Celiac Disease Screening Should Focus on Kids With IBS

Marcia Frellick

April 21, 2014

Children with irritable bowel syndrome (IBS) were 4 times more likely to have celiac disease than the general pediatric population, researchers report in a study published online April 21 in JAMA Pediatrics. According to the findings from the prospective study, screening should focus on children with IBS instead of generally among children reporting recurrent abdominal pain, the authors advise.

Previous studies of adults have shown a strong link between celiac disease and IBS, but few data were available on children.

Fernanda Cristofori, MD, from the University of Bari, Italy, and colleagues note that recurrent abdominal pain affects 10% to 15% of school-aged children and accounts for more than 50% of the consultations in pediatric gastroenterology and 2% to 4% of all general pediatric office visits.

To estimate the prevalence of celiac disease in children with recurrent abdominal pain, the researchers tested 782 children who presented with abdominal, pain-related disorders: 270 with IBS, 201 with functional dyspepsia, and 311 with functional abdominal pain.

The prospective observational study was conducted between 2006 and 2012 at the university hospital of Bari, which is the tertiary referral center for gastrointestinal disorders in the region. The researchers used serum tests for immunoglobulin A, immunoglobulin A antitissue transglutaminase, and endomysial antibodies as an initial screen for celiac disease and confirmed the diagnosis with upper endoscopy, including multiple duodenal biopsies.

Fifteen patients tested positive for celiac: 12 (4.4%; 95% confidence interval [CI], 2.5% - 7.6%) of the children with IBS, 2 (1.0%; 95% CI, 0.2% - 3.5%) of those with functional dyspepsia, and 1 (0.3%; 95% CI, 0.1% - 1.7%) of the children with functional abdominal pain.

"The identification of IBS as a high-risk condition for celiac disease might be of help in pediatric primary care because it might have become routine to test for celiac disease indiscriminately in all children with recurrent abdominal pain, although our finding suggests that the screening should be extended only to those with IBS," the authors write.

In an accompanying editorial, James E. Squires, MD, from the Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center in Ohio, and colleagues write: "Based on the study by Cristofori et al, we suggest that selective screening for celiac disease is warranted for children with IBS but not for children with other [functional gastrointestinal disorders (FGIDs)]. However, the lines distinguishing IBS from alternative FGIDs are often blurred."

Noting that the blood tests have a relatively high false-positive rate in the general pediatric population, the researchers recommend that pediatricians weigh the possible benefits against the risks, including endoscopy, and consider environmental factors in decisions to screen.

This study was sponsored by the Commonwealth Fund and Aetna. The authors have disclosed no relevant financial relationships.

Breast-fed Newborns: How Much Weight Loss Is Normal?

Diedtra Henderson

December 01, 2014

Exclusively breast-fed newborns typically lost as much as 10% or more of their birth weight before beginning to gain again in the first days after birth, according to a recent study. By 48 hours, almost 5% of babies born vaginally and 10% of those born by cesarean delivery lost at least 10% of their birth weight. By 72 hours, 25% of cesarean delivered infants lost at least 10% of their birth weight. These metrics may help identify babies with steeper weight loss trajectories that could increase morbidity risk.

Valerie J. Flaherman, MD, MPH, from the Department of Pediatrics and the Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, and colleagues report the findings of their study in an article published online December 1 in Pediatrics.

According to the authors, 60% of newborns in the United States are breast-fed exclusively in the first 2 days after birth, in keeping with recommendations from a number of expert organizations, including the American Academy of Pediatrics. Most of those infants lose weight daily, but a small number of infants suffer complications from excessive weight loss, including hyperbilirubinemia and dehydration.

"These results provide the first graphical depiction of hourly weight loss for exclusively breastfed newborns from a large, diverse population," Dr Flaherman and coauthors write. "Because weight changes steadily throughout the birth hospitalization and is measured at varied intervals from the hour of birth, these new nomograms should substantially aid medical management by allowing clinicians and lactation support providers to categorize newborn weight loss and calibrate decision-making to reflect hour of age."

The authors note that hour-by-hour bilirubin levels, tracked to guard against jaundice, have been incorporated into practice guidelines. To provide a similar type of nomogram for neonate weight loss in exclusively breast-fed newborns, Dr Flaherman and coauthors studied data from 108,907 newborns born at 36 weeks' gestation at Northern California Kaiser Permanente hospitals from January 1, 2009, through December 31, 2013.

Some 83,433 (76.6%) of the neonates were delivered vaginally, whereas 25,474 (23.4%) were born by cesarean delivery. For the 97.3% of mothers who had race or ethnicity noted, 43% were white non-Hispanic, 24% were Hispanic, 24% were Asian, and 7% were black non-Hispanic.

The researchers excluded infants who had received level 2 or 3 care and infants whose steep weight gain or loss was "implausible." Because infants delivered vaginally are hospitalized for shorter periods, they determined weight loss percentile from 6 to 72 hours compared with 6 to 96 hours for cesarean births.

Weight loss differences by delivery type were clear within 24 hours of birth, the authors write. Neonates delivered vaginally experienced a median weight loss of 4.2%, 7.1%, and 6.4%, respectively, at 24, 48, and 72 hours of age. That compared with median weight loss among infants born by cesarean delivery of 4.9%, 8.0%, 8.6%, and 5.8%, respectively, at 24, 48, 72, and 96 hours after delivery.

In an accompanying editorial, James A. Taylor, MD, and Elizabeth A. Simpson, MD, applauded the researchers for their "elegant methodology" and for providing "much needed data" to help provide instruction to the 79% of mothers who now breast-feed and to clinicians managing complications.

"With the nomograms, clinicians can plot the percent weight loss for a neonate at a specific age and determine, with precision, whether this percentage is normal for a breastfed newborn (eg, at the 50th percentile) or excessive (eg, ≥95th percentile). Although these assessments have been done informally for many years in newborn nurseries, the new nomograms provide much-needed rigor," the editorialists write.

Dr Taylor, from the University of Washington Department of Pediatrics, Seattle, and Dr Simpson, from the Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri, call the weight loss seen among infants delivered by cesarean "jarring" but suggest that infants delivered vaginally also continued to shed weight postdischarge, when weight loss data were not collected systematically. Although they call the project a good first step, they call for strengthening the evidence base by using the nomograms "to characterize weight loss in a group of newborns and link specific patterns of weight loss with relevant outcomes."

Dr Flaherman and colleagues conclude by saying their "curves demonstrate that expected weight loss differs substantially by method of delivery and that this difference persists over time. Our results also show that weight loss ≥10% of birth weight is common and often occurs earlier in the postnatal course than previously documented."

Financial support for the study was provided by the Department of Health and Human Services and the National Institutes of Health. The study authors and the commentators have disclosed no relevant financial relationships.

Pediatrics. Published online December 1, 2014.

 

Medscape Medical News © 2014  WebMD, LLC 

Sodium Intake Tied to Obesity Among Teens

By Shereen Jegtvig

February 05, 2014

NEW YORK (Reuters Health) - Teenagers who eat a high-sodium diet tend to be heavier and have more body fat than those who eat less salt, according to a new study.

Researchers found that was the case regardless of how much total food teenagers ate or how often they drank sugary beverages.

Dietary sodium has been linked to obesity in previous studies. But most scientists believe it's only an indirect association, because people who consume a lot of sodium tend to eat more food in general.

"Our study and studies looking into national data all show that average dietary sodium consumed is 3,300-3,400 milligrams daily in children, as high as that of adults," Dr. Haidong Zhu told Reuters Health in an email. She led the new study at Georgia Regents University in Augusta.

The American Heart Association recommends that everyone keep sodium intake to less than 1,500 mg per day, but 90 percent of children exceed that amount, Zhu noted.

For their study, she and her colleagues measured the body composition of 766 healthy 14- to 18-year-olds. About half of the teens were African American and the other half were white.

The researchers also collected diet information from the participants by asking them to remember everything they had eaten in the past 24 hours up to seven different times over a few months. On average, the teens consumed about 3,280 mg of sodium every day.

Kids who ate more sodium tended to be heavier. Those in the top third of sodium intake weighed approximately four pounds more than those in the bottom third, on average - about 149 pounds versus 145 pounds.

Teens with a high-sodium diet also generally had a higher percentage of body fat and showed more signs of body-wide inflammation.

Those associations held up when the researchers took into account teens' physical activity levels as well as how much food they ate and how many sugar-sweetened beverages they drank, according to the findings published February 3 in Pediatrics.

Although the study links sodium intake to inflammation and weight regardless of calories and soft drink consumption, Zhu said, it doesn't explain why.

"Animal studies suggest that diets high in salt promote fat cells to grow bigger," Zhu said.

She added that high-salt diets might stimulate the brain's reward and pleasure center, which increases the chance of overeating and obesity.

"More research in humans is needed," Zhu said.

"This study suggests that limiting sodium intake will help reduce obesity - we already know that limiting sodium intake helps reduce high blood pressure," Dr. Elliott Antman told Reuters Health in an email.

"It reinforces the fact that our population - children and adults - consumes too much sodium in the course of a day," he added.

Antman is a cardiologist at Brigham and Women's Hospital in Boston and president-elect of the American Heart Association. He was not involved in the new study.

He commended the authors for enrolling a large number of African-American adolescents. African Americans tend to have higher risk of obesity, type 2 diabetes and high blood pressure than the general population.

Antman advised parents to be careful about how much sodium their children are getting.

"Taste preferences for salt appear to be formed early in life. Therefore, parents should worry about their kids' sodium intake since healthy dietary habits learned in childhood are carried forward to adulthood," he said.

Parents should read nutrition labels at the supermarket to shop wisely for the foods they feed their children, Antman added.

"Parents should also emphasize eating at home rather than eating at restaurants or fast food chains. Using spices rather than salt may help reduce the amount sodium their children eat," he said.

Zhu noted that more than 75 percent of consumed sodium comes from processed foods and fast food.

"This is why establishing a healthy food habit in early childhood is so important," she said. "People should eat less processed foods (and) fast food and eat more fresh fruits and vegetables."

SOURCE: http://bit.ly/1et1FpN

Pediatrics 2014.

Febrile Infants: How Long Until a Positive Blood Culture?

William T. Basco, Jr., MD, MS

November 14, 2014

Blood Culture Time to Positivity in Febrile Infants With Bacteremia

Biondi EA, Mischler M, Jerardi KE, et al; Pediatric Research in Inpatient Settings (PRIS) Network

JAMA Pediatr. 2014;168:844-849

Study Summary

This was a multicenter, retrospective evaluation of blood culture results in 17 pediatric hospitals. The study included febrile infants (aged 0 to 90 days) who experienced bacteremia. Children who were admitted to an intensive care unit, had central lines, or had undergone surgery were excluded. Other clinical parameters were used to classify the children as either "low risk" or "high risk" for serious bacterial infection to allow for grouping of children for the analyses. Each site provided at least 2 years' worth of data for the study, and they all used the same microbiology blood culture system. The time to culture positivity was calculated in minutes. Typical contaminants and cultures positive with nonpathogenic organisms were excluded from the analyses.

Positive blood cultures from a cohort of 392 children (51% boys, 40% younger than 30 days of age) were included in the analysis. Only 25% of the children would have been classified as "low risk." Among all children, the mean time to positive blood culture was 15.4 hours (median, 13 hours). The average time to positive culture (13.9 hours) was shorter among the youngest infants compared with 15.6 hours for children who were 31-60 days old and 17.9 hours for children who were 61-90 days old. The time to positive culture was not significantly altered by inclusion of contaminant organisms. By 24 hours, 91% of the cultures that would become positive were positive (95% confidence interval, 88%-93%). By 36 hours, 96% of the cultures were positive; and by 48 hours, 99% of the cultures were positive.

Approximately 30% of the bacteria that grew after 24 hours were Escherichia coli. In fact, E coli was the most commonly isolated bacterium (41%), followed by group B streptococci (22%). All other bacterial species found were cultured from less than 10% of the children. When comparing time to positivity among the species, the median time to positivity for E coli was 13 hours compared with 10.5 hours for group B streptococci and 18.5 hours for Staphylococcus aureus. Significantly longer median times to positivity occurred with coagulase-negative streptococci (27.2 hours), Moraxella species (39.8 hours), and Neisseria species (23.5 hours). Biondi and colleagues concluded that most children with a positive bacterial blood culture will be identified within the first 24 hours of obtaining the culture. Keeping children longer than 24 hours would identify one child with bacteremia for every 556 children treated.

Viewpoint

To anyone who has seen some of the previous studies evaluating time to positive blood cultures, this study demonstrates results that are very much in line with previous studies. By far, most pathogenic blood cultures will turn positive within the first 24 hours. These data support 24 hours as a reasonable duration of observation if the infant appears well enough for discharge, and proper follow-up (ideally the next day) can be ensured. These data also reinforce the fact that E coli is the predominant blood pathogen in the newborn, likely owing to more prevalent screening for group B streptococci in pregnant women.

Finally, I was struck by the fact that the time to positive culture varied little among the infants classified as "low risk" or "high risk" on the basis of screening criteria, but the decision to admit the child from the emergency department or outside facility is already a marker of "high risk" in children. Therefore, additional laboratory parameters may be less helpful among the subset of children for whom the decision to admit has already been made.

 

Medscape Pediatrics © 2014  WebMD, LLC 

Two Cups of Milk May Be Best for Preschoolers

By Shereen Lehman

December 31, 2014

(Reuters Health) - Preschoolers who drink three or more cups of milk a day may get a small height boost, but they're also more likely to be overweight or obese, according to a new U.S. study.

The results, based on nearly 9,000 children, support current recommendations that preschoolers consume two servings of milk a day, the authors say - with one serving equal to one cup.

"Overall, we were most struck by the heavier BMI (body mass index) among four-year-old children drinking high volumes of milk," said Dr. Mark DeBoer, a pediatrician at the University of Virginia in Charlottesville who led the study.

"Given the country's current obesity epidemic, we felt as though the data supported the current recommendations of the American Academy of Pediatrics, recommending that children drink two servings of milk daily - but restrain them from drinking higher volumes because of the potential for unhealthy weight gain," he told Reuters Health by email.

DeBoer said earlier research in other age ranges had noted a connection between higher amounts of milk intake and taller stature. But, his team wrote December 15 online in Archives of Disease in Childhood, studies have found mixed results when it comes to milk and excess weight gain.

Data for the new study came from the Early Childhood Longitudinal Survey, a U.S. study that began when the kids were born in 2001.

The researchers examined the milk-consumption patterns of 8,950 children during their first four years, based on interviews with parents. They were able to follow up with 7,000 of those kids at age five.

They found that 53% of children who drank milk consumed two or three servings daily.

Four-year-olds who drank more than the recommended two servings per day were 16% more likely to be overweight (i.e., in the 85th percentile or above) than the kids who drank less.

The study team also found that on average, kids who drank two, three and four or more servings of milk per day were about a centimeter taller than kids who drank one serving or less.

By age five, the weight differences were no longer statistically significant and drinking more milk was only associated with being slightly taller.

"As pediatricians, we had noticed that some families do not appear to restrain their children's milk intake, and we were wondering whether high amounts of milk intake would be associated with higher body mass index," DeBoer said. "In that sense, we were not surprised when we noted that children at four years old who drank a larger number of servings of milk daily also had a higher BMI."

There are several possible explanations for the results, particularly given that milk is high in growth factors that may or may not contribute to getting taller, DeBoer noted. It's also possible, he said, "that the heavier weight status associated with more milk intake could push children toward earlier growth."

Because the study is based on observation, it cannot draw conclusions about cause and effect, he cautioned.

Dr. Jonathon Maguire, a pediatrician and researcher at St. Michael's Hospital in Toronto, said studies based on observing people over time, like the one DeBoer's team used, are very important.

"We learn from those children about what's healthy and what's potentially not healthy, and this study is a nice example of that," said Maguire, who wasn't involved in the new study.

The findings are also compatible with Maguire's 2012 paper in Pediatrics (bit.ly/T568Dc) showing that around two cups of milk per day balances vitamin D and iron stores nicely, he said.

"And what this study emphasizes is that around two cups is a nice balance between linear growth in terms of stature and avoiding problems like obesity and overweight," he said.

Milk is a staple of the Western diet, MacGuire said, "It's a very important source of calories and essential fats, but too much of a good thing may not be a good thing and that's what this study is supporting," he said.

SOURCE: http://bmj.co/1tesUsF

Arch Dis Child 2014.

We are losing the arms race against many common bugs.

Bad Bugs Behaving Badly

Robert Welliver, MD, an infectious disease physician at the University of Oklahoma, chose the World Health Organization(WHO) 2014 summary of its antimicrobial resistance global report on surveillance^[1] as the most important paper of the year. He states, "This issue is a major threat to the United States—more than Ebola, more than methicillin-resistant Staphylococcus aureus, more even than obesity."

The summary notes the following key findings.

1. In many WHO regions, very high rates of antimicrobial resistance have been observed for common bacteria, such as Escherichia coli, Klebsiella pneumoniae, and S aureus; these organisms cause common infections involving the urinary tract, bloodstream, respiratory system, and wounds.

2. There is a significant gap in surveillance techniques, standards for methodology, and data sharing and coordination.

3. Multidrug-resistant tuberculosis is a growing, and largely underreported, problem.

4. Increasing levels of transmitted anti-HIV drug resistance have been observed among patients initiating antiretroviral treatment.

The bottom line as to why this is significant is as follows. According to the summary, "Patients with infections caused by bacteria resistant to a specific antibacterial drug generally have an increased risk of worse clinical outcomes and death, and consume more healthcare resources, than patients infected with the same bacteria not demonstrating the resistance pattern in question." In a phrase, more resistant bugs means more lost lives and more money.

Antimicrobial resistance is not a topic for medical journals alone. From the New York Times ^[2] to The Economist,^[3] articles in lay publications have brought this issue to the fore in many countries. Yet inappropriate requests for antibiotics, accompanied by their injudicious use, indicate that there is more to do to reverse these trends.

Antimicrobial stewardship programs are one such approach. A second involves the curtailment of antibiotic use in livestock. According to the National Resources Defense Council, 80% of antibiotic in the United States is used to promote livestock growth.^[4]

The pharmaceutical research and development pipeline is losing the arms race against many common bugs. The WHO 2014 summary is likely to be a harbinger, unless some drastic policy changes come about.

How to handle questions about vaccine safety

By: AMY KARON, Pediatric News Digital Network |

SAN DIEGO – Parental concerns about vaccine safety are a reality of pediatric practice. False perceptions that vaccines are dangerous or unnecessary have eroded herd immunity to the extent that almost 600 measles cases have been reported thus far in 2014 – an unprecedented number, Dr. Paul Offit said at the annual meeting of the American Academy of Pediatrics.

Dr. Offit recommended strategies for handling some of the most common questions and concerns parents raise about vaccine safety. He is director of the Vaccine Education Center at the Children’s Hospital of Philadelphia, and is the Maurice R. Hilleman Professor of Vaccinology and professor of pediatrics at the University of Pennsylvania, also in Philadelphia.

Parents may ask: How do you know vaccines are safe? I researched them on the Internet and learned they’re not.

“When people say they’ve done their research on a vaccine and have decided not to get it, what they really mean is they’ve read other people’s opinions on the Internet,” Dr. Offit said. Parents need to understand that not all information sources are equivalent, and that a vaccine must undergo extensive testing before the Food and Drug Administration licenses it or the American Academy of Pediatrics and the Centers for Disease Control and Prevention recommend it, he said. “The phase III trials invariably involve thousands of children,” he added.

But the package insert for the vaccine lists a lot of adverse events.

Any adverse event reported before the vaccine is licensed will be listed on the package insert, whether or not the vaccine caused the event, Dr. Offit said. For example, the original package insert for the chicken pox (varicella) vaccine listed fractured leg as an adverse event, because one recipient of the varicella vaccine broke his or her leg within 42 days after receiving the vaccine, he said. “Package inserts are not a medical communication document,” he added. “They are a legal communication document.”

 

Why are people being compensated for vaccine harm if it isn’t a problem?

The question refers to the National Vaccine Injury Compensation Program, which has paid more than $2.8 billion in compensation awards to petitioners since 1989. The program is “a large and tempting pool of money for personal injury lawyers to file compensatory injury suits on behalf of their clients,” Dr. Offit said. But just because a court awarded damages for harm does not mean the vaccine actually caused harm, he said. “The courts are never a place to determine scientific truths. The place you do that is in the scientific venue, by studies.”

Vaccines can contain potential allergens, primarily gelatin (a stabilizer) and latex (in vials or syringes that contain natural rubber), Dr. Offit noted. However, the rate of truly severe reactions to vaccines is extremely low – about one case per 1-2 million doses of vaccine, he said. An exception is yellow fever vaccine , which has caused fatal anaphylaxis, and oral polio vaccine also “had the potential to revert to wild type, which is why we went to the fully inactivated polio vaccine by the year 2000,” Dr. Offit noted. Thrombocytopenia is a potential adverse reaction of some vaccines, but is rare, and there are no compelling data associating measles vaccine with encephalopathy, he said.

The fact of the matter is that vaccines are a product of pharmaceutical companies. Why should I trust a product that is from a pharmaceutical company?

“The fact is you don’t have to trust pharmaceutical companies,” Dr. Offit said. “A reporting system for adverse events is out there – VAERS [Vaccine Adverse Event Reporting System]. The vaccination safety data will show whether or not there is a safety issue.”

As an example, the human papillomavirus (HPV) 4 vaccine was studied in millions of children after it was licensed in the United States, Dr. Offit said. “The only symptom found was fainting,” he emphasized. 

“It’s also not good business to make a vaccine that will do harm,” Dr. Offit said, adding that prelicensure studies of vaccines have cost up to $600 million.

I heard that if I am pregnant, I should not get the flu vaccine because it contains mercury, which is neurotoxic and can harm my baby.

Parents can benefit from understanding the difference between methylmercury – which naturally occurs in the environment and is neurotoxic at high levels of exposure – and ethylmercury, which is formed when the body breaks down the thimerosal that is found in small amounts in some vaccines, Dr. Offit said. Ethylmercury poses much less risk to humans than methylmercury, because it is excreted from the body about 10 times faster, he added.

“Mercury is in the earth’s crust, and always has been in inorganic form,” Dr. Offit said. “If you live on this planet, if you drink anything made from water on this planet, you will be exposed to methylmercury. The quantity of mercury that you ingest every day is logarithmically greater than anything you would get from vaccines. You are at no greater risk of neurodevelopmental problems, including autism, from being vaccinated than if you did not receive any vaccines containing thimerosal.”

Parents may argue that drinking a substance is different from injecting it, but in fact, “mercury is very well absorbed in organic form,” Dr. Offit said. “If it’s ingested, it will cross cell membranes.”

And while thimerosal-free vaccines are available, “advertising these vaccines as safer is not true,” because the small amounts of thimerosal in current vaccines do not pose a health risk, Dr. Offit said.

Why is my child getting hepatitis B vaccine at birth? My child won’t be at risk for a long time.

“The hepatitis B vaccine first came on the market in the early 1980s, and was originally recommended only for high-risk groups,” Dr. Offit said. “For 10 years, the incidence of hepatitis B in this country did not budge. Then it was recommended as a routine vaccination for newborns, because every year, there were 18,000 cases of hepatitis B in kids under 10 years old.” Only half these cases were a result of exposure to hepatitis B virus in the vaginal canal during delivery, he emphasized. The rest resulted from “casual contact with someone who was infected and did not know it, such as a kiss on the lips from an uncle.”

Parents also should understand that chronic hepatitis B infection is associated with a high risk of liver cancer or cirrhosis, Dr. Offit said.

I’m Catholic, and I see that a number of vaccines contain cells that are from aborted fetuses.

In the early 1960s, cells from elective abortions in Sweden and England were used to make vaccines such as hepatitis A, varicella, rubella, and rabies, Dr. Offit noted. Some vaccines are still made in cells that have grown or descended independently from these aborted fetuses, he said. The Catholic Church teaches that Catholics should ask for alternatives when available, but are morally free to use vaccines prepared in cells descended from aborted fetuses, because the greater harm is to the unvaccinated child. The National Catholic Bioethics Center, which derives its teachings directly from the Catholic Church, states, “ The risk to public health, if one chooses not to vaccinate, outweighs the legitimate concern about the origins of the vaccine. This is especially important for parents, who have a moral obligation to protect the life and health of their children and those around them.”

I don’t want my child to receive vaccines because natural infection is better for the immune system.

The infections against which vaccines protect can be fatal, cause serious illness, and lead to long-term disability, Dr. Offit emphasized. “The fact is that vaccines are good enough,” he emphasized. “The immunity is good enough. You just need it to be good enough to protect you long-term.”