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CONTEMPORARY PEDIATRICS MARCH 2016 VOL. 33 NO. 03 Contemporary JOURNAL CLUB ANNUAL TOP 10 MARCH 2016 PEDIATRICS VOL. 33 | NO. 03 Expert Clinical Advice for Today’s Pediatrician RETHINKING ASTHMA: ENGAGING TOP TOOLS & TECHNIQUES More than 50 published studies supporting accuracy. Special limited-time offer* 199. Regular $475.00 L Accuracy proven for all ages Call 617-923-9900 x6234 or email [email protected] L #1 Most preferred by pediatricians SPIROMETRY WORKSHOP TemporalScanner 00 $ L Makes rectal thermometers unnecessary ™ ContemporaryPediatrics.com Temporal Artery Thermometer 6 TAT-5000 and TAT 2000C models included. Limited to Pediatricians & Family Practitioners. *Offer expires March 31, 2015. OBSTRUCTIVE SLEEP APNEA IN KIDS Includes: JOURNAL CLUB ANNUAL TOP 10 TAT-5000 TAT-2000C Consumer Hospital Model Consumer Model Educational Pamphlets Lifetime Warranty Regular $425 New Smart Glow Features Regular $50 Includes $5 Rebate Coupon. Available at no charge. Clinical Studies Makes Rectal Thermometers Unnecessary ™ TemporalScanner 1.Bahorski J, Repasky T, Ranner D, Fields A, Jackson M, Moultry L, Pierce K, Sandell M (Tallahassee Memorial Healthcare). Temperature measurement in pediatrics: a comparison of the rectal method versus the temporal artery method. In Press, Corrected Proof, Available online 24 February 2011, Journal of Pediatric Nursing (2011). 2.Batra P, Goyal S. Comparison of rectal, axillary, tympanic, and temporal artery thermometry in the pediatric emergency room. Pediatr Emerg Care. 2013 Jan;29(1):63-6. doi: 10.1097/PEC.0b013e31827b5427. 3.Batra P, Saha A, Faridi MM. Thermometry in children. J Emerg Trauma Shock. 2012 Jul;5(3):246-9. 4.Carr EA, Wilmoth ML, Eliades AB, Baker PJ, Shelestak D, Heisroth KL, Stoner KH (Akron Children’s Hospital). Comparison of Temporal Artery to Rectal Temperature Measurements in Children Up to 24 Months, Journal of Pediatric Nursing, In Press, [Epub ahead of print], Jan 25, 2010. 5.Gunawan M, Soetjiningsih I ( Udayana University, Sanglah Hospital, Denpasar, Indonesia). Comparison of the accuracy of body temperature measurements with temporal artery thermometer and axillary mercury thermometer in term newborns. Paediatr Indones, Vol. 50, No. 2, March 2010. 6.Kemp, C. (2013). Temporal artery thermometers may rival rectal thermometers in ED. AAP News, 34(4). 7.Reynolds M, et al. Are temporal artery temperatures accurate enough to replace rectal temperature measurement in pediatric ED patients? J Emerg Nurs. 2012 Nov 8. pii: S0099-1767(12)00329-7. doi: 10.1016/j.jen.2012.07.007. [Epub ahead of print] 8.Titus MO, Hulsey T, Heckman J, Losek JD (Medical University of South Carolina and Children’s Hospital). Temporal artery thermometry utilization in pediatric emergency care. Clinical Pediatrics, Mar 2009; vol. 48: pp. 190 - 193. Accuracy Proven for All Ages (Studies including premature neonates to infants younger than 3 months) 1.Batra P, Saha A, Faridi MM. Thermometry in children. J Emerg Trauma Shock. 2012 Jul;5(3):246-9. 2.Burdjalov et al. Non-Invasive infrared temperature assessment of the temporal artery for core temperature determination in premature neonates. American Pediatric Society and the Society for Pediatric Research, 5/1/2001 3.Carr et al. Comparison of Temporal Artery to Rectal Temperature Measurements in Children Up to 24 Months, J of Ped Nursing (2011) 26, 179–185 4.Gunawan et al. Comparison of the accuracy of body temperature measurements with temporal artery thermometer and axillary mercury thermometer in term newborns. Paediatr Indones, 50 (2) 2010. 5.Haddad et al. Comparison of temporal artery and axillary temperatures in healthy newborns. JOGNN, 41, 383-388; 2012. For more information and access to clinical studies: 6.Lee et al. Accuracy of temporal artery thermometry in neonatal intensive care infants. Adv Neonatal Care, 11(1) 62-70, 2011. 7.Reynolds M, et al. Are temporal artery temperatures accurate enough to replace rectal temperature measurement in pediatric ED patients? J Emerg Nurs. 2012 Nov 8. pii: S0099-1767(12)00329-7. doi: 10.1016/j.jen.2012.07.007. [Epub ahead of print] #1 Most Preferred by Pediatricians Surveys by Pragmatic Research, Inc. for the years 2010 to 2013. www.exergen.com/199offer Invented, designed, assembled, tested, and packaged in the USA by Exergen Corporation. CONTEMPORARY PEDIATRICS MARCH 2016 VOL. 33 NO. 03 Contemporary JOURNAL CLUB ANNUAL TOP 10 PEDIATRICS MARCH 2016 VOL. 33 | NO. 03 Expert Clinical Advice for Today’s Pediatrician ContemporaryPediatrics.com RETHINKING ASTHMA: ENGAGING TOP TOOLS & TECHNIQUES RETHINKING ASTHMA SPIROMETRY WORKSHOP Engaging top tools & techniques OBSTRUCTIVE SLEEP APNEA IN KIDS Spirometry workshop JOURNAL CLUB ANNUAL TOP 10 Obstructive sleep apnea in kids Contemporary editorial advisory board PEDIATRICS Gary L Freed, MD, MPH Michael S Jellinek, MD Scott A Shipman, MD, MPH Director, Division of General Pediatrics, Professor of Pediatrics and Health Management and Policy, and Director, Child Health Evaluation and Research (CHEAR) Unit, University of Michigan Health Systems, Ann Arbor, Michigan Professor of Psychiatry and of Pediatrics, Harvard Medical School, Boston, and Chief Executive Officer, Community Network, Lahey Health System, Burlington, Massachusetts Director of Primary Care Initiatives and Workforce Analysis, Association of American Medical Colleges, Washington, DC, and Assistant Professor of Pediatrics, Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire Jane A Oski, MD, MPH Harlan R Gephart, MD Department of Pediatrics, Tuba City Regional Health Care Corporation, Tuba City, Arizona Clinical Professor of Pediatrics, University of Washington School of Medicine, Seattle, Washington Andrew J Schuman, MD W Christopher Golden, MD physician contributing editors Section Editor for Peds v2.0, Adjunct Assistant Professor of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire Assistant Professor of Pediatrics (Neonatology), Johns Hopkins University School of Medicine, and Medical Director, Full Term Nursery, Johns Hopkins Hospital, Baltimore, Maryland Michael G Burke, MD Section Editor for Journal Club, Chairman, Department of Pediatrics, Saint Agnes Hospital, Baltimore, Maryland Steven M Selbst, MD Professor of Pediatrics, Vice Chair for Education, Director, Pediatric Residency Program, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, and Attending Physician, Pediatric Emergency Medicine, Nemours/Alfred I duPont Hospital for Children, Wilmington, Delaware Veronica L Gunn, MD, MPH Medical Director, Community Services for Children’s Hospital and Health System, Milwaukee, Wisconsin Donna Hallas, PhD, CPNP, PNP-BC, PMHS, FAANP Bernard A Cohen, MD Section Editor for Dermcase, Professor of Pediatrics and Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland Clinical Professor, New York University (NYU) College of Nursing, and Coordinator, Pediatric Nurse Practitioner Program, New York, New York OUR MISSION Office- and hospital-based pediatricians and nurse practitioners use Contemporary Pediatrics’ timely, trusted, and practical information to enhance their day-to-day care of children. We advance pediatric providers’ professional development through in-depth, peer-reviewed clinical and practice management articles, case studies, and news and trends coverage. content founding editor Frank A Oski, MD NANCY BITTEKER DIANE CARPENTERI REPRINTS SARA MICHAEL Director, Design and Digital Production VP, Content & Strategy NICOLE DAVIS-SLOCUM Associate Publisher 732-346-3092 / [email protected] TERESA MCNULTY Art Director JOANNA SHIPPOLI [email protected] 877-652-5295 ext 121 Outside US, UK, direct dial: 281-419-5725 ext 121 Group Content Director publishing & sales Acct Manager, Recruitment 440-891-2615 / [email protected] CUSTOMER SERVICE CATHERINE M. 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Data on file. Bayer. Bayer, the Bayer Cross, and Claritin are registered trademarks of Bayer. Children’s Allegra, Children’s ZYRTEC, and Children’s Benadryl are registered trademarks of their respective owners. © 2016 Bayer January 2016 61067-PP-CLA-CCL-US-0149 Contemporary PEDIATRICS March 2016 VOL. 33 NO. 3 clinical features 14 Rethinking asthma: Prevention & management Pediatricians should target lung function as well as lifestyle, diet, and obesity as contributing factors for pediatric asthma and provide interventions that will improve patients’ compliance with treatment regimens. Pat F Bass III, MD, MS, MPH 20 Spirometry establishes asthma control in children Here’s a quick primer on the use of the spirometer in children with asthma and guidance for incorporating this tool into the clinical setting. Mary Beth Nierengarten, MA 26 Obstructive sleep apnea syndrome in kids A co-author of the recent Childhood Adenotonsillectomy Trial study discusses key issues for diagnosing and treating kids with OSAS as well as current American Academy of Pediatrics clinical practice guidelines for OSAS. Mary Beth Nierengarten, MA. Reviewed by Carol M Rosen, MD. 13 puzzler 44 dermcase TODDLER WITH BLISTERING ACRODERMAL RASH UNUSUAL SKIN LESION IN A TEENAGED BOY Cindy Luu, MD; Jane OH, MD; Minnelly Luu, MD; Brittney DeClerck, MD Jacqueline Michel, DO; Kathryn Wheeler, MD; Jaclyn Otero, MD; Kristina Carswell, MD; Molly Posa MD; Maria N Kelly, MD CLINICAL THERMOMETRY: AN UPDATE AND REVIEW Dr. Schuman reviews what’s new in tools for determining one of the body’s most vital signs. Andrew J Schuman, MD, FAAP Contemporary Pediatrics (Print ISSN: 8750-0507, Digital ISSN: 2150-6345) is published monthly by UBM Medica, 131 W. 1st Street, Duluth, MN 55802. Subscription rates: one year $89, two years $150 in the United States & Possessions, $105 for one year, $189 for two years in Canada and Mexico; all other countries $105 for one year, $189 for two years. Single copies (prepaid only) $18 in the United States; $22 in Canada and Mexico, and $24 in all other countries. Include $6.50 per order plus $2.00 per additional copy for U.S. postage and handling. Periodicals postage paid at Duluth, MN 55806 and additional mailing offices. POSTMASTER: Please send address changes to Contemporary Pediatrics, PO Box 6083, Duluth, MN 55806-6083. Canadian GST number: R-124213133RT001. Publications Mail Agreement Number 40612608. Return Undeliverable Canadian Addresses to: IMEX Global Solutions, P. O. Box 25542, London, ON N6C 6B2, CANADA . Printed in the U.S.A. © 2016 UBM. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical including by photocopy, recording, or information storage and retrieval without permission 6 4 EDITORIAL ADVISORY BOARD 45 ADVERTISING INDEX departments 9 EYE ON WASHINGTON Why the jump in SSI benefits for kids? Do you have a manuscript to submit to Contemporary Pediatrics? 10 JOURNAL CLUB E-mail [email protected] for submission guidelines. Dr. Burke’s top 10 list for the last year in writing from the publisher. Authorization to photocopy items for internal/ educational or personal use, or the internal/educational or personal use of specific clients is granted by UBM for libraries and other users registered with the Copyright Clearance Center, 222 Rosewood Dr. Danvers, MA 01923, 978750-8400 fax 978-646-8700 or visit http://www.copyright.com online. 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GE T T Y IMAGES/ALLEN DONIKOWSKI 37 peds v2.0 in addition inter ctive JOI N US A ND JOIN IN W IT H YOU R P E D IATR IC PEERS AT C ON TEM POR A RYPED IATR IC S.C OM ‘NOTE BLOAT’ PART 2 Readers (Still) React Our Editorial Board Advisor (and Tech Guru) Dr Andrew Schuman’s January 2016 Peds v2.0 column (“Expediting medical documentation”) is still resonating. Contemporary L PEDIATRICS PRACTICA THE PEARLS FROM 4 TRENCHES: PART S PEDIATRIC p JANUARY 201601 VOL. 33 | NO. First, David Notrica, MD, from Phoenix, AZ, runs the numbers for us: ’s Pediatrician Advice for Today Expert Clinical For example: (Minutes) x (complexity of diagnoses factor) + (office expense of a new patient) 30 minutes x 1.2 = 36 minutes + new patient overhead costs (converted to + 5 minutes) = 42 minutes eds v2 D .0 SECON Expediting medic SENS doE cumentation al THE Dr Schuman, I enjoyed your article. EHRs should have been an amazing advance for doctors and patients. Instead they became a scaffold to improve billing. As much as I hate the thought of doctors becoming hourly (minutely) employees, it would lead to cleaner documentation. With a little adjustment, physicians could indeed take back medicine. s.com ContemporaryPediatric ANDREW J SCHUMA N, MD SECTION EDITOR Dr Schuman lays out his plan for a more meaningful way to document medical encounters and eliminate “note bloat,” thereby ensuring that physicia appropriately compen ns are sated by governm ent and insurance compan ies. Early loss detection & intervention TREATMENT OF OME y Autoinflation stud impression of the patient’s medical problems and communicate our plan for treatment and further evaluation to those who will read our note. The EHR note ensures continuity of care for When the editors our patients. at Contemp oworkshop at the rary Pediatrics invited If you read the American Peds v2.0 article me to launch “Level 4 office-vis of Pediatrics National Academy this section in 2012, it coding” from I had no idea Conference February 2013, you and Exhibition in how much fun I would have writOctober last year know that coding office visits is (see “Best tech for ing it, and that based on our readers would pediatrics 2015,” ical decision making” the “medContemporary Pediatrics actually find the topics interestin , December involved, g. the nature of the 2015), pediatricia Like most of you, ns told me that their presenting probI work in a clinic. lem, and the number EHRs were too hard I enjoy treating my patients, and to use, with the of problems addressed at the majority of attendees there is not a day visit. Unless you that goes by that reporting that I assign a time designatio they are unable need to navigate to complete their obstacles imposed n with your note, to justify office notes during by insurance companie a 99214 their regular s, governmust include numerou visit you hours. Many, if ment reforms, not most, were freand my electroni s elements c in your note to quently taking at health record (EHR). ensure payment least an hour’s work If there were to as a level 4 visit. Thus, home with them. be a theme for this This is no way to year’s Peds v2.0, a level 4 history includes at care for patients it would be “taking or ensure least 4 history back the pracof present illness life for medical providers! a quality tice of pediatrics (HPI) elements; ” for ourselves and at least 1 item from our patients. Yes, the past medical there will be lots history (a medicatio Our current of tech articles this n list or allergy year because this list qualifies), social documentatio leopard will never history, or famchange his digin system ily history; and . . . is designed tal spots. However, at least a 2-system to justify let’s begin our review of systems of coding for insurance the level recovery of medical (ROS). The level practice by discompany 4 physical exam reimbursement cussing alternativ requires examinarather than facilie ways of docution of 5 to 7 systems, tating documen menting office visits. tation of the office including the patient’s vital signs. visit. The purpose When I conducted of the office note my last tech should be to convey As every provider knows, when our clinical a note is reviewed 36 CONTEMPO we glance at the RARYP EDI AT R ICS.COM | JANUARY 2 016 YOU ARE NOW ON EHR SYSTEM NUMBER . . . #1 66% 21% #2 I hope your article gets legs and moves things forward. John Montgomery, MD, hailing from Columbus, IN, responds with a tech tip of his own: #3 7% DO NOT KNOW 6% SOURCE: Contemporary Pediatrics Annual Issues & Attitudes Survey, 2015 Andrew, this is a great article. I agree that EMR documentation is very time consuming and drains enjoyment from practice. I have found that the 2 EMR programs I have used do not time-stamp well. And as you know, you may be in and out of a room several times (like with an asthma patient getting treatments) or if you are not open to the exam screen in EMR, it is not recording When I run across a useful set of text, I “copy it” and then add it to my list. As an example, this last week, I got a letter on a patient from a Peds urologist. He gave good parent instructions on vulvovaginitis treatment, so I added it to my list. [Now I can just] type “fuvaginitis” for “follow-up vaginitis” . . . it types [out the entire parent instruction list I had entered]. That list took a couple seconds. I will be watching for more of your posts. Thanks. time as with patient. I depend heavily on a program called “Typinator.” I have over 400 macros that range from one word to many sentences. Some are just typo fixers like correcting “adn” to “and.” I would not be able to practice without this. (Especially in light of a serious hand injury last year resulting in loss of use of my middle finger on nondominant hand). Jay A. Bernstein, MD, FAAP, of Rockville, MD, sees it this way: I am fortunate to be at the end of my career in pediatrics. Having seen the metamorphosis of medical practice over the years, my conclusion [is] that physicians in general, and pediatricians in particular, are followers and weak minded in terms of their own value. As one who has yet to be convinced of the benefits of any of the technology-driven issues you cite, I have maintained a successful non-EHR practice and hope to be able to finish up that way. It is not difficult to justify levels of service in written notes. Those who complain about it have only themselves to blame. They have accepted a new system on blind faith without being asked to meaningfully contribute to its construction. Want to have your say? We’re a click away at [email protected] Part of the 8 Contemporary Pediatrics is part of the ModernMedicine Network, a Web-based portal for health professionals offering best-in-class content and tools in a rewarding and easy-to-use environment for knowledge sharing among members of our community. C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 EYE ON washington BY KATHRYN FOXHALL CONTEMPORARYPEDIATRICS.COM/EOW FOR MORE NEWS @CONTEMPEDS Why the jump in SSI benefits for kids? T he number of children on Supplemental Security Income (SSI) disability has surged in recent years, and even after much discussion over the last 5 years, people are still trying to determine all the reasons. Some are asking whether we are doing the best we can for the children involved. In addition, the fact that the percentage of children getting SSI differs greatly by state and even by county has people wondering. Much of the discussion began w it h a s er ie s i n t he B o s to n Globe in 2010 called “The Other Welfare,” which indicated that once families begin getting the checks, it’s hard to give up the money; that getting the checks creates a mindset that the child is disabled; that sometimes teenagers avoid getting jobs so as not to lose the funding; and that some families believe a child must be on medication to qualify. A recent report from the National Academy of Medicine (NAM) says that for more than 1.3 million lowincome children with severe disability, “the Supplemental Security Income program offers a vital source of financial support.” To be eligible, children must be in low-income households. Most current child recipients are in households below 200% of the federal poverty level. In 2014, the maximum SSI benefit was $721 per month, according to a brief by Mathematica Policy Research staff. From 1998 to 2013, SSI child caseloads grew by 45% and the ratio of children on SSI increased by 45% up to 1.8% of all children, according to Mathematica. I n 2 012 , t he G over n ment Accountability Office, a branch of Congress, found that 65% of child SSI recipients are awarded these disability benefits for “mental over the 10 years ending in 2013, the percentage of low-income household children allowed SSI for mental disorders had actually decreased. However, the total percentage of children in poverty had increased, so more children with mental disorders had become eligible for the program. About 22% of these children had a diagnosis of ADHD and another 21% had autistic disorder and other perva- About .31% of US children receive SSI benefits for speech and language disorders, and the total number has tripled in the past decade. —National Academy of Medicine impairment.” The 3 most prevalent primary mental impairments of those children in 2011 were attention-deficit/hyperactivity disorder (ADHD), speech and language delays, and autism. Last year, at the request of the Social Security Administration, a NA M commit tee looked at mental impairments other than speech and language problems. In its report “Mental Disorders and Disabilities Among Low-Income Children,” the committee stressed, first off, that there is limited information about the trends in mental disorder rates and the disabilities associated with them in children in general, but it found that M A R C H 2 016 | sive developmental disorders. Another NAM committee looked at speech and language issues separately. In a January 2016 report titled “Speech and Language Disorders in Children: Implications for the Social Security Administration’s Supplemental Security Income Program,” the committee said that currently about .31% of US children receive SSI benefits for speech and language disorders, and the total number has tripled in the past decade. Surveys have found an increase in speech and language disorders in children in the general population. The National Survey of CONTINUED ON PAGE 43 C O N T E M P O R A RY P E D I AT R I C S . C O M 9 journal club BY MARIAN FREEDMAN COMMENTARY BY MICHAEL G BURKE, MD CONTEMPORARYPEDIATRICS Two sides to bariatric surgery for teens T hree years after undergoing bariatric surgery, obese adolescents had lost significant weight and improved their cardiometabolic health and weight-related quality of life, according to a prospective study in 242 teenagers. However, some participants also developed micronutrient deficiencies during the 3-year period and needed additional abdominal procedures. Of total participants, most (67%) under went Rou x-en-Y gastric bypass, with 28% having sleeve gastrectomy and 6% adjustable gastric banding. (Because so few participants had adjustable gastric banding, investigators did not include results for this group in their analysis.) The adolescents ranged in age from 13 to 19 years and had a mean body mass index (BMI) of 53 before the procedure; 98% had a BMI higher than 40. After collecting baseline data for all participants, investigators evaluated changes in body weight, coexisting conditions, and other data periodically for 3 years after the procedure. At 3 years postsurgery, 26% of participants were no longer obese. Participants overall had a mean weight loss of 27%; for those who underwent gastric bypass, this figure was 28%, and for those who had sleeve gastrectomy, 26%. Among participants who underwent gastric bypass, 89% had at least a 10% reduction in BMI; for sleeve gastrectomy this figure was 85%. At the end of the study, only 2% of participants who underwent gastric bypass and 4% of those who had sleeve gastrectomy weighed more than they had at baseline. Surgery also led to related health improvements, with remission of several comorbidities in those who had these conditions at baseline: remission of type 2 diabetes in 95%; abnormal kidney function in 86%; commentary Surgical intervention as treatment for obesity is not for everyone. However, for this group of severely obese teenagers, these interventions may be the best that we have to offer, and earlier may be better. Hypertension and diabetes mellitus resolved more often in these adolescents than in similar populations of obese adults who had bariatric surgery for longstanding obesity. —Michael G Burke, MD Mindfulness instruction relieves mental/behavioral health problems Mindfulness instruction improved psychological functioning and reduced post t rau mat ic st ress 10 prediabetes in 76%; elevated blood pressure in 74%; and dyslipidemia in 66%. Weight-related quality of life also improved, as assessed by the Impact of Weight on Quality of Life-Kids instrument that measures how weight affects a child’s physical comfort, body esteem, social life, and family relations. On the negative side, 57% of participants had low ferritin levels at 3 years postsurgery compared with 5% at baseline. The proportion of participants with deficiencies of vitamin B12 or vitamin A also increased over time. In addition, 13% of participants underwent 1 or more additional intra-abdominal procedures, all but 3 of which were related to the prior bariatric surgery (Inge TH, et al. N Engl J Med. 2016;374[2]:113-123). symptoms in low-income, minority middle school students, a trial in 2 Baltimore City Public Schools C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 showed. The 300 5th-grade to 8th-grade participants—almost all African Americans and eligible for free lunches—were assigned to either a mindfulness-based stress reduction (MBSR) program or to a CONTINUED ON PAGE 12 journal club Top 10 list for the last year Machine It’s that time again! Here is Dr. Michael Burke’s selection of the 10 best articles he’s reviewed for Journal Club in the last 12 months. The summaries of these articles and Dr. Burke’s commentaries are listed chronologically by publication date as they appeared in Contemporary Pediatrics. To read the complete summaries and commentaries, go to ContemporaryPediatrics.com/Journal-Club. 1 2 3 4 5 6 7 8 9 Cesarean delivery raises infants’ risk of RSV hospitalization. Kristensen K, et al. Pediatr Infect Dis J. 2015;34(2):145-148 (May 2015) Study finding turns peanut-allergy avoidance strategy on its head. Du Toit G, et al. N Engl J Med. 2015;372(9):803-813 (May 2015) Automated EMR alert helps clinicians pay attention to elevated BP. Brady TM, et al. Clin Pediatr. 2015;54(7):667-675 (July 2015) Physician-provided oral health services reduce caries in kindergarteners. Kranz AM, et al. Pediatrics. 2015;136(1):107-114 (September 2015) 4 behavior targets help prevent obesity. Cloutier MM, et al. J Pediatr. 2015;167(2):372-377 (October 2015) Why do pediatricians work when sick? Szymczak JE, et al. JAMA Pediatr. 2015;169(9):815-821 (November 2015) A place for acupuncture in NAS treatment? Raith W, et al. Pediatrics. 2015;136(5):876-884 (January 2016) E-cigarette use likely leads to future cigarette use. Primack BA, et al. JAMA Pediatr. 2015;169(11):1018-1023 (January 2016) Is it okay to return to school the day after 1 strep throat treatment? Schwartz RH, et al. Pediatr Infect Dis J. 2015;34(12):1302-1304 (February 2016) 10 Toddlers’ media use goes way beyond TV. Kabali HK, et al. Pediatrics. 2015;136(6):1044-1050 (February 2016) Medical waste removal has cost physicians thousands of dollars over the year with the charges going up every year and their business having nothing to show for their expense. There is now a cost-effective, professionally recognized alternative. The Medical Waste Machine system replaces an expensive, ongoing medical waste removal cost, which increases regularly and incurs a cost to the doctors forever. The system can save small and large businesses up to 80% yearly. The Medical Waste Machine system improves the liability situation because there are no sharps (needles and syringes, lancets, blades, broken glass carpules, etc.) and other medical waste onsite due to the sterilization process that converts the medical waste to ordinary waste immediately. Also, the system makes an important environmental contribution because the waste going to the landfill is not only reduced in volume by an average of 75% but is sterile as well. Due to the monoply that has occured in the medical waste removal industry, prices are increasing considerably and regularly. By saving physicians money, eliminating their liability, which they are responsible forever (from cradle to grave), eliminating their paperwork and improving the environment, the Medical Waste Machine offers an unequivocal number of advantages over medical waste carriers and mail back services. For more information: Dr Burke, section editor for Journal Club, is chairman of the Department of Pediatrics at Saint Agnes Hospital, Baltimore, Maryland. Telephone: 508-358-8099 Fax: 508-358-2131 E-Mail: [email protected] www.medicalinnovationsinc.com journal club CONTINUED FROM PAGE 10 health education program (Healthy Topics [HT]) that focused on overall student wellness. The MBSR program consists of: material related to mindfulness, meditation, yoga, and mind/body connection; mindfulness meditations, mindful yoga, and body awareness; and group discussion about applying mindfulness to everyday situations. In the HT control program, students learn about topics, such as nutrition, exercise, body systems, adolescence, and puberty. At baseline and after completion of the 12-week programs, investigators compared mindfulness, psychological symptoms, mood and emotion regulation, coping, and posttraumatic symptoms in the 2 groups. The MBSR participants showed lower levels of both depressive symptoms and posttraumatic symptoms (Sibinga EM, et al. Pediatrics. 2016;137[1]:e20152532). commentary This was a carefully planned and implemented in-school program that required buy-in from teachers and school administrators, all of whom must constantly juggle competing demands. However, the results showed that the juggling was worthwhile. Middle school children who underwent mindfulness training emerged with skills to help them safely navigate high school and the neighborhoods where they live. —Michael G Burke, MD AD keeping your patient awake? Melatonin might help! A nightly 3-mg dose of melatonin can help children with atopic dermatitis (AD) fall asleep more quickly and reduce the severity of their AD. This was the finding of an 8-week trial in Taiwan in 48 youngsters with AD aged from 1 to 18 years. Pa r t icipa nts were div ided into 2 groups, 1 of which received melatonin for 4 weeks and then a placebo for another 4 weeks. The second group did the reverse, taking a nightly placebo first and then crossing over to melatonin. Investigators assessed AD severity on the first and last day of the 2 treatment periods, using the Scoring Atopic Dermatitis (SCORAD) index, and used questionnaires to evaluate subjective symptoms. Melatonin shortened by 21.4 minutes how long it took participants to fall asleep, compared with placebo. In addition, after melatonin treatment, the SCORAD index decreased by 9.1 (on a best-to-worst scale of 0 to 103) compared with the score after taking placebo. (These 2 melatonin-related improvements did not correlate with one another, however.) Patients themselves thought that melatonin improved their sleep and their AD (Chang YS, et al. JAMA Pediatr. 2016;170[1]:35-42). commentary All the patients in this study had both AD and a sleep problem involving either delayed sleep initiation or disrupted sleep on 3 or more nights per week for 3 months prior to the study. It may be that sleeplessness leads to more awareness of itching, more scratching, and worsened AD. If so, improved sleep might explain improved AD. Or, it may be that antiinflammatory properties of melatonin decrease itching, which leads to less scratching and improved AD. Bedtime melatonin may be worth a try! —Michael G Burke, MD 12 C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 also of note Infant mortality rates can be affected by changes in cigarette taxes and prices. An analysis of the relationship between changes in cigarette taxes and prices over time and infant mortality rates found that higher cigarette taxes are strongly associated with decreases in infant mortality. Using data for all states from 1999 to 2010, researchers found that for every dollar in increased taxes on cigarettes, infant deaths decreased by 0.19 per 1000 live births—a potential annual reduction of 750 US infant deaths, or an average of 2 averted deaths each day. This association was strongest among non-Hispanic African Americans (Patrick SW, et al. Pediatrics. 2016;137[1]:e20152901). puzzler Toddler with blistering acrodermal rash CINDY LUU, MD, PGY3 JANE OH, MD MINNELLY LUU, MD BRITTNEY DECLERCK, MD S FIGURE 1 Erythematous papules and plaques covering the patient’s perineal, acrodermal, and facial areas, as well as alopecia. THE CASE The anxious parents of a previously healthy, 19-month-old boy bring the child to the emergency department (ED) for evaluation of progressive rash IMAGE CREDIT/AUTHOR SUPPLIED that began 4 months ago. The skin eruption started as small blisters on his knees, which became tense and ruptured, eventually evolving to red-pink scaly plaques. Over the next few months, the boy developed similar lesions on his hands, elbows, neck, perineal area, and face, with sparing of the mucous membranes. FOR MORE ON THIS CASE, TURN TO PAGE 33. M A R C H 2 016 | C O N T E M P O R A RY P E D I AT R I C S . C O M 13 CLINICAL FEATURE Rethinking Asthma Rethinking asthma Prevention & management PAT F BASS III, MD, MS, MPH Dr Bass is chief medical information officer and associate professor of medicine and of pediatrics, Louisiana State University Health Sciences Center– Shreveport. The author has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article. Pediatricians should target lung function as well as lifestyle, diet, and obesity as contributing factors for pediatric asthma and examine interventions that will improve patients’ compliance with treatment regimens. function in a dose-dependent manner.4 Despite significant advances in asthma research and care, the burden of asthma Adult studies have demonstrated that remains high. On a daily basis, asthma weight loss can, in fact, improve lung funcleads to: 68,000 missed school days or worktion.5 As a result, office interventions tardays; 36,000 asthma attacks and geting activity levels may impact 4800 emergency department asthma or its severity. Further, visits; 1250 hospital admisthis evidence demonstrates sions; and 11 deaths.1 This additional benefit of the pediatrician targeting article will review a numNumber of ED visits healthy weight loss and ber of different aspects of due to asthma by kids maintenance beyond traasthma care that impact under age 15 in 2010. ditional cardiovascular the pediatrician. Source: American Lung and endocrine targets that Association. 2014. are well known. Lifestyle, obesity, 640,000 and asthma A link between lifestyle, obesity and asthma has been discussed in the medical literature for some time.2,3 In 1 long-term study, decreased levels of physical activity and increased screen time were associated with obesity. In turn, obesity in the 4th to 6th grades was associated with asthma and decreased lung 14 C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 Outcomes of asthma in pediatrics Control of asthma in the pediatric years has a tremendous impact on the patient in adulthood. In the Melbourne Asthma study that examines the natural history of asthma, results demonstrate that lung function as well as clinical outcomes clinical feature are predicted by asthma severity in childhood. 6 Poorly controlled asthma in childhood can result in significant respiratory morbidity into adulthood, and poor control in childhood represents a significant risk of morbidity as children transition into their adult lives. Diagnosing asthma severity: FeNO Fractional exhaled nitric oxide (FeNO) is a relatively recent, pointof-care diagnostic tool used to identify T-helper cell type 2 (Th2)driven a llergic inf lammation, which is present in up to 80% of children and 50% of adult asthma patients.7 Elevated FeNO levels are indicative of airway inflammation that is likely to respond to inhaled steroids. Additionally, FeNO-based management of asthma symptoms is associated with less asthma exacerbations compared with management based on clinical parameters alone. However, what is considered a meaningful difference in FeNO measurement still is under debate, and not all experts believe FeNO is useful in managing pediatric asthma. It also should be noted that use of FeNo is limited in patients with asthma phenotypes not characterized by inflammation. There is 1 FeNO measurement device approved by the US Food and Drug Administration (FDA) and available for use in clinical practice—the Nioxx Vero.7 Yellow-zone asthma management The 2007 Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma8 recommends a short course of oral corticosteroids if increased doses of a short-acting beta agonist (SABA) do not lead to improved control of asthma symptoms. A recent practice guideline, Management of acute loss of asthma control in the yellow zone: a practice parameter,9 provides additional treatment options based on research published since the 2007 report. Montelukast and neuropsychiatric events Many parents like the ease and simplicity of montelukast or other leukotriene inhibitors compared with an asthma inhaler. Although labeling was added in 2009 outlining risk for neuropsychiatric events, the FDA Pediatric Advisory Committee (PAC) recently rec- 13.8 million NUMBER OF SCHOOL DAYS KIDS WITH ASTHMA MISSED IN 2013 Source: Centers for Disease Control and Prevention. The repor t emphasizes t he importance of quick relief, but discourages scheduled SABA as the only treatment because this strategy fails to prevent progression into the red zone consistently.9 The guideline offers several options including: 1. Increase inhaled steroid doses by 4-fold by increasing either the frequency or dose of medication. 2. Dynamic dosing in which the patient uses his/her controller medication each time the SABA is used. In this way, the amount of steroids received is in proportion to the severity of the asthma symptoms. These enhanced yellow-zone strategies should be continued for 14 days to ensure symptoms resolve and lung function improves.9 The guideline emphasizes that the strategies be tailored to the individual patient and that clinicians make changes to the action plan based on how well it performs with each episode of poor control. M A R C H 2 016 | ommended strategies to increase awareness with health providers and parents.10 Montelukast was discussed as part of a routine PAC pediatric safety review in September 2014.11 Public testimony by parents outlined that although the FDA has attempted to communicate these risks to clinicians, many are not aware of or fail to communicate this risk to parents. T he pre s c r i bi n g i n for m ation for montelukast includes the following:10 “Neuropsychiatric events have been repor ted in adu lt, adolescent, and pediatric patients ta k ing [montelukast sodium]. Postmarketing reports with [montelu kast sodium] use include agitation, aggressive behavior or hostility, anxiousness, depression, disorientation, disturbance in attention, dream abnormalities, hallucinations, insomnia, irritability, memory impairment, restlessness, somnambulism, suicidal C O N T E M P O R A RY P E D I AT R I C S . C O M 15 clinical feature thinking and behavior (including suicide), and tremor. The clinical details of some postmarketing reports involving [montelukast sodium] appear consistent with a drug-induced effect.” In the very young pediatric patient who is not able to fully communicate (montelukast is approved in children aged as young as 6 months), detection of these adverse effects can be very difficult. Similarly, some of these adverse effects can be easily attributable by a parent or pediatrician as part of adolescence in older children. As a result, it is only increased awareness that can identify this problem. Providers should educate parents and then follow up specifically after starting therapy.11 The most common adverse effects of montelukast are not serious and symptoms generally resolve with cessation of treatment. New drugs for asthma For the longest time, Xolair has been t he on ly biolog ic ava i lable for patients with poorly controlled moderate-to-severe asthma. Importantly, long-term followup studies (median follow-up of 5 years) have now demonstrated rates of cancer are similar between patients treated with Xolair and those not receiving Xolair. There are now other biologic options available to the pediatrician.3 Mepolizumab, a monoclonal anti-IL-5 antibody, was recently approved by the FDA as an add-on therapy for patients aged 12 years and older with severe asthma.12 Administered via injection once per month, the drug lowers eosinophil levels. Studies demonstrated 16 decreased hospitalization and decreased steroid use but not WHAT’S THE SINGLE BIGGEST BARRIER YOU SEE TO GOOD ASTHMA SYMPTOM CONTROL IN YOUR PATIENTS? 50 % Noncompliance with treatment 5% Difficulty of medication delivery devices 10 % Environmental triggers out of your control 34% Insufficient caregiver support Source: Contemporary Pediatrics online poll. March 2016. improvements in lung function.2,3 Headache, injection-site reactions, back pain, and weakness were common adverse effects in clinical trials.12 Less-common but Diet and asthma There has been a great deal of interest and research in recent years into diet and patterns of asthma. Current evidence points to a “Mediterranean diet” decreasing asthma risk while a “Western diet” increases risk. The Western diet (increased amounts of refined grains and saturated fats with low amounts of fruits and vegetables) is proinflammatory and increases risk of asthma while the Mediterranean diet (limited amounts of refined grains and saturated fats but increased amounts of fruits and vegetables) is antii n f la m mator y a nd de c re a s e s asthma risk. However, evidence for specific anti-inf lammatory foods is still lacking to the point that the supplementation can be recommended. 2 This has led to multiple studies looking at the relationship between specific foods or supplements and how they might be related to or treat asthma. Previous evidence has noted increases in allergic disease and asthma in places where vitamin D is deficient, and more severe exacerbations of asthma with exposure to a trigger such as a viral respiratory tract infection.13 However, the Vitamin D Add-on Poor control [of asthma] in childhood represents a significant risk of morbidity as children transition into their adult lives. serious adverse effects included swelling of the face, mouth, and tongue; dizziness; hives; breathing problems; and rash. Herpes zoster infections also can occur. C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 Therapy Enhances Corticosteroid Responsiveness in Asthma (VIDA) trial failed to demonstrate more rapid tapering of inhaled steroids CONTINUED ON PAGE 19 For bacterial conjunctivitis in children as young as 12 months – Unleash power against pathogens of concern. 1 1 1 1 drop 3x a day 4 to 12 hours apart For 7 days Indication BESIVANCE® (besifloxacin ophthalmic suspension) 0.6% is a quinolone antimicrobial indicated for the treatment of bacterial conjunctivitis caused by susceptible isolates of the following bacteria: Aerococcus viridans*, CDC coryneform group G, Corynebacterium pseudodiphtheriticum*, Corynebacterium striatum*, Haemophilus influenzae, Moraxella catarrhalis*, Moraxella lacunata*, Pseudomonas aeruginosa*, Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus hominis*, Staphylococcus lugdunensis*, Staphylococcus warneri*, Streptococcus mitis group, Streptococcus oralis, Streptococcus pneumoniae, Streptococcus salivarius* * Efficacy for this organism was studied in fewer than 10 infections. Important Safety Information about BESIVANCE® BESIVANCE® is for topical ophthalmic use only, and should not be injected subconjunctivally, nor should it be introduced directly into the anterior chamber of the eye. As with other anti-infectives, prolonged use of BESIVANCE® may result in overgrowth of non-susceptible organisms, including fungi. If super-infection occurs, discontinue use and institute alternative therapy. Patients should not wear contact lenses if they have signs or symptoms of bacterial conjunctivitis or during the course of therapy with BESIVANCE®. The most common adverse event reported in 2% of patients treated with BESIVANCE® was conjunctival redness. Other adverse events reported in patients receiving BESIVANCE® occurring in approximately 1-2% of patients included: blurred vision, eye pain, eye irritation, eye pruritus and headache. BESIVANCE® is not intended to be administered systemically. Quinolones administered systemically have been associated with hypersensitivity reactions, even following a single dose. Patients should be advised to discontinue use immediately and contact their physician at the first sign of a rash or allergic reaction. Safety and effectiveness in infants below one year of age have not been established. Please see brief summary of Prescribing Information on adjacent page. Reference: 1. BESIVANCE® Prescribing Information, September 2012. Besivance is a trademark of Bausch & Lomb Incorporated or its affiliates. © 2015 Bausch & Lomb Incorporated. All rights reserved. US/BES/15/0011 BRIEF SUMMARY OF PRESCRIBING INFORMATION This Brief Summary does not include all the information needed to use Besivance safely and effectively. See full prescribing information for Besivance. Besivance (besifloxacin ophthalmic suspension) 0.6% Sterile topical ophthalmic drops Initial U.S. Approval: 2009 1 INDICATIONS AND USAGE Besivance® (besifloxacin ophthalmic suspension) 0.6%, is indicated for the treatment of bacterial conjunctivitis caused by susceptible isolates of the following bacteria: Aerococcus viridans*, CDC coryneform group G, Corynebacterium pseudodiphtheriticum*, Corynebacterium striatum*, Haemophilus influenzae, Moraxella catarrhalis*, Moraxella lacunata*, Pseudomonas aeruginosa*, Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus hominis*, Staphylococcus lugdunensis*, Staphylococcus warneri*, Streptococcus mitis group, Streptococcus oralis, Streptococcus pneumoniae, Streptococcus salivarius* *Efficacy for this organism was studied in fewer than 10 infections. 2 DOSAGE AND ADMINISTRATION Invert closed bottle and shake once before use. Instill one drop in the affected eye(s) 3 times a day, four to twelve hours apart for 7 days. 4 CONTRAINDICATIONS None 5 WARNINGS AND PRECAUTIONS 5.1 Topical Ophthalmic Use Only NOT FOR INJECTION INTO THE EYE. Besivance is for topical ophthalmic use only, and should not be injected subconjunctivally, nor should it be introduced directly into the anterior chamber of the eye. 5.2 Growth of Resistant Organisms with Prolonged Use As with other anti-infectives, prolonged use of Besivance (besifloxacin ophthalmic suspension) 0.6% may result in overgrowth of non-susceptible organisms, including fungi. If super-infection occurs, discontinue use and institute alternative therapy. Whenever clinical judgment dictates, the patient should be examined with the aid of magnification, such as slit-lamp biomicroscopy, and, where appropriate, fluorescein staining. 5.3 Avoidance of Contact Lenses Patients should not wear contact lenses if they have signs or symptoms of bacterial conjunctivitis or during the course of therapy with Besivance. 6 ADVERSE REACTIONS Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in one clinical trial of a drug cannot be directly compared with the rates in the clinical trials of the same or another drug and may not reflect the rates observed in practice. The data described below reflect exposure to Besivance in approximately 1,000 patients between 1 and 98 years old with clinical signs and symptoms of bacterial conjunctivitis. The most frequently reported ocular adverse reaction was conjunctival redness, reported in approximately 2% of patients. Other adverse reactions reported in patients receiving Besivance occuring in approximately 1-2% of patients included: blurred vision, eye pain, eye irritation, eye pruritus and headache. 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Pregnancy Category C. Oral doses of besifloxacin up to 1000 mg/kg/day were not associated with visceral or skeletal malformations in rat pups in a study of embryo-fetal development, although this dose was associated with maternal toxicity (reduced body weight gain and food consumption) and maternal mortality. Increased post-implantation loss, decreased fetal body weights, and decreased fetal ossification were also observed. At this dose, the mean Cmax in the rat dams was approximately 20 mcg/mL, >45,000 times the mean plasma concentrations measured in humans. The No Observed Adverse Effect Level (NOAEL) for this embryo-fetal development study was 100 mg/kg/day (Cmax, 5 mcg/mL, >11,000 times the mean plasma concentrations measured in humans). In a prenatal and postnatal development study in rats, the NOAELs for both fetal and maternal toxicity were also 100 mg/kg/day. At 1000 mg/kg/day, the pups weighed significantly less than controls and had a reduced neonatal survival rate. Attainment of developmental landmarks and sexual maturation were delayed, although surviving pups from this dose group that were reared to maturity did not demonstrate deficits in behavior, including activity, learning and memory, and their reproductive capacity appeared normal. Since there are no adequate and well-controlled studies in pregnant women, Besivance should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. 8.3 Nursing Mothers Besifloxacin has not been measured in human milk, although it can be presumed to be excreted in human milk. Caution should be exercised when Besivance is administered to a nursing mother. 8.4 Pediatric Use The safety and effectiveness of Besivance® in infants below one year of age have not been established. The efficacy of Besivance in treating bacterial conjunctivitis in pediatric patients one year or older has been demonstrated in controlled clinical trials [see CLINICAL STUDIES (14)]. There is no evidence that the ophthalmic administration of quinolones has any effect on weight bearing joints, even though systemic administration of some quinolones has been shown to cause arthropathy in immature animals. 8.5 Geriatric Use No overall differences in safety and effectiveness have been observed between elderly and younger patients. 12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Besifloxacin is a fluoroquinolone antibacterial [see CLINICAL PHARMACOLOGY (12.4)]. 12.3 Pharmacokinetics Plasma concentrations of besifloxacin were measured in adult patients with suspected bacterial conjunctivitis who received Besivance bilaterally three times a day (16 doses total). Following the first and last dose, the maximum plasma besifloxacin concentration in each patient was less than 1.3 ng/mL. The mean besifloxacin Cmax was 0.37 ng/mL on day 1 and 0.43 ng/mL on day 6. The average elimination half-life of besifloxacin in plasma following multiple dosing was estimated to be 7 hours. 12. Microbiology Besifloxacin is an 8-chloro fluoroquinolone with a N-1 cyclopropyl group. The compound has activity against Gram-positive and Gram-negative bacteria due to the inhibition of both bacterial DNA gyrase and topoisomerase IV. DNA gyrase is an essential enzyme required for replication, transcription and repair of bacterial DNA. Topoisomerase IV is an essential enzyme required for partitioning of the chromosomal DNA during bacterial cell division. Besifloxacin is bactericidal with minimum bactericidal concentrations (MBCs) generally within one dilution of the minimum inhibitory concentrations (MICs). The mechanism of action of fluoroquinolones, including besifloxacin, is different from that of aminoglycoside, macrolide, and β-lactam antibiotics. Therefore, besifloxacin may be active against pathogens that are resistant to these antibiotics and these antibiotics may be active against pathogens that are resistant to besifloxacin. In vitro studies demonstrated cross-resistance between besifloxacin and some fluoroquinolones. In vitro resistance to besifloxacin develops via multiple-step mutations and occurs at a general frequency of < 3.3 x 10-10 for Staphylococcus aureus and < 7 x 10-10 for Streptococcus pneumoniae. Besifloxacin has been shown to be active against most isolates of the following bacteria both in vitro and in conjunctival infections treated in clinical trials as described in the INDICATIONS AND USAGE section: Aerococcus viridans*, CDC coryneform group G, Corynebacterium pseudodiphtheriticum*, C. striatum*, Haemophilus influenzae, Moraxella catarrhalis*, M. lacunata*, Pseudomonas aeruginosa*, Staphylococcus aureus, S. epidermidis, S. hominis*, S. lugdunensis*, S. warneri*, Streptococcus mitis group, S. oralis, S. pneumoniae, S. salivarius* *Efficacy for this organism was studied in fewer than 10 infections. 13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Long-term studies in animals to determine the carcinogenic potential of besifloxacin have not been performed. No in vitro mutagenic activity of besifloxacin was observed in an Ames test (up to 3.33 mcg/ plate) on bacterial tester strains Salmonella typhimurium TA98, TA100, TA1535, TA1537 and Escherichia coli WP2uvrA. However, it was mutagenic in S. typhimurium strain TA102 and E. coli strain WP2(pKM101). Positive responses in these strains have been observed with other quinolones and are likely related to topoisomerase inhibition. Besifloxacin induced chromosomal aberrations in CHO cells in vitro and it was positive in an in vivo mouse micronucleus assay at oral doses × 1500 mg/kg. Besifloxacin did not induce unscheduled DNA synthesis in hepatocytes cultured from rats given the test compound up to 2,000 mg/kg by the oral route. In a fertility and early embryonic development study in rats, besifloxacin did not impair the fertility of male or female rats at oral doses of up to 500 mg/kg/day. This is over 10,000 times higher than the recommended total daily human ophthalmic dose. 14 CLINICAL STUDIES In a randomized, double-masked, vehicle controlled, multicenter clinical trial, in which patients 1-98 years of age were dosed 3 times a day for 5 days, Besivance was superior to its vehicle in patients with bacterial conjunctivitis. Clinical resolution was achieved in 45% (90/198) for the Besivance treated group versus 33% (63/191) for the vehicle treated group (difference 12%, 95% CI 3% - 22%). Microbiological outcomes demonstrated a statistically significant eradication rate for causative pathogens of 91% (181/198) for the Besivance treated group versus 60% (114/191) for the vehicle treated group (difference 31%, 95% CI 23% - 40%). Microbiologic eradication does not always correlate with clinical outcome in anti-infective trials. 17 PATIENT COUNSELING INFORMATION Patients should be advised to avoid contaminating the applicator tip with material from the eye, fingers or other source. Although Besivance is not intended to be administered systemically, quinolones administered systemically have been associated with hypersensitivity reactions, even following a single dose. Patients should be advised to discontinue use immediately and contact their physician at the first sign of a rash or allergic reaction. Patients should be told that although it is common to feel better early in the course of the therapy, the medication should be taken exactly as directed. Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by Besivance or other antibacterial drugs in the future. Patients should be advised not to wear contact lenses if they have signs or symptoms of bacterial conjunctivitis or during the course of therapy with Besivance. Patients should be advised to thoroughly wash hands prior to using Besivance. Patients should be instructed to invert closed bottle (upside down) and shake once before each use. Remove cap with bottle still in the inverted position. Tilt head back, and with bottle inverted, gently squeeze bottle to instill one drop into the affected eye(s). Manufactured by: Bausch & Lomb Incorporated Tampa, Florida 33637 Besivance® is a registered trademark of Bausch & Lomb Incorporated. ©Bausch & Lomb Incorporated U.S. Patent Nos. 6,685,958; 6,699,492; 5,447,926 †DuraSite is a trademark of InSite Vision Incorporated US/BES/15/0019 Based on 9142605(flat)-9142705(folded) clinical feature CONTINUED FROM PAGE 16 general diets (eg, Mediterranean diet) or should researchers continue to go down a path examining specific components looking for some sort of magic bullet? There is at least some evidence that trying to encourage better diets may asthma costs.19 Research recently began looking at whether today’s increasingly “plugged-in” society might help improve asthma control. One study looked at more than 1000 children in the Kaiser Permanente Colorado or improved asthma control when vitamin D-deficient patients were supplemented or given a placebo.14 Despite a n i ma l models of vitamin A deficiency being significantly associated with airway inf lammation and evidence of vitamin A deficiency being proinflammatory in adults, there is little evidence to support if vitamin A impacts asthma.15 In the Danish ESTIMATED ANNUAL COST OF TREATING ASTHMA National Birth Cohort,16 maternal vitamin A intake did not impact IN KIDS AGED YOUNGER THAN 18 YEARS Source: Weiss KB, et al. Journal of Allergy and Clinical Immunology. 2000. asthma in the first 7 years of life. Other studies have failed to demhave an impact. In a Spanish study, health maintenance organization onstrate any impact on the develchildren who ate an overall highand the impact of speech recogniopment or treatment of asthma antioxidant diet were less likely tion on asthma adherence.19 with vitamin A supplementation in 16,17 to experience an asthma episode early life. Speech recognition phone calls compared with children consumwere made to intervention parents Although the results for vitamin ing lower levels of antioxidants.18 when inhaled steroid refills were C supplementation are more promdue or overdue.19 Although adherising, the evidence still appears Future research hopefully will insufficient to make a recomprovide an answer, but there is a ence overall in both the intervenmendation that supplementation definite benefit from a reasonable tion arm and the standard care improves asthma.15 diet that encourages weight loss in arm was poor, adherence was 25% the obese and overweight or maingreater in the intervention group as Similarly, there is not enough tenance of a healthy weight. measured by a possession ratio over current evidence to suggest that 24 months. Interestingly, urgent vitamin E supplementation in care visits did not differ between pregnancy prevents respiratory Improving adherence the 2 groups. Low-cost intervendisease in early childhood despite Depending on what one reads and tions such as the one described animal models that support the how one defines adherence, com15 have the potential for significant concept. Recent randompliance ranges somewhere improvements in adherence and between 22% and 78%. ized trials also have subsequent asthma control and Adherence is poor in not demonstrated a FAST FACT The death rate potential cost savings. asthmatic patients positive impact of from asthma among In another adherence study, the for a nu mber of supplementat ion African American target was adolescents and deliverdifferent reasons with vitamin E on children is 500% higher ing messages to their ever-present including parenasthma. than in white children. smartphones to help improve comtal concern about Like with studies Source:Akinbami LJ, et al. pliance.20 Using a web-based appliadverse effects, the in cancer and other Ambul Pediatr. 2002. complexity of asthma diseases that appear cation, patients sign up and request regimens, cost, and a a menable to d iet a r y med reminder delivery messages. whole host of other factors. intervention, research appears In addition to improvements in Interventions that can improve to be at a crossroads in regard adherence, improvements in selfadherence will likely improve to diet and its association with efficacy and quality of life also C O N T I N U E D O N PAGE 32 a st h ma cont rol a nd decrea se asthma. Is it better to look at more $3.2 billion M A R C H 2 016 | C O N T E M P O R A RY P E D I AT R I C S . C O M 19 CLINICAL FEATURE Spirometry Workshop Spirometry establishes asthma control in children MARY BETH NIERENGARTEN, MA Ms Nierengarten, a medical writer in Minneapolis, Minnesota, has more than 25 years of medical writing experience, authoring articles for a number of online and print publications, including various Lancet supplements, and Medscape. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article. 20 Good asthma control in children begins with an accurate diagnosis and uses spirometry to control patients’ symptoms and monitor their lung function. This article provides pediatricians with a quick primer on the use of the spirometer in children with asthma and guidance for incorporating this tool into the clinic setting. As one of the most common chronic diseases in childhood, asthma affects millions of children in the United States.1 Data from the 2012 National Health Interview Survey show that 6.8 million children aged younger than 18 years (9% of all children) have asthma and 10 million (14%) have been diagnosed at one time with asthma.2 Broken down by race and socioeconomic conditions, the numbers get worse. Among non-Hispanic black children, 16% have asthma and 22% have ever been diagnosed with it. Among children in poor families, 13% have asthma and 19% have received a diagnosis at one time. The worst rates are for children in fair to poor health, C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 with 37% of children with asthma and 40% receiving a diagnosis at one time.2 These numbers highlight the many children with asthma who require ongoing management so that they can achieve and maintain good asthma control. To provide these children with the best care, pediatricians and other healthcare providers who have them as patients need to become educated on and facile in using a tool that is critical to the accurate diagnosis of asthma and asthma control. That tool is spirometry. “The goal of caring for children with asthma is to ensure their disease is well controlled, and that boils down to both PROFESSIONALLY RECOMMENDED PROBLEM-SOLVING PRODUCTS FUNGAL INFECTIONS DIAPER RASH ECZEMA HEALING TREATMENT HEALING )RUWKHWUHDWPHQWRIVXSHUÀFLDOVNLQ infections caused by yeast (Candida albicans) 8VHDWWKHÀUVWVLJQRIUHGQHVV PREVENTION Awarded the Seal of Acceptance by the National Eczema Association Use daily to prevent diaper rash SOOTHING Relief from burning, itching and discomfort TRUSTED PROTECTING Recommended by pediatricians, loved by parents Relief from dry skin associated with eczema SOOTHING Repels moisture and provides an effective barrier FOR EVERYONE MOISTURIZING Rich and long-lasting formula FOR BABY FOR EVERYONE THE RIGHT BALANCE FOR BARRIER PROTECTION AND SKIN HEALING INGREDIENTS To learn more or to request samples and coupons for your patients, please visit www.summers-direct.com/samples. clinical feature DIAGNOSIS OF ASTHMA 1 Detailed medical history Suggested items to include: } Symptoms } Patterns of symptoms } Precipitating and/or aggravating factors } Development of disease and treatment } Family history } Social history } History of exacerbations to guide them when using it in the clinic. The information provided debunks several myths about spirometry that may interfere with its more widespread use. Among these myths are that spirometry can’t be used in children; spirometry takes a long time to administer and can only be performed by respiratory therapists; and the curves and numbers generated from spirometry are difficult to interpret. } Impact of asthma on patient and family } Assessment of patient’s and family’s perceptions of disease Physical examination Examination focuses on: } Upper respiratory tract: increased nasal secretion, mucosal swelling, and/or nasal polyp } Chest: wheezing during normal breathing or prolonged phase of forced exhalation, hyperexpansion of thorax, use of accessory muscles, appearance of hunched shoulders, chest deformity. Key symptoms include wheezing; history of cough (especially at night), recurrent wheeze, difficulty breathing, or chest tightness; worsening symptoms with exercising, viral infection, inhaling allergens or irritants, weather changes, strong emotional expression, stress, or menstrual cycle; and symptoms worsen or occur at night, waking patient.a } Skin: atopic dermatitis, eczema Spirometry Can demonstrate obstruction and assess reversibility } Recommended in children aged >5 yearsb a Lack of wheezing and normal chest exam do not exclude asthma. Although guidelines recommend children be aged ≥5 years before using spirometry, some aged as young as 3 years are able to use it well enough to get useful information. Very young children can get frustrated with the machine and should wait until they are older to use it. Adapted from National Institutes of Health. National Heart, Lung, and Blood Institute.1 b controlling their symptoms and objectively measuring lung function with spirometry,” says John Kelso, MD, from the Division of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, California. For the past 10 years, Kelso, who also is a clinical professor of pediatrics at the University of California, San Diego School of Medicine, has conducted a workshop on spirometry at the American Academy of Pediatrics (AAP) annual meeting. The workshop provides information 22 on the latest guidelines for the recommended use of spirometry to diagnose and monitor asthma in children, as well as instructions on how to use and interpret the findings of spirometry and incorporate this tool into office flow. This article summarizes the workshop Kelso gave at the most recent AAP annual meeting in October 2015 in Washington, DC, with an eye to providing pediatricians with a quick primer on spirometry and some useful and accessible information C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 Symptoms and spirometry: twin components of diagnosis and monitoring Referring to the most recent national guidelines for the diagnosis and management of asthma by the National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program Expert Panel Report 3 (EPR3), Kelso highlighted the recommendation for including spirometry in a comprehensive evaluation of asthma that also includes physical examination and a detailed medical history.1 Table 1 lists these 3 main components of a thorough clinical evaluation of a child with suspected asthma. Spirometry is specifically needed to provide an objective measure of pulmonary function, because subjective measures such as patient perceptions of airf low obstructions, medical history, and physical examination are not reliable for assessing lung status or adequate to rule out other potential conditions (Table 2).1 According to the guidelines, diagnosing asthma with spirometry is recommended over measuring peak f low meters because of the wide variability in peak flow meters and clinical feature 2 OTHER CONDITIONS TO RULE OUT: MAKING THE DIFFERENTIAL DIAGNOSIS Upper airway diseases } Allergic rhinitis Large airway obstructions } Foreign body in trachea or bronchus } Allergic sinusitis } Vocal cord dysfunction } Vascular rings or laryngeal webs } Laryngotracheomalacia, tracheal stenosis, or bronchostenosis } Enlarged lymph nodes or tumor Small airway obstructions } Viral or obliterative bronchiolitis } Cystic fibrosis How spirometry works } Bronchopulmonary dysplasia } Heart disease Other causes } Recurrent cough (not attributed to asthma) } Aspiration from dysfunction of swallowing mechanism or gastroesophageal reflux Adapted from National Institutes of Health. National Heart, Lung, and Blood Institute.1 3 CRITERIA TO EVALUATE PROPER PERFORMANCE OF SPIROMETRY Peak Does each effort, as demonstrated by flow-volume curve, have a sharp initial peak? Finish Does each effort extend all the way down to baseline at the end? Reproducible Are at least 2 of the efforts superimposable? From John Kelso, MD. reference values. Once a child is diagnosed with asthma, the guidelines also recommend the use of spirometry to measure pulmonary function at 1-month to 6-month intervals, as well as ongoing monitoring over the patient’s lifetime to detect the potential for and rate of decline of pulmonary function over time.1 Such lifetime monitoring is needed to determine if the goals of treatment suggest that his or her asthma is well controlled,” he said. “However, [his/her] spirometry may be abnormal and in that case it is important to intensify treatment because the abnormal spirometry may indicate underlying inflammation that, if not adequately treated, may lead to airway remodeling.” The reverse is also true. “If a child has a normal spirometry but needs to take albuterol frequently, that child needs to have [his/her] treatment intensified,” Kelso added. are being met or if and when adjustments are needed. Ongoing spirometry along with symptom assessment for evaluating asthma control is needed, said Kelso. This is because of the discrepancy that often occurs between what symptoms suggest and what information obtained from spirometry reveals. “For example, a child may rarely need to use albuterol, which may M A R C H 2 016 | Spirometry is a pulmonary function test that measures the airflow and volume during forced expiration into a spirometer. To use it, the child inhales completely to total lung capacity (TLC), seals his or her mouth over a mouthpiece, and then forcefully exhales the air and continues to blow until no more air can be expelled (residual volume). The volume of air expelled in this maneuver is the forced vital capacity (FVC). To obtain accurate assessment of pulmonary function, correct use of the spirometer is essential. Table 3 lists criteria for assessing whether the child is performing the test well enough (ie, expending maximal effort) to provide accurate results. Of critical importance is for the child to exert maximal effort in blowing into the spirometer. If the child exhales too weakly, quits too soon, or the efforts are not reproducible, the results will not be accurate. Although technically blowing out for 6 seconds or more is required to ensure all air is exhaled, Kelso explained that a shorter effort of 6 seconds or less is acceptable in children. To ensure an adequate C O N T E M P O R A RY P E D I AT R I C S . C O M 23 clinical feature 4 ABNORMAL SPIROMETRY READING APPEARANCE ON SPIROMETRY CHARACTERISTICS Obstructive lung disease (eg, asthma) } Obstruction to airflow } Trouble getting air out } PFT: decreased FEV1 /FVC, decreased Flow-volume curve is “scooped” FEV1, maybe decreased FVC (FEV1 decreased out of proportion to FVC) Restrictive lung disease (eg, pulmonary fibrosis) } Restriction to full inhalation } Trouble getting air in } PFT: normal or increased FEV1 /FVC, Small triangle on flow-volume curve decreased FEV1, decreased FVC (FEV1 and FVC decreased proportionally) Abbreviations: FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; PFT, pulmonary function test. From John Kelso, MD. 5 USEFUL FEATURES OF A SPIROMETER } Inclusion of “incentive” screens for children to motivate them to blow as hard as they can (eg, simulate blowing candles on a birthday cake) } A standard printer attached to spirometer to print out reports or interface directly with electronic medical record } Reports customized to print out only the parameters of interest. } Ability to print dates and results of spirometry from previous visits on same report } Ability to print “pre-” vs “post-” bronchodilator reports 24 Clinics that care for children with asthma should have spirometry available because it improves their care, emphasized Kelso. He cited several features that are particularly useful, which are listed in Table 5. Although he said there is some upfront cost in obtaining the machine and a learning curve in using it, the advantages of having a spirometer far outweigh either of these potential downsides. Included in the cost are the machine (~$2000), 3-liter calibration syringe (~$300), filters (~$2 each), and a dedicated computer/printer. He emphasized that these upfront costs are recouped by the reimbursement for the test. In terms of a learning curve, Kelso emphasized that with some experience the test is easy to interpret for both assessing if the child is using it to maximal effort and whether the results are normal or abnormal. He also emphasized that spirometry can be incorporated in the clinical setting or office flow to be done easily and quickly. Conclusion From John Kelso, MD result, the child must do at least 2 to 3 maximal efforts that are reproducible and provide results (f low-volume curves) that are superimposable. Once the criteria are met, meaning that the child has exerted maximal effort in blowing into the spirometer at least 2 times with reproducible results, the results of the spirometer will reveal if the test is normal or abnormal. If abnormal, the test will show what the patterns Incorporating spirometry in the clinic of abnormality are; that is, whether or not these indicate obstructive lung disease or restrictive lung disease (Table 4). For children with indications of asthma, which is obstructive lung disease, Kelso said he typically gives the child albuterol, waits 10 minutes, and then repeats the spirometry. This is to see if there is an increase in the spirometry and how much of the asthma is acutely reversible with the bronchodilator. C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 Good asthma control starts with an accurate diagnosis, and an accurate diagnosis includes spirometry. Ongoing monitoring of asthma control also requires spirometry. To provide the best care for children with asthma, clinics should invest in a spirometer to give the most accurate information on which to base diagnostic and treatment decisions. For references, go to ContemporaryPediatrics.com/ spirometry-workshop Show How Much You Care for Sensitive Skin Now available in a 34-oz pump Dove Sensitive Skin Bar and Body Wash ,&%!# %$ *!&#+ patients ," $$%#.%%%* !$%!% )%#%#!%$%#%& !# &&# $ .% 1-to-1 ratio ,!#&%(% ! $&#% %!")(%% $ %"$%#%!" "#$#'%$ ### *Directly Esterified Fatty Isethionate. Dove and NutriumMoisture are Registered Trademarks. © 2016 Unilever CLINICAL FEATURE Pediatric OSAS Obstructive sleep apnea syndrome in kids MARY BETH NIERENGARTEN, MA. REVIEWED BY CAROL M ROSEN, MD. Ms Nierengarten, a medical writer in Minneapolis, Minnesota, has more than 25 years of medical writing experience, authoring articles for a number of online and print publications, including various Lancet supplements, and Medscape. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article. 26 A co-author of the recent Childhood Adenotonsillectomy Trial study discusses key developments for diagnosing and treating kids with obstructive sleep apnea syndrome (OSAS) as well as current AAP clinical practice guidelines for OSAS. with attention, behavior, and learning, Among the clinical syndromes that fall as well as worsening of any underlying under the umbrella of sleep disordered comorbidities including obesity, asthma, breathing (SDB), obstructive sleep apnea or psychological distress such as anxiety syndrome (OSAS) that affects the upper or depression. Thus, early diagnosis and airway is the most common and occurs in treatment is critical for preventing longabout 1% to 5% of children.1 Other more term morbidity.2 rare SDB clinical problems occur in children with brain and respiGiven that OSAS is the most FAST FACT ratory control deficits (central prevalent form of SDB and Obstructive sleep sleep apnea and/or hypoventhe one most likely to be apnea syndrome tilation disorder) or in those encountered in clinical pracoccurs in about who have abnormalities of tice, this article focuses only 1% to 5% of their spinal cord, nerves, muson this type of SDB. In 2012, children.1 cles, lungs, or chest wall that t he A merica n Academy of interfere with sufficient breathing Pediatrics (AAP) published cliniduring sleep. cal practice guidelines on the diagnosis For all children with SDB, chroniand management of childhood obstruccally disrupted sleep places them at tive sleep apnea syndrome.1,3 Since the increased risk of developing problems publication of those guidelines, important C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 clinical feature new findings from the Childhood Adenotonsillectomy Trial (CHAT) have been published that provide more insight into the expected benefits of adenotonsillectomy for children with mild-to-moderate OSAS, as well as on the natural history of milder OSAS.4 In this inter view, Carol L . Rosen, MD, professor of Pediatrics, J.S. Rube Endowed Chair in Pedia- will be taken from that presentation, as well as recommendations made in the most recent AAP guidelines (Table 1).1 Between 1 in 20 to 1 in 100 children suffer from OSAS, which is between 1% and 5% of children. Prevalence increases in African A merica n chi ld ren a nd lowincome children, with further evidence showing some disparities in The peak age of developing pediatric OSAS is between 2 years and 8 years, and it occurs before puberty with the same prevalence in boys and girls. tric Sleep Medicine, Division of Pediatric Pulmonology, Allergy/ Immunology, and Sleep Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, discusses key issues of screening, diagnosing, and treating children with OSAS based on her experience and how that experience is guided primarily by the current AAP practice guideline. As a coauthor of the more recent CHAT study, she also highlights the evolution of current thinking about childhood OSAS, management options, and unanswered questions going forward. Q. As discussed, this article focuses on children with obstructive sleep apnea. Let’s start by talking about the prevalence of pediatric OSAS. Dr. Rosen: I just gave a talk on this subject to pediatrician colleagues and residents, so some of the answers to this question and the following health outcomes and a differential response to therapy for these children. Years ago, we reported that African Americans were less likely to have undergone an adenotonsillectomy. Yet, in those who did, these children were 4 times more likely to have OSAS in the years following that surgery. In the CHAT study, African American children with OSA were less likely to normalize after surgery.4 The peak age of developing pediatric OSAS is between 2 years and 8 years, and it occurs before puberty with the same prevalence in boys and girls. Genetics play a role, with children in families with a history of OSAS at 2-fold to 4-fold increased risk of developing it. Obesity is also a risk factor for OSAS in children, but it is not as powerful a risk factor in children compared with adults. (However, obesity in the teenaged years is linked to a 5-fold risk for developing OSAS compared with nonobese M A R C H 2 016 | teenagers.) In children, obesity is a risk factor for incomplete response to adenotonsillectomy, and if children are already overweight before adenotonsillectomy, they are at increased risk for becoming overweight after that surgery.4,5 Q. What are the causes of OSAS in children and who are most at risk? Dr. Rosen: The number 1, 2, and 3 cause is adenotonsillar hypertrophy; that is to say, the main cause or “tipover” for children is having enlarged tonsils and adenoids. Other lessfrequent causes include craniofacial or genetic factors, neuromuscular disorders, or obesity. So, enlarged tonsils/adenoids are commonly found in children who develop OSAS. Other risk factors include the presence of comorbidities (ie, asthma, allergies), perinatal influences (former premature babies have 3 times the risk of developing OSA),6 living in disadvantaged neighborhoods,7 and exposure to irritants such as environmental tobacco smoke,8 infectious agents, and being sleep deprived. Finally, children with specific medical conditions are at increased risk, including those with Down syndrome, Prader-Willi syndrome, achondroplasia, Pierre Robin anomalad, sickle cell anemia,9 craniosynostosis, spina bifida, and Hunter disease. Q. What are the signs and symptoms of OSAS in children? Dr. Rosen: The most common symptom of OSAS in children is snoring. That is why I often use t he description “snoring and CONTINUED ON PAGE 30 C O N T E M P O R A RY P E D I AT R I C S . C O M 27 clinical feature 1 AAP CLINICAL PRACTICE GUIDELINE: KEY ACTION STATEMENTS (RECOMMENDATIONS) STATEMENT 1: Screening for OSAS } Clinicians should ask during each healthcare visit whether a child snores. } Clinicians need to do a more focused evaluation in children who snore, or who present with signs and symptoms of OSAS. STATEMENT 2A: Polysomnography For children who regularly snore or present with signs and symptoms of OSAS, clinicians should: } Obtain a polysomnogram, or } Refer child to a specialist (sleep or otolaryngologist) for a more extensive evaluation. STATEMENT 2B: Alternative testing STATEMENT 3: Adenotonsillectomy Clinicians may order alternative diagnostic tests if polysomnography is not available, including nocturnal video recording or oximetry, daytime nap polysomnography, or ambulatory polysomnography. Adenotonsillectomy should be the first line of treatment for children: } Diagnosed with OSAS, } Having adenotonsillar hypertrophy on clinical exam, and } In whom surgery is not contraindicated. Consider other treatments (see Statement 6) in children diagnosed with OSAS but without adenotonsillar hypertrophy. For obese children with varying degrees of adenotonsillar hypertrophy, use clinical judgement to assess the benefits of adenotonsillectomy compared with alternative treatments. STATEMENT 4: High-risk patients undergoing adenotonsillectomy Need to monitor high-risk patient undergoing adenotonsillectomy as in patients after surgery. STATEMENT 5: Reevaluation Patients with persistent signs and symptoms of OSAS after treatment should be clinically reassessed to determine if further treatment is needed. STATEMENT 5B: Reevaluation of high-risk patients High-risk patients, including those with a significantly abnormal baseline polysomnogram, with sequelae of OSAS, who are obese, or who remain symptomatic after treatment should be: } Reevaluated with an objective test for persistent OSAS after adenotonsillectomy, or } Referred to a sleep specialist. STATEMENT 6: CPAP Patients should be referred for CPAP management if symptoms/signs or objective evidence of OSAS persists (regardless of whether adenotonsillectomy was performed or not). STATEMENT 7: Weight loss Recommend weight loss as well as other therapy in obese or overweight children with OSAS. STATEMENT 8: Intranasal corticosteroids Prescribe topical intranasal corticosteroids for: } Children with mild OSAS in whom adenotonsillectomy is contraindicated, or } Children with mild postoperative OSA. Abbreviations: AAP, American Academy of Pediatrics; CPAP, continuous positive airway pressure; OSAS, obstructive sleep apnea syndrome. From Marcus CL, et al.1 28 C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 clinical feature 2 SYMPTOMS AND SIGNS OF OSAS IN CHILDREN History } Frequent snoring (at least 3 } Sleeping either in a seated nights/wk) position or with neck hyperextended } Labored breathing during } Headaches when waking up sleep } Gasps, snorting, observed } Cyanosis episodes of apnea } Sleepiness during the day } Sleep enuresis, particularly } Attention-deficit/ secondary enuresis (ie, after at least 6 months of continence) Physical examination hyperactivity disorder } Problems with learning } Tonsillar hypertrophy } Hypertension } Adenoidal facies } Micrognathia/Retrognathia } Overweight or underweight } Failure to thrive } High-arched palate Abbreviation: OSAS, obstructive sleep apnea syndrome. From Marcus CL, et al.1 CONTINUED FROM PAGE 27 obstructive sleep apnea” when referring to OSAS in children. About 10% of children habitually snore, that is, snore more than 3 nights a week, but not all children have OSAS. The AAP guidelines provide a list of additional signs and symptoms1 of OSAS beyond just snoring (Table 2). When taking a history of a child, it can be challenging to recognize OSAS because parents may not report some of the most common symptoms, such as snoring, difficult breathing, observed apnea and arousals, and any changes in daytime sleepiness. The clinical evaluation during wakefulness (history and physical examination) has only a 50-50 chance for predicting OSAS. Some children have lots of symptoms and enlarged tonsils, but only minimal findings when an overnight diagnostic test is performed. On the other hand, some children 30 may have minimal symptoms and mildly enlarged tonsils, but will show significant OSAS when overnight diagnostic testing is performed. Q. What are the current recommendations for screening and diagnosis? Dr. Rosen: As highlighted in the guidelines (Table 1, Statement 1),1 clinicians should screen all chil- signs and symptoms and family history of OSAS. The Sleep-Related Breathing Disorders Scale of the Pediatric Sleep Questionnaire (PSQ), by Chervin and colleagues, is a well-validated symptom inventory and popular screening tool.10 It should be noted, however, that the PSQ is not perfect at correctly identifying OSAS. In the CHAT study, this screening tool was “positive” in about 75% of snoring children who had OSAS diagnosed by overnight sleep study.4 For diagnosing OSAS in children, the AAP guideline provides a couple of options (Table 1, Statement 2A and 2B).1 For children who snore on a regular basis or present with signs/symptoms of OSAS (Table 2),1 the guidelines recommend a sleep study (which measures the severity of sleep apnea by using the apnea hypopnea index [AHI] measure) or referring the child to a specialist (such as a sleep specialist or otolaryngologist) for more extensive evaluation. Alternatively, clinicians can order tests other than a sleep study (Table 1, Statement 2B).1 There are a couple of challenges to diagnosis. Tonsil size does not Obstructive sleep apnea in children is a distinct disorder from the condition that occurs in adults. Source: Tauman R, et al. Expert Rev Resp Med. 2011. dren at every health encounter for snoring because snoring is the most common symptom. If the child snores, then the pediatrician should “do more,” checking into other potentially OSAS-related C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 predict OSAS severity and there is poor correlation between snoring, the AHI measured on the sleep study, and daytime dysfunction. Some children may have a lot of daytime problems believed to be clinical feature (CPAP), which is the standard treatbreathing in children. This indiment for adults with OSAS, the vidual may be a sleep medicine spestandard first-line treatment for cialist or other specialist, including children with enlarged tonsils and otolaryngologists. adenoids is adenotonsillectomy that has about an 80% cure rate (Table Does OSAS affect children What would you further 1, Statement 3).1 If the child already differently than adults? If so, how? highlight as important for Dr. Rosen: Yes, there are several difpediatricians to know about OSAS has had an adenotonsillectomy, then ferences. In adults, OSAS is much in children? CPAP is the next line of therapy and more common in men than women. Dr. Rosen: I would highlight the can be effective. However, impleIn children before puberty, CHAT study, which was a ranmentation and adherence are there’s no difference in domized, controlled trial in which problematic, especially in FAST FACT prevalence between girls children with mild-to-moderate children with limited Clinicians and boys. In adults, OSAS were randomized to surgery ability to cooperate or in should screen all the peak age for OSAS or watchful waiting and supportteenagers who are oppochildren at every is midlife, whereas ive care. After 7 months followsitional. Parent superhealth visit for in children it peaks ing surgery or watchful waiting, vision and commitment snoring.1 between ages 2 years the children were reassessed for are key. Although nonsurand 8 years. The presentOSAS. gical CPAP can be an altering symptoms also differ in that for The study found no differences native treatment in children with children the main complaints are between the 2 groups in terms enlarged tonsils and adenoids, it is snoring and behavioral or learnof the primary outcome, which much harder to deliver and tolerate ing problems, whereas for adults looked at attention/executive and than effective CPAP therapy when cognitive functioning. 5 Children the chief complaint is daytime the tonsils and adenoids are blocking sleepiness. the upper airway. who did undergo surgery, however, There are also different patterns Other treatments for specific reported significant improvements of breathing. Adults have more children may include denta l/ in global behaviors, generic and specific discreet airway collapses, orthodontic devices, specialized disease-specific quality of life, and whereas children are more likely to have partial collapses because they are better at keeping their airway For every increment in BMI of 1 kg/m2 open than adults. This may explain beyond the mean BMI for age and gender, why children don’t necessarily have the risk of OSAS increased by 12%. as much daytime sleepiness as adults Source: Arens R, et al. J Appl Physiol. 2010. because they are better at staying asleep during their partial airway collapse compared with adults who regularly wake up when their airaggressive surgeries, positional symptoms of OSAS such as snoring ways collapse completely. However, therapy, or weight loss. and sleepiness. In the early surgery the clinical picture of obese children group, most of these children (79%) with OSAS may be more similar to also had a normal polysomnograWhen should a pediatrician adults with OSAS. phy 6 months later compared with refer a child with OSAS to a sleep only 46% of the kids in the watchspecialist? ful waiting group. Dr. Rosen: That is clearly stated in What is the standard In the surgery group, finding the guidelines (Table 1, Statements 1 treatment for OSAS in children? a normal sleep study 6 months and 2).1 The guidelines recommend Dr. Rosen: Unlike the use of conlater is similar to previous studies tinuous positive airway pressure referral to a specialist in sleep and related to OSAS, but only low AHI during overnight testing. Other children with a high AHI may have only minimal daytime problems. Q. Q. Q. Q. M A R C H 2 016 | C O N T E M P O R A RY P E D I AT R I C S . C O M 31 clinical feature suggesting an 80% to 85% “cure rate” for OSAS af ter surger y. On the other hand, the finding that almost one-half of the children who did not have surgery had a normal sleep study option in children with milder OSAS and fewer symptoms. However, there are still many unanswered questions about what the best practices are with regard to how to best treat children who Symptoms of OSAS are often subtle, and therefore not always immediately recognized by parents. Source: Tauman R, et al. Expert Rev Resp Med. 2011. 7 months later was somewhat of a surprise. Children with milder OSAS and less obesity, and who were non-African American, were more likely to “normalize” their sleep studies. However, normalization of the sleep study doesn’t mean that symptoms got better.11 Nevertheless, watchful waiting may be a reasonable management snore. The interesting thing about the CHAT study is that nearly half the children who met criteria for study participation (ie, candidates for surgery) based on clinical assessments that indicated OSAS actually had normal sleep studies without OSAS, and therefore were not eligible for enrollment in the CHAT study. T he Nat iona l Inst it utes of Health (NIH) is sponsoring a new multisite clinical trial called the Pediatric Adenotonsillectomy for Snoring (PATS) trial that begins this spring. The trial will look at children with mild SDB (that is, children who snore but don’t have OSAS) and examine whether tonsillectomy and adenoectomy will change outcomes in this group. It will assess the effect of early adenotonsillectomy on behavior, vigilance, OSAS symptoms and quality of life, and healthcare use. It will also identify factors that moderate a child’s response to surgery, including age, race, asthma, tobacco exposure, and socioeconomic status. For references, go to ContemporaryPediatrics.com/ pediatric-OSAS Rethinking asthma CONTINUED FROM PAGE 19 were seen. There are a number of different smartphone applications offering free (Medisafe [www.medisafe. com/]; MedActionPlan [w w w. medactionplan.com/]; MyMeds [http://my-meds.com]) and paid (Rx Remind Me [https://itunes. apple.com/us/app/rx-remind-me/ id972766049?mt=8]) apps and plans that allow one to enter a medication to receive text or e-mail reminders. For some patients, this type of reminder system may significantly 32 improve compliance and potential control.20 Immunotherapy Despite being used in clinica l practice for more than 100 years, immunotherapy remains underused in clinical practice related to asthma. 21 As healthcare moves toward more personalized medicine, immunotherapy holds great promise—identification of specific subsets of patients that will be ident i f ied f rom a speci f ic therapy. C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 Increasingly, available molecular diagnosis tools will allow for better identification of patients who will benefit from particular immunotherapies. As an example, 2 recent studies have demonstrated decreased need for inhaled steroids among patients sensitized to house dust mites and started on a targeted oral immunotherapy.22,23 For references, go to ContemporaryPediatrics.com/ rethinking-asthma puzzler TODDLER WITH BLISTERING ACRODERMAL RASH CONTINUED FROM PAGE 13 History and physical The child was evaluated at multiple clinics and treated with topical steroids and antifungal creams without improvement. Two weeks prior to this visit, he developed a tactile fever with increased blistering. He was treated with a 7-day course of oral antibiotics without change in the rash. The parents also noted recent thinning of the boy’s hair. The patient was of appropriate size and meeting his developmental milestones. He had traveled to Mexico 3 weeks after onset of the knee rash, at which point he developed mild diarrhea that resolved without treatment. He was exclusively breastfed until aged 2 months, at which time he was transitioned to full formula. He began eating solids at age 4 months, and continued formula feeding through age 14 months. At the time of presentation, he was eating a full and varied diet. His 3 siblings are healthy. On examination, the patient appeared alert and well-nourished (Figure 1). He had erythematous, superficially eroded, and crusted papules and plaques on the periorbital, perinasal, and perioral skin as well as on his cheeks, ears, posterior scalp, dorsal hands, dorsal feet, elbows, and knees. A few plaques were noted on the antecubital fossae, forearms, and trunk. Confluent, beefy-red eroded plaques with polycyclic borders covered his penis, scrotum, perineum, inguinal folds, medial thighs, and gluteal cleft. Multiple smaller, erythematous, eroded papules were present at the margin of these lesions. His hair was diffusely thin. No lymphadenopathy was appreciated. Neurologic exam was unremarkable. Pertinent laboratory data included a hemoglobin of 10.8 g/dL (normal: 10.5-13.5 g/dL); mean cell volume, 83.5 fL (normal: 70-86 fL); albumin, 4.3 g/dL (normal: 3.4-4.2 g/dL); alkaline phosphatase, 83 U/L (normal: 115-460 U/L); and C-reactive protein, 3.0 mg/dL (normal: 0.0-0.9 mg/dL). Blood cultures returned negative, and a punch biopsy of the thigh was performed by the Dermatology service. Other testing included a wound culture and herpes simplex virus (HSV) polymerase chain reaction (PCR). Differential diagnosis The differential diagnosis for this child presenting with chronic, diffuse, eroded, and scaly red papules and plaques is broad and includes infectious etiologies, autoimmune disorders, drug reactions, and nutritional deficiencies (Table). Infectious etiologies that can cause rash, particularly in the intertriginous areas, include erythrasma, erysipelas, cellulitis, bullous impetigo, staphylococcal scalded skin syndrome (SSSS), and cutaneous candidiasis. Erythrasma, which typically affects adolescents and adults, is a superficial skin infection caused by the skin flora Corynebacterium, and it presents with macerated, scaly plaques in the axillae, groin, and between the toes. Erysipelas involves the upper dermis, while cellulitis involves the deeper dermis. In distinguishing between the 2 rashes, erysipelas has a clear line of demarcation with affected tissue and is associated more with systemic symptoms of fever and chills. M A R C H 2 016 | TABLE DIFFERENTIAL DIAGNOSIS FOR ACRODERMAL RASH INFECTIOUS } Erythrasma } Erysipelas } Cellulitis } Cutaneous candidiasis } Bullous impetigo } Staphylococcal scalded skin syndrome IMMUNE } Linear IgA bullous dermatosis } Bullous pemphigoid } Atopic dermatitis } Seborrheic dermatitis } Psoriasis } Allergic/irritant contact dermatitis } Primary immunodeficiencies (eg, Wiskott-Aldrich syndrome) NUTRITIONAL DEFICIENCIES } Zinc } Essential fatty acids } Biotin (vitamin B7) } Niacin (vitamin B3) } Protein OTHER } Epidermolysis bullosa } Drug reaction } Toxic epidermal necrolysis } Stevens-Johnson syndrome Abbreviation: IgA, immunoglobulin A. Exfoliative toxins elaborated by Staphylococcus aureus cause a range of skin lesions by binding to and disrupting adhesion molecules high C O N T E M P O R A RY P E D I AT R I C S . C O M 33 puzzler in the epidermis. In bullous impetigo, which usually occurs in older children and adults who have antibodies to the toxins and can readily clear them in their kidneys, patients can develop localized lesions. The eruption begins as small red papules that progress to vesicles surrounded by erythema, then into expanding flaccid bullae with clear yellow fluid and central crusts. In SSSS, which occurs in younger children who lack antibodies and patients with renal failure who cannot clear the antibody-bound toxin, toxins disseminate to the same epidermal adhesion molecules resulting in total body erythema and generalized superficial sloughing of the skin. Patients are usually febrile with diffuse blanching erythema, and f laccid bullae and erosions develop first over areas with the most frictional trauma (feet, hands, buttocks, flexural surfaces) 1 to 2 days later. Gentle pressure to the skin by the examining finger results in a Nikolsky sign or skin sloughing. Candida infections often occur as a secondary infection in patients with chronic seborrheic dermatitis or contact irritant dermatitis. They tend to manifest as erythematous, macerated plaques/erosions with fine scaling and satellite lesions, which can occur in the inguinal folds, axillae, scrotum, and intergluteal folds. However, given this patient’s lack of response to antifungals, antibiotics, and topicals, there was a greater concern for an underlying systemic process triggering his rash. Immune etiologies that can present with diffuse red scaly rash include atopic dermatitis, psoriasis, and seborrheic dermatitis. The 34 infantile form of atopic dermatitis presents with pruritic, red scaly lesions on the extensor surfaces of the arms, legs, face, and scalp, with sparing of the diaper area, which makes it unlikely in this patient. Psoriasis presents with symmetrically distributed cutaneous plaques with sharply defined margins and a silver scale, while seborrheic dermatitis is characterized by well- Finally, various nutritional deficiencies that can result in skin fragility, rash, hair loss, impaired immune function, and delayed developmental growth should be considered, including deficiencies in essential fatty acids, biotin, niacin, or zinc. Biotin is essential in carbohydrate and fatty acid metabolism. Symptoms of deficiency may include mental status changes, Nutritional deficiencies that can result in skin fragility, rash, hair loss, impaired immune function, and delayed developmental growth should be considered. demarcated erythematous papules and greasy yellow scales, usually around the scalp, ear, midface, and intertriginous areas, particularly the diaper. Both processes are not consistent with the patient’s presentation. Other etiologies to consider include junctional disorders that disrupt the integrity of the dermal keratinocytes such as epidermolysis bullosa, or drug reactions causing toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome (SJS). In epidermolysis bullosa, genetically mediated defects in cell adhesion molecules in the epidermis, epidermal-dermal junction, or in the dermis result in blistering and erosions/ulcerations in areas of friction-induced trauma. In some variants, the mucous membranes are also involved in these chronic disorders. Although the patient did have drug exposure with antibiotics, there was no mucosal involvement, which excludes SJS and TEN. C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 myalgias, anorexia, nausea, and red scaly dermatitis of the extremities. Both the rashes seen in biotin and essential fatty acid deficiency can result in skin changes similar to that of zinc deficiency. The patient’s varied diet made this an unlikely cause. Niacin deficiency can result in pellagra, a triad of photosensitive dermatitis in sun-exposed areas, diarrhea, and dementia. Given the patient’s rash in the perineal area, this also was unlikely. The rash associated with zinc deficiency, secondary to a zinc-deficient diet, chronic zinc loss in the gastrointestinal tract, or acrodermatitis enteropathica (AE), presents with erythematous scaly plaques and/or erosions on the extensor surfaces of the extremities and periorificial areas, and hair loss, which occurred in this patient. In time, children with zinc deficiency also stop gaining weight and become fussy. Any gastrointestinal disorder resulting in malabsorption (eg, puzzler cystic fibrosis [CF]) and secondary zinc deficiency can result in similar symptoms, and needs to be distinguished from AE. Diagnosis The patient’s zinc level returned low at 26 μg/dL. The punch biopsy showed epidermal hyperplasia, spongiosis, keratinocyte vacuolization, upper epidermal necrosis, and significant neutrophilic exocytosis with occasional clusters of gram-positive cocci in the stratum corneum consistent with necrolytic migratory erythema seen in nutritional deficiency and superimposed bacterial infection. The HSV PCR remained negative, and wound culture returned positive for methicillin-sensitive S aureus and Corynebacterium sp. Patient outcome IMAGE CREDIT/AUTHOR SUPPLIED The patient was discharged home on oral clindamycin and topical mupirocin, and initiated on zinc acetate supplementation at 1.7 mg/kg/day. One month later, his rash had improved, but he continued to develop intermittent new vesicles. His zinc level was rechecked and remained low at less than 16 μg/dL. Zinc supplementation was increased to 4 mg/kg/day, which resulted in resolution of the rash and a normal serum zinc level after 1 month. With follow-up over the succeeding months, his alopecia began to resolve and no further lesions were noted (Figure 2). Discussion Acrodermatitis enteropathica is a rare inherited form of zinc deficiency, characterized by diarrhea, alopecia, acral dermatitis, and S FIGURE 2 Resolution of prior lesions, resulting in postinflammatory hyperpigmentation, as well as improvement in alopecia. “dementia” (irritability). It is caused by an autosomal recessive defect in the SLC39A4 gene, which impairs intestinal zinc absorption.1 Studies have shown that human breast milk compared with formula has a relatively high concentration of zinc because of greater bioavailability from the high-citrate, lactoferrin, and low-phosphorus environment, as well as the presence of a zinc transporter protein that facilitates absorption. These factors often compensate for an affected child’s M A R C H 2 016 | poor absorption. Breast milk zinc levels start declining around age 6 months and no longer compensate adequately. 2 In patients who develop these characteristic symptoms upon weaning from breast milk, it is best to consider a diagnosis of AE. It is atypical in this patient that his symptoms developed over a year from weaning off breast milk. Rarely breast milk is low in zinc, and full-term babies of affected mothers will present with zinc-deficiency symptoms at 1 month of age. C O N T E M P O R A RY P E D I AT R I C S . C O M 35 puzzler Because zinc is not concentrated in babies until the last month of gestation, symptoms will develop sooner in premature infants. In patients who develop symptoms while on breast milk, it is important to consider malabsorption syndromes in the differential, such as CF. Zinc acts like a metal component of an activating cofactor for many enzymatic systems in the body, including alkaline phosphatase, carbonic anhydrase, or dehydrogenases. 3 Accordingly, this patient’s relatively low level of alkaline phosphatase was an important early clue to his diagnosis of zinc deficiency. Zinc also plays a vital role in wound healing and growth, and it is involved in immune responses to infection.4 Ten percent to 40% of dietary zinc is absorbed in the small bowel, but absorption can be inhibited by other factors in the bowel such as the presence of fiber, iron, or other heavy metals. Sixty percent of zinc is loosely bound to albumin, while 30% is bound tightly to macroglobulins. Normal zinc levels range from 70 μg/dL to 120 μg/dL. Zinc is mostly bound intracellularly to metalloproteins, with primary stores in the liver and kidney.5 Clinical manifestations of zinc deficiency commonly include an erythematous and vesiculobullous dermatitis; alopecia; ophthalmic disorders including photophobia; anorexia; diarrhea; growth retardation; delayed sexual maturation; impaired taste or smell; hypogonadism; neuropsychiatric manifestations; anemia; and frequent infections with poor wound healing.3 The rash associated with low zinc levels typically presents with erythematous scaly plaques, 36 which can develop into vesicular, bullous, or pustular lesions with subsequent desquamation, particularly in areas where the skin turns over most quickly (intertriginous and periorificial areas). Characteristic locations include the extensor extremities, the anogenital skin, and the periorificial area of the face. Other cutaneous stigmata include angular cheilitis, of elemental zinc) are generally required. 8 Symptoms should resolve within 1 month of appropriate supplementation, as was seen in this patient. In patients whose symptoms do not respond within 1 month of initiation of therapy, it is important to consider the therapeutic level of treatment versus another underlying cause, such as malabsorption syndromes (eg, CF). The child in this case demonstrated alopecia with perioral and acral distribution of rash, as well as lab data supporting zinc deficiency. paronychia, and generalized alopecia. Skin lesions often become secondarily infected with bacterial or fungal infections.3 Sy mptomat ic low levels of zinc also may be associated with impaired intestinal absorption (Crohn disease, CF); increased urinary excretion (renal tubular defect in sickle cell disease, nephrotic syndrome); decreased binding capacity (hypoalbuminemia secondary to liver disease); or iatrogenic causes (inadequate supplementation in total parenteral nutrition [TPN]dependent patients, those with decreased i nta ke, or premature infants whose nutritional demands are greater than maternal supply).6,7 For zinc deficiency related to dietary intake, supplementation with 1-2 mg/kg/day of elemental zinc is generally suff icient; for def icits related to impaired zinc absor pt ion, higher replacement dos e s (a rou nd 3 mg / k g /d ay C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 These syndromes will only partially improve with supplementation, and will require addressing the primary defect, such as the utility of pancreatic enzyme replacement in CF. The child in this case demonstrated alopecia with perioral and acral distribution of rash, as well as lab data supporting zinc deficiency that was determined to be of unknown etiology because symptoms developed almost a year after weaning off breast milk. He also lacked clinical symptoms such as failure to thrive or frequent infections. Although the etiology of the patient’s zinc deficiency continues to be evaluated at this time, he had substantial clinical improvement once his zinc level returned to normal. For references and authors’ biographies, go to ContemporaryPediatrics.com/ puzzler-0316 peds v2.0 ANDREW J SCHUMAN, MD SECTION EDITOR Clinical thermometry An update and review IMAGE CREDIT/AUTHOR SUPPLIED Thermometry has come a long way since 1592 when Galileo first fashioned a crude thermometer to measure temperature. In this month’s article, Dr. Schuman reviews what’s new in tools for determining one of the body’s most vital signs. When I opened my first practice in 1986, I was intrigued by an advertisement in Contemporary Pediatrics that caught my attention, and days later I was the proud owner of a FirstTemp tympanic thermometer. The manufacturer (Intelligent Medical Systems; Carlsbad, California) promised the device’s measurements were as accurate as oral and rectal temperatures taken with glass thermometers. I was initially skeptical of this high-tech thermometer, but within weeks it proved to be a very popular device among staff, providers, and patients. The reason it was successful was that it required little patient cooperation and took temperatures in seconds, and it produced measurements comparable to those obtained with our digital oral and rectal thermometers. This month’s Peds v2.0 provides an overview of the history of clinical thermometry and reviews some of the thermometers that are currently available for home and office use. A brief history of clinical thermometry Early physicians recognized that illness often was associated with fever, but it took centuries for scientists to develop the means to actually measure body temperature. Although Galileo in 1592 was the first to fashion a crude thermometer, it was another Italian scientist, Santorio Santorio, who was the first to take oral temperatures in 1625.1 His thermoscope, as it was called, was large and cumbersome, and took hours to perform a single measurement. It was not until the mid-1800s that the German physician Carl Wunderlich developed a footlong thermometer that could take clinical temperatures.1 In 1868, he published his data of more than 1 million axillary readings from M A R C H 2 016 | Kinsa Smart Thermometer Accurate temperatures can quickly be included in EHRs. See page 40. more than 25,000 patients. He determined that there was a diurnal variation in daily body temperatures ranging from 97.3°F in the morning to 99.5°F in the evening. He also originated the standard of 98.6°F as “normal body temperature” that we use today. His readings took 20 minutes to perform, and for anyone but the most patient of physicians, this was not a practical device. It was a contemporary of Carl Wunderlich, Thomas Clifford Allbutt, an Englishman, who introduced the first portable 6-inch thermometer in 1866 that could record a temperature in 5 minutes.1 His C O N T E M P O R A RY P E D I AT R I C S . C O M 37 pediatrics v2.0 Thermofocus 01500A3 is an easy-to-use, noncontact, infrared forehead thermometer. See page 40. Fever and children Before the Haemophilus influenzae type b vaccine first became available in 1985 and the first pediatric conjugate pneumococcal vaccine became available in 2000, pediatricians routinely encountered severe illnesses in patients that included meningitis, septic arthritis, osteomyelitis, and sepsis. These were so common that blood cultures and spinal taps were routine office procedures. Before the introduction of the H influenzae and pneumococcal vaccines, 3% of young febrile children without a focus of infection had positive blood cultures for H influenzae, Streptococcus pneumoniae, or Neisseria meningitides. Six percent of those patients positive for pneumococcus also were discovered to have meningitis, while up to 20% of positive blood cultures for H influenzae were associated with meningitis.2,3 Today, the incidence of occult bacteremia is 0.5%, and we rarely perform blood cultures or spinal taps in the workup of infections, except in febrile young infants.4 The 38 key point is that just 2 decades ago in the last century, parents and pediatricians were alerted to the possibility of severe pediatric illness by the presence of fever, and they were comforted by its absence. Today, documentation of a fever alerts physicians regarding the cause of the associated symptoms. In most situations, there is an infectious cause with rheumatologic illnesses, malignancy-related fevers, and period fevers being much less common.5 Identification of fever in young infants is very important with most protocols identifying “fever” as a rectal temperature of 100.4°F or higher. Fever in young infants Even today, when an infant in the first 2 month of life presents with fever, we proceed to evaluate that child for sepsis, meningitis, pneumonia, or a urinary tract infection. In most circumstances, this warrants admission of young infants for empiric antibiotic therapy pending results of cultures. Therefore, identification of fever in young infants is very important with most protocols identifying “fever” as a rectal temperature of 100.4°F or higher. Studies have repeatedly shown that parents overdiagnose fever C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 temperature, as well as recommend a thermometer for home use and recommend an age-dependent site for temperature measurement. Tympanic temperatures: Reliable or not? Fever and its measurement was a popular topic in the pediatric literature during the 1980s through 2000 when infrared “tympanic” thermometers (the FirstTemp was introduced in 1984) became available, and pediatricians published study after study comparing this device’s measurement to those taken by more IMAGE CREDIT/AUTHOR SUPPLIED thermometer could be transported in a pocket. Subsequently, temperature measurement became a routine vital sign. (You can view one of Allbutt’s thermometers by visiting https://museumofhstm.wordpress. com/2012/08/31/allbutts-clinicalthermometer/.) Allbutt eventually received a knighthood for his achievement and service to medicine. when they rely on touch alone. There are also a wide variety of home thermometers available for use in infants including pacifier thermometers, forehead thermometers, ear thermometers, and digital thermometers that can be used either orally or rectally. When parents report an elevated temperature in a young infant above the threshold of 100.4°F degrees, it often is followed by the recommendation for the parent to take the baby to the emergency department for a septic workup. Emergency department physicians, erring on the side of caution, often will do this workup if the infant has no fever on arrival, and even when an antipyretic has not been given. It is therefore important for pediatricians to instruct new parents regarding how to take a pediatrics v2.0 traditional means. The tympanic membrane was an attractive site for temperature measurement because of its shared blood supply with the hypothalamus, the body’s thermoregulatory center. Many arguments ensued regarding the appropriateness of the use of tympanic thermometers in clinical practice, with some studies showing good correlation and others showing poor correlation between temperatures taken from the ear canal and oral, axillary, and rectal sites.6,7 Many other companies introduced their own ear thermometers. All the devices had 1 thing in common: They did not really measure temperatures of the tympanic membrane, but measured the temperature of the ear canal. To present measurements with which physicians were more familiar, all these devices added a “fudge factor,” called an “offset,” to the actual ear canal measurement to present an equivalent oral or rectal temperature. Although these temperatures were not influenced by the presence of cerumen or otitis media, measurements were affected by the size of the ear canal and how deep the probe could be inserted comfortably. Overall, because of their speed and ease of use, ear thermometers became an office staple to screen children aged older than 2 years for the presence or absence of fever. IMAGE CREDIT/AUTHOR SUPPLIED Temporal artery thermometry It was Exergen (Watertown, Massachusetts) that introduced the next innovation in infrared temperature measurement. Forehead temperatures have been taken by concerned mothers since the dawn of time, HOW TO TAKE A TAT-2000C OR TAT-5000 MEASUREMENT } Slide the thermometer straight across the forehead (mid- line), and not down the side of the face. Hold down the button when you do so. You will hear a series of audible clicks as the device records higher temperature readings. } It is preferable to hold the instrument sideways. Approaching your patient with the instrument straight up and down could be somewhat intimidating. } Finish the measure by touching the device behind the ear. This TAT-2000C lets the device display accurate readings when the patient is perspiring. When making the measurement behind the ear, tuck the thermometer under the ear lobe in the soft conical depression on the neck just below the mastoid. Take your finger off the button to display the reading. An excellent animated in-service video can be viewed at www.exergen. com/ww/index.htm. It features the voice of Exergen’s chief clinical scientist (and the device inventor’s wife), Mary Beth Pompei. From: Exergen Corp.8 and Francesco Pompei, the founder and chief executive officer of Exergen, suspected that the superficial branch of the temporal artery was an ideal site for reliable and reproducible temperature measurement. Exergen introduced its clinical temporal artery thermometer, the TAT5000, in 2000. Now nearly 16 years later, the company has sold more than 400,000 devices and the thermometer is being used by over half of pediatric practices in the United States. The device measures the patient’s core body temperature, which is about 1°F or 0.5°C higher than oral readings. The TAT-5000 thermometer uses dual scanners, one that measures ambient environmental temperature and another that gauges the arterial temperature of M A R C H 2 016 | TAT-5000 the patient’s skin. The thermometer records over 1000 readings per second, producing an audible click as the device registers a higher reading. After taking 3000 readings, an internal “heat balance” algorithm determines the arterial temperature, which is displayed on the unit’s LED screen. Best of all, although the thermometer lists for over $400, Exergen frequently puts the device on sale for $200. One reason the device is so popular in the medical community is that it carries a lifetime warranty. Parents also can purchase a home forehead thermometer manufactured by Exergen for less than $30. This is the Exergen consumer TAT2000C. It uses the same technology C O N T E M P O R A RY P E D I AT R I C S . C O M 39 pediatrics v2.0 Home thermometers If you view the thermometers available for home use displayed at any pharmacy, you will see a wide variety of thermometers for taking temperatures on children. Consumer sites such as Consumer Search (www.consumersearch.com/digital-thermometers/best-temporalthermometers) list thermometers that they recommend for home use. These include the Kinsa Smart Thermometer (New York, New York) that I reviewed in “What’s new in ‘connected’ medical devices” that appeared Caregiver Noncontact infrared device also measures temps of objects like heated baby bottles. 40 TEMPORAL ARTERY THRESHOLD MEASUREMENTS FOR FEVER BY AGE TABLE AGE UPPER RANGE OF NORMAL TEMPERATURE 0-2 mo 100.7°F (38.1°C) 3-47 mo 100.3°F (37.9°C) 4-9 yr 100.1°F (37.8°C) 10-18 yr 100.1°F (37.8°C) From: Exergen Corp.8 in the November 2015 issue of Contemporary Pediatrics. Other Consumer Search favorite models include the Vicks V934 digital thermometer (Kaz Inc; Southborough, Massachusetts) for rectal temps; the Braun Thermoscan 5 (Kronberg, Germany) for ear temperatures; and the Exergen TAT-2000C for forehead temperatures. Please note that pacifier thermometers should be avoided because they are not believed to be accurate. Newest clinical thermometers The latest innovation in clinical thermometry is the noncontact, infrared forehead thermometer. One model sold for use in pandemics (eg, Ebola, influenza) is the Thermofocus 01500A3, manufactured by Tecnimed (Varese, Italy). It is placed a few inches from the center of the forehead and positioned so that 2 beams of light emanating from the device overlap. A button is depressed and the temperature is displayed seconds later. Tecnimed states that the device’s reading is as accurate as an axillary temperature. C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 The Thermofocus can store up to 9 measurements, and it sells for about $80 on Amazon.com. Thermomedics (Delray Beach, Florida) released its Caregiver clinical-grade, noncontact infrared thermometer last year. The device is very rugged, and takes a measurement when placed 0.5 inches to 2 inches from the forehead. It can store up to 30 readings. Like the Thermofocus, the Caregiver can be used to measure environmental objects (eg, heated baby formula in a bottle) as well. The Caregiver sells for $357 and comes with a 2-year warranty, with a lifetime warranty optional. According to the manufacturer, the device displays a reading that should be interpreted as an oral temperature. Note that I’m not aware of any peer-reviewed articles evaluating noncontact, clinical-grade thermometers such as the Caregiver and the Thermofocus. I’ve used both devices in my clinic on dozens of children, both febrile and afebrile, and I have found the readings to closely correlate with temperatures taken by our TAT-5000. In conclusion As clinicians, we often take our tools for granted. We are able to record one of our most important vital signs because of the efforts of scientists and physicians centuries ago. Our readings are displayed in seconds, but it remains up to the pediatrician to determine the cause, treatment, and consequences of the illness associated with the fever. For references, go to ContemporaryPediatrics.com/ thermometry IMAGE CREDIT/AUTHOR SUPPLIED as the TAT-5000, but it can store up to 8 temperatures, has an illuminated screen, and can be silenced so it doesn’t wake a child. The device has a warranty of 1 year. Exergen worked with Dr. Keith Powell and 15 pediatric practices affiliated with the Children’s Hospital Medical Center of Akron, Ohio, to establish a normal upper limit of measurements for its temporal artery thermometers. Powell recorded 2300 temperatures from children to determine the “threshold” for fever as displayed in the Table.8 Prevent, soothe, and treat diaper rash with Aquaphor® Healing Ointment and NEW Aquaphor Diaper Rash Cream Clinically proven to relieve diaper rash within 6 hours1 Gentle for babies’ sensitive skin Free of dyes and fragrances Preservative-free, unlike other brands* Aquaphor Healing Ointment Aquaphor Diaper Rash Cream with 15% zinc oxide In addition to diaper rash, Aquaphor Healing Ointment can be used to treat * When compared to A+D®, Desitin®, and Balmex® products, which all use preservatives in their pediatric treatments. The brands listed are the registered trademarks of their respective owners. Reference: 1. Data on file. Beiersdorf Inc. ©2015 Beiersdorf Inc. magenta cyan yellow black ES745376_CNTPED0316_041_FP.pgs 03.01.2016 02:28 ADV CONTINUED FROM PAGE 44 dermcase Discussion Also known as Becker melanosis or Becker pigmentary hamartoma, a Becker nevus (BN) is an acquired benign hamartoma. Although the exact cause is unknown, BN has been described in both sporadic and familial cases by a paradominant mode of inheritance.1-3 It occurs at an incidence of 0.5% in adolescent males with a 6:1 male predominance. 2 Approximately half of BN cases begin to develop before age 10 years. It is hypothesized that these nevi have an increased number of androgen receptors, which can explain the typical history of onset around puberty and hypertrichosis of the nevus.2 The nevi most commonly occur unilaterally on the shoulder or back. Lesions can appear as a macule or plaque and can be smooth or verrucous textured; range in color from skin colored to brown; and vary from 1 cm to many centimeters in size. They are generally irregularly shaped but well demarcated. Becker nevi typically last for a BECKER NEVUS are not limited to, tinea versicolor, eczema, acne vulgaris, acanthosis nigricans, neurofibromatosis type 1, hypoplasia of the ipsilateral breast, scoliosis, lumbar spina bifida, and pectus carinatum.1-3 Becker nevus syndrome occurs when there are associated cutaneous, muscular, or skeletal abnormalities or unilateral breast hypoplasia in addition to the nevus.1-3 Not surprisingly, acanthosis nigricans was appreciated during this patient’s physical exam, and he has a past medical history of eczema. Diagnosis is usually made by history and physical examination in a patient who has a hyperpigmented patch with hypertrichosis on the shoulder or back. Differential diagnosis includes café au lait spots, postinf lammatory hyperpigmentation, congenital melanocytic nevus, and plexiform neurofibroma 1 (Table).2 Congenital smooth muscle hamartoma is actually the newborn equivalent of a BN with similar clinical and histological findings at birth. Reassurance should be provided that Becker nevus represents a benign entity and malignant conversion has not been demonstrated. lifetime, but many fade with time. They are benign and have not been reported associated with malignant transformation.2 Although a BN can be an isolated cutaneous finding, many associated cutaneous, muscular, and skeletal anomalies have been reported. These include, but 42 Histopathology shows epidermal papillomatosis, horn cysts, acanthosis, and hyperkeratosis. Often there are increased numbers of thickened smooth muscle bundles that connect to hair follicles.1,2 There are no nevomelanocytes present, helping to distinguish this from a congenital C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 TABLE DIFFERENTIAL DIAGNOSIS FOR BECKER NEVUS Café au lait spots } Congenital melanocytic nevus Plexiform neurofibroma Congenital smooth muscle hamartoma Postinflammatory hyperpigmentation From Shou-Mei Kane K. et al.2 nevomelanocytic nevus.2 Although the basal cell keratinocytes are filled with melanin, there is no increase in the number of melanocytes present. Because of the association with rare muscular, skeletal, and cutaneous abnormalities, further evaluation should be considered when a patient is diagnosed with a BN.1,2 Biopsies are performed on occasion to rule out other etiologies. Because the lesions are benign, no treatment is required. However, for irritation or cosmetic reasons, laser therapy can be used to remove hair and lighten the lesions. Newer studies have revealed that using low-fluence high-repetition-rate diode lasers (808-801 nm) can provide significant hair reduction at 6 and 12 months posttreatment providing substantial aesthetic improvement of the lesion.4 There also have been reports of the use of topical flutamide therapy for 8 weeks to treat the hyperpigmentation in the lesion. 5 With dermcase this treatment, no change in the pigmentation of the surrounding skin outside the nevus was reported. However, there was no observed improvement in the hypertrichosis. Spironolactone also has been reported as a treatment for a case of BN with ipsilateral breast hypoplasia.6 In this report, the patient had enlargement of the hypoplastic breast after 1 month of taking spironolactone. Both cases help to support the association with increased androgen receptors in BN.5,6 Conclusion Becker nevi are more common than appreciated because of underreporting. It is imperative that clinical practitioners accurately identify this skin lesion in order to reassure the patient and family; recognize associated cutaneous, muscular, and skeletal anomalies; and refer appropriately to subspecialists if needed. Patients typically present with complaints related to hypertrichosis and hyperpigmentation. Although the lesions can be quite large and cosmetically concerning, reassurance should be provided that BN represents a benign entity and malignant conversion has not been demonstrated. A variety of therapeutic interventions for BN are available; however, these are primarily for cosmetic improvement only. Patient follow-up The patient was referred to pediatric dermatology who confirmed the diagnosis of BN. Dermatology educated the family on this diagnosis and confirmed that no other associated anomalies were present on his physical examination. Because the patient was not concerned with the hyperpigmentation or hypertrichosis, no treatment was recommended at this time. Dermatology recommended follow-up annually for surveillance of the lesion and routine skin checks. Dr Michel is a pediatric resident, University of Florida College of Medicine, Gainesville. Drs Wheeler, Otero, Carswell, and Posa are assistant professors of Pediatrics, Division of General Academic Pediatrics, Department of Pediatrics, University of Florida College of Medicine. Dr Kelly is clinical associate professor of Pediatrics, Division of General Academic Pediatrics, Department of Pediatrics, University of Florida College of Medicine. Dr Cohen, section editor for Dermcase, is professor of pediatrics and dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland. The authors and section editor have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in this article. For references, go to ContemporaryPediatrics.com/ dermcase-0316 eye on washington CONTINUED FROM PAGE 9 Children’s Health, done by telephone by the National Center for Health Statistics, showed the percentage of children with these disorders increased from 3.8% to 4.8% of the child population from 2007 to 2011, and, says the panel, the trends in annual SSI initial allowances parallel the overall increases in these disorders in the child population. There are no studies on why the increase in the population is happening, said the committee, but it noted that studies on autism spectrum disorder and ADHD say causes of the increases in those disorders include awareness of developmental disorders, more availability of early intervention and special education, and changes in definition. The 2 NAM reports did not investigate the cause of the stateby-state variation in the percentages of children receiving SSI. The Mathematica report found that in 2013, “There was a pattern of larger SSI-child population ratios in Northeastern and Southern states, suggesting regional concentration in caseload growth, [although] some states in these regions (such as New Jersey) had SSI-child population ratios below 1.5%.” Seven states, mostly in the South, had M A R C H 2 016 | ratios above 2.5%. The percentage of children on SSI in 2013 varied from .6% in Hawaii, North Dakota, and Utah to 3.3% in Louisiana and Mississippi. The NAM Mental Disorders and Disabilities report said investigations are also needed on improving evaluation of impairment and disability in children and on the effects of child SSI benefits on family income and work. Both NAM reports are available for download at no cost at iom.nationalacademies.org. Search under “Reports” for SSI. The mental disorders report also features an in-depth review of how SSI works. C O N T E M P O R A RY P E D I AT R I C S . C O M 43 dermcase BERNARD A COHEN, MD SECTION EDITOR W The patient presents with a large hyperpigmented patch on his chest with well-demarcated borders and increased hair growth throughout. Unusual skin lesion in a teenaged boy JACQUELINE C MICHEL, DO; KATHRYN WHEELER, MD; JACLYN OTERO, MD; KRISTINA CARSWELL, MD; MOLLY POSA, MD; MARIA N KELLY, MD The mother of a healthy 15-year-old boy brings him to the office for evaluation of a darkening hairy patch on his left upper chest and shoulder. The patch is not symptomatic, and it first appeared as a subtle, poorly defined brown area when he was aged 10 years. FOR MORE ON THIS CASE, TURN TO PAGE 42. DERMCASE diagnosis 44 BECKER NEVUS C O N T E M P O R A RY P E D I AT R I C S . C O M | M A R C H 2 016 IMAGE CREDIT/AUTHOR SUPPLIED THE CASE careers A R I ZO N A ARIZONA Great family and golf community. Full-time Pediatrician BC/BE to join well established Pediatric practice in Tucson, Az. Competitive salary with excellent benefit package, including bonus compensation. Send CV to [email protected] Be part of a wonderful Pediatric Hospitalist program in our Southwest community of Yuma, Arizona!! ’Yuma Regional Medical Center Pediatric Hospitalists’ seeks both full-time and part-time BC/BE Pediatricians for our dynamic Peds Hospitalist program, in place for the past 3 years and extremely supported by our community physicians. *This excellent opportunity includes a strong hospital salary, full benefits package, a generous relocation allowance and a flexible schedule* Yuma Regional Medical Center (YRMC), a 406 bed top-in-technology facility, includes a 22-bed pediatric unit and a 15-bed level IIEQ Neonatal ICU to help care for the pediatric patients within our community of 205k residents. For Recruitment Advertising Contact Joanna Shippoli at This position will provide limited coverage for healthy newborns and will require no delivery attendance. Sub-specialty support is available through a combination of local physicians, as well as through affiliated tertiary care centers. 800.225.4569 ext. 2615 Yuma, Arizona is located just over 2 ½ hours drive- either directionfrom both San Diego, California and Phoenix, Arizona and offers family-friendly, year around recreational opportunities in one of the sunniest cities across the US. [email protected] I welcome all inquiries into this exciting position! 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