Wednesday, November 27, 2013

Solid foods started earlier than 17 weeks may increase foo

Infants who are introduced to their first solid foods before 17 weeks of age have a higher likelihood of developing food allergies by 2 years, a U.K. team of researchers found.
Additionally, the researchers discovered that infants who receive their first cow’s milk products while still being breastfed were less likely to develop allergies than were those introduced to cow’s milk after breastfeeding had stopped.
The research, led by Kate E.C. Grimshaw, Ph.D., of the University of Southampton, England, and published online Nov. 18 in Pediatrics (2013 [doi:10.1542/peds.2012-3692]), supports currentrecommendations by the American Academy of Pediatrics that solid food be introduced at between 4 and 6 months, concurrent with breastfeeding, to prevent allergies (Pediatrics 2008;121:183-91;Pediatrics 2012;129:e827-41).
Dr. Grimshaw and her colleagues’ study identified the 17-week mark as the "crucial time point," with solid food introduced before this time appearing to promote food allergies, while solid food introduced after this time apparently not doing so.
For their research, Dr. Grimshaw and her colleagues used a large prospective cohort study (n = 1,140) to identify mothers of 41 infants diagnosed with food allergies by age 2 years. These infants were matched with 82 controls born on close to the same date. All mothers of infants in the cohort study kept detailed daily food diaries describing their feeding practices through the first year after birth.
Dr. Grimshaw and her colleagues found that solid foods were introduced significantly earlier among the infants with allergies, with 35% of the former receiving their first solids before and including 16 weeks, compared with 14% of control infants (P = .011).
Of the infants who received cow’s milk concurrently with breast milk, the duration of concurrent feeding was longer – 9 weeks – in the control group, compared with 5.5 weeks in the allergy group (P = 0.47), suggesting that the duration of overlap was important and that longer overlap was helpful. However, there was no significant difference between the two groups in terms of the age at when the cow’s milk was introduced into the diet, they said.
Dr. Grimshaw and her colleagues listed as strengths of their study its prospective design that allowed for data collection from birth onward, and before any signs of allergy could become evident; only three infants in the study had evidence of allergy before 24 months. Also, they noted, a thorough diagnostic standard was used to identify allergies.
Although the optimum duration of exclusive breastfeeding has yet to be established, "Health professionals can provide advice that is consistent by encouraging exclusive breastfeeding for as long as possible followed by continued breastfeeding alongside the introduction of complementary foods to maximize the duration of concurrent breastfeeding and solid food introduction," Dr. Grimshaw and her colleagues wrote in their analysis.
The study was funded by the U.K. Food Standards Agency. Dr. Grimshaw declared an advisory relationship with Nutricia, while her coauthor Dr. Graham Roberts disclosed a relationship with Danone Baby Nutrition. Another coauthor on the study, Clare Mills, Ph.D., disclosed associations with Novartis, PepsiCo International, and DBV Technologies.
Comment: The recommendation for exclusive Breast feeding for the first 6 months continues to gain credence with increasing scientific evidence in its favor.

Tuesday, November 26, 2013

Use a smartphone to diagnose ear infections in kids !

ORLANDO – A novel smartphone otoscope attachment provides clear, transmittable images of the ear drum or tympanic membrane, and could revolutionize the approach to diagnosing and managing ear infections, according to Dr. Kathryn Rappaport.
In a prospective study involving 63 children who presented to an emergency department between May and December 2012 with upper respiratory tract symptoms, the technology was as effective as a conventional otoscope, and was widely accepted by parents, Dr. Rappaport of Baylor College of Medicine, Houston, reported at the annual meeting of the American Academy of Pediatrics.After receiving clinical care, each child in the study underwent bilateral otic videoscopy using both the smartphone otoscope (CellScope Oto) and a camera-fitted conventional otoscope. The procedures were performed in random order, said Dr. Rappaport, who was at Emory University in Atlanta when the study was conducted.
Of the children, who had a mean age of 2.9 years, 49 received a clinical diagnosis of acute otitis media by an ED practitioner. Based on independent scoring by four physicians who evaluated 31 CellScope Oto videos and 31 conventional otoscope videos from 26 subjects, there was no difference between the two technologies in either the diagnostic quality of the images or diagnosis confidence ratings.
Diagnosis and treatment decision making were similar with each device. Overall, the physician raters were in fair agreement regarding the clinical ED diagnosis of acute otitis media, while two of the raters had moderate to substantial agreement with the ED diagnosis and two had poor agreement with the ED diagnosis from images obtained via conventional otoscope, Dr. Rappaport said, noting that there was a significant correlation between antimicrobial use and image quality.
This indicated that higher-quality images were more likely to be associated with a definitive diagnosis, she said.
As for parent reactions to the use of the device, most (95%) responded favorably, stating that the CellScope Oto images improved their understanding of their child’s management. Also, 90% said they thought the technology would be easy to use, and they would feel comfortable using it remotely to transmit images to a provider.
The CellScope Oto has the potential to improve diagnosis and management, and to reduce costs associated with acute otitis media in children, Dr. Rappaport said.
The video images can provide a baseline, as well as ongoing documentation of a child’s condition. The video documentation could allow a child to be followed over a period of time – without the need for regular office visits – to help monitor for progression or resolution of middle ear effusion and to guide diagnosis and treatment decision making, she explained.
"Acute otitis media is the most common reason for antimicrobial prescriptions in children. In the future, we would like to study whether the ability to monitor for resolution of a patient’s middle ear effusion using digital imaging with the smartphone otoscope will lead to decreased antimicrobial prescriptions for acute otitis media in children," she said in an interview.
Dr. Rappaport reported having no relevant financial disclosures.
Comments: While many Indian doctors have been shy in adding emails / internet to their forte, almost everyone possesses a smartphone. Hence these technological innovations, once popularized can certainly impact the practice of the Indian pediatrician too !

Saturday, November 23, 2013

How long after reconstitution (mixing) can I use a vaccine?

Q: I have accidentally reconstituted a Chicken Pox & MMR vaccine (mixed the powder & the diluent) for a child who did not need the vaccine. For how long can I store this vaccine after this?
A. Vaccines should be used immediately after reconstitution if possible. The life of each reconstituted vaccine varies from product to product. Consult the product package insert for the most up-to-date information about expiration dates and times following reconstitution. Unused reconstituted vaccines kept beyond these limits should not be administered. The best way to avoid such waste is to reconstitute and draw up vaccines
immediately before administration.

Shelf Lives of Reconstituted Vaccines
Expiration after Reconstitution
Varicella (Chicken Pox)
30 minutes (protect from light)
30 minutes
MMR vaccine
8 hours (protect from light)
 vaccine (Hib)
24 hours
--> Mark each opened multidose vial with the date it was first opened. Mark reconstituted vaccine with the date and time it was reconstituted. Dating these vials is important for two reasons. First, some vaccines expire within a certain time after opening or after reconstitution. This may not correspond to the expiration date printed on the vial by the manufacturer. For example, multidose vials of meningococcal vaccine should be discarded if not used within 35 days after reconstitution, even if the expiration date printed on the vial by the manufacturer has not passed. Second, dating opened or reconstituted vials helps manage vaccine inventory by identifying vials that should be used first.

On a slightly different note, Multi-dose vials used for mass immunizations are to be best used as per the following WHO policy

Multi dose vials of OPV, DTP, TT, DT, Td, hepatitis B, and liquid formulations of Hib vaccines from which one or more doses of vaccine have been removed during an immunization session may be used in subsequent immunization sessions for up to a maximum of four weeks provided that all of the following conditions are met:
  • The expiry date has not passed;
  • The vaccines are stored under appropriate cold chain conditions;
  • The vaccine vial septum has not been submerged in water;
  • Aseptic technique has been used to withdraw all doses;
  • The VVM, if attached, has not reached its discard point.
The revised policy does not change recommended procedures for handling vaccines that must be reconstituted, that is, BCG, measles, yellow fever, and some formulations of Hib vaccines. Once they are reconstituted, vials of these vaccines must be discarded at the end of each immunization session or at the end of six hours, whichever comes first.

The rationale for these differing recommendations is as follows. Most freeze-dried (lyophilized vaccines) do not contain preservatives and consequently must not be kept more than the manufacturer's recommended limit and never longer than six hours after they are reconstituted. Liquid injectable vaccines such as DTP, TT, DT and hepatitis B contain preservatives that prevent growth of bacterial contamination. Should contamination take place within the vial, the action of these preservatives prevents any increase in bacterial growth over time and actually decreases the level of contamination.

AAP Releases New Principles for rational use of antibiotics in URI

Effective use of antibiotics to treat pediatric upper respiratory tract infections (URIs) rests on 3 basic principles: accurate diagnosis, consideration of risks vs benefits, and recognizing when antibiotics may be contraindicated, according to a clinical report by the Committee on Infectious Diseases of the American Academy of Pediatrics (AAP).
Of the nearly 50 million pediatric antibiotic prescriptions written annually, as many as 10 million of those "are directed toward respiratory conditions for which they are unlikely to provide benefit," lead author Adam L. Hersh, MD, PhD, and fellow committee members write in an article published in the December issue of Pediatrics. Often this occurs because it is hard to distinguish bacterial infections, which respond to antibiotics, from viral infections, which do not.
The report emphasizes "the importance of using stringent and validated clinical criteria when diagnosing acute otitis media (AOM), acute bacterial sinusitis, and pharyngitis caused by group A Streptococcus(GAS), as established through clinical guidelines," the authors write.
The first principle of judicious antibiotic prescribing is to determine the presence of a bacterial infection. For example, with AOM, this requires an otoscopic examination to observe characteristic inflammatory changes in the tympanic membrane plus bulging of the membrane or new-onset otorrhea not attributable to otitis externa, or mild bulging of the tympanic membrane accompanied by intense erythema or pain of recent onset. Acute bacterial sinusitis is diagnosed from persistent, worsening, or severe symptoms. Pharyngitis resulting from GAS can be diagnosed by taking a throat culture to identify the organism.
Following these diagnostic guidelines can help clinicians rule out the common cold, nonspecific URI, and bronchitis, which are viral in origin and will not respond to antibiotics, the authors write.
The second principle is to weigh the benefits against the harms of antibiotics. In the case of AOM, the evidence suggests that although at least 50% of patients may get well without antibiotics, antibiotics hasten recovery and are especially helpful for patients who are younger or have bilateral or severe disease. The evidence for using antibiotics to treat acute bacterial sinusitis is limited and mixed, and the role of the drugs in preventing complications such as orbital cellulitis or intracranial abscess also is unproven. Nevertheless, the AAP recommends antibiotics for children with clinical features of acute bacterial sinusitis, especially when the symptoms are worsening or severe. As for GAS pharyngitis, good evidence suggests that antibiotics can shorten symptom duration, although their effect on limiting fever is less clear, and they may reduce horizontal transmission. Antibiotics also may prevent suppurative complications of GAS pharyngitis such as peritonsillar abscess.
The harms of antibiotics can potentially outweigh these benefits, the authors warn. Most of the clinical trials reviewed have used amoxicillin or amoxicillin-clavulanate, which have been associated with adverse events ranging from mild (eg, diarrhea and rash), to severe (eg, Stevens-Johnson syndrome), to life-threatening cardiac and anaphylactic reactions. What is more, a growing body of evidence suggests that antibiotic use early in life may upset the normal microbial balance in the intestine and other organs, possibly setting the child up for lifelong health problems, including inflammatory bowel disease, obesity, eczema, and asthma. "Application of stringent diagnostic criteria and use of therapy only when the diagnosis and potential benefits are well established is essential to minimizing the impact of antibiotic overuse on resistance in individuals and within communities," the authors write.
Principle 3 is implementation of judicious prescribing strategies, including selection of the antibiotic most likely to eliminate the infecting organism, using an appropriate dose, and treating for the shortest duration possible. The committee suggests that physicians consider a "wait-and-see" approach before prescribing antibiotics, especially for older patients with mild to moderate AOM or sinusitis. They also recommend an assessment of the child's overall antibiotic exposure.
These principles "can be used to amplify messages from recent clinical guidelines for local guideline development and for patient communication; they are broadly applicable to antibiotic prescribing in general," the authors conclude.
The authors have disclosed no relevant financial relationships.
Pediatrics. 2013;132:1146-1154.
Source (requires free medscape account)
Comments: I am a firm believer in reducing antibiotic use in children, and it pains me to see most prescriptions by private pediatricians in India featuring antibiotics almost by default. I think that over the next few decades, we will reduce the use of antibiotics since the long term problems related to their overuse will become even more evident.