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CONTEMPORARY PEDIATRICS JUNE 2016 VOL. 33 NO. 06 Contemporary ZIKA SPECIAL REPORT A GO-TO GLUTEN GUIDE PEDIATRICS JUNE 2016 VOL. 33 | NO. 06 Expert Clinical Advice for Today’s Pediatrician ContemporaryPediatrics.com A GO-TO HYPOGLYCEMIA GUIDELINES GLUTEN GUIDE 5 BABY STEPS TO BETTER NUTRITION FAQS, SCREENING, & COUNSELING PROBIOTICS FOR C. DIFFICILE + HYPOGLYCEMIA GUIDELINES ZIKA SPECIAL REPORT 5 baby steps to better nutrition Probiotics for C. difficile VIDEO 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 Harlan R Gephart, MD Jane A Oski, MD, MPH Clinical Professor of Pediatrics, University of Washington School of Medicine, Seattle, Washington Department of Pediatrics, Tuba City Regional Health Care Corporation, Tuba City, Arizona W Christopher Golden, MD Andrew J Schuman, MD Assistant Professor of Pediatrics (Neonatology), Johns Hopkins University School of Medicine, and Medical Director, Full Term Nursery, Johns Hopkins Hospital, Baltimore, Maryland Section Editor for Peds v2.0, Adjunct Assistant Professor of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire physician contributing editors Michael G Burke, MD Bernard A Cohen, MD Donna Hallas, PhD, CPNP, PNP-BC, PMHS, FAANP 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 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 Section Editor for Journal Club, Chairman, Department of Pediatrics, Saint Agnes Hospital, Baltimore, Maryland Section Editor for Dermcase, Professor of Pediatrics and Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland 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. RADWAN Content Managing Editor 440-891-2636 / [email protected] MIRANDA HESTER Content Specialist GEORGIANN DECENZO RENEE SCHUSTER EVP, Managing Director AVIVA BELSKY List Acct Executive 440-891-2613 / [email protected] Group Publisher 732-346-3044 / [email protected] MAUREEN CANNON KATHRYN FOXHALL & MARIAN FREEDMAN Contributing Editors 4 C O N T E M P O R A RY P E D I AT R I C S . C O M | Permissions 440-891-2642/ [email protected] J U N E 2 016 888.527.7008 Pedia-Lax® is a line of constipation-relief products made specially for children ages 2 to 11. *Pedia-Lax works in minutes to hours, while MiraLAX® can take days to work. MM001400 Learn more at pedia-lax.com. MiraLAX is the registered trademark of Schering-Plough. Contemporary PEDIATRICS June 2016 VOL. 33 NO. 6 clinical feature 18 Gluten-free diet: Not for all children A gluten-free diet for most healthy children actually can be less healthy, but for kids diagnosed with celiac disease, a gluten-free diet is definitive and lifelong treatment. Mary Beth Nierengarten, MA. Reviewed by John Snyder, MD, FAAP. clinical feature clinical feature 22 Hypoglycemia guidelines: AAP vs PES 27 5 baby steps to better nutrition The American Academy of Pediatrics and the Pediatric Endocrine Society advance different plasma glucose values for hypoglycemia. Teaching patients these simple strategies will empower them to make better choices about what they eat and take control of their health. John Jesitus. Reviewed by Paul S Thornton, MD, and David Adamkin, MD INTER@ACTIVE: MORE ON NUTRITION NEW to Contemporary Pediatrics! Check out the first 2 of our new evidence-based Medical Minute video series with Bobby Lazzara, MD. This month? A recent study shows psyllium holds promise in treating kids with IBS. PLUS! Learn probiotics’ positive impact on Clostridium difficileassociated diarrhea. special report 14 Zika virus: Top mosquito repellent recommendations Contemporary Pediatrics asked pediatric and dermatology experts to share recommendations for insect repellents to prevent mosquito bites that might spread the Zika virus. Lisette Hilton 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 13 puzzler departments HYPOTHERMIA AND EMESIS IN A NEWBORN 9 EYE ON WASHINGTON Mike T Wei, BS, MS4; Nistana A Spigland, MD; Cori M Green, MD, MS 11 JOURNAL CLUB 34 peds v2.0 MOC REFORM: ONE YEAR LATER Here’s how the American Board of Pediatrics is transforming MOC and what further changes lie ahead. CMS Medicaid mandates are now final. in addition 4 EDITORIAL ADVISORY BOARD 41 ADVERTISING INDEX Andrew J Schuman, MD, FAAP 40 dermcase VESICULAR RASH IN AN INFANT WITH ECZEMA Do you have a manuscript to submit to Contemporary Pediatrics? E-mail [email protected] for submission guidelines. Amy Vandiver, BA, MS3; Bernard A Cohen, MD 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. For uses beyond those listed above, please direct your written request to Permission Dept. fax 440-756-5255 or email: [email protected]. 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IMAGE CREDIT: GE T T Y IMAGES / HERO IMAGES 8 Pat F Bass III, MD, MS, MPH ® Look how Children’s Claritin stacks up Children’s Claritin Grape Syrup Children’s Allegra® Berry Syrup Children’s ZYRTEC® Grape Syrup Children’s Benadryl® Cherry Syrup Non-Drowsy (based on label direction) 24-Hour Once-Daily Dosing Indicated for Kids Ages 2+ #1 Pediatrician-Recommended Non-Drowsy OTC Oral Allergy Brand1 Remind parents to always read the label 24-hour non-drowsy allergy relief Register at www.claritin.com/healthcareprofessionals1 to receive samples Children’s Claritin Syrup is: Dye free Sugar free Alcohol free Gluten free Kosher certified Use as directed. Reference: 1. 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 April 2016 63698-PP-CLA-CCL-US-0247 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 NOW ON A PHONE NEAR YOU e’ve teamed with clinical technology leader Bobby Lazzara, MD, to take your CP user experience to the small screen. Check out our new short, phonefriendly videos as Dr. Lazzara highlights 2-minute takeaways on pediatric trials you’ll want to know about. Dr. Lazzara was trained as a cardiothoracic surgeon and holds board certifications in general surgery, critical care medicine, and cardiothoracic surgery. His formal training included experience in general and pediatric cardiac surgery, and he maintains a running dialog on pediatric issues with his brother, Anthony Lazzara, MD, founder of Villa La Paz Foundation, a hospital and refuge for ill and destitute children in Peru. Dr. Bobby was an early adopter of technology in the service of physician learning, receiving a Smithsonian Computer World Award for performing the world’s first cardiac surgery over the Internet in 1998. As founder of Virtual Operating Room, LLC, and MDiTV, Inc., he pioneered live streaming and video on demand for W Video Exclusives from Contemporary Pediatrics The latest way we’re speeding you innovative data that may inform your treatment practices. medical education, including the first transmission of live surgery to mobile devices in 2009. As creator and producer of the Medical News Minute, he now focuses on harnessing the power of video to deliver physicians and healthcare professionals the latest in clinical trial data and treatment innovations. He completed his undergraduate and master’s degrees at Tulane University, WE WANT TO HEAR FROM YOU Want to let Contemporary Pediatrics know what you thought of this month’s cover story? Feel like voicing your opinion on Dr. Schuman’s latest MOC update? There are lots of ways to interact with us. You can: E-mail us at [email protected] .COM Part of the 8 Leave comments on our Facebook page: Facebook.com/ ContemporaryPediatrics Comment online at the bottom of any Contemporary Pediatrics article Follow us and tweet to @ContemPeds and graduated from the Emory University School of Medicine. Watch these videos now at www.modernmedicine.com/tag/ contemporary-pediatrics-video As always, turn to Contemporary Pediatrics for evidence-based, pragmatic clinical info you can learn about today and apply in your care of kids tomorrow. Take Our Poll If you receive Contemporary Pediatrics in print, do you receive it: R At home RAt work Let us know at ContemporaryPediatrics.com/ print-poll 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 | J U N E 2 016 EYE ON washington BY KATHRYN FOXHALL CONTEMPORARYPEDIATRICS.COM/EOW FOR MORE NEWS @CONTEMPEDS Update: Medicaid mandates are now final I n late April, the Centers for Medicare and Medicaid Services (CMS) published the final rules for remaking Medicaid managed care, starting a huge reform process that will impact the majority of Medicaid recipients. (“CMS proposes Medicaid program change,” Contemporary Pediatrics, April 2016.) The rules, proposed in fairly similar form a year ago, set new mandates for the states to develop rules for managed care plans serving Medicaid recipients. That’s big, because as of 2013, 46 million—almost three-fourths— of Medicaid beneficiaries had all or part of their benefits in managed care, according to the CMS. The Government Accountability Office in December said that as of fiscal 2013, 39 states were using comprehensive, risk-based managed care in their Medicaid programs. Even Medicaid experts are still combing through the 1230 pages of explanations and responses to public comments and (at the end of the document) the 200 pages of actual rules. The regulations cover a large number of topics including what information should go to patients, how to ensure provider networks are adequate to take care of patients, and what enrollment protections should be available patients. Joseph Zickafoose, MD, a senior researcher at the Mathematica Policy Research group and a practicing pediatrician, said that as far as he has analyzed the rules, “I think that CMS worked hard and probably did a good job at trying to strike the balance” between federal regulatory authority and state ownership of the Medicaid program. “What these rules really do is direct the states to get more specific about certain things that they haven’t had to be specific about in the past,” he notes. This is only the beginning because states will now begin to set their own rules based on the regulations, with some of the implementation beginning almost immediately and other parts coming in over several years. Information to consumers “The rule is going to require more consumer information than we have ever had before,” says Kelly Whitener, associate professor at the Georgetown University Health Policy Institute Center for Children and Families, Washington, DC. That will be very important in helping consumers to understand their plans, she notes. Among other things, the rules require that managed care plans frequently update provider directories and post them on the plan’s website, “which will ensure managed care plans are actively monitoring the status of their contracted providers.” Prov ider directories are to include information such as the provider’s group/site affiliation, website URL and physical accessibility for enrollees with physical disabilities, and the plan’s formularies. The CMS says the rules will permit both states and managed care plans to use a variety of electronic communication methods while requiring that beneficiaries also be able to get the information by paper for free. Plans must provide information “in each state’s prevalent languages explaining the availability of oral interpretation services or written translations, if requested.” CORRECTION Contempora PEDIATRryICS Expert Clini cal Advice for Today’s In the Eye on Washington article that appeared in the May 2016 edition of Contemporary Pediatrics, the headline “Pediatric drug voucher program renewed” should have read: “Pediatric drug voucher program moves through Congress.” J U N E 2 016 | Pediatricia n PEDS V2.0 MAY 2016 VOL. 33 | NO. 05 WHAT’S NEW IN BABY TECH Contemporary Pediat PARENTING &ReacPEDIA hing grads TRICS of Google U. rics.com TOP SEARC HES Safe sleep Living life onli ne Kids on planes C O N T E M P O R A RY P E D I AT R I C S . C O M 9 eye on washington Enrollment Insurance Program (CHIP) to ensure that patients don’t have to “The importance of rapid enrolldo inordinate travel. The providers ment and access to a network procovered by these standards include vider can hardly be overstated,” primary and specialty care as well says Sara Rosenbaum, a national as behavioral health for both adult expert on Medicaid, in an analysis and pediatric patients, and “OB/ of the rules in a HealthAffairs blog. GYN, pediatric dental, hospital, and She explains, “The rule allows pharmacy providers if these providstates to use a passive enrollment ers’ services are covered under the approach in which beneficiaries are managed care contract.” assigned to plans through a proIt’s important that the CMS cess that simultaneously provides has called for standards for pedia period of time ‘for the enrollee to atric providers specifically, says make an active choice of delivery Zickafoose, but providers should system’ or select a different plan.” remember these new reguZickafoose explains that lations don’t set specific families are offered the FAST FACT standards: “They tell opportunity to pick a By 2013, 46 million states that the states managed care plan and Medicaid need to set standards.” a primary care provider, beneficiaries had Whitener points out but many times they their benefits in managed care. there is an extended don’t and get assigned to period for the network adeboth a plan and primary quacy standard to be worked care provider. out at the state level. That allows In these new rules, he notes, if time, she notes, for stakeholders states do that assigning they need including pediatricians to reach out to take into account the needs of to states and managed care plans to the child and the family, for exampush for better standards. ple, trying to preserve an existing patient provider relationship. Zickafoose says that suggests to him Medical loss ratio that states should try to assign those The regulations’ provision that kids to a plan that allows them to go probably has received the most to a doctor they have seen before. attention is the medical loss ratio (MLR). Under the rules, the managed care plans must develop rates Network adequacy that “would reasonably achieve a There has been concern about medical loss ratio standard . . . of at whether plans provide adequate least 85% for the rate year,” Rosennetworks to serve patients. Zickafbaum states. That would mean that oose says that for the first time these at least 85% of funds would be spent regulations are requiring states to on claims and quality improvement have rules for the types and numactivities rather than on adminisbers of providers in a network. trative expenses. Under the new mandates, the The CMS says Medicaid and states will develop their travel time CHIP are the only coverage proand distance standards for mangrams in which an MLR standard aged care and the Children’s Health 10 C O N T E M P O R A RY P E D I AT R I C S . C O M | J U N E 2 016 does not apply to managed care plans, although some states have their own or similar measures of health plans’ administrative expenditures and profits. Family planning As Rosenbaum notes, under the rules, “Plans must specifically demonstrate a sufficient family planning network (although enrollees have the right to seek family planning services from the provider of their choice, regardless of network status).” In an e-mail, Jamie Poslosky, director of t he American Academy of Pediatrics’ Division of Advocacy Communications, says the regulations “could have gone further in requiring plans to cover all [US Food and Drug Administration]-approved contraceptive drugs/devices and services without prior authorization, but it did give states welcome guidance about what services they can and cannot restrict.” Posting of contracts Whitener of Georgetown points out that for the first time the rules require that the managed care contracts be posted on the state website. That will be “really important” in helping research and advocacy groups understand what is happening, she says. Currently, the documents must be obtained through a Freedom of Information Act request, she says. Links to the CMS discussion and the final rule (found at the end of the document), summary fact sheets, and the timeline for implementation dates are available at www.medicaid.gov. journal club BY MARIAN FREEDMAN COMMENTARY BY MICHAEL G BURKE, MD CONTEMPORARYPEDIATRICS Parent mentors get uninsured kids insured C ompared with traditional Medicaid/Children’s Health Insurance Program (CHIP) outreach, the use of parent mentors (PMs) raises rates of insured minority children and improves healthcare access along with providing other benefits— including cost effectiveness—a new study shows. Investigators conducted a yearlong trial in Dallas, Texas, communities with high proportions of low-income, minority families with uninsured children. The 237 parent participants, all of whom were Latino or African American, were assigned to either the group with which PMs engaged (via home visits and phone/e-mail/texts) or the control group. The PMs were parents with 1 or more children covered by Medicaid/CHIP who participated in 2-day training sessions that enabled them to assist families with insurance applications, retaining coverage, medical homes, and social needs. Those in the control group were given access to standard-ofcare outreach/enrollment by Texas Medicaid/CHIP and were subject to a campaign to raise CHIP/Medicaid awareness that included bilingual advertisements, websites with application links and order forms, and daycare-center outreach. In the PM group, 95% of children obtained insurance compared with 68% of controls. The PM intervention also insured children more quickly and was more effective in renewing coverage. In addition, PMs were associated with improving access to medical and dental commentary This is a great program! It provides a model for a cost-effective means of enrolling the 4 million insurance-eligible, uninsured children in the United States. Keep in mind that the parent mentors described here are not health professionals. They are essentially peers with just 2 days of training who step in to act like an experienced family member invested in getting children the healthcare they need. In the year of the study, these role models visited each of their assigned families a mean of almost 20 times and made more than 160 phone/text/e-mail contacts. The results, including the cost savings, are impressive. —Michael G Burke, MD Too little sleep is tied to teenagers’ injury-related risk behaviors High school students who report sleeping 7 hours or less on an average school night are significantly more likely than their peers who sleep up to 9 hours a night to engage care, reducing out-of-pocket costs, achieving parental satisfaction and quality of care, and sustaining insurance after the intervention ended. Controls had higher total costs than the PM group for emergency department visits, hospitalizations, intensive care unit stays, and wage loss and other costs of caring for sick children. Investigators calculated that PMs, who received $53 per child per month and followed up to 10 families at a time, saved $6045 per year per child insured (Flores G, et al. Pediatrics. 2016;137[4]:e20153519). in several injury-related risk behaviors: infrequent bicycle helmet use; infrequent seatbelt use; riding with a driver who has been drinking; drinking and driving; and texting J U N E 2 016 | while driving. An analysis of risk data from 50,370 high school students in the national Youth Risk Behavior Surveys in 2007, 2009, 2011, or 2013 found that 3 of these behaviors— infrequent seatbelt use, riding with a driver who has been drinking, and drinking and driving—also C O N T E M P O R A RY P E D I AT R I C S . C O M 11 journal club were more likely for students who reported sleeping 10 or more hours compared with 9 hours on an average school night. A full 68.8% of respondents reported getting 7 hours or less sleep on an average school night: 4 hours or less, 6.3%; 5 hours, 10.5%; 6 hours, 21.9%; or 7 hours, 30.1%. Another 23.5% reported 8 hours sleep, 5.8% reported 9 hours, and 1.8%, 10 or more hours. Girls were more likely than boys to report insufficient sleep. The overall percentage of those reporting insufficient sleep ranged from 59.7% of students in the 9th grade to 76.6% of those in the 12th grade. Prevalence of insufficient sleep was lowest for American Indian/Alaska Native students (60.3%) and highest for Asian students (75.7%). O vera l l, 86.1% of students reported infrequent bicycle helmet use in the past 30 days; 8.7% reported infrequent seatbelt use; 26% reported riding with a driver who had been drinking at least once; 8.9% reported drinking and driving; and 30.3% reported texting while driving (Wheaton AG, et al. MMWR Morb Mortal Wkly Rep. 2016;65[13]:337-341). commentary Although cause and effect aren’t clearly established here, this study suggests that teenagers are not just more likely to be injured because of fatigue and drowsiness leading to falling asleep at the wheel, but that they also may be too sleepy to be smart. Tired teenagers may be making high-risk choices that their well-rested peers avoid. —Michael G Burke, MD Predicting hyperbilirubinemia in babies Newborn babies are more likely to develop jaundice requiring treatment if they have significant hemolysis contributing to their bilirubin levels (ie, bruising, ABO blood group incompatibility, glucose-6-phosphate dehydrogenase [G6PD] deficiency). To detect hemolysis and predict hyperbilirubinemia (HB), investigators tested a bedside endtidal carbon monoxide concentration (ETCOc) monitor in conjunction with hour-of-life stratified bilirubins. A total of 79 infants—gestational age ≥35 weeks, birth weight ≥2000 g, and postnatal age >6 hours and <6 days— underwent up to 4 ETCOc measurements a day for up to 4 days of life in conjunction with total bilirubin (TB) measurements. Investigators followed these infants for 30 to 35 days after birth for clinical outcomes and results from laboratory tests and determined the relationship between ETCOc and risk for HB. Infants with ETCOc ≥2.5 ppm were at high risk of neonatal HB; those with ETCOc between 1.5 ppm and 2.5 ppm were at moderate risk; and those with ≤1.5 ppm were at low risk. Of the 31 infants whose TB was >75th percentile, 23% had ETCOc ≤1.5 ppm and 77% had ETCOc >1.5 ppm, suggesting that the highest-risk babies have the highest degree of hemolysis (Bhutani VK, et al. Acta Paediatrica. 2016;105[5]:e189-e194). commentary To understand this article, you need to reach all the way back to biochemistry class to remember that breakdown of a molecule of heme leads to production of 1 molecule of bilirubin and 1 molecule of carbon monoxide. By using both bilirubin level by hour of life and ETCOc, the researchers propose that we will be able to more accurately predict which babies will likely need treatment for their jaundice. —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 | J U N E 2 016 also of note Do you really want to supersize that baby? Bottle size is significantly associated with the volume of formula an infant consumes, according to a study— conducted via parental questionnaire—in 378 2-month-old infants who were exclusively formula fed. Infants who were fed with bottles with a capacity of 6 ounces or more consumed about 4 ounces more formula each day than infants fed using bottles that were smaller than 6 ounces (33.3 oz vs 29.8 oz, respectively)—a daily 80-kcal difference (Wood CT, et al. Acad Pediatr. 2016;16[3]:254-259). puzzler S FIGURE 1 Abdominal X-ray shows gaseous distension of stomach and enlarged duodenal bulb (double bubble). There is only minimal distal gas in the left lower quadrant and paucity of bowel gas. S FIGURE 2 Upper gastrointestinal series demonstrates a dilated first portion of the duodenum and no contrast beyond the duodenal bulb. Hypothermia and emesis in a newborn MIKE T WEI, BS, MS4; NISTANA A SPIGLAND, MD; CORI M GREEN, MD, MS THE CASE The patient, a 7-day-old, small-for-gestational-age (SGA) female (birth weight, 2.21 kg), born by vaginal delivery at 37 weeks to a G1P0 mother, presented to IMAGE CREDIT/AUTHOR SUPPLIED the pediatric emergency department (ED) for hypothermia and emesis at the recommendation of her pediatrician. The neonate’s delivery was complicated by maternal and newborn fever, and she received antibiotics for 48 hours. Ultimately, her blood cultures were negative. Otherwise, she did well in the nursery and was discharged at 2 days of age. FOR MORE ON THIS CASE, TURN TO PAGE 31. J U N E 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 SPECIAL REPORT Zika Virus Zika virus: Top mosquito repellent recommendations LISETTE HILTON Ms Hilton is a medical writer who has covered health and medicine for 25 years. She resides in Boca Raton, Florida. 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. 14 Contemporary Pediatrics asked pediatric and dermatology experts to share recommendations for insect repellents to prevent mosquito bites that might spread the Zika virus. and dermatology experts to share their best With summer here and concern growing patient recommendations for insect repelabout the spread of the Zika virus to the lents. This article summarizes what they United States, pediatricians might notice had to say. more patients inquiring about how to Since it was developed in 1957, DEET safely repel mosquitoes and their diseasehas demonstrated that it is the best inducing bites. insect repellent humans have ever The Centers for Disease Control invented, says Tucson, Arizonaand Prevention (CDC) is urging FAST FACT based dermatologist Ronald G. everyone to take steps to preSince 1957, DEET Wheeland, MD. vent mosquito bites with such has demonstrated “In a 20% to 50% concenthings as appropriate clothing that it is the best tration, it is effective and safe, and Environmental Protection insect repellent according to the US Agency A genc y (E PA)-re g i s tere d ever invented. for Toxic Substances and Disease insect repellents. The repellents, Registry. In addition, use of long according to the CDC, should have sleeves and pants will help reduce the inci1 of the following active ingredients: DEET dence of mosquito bites,” Wheeland says. (N,N-diethyl-meta-toluamide); picaridin Tina S. Alster, MD, director, Washington (2-[2-hydroxyethyl]-1-piperidinecarboxInstitute of Dermatologic Laser Surgery, ylic acid 1-methylpropylester); IR3535 Washington, DC, says that according to (3-[N-acetyl-N-butyl]-aminoproprionic Consumer Reports, the most effective prodacid ethyl ester); or oil of lemon eucalyptus ucts against the Aedes species mosquito (para-menthane-3.8-diol). that spreads the virus are Sawyer Picaridin Contemporary Pediatrics asked pediatric C O N T E M P O R A RY P E D I AT R I C S . C O M | J U N E 2 016 special report TABLE RECOMMENDED INSECT REPELLENTS The products listed below are those recommended by the pediatric experts contacted for this report augmented by those products rated by Consumer Reports for repelling insects, especially mosquitoes and ticks. Discuss use of any insecticide with the child’s pediatrician prior to application. BRAND AND MODEL ACTIVE INGREDIENTS All-Terrain Kids Herbal Armor Oil of soybean, 11.5%; oil of citronella, 10.0%; oil of peppermint, 2.0%; oil of cedar, 1.5%; oil of lemongrass, 1.0%; oil of geranium, 0.05% Avon Skin-So-Soft Bug Guard Plus Picaridin Picaridin, 10% Avon Skin-So-Soft Original Bath Oil None stated Ben’s 30% DEET Tick and Insect Wilderness Formulaa DEET, 30% Burt’s Bees Herbal Castor oil, 10%; rosemary oil, 3.77%; lemongrass oil, 2.83%; cedar oil, 0.94%; peppermint oil, 0.76%; citronella oil, 0.57%; clove oil, 0.38%; geranium oil, 0.19% California Baby Natural Bug Blend Pure essential oils of cymbopogon nardus (citronella grass), 5%; cymbopogon schoenanthus (lemongrass), 0.5%; Cedrus atlantica (cedar), 0.5% Coleman SkinSmart IR3535, 20% Cutter Natural Geraniol, 5%; soybean oil, 2%; sodium lauryl sulfate, 0.4%; potassium sorbate, 0.1% Cutter Skinsations DEET, 7% EcoSmart Organicb Geraniol, 1.0%; rosemary oil, 0.5%; cinnamon oil, 0.5%; lemongrass oil, 0.5% HOMS Bite Blocker BioUD Mini Trigger 2-undecanone (CAS #112-12-9), 7.75% Natrapel 8-Hour Picaridin, 20% OFF! Deep Woods VIII DEET, 25% OFF! FamilyCare Insect Repellent I (Smooth and Dry) DEET, 15% OFF! FamilyCare Insect Repellent II (Clean Feel) Picaridin, 5% Repel Lemon Eucalyptusa Oil of lemon eucalyptus, 30.0% (approximately 65% para-menthane-3.8-diol) Repel Scented Family DEET, 15% Sawyer Picaridina Picaridin, 20% a Indicates a top 3-rated product for repelling Aedus and Culex mosquitoes and ticks according to Consumer Reports. Does not contain certified organic ingredients. Abbreviations: CAS, Chemical Abstract Service; DEET, N,N-diethyl-meta-toluamide; IR3535, 3-(N-acetyl-N-butyl)-aminopropionic acid ethyl ester. b Adapted from: Consumer Reports. Insect repellent ratings. Available at: http://www.consumerreports.org/cro/health/beauty-personal-care/insect-repellent/insect-repellentratings/ratings-overview.htm. Accessed May 16, 2016. J U N E 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 15 special report PROTECT KIDS FROM INSECT BITES } Ensure that children’s clothing covers their arms and legs. } Cover cribs, strollers, and baby carriers with mosquito netting. } Treat kids’ clothing and gear with permethrin. } Use only EPA-registered, pediatrician-recommended insect repellents. } Do not use insect repellents on babies aged <2 months. } Do not use products with lemon eucalyptus oil or para-menthane-diol on children aged <3 years. } Do not apply insect repellent onto a child’s hands, eyes, mouth, or cut or irritated skin. Abbreviation: EPA, Environmental Protection Agency. From Centers for Disease Control and Prevention. Available at: www.cdc.gov/zika/prevention/. Accessed May 27, 2016. considering going to an infested Insect Repellent (Sawyer; Safety area, they can purchase hats with Harbor, Florida), containing 20% netting on them and clothing that picaridin; Ben’s 30% DEET Tick is long sleeved in advance. During and Insect Wilderness Formula the night, they should sleep in beds (Tender Corporation; Littleton, New that have netting around them. Hampshire); and Repel Lemon One particularly effective Euc a ly pt u s (Spec t r u m tool is to spray clothing Bra nds; Midd leton, FAST FACT with DEET-containing W i s c on s i n), w h i c h Biting insects are repellent. This allows most attracted contains 65% parato where carbon for better control of menthane-3.8-diol). dioxide is being bugs and potential Zika “ T hese produc ts emitted. vectors.” provided protection for Sandy Tsao, MD, assisabout 8 hours and were as tant professor, Harvard Medical effective as products with higher School, Boston, Massachusetts, and chemical concentrations,” Alster a dermatologist at the Dermatology says. Laser and Cosmetic Center at Dermatologist Joel Schlessinger, Massachusetts General Hospital, MD, president of LovelySkin.com, Boston, says DEET is her go-to recsays that although DEET is very ommendation for repelling mosquiimportant for protection, the use toes. Tsao says she uses OFF! Deep of barrier clothing and nets in the Woods, but there are other OFF! home (particularly around the bed products, such as Off! FamilyCare area) are essential. Smooth and Dry and Off! Skintastic “Mosquito repellent will never FamilyCare Insect Repellent, that be completely effective and, for are less concentrated. that reason, it is imperative to “DEET is seen as one of the most put other roadblocks between the effective products for repelling mosquito and you,” Schlessinger insects, but the concern is that it can says. “If any of your patients are 16 C O N T E M P O R A RY P E D I AT R I C S . C O M | J U N E 2 016 be neurotoxic,” Tsao says. She recommends that parents discuss with their child’s pediatrician his or her recommended products to minimize insect bites prior to any insecticide application. The pediatrician may recommend a specific brand of insecticide or recommend alternate skin protective measures other than insecticide use to minimize any potential insecticide adverse effects. Tsao also recommends permethrin clothing treatment that lasts for 6 washes. Using these products, which impregnate clothing with insect repellent, could lead to less need for DEET and other insecticides, she says. “Biting insects, including mosquitoes, are most attracted to where carbon dioxide is being emitted, so your face and ears are prime targets for a bite,” Tsao says. “As well, insects tend to gravitate to areas of heavy sweat.” She recommends that patients apply the insecticide to any areas of exposed skin—making sure to not forget the ankles, feet, hands, and scalp. Medina, Ohio, dermatologist Helen M. Torok, MD, says she has trepidation about recommending DEET, but will talk to patients about DEET if asked about mosquito repellents. “Of those [patients] that are also uncomfortable with DEET, then I recommend the lemoneucalyptus products,” she says. Elaine C. Siegfried, MD, professor of pediatrics and dermatology, Saint Louis University, Missouri, says she defers to CDC recommendations for Zika prevention. “For children with sensitive skin, treat clothing and gear with permethrin or purchase permethrin-treated items,” she says. FLARE FREE AND LOVING IT 4 EUCERIN® ECZEMA RELIEF BODY CREME HELPED OUT OF 5 CHILDREN STAY FLARE FREE FOR 6 MONTHS1* Eucerin Eczema Relief Body Creme relieves dry, itchy skin and provides hydration for patients with eczema-prone skin1—in a light, fast-absorbing daily formula SKIN PROTECTANT *Subjects applying daily Eucerin® Eczema Relief Body Creme demonstrated a statistically significant difference (P =0.006) in the prevention of eczema flares compared with control group subjects.1 Reference: 1. Weber TM, Samarin F, Babcock MJ, Filbry A, Rippke F. Steroid-free over-the-counter eczema skin care formulations reduce risk of flare, prolong time to flare, and reduce eczema symptoms in pediatric subjects with atopic dermatitis. J Drugs Dermatol. 2015;14(5):478-485. ©2016 Beiersdorf Inc. Trust Eucerin. Over 100 years committed to skin science. CLINICAL FEATURE Gluten-free Diet Gluten-free diet: Not for all children MARY BETH NIERENGARTEN, MA. REVIEWED BY JOHN SNYDER, MD, FAAP. 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 anothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article. 18 A gluten-free diet for most healthy children actually can be less healthy, but for kids who have been diagnosed with celiac disease, a gluten-free diet is definitive and lifelong treatment. The popularity of gluten-free diets continSuch a diet, however, is not for all chilues to grow as people increasingly turn to dren and actually can be less healthy diet as a way to manage copious symptoms for otherwise healthy children because from gastrointestinal disturbances, which of the reduced nutritional benefits and can range from headaches to skin rashes, often-enhanced sugar and fat content of behavioral problems, and psychological gluten-free diets if not monitored carefully. difficulties. Data from the NPD Group Along with the lack of supplementation Dieting Monitor, which regularly tracks of vitamins and minerals in most glutendieting and nutrition-related issues, free foods, gluten-free diets often are show a steady increase in the permore expensive for families. FAST FACT centage of American adults who For children diagnosed with 26% of adults say they are cutting down or celiac disease, the role of a gluaged 18 to trying to avoid gluten in their ten-free diet as definitive ther49 years cut down diets. As of 2012, 30% of Amerapy is well established. Other or avoid gluten ican adults aged older than conditions as well warrant concompletely.1,2 50 years and 26% of adults aged sideration of this diet in children, 18 to 49 years claimed to be cutting including wheat allergy and gluten down or avoiding gluten completely.1,2 sensitivity. Other children with gastrointestinal symptoms with no obvious cause For parents who are trying to provide also may benefit, as perhaps subgroups of the healthiest environment for their chilchildren with autism spectrum disorder dren, the media-hyped benefits of a gluten(ASD). free diet may help steer them to placing To help pediatricians navigate through their child on a gluten-free diet in the belief the morass of information emerging on that it will provide symptom relief, prevent gluten-free diets, John Snyder, MD, FAAP, celiac disease, or just be healthier.3 C O N T E M P O R A RY P E D I AT R I C S . C O M | J U N E 2 016 clinical feature 1 DIFFERENTIAL DIAGNOSIS OF CELIAC DISEASE, WHEAT ALLERGY, AND GLUTEN SENSITIVITY CELIAC DISEASE WHEAT ALLERGY GLUTEN SENSITIVITY Time to onset of symptoms after gluten exposure Weeks to years Minutes to hours Hours to days Screening } Recommended tests for diagnosis } Diagnosis includes: } Diagnosis includes: include: 1) Quantitative IgA and 2) IgA anti-tTG antibody (IgA antiendomysial antibody for children with autoimmune disease). } Diagnosis confirmed by endoscopy and biopsies. 1) Double blind food challenge; 2) Skin tests; and 3) IgE serology. 1) Negative immune-allergy tests to wheat; 2) Negative celiac disease serology in IgA-competent person; 3) Negative duodenal histopathology; and 4) Symptom resolution on a gluten-free diet. Pathogenesis/ HLA Autoimmune condition (both innate and adaptive immunity). Almost all cases are in the HLA-DQ2 or 8 region. Allergic immune response/no association to HLA Possible innate immunity/no association to HLA Autoantibodies and enteropathy Almost always present Always absent Always absent Abbreviations: HLA, human leukocyte antigen; IgA, immunoglobulin A; IgE, immunoglobulin E; tTG, tissue transglutaminase antibody. From Snyder J4; Fasano A, et al7; Pietzak M.8 professor of pediatrics and chief, Division of Gastroenterolog y, Hepatolog y, and Nutrition, at Children’s National Health System in Washington, DC, spoke on indications for a gluten-free diet in children and key issues to keep in mind when talking to parents and children about a gluten-free diet in his presentation “The gluten-free diet—not for everyone?” at the American Academy of Pediatrics 2015 National Conference and Exhibition, Washington, DC.4 Definition of and indications for a gluten-free diet Gluten is a complex of water-insoluble proteins found in wheat, rye, barley, and crossbreed grains such as wheat-rye (ie, triticale).4,5 The 2 main proteins found in gluten are gliadins and glutenins, and they provide dough with its elasticity, shape, and chewy texture. A g luten-f re e produc t , a s defined by the US Food and Drug Administration (FDA), is a food that is inherently free of gluten or one that contains no ingredient that is: 1) a gluten-containing grain such as spelt wheat; 2) derived from a grain in which the gluten has not been removed such as wheat flour; or 3) derived from a good in which gluten has been removed but greater than 20 parts per million (ppm) of gluten remain in the product.4,6 Indications for considering a gluten-free diet in a child include, most importantly, the diagnosis of J U N E 2 016 | celiac disease for which a gluten-free diet is definitive treatment. Along with celiac disease, the other 2 primary conditions for which a glutenfree diet should be considered are wheat allergy and gluten sensitivity. Because the symptoms of all these conditions are similar, and may include chronic diarrhea, weight loss, and abdominal distension, a thoughtful approach to making the diagnosis is critical (Table 1).4,7,8 To make the accurate diagnosis for celiac disease, Snyder highlighted the importance of using the recommended screening tests to measure quantitative immunoglobulin A (IgA) level and the IgA anti-tissue transglutaminase (tTG) antibody level for celiac disease followed by endoscopic intestinal biopsy of the 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 small intestine in patients with symptoms and positive screening serology (Table 1).4,7,8 If celiac disease is not found, consideration of a wheat allergy or gluten sensitivity can then be considered. It is particularly important to accurately diagnose children with celiac disease because these children, unlike those diagnosed with a wheat allergy or gluten sensitivity, are at increased risk of a number of other comorbidities, including the development of other autoimmune diseases, and increased risk of cancer later in life if they do not carefully follow a gluten-free diet (Table 2).8 Other situations in which pediatricians may consider a gluten-free diet are for children with ASD and those with chronic problems with no obvious cause, according to Snyder. Although the recent consensus report on gastrointestinal disorders in persons with ASD found no definitive data on specific patterns of gastrointestinal abnormalities in these people or efficacy in any specific diet, the report does specify that the data did not look at whether subgroups of patients may benefit from such diets. For patients who try a restricted diet, the report recommends professional supervision, including the input of an experienced dietitian, to prevent nutritional inadequacies.9 Before the trial is undertaken, the child should be tested for celiac disease. For children who present with chronic problems with no obvious cause, Snyder said that a trial of dietary therapy is often considered after celiac disease has been ruled out. For these children and all children who go on a gluten-free diet, he 20 IMPORTANCE OF DIFFERENTIATING CELIAC DISEASE FROM WHEAT ALLERGY OR GLUTEN SENSITIVITY 2 Nutritional deficiencies Persons with celiac disease are at risk of severe intestinal damage caused by the immune system attacking normal tissue in response to eating gluten. This can result in malabsorption of food and nutritional deficiencies that in turn can lead to morbidities such as iron deficiency anemia and osteoporosis. Development of other autoimmune conditions Persons with celiac disease are at risk of developing other autoimmune conditions. Risk of malignancies Persons with celiac disease are at increased risk of developing certain types of cancers (eg, gastrointestinal cancers, particularly T cell enteropathy lymphoma). Increased mortality Persons with celiac disease have a 2-fold to 4-fold increased risk of mortality at any age compared with the general population if they do not follow a glutenfree diet. Familial risk Persons with a first[- and second]-degree relative with celiac disease are at higher risk of developing it. From Pietzak M.8 LIMITATIONS OF A GLUTEN-FREE DIET 3 Can be nutritionally lacking (it does not have to be) } Micronutrients and macronutrients can be imbalanced. } Gluten-free grains often are not enriched with vitamins and minerals; can be low in thiamin, riboflavin, niacin, folate, iron, and dietary fiber. } Gluten-free processed foods can be higher in saturated fats than comparable gluten-containing foods. Can be expensive } Gluten-free foods often cost more. Compliance } Often difficult for children to follow a diet that is more restrictive than their peers. } Can be difficult to determine if a food is gluten-free because gluten is hidden in many foods. 3 From Reilly NR ; Snyder J. 4 emphasized the need to work with a dietitian experienced in using the gluten-free diet to ensure a balanced, healthy diet. C O N T E M P O R A RY P E D I AT R I C S . C O M | J U N E 2 016 Eating a gluten-free diet: Involve a dietitian For children who are placed on a gluten-free diet, involving a dietitian clinical feature ONLINE RESOURCES FOR PEDIATRICIANS AND FAMILIES } Children’s National Health System: Celiac disease program Information for children with celiac disease, including gluten-free recipes, celiac disease-friendly restaurants. bit.ly/childrens-national-celiac } One Medical Group: 10 apps to keep you gluten-free bit.ly/gluten-free-apps } Academy of Nutrition and Dietetics: Kids eat right Apps with information to help maintain a gluten-free diet. Helpful apps: “Is That Gluten Free?” and “Find Me Gluten Free” and more. Information on nutrition and eating for children, videos, recipes. bit.ly/kids-eat-right } North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN): GI Kids: Celiac disease Information on managing celiac disease in children. Links to resources on gluten-free diet for families (in English and Spanish). bit.ly/NASPGHAN-celiac } American Academy of Pediatrics: HealthyChildren.org: Gluten-free food labeling Information on the FDA’s final rule on defining gluten-free food labeling with links to additional information. bit.ly/AAP-gluten-free-labeling found in them because of contamination with gluten during transportation, storage, and processing.11 In addition to talking to patients and guiding them in food choices to reduce or avoid eating diets too low in nutrients, pediatricians working with dietitians can address other potential limitations of gluten-free diets such as cost and issues of adherence (Table 3).3,4 Adhering to a gluten-free diet can be costly, and for many children may affect their psychosocial well-being because of the restrictions of the diet that may lead to social isolation.1,12 As with any therapy, follow-up visits with children on a gluten-free diet are important to ensure adherence to the diet as well as to evaluate symptoms and monitor for complications. Pediatricians, working with dietitians, can help improve adherence by ongoing education and support to families.12 Summary Abbreviation: FDA, Food and Drug Administration. From Snyder J.4 increased saturated fat and sugar is highly recommended. “Involve a content,10,11 which can lead to obedietitian since gluten-free foods can be deficient in macronutrients and sity, new-onset insulin resistance, micronutrients and are often not and metabolic syndrome.3 enriched with vitamins and minerAlong with ensuring proper als,” emphasized Snyder. nutrition, involvement of a The need to ensure that dietitian can help with FAST FACT children on a gluten-free choosing foods that are Children on glutendiet receive sufficient gluten-free. Because free diets may lack nutrients is highlighted even small amounts of certain vitamins, by studies show ing gluten can be harmful, minerals, and that these children may particularly for children dietary fiber.10,11 be getting low amounts on definitive treatment of important vitamins and for celiac disease, working minerals as well as dietary fiber. with a trained professional can help Along with the lack of nutrient foridentify safe foods. For example, tification in gluten-free products, although oats are safe for most peomany of these products also have ple, trace amounts of gluten may be J U N E 2 016 | With the increasing popularity of gluten-free diets, questions of who actually may benefit from this type of diet need some answers. Prior to initiating a gluten-free diet, all children need to be tested for celiac disease. If diagnosed, a gluten-free diet is required as definitive and lifelong treatment. Other conditions that warrant a gluten-free diet include wheat allergy and gluten sensitivity. For all children, education on adhering to a healthy, balanced diet is needed, and involving a dietitian is integral to their care. For answers to frequently asked questions about gluten-free diets, go to ContemporaryPediatrics.com/ FAQs-gluten-free-diet. C O N T E M P O R A RY P E D I AT R I C S . C O M 21 CLINICAL FEATURE Hypoglycemia Guidelines Hypoglycemia guidelines: AAP vs PES JOHN JESITUS. REVIEWED BY PAUL S THORNTON, MD, AND DAVID ADAMKIN, MD. Mr Jesitus is a medical writer based in Colorado. He 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. Dr Thornton and Dr Adamkin also report no conflicts of interest. The American Academy of Pediatrics (AAP) and the Pediatric Endocrine Society (PES) advance different plasma glucose values for hypoglycemia in children. The topic of hypoglycemia in neonates and children has generated significant debate of late, with the American Academy of Pediatrics (AAP) and the Pediatric Endocrine Society (PES) having advanced apparently conf licting guidelines.1,2 To avoid overscreening of healthy infants and children without discharging babies who may have glucose-regulation problems beyond the first days of life, the community pediatrician is perhaps best served by observing the AAP’s approach for the first 48 hours, with increased vigilance consistent with the PES approach thereafter.3 Introduction The disconnect between the 2 societies’ guidelines comes as little surprise, considering the paucity of evidence regarding clinically significant levels of neonatal hypoglycemia (NH) and the lack of consensus regarding a specific level to define hypoglycemia in the first 2 days of life.4 In reviewing NH studies to date, 22 C O N T E M P O R A RY P E D I AT R I C S . C O M | J U N E 2 016 confounding factors such as variable definitions of hypoglycemia and lack of control groups make it impossible to define a specific plasma glucose (PG) concentration or duration that can predict permanent neurologic injury in high-risk infants.5-7 Although it is known that symptoms and long-term neurological damage occur within a range of low PG values of varying duration and severity,1 it is also critically important to remember that factors such as the presence of the alternative brain fuels beta-hydroxybutyrate (BOHB) and lactate, as well as hypoxia or ischemia, can affect whether brain injury will occur in conjunction with hypoglycemia.2 Hypoglycemia is defined as a glucose concentration low enough to cause signs or symptoms of impaired brain function (neuroglycopenia).8 Various authors have noted that the generally adopted PG concentration historically used to define NH for all infants, <47 mg/dL, lacks rigorous scientific justification. clinical feature 1 SCREENING AND MANAGEMENT OF POSTNATAL GLUCOSE IN AT-RISK INFANTS: AAP WHICH INFANTS WHEN WHAT THRESHOLD INTERVENTION Symptomatic <48 h Any screening value <40 mg/dL IV glucosea Asymptomatic 0-4 h (Feed in first h, screen glucose 30 min later) Initial screening <25 mg/dL Feed infant, recheck glucose in 1h A subsequent screening <25 mg/dL IV glucosea 25-40 mg/dL Refeed, IV glucose as needed Initial screening <35 mg/dL Feed infant, recheck in 1 h Subsequent screening <35 mg/dL IV glucose 35-45 mg/dL Refeed, IV glucose as needed <45 mg/dL IV glucose ≥45 mg/dL Discharge when infant can maintain this level before routine feeding ≥60 mg/dL Discharge when infant can maintain this level before routine feeding 4-24 h (Continue feeds q 2-3 h; screen before each feeding) 24-48 h Any infants treated 48-96 h intravenously Any screening value Any screening value a Glucose dose: 200 mg/kg (dextrose 10% at 2 mL/kg) mini-bolus and/or IV infusion at 5-8 mg/kg/min (80-100 mL/kg/d). AAP’s general target glucose range is 40-50 mg/dL. Abbreviations: AAP, American Academy of Pediatrics; IV, intravenous. From: Committee on Fetus and Newborn, et al.1 Who, when, how? To help determine which infants to screen, at what intervals, and what glucose levels to target during the first 48 hours of life, the AAP examined whether specific ranges of PG levels have been associated with neurodevelopmental harm in longterm follow-up studies (Table 11). 3 Recommended values for intervention are somewhat arbitrary, the AAP concedes, but designed to provide a margin of safety above glucose concentrations associated with clinical signs. T h e PE S g u i d e l i n e s d i ffer in that they expand the list of whom to screen and recommend that the target for treatment in these at-risk babies is 50 mg/dL if being treated by feeding and 70 mg/dL if treated by intravenous (IV) glucose (Table 2).2 To help physicians recognize hypoglycemic disorders that persist beyond 48 hours and prevent brain damage in at-risk infants, the PES analyzed mean glucose levels found in newborns in establishing its guidelines, while also broadening the list of at-risk infants.2 When diagnosing hypoglycemia, the PES highlights the following issues: } One should use only PG concentrations determined by a clinical laboratory method (not a pointof-care analyzer); } Whole-blood glucose values are approximately 15% lower than J U N E 2 016 | PG concentrations; and } Red-cell glycolysis occurring during sample processing delays can cut glucose concentration by up to 6 mg/dL hourly. Signs and symptoms Clinical signs of NH—ranging from cyanosis to seizures—are nonspecific and common to sick neonates. Other symptoms may include jitteriness, apneic episodes, tachypnea, lethargy, poor feeding, and weak crying. Who’s at risk? The AAP and PES guidelines concur that infants at highest risk for NH include those who are: } Late preterm (34-36 weeks); 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 2 HYPOGLYCEMIA EVALUATION AND INVESTIGATIONS IN INFANTS AND CHILDREN: PES PATIENT STRATEGY STRENGTH OF SUPPORTING EVIDENCE Children able to communicate symptoms Evaluate and treat only those in whom Whipple’s triad is documented: Recommended (Grade 1++++) } Symptoms and/or signs of hypoglycemia; } A documented low PG concentration; and } Relief of signs/symptoms when PG is restored to normal. Evaluate and manage only those whose PG concentrations are documented by laboratory quality assays to be below the normal threshold for neurogenic responses (<60 mg/dL). Suggested Neonates suspected to be at high risk for persistent hypoglycemia disorder Screen and manage glucose for the first 48 h of life, then evaluate for etiology when infant is ≥48 h old (after the normal period of transitional neonatal hypoglycemia has passed). Suggested Infants and children with persistent hypoglycemic disorders Investigate to diagnose underlying mechanism of the disorder. Recommended (Grade 1++++) Infants and younger children unable to reliably communicate symptoms (Grade 2+++0) Workup/investigation (Grade 2++00) Abbreviation: PES, Pediatric Endocrine Society; PG, plasma glucose. From: Thornton PS, et al.2 } Small for gestational age; } Large for gestational age; } Infants of diabetic mothers. Babies at increased risk for persistent hypoglycemia (lasting beyond the first 2 days of life) also include those with the following characteristics, says the PES: } Postmature delivery; } Family history of genetic forms of hy p o g l yc e m i a (s u c h a s 24 congenital hyperinsulinism or hypopituitarism); } Congenital syndromes (such as Beckwith-Wiedemann); } Abnormal physical features (such as midline facial deformations, microphallus); and } Perinatal stress (birth asphyxia/ ischemia, cesarean delivery, maternal preeclampsia/eclampsia or hypertension, meconium C O N T E M P O R A RY P E D I AT R I C S . C O M | aspiration syndrome, erythroblastosis fetalis, polycythemia, hypothermia). Both guidelines agree that only infants who show clinical manifestations or who are otherwise known to be at risk require blood glucose measurements.1,2 In such cases, the AAP recommends measuring plasma or blood glucose concentration as soon as possible (point of care)—in minutes, not hours—while keeping in mind that breastfed term infants have lower PG concentrations but higher concentrations of ketone bodies than do formula-fed infants.9,10 These higher ketone concentrations may allow breastfed infants to tolerate lower plasma glucose concentrations without showing NH symptoms. J U N E 2 016 For children with confirmed persistent hypoglycemia or those needing IV glucose to treat hypoglycemia, say PES guidelines, workup/investigation should include (Table 32): Thorough history. Include timing of episode, in context of food, birth weight, gestational age, and family history. Physical exam. Seek evidence of hypopituitarism, glycogenosis, adrenal insufficiency, or BeckwithWiedemann syndrome. Specimen or “critical sample.” Whenever possible, obtain at time of spontaneous presentation of hypoglycemia <50 mg/dL after 48 hours of life and before treatment that might alter intermediary metabolites and hormone levels is given. Readily available assays for PG, insulin, BOHB, and lactate are useful for distinguishing categories of hypoglycemia disorders. clinical feature 3 POSTNATAL GLUCOSE TREATMENT TARGETS: PES High-risk newborns without a suspected congenital hypoglycemia disorder Neonates with suspected congenital hypoglycemia disorder and those requiring IV glucose to treat hypoglycemia 0-48 h >50 mg/dL >48 h >60 mg/dL Any time >70 mg/dL The PES set the above thresholds based on the following observations about the impact of specific glucose concentrations in adults: 55-65 mg/dL Brain glucose utilization becomes limited. 50-55 mg/dL Neurogenic symptoms (palpitations, tremor, anxiety, sweat, hunger, paresthesia) perceived. <50 mg/dL Discussion Cognitive function impaired (neuroglycopenia, characterized by confusion, seizures, coma). Abbreviations: IV, intravenous; PES, Pediatric Endocrine Society. From: Thornton PS, et al.2 Consider reserving extra plasma for tests such as plasma cortisol, growth hormone, or free fatty acids. Provocative fasting test. If a spontaneous episode of glucose <50 mg/dL does not occur in a patient in whom workup is warranted, a 6-hour fast should be performed. Additionally, if the patient is unable to maintain PG >60 mg/dL, then further consideration of a persistent hypoglycemic disorder should be entertained. Managing persistent hypoglycemia Neonates with persistent hypoglycemia: Because recurrent PG levels of 50 mg/dL to 70 mg/dL can blunt awareness of hypoglycemia and impair hepatic glucose release (ie, hypoglycemia-associated autonomic failure),11 PES treatment targets aim to maintain PG concentration within the normal range of 70 mg/dL to 100 mg/dL. For defects in glycogen metabolism and gluconeogenesis, maintaining such a PG concentration prevents metabolic acidosis and growth failure; for hyperinsulinism, it can prevent recurrent hypoglycemia, which raises the risk of subsequent hypoglycemic episodes. For any hypoglycemia disorder, base long-term therapy on the specific disorder’s etiology, consulting with a physician experienced in diagnosing and managing pediatric hypoglycemia. High-risk neonates without a suspected congenital hypoglycemia disorder: The PES committee’s consensus was that during the first 48 hours of life, a safe target for such an infant should be near the mean for healthy newborns on the first day of life, and above the threshold for neuroglycopenic symptoms (>50 mg/dL). After 48 hours of age, the committee raised the glucose target (>60 mg/dL) above the threshold for neurogenic symptoms and J U N E 2 016 | near the target for older infants and children because hypoglycemia that persists beyond the first 48 hours (and particularly beyond the first week) increases the concern for an underlying hypoglycemia disorder. Absent evidence regarding shortterm or long-term consequences of different treatment targets, the PES committee focused on physiology, etiology, and mechanism, balancing the risks and benefits of interventions in setting these targets. The apparent conflict between the AAP and PES recommendations stems from philosophical and methodological differences. Experts concur that within an hour or 2 of birth, PG concentrations in normal neonates temporarily drop by up to 30 mg/dL,1,2 a phenomenon known as transitional neonatal hypoglycemia (TNH).12 However, questions such as what this natural nadir means, how to respond to PG concentrations during the first 2 days of life, and whether newborn brains are more or less susceptible to hypoglycemic injury have sparked controversy.13-15 A PES committee reviewed available data regarding metabolic fuel and hormonal responses during this period in normal newborns and determined that TNH most closely resembles known genetic forms of congenital hyperinsulinism.12 During this mild form of hyperinsulinism, mean PG threshold for insulin suppression is approximately 55 mg/dL to 65 mg/dL shortly after birth and rises to approximately 80 mg/dL to 85 mg/dL—the mean level found in older infants, children, and adults—by age 72 hours, C O N T E M P O R A RY P E D I AT R I C S . C O M 25 clinical feature as the glucose-stimulated insulin secretion mechanism matures.16,17 The difficulty in distinguishing TNH from a suspected persistent hypoglycemic disorder during an infant’s first 48 hours supports the PES’ suggestion to delay any diagnostic evaluation until 2 to 3 days after birth.2 In a recent reexamination of the mechanism and implications of TNH, the PES reviewed the major metabolic fuel and hormonal responses to hypoglycemia in neonates.12 Considering published data from normal newborns during this phase, Stanley and colleagues rea- necessary for postnatal survival (such as enhancing oxidative fat metabolism, stimulating appetite).20 An alternate explanation advanced by the PES is that this lower threshold for insulin secretion is essential for in utero fetal nutrition and growth, and that persistence of this lower set point of insulin secretion is caused by peripartum stress. In 126 term-appropriate for gestational age neonates, the lowest glucose values (<30 mg/dL) appeared to be especially associated with peripartum stresses (fetal distress, birth asphyxia, low Apgar scores) and low weight-versus-length ratios, consis- The apparent conflict between the AAP and PES recommendations stems from philosophical and methodological differences. soned that mean responses most likely reflected the responses of normal newborns. Additionally, the PES found the PG concentrations of normal newborns during the transitional period to be “remarkably stable and relatively unaffected by the timing of initial feeding or interval between feedings.” However, Adamkin believes feeding will affect infants with lower levels of glucose.4 Studies published between 1950 and 1992 show mean PG levels of approximately 57 mg/dL across fasting times that ranged from 8 to 24 hours.18,19 These data led the PES to conclude that TNH appears to be a regulated process in normal newborns. Researchers have speculated that this dip in glucose levels might stimulate physiological processes 26 tent with fetal growth restriction. By 72 hours, only 0.5% of these babies will have persistent glucose values <50 mg/dL.21 Perinatal stress has been associated with hyperinsulinemic hypoglycemia that may persist until 6 months of age.22,23 These factors explain why the PES considers birth asphyxia, ischemia, and other stressors to put infants at risk of hypoglycemia, although the AAP counters that routinely screening such patients would be burdensome and produce many enigmatic readings in asymptomatic infants.3 In setting its thresholds, the AAP focused instead on the lower ranges of glucose concentrations found in fetuses and asymptomatic infants17,24 in suggesting a bottom line of <25 mg/dL and actionable levels of 25 mg/dL to 40 mg/dL during an C O N T E M P O R A RY P E D I AT R I C S . C O M | J U N E 2 016 infant’s first 4 hours of life. From 4 to 24 hours, the AAP’s lower range is <35 mg/dL, with actionable values of 35 mg/dL to 45 mg/dL. T he neu rodevelopmenta l approach that underlies the AAP thresholds is hardly free of controversy. For starters, the 1988 study25 that resulted in widespread adoption of 47 mg/dL as the threshold for NH in all infants had methodological flaws, and focused not on hypoglycemia but on feeding patterns of low-birth-weight babies.1 Subsequent studies in various newborn populations—including a follow-up study showing less dramatic impact when these infants were aged 7 or 8 years26 —have yielded conflicting results. Recent reviews have revealed a dearth of highquality data regarding the relationship between early glucose levels and neurodevelopmental outcome, especially in late-preterm and newborn infants with risk factors.27 It should be noted that any study that looks only at glucose levels without examining all the brain fuels including oxygen and blood flow is flawed. The AAP authors conclude that sticking with this group’s recently reratified 2011 recommendations, “along with enhanced vigilance to identify persistent hypoglycemia symptoms after 48 hours, might be the best compromise” to prevent overscreening and overtreatment while still committing to diagnosing persistent hypoglycemia after the transitional period, but before infants are discharged home.3 For references, go to ContemporaryPediatrics.com/ hypoglycemia-guidelines CLINICAL FEATURE Nutrition Strategies 5 baby steps to better nutrition 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. Teaching patients these simple yet specific strategies for better nutrition will empower them to make better choices about what they eat and take control of their health. control of their eating. Patients often want to make big changes Here are 5 small strategies that will to improve their health. However, there make significant nutritional improvements often is a disconnect between wanting to for the pediatric patient. make a change and the ability to carry 1. Switch from soft drinks to water. the change through and make it a habit. Sugar-sweetened beverages are a main Rather, the patients that are successful in source of extra calories for the pediatric improving their nutrition are those who population. These beverages include not make small but sustainable changes and only soft drinks, but also specialty coffee maintain those changes over time. drinks, fruit juices, sports drinks, energy The difficulty in change often frusdrinks, and vitamin water drinks. trates clinicians and discourages Although soda consumption has them from making interventions FAST FACT decreased over the last 10 years, at all. Physicians sometimes Sugar-sweetened consumption of the other lack self-efficacy to deliver beverages are a drinks has been on the rise. behavioral interventions, or main source of These drinks add a significant they may not have signifiextra calories for children. amount of calories to the avercant experience with deliverage American diet.1 ing nutritional counseling in their practice. This article seeks to give the Consumption of sugar-sweetened pediatrician a number of focused, spedrinks places children at risk for a number cific, and brief strategies that can be impleof poor outcomes including elevated blood mented in a busy office practice to achieve glucose levels, diabetes mellitus, oversustainable, long-term nutritional change weight or obesity, metabolic syndrome, and help patients make better day-to-day and cardiovascular disease as an adult.1 decisions by empowering them to take Sugary drinks have very few dietary J U N E 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 27 clinical feature or other benefits for the pediatric patient, and they are associated with the aforementioned impacts on overall health. As a result, the pediatrician should consider recommending that caregivers eliminate sugar-sweetened beverages as much as possible from their children’s diet. Instead, children and adolescents should be encouraged to drink water. Developing this habit at an early age will significantly reduce wasted calories for the pediatric patient over his or her lifetime. If parents do not offer these drinks in their home, their children will have significantly reduced access to these extra, empty calories. When beverages other than water are consumed, zero-calorie in a dose-dependent manner. The Physicians’ Health Study and the Nurses’ Health Study both demonstrated that consumption of more whole grain foods was associated with lower weight compared with those who consumed fewer wholegrain foods at all follow-up points.3 Increased intake of whole grains additionally has been associated with decreased risk of high cholesterol, diabetes, heart disease, and cancer. The US Department of Health and Human Services recommends that whole grains make up at least half of all grains consumed.4 However, fewer than half of all American meet this goal. Pediatric patients can increase When beverages other than water are consumed, zero- or low-calorie drinks or skim milk are good recommendations. drinks, low-calorie drinks, or skim milk are good recommendations. Additionally, children should eat fruit rather than drink fruit juice or other fruit beverages. If fruit juice is to be consumed, it is recommended that children aged 1 to 6 years limit their intake to 4 oz. to 6 oz. per day, and for children aged 7 to 18 years, 8 oz. to 12 oz. (2 servings) per day.2 2 . C ho o s e w hole g r a i n s . Increased intake of whole grains is inversely associated with a number of different parameters associated with obesity such as body mass index, waist-to-hip ratio, and waist circumference. Lower abdominal fat has been associated with increased intake of whole grains 28 intake of whole grains by eating more brown rice, oatmeal, whole oats, bulgur (cracked wheat), popcorn, whole rye, graham flour, pearl barley, whole wheat, and whole grain corn. Also, referral to a nutritionist is another strategy for the pediatrician to improve consumption of whole grains and other dietary interventions. Physicians generally underrefer to ancillary services, but many physicians also do not feel skilled in dietary counseling. Some simple substitutions to recommend to parents are to buy whole-wheat bread, pasta, and crackers instead of the versions made with white f lour. C O N T E M P O R A RY P E D I AT R I C S . C O M | J U N E 2 016 Whole-wheat products retain vitamins and other nutrients that are lost during the bleaching process to make white flour. Additionally, the whole-wheat versions contain more fiber. Although some patients complain that the taste, texture, and feel of whole-grain products are different, many patients come to like them over time, especially if parents do not offer the white-f lour versions. Encourage parents to experiment with different grains. There is a plethora of commercially available products that allow increased intake of grains without a lot of sacrifice. However, parents need to be mindful of words on labels such as wheat, stoned wheat, enriched wheat, or 7-grain. These may not be whole grains although they give the appearance of being so. Try offering the following suggestions during meals or snacks to increase the amount of different grains over time and slowly introduce as snacks or pastas. Here are some suggestions of whole grains for each part of the day: } Breakfast: Whole-wheat cereals, whole-grain muffins, or oatmeal. } Lunch: Whole-grain bread for sandw iches or whole-grain crackers to accompany soup. } Dinner: Brown or wild rice as a side instead of white rice or whole-grain pasta. } Snacks: Unbuttered popcorn or whole-grain crackers. 3. Always eat breakfast. Eating breakfast has been associated with decreased risk of overweight and obesity. 5 Breakfast eaters have a higher consumption of fiber, calcium, vitamins A and C, and other nutrients as well as being more likely clinical feature } Fresh fruit; and } Dry cereal. RESOURCES FOR PEDIATRICIANS AND FAMILIES American Heart Association (AHA): Dietary Recommendations for Healthy Children } bit.ly/AHA-diet-recommendations-kids Centers for Disease Control and Prevention (CDC): CDC Guide to Strategies for Reducing the Consumption of Sugar-Sweetened Beverages } bit.ly/CDC-reduce-sugar-beverages US Department of Agriculture (USDA). ChooseMyPlate.gov: Choose my plate: 10 tips to a great plate English: } bit.ly/USDA-choose-my-plate-10-tips-eng Spanish: } bit.ly/USDA-choose-my-plate-10-tips-sp US Department of Agriculture (USDA): Dietary Guidelines for Americans 2015-2020, 8th edition } bit.ly/USDA-diet-guidelines-2015 US Department of Health and Human Services (USDHHS). Dietary guidelines 2015-2020: Appendix 7. Nutritional Goals for Age-Sex Groups Based on Dietary Reference Intakes and Dietary Guidelines Recommendations } bit.ly/USDHHS-nutrition-goals-2015 US Department of Health and Human Services, Office of Disease Prevention and Health Promotion (ODPHP): health.gov: Toolkits and Resources } bit.ly/ODPHP-diet-guidelines-2015-tools to meet general nutrition recommendations compared with breakfast skippers.6 Eating breakfast is also associated with better school attendance, grades, performance, and test scores.7,8 As children get older, they are more likely to skip breakfast. More than 95% of children aged 5 years and younger eat breakfast daily, although this number decreases to 87% among 6- to 11-year-olds and 69% in children aged 12 years and older.9 Encourage parents to be good role models for their children and not skip breakfast. If children are already overweight or obese, eating a good breakfast is an invaluable asset in helping patients control weight gain. Healthy breakfast options that are quick for parents include: } A bowl of whole-grain cereal topped with low-fat milk or yogurt, and fruit; } Granola bars; } Breakfast bars; } Dried fruit; J U N E 2 016 | 4. Avoid processed foods. Although patients will never be totally able to avoid processed foods, they should be encouraged to choose unprocessed foods when available. Processed foods are energy dense with a high calorie per unit weight. They are often high in added sugars, sodium, and fat, and low in fiber and whole grains as well. A better choice is a natural food with a higher content of water. For example, a fresh apple is a better choice than applesauce or some sort of apple snack that comes in a bag. S ome com mon food s t hat patients think are healthy and often do not consider processed can turn what seems to be a healthy food choice into a poorer, unhealthy one. For example, the cereal industry spends a lot of time, effort, and money convincing parents that their products are a great way for kids to start their day. However, examining the label of many popular cereal boxes reveals ingredients such as artificial sugars, artificial dyes, sodium, partially hydrogenated oils, trans fats, and butylated hydroxyanisole (BHA), a product in embalming f luid. Mixing rolled oats, sunflower seeds, sliced almonds, chopped pecans, and raisins or a dried fruit of choice is a much healthier option. Mixing granola, steel cut oats, and millet is another homemade cereal that is much healthier than the more processed, off-the-shelf versions. Salad dressing can easily turn a healthy meal idea into a processed calorie feast that is not so healthy. A quick glance at salad dressing labels marketed as “all natural” and “lite” C O N T E M P O R A RY P E D I AT R I C S . C O M 29 clinical feature reveals ingredients such as maltodextrin, sodium benzoate, calcium disodium ethylenediaminetetraacetic acid (EDTA), modified food starches, monosodium glutamate, corn syrup, autolyzed yeast extract, sodium chloride, and xanthum gum. Instead, suggest trying oil and vinegar with a little Dijon mustard and garlic mixed in. Another healthier option is to mix Greek yogurt, yellow mustard, raw honey, and lemon juice. Ketchup, tortilla chips, pasta sauce, soup, flavored yogurt, granola bars, and energy bars are just a few of the other foods that may suggest one is eating healthy, but the label may reveal something different. However, all these items, with a quick Internet search, can be made from more natural and healthy ingredients easily at home. These unprocessed versions are much healthier and contain significantly fewer processed ingredients. Patients can be instructed to read a label and if they have trouble pronouncing or do not recognize a large number of the ingredients, there is a good chance the product is highly processed, and the parent might be better advised to consider an alternative option. 5. Avoid junk food. If parents choose not to buy junk food, children simply will have significantly fewer opportunities to eat these calorie-rich, low-nutritionalquality foods. Although efforts to ba n ju n k food f rom t he Supplemental Nutrition Assistance Program (SNAP), as was successful for alcohol and cigarettes, have failed, it is estimated that changes in the program could significantly improve diets of the 30 1 in 7 Americans that receive food assistance. One pilot project that has yet to be implemented found that fruit and vegetable consumption increased by 25% when SNAP recipients were incentivized with 30 cents for every dollar used to purchase fruits and vegetables.10 In addition to providing patient education on these topics, pediatricians can advocate for policies that improve the likelihood that patients will make better food choices. Because so many people in the United States receive food assistance, most grocery chains and convenience stores want to participate. Few stores opt out of programs such as SNAP or Women, Infants, and Children (WIC). In 2009, the measuring eating habits, calorie intake, or exercise, self-tracking demonstrates benefits across a wide range of desired activities. When patients record both what and how much they eat, they generally eat less and lose more weight compared with those who do not self-track the activity.14 With some activities such as exercise, patients tend not only to perform the desired activity more, but they also seem to get greater enjoyment from that activity. With self-tracking, a patient can set smaller waypoints on the way to achieving a bigger goal. Measurement allows patients to not be overwhelmed by a larger goal, and allows them to see where they are on the path to achievement. Studies have demonstrated that doubling shelf space for fruits and vegetables increased consumption by 30% to 60%.12,13 WIC program increased the types of foods stores were required to stock in order to participate. Nearly all stores participated, and milk, whole grain, and fruit consumption increased.11 Similarly, studies have demonstrated that simply doubling shelf space for fruits and vegetables increased consumption by 30% to 60%.12,13 The SNAP or WIC mandates for certain amounts of shelf space for fruits, vegetables, and other healthy, nutritionally desirable foods will likely improve consumption of these items for people beyond participants in food assistance programs.11 Finally, there is a saying in business that “You cannot change what you do not measure.” Whether C O N T E M P O R A RY P E D I AT R I C S . C O M | J U N E 2 016 Small incremental changes in eating habits and purchasing decisions can make a big difference in the nutritional state of children and adolescents. The pediatrician has an opportunity to counsel in the office as well as participate in local and national advocacy related to food assistance programs and food programs in public schools. Finally, advocating for patients to measure and record aspects of their nutritional habits is likely to lead to improvements in what patients consume. For references, go to ContemporaryPediatrics.com/ 5-steps-to-nutrition puzzler CONTINUED FROM PAGE 13 HYPOTHERMIA AND EMESIS IN A NEWBORN After discharge, the baby was breastfeeding without emesis, and although she was thought to be sleepy (by mother’s report), she did wake for feeds. At baseline, she breastfed for 5 to 10 minutes every 3 to 4 hours, but starting at age 5 days she was having greater difficulty latching. Furthermore, she became lethargic and developed nonbilious, nonbloody, nonprojectile emesis with each feed. The neonate maintained continued daily bowel movements. Simultaneously, she had decreased urine output, with 2 small wet diapers the night prior to admission. The morning of admission, the patient was taken to her pediatrician, who noted a rectal temperature of lower than 36°C, along with emesis with feeding trial. Physical exam In the pediatric ED, the patient weighed 2.20 kg and had a rectal temperature of 35.8°C, heart rate of 138 beats per minute, respiratory rate of 32 breaths per minute, and a blood pressure of 77/51 mm Hg. Physical exam revealed an active and alert neonate in no apparent distress; her abdomen was soft, nontender, nondistended, and without hepatosplenomegaly. The remainder of the examination was noncontributory. Differential diagnosis The patient presented with 2 primary symptoms, both of which have unique differential diagnoses. Hypothermia in a newborn is concerning for many possible conditions (Table 11,2). Although 1 DIFFERENTIAL DIAGNOSIS OF HYPOTHERMIA DIAGNOSIS CHARACTERISTIC FINDINGS Cold exposure } History pointing toward difficulty with swaddling infant; neonate being outside in cold weather without adequate protection; or not dressing neonate in adequate levels of clothing. } May demonstrate signs of abuse. } History of maternal GBS colonization; premature Infection rupture of membranes; preterm rupture of membranes; prematurity; prolonged rupture of membranes; maternal UTI; chorioamnionitis. } Presentation dependent on the causative agent and source. Nonspecific signs include pulmonary hypertension, hypoxemia, decreased cardiac output, or signs of overt shock. Metabolic signs include hypoglycemia/hyperglycemia, jaundice, or metabolic acidosis. Signs of meningitis or temperature instability may also be seen. } Very unlikely in a newborn; would most likely be from Ingestions abuse. History of ingestion of poison or drugs. Metabolic derangements/ Endocrinopathies } Laboratory findings demonstrating electrolyte abnormalities, hypothyroidism (high TSH, low T 3 /T4), abnormal urine findings, abnormal newborn screen. } Patient may demonstrate nonspecific findings such as fatigue and hypoactivity or hyperactivity. Abbreviations: GBS, group B streptococcus; T3, triiodothyronine; T4, thyroxine; TSH, thyroid-stimulating hormone; UTI, urinary tract infection. From Mandt MJ, et al1; Fein DM, et al.2 the definition is controversial, the World Health Organization (in 1997) categorized hypothermia as an unintentional temperature drop below 36.5°C and further divided hypothermia into 3 stages: cold stress (36.0°C-36.4°C), moderate hypothermia (32.0°C-35.9°C), and severe hypothermia (<32.0°C).3 Neonates are at higher risk of developing hypothermia because of their large surface-to-mass ratio, lack of subcutaneous tissue, and poorly developed thermoregulation. Hypothermia may occur secondary to environmental exposure, infections J U N E 2 016 | (sepsis, meningitis), metabolic/ endocrine disorders, drugs, central nervous system dysfunction, shock, burns, or iatrogenic causes.2 The initial concern in this neonate with hypothermia was a serious bacterial infection, which should be highly considered until proven otherwise. The patient’s concurrent lethargy and emesis in the context of peripartum maternal fever could have been consistent with an undertreated infection or late-onset infection. Although lower on the differential, metabolic derangement was considered given the patient’s C O N T E M P O R A RY P E D I AT R I C S . C O M 31 puzzler 2 DIFFERENTIAL DIAGNOSIS OF EMESIS DIAGNOSIS CHARACTERISTIC FINDINGS Gastroesophageal reflux Effortless regurgitation (“happy spitter”). Gastroesophageal reflux disease Neonate may demonstrate fussiness, irritability, or feeding aversion. Food protein-induced enteropathy Colitis with bloody stooling, diarrhea, and failure to thrive. Pyloric stenosis Typically 3-6 wk neonate with postprandial nonbilious. nonbloody projectile vomiting; demanding feeding after (“hungry spitter”). Physical exam may demonstrate “olive-like” mass in the right upper quadrant. Laboratory exam may show hypochloremic metabolic alkalosis. Adrenal insufficiency Similar presentation to pyloric stenosis. May demonstrate hyponatremia and hyperkalemic acidosis. Intestinal obstruction (intestinal atresia, Hirschsprung disease, malrotation with/without volvulus, intussusception) May demonstrate bilious and prolonged vomiting (>12 h). Neonate may have abdominal distension and tenderness. Hematemesis or hematochezia may be present as well. From Fein DM, et al2; Zenel JA4; Nazarey P, et al.5 emesis, which would lead to electrolyte imbalance and nutritional deficiency, ultimately resulting in hypothermia. The lack of history of cold exposure and ingestions made these diagnoses less likely in this neonate. Emesis in the newborn also can be attributed to a myriad of pathologies. Primary diagnoses include gastroesophageal ref lux/gastroesophageal reflux disease, feeding intolerance, obstruction, necrotizing enterocolitis, metabolic disorders, milk-protein intolerance, and infections (urinary tract infection or meningitis; Table 22,4,5).6 Given the hypothermia and history of peripartum maternal fever, infection 32 was the top diagnosis in the differential. Suspicion for a primary gastrointestinal etiology was initially lower on the differential because the newborn presented with normal stooling and intermittent spit-up. Laboratory tests Workup for infectious etiology revealed normal urinalysis, complete blood count, and comprehensive metabolic panel. A respiratory viral panel was negative, and a bloody lumbar puncture was significant for elevated protein (839 mg/dL). At 48 hours into the evaluation, all cultures and the herpes simplex virus polymerase chain reaction test were negative. Antibiotics C O N T E M P O R A RY P E D I AT R I C S . C O M | J U N E 2 016 were discontinued but emesis persisted. During the first 24 hours in the hospital, the patient had 6 episodes of nonbilious, nonbloody emesis described as “spit-up.” She was started on ranitidine with little relief. Throughout the hospital course, emesis occurred either immediately after feeds or within 30 minutes, varying in quantity between 10 mL and 40 mL. The patient continued to have bowel movements and a benign abdominal exam. However, given the emesis, nasoduodenal (ND) tube placement was attempted on day 2 of the admission. This procedure was unsuccessful and an abdominal X-ray at the time of placement demonstrated the ND tube tip within the region of the stomach along with gaseous distension of the stomach and an enlarged duodenal bulb (double bubble; Figure 1). The X-ray also showed minimal distal gas in the bowel in the left lower quadrant and an overall paucity of bowel gas. While awaiting further imaging in the radiology suite, the patient had her first episode of bilious vomiting. Upper gastrointestinal (GI) series demonstrated dilatation of the first portion of the duodenum without contrast beyond the duodenal bulb (Figure 2). Given these findings, intestinal obstruction became the leading diagnosis, although the patient’s hy pothermia could have been explained by being SGA at birth (with resultant impaired thermoregulation), or by infection.4,5 Diagnosis Pediatric surgery was consulted. The patient underwent an exploratory laparotomy that revealed an puzzler annular pancreas with duodenal stenosis above the level of the common bile duct, as well as malrotation. No ischemic bowel changes were noted. Discussion O vera l l, congenita l duodena l obstruction affects 1 in 2500 to 1 in 10,000 live births.7 In 1980, Kiernan and colleagues published a seminal review of annular pancreas, which encompassed 266 literature reports and 15 operations at the Mayo Clinic between 1957 and 1976.8 In this series, 51.5% of cases of annular pancreas occurred in children, that led to the more traditionally seen emesis pattern.9,10 Clinical presentation of different medical conditions often can be subtle in newborns. The presentation of gastrointestinal obstruction is clear when a patient presents with early projectile and/or bilious vomiting combined with absent flatus or bowel movements. However, as in this case, the clinical picture can be obscured when a neonate presents with nonbilious emesis, and complicated further by hypothermia and lethargy, suggesting an infectious etiology until proven otherwise. This case underscores the importance of having a high index of suspicion for neonatal bowel obstruction. and almost all neonates presented unable to swallow secretions or by vomiting feedings, usually with first feed.4,5,8 This finding is supported by a review by Chen and associates from records at the Children’s Hospital of Zhejiang University School of Medicine, China.7 Among the 287 neonates identified in their facility with duodenal obstruction, 86.06% presented with vomiting and 83.81% with bilious vomiting. However, the patient in this case had an atypical presentation, with hypothermia occurring later in the first week of life and nonbilious vomiting that appeared more characteristic of spit-up. Interestingly, the patient developed bilious vomiting while in the radiology suite. Because the lesion was above the level of the common bile duct, likely there was an accumulation of bile This case underscores the importance of having a high index of suspicion for neonatal bowel obstruction, particularly in babies presenting with vomiting (regardless of the character or timing) and systemic signs of illness. Additionally, pediatricians should have a low threshold for ordering abdominal imaging in neonates presenting with emesis. If an abdominal X-ray demonstrates a pattern of general gas paucity, clinicians should perform additional radiographic imaging (such as an upper GI series or abdominal sonogram) to evaluate for a possible bowel obstruction. Patient outcome The patient underwent an uncomplicated duodenoduodenostomy and was safely discharged 20 days after the surgery. J U N E 2 016 | Mr Wei is a fourth-year medical student at Weill Cornell Medicine, New YorkPresbyterian Hospital, New York City, New York. Dr Spigland is professor of Clinical Surgery, Weill Cornell Medicine, and chief, Division of Pediatric Surgery and Pediatric Trauma, New York-Presbyterian Hospital, Cornell Campus. Dr Green is assistant professor of Pediatrics, Weill Cornell Medicine, New York-Presbyterian Hospital, New York City. The authors have 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. REFERENCES 1. Mandt MJ, Grubenhoff JA. Emergencies and injuries. In: Hay WW Jr, Levin MJ, Deterding RR, Abzug MJ, Sondheimer JM. Current Diagnosis and Treatment: Pediatrics. 21st ed. New York, NY: McGraw-Hill Companies; 2012:351-352. 2. Fein DM, Avner JR. The febrile or septic-appearing neonate. In: Schafermeyer RW, Tenenbein M, Macias CG, Sharleff GQ, Yamamoto LG. Strange and Schafermeyer’s Pediatric Emergency Medicine. 4th ed. New York, NY: McGraw-Hill Education; 2015:5-7. 3. Kumar V, Shearer JC, Kumar A, Darmstadt GL. Neonatal hypothermia in low resource settings: a review. J Perinatol. 2009;29(6):401-412. 4. Zenel JA. Examination of the newborn infant. In: Rudolph CD, Rudolph AM, Lister GE, First LR, Gershon AA. Rudolph’s Pediatrics. 22nd ed. New York, NY: McGraw-Hill Companies; 2011:174-183. 5. Nazarey P, Sato TT. Gastrointestinal obstruction. In: Rudolph CD, Rudolph AM, Lister GE, First LR, Gershon AA. Rudolph’s Pediatrics. 22nd ed. New York, NY: McGraw-Hill Companies; 2011:1394-1395. 6. Parashette KR, Croffie J. Vomiting. Pediatr Rev. 2013;34(7):307-319. 7. Chen QJ, Gao ZG, Tou JF, et al. Congenital duodenal obstruction in neonates: a decade’s experience from one center. World J Pediatr. 2014;10(3):238-244. 8. Kiernan PD, ReMine SG, Kiernan PC, ReMine WH. Annular pancreas: Mayo Clinic experience from 1957 to 1976 with review of the literature. Arch Surg. 1980;115(1):46-50. 9. Merianos DJ, Schwab CW II. Pediatric surgery. In: Atluri P, Karakousis GC, Porrett PM, Kaiser LR. The Surgical Review: An Integrated Basic and Clinical Science Study Guide. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:382-393. 10. Hackam DJ, Grikscheit T, Wang K, Upperman JS, Ford HR. Pediatric surgery. In: Brunicardi FC, Anderson DK, Billiar TR, et al. Schwartz’s Principles of Surgery. 10th ed. New York, NY: McGraw-Hill Companies; 2014;chap 39. C O N T E M P O R A RY P E D I AT R I C S . C O M 33 peds v2.0 ANDREW J SCHUMAN, MD SECTION EDITOR MOC reform: One year later This article reports the latest developments in the process of reform for the American Board of Pediatrics’ Maintenance of Certification (MOC) requirements, what transformations already have occurred, and what changes still lie ahead. It’s been over a year since the American Board of Pediatrics (ABP) announced its intentions to overhaul the maintenance of certification (MOC) process. In this reportorial article, I’ll bring you up-to-date with current MOC requirements and the changes likely to occur over the next year. In addition, I’ll provide some updates regarding several developments that pertain to MOC opposition. MOC circa 2016 In 2010, the American Board of Medical Specialties (ABMS) and its member boards changed the model of certification to today’s model that is based on continuous “maintenance” of certification. As a consequence, in 2010, the ABP began issuing certificates with no end dates. Pediatricians were listed either as “participating in MOC” on the ABP website or “not participating in MOC.” According to current data provided by the ABP website, as of December 2015, approximately 34 34% of the pediatrician workforce has a permanent certificate and 53% of pediatricians have time-limited certificates. These numbers are essentially unchanged from 2013. Of note is that about 14% of pediatricians have let their ABP certificates lapse, which represents a small increase from 11% in 2013 (Figure). The situation that ultimately caused many of the member boards of the ABMS to consider a “gentler” approach to MOC involved a directive imposed on membership by the American Board of Internal Medicine (ABIM) in 2014. In that year, the ABIM mandated that member physicians participate in MOC every 2 years. Additionally, grandfathered ABIM physicians began to be listed as “certified, not meeting MOC requirements” on the ABIM website if they didn’t register for continuous MOC. In response to written protests from over 20,000 internists, the ABIM issued an “apology” letter that indicated that the ABIM would C O N T E M P O R A RY P E D I AT R I C S . C O M | J U N E 2 016 suspend several of its Part 4 requirements and change the language reporting a diplomate’s MOC status on its website. The letter also indicated that the ABIM will update the MOC written exam to make it more relevant to current practice. This event led to the development of an alternative board (more on this later) as well as the expectation among other physicians that their own boards would begin embracing “reform.” Changes in ABP MOC Over the past year, the ABP began to solicit feedback from member pediatricians and expressed its intention to make MOC requirements less rigorous and more relevant to pediatric practice. The 2016 annual report from the ABP was recently published, and it includes much information regarding what transformations already have occurred and what is likely to happen to the 10-year recertification exam (MOC Part 3). Firstly, in response to discussions surrounding the quality assurance (QA) projects required for Part 4, the ABP now provides full 40 credits for pediatric practices that have achieved National Center for Quality Assurance pediatrics v2.0 GENERAL PEDIATRICS DIPLOMATES (ALL): DISTRIBUTION OF CERTIFICATE TYPE Diplomates who achieved their certificates before 1989 were awarded permanent certificates. Beginning in 1989, diplomates were issued time-limited certificates. In 2010, the American Board of Pediatrics began issuing certificates with no end dates. Diplomates holding time-limited certificates or certificates with no end dates must meet the requirements of Maintenance of Certification to keep their certification active. Data include all diplomates ever certified, regardless of age, as of December 31, 2015. 54.7 48.8 32.1 33.5 12.9 Permanent Time-limited/ no end date US/Canadian medical school graduate 17.2 Lapsed 0.3 0.4 Revoked International medical school graduate From American Board of Pediatrics. Workforce data, 2015-2016. Available at: https://www.abp.org/sites/ abp/files/pdf/workforcebook.pdf. Accessed May 5, 2016. (NCQA), patient-centered medical home (PCMH) status. Many practices have sought this certification (see “Home sweet ‘medical home’” (Contemporary Pediatrics, November 2013). Achieving PCMH status assures patients (and insurance companies) that practices have met or surpassed quality benchmarks. This enables certified practices to prove eligibility for quality payment incentives offered by many accountable care organizations and insurance companies. It should be noted, however, that the ABP only provides MOC Part 4 credit for PCMH certification via NCQA, which is just one of several organizations that provide PCMH certification. These include URAC (formerly the Utilization Review Ac c re d it at ion C om m i s sion), the Joint Commission, and the Accreditation Association for Ambulatory Health Care. The ABP also provides MOC credit for participation in state or national quality initiatives. For example, the American Academy of Pediatrics (AAP) Division of Chapter Quality includes several ongoing quality projects involving asthma care, attention-deficit/ hyperactivity disorder diagnosis and management, immunizations, and mental health and adolescent J U N E 2 016 | substance abuse. Now MOC Part 4 credit is also granted for small practices that design and pursue their own QA projects, such as undertaking a project to improve rates of handwashing among providers and staff. A new exam format In May 2015, the ABP convened a conference to discuss converting the 10-year exam to one that is a complete departure from the existing format. The new testing concept is that pediatricians will be given questions on a regular ongoing basis, perhaps monthly via the Internet, and be allowed to research the topic before submit ting t heir answers. In the view of the ABP, by changing to this format, pediatricians will utilize these questions either to gain new knowledge or reinforce present understanding. The idea was based on a pilot program developed by the American Board of Anesthesiology (ABA). In 2015, 1400 ABA members participated in a Maintenance of Certification Assessment (MOCA) pilot. Participants received 1 multiple choice question via e-mail once a week. Once accessed, they had a limited amount of time to answer. They received feedback immediately indicating whether the answer was correct and a brief discussion, including references. If answered incorrectly, they would receive follow-up questions on the same subject weeks or months later. The ABA has subsequently replaced its current system with a redesigned MOCA 2.0 program that went into effect in January of this year. According to a recent blog posted by ABP President and CEO David C O N T E M P O R A RY P E D I AT R I C S . C O M 35 pediatrics v2.0 G. Nichols, MD, provisional features of the ABP version of the MOCA exam will include the following (subject to change): } Diplomates will establish a practice profile when registering for MOCA, so that the content can be weighted to suit the type of practice. } Diplomates may receive 1 to 3 multiple choice questions per week. } The amount of time allowed for the answer may vary depending on the complexity of the question. } Online resources or books may be used, but because each question is timed, the diplomate will need to judge carefully whether to invest time in searching through a resource. } A feedback page will pop up after submitting the answer. } A randomization protocol will minimize the likelihood that any 2 diplomates receive the same questions during a given time period. HOW TO OBTAIN MOC CREDITS As discussed in the Peds v2.0 article “Improve your practice with behavior evaluation and management portals” (Contemporary Pediatrics, February 2016), if a practice enrolls in either CHADIS or mehealth for attention-deficit/hyperactivity disorder (ADHD) and uses these portals for evaluation and management of ADHD, developmental screening, and depression and anxiety screens, practices are eligible for MOC Part 4 credits. The CHADIS program (bit.ly/CHADIS) currently offers 3 MOC Part 4 modules, while mehealth for ADHD (bit.ly/mehealth-for-ADHD) offers 1 module. Each module provides 25 MOC Part 4 credits. Abbreviations: CHADIS, Child Health and Development Interactive System; MOC, maintenance of certification. decisions based on the response patterns. Those who successfully participate will meet standards for Part 3 of MOC. An ABP MOCA pilot (MOCAPeds [Maintenance of Certification Assessment for Pediatrics]) will be launched next year. Interested pediatricians should visit the ABP website (www.abp.org) to find out more about the program and consider participating in focus groups A MOCA pilot (MOCA-Peds [Maintenance of Certification Assessment for Pediatrics]) will be launched next year. } Flexibility will allow diplomates to decide when to respond based on their schedule and time availability. Test security provisions may vary depending on whether the diplomate chooses to answer questions during the week they are delivered or wait to answer a batch of questions. } If MOCA is ultimately adopted, the ABP will make pass/fail 36 regarding the MOCA pilot. this alternative board to hospitals and insurance companies as well as to other physicians. The NBPAS requires previous board certification and participation in yearly continuing medical education, and membership costs only $169 every 2 years. As of this writing, the NBPAS has enrolled more than 3000 members and is accepted by 26 hospitals nationwide. Many pediatricians continue to express their opposition to MOC. Interested pediatricians should view the many anti-MOC blogs available on the Rebel.MD website. Last year, several pediatricians developed the Peds4MOCreform.org website to express their opposition to MOC. So far, their site has garnered more than 6500 signatures supporting MOC reform. More nays There are many physicians opposed to the MOC certification. Cardiologist Paul Teirstein, MD, has started an alternative board of medical specialties called the National Board of Physicians and Surgeons (NBPAS) and is encouraging interested physicians to promote C O N T E M P O R A RY P E D I AT R I C S . C O M | J U N E 2 016 First anti-MOC laws The state legislature of Oklahoma unanimously passed a law that went into effect on April 12, 2016, making it illegal for medical facilities to make MOC a requirement for medical practice. The law states: “Nothing in the pediatrics v2.0 SAMPLE MOC PART 3 PILOT EXAM QUESTION QUESTION A 16-year-old girl has a fever and rash. Her symptoms began abruptly today with fever, headache, myalgias, and nausea. She now has a petechial rash on her extremities that spares her palms and soles. She is hypotensive and tachycardic. A complete blood count reveals thrombocytopenia and leukopenia. Which of the following is the most likely diagnosis? A. Infectious mononucleosis B. Infective endocarditis C. Meningococcemia D. Rocky Mountain spotted fever E. Toxic shock syndrome ANSWER The correct answer is: C – Meningococcemia. KEY LEARNING OBJECTIVE Differential diagnosis of fever and rash REFERENCE(S) American Academy of Pediatrics. Meningococcal infections. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015:547. American Academy of Pediatrics. Rocky Mountain spotted fever. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015:682. American Academy of Pediatrics. Staphylococcal infections. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015:715. RATIONALE Fever with accompanying rash is a common presentation in pediatric offices and emergency departments. Many causes are benign and self-limited, but the physician must be able to recognize emergencies with this presentation. Rocky Mountain spotted fever, meningococcemia, and toxic shock syndrome may all present with fever, malaise, headache, nausea, hypotension/ shock, and thrombocytopenia. The onset of symptoms is abrupt with meningococcemia. Although the rash may originally appear as macular, it may quickly progress to petechia/purpura. A complete blood count may show leukopenia in addition to thrombocytopenia. Rocky Mountain spotted fever can have a similar presentation, although typically the rash occurs 3 to 4 days following the fever and is more likely to involve the palms and soles. The rash of toxic shock syndrome is diffuse and may resemble a sunburn. Conjunctivae may also be involved. REFERENCE If you’d like to provide feedback on this question, click here to let us know. Abbreviation: MOC, Maintenance of Certification. Provided by American Board of Pediatrics. J U N E 2 016 Oklahoma Allopathic Medical and Surgical Licensure and Supervision Act shall be construed to require a physician to secure a Maintenance of Certification (MOC) as a condition of licensure, reimbursement, employment, or admitting privileges at a hospital in this state.” Other states such as Michigan and Missouri have similar laws currently under consideration. In addition, in early April, Kentucky governor Matt Bevin signed SB17 into law. This bill is the first state law to be passed and signed that makes it illegal to require specialty medical board certification or MOC as a requirement for practicing medicine in the state. There are also 19 state medical societies that have officially expressed opposition to MOC. These are California, Florida, Georgia, Indiana, Iowa, Massachusetts, Michigan, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Texas, Virginia, Washington, West Virginia, and Wisconsin. To be continued This concludes the reportorial update on MOC reform and opposition. Just because I have not expressed my opinion does not mean that you should not express yours. Has the ABP done enough, or should it do more? Please contact the editors of Contemporary Pediatrics to tell them what you think of these ABP MOC changes. Send your comments to [email protected] | C O N T E M P O R A RY P E D I AT R I C S . C O M 37 CONTINUED FROM PAGE 40 dermcase Etiology Hand, foot, and mouth disease has been classically associated with the enterovirus coxsackievirus A16 (CVA16) and enterovirus 71 (EV71) in North America. It presents with vesicles and erosions on the hard palate and vesicles with a red to hemorrhagic border on the hands, feet, and occasionally buttocks. A novel presentation with widespread symmetric involvement of the arms, legs, diaper area, and mid-face has been reported with increasing frequency over the last 5 years and has become the new norm (Figure). In children with atopic dermatitis, the enteroviral exanthema is often exacerbated in areas affected ECZEMA COXSACKIUM months have been observed with the CVA6 virus strain.4,5 As with other enteroviruses, CVA6 is spread through fecal-oral transmission. Clinical manifestations Eczema coxsackium presents with uniform, clustered, 2-mm to 4-mm vesiculobullous and erosive lesions in regions previously affected by atopic dermatitis, resembling eczema herpeticum. The eruption may consist solely of small vesicles that often evolve into hemorrhagic crusts or conf luent hemorrhagic bullae. In addition to areas affected by eczema, CVA6 has a tendency to trigger lesions in regions affected by other trauma such as diaper der- Eczema coxsackium presents with uniform, clustered, 2-mm to 4-mm vesiculobullous and erosive lesions. by eczema. This presentation, termed “eczema coxsackium,” was reported as early as 1968 to be associated with CVA16.1 Since 2008, eczema coxsackium and the more widespread eruption in children without eczema have been linked to both CVA16 and, more recently, to coxsackievirus A6 (CVA6). 2,3 Coxsackievirus A6 is more often associated w it h disseminated lesions, including perioral and buttock lesions, than the CVA16 virus. Eczema coxsackium is most commonly observed among preschoolers in the summer through late fall. However, adult cases and increasing reports of cases in the fall and winter 38 matitis and burns, or in a GianottiCrosti–type distribution. Unlike with eczema herpeticum, CVA6-associated skin findings are not usually linked with fever, decreased appetite, or decreased activity. Rarely, children become dehydrated because of decreased oral intake. Many parents report a brief history of fever or diarrhea during the week before appearance of the exanthema. 6 Rare, serious complications including aseptic meningitis have been reported.7 Onychomadesis, Beau’s lines, and desquamation of the palms and soles may develop 1 to 3 weeks after resolution of the rash, which may C O N T E M P O R A RY P E D I AT R I C S . C O M | J U N E 2 016 persist for 2 to 3 weeks.6-8 Differential diagnosis The differential diagnosis includes eczema herpeticum, varicella, contact dermatitis, and blistering drug reactions. Diagnosis can be made based on history, presence of systemic symptoms, and reversetranscription polymerase chain reaction assay from vesicular fluid, throat swabs, or stool samples. Management Eczema coxsackium is managed with supportive care. Aggressive use of moisturizer for managing underlying eczema is recommended. Lowpotency topical steroids are used for managing itch. Isolation from other children is not necessary. Outcome The patient continued to eat and drink normally, and his exanthem crusted over and healed over the next 2 weeks. Ms Vandiver is a third-year medical student at Johns Hopkins University School of Medicine, Baltimore, Maryland. Dr Cohen, section editor for Dermcase, is professor of pediatrics and dermatology, Johns Hopkins University School of Medicine, Baltimore. The author and section editor have 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. Vignettes are based on real cases that have been modified to allow the author and section editor to focus on key teaching points. Images also may be edited or substituted for teaching purposes. For references, go to ContemporaryPediatrics.com/ dermcase-0615 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 dermcase BERNARD A COHEN, MD SECTION EDITOR W FIGURE Vesicular rash on the patient’s elbow. Vesicular rash in an infant with eczema AMY VANDIVER, BA, MS3; BERNARD A COHEN, MD The parents of a healthy 6-month-old boy with eczema bring him to the office for evaluation of a rapidly progressive rash on his arms, legs, face, and back. He had a low-grade fever and loose stools for 2 days last week. FOR MORE ON THIS CASE, TURN TO PAGE 38. DERMCASE diagnosis 40 ECZEMA COXSACKIUM C O N T E M P O R A RY P E D I AT R I C S . 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