- Email: [email protected]
Direct mail does not improve screening in sickle cell disease
January 2015 Volume 166 Number 1
Identifying intentional use of alternative vaccine schedules, New York State — Sarah S. Long, MD
Walking when sleepy –a dangerous mix — Denise M. Goodman, MD, MS
Copyright ª 2015 by Elsevier Inc.
I
n an important study, Nadeau et al in New York State used their comprehensive Immunization Information System and cleverly codified patterns of infants’ receipt of vaccines and numbers of healthcare visits in which at least one vaccine was received in order to distinguish use of routine immunization schedule from intentional use of selective (exclusion of certain vaccines), restrictive (reduction in number of vaccines per visit), or selective and restrictive schedules. Vaccine receipt patterns of a 30-month birth cohort between 2009 and 2011 were analyzed through 9 months of age; New York City County was excluded. A hefty 222 628 infants (81% of cohort) had at least three immunization visits and, thus, were eligible for study; 95% of recorded vaccinations permitted classification as following a routine or alternative schedule. A remarkable 25% used an alternative schedule; distribution was almost equal between restrictive, selective, and restrictive-selective patterns. Although those using alternative schedules had more vaccination visits than infants on routine schedules, only 15% on alternative schedule versus 90% on routine schedule had received all Centers for Disease Control and Prevention/ American Academy of Pediatrics recommended vaccines (ie, were “up-to-date”) at 9 months of age. Parents, their friends, and lay advisors, sometimes with the help of healthcare providers, set alternative vaccination schedules. Although their intent is heightened protection of their children/patients from harm, the result is the opposite. Alternative “schedules” are completely untested for immunogenicity or safety. The Institute of Medicine (IOM) has concluded after careful review of the scientific data that the current routine childhood immunization schedule is safe. And as this study shows and the IOM concluded, alternative schedules leave the patient and his/her community critically vulnerable to vaccine preventable diseases. As the authors conclude, attempts to bolster immunization coverage by reducing missed opportunities through enhanced access and education of the healthcare community will not address this growing group of vaccine hesitant parents. The authors’ work informs further investigations and potential studies of interventions by harnessing electronic registry data and developing a system to differentiate and quantify tardy implementation of the recommended schedule from intent of use of alternative schedules. Article page 151<
T
he effects of sleep deprivation on mood, cognitive functioning, problem solving, and even visual perception, are well described. This is no less true for children, but the consequences of sleep disorders on childhood safety have not been extensively studied. Pedestrian safety is one such situation, requiring a complex blend of visual, motor, and decisional activities. In this issue of The Journal, Avis et al used an intriguing approach to examine this issue. Because there is no ethical way to study childhood behavior in traffic situations in the real world, they employed an immersive virtual environment to study 60 children with newly diagnosed obstructive sleep apnea syndrome (OSAS) and 61 normal controls. They found that children with untreated OSAS waited less time to cross the virtual street, suggesting greater impulsivity in behavior. This finding is not surprising in view of 1
numerous published reports documenting improvements in attention and behavior after treatment for OSAS, and the observation that in children with both attention deficit hyperactivity disorder (ADHD) and OSAS, ADHD symptoms improve if the OSAS is treated. However, by placing these observations in an applied environment of pedestrian safety and using virtual technology to demonstrate the associations, these investigators have added substantively to our understanding of the importance of sleep hygiene. A well-rested child is a more able learner, but now we know that the child also is safer at getting to and from school in the first place. Article page 109<
How many steps are our children taking each day? — Stephen R. Daniels, MD, PhD
Does swimming prevent spinal deformities? — Paul G. Fisher, MD
Direct mail does not improve screening in sickle cell disease — Paul G. Fisher, MD
2
T
he increasing prevalence and severity of obesity in children and adolescents has focused our attention on the components of energy balance, diet, and physical activity. With this in mind, it is interesting that there are so few normative data on activity in these age groups. In this issue of The Journal, Barreira et al report on an analysis of NHANES data to evaluate activity levels. In NHANES, accelerometers were used to measure activity levels. Barreira et al used those measures to determine steps per day and, thus, develop sex- and age-specific normative values for the number of steps. Although these values reflect the current situation and should not necessarily be interpreted as healthful levels of activity, they do provide useful information to clinicians and researchers from which comparisons can be made. Article page 139< aina et al respond a resounding “no.” In this issue of The Journal, their crosssectional study compared the prevalence of spinal deformities and low back pain in adolescent swimmers and controls. The investigators examined 112 competitive preteen and teen swimmers in Italy and compared them with 217 students of the same age. All children were examined via scoliometer for angle of trunk rotation and measured for kyphosis and lordosis. Back pain was surveyed by questionnaire. Swimming was associated with a nearly two-fold risk of truncal asymmetry and more than double the risk of hyperkyphosis and hyperlordosis among both boys and girls. Female swimmers also reported back pain twice as much as controls. It seems unlikely that these findings were present prior to competitive swimming. This study should not be interpreted to negate the many health benefits of swimming. Swimming has been viewed as salubrious since ancient times of Babylonia, Egypt, and Greece. However, swimming cannot be viewed as a treatment for scoliosis and other spinal deformities. Article page 163<
Z
B
ecause children with sickle cell disease have an increased risk for stroke, annual transcranial Doppler (TCD) screening is recommended for children diagnosed with sickle cell disease from ages 2 to 16 years, yet implementation has been limited. Can letters mailed directly to parents and primary providers improve compliance? To investigate this, Bundy et al mailed reminders to families and primary doctors of eligible children in one Medicaid managed care organization, and compared results with 6 other Medicaid managed care organizations serving as controls. There was no difference in screening rates following the intervention, and less than 10% of unscreened individuals in either group underwent TCD screening. This very low rate of compliance is discouraging. Although direct mail might work for marketing, such does not improve screening compliance in sickle cell disease. Other ways to increased TCD screening are needed if we aim to identify candidates for chronic blood transfusions or hydroxyurea and hope to prevent strokes in patients with sickle cell disease. Article page 188< Vol. 166, No. 1
Implementing screening recommendations for adolescents with heavy menstrual bleeding — Sarah S. Long, MD
Congenital hearing loss in Down syndrome — Paul G. Fisher, MD
January 2015
I
n 2001, the American College of Obstetricians and Gynecologists (ACOG) recommended screening for von Willebrand disease in adolescents with severe menorrhagia. In 2006, the American Academy of Pediatrics in collaboration with ACOG advised screening for hematologic disorders, von Willebrand disease in particular, in adolescents with heavy menstrual bleeding especially at menarche. The estimated prevalence of von Willebrand disease in women with heavy menstrual bleeding is 13%. One goal of the US Department of Health and Human Services Healthy 2020 People is the accurate and timely diagnosis of von Willebrand disease within one year of a patient’s first bleeding event. Using Medicaid claims data from 2007-2011, covering all Medicaid-eligible patients in central and southeast Ohio, O’Brien et al assessed screening rate for adolescents with two provider visits coded as heavy menstrual bleeding. Only 10% of such patients were screened. Of those classified as having severe bleeding (ie, requiring hospitalization or transfusion or leading to iron deficiency anemia), only 24% had testing performed for von Willebrand disease. We must identify every road block to appropriate investigation of genetic bleeding disorders, and break through all in order to afford the diagnosis and treatment that these women deserve. Article page 195<
N
ormal hearing and communication are essential components of a child’s development and education. Children with Down syndrome are prone to hearing loss because of stenotic ear canals, chronic otitis, Eustachian tube dysfunction, and inner ear dysplasia. Periodic screening of hearing has long been recommended in the health care supervision of children with Down syndrome. But how many of these children are born with hearing loss? To determine the prevalence of hearing loss in newborns with Down syndrome, and improve our knowledge gap regarding congenital hearing loss, Roizen et al examined the results of serial automated auditory brainstem technology screening, followed by diagnosis with auditory brainstem responses and distortion product otoacoustic emissions, at university hospitals in Cleveland among all infants born with or transferred in following birth over 15 years. From a sample of 109 newborns with Down syndrome screened, 15% were confirmed to have congenital hearing loss. Even more children failed the screen, and some were lost to follow-up. The authors speculate that the prevalence of hearing loss might be as high as 22%. Mechanical ventilation was associated with hearing loss in some children with Down syndrome. The full etiology of congenital hearing loss will require additional research. Clearly, detection of hearing loss and intervention as soon as possible is key to the optimal development of children with Down syndrome. Moreover, we should not forget that new onset hearing loss can continue to occur as the child with Down syndrome grows older. Article page 168<
3
Identifying intentional use of alternative vaccine schedules, New York State — Sarah S. Long, MD
Walking when sleepy –a dangerous mix — Denise M. Goodman, MD, MS
Copyright ª 2015 by Elsevier Inc.
I
n an important study, Nadeau et al in New York State used their comprehensive Immunization Information System and cleverly codified patterns of infants’ receipt of vaccines and numbers of healthcare visits in which at least one vaccine was received in order to distinguish use of routine immunization schedule from intentional use of selective (exclusion of certain vaccines), restrictive (reduction in number of vaccines per visit), or selective and restrictive schedules. Vaccine receipt patterns of a 30-month birth cohort between 2009 and 2011 were analyzed through 9 months of age; New York City County was excluded. A hefty 222 628 infants (81% of cohort) had at least three immunization visits and, thus, were eligible for study; 95% of recorded vaccinations permitted classification as following a routine or alternative schedule. A remarkable 25% used an alternative schedule; distribution was almost equal between restrictive, selective, and restrictive-selective patterns. Although those using alternative schedules had more vaccination visits than infants on routine schedules, only 15% on alternative schedule versus 90% on routine schedule had received all Centers for Disease Control and Prevention/ American Academy of Pediatrics recommended vaccines (ie, were “up-to-date”) at 9 months of age. Parents, their friends, and lay advisors, sometimes with the help of healthcare providers, set alternative vaccination schedules. Although their intent is heightened protection of their children/patients from harm, the result is the opposite. Alternative “schedules” are completely untested for immunogenicity or safety. The Institute of Medicine (IOM) has concluded after careful review of the scientific data that the current routine childhood immunization schedule is safe. And as this study shows and the IOM concluded, alternative schedules leave the patient and his/her community critically vulnerable to vaccine preventable diseases. As the authors conclude, attempts to bolster immunization coverage by reducing missed opportunities through enhanced access and education of the healthcare community will not address this growing group of vaccine hesitant parents. The authors’ work informs further investigations and potential studies of interventions by harnessing electronic registry data and developing a system to differentiate and quantify tardy implementation of the recommended schedule from intent of use of alternative schedules. Article page 151<
T
he effects of sleep deprivation on mood, cognitive functioning, problem solving, and even visual perception, are well described. This is no less true for children, but the consequences of sleep disorders on childhood safety have not been extensively studied. Pedestrian safety is one such situation, requiring a complex blend of visual, motor, and decisional activities. In this issue of The Journal, Avis et al used an intriguing approach to examine this issue. Because there is no ethical way to study childhood behavior in traffic situations in the real world, they employed an immersive virtual environment to study 60 children with newly diagnosed obstructive sleep apnea syndrome (OSAS) and 61 normal controls. They found that children with untreated OSAS waited less time to cross the virtual street, suggesting greater impulsivity in behavior. This finding is not surprising in view of 1
numerous published reports documenting improvements in attention and behavior after treatment for OSAS, and the observation that in children with both attention deficit hyperactivity disorder (ADHD) and OSAS, ADHD symptoms improve if the OSAS is treated. However, by placing these observations in an applied environment of pedestrian safety and using virtual technology to demonstrate the associations, these investigators have added substantively to our understanding of the importance of sleep hygiene. A well-rested child is a more able learner, but now we know that the child also is safer at getting to and from school in the first place. Article page 109<
How many steps are our children taking each day? — Stephen R. Daniels, MD, PhD
Does swimming prevent spinal deformities? — Paul G. Fisher, MD
Direct mail does not improve screening in sickle cell disease — Paul G. Fisher, MD
2
T
he increasing prevalence and severity of obesity in children and adolescents has focused our attention on the components of energy balance, diet, and physical activity. With this in mind, it is interesting that there are so few normative data on activity in these age groups. In this issue of The Journal, Barreira et al report on an analysis of NHANES data to evaluate activity levels. In NHANES, accelerometers were used to measure activity levels. Barreira et al used those measures to determine steps per day and, thus, develop sex- and age-specific normative values for the number of steps. Although these values reflect the current situation and should not necessarily be interpreted as healthful levels of activity, they do provide useful information to clinicians and researchers from which comparisons can be made. Article page 139< aina et al respond a resounding “no.” In this issue of The Journal, their crosssectional study compared the prevalence of spinal deformities and low back pain in adolescent swimmers and controls. The investigators examined 112 competitive preteen and teen swimmers in Italy and compared them with 217 students of the same age. All children were examined via scoliometer for angle of trunk rotation and measured for kyphosis and lordosis. Back pain was surveyed by questionnaire. Swimming was associated with a nearly two-fold risk of truncal asymmetry and more than double the risk of hyperkyphosis and hyperlordosis among both boys and girls. Female swimmers also reported back pain twice as much as controls. It seems unlikely that these findings were present prior to competitive swimming. This study should not be interpreted to negate the many health benefits of swimming. Swimming has been viewed as salubrious since ancient times of Babylonia, Egypt, and Greece. However, swimming cannot be viewed as a treatment for scoliosis and other spinal deformities. Article page 163<
Z
B
ecause children with sickle cell disease have an increased risk for stroke, annual transcranial Doppler (TCD) screening is recommended for children diagnosed with sickle cell disease from ages 2 to 16 years, yet implementation has been limited. Can letters mailed directly to parents and primary providers improve compliance? To investigate this, Bundy et al mailed reminders to families and primary doctors of eligible children in one Medicaid managed care organization, and compared results with 6 other Medicaid managed care organizations serving as controls. There was no difference in screening rates following the intervention, and less than 10% of unscreened individuals in either group underwent TCD screening. This very low rate of compliance is discouraging. Although direct mail might work for marketing, such does not improve screening compliance in sickle cell disease. Other ways to increased TCD screening are needed if we aim to identify candidates for chronic blood transfusions or hydroxyurea and hope to prevent strokes in patients with sickle cell disease. Article page 188< Vol. 166, No. 1
Implementing screening recommendations for adolescents with heavy menstrual bleeding — Sarah S. Long, MD
Congenital hearing loss in Down syndrome — Paul G. Fisher, MD
January 2015
I
n 2001, the American College of Obstetricians and Gynecologists (ACOG) recommended screening for von Willebrand disease in adolescents with severe menorrhagia. In 2006, the American Academy of Pediatrics in collaboration with ACOG advised screening for hematologic disorders, von Willebrand disease in particular, in adolescents with heavy menstrual bleeding especially at menarche. The estimated prevalence of von Willebrand disease in women with heavy menstrual bleeding is 13%. One goal of the US Department of Health and Human Services Healthy 2020 People is the accurate and timely diagnosis of von Willebrand disease within one year of a patient’s first bleeding event. Using Medicaid claims data from 2007-2011, covering all Medicaid-eligible patients in central and southeast Ohio, O’Brien et al assessed screening rate for adolescents with two provider visits coded as heavy menstrual bleeding. Only 10% of such patients were screened. Of those classified as having severe bleeding (ie, requiring hospitalization or transfusion or leading to iron deficiency anemia), only 24% had testing performed for von Willebrand disease. We must identify every road block to appropriate investigation of genetic bleeding disorders, and break through all in order to afford the diagnosis and treatment that these women deserve. Article page 195<
N
ormal hearing and communication are essential components of a child’s development and education. Children with Down syndrome are prone to hearing loss because of stenotic ear canals, chronic otitis, Eustachian tube dysfunction, and inner ear dysplasia. Periodic screening of hearing has long been recommended in the health care supervision of children with Down syndrome. But how many of these children are born with hearing loss? To determine the prevalence of hearing loss in newborns with Down syndrome, and improve our knowledge gap regarding congenital hearing loss, Roizen et al examined the results of serial automated auditory brainstem technology screening, followed by diagnosis with auditory brainstem responses and distortion product otoacoustic emissions, at university hospitals in Cleveland among all infants born with or transferred in following birth over 15 years. From a sample of 109 newborns with Down syndrome screened, 15% were confirmed to have congenital hearing loss. Even more children failed the screen, and some were lost to follow-up. The authors speculate that the prevalence of hearing loss might be as high as 22%. Mechanical ventilation was associated with hearing loss in some children with Down syndrome. The full etiology of congenital hearing loss will require additional research. Clearly, detection of hearing loss and intervention as soon as possible is key to the optimal development of children with Down syndrome. Moreover, we should not forget that new onset hearing loss can continue to occur as the child with Down syndrome grows older. Article page 168<
3