffective in changing the course of bronchiolitis (evidence quality: B, strong recommendation). In addition, in accordance with a policy statement published in July by the AAP, the new guideline updates recommendations for use of palivizumab to prevent respiratory syncytial virus infections: Otherwise-healthy infants with gestational age of 29 weeks or more should not receive palivizumab, but during the first year of life, infants with hemodynamically significant heart disease or chronic lung disease of prematurity should receive palivizumab (maximum of 5 monthly doses, 15 mg/kg per dose, during the respiratory syncytial virus season).

Other recommendations include that when making decisions about the assessment and management of children with bronchiolitis, clinicians should evaluate risk factors for severe disease, such as age less than 12 weeks, prematurity, underlying cardiopulmonary disease, or immunodeficiency. Finally, clinicians should not give epinephrine to infants and children diagnosed with bronchiolitis, nor should they receive chest physiotherapy.

Behavioral Treatment for Tics: A Novel Approach

Rebecca Bitsko, PhD

November 03, 2014

Tourette syndrome is a neurologic condition that often presents in childhood and is characterized by motor and vocal tics that can be simple or complex, and can range from mild to severe. CDC recently published a profile of Tourette syndrome among US children in the Journal of Developmental and Behavioral Pediatrics. ^[1] Based on parent-reported data from the 2011-2012 National Survey of Children's Health, we found that 1 in 360 children had ever been diagnosed with Tourette syndrome, which is similar to estimates from 2007. Compared with children without Tourette syndrome, children with this condition were three times more likely to have co-occurring neurobehavioral conditions such as attention-deficit/hyperactivity disorder and were two times more likely to have unmet mental healthcare needs. Their parents reported more parenting aggravation and were more likely to be contacted about school problems. Parents also reported having difficulty coordinating the care they needed for their child with Tourette syndrome. This is further evidence that living with Tourette syndrome can affect a person's health, education, family relationships, and well-being.

Until recently, medication was the only option for those with Tourette syndrome who needed treatment to manage their symptoms. However, medication doesn't always work, and side effects can discourage compliance with medication treatment. The good news is that a new behavioral treatment has recently been developed, called comprehensive behavioral intervention for tics (CBIT).

Like other behavioral therapies, CBIT works by teaching people with Tourette syndrome a step-by-step process to become aware of their behavior (in this case, tics), learn how to change that behavior, and identify factors or situations that exacerbate their tics. During CBIT, therapists help patients increase their awareness of tics and their urge to tic, and then to perform a "competing response," which is a behavior incompatible with the tic. For example, a competing response for a head-shaking tic could be gently tensing neck muscles. Practicing the competing response over time can help reduce or even eliminate the tic. This part of CBIT is known as habit reversal therapy.

In addition to habit reversal, in CBIT, the therapist will help the patient identify and address factors that might make tics worse—for example, stress or fatigue, or certain activities such as homework or public speaking. They will help the individual identify strategies to address the factors that are within the person's control—for example, stress relief exercises, or getting more rest.

Two randomized controlled trials^[2,3] have shown that CBIT is effective for children and adults with Tourette syndrome. More than half of the children treated with CBIT had significantly less severe tics and had better measures of functioning. Among adults, 38% were much improved or very improved. And a recent meta-analysis^[4]showed the effectiveness of habit reversal and CBIT overall for treating tics. These studies also show that CBIT does not work for everyone. Although more research is needed to determine when CBIT works best, and for whom, CBIT is a promising and novel approach to help people manage their tics.

Because CBIT is a relatively new treatment, health professionals are still learning about it. To educate professionals, CDC has partnered with the national Tourette Syndrome Association to provide the necessary training, and also to make sure that people with Tourette syndrome and their families know about CBIT as a treatment option.

I invite you to take a look at the listed Web resources for additional information about Tourette syndrome and CBIT so you can learn more about this treatment option for your patients and their families.

Web Resources

CDC Tourette Syndrome

CDC Key Findings: A National Profile of Tourette Syndrome

Tourette Syndrome: New Treatment Option

Tourette Syndrome Association

Smartphones and TVs in the Bedroom -- What's the Harm?

William T. Basco, Jr, MD, MS

February 13, 2015

Sleep Duration, Restfulness, and Screens in the Sleep Environment

Falbe J, Davison KK, Franckle RL, et al

Pediatrics. 2015;135:e367-e375

Study Summary

The presence of a television in a child's bedroom can have detrimental effects on sleep quality and duration. However, relatively few studies have assessed the potential detrimental effects of smaller screens, such as those on handheld devices. In addition to the light from screens and the potential alterations of sleep cues that might be induced by the light, handheld devices or tablets can also alarm with emails or texts, potentially creating even more sleep disruption.

This study assessed seventh- and fourth-grade children in public schools in Massachusetts to correlate nocturnal screen use with perceived sleep sufficiency. The data were collected in 2012 as part of a statewide obesity research effort. There were two primary outcomes of interest. One was the children's weeknight sleep duration. The second outcome was a measure of whether the children perceived that they had received sufficient sleep during the previous week. Sleep duration was calculated by subtracting the child's usual weeknight bedtime from reported usual weekday awakening times. Sleep adequacy was assessed by asking the students about how many days in the past week they felt that they needed more sleep. This response was dichotomized into those who indicated that they needed more sleep on 3 or fewer days per week (sufficient sleep) vs those who needed more sleep on 4 or more days per week (insufficient sleep).

The students were asked how often they slept with a device near their bed, and they again responded with the number of days per week. They also indicated whether they had a TV in the room. Analyses accounted for sex, grade in school, race/ethnicity, and reported physical activity. Complete data were provided by 2000 students (mean age: 10.6 years; 40% Hispanic, 38% non-Hispanic white, 10% non-Hispanic black). Slightly more than half (54%) of the students reported sleeping near small screens, and 75% slept in a room with a television. When looking at differences by grade, 65% of the seventh graders slept near a small screen compared with 46% of fourth graders. The seventh graders reported a mean sleep time of 8.8 hours compared with 9.8 hours for the fourth graders. Children who slept near a small screen averaged 20.6 fewer minutes of sleep per night (95% confidence interval, 29.9-11.4) compared with those who did not sleep near a small screen. A similar association was seen in children who slept with a television in the room.

The differences in sleep among the groups were mainly accounted for by a delay of bedtime. When looking at the effects on perceived sufficiency of sleep, the prevalence ratio for sleeping near a small screen was 1.38, indicating that the presence of a small screen was associated with a higher prevalence of reporting insufficient sleep. Demographic variables did not generally correlate with reports of insufficient sleep. Even among those exposed to small screens, the duration of screen time was associated with a greater prevalence ratio of reporting insufficient sleep. The investigators concluded that sleeping in proximity to a small screen, having a television in the bedroom, and longer duration of screen time were all associated with shorter sleep durations. Presence of a small screen (but not a TV) and longer screen time were associated with perceived insufficiency of sleep.

Viewpoint

This is one of those studies that strikes me as having findings that one might fully expect, but seeing them in print really underscores the magnitude of the problem. Although pediatric clinicians are used to asking about televisions at night and associated problems of sleep latency, I wonder how many of us are attuned to also asking about small screens and the myriad disruptions that they might bring. Although sleep duration and perceived quality of sleep in this study are self-reported, I don't think it's too much of a stretch to presume that these findings would hold if we had objective measures of sleep duration and quality. So, remember these data when evaluating sleep hygiene and remember to ask about bedtime small-screen use, particularly among teenagers.

Babies' Eyes Offer Clues to Autism Resilience

Pam Harrison

May 22, 2014

ATLANTA ― A subgroup of infants who have siblings who develop autism spectrum disorder (ASD) show milder declines in early eye-looking patterns that begin to self-correct at approximately 9 months of age, new research shows.

By 18 months of age, this same group of infants has more typical development profiles than their siblings who are later diagnosed with ASD who have declines in eye-looking patterns that begin in the first 6 months of life.

Findings from the current study may reveal a pathway to sibling resilience against developing ASD to which they are otherwise greatly predisposed.

"The important take-away from this study is that for unaffected siblings as well as typically developing infants, there is no difference in levels of eye-looking and no difference in the developmental transitions that happen over time," study investigator Warren Jones, PhD, director of research, Marcus Autism Center, Children's Healthcare of Atlanta, and assistant professor of pediatrics, Emory University School of Medicine, Atlanta, Georgia, said a press conference here at the 13th Annual International Meeting for Autism Research (IMFAR).

"What really excited us, however, is the difference we observed in the developmental profiles of infants who were later diagnosed with autism relative to those infants who show some symptoms of atypical social development but who do not meet full diagnostic criteria for ASD. These infants have vulnerabilities, but the vulnerabilities are not so concerning as to warrant diagnosis, and [it is] these infants who have a more positive prognosis than infants later diagnosed with autism," Dr. Jones added.

Earlier Study

In an earlier 2013 study published in Nature and reported by Medscape Medical News at that time, Dr. Jones and colleague Ami Klin, PhD, who is also with Emory University School of Medicine, compared eye-tracking "growth charts" of social visual engagement in infants at high risk for ASD and typically developing infants. Some 13 infants were diagnosed with ASD at 36 months of age; 29 were typically developing infants.

At 10 different time points between 2 and 24 months of age, researchers measured the infants' eye movements as the children watched video scenes of a caregiver.

Researchers then calculated the percentage of time each child fixated on the caregiver's eyes, mouth, and body as well as on the nonhuman spaces in the images.

"Long before infants can crawl or walk, they explore the world by looking at it," Dr. Jones said. "And infants later diagnosed with autism exhibited a steady decline in eye-looking from the second month of life until month 24."

Importantly, decline in eye fixation in the first 6 months of life in this earlier study predicted the diagnosis of ASD at the ages of 24 and 36 months. Decline in eye fixation in the first 12 months of life also predicted the child's level of disability at the ages of 24 and 36 months, as Dr. Jones added.

For this study, researchers asked the question, What separates those infants who are later diagnosed with autism from the ones who have "shadow" ASD, otherwise referred to as broader autism phenotype, or BAP, but who do not meet full ASD criteria later on in life?

The group of interest for the current analysis included 18 infants who were unaffected by ASD at 36 months and 10 infants who had BAP. Investigators then divided this subgroup of infants on the basis of early decline in eye fixation or the absence of such decline.

Sixteen infants in the overall subgroup had no sign of early decline in eye fixation, and 15 out of this subgroup were clinically unaffected at follow-up. One infant was, however, identified as having BAP.

Another 12 infants out of the overall subgroup did show signs of early decline in eye fixation, and 9 of these infants were identified at follow-up as having BAP; 3 remained clinically unaffected.

It was in these 9 infants in whom eye fixation, though initially in decline, changed course and among whom investigators documented positive increases in time spent fixing on other people's eyes at 18 months of age.

These results suggest an early loss of traction in social engagement for infants who show more resilient outcomes ― a "slippage of the disks," as Dr. Jones noted, but then this subgroup catches up, and there is overt evidence of a developing change in behavior.

"Eye-looking is neither causing nor correcting autism, it's a marker: a manifestation of the derailment of typical social development [that occurs in ASD]," Dr. Jones told Medscape Medical News. "What's exciting about these new findings is that we're tracking the way in which some infants change their behavior and ultimately end up with more social skills than their affected siblings. We need to understand the underlying neurobiology that accompanies these changes in early development, and being able to observe and quantify these differences is the first step."

Seminal Research

Asked by Medscape Medical News to comment on the clinical relevance of the findings, Laura Klinger, PhD, University of North Carolina TEACCH Autism Program, Chapel Hill, said this represented "very seminal research" in that it showed 2 groups of children who look identical at 2 months, yet one group goes on to develop autism and the other group shows resiliency and does not.

"This is truly one of the first datasets we've had where we see differences at 2 months, where one group ends up correcting and not having atypical behaviors later on in life, whereas the other group does not," she added.

What would be helpful, as Dr. Klinger suggested, is to target these 2 groups of infants with atypical eye-tracking behavior to see whether interventions might be able to move more of them into a typical pattern as early as the first year of life.

"We know that early intervention in the first few years of life makes a significant difference on long-term outcomes for individuals with autism," Dr. Klinger noted. "So researchers around the globe have been looking at whether we can identify early signs of autism in the first year of life to promote earlier and earlier intervention. That is one of the main themes of this year's meeting at IMFAR, and it's an important one to explore."

The study was funded by the National Institute of Mental Health, the Simons Foundation, the Marcus Foundation, and the Whitehead Foundation. The investigators have disclosed no relevant financial relationships.

13th Annual International Meeting for Autism Research (IMFAR). Abstract 145.002. Presented May 16, 2014.

Early Repetitive Behaviors Reliably Predict Autism

Pam Harrison

May 22, 2014

ATLANTA ― Multiple repetitive behaviors observed in infants at 12 months of age are associated with a highly significant risk for a diagnosis of autism spectrum disorder (ASD) at the age of 2 years, new research shows. 

Investigators at the University of North Carolina in Chapel Hill found that infants with 3 or more types of repetitive behavior at 12 months of age were 4 times more likely to meet diagnostic criteria for ASD at age 2 years compared with low-risk infants and, importantly, high-risk infants who were not diagnosed with ASD at 2 years of age. 

Infants who were diagnosed with ASD at 24 months also not only had higher levels of motor movements at 12 months but had higher levels of self-injurious behavior, higher levels of insistence on sameness, and higher levels of a requirement to engage in complex routines.

"Even our best clinicians are only able to diagnose autism reliability at around 18 months, so 12 months of age is really pushing the lower limit of what we can currently do," lead investigator Jason Wolff, PhD, assistant professor of psychiatry, said in a press conference.

"And it's not an onerous task for parents, it's the kind of behavior parents are able to observe and report on, so it gives us great hope in terms of thinking about next steps and how we might improve our screening tools to assess for autism risk in a very young child."

The study was presented here at the 13th Annual International Meeting for Autism Research.

Red Flag

In partnership with colleagues from the National Institutes of Health–funded Infant Brain Imaging Study, Dr. Wolff and colleagues followed 184 toddlers at high risk for ASD and 59 low-risk control infants out to 24 months of age.

Parents were asked to document the presence of different types of repetitive behavior at 12 and 24 months of age.

Behaviors included stereotypical motor behaviors (hand and arm flapping); self-injurious behaviors; compulsive behaviors (in which things have to be done in a certain order); ritualistic behaviors (toys lined up in a certain way, eating only certain colored foods at mealtime), and restrictive behavior (limited activities of interest).

Children who were diagnosed with autism averaged between 4 and 8 types of repetitive parent-reported behaviors at 12 months, Dr. Wolff told Medscape Medical News.

In contrast, infants with the same high risk of developing ASD who were not diagnosed with the disorder at 24 months as well as low-risk infants had only 1 or 2 parent-reported repetitive behaviors.

Differences between the groups also became more pronounced with age so that by the time infants were 24 months of age, "there was an even bigger gap between groups," he added.

Furthermore, having more repetitive behaviors at the age of 12 months significantly predicted how severe the child's social deficits were at the age of 24 months — "and the more repetitive behaviors they had, the less adept a child would be in engaging in social interaction," said Dr. Wolff.

Unlike other studies, repetitive behaviors in this study were not related to general cognitive ability in this sample of toddlers.

"There's always going to be some repetitive behavior in infants and toddlers, it's part of how a child negotiates with their environment and become more goal-directed in their behavior," Dr. Wolff said. "But there's a level where you see too much repetitive behavior, and it becomes a possible red flag for developing autism. And if we can do a good job of identifying and screening those children who exhibit a high-risk level of repetitive behavior early on and get that child outside of their locked patterns of behavior, we may be able to improve outcomes."

Potential for Earlier Diagnosis

Asked to comment on the study, Laura Klinger, PhD, University of North Carolina TEACCH Autism Program, Chapel Hill, told Medscape Medical News that this is another study showing that recognition of early symptoms of ASD could lead to earlier diagnosis and hopefully improved outcomes in these children.

"We know that most patients approach their family practitioner by around 18 months to say that they think there is something not quite right with their child's development," she said.

"So parents have concerns and have historically asked physicians for guidance, and I think that some of the tools we discussed at this year's conference give us a way to measure and see what is developing atypically in these young children."

Dr. Klinger also said that it is also difficult for clinicians to recognize whether the presence of repetitive behaviors are typical or atypical because young children normally engage in all sorts of repetitive behaviors, including wanting to watch a movie over and over again or jumping up and down with their hands flapping when they get excited.

"Those are very normal behaviors," she emphasized. "But what we see from this study when we have problems with ASD is that parents see so much more of these behaviors, so it's the amount that is different, not the behavior itself."

Dr. Wolff and Dr. Klinger have disclosed no relevant financial relationships.

13th Annual International Meeting for Autism Research (IMFAR). Abstract 169.006. Presented May 17, 2014.

 

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