Diet may lessen heart disease as SGA infants grow up

May 2015  Volume 166  Number 5

The Journal meets Android — Monica L. Helton, BA

Good news about doxycycline and dental staining — Sarah S. Long, MD

Copyright ª 2015 by Elsevier Inc.

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ince 2013, The Journal has been pleased to offer readers two useful mobile apps for their iPhone and iPad (available through the Apple App Store)—one provides individual access to The Journal and the other provides institutional access to The Journal and Elsevier’s 500+ health science journals through ScienceDirect. If you are one of the many (majority, in fact) Android users, you may be thinking something along the lines of “great for them, but what about non-Apple users?”. We are now pleased to offer The Journal of Pediatrics app for Android smartphone and tablets, available in Google Play. Whether you are accessing The Journal through the iOS or Android apps, all users get free access to abstracts, but subscribers have access to full-text articles. If you prefer to use the ScienceDirect app, your institution’s librarian can provide you with the username and password. Alternatively, jpeds.com is available in a mobile-optimized format on any device, which rounds out a complete array of mobile options for accessing The Journal anywhere you go. Regardless of your operating system of choice, please try The Journal’s apps and mobile-optimized website, and let us know what you think.

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ue to the history of association of use of tetracycline-class antibiotics in young children with staining and enamel hypoplasia of developing teeth, doxycycline labeling includes caution against unnecessary use in children younger than 8 years. Although observations of many physicians and a few reports have not found adverse effects associated with doxycycline use, the shadow of caution is long. Rocky Mountain spotted fever (RMSF) is a serious rickettsial disease which frequently is fatal if untreated. Therapy is empiric, and doxycycline is the only effective drug available. Doxycycline is recommended by the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics for empiric therapy for all ages. Children under 10 years of age have RMSF case-fatality rates 5 times greater than older individuals. Fatality rate in RMSF is associated with time after symptom onset to commencement of therapy. Zientek et al reported a survey showing that although 80% of US healthcare providers correctly identified doxycycline as the treatment for RMSF, a frightening 65% would not use doxycycline for a suspected case in a child under 8 years of age (J Pediatr 2014;164:416-8). In this issue of The Journal, investigators from the Divisions of Vectorborne Diseases and Oral Health at the CDC, the Indian Health Service, and the White Apache Tribe performed a study with results that should change practice. By abstraction of medical and pharmacy records, children who lived on an American Indian reservation in eastern Arizona (where there occurs a high incidence of RMSF) were classified as having been exposed or to doxycycline or not prior to the age of 8 years. Consenting subjects (mean age of 9.8 years for 58 exposed subjects, and mean age of 11.8 years for 213 unexposed subjects) were examined by licensed, trained dentists. Dentists evaluated visible staining patterns and enamel hypoplasia, and measured tooth color

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objectively using a spectrophotometer. Exposed children had received a mean 1.8 courses of doxycycline of average duration of 7.3 days each. No visible tetracycline-like staining pattern was observed on any teeth. With the study adequately powered to detect relevant/small differences, children exposed to doxycycline were not more likely to have enamel hypoplasia, fluorosis-like hypomineralization, or a darker shade of tooth color. The authors conclude that “healthcare provider confidence in use of doxycycline for suspected RMSF in children may be improved by modifying the drug’s label.” The longstanding, lifesaving recommendation for the appropriate use of doxycycline in young children, bolstered by the removal of concern for adverse dental effects that the current study provides, should correct surveyed providers’ “answer to the question,” and more importantly, impact the correct use of doxycycline for suspected RMSF at all ages by the 65% of providers who checked the life-threateningly wrong answer—post haste. Article page 1246<

Do we practice what we preach about concussion? — Paul G. Fisher, MD

Diet may lessen heart disease as SGA infants grow up — Reginald L. Washington, MD

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oday’s professional societies and ad hoc working groups posit seemingly endless guidelines, practice parameters, and consensus statements. Do we and should we adhere to these statements? Concussion provides a case in point. With about 250 000 US children annually visiting emergency departments for “concussion,” we should reflect on how physician diagnosis compares with “standard criteria.” The 4th International Conference on Concussion in Sport, held in Zurich in 2012, put forth a consensus statement on the diagnosis and management of concussion. In this issue of The Journal, Boutis et al report a single tertiary-institution, cross-sectional study of 495 school-age children diagnosed with head trauma. Two-hundred were diagnosed by pediatric emergency department physicians as having concussion, yet 443 fulfilled the Zurich criteria as determined by a research assistant onsite at the time of the encounter. Physicians were more likely to diagnose a concussion versus a minor head injury if the child was over age 10 years, presented more than one day from onset of injury, sustained the injury during collision sports, and/or presented with headache or amnesia. In contrast, just under one-half of the concussions diagnosed by physicians were unrelated to sports, and well more than one-half of concussions determined by Zurich criteria were unrelated to sports. Are these consensus criteria too inclusive, or are some physicians underdiagnosing concussion? As frequently happens, the truth could be in the middle. We might have to clarify and validate diagnostic criteria for concussion while also raising physician awareness of this diagnosis. We will likely see an abundance of continued research on childhood concussion. Article page 1214<

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he fact that people born small for gestational age (SGA) have increased risk of having cardiovascular disease is well described. Advances in the care of these infants have resulted in the majority of them surviving into adulthood only to suffer from premature atherosclerosis and elevations in blood pressure. Currently little is known about prevention strategies that may be helpful in reducing this increased risk. Dietary omega-3 fatty acids may be useful in reducing this problem in SGA people as the age but studies to date have been limited by size and design. In this issue of The Journal, Skilton et al report the results of the STRIP study which followed 115 infants who were born SGA and recorded their food records, blood pressure, and aortic intima-media wall thickness every 3-12 months for 19 years. The results suggest that long-term dietary alpha-linolenic acid intake during

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childhood is associated with improved vascular health and blood pressure in people who are born SGA. The results of this study are promising; however, randomized trials with evaluations of other possible dietary components will be needed before firm conclusions and recommendations can be made. This study is an excellent start. Article page 1252<

Asthma care—when prescribing is not enough — Denise M. Goodman, MD, MSc

Partially hydrolyzed formula-whey for atopic dermatitis: What is the price? — Carlos A. Cuello-Garcıa, MD

May 2015

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n this issue of The Journal, Kenyon et al report the relationship between discharge prescription fill rates and readmissions in patients with asthma, using a multistate Medicaid data set that includes 31 658 discharges. An accompanying editorial by Homer puts these findings in perspective. Not surprisingly, filling prescriptions for beta agonists and inhaled corticosteroids reduces readmissions, and these findings hold up under a number of sensitivity tests. The truly concerning finding is the low rate at which these prescriptions are filled. Just 55% of children fill a prescription for beta agonist within 3 days of discharge, 57% obtain oral corticosteroids, and 37% fill their inhaled corticosteroid prescription with 3 days. When accounting for prescription fills in the 30 days before admission and 3 days after discharge, just two-thirds of children received a beta agonist and less than one-half received an inhaled corticosteroid. Fill rate was associated with age, race/ethnicity, managed care coverage, length of stay, and prior utilization. These findings underscore the notion that good clinical practice requires not just guidelines and prescriptions, but an understanding of the social and environmental barriers to adherence. In an era where payment to providers is predicated on managing risk and promoting wellness, this is not only good care, it’s smart business. Article page 1121< Editorial page 1107<

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lthough atopic dermatitis it is not considered a life threatening condition, it can significantly affect the quality of life and healthcare costs of many families. Making health choices has never been easy. From the individual clinician-patient relationship to the health policy level, decision makers have to look beyond research evidence of efficacy of the choices at hand. Within these issues, cost is frequently overlooked, controversial, and difficult to understand by the health professional. Bhanegaonkar et al present an interesting healthcare economic evaluation using a Markov model to assess the economic impact of feeding partially hydrolyzed formula-whey compared with a standard cow milk formula for the first 4 months of life among US infants at high risk of developing atopic dermatitis. Markov models are economic evaluation tools that are useful when the timing of events in a decision is important, when risks are continuous over time, and when important events happen more than once. By adding to the model other variables such as direct and indirect costs, and information obtained from surveys to US pediatricians from 25 states, Bhanegaonkar et al present a structured final model that suggests a 14% risk reduction in atopic dermatitis in high risk infants, and a reduction in cost of $495 during a 6-year timeframe. It is now the work of the decision makers, at the different levels of healthcare provision, to ponder the research evidence of efficacy, the feasibility and availability of the intervention, the balance between desirable and undesirable effects (benefits versus harms), and the available cost-related information from this and other models. Article page 1145<

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Pay attention to parental stress from ADHD in Tourette syndrome — Paul G. Fisher, MD

Do we report secondary findings from genetic testing? — Denise M. Goodman, MD, MSc

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ttention is fundamental to learning and memory formation. Impaired attention limits school success. Thus, as pediatricians we are accustomed to screening for childhood attention problems and intervening when indicated with behavioral interventions or medications. Attention deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder in children. Children with Tourette syndrome are predisposed to ADHD and obsessivecompulsive disorder (OCD), in addition to their unwanted motor and vocal tics. Which among these symptoms causes the most stress to parents whose children have Tourette syndrome? In this issue of The Journal, Stewart et al present a crosssectional study of parents to 74 children diagnosed with Tourette syndrome and 48 unaffected controls. While the parents of children with Tourette syndrome had more stress overall, their stress was not related to tic severity. Indeed, stress was significantly associated with ADHD symptoms in both Tourette syndrome, as well as typically developing children. Furthermore, ADHD plus OCD was responsible for more parental stress than tics in the Tourette syndrome group. Parents and pediatricians should pay attention to these findings. In children with and without Tourette syndrome, ADHD is a striking source of parental stress. ADHD is sometimes more important to manage than tics in Tourette syndrome. Treating just tics in Tourette syndrome often is not the answer to decreasing family stress and helping the child succeed. Article page 1297<

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he rapid development of genetic testing carries with it challenging questions regarding reporting of secondary findings, those not related to the initial clinical question. In March 2013, the American College of Medical Genetics and Genomics (ACMG) promulgated a recommendation that whenever whole exome sequencing or whole genome sequencing is used to address clinical concerns, the lab must also look for 56 specific genes known to be highly penetrant in high risk groups, without requiring consent for this aspect of testing. This was immediately controversial, due to a number of concerns, including the fact that some abnormalities increase risk of subsequent disease, but by no means certainty, that the condition exists. Moreover, there remains uneasiness regarding confidentiality and the risk for genetic discrimination due to an increased risk for eventual disease. These concerns are amplified when children are tested. The American Academy of Pediatrics (AAP) partnered with ACMG for a separate statement asserting that genetic testing should promote the child’s best interest. But what if the testing reveals a genetic condition with consequences for one of the parents? In the wake of these policies, Barajas and Ross queried members of the AAP Section on Bioethics (SOB) and the Section on Genetics and Birth Defects (SOG) to ascertain opinions about the mandatory testing and reporting without consent, and to examine diversity within the community of pediatricians. They found a nuanced approach—although most members of both sections felt that patients and parents should have the right to refuse to be informed of secondary findings, more members of the SOG favored the mandatory search policy than did SOB members. The report goes on to examine opinions regarding parental rights if testing reveals adult-onset conditions in the child, and if testing of the child reveals a finding benefiting the parent. After the study was completed, about a year after the original policy, ACMG modified its stance to allow the patient or parent to optout of receiving results for the 56 specific conditions that are tested, but simply knowing that testing was performed may be a source of anxiety for families. By clarifying the diversity of opinion around this challenging topic, the report of Barajas and Ross may help any clinician in counseling families regarding genetic testing. Article page 1276<

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