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NEWS FLASH Dawn Drennan Nahlen Column Editor
Infectious Diseases Hospitalize More Than a Quarter Million Infants Despite advances in public health, childhood infectious diseases continue to be a major health problem. One of every 14 American infants is hospitalized for a respiratory illness, kidney infection, septicemia, or other infectious disease before 1 year of age, according to a new study funded by Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention. The researchers found that 4 of every 10 babies—287 000—who were hospitalized before reaching 1 year of age were treated for an infectious disease. The study was published in the February 2008 issue of Pediatrics.
Sugar Water Reduces Pain Associated With Infant Shots A Pennsylvania State University study has found that giving oral sucrose (sugar water) just before regular shots can help reduce pain responses in 2- and 4month-old infants. The finding, detailed in the journal Pediatrics, has broad implications when considering recent data suggesting that exposure to repeated or severe pain in early life can subsequently affect development of the central nervous system and possibly have long-lasting effects on neurologic function and behavior. In the study, 100 infants receiving routine immunizations received either a weight-controlled amount of sugar water or a placebo. Then, they were observed for pain responses such as crying, facial expression, and body posture. Pain response measurements were taken immediately after each shot. The group receiving sugar water had lower pain scores and took E-mail: [email protected]. 1527-3369/08/0802-0245$34.00/0 doi:10.1053/j.nainr.2008.03.003
less time to return to normal than those in the control group. Over the course of 9 minutes, the sugar water group had an average of 78% lower pain scores than the control group. The authors conclude that oral sucrose is an inexpensive, shortacting, nonsedating, easily administered method of reducing pain for infants undergoing minor invasive procedures. Medical staff can easily administer sugar water to infants with no additional training, and the treatment presents no additional risk to the children. Although the sugar water did not completely eliminate pain during the immunization process, the researchers suggest that other measures— acetaminophen, distraction, holding, feeding—in conjunction with sugar water may provide additional comfort. Sugar water has been studied for use as a pain relief and comforting measure in preterm infants. The Penn State Hershey study is the first to compare a controlled dosage of sugar water as a comforting measure to full-term babies during routine, follow-up procedures and care. For more information, refer to http:// live.psu.edu/story/28789.
First Quadrivalent Meningococcal Vaccine Promises to Protect Infants Menveo, a vaccine in development by Novartis, may protect infants using a schedule beginning at 2 months of age against four of the most common causes of meningococcal disease. Menveo is the only meningococcal vaccine shown to generate protection against a broad range of serogroups in infants. New data published in the Journal of the American Medical Association show that the drug was well tolerated and generated high levels of immunogenicity in infants against meningococcal serogroups A, C, W-135, and Y with a standard infant vaccination dosing schedule. Infants have the highest rate of meningococcal disease, a potentially deadly bacterial infection. However, no currently available quadrivalent vaccine,
including Menomune and Menactra, has demonstrated a strong and lasting immune response for this age group. These results build on numerous other clinical trial findings, which support that Menveo generates a strong immune response across all age groups. Novartis plans regulatory submissions for Menveo in the United States this year, although the drug would not be available before 2009. Go to http://www.novartis.com/ newsroom/media-releases/en/2008/ 1180471.shtml for details.
Women With Psychiatric Illness More Likely to Experience Adverse Pregnancy Outcomes New findings in Elsevier's International Journal of Gynecology & Obstetrics support a growing body of research that links maternal psychiatric illness and adverse pregnancy outcomes. Of 181 479 deliveries that occurred at a hospital in Israel between 1988 and 2005, 607 women reported psychiatric illness ranging from anxiety disorders to schizophrenia. Although the psychiatric patients were significantly older, with a higher prevalence of diabetes and hypertensive disorders, the analysis revealed that even after controlling these variables, these women had higher perinatal mortality rates and their babies had more congenital malformations and lower Apgar scores and birth weights. The data conclude that psychiatric illness is an independent risk factor for congenital malformations and perinatal mortality, and as a result, prenatal care should be adjusted accordingly.
MRI Seen as Alternative to Chest X-Rays in Children With Lung Disease Optimized low-field magnetic resonance imaging has the potential to
replace plain chest radiographs in the assessment of lung disease in children, according to results of a poster study presented at the annual meeting of the Radiological Society of North America. As reported by Mosby's Nursing Consult on January 25, 2008, “The goal is to reduce radiation exposure for these very young patients—many with cystic fibrosis—while visualizing pathologies such as pneumonia and atelectasis,” Dr Joachim Bernhardt, lead author, said in an interview. “We achieved that goal in about half of the 12 children involved in our study.” A total of 48 examinations were conducted in 9 boys and 3 girls, mean age 4 years, with pathologic lung alterations using a Magnetom open 0.2-T scanner (Siemens, Germany). Images were acquired with interleaved multislice 2- and 3-dimensional gradient echo sequences in combination with standard steady-state MRI, said Bernhardt of the University of Wurzburg (Germany). Imaging allowed an exact localization of presented pathologies and resulted in a modification of the therapeutic regimen in 5 of 12 patients. In addition, the researchers were able to dispense with bronchoscopy in 5 of 12 patients, and antibiotic therapy was changed in four of those five children because magnetic resonance images could differentiate between atelectasis and pneumonia, said Dr Maynard Beer, senior investigator, who outlined the distinct advantages of low-field MRI. “For example, image artifacts are reduced when field strength is reduced, so we get more reliable images. For these children, we don't need the sharper image because we're looking for larger pathologies rather than small nodules, and our clinicians are very satisfied with these images,” Beer, also of the University of Wurzburg, said in an interview. Because the images are acquired so quickly and the open machine allows a parent to sit next to the child in full view, sedation is unnecessary, Beer said, adding that even when the baby or child is crying and moving, image integration produces good clinical results. “We get a stack of 10-15 coronal images in 10 seconds, and we choose those that are most important.”
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The use of the magnet resulted in a relevant influence on clinical therapy in nearly half of this small group of patients, the investigators concluded. “MRI demonstrated multiple additional pathologies compared to plain chest radiographs and in our institution is now the primary chest imaging modality for infants,” Beer concluded.
Review Offers Primer for Infant Skin Conditions According to a review article published in the January 1 issue of American Family Physician, pediatric clinicians should be able to identify and treat common skin conditions, in addition to reassuring concerned parents. The researchers summarize the presentation, prognosis, and treatment of the rashes most often presenting during the first month of a baby's life. Nina R. O'Connor, MD, with Chestnut Hill Hospital Family Practice Residency Program in Philadelphia, wrote, “A newborn's skin may exhibit a variety of changes during the first 4 weeks of life. Most of these changes are benign and self-limited, but others require further work-up for infectious etiologies or underlying systemic disorders.” A Medscape summary of the article says, “The most common pustular eruption during the first month of life is erythema toxicum neonatorum, affecting 40% to 70% of newborns. Typical lesions are erythematous, 2- to 3-mm macules and papules that evolve into pustules on the face, trunk, and proximal part of the limbs. When rashes are accompanied by signs of systemic illness or unusual presentations, infants should be evaluated for Candida, viral, and bacterial infections.” Among the review's clinical recommendations in the Medscape article: • “Infants who have vesiculopustular rashes and who appear ill should be tested for Candida, viral, and bacterial infections. • Although acne neonatorum usually resolves within 4 months without scarring, resolution of severe cases may be facilitated by 2.5% benzoyl peroxide lotion.
NEWBORN
& INFANT NURSING REVIEWS
• Miliaria rubra, or heat rash, typically resolves with avoidance of overheating, removal of excess clothing, and treatment with cool baths and air conditioning. • Infantile seborrheic dermatitis generally resolves with conservative treatment, such as petrolatum, soft brushes, and tarcontaining shampoo. • Topical antifungals or mild corticosteroids may be used to treat seborrheic dermatitis that is refractory to conservative management.” The bottom line? “Management of most transient newborn rashes is observation with no treatment, whereas rashes resulting from infection should be excluded for atypical or systemic presentations.” Check out the article at http://www.medscape.com/viewarticle/ 568652.
Some Bacterial Infections Predispose Kids to Asthma Infants whose airways are colonized by one or more of three bacterial species are significantly more likely to develop asthma by 5 years of age than are other children. Dr Hans Bisgaard and his colleagues from the Copenhagen University Hospital found that colonization with Streptococcus pneumoniae, Haemophilus influenzae, and/or Moraxella catarrhalis in 1-month-old infants also was associated with significant increases in the risk of the later development of certain asthma precursors, including persistent wheeze (hazard ratio [HR], 2.01), acute severe exacerbation of wheeze (HR 3.14), and hospitalization for wheeze (HR 3.57). Colonization by Staphylococcus aureus at 1 month of age, on the other hand, was not associated with an increased risk of asthma or its precursors, nor was colonization with any of the organisms at 12 months of age (N Engl J Med. 2007;357:1487-95). It is unlikely that this association is causal, Dr Erika von Mutius wrote in an accompanying editorial (N Engl J Med. 2007;357:1545). Instead, early colonization with those three organisms may signal a defective innate immune response, and it
is that defective immune response that promotes the development of asthma. The investigators followed 321 infants as part of the Copenhagen Prospective Study on Asthma in Childhood (COPSAC). All infants were born to mothers with current or previous asthma. Physicians aspirated samples from the asymptomatic infants' hypopharyngeal region at 1 and 12 months of age, and these samples were cultured for the presence of the four bacterial species. At 1 month, 21% of the infants were found to be colonized with S. pneumoniae, H. influenzae, and/or M. catarrhalis, and 61% were colonized with S. aureus. At 12 months, 71% were colonized with the first three organisms and only 13% were colonized with S. aureus. Children colonized at 1 month of age who were available for testing at 5 years had a 33% (17/52) prevalence of asthma at that age compared with 10% (20 of 208) in those not colonized. Total immunoglobulin E was increased by 47% in colonized children; there was no significant increase in specific immunoglobulin E. Whereas Bisgaard and his colleagues proposed that bacterial colonization may induce neutrophilic inflammation of the airways and thereby cause asthma, von Mutius, professor of pediatrics at Munich University Children's Hospital and head of the outpatient clinic for asthma and allergy, disagreed. Colonization may indicate a defective clearance of those flora. The impaired innate immune response also might be expected to decrease a child's resistance to viruses, and studies have recognized that people with asthma are unable to limit viral infections to the upper respiratory tract. It is possible, Dr von Mutius wrote, that exposure to certain bacterial strains may contribute to the development of asthma by inducing inflammatory responses in a child's airway. But, if that were the case, treatment with antibiotics during the first weeks of life should protect children from developing asthma. Although no clinical trial has examined this question, several population-based cohort studies have failed to find an association between early antibiotic therapies and the risk of asthma.
“Early Asthma Tied to Bacteria in Neonatal Airways,” Family Practice News, February 2008, vol 38, page 41). Reprinted with permission from Elsevier.
Health Groups Release 2008 Immunization Schedules Updated immunization recommendations for childhood influenza are included in the 2008 Childhood and Adolescent Immunization Schedules by the Centers for Disease Control and Prevention, the American Academy of Pediatrics, and the American Academy of Family Physicians. The childhood schedule expands the recommendation for the nasal spray influenza vaccine, FluMist, to include children from 2 to 4 years of age who do not have a history of asthma or wheezing. The vaccine, which contains a weakened form of the live virus and is sprayed in the nose, had previously been limited to healthy children 5 years of age and older and healthy adults up to 50 years of age. The new schedule also clarifies and updates recommendations for use of pneumococcal vaccine. Healthy children 24 through 59 months of age who are incompletely vaccinated should receive one dose of pneumococcal conjugate vaccine (PCV7). Children 2 years and older with underlying medical conditions should receive pneumococcal polysaccharide vaccine (PPV). The 2008 immunization schedule can be found at Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report at http://www.cdc.gov/ mmwr or http://www.cdc.gov/vaccines/ recs/schedules/child-schedule.htm.
ence less stress, regardless of income, sex, or other known asthma risk factors. Kozyrskyj and her colleagues studied medical records of almost 14 000 children born in Manitoba in 1995 until the children were 7 years old in 2003. After controlling for known risk factors, longterm maternal stress was associated with an increase of nearly a third in the prevalence of childhood asthma. A curious finding from the study is that the risk of asthma associated with maternal stress was greater in high-income households or if there was more than one sibling in the household. Kozyrskyj suggests that, in low-income households, more factors could contribute to asthma, whereas many of these will be absent in higher-income homes. This would thus overemphasize the contribution of stress as a factor in the latter situation. Kozyrskyj cautions that exactly how maternal distress causes asthma is not well understood. Depressed mothers are more likely to smoke and less likely to breastfeed, actions associated with asthma development. However, research has also suggested that depressed mothers are also less likely to interact with their infants. “Our findings may be limited to more severe depression and anxiety,” said Kozyrskyj. “We plan to do further studies linking health care records and public health nurse assessments of depression and anxiety. This will enable us to assess the effects of less severe depression and anxiety during the postpartum period.” The findings appeared in the American Journal of Respiratory and Critical Care Medicine. Go to http://myuminfo. umanitoba.ca/index.asp?sec=209& too=100&eve=1000&id=14741 for additional details.
Maternal Stress Can Antiplatelet Therapy for Increase Child Asthma Risk Kids Looks Promising Mothers who are chronically stressed may unwittingly increase the likelihood of asthma in their children, according to a new study published by a University of Manitoba researcher. Lead researcher for the study, Anita Kozyrskyj in the faculty of Pharmacy, says children from stressedout mothers are more likely to have asthma than those whose moms experi-
VOLUME 8, NUMBER 2, JUNE 2008
Dr Jennifer Li, a pediatric cardiologist at Duke University Medical Center, and colleagues from 22 research centers around the world have completed the first study examining an anticlotting drug called clopidogrel, also known as Plavix, in children younger than 2 years. The study, known as the PICOLO Trial, appeared in the January 29 issue of Circulation.
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Clopidogrel, like aspirin, is useful in keeping platelets from sticking together and forming blood clots. Studies show it can reduce the risk of myocardial infarction, stroke, or death in adults who are at high risk for cardiovascular problems. However, children with heart disease can benefit from clopidogrel, too, says Li. It is just not been clear what the optimal dose should be. “Just because a kid is one-eighth the size of an adult doesn't mean you give them one-eighth the amount of medicine,” says Li, who is chief of cardiovascular research in the division of pediatric cardiology. “Kids are not just small adults. Their bodies are changing faster; they metabolize drugs differently; they are just biologically different.” Li recruited 92 participants with heart disease that put them at high risk of developing life-threatening blood clots. Most had been diagnosed with hypoplastic left heart syndrome, a disorder involving a poorly performing, small ventricle that left them weak and blue. Others had problems with floppy or imperfect valves and one had Kawasaki disease, a condition that causes inflammation in coronary arteries. Many of the children were facing multiple surgeries to correct the defects, and three quarters of them had already had shunts implanted in their hearts to keep their blood flowing properly. The patients received either clopidogrel or a placebo. Those in the treatment group were given one of four doses of clopidogrel, ranging from 0.01 to 0.20 milligrams per kilogram of weight over a period of 1 to 4 weeks. Li notes that adults, with an average weight of 75 kilograms, are typically given 75 milligrams of clopidogrel per day to inhibit clot formation. When extrapolated, would predict an optimal dose of about 1 milligram per day for children younger than 2 years. However, the study showed that the optimal dose for infants and toddlers up to 24 months was actually only 0.2 milligrams per day—about a fifth of that amount. Bristol-Myers Squibb and sanofiaventis, the makers of Plavix, sponsored the study. Visit http://www.dukemednews.org/news/article.php?id=10221 for more information.
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Mosby's Nursing Skills Launches Pediatric Collection In the ever-evolving field of pediatric nursing, practitioners must have easy access to the latest clinical information. Mosby's Nursing Skills—Pediatric Collection provides a comprehensive online system to monitor training and learning. More than 320 topics are covered, from how to clean and treat traumatic wounds to the procedure for performing a lumbar puncture. The Pediatric Collection was created from two peer-reviewed references—the current editions of the American Association of Critical Care Nursing Procedure Manual for Pediatric Acute and Critical Care and Wong's Nursing Care of Infants and Children. These two references provide more breadth and depth of coverage than available anywhere else online. The product is endorsed by the American Association of Critical Care Nursing and has been adopted by several high-profile institutions, including the entire Kaiser Permanente provider network. Go to http://eresourcesonline.com/ pedskills for more information.
Survey Highlights Progress and Barriers to Care for Premature Infants A recent survey of 202 neonatologists and pediatricians that examined current attitudes and practices when caring for the specialized health needs of preterm infants revealed that 70% of respondents think the US health care system does not place enough emphasis on or dedicate enough resources to preventive health care for premature infants. The incidence of preterm birth, when infants are born at less than 36 weeks' gestation, has increased steadily in the United States since the mid-1990s. Because preterm babies lack the usual complement of antibodies, which are supplied by the mother in late gestation, they are at high risk of getting a host of infectious diseases, including respiratory syncytial virus, the leading cause of infant respiratory hospitalization. That risk can be even greater among infants that have an array of complex health problems,
NEWBORN
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including immune deficiencies, chronic lung disease, congenital heart disease, and neurologic disorders. Additional key survey findings shed light on reasons why premature infants may not receive the specialized care they require: • More than half (53%) of pediatricians with 10 years of experience or less relied on parents to find out if a patient was born prematurely, compared with just 14% of pediatricians with 21-plus years of experience. The more experienced pediatricians favored the hospital discharge summary (43%) or communication with the child's neonatologist for this information (36%). • Twenty-one percent of neonatologists with more than 10 years of experience said providing parents with a copy of their child's discharge plan is the most important step when discharging a preemie from the hospital. Only 3% of neonatologists with fewer years of experience named this as the most important step. • Most pediatricians (56%) with 10 years of experience or less said they stop working with a preemie's neonatologist immediately after discharge, whereas most pediatricians (54%) with 21-plus years of experience keep working with the neonatologist until their patient is at least 3 months old. • Fifty-eight percent of 34- to 35week infants are perceived by their surveyed physicians as healthy (not at high-risk), although they are premature and at high risk for respiratory syncytial virus disease. The survey was sponsored by MedImmune, Inc. An independent research company surveyed a random sample of 202 neonatologists and pediatricians in September 2007. Respondents had to have spent at least 50% of their time in a clinical setting, with neonatologists treating at least three preemies per month and pediatricians treating at least three preemies in the past 4 months. Ninety-seven neonatologists participated in the survey: 32 had 10 years of experience or less, 37 had between 11 and 20 years, and 28 had
at least 21 years. A total of 105 pediatricians participated in the survey: 12 were pediatric pulmonologists and 15 were pediatric cardiologists. Thirty-two pediatricians had 10 years of experience or less, 45 had between 11 and 20 years, and 28 pediatricians had at least 21 years.
French Study Finds Breast Milk May Protect Against Asthma Research from the French INSERM institute indicated that lactating mice can transmit ovalbumin, an allergen protein found in egg whites, to their newborns through their milk, and the newborns develop an immunologic tolerance to it. A BBC report on the study said, “However, in humans, the link between breastfeeding and reduced asthma risk remains unproven, say experts.” For more information, go to http:// news.bbc.co.uk/2/hi/health/7208941.stm.
Nutrition Programs Dramatically Improve Child Survival and Health A landmark series of research articles on maternal and child undernutrition published in The Lancet in January
shows that children will have irreversible damage into their adult life if proper nutrition interventions are not delivered before the 24 months of age. The Lancet's Series on Maternal and Child Undernutrition reviews and analyzes the effectiveness and potential impact of nutrition-related interventions and policies in developing countries and recommends actions to accelerate efforts to improve maternal and child undernutrition. The five-part series aims to draw international attention to the critical role of early nutrition in the health and development of children and the economic growth of nations. The articles quantify the prevalence of maternal and child undernutrition and consider the short-term consequences in terms of deaths and disease burden, as measured by disability-adjusted life years and long-term educational and economic effects and associations with adult chronic diseases. Undernutrition includes a wide array of effects, including: • Intrauterine growth restriction (IUGR), resulting in low birth-weight • Stunting, a chronic restriction of growth in height indicated by a low height for age • Wasting, an acute weight loss indicated by a low weight for height
VOLUME 8, NUMBER 2, JUNE 2008
• Less visible micronutrient deficiencies This research shows that nutrition in first 2 years of life is more critical to longterm health than previously thought. Conditions such as stunting, severe wasting, and low birth weight in the first 2 years of life cause irreparable harm by impeding physical growth and—if followed by rapid weight gain in the 3- to 5-year age range—increasing the risk of chronic disease later in life. Children who are stunted or underweight at birth are also shown to complete fewer years of schooling and earn less income as adults. To help address nutrition in this critical age group, the Global Alliance for Improved Nutrition has announced a new initiative to strengthen private sector engagement in the fight against malnutrition in children younger than 2 years. GAIN, with support from a US $38 million grant from the Bill & Melinda Gates Foundation, will provide loans, grants, and technical advice to help develop and distribute low-cost, easyto-use, nutritious foods. • The full articles plus accompanying materials are also available for download free of charge at http:// www.globalnutritionseries.org/ and at http://www.thelancet.com/.
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Infectious Diseases Hospitalize More Than a Quarter Million Infants Despite advances in public health, childhood infectious diseases continue to be a major health problem. One of every 14 American infants is hospitalized for a respiratory illness, kidney infection, septicemia, or other infectious disease before 1 year of age, according to a new study funded by Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention. The researchers found that 4 of every 10 babies—287 000—who were hospitalized before reaching 1 year of age were treated for an infectious disease. The study was published in the February 2008 issue of Pediatrics.
Sugar Water Reduces Pain Associated With Infant Shots A Pennsylvania State University study has found that giving oral sucrose (sugar water) just before regular shots can help reduce pain responses in 2- and 4month-old infants. The finding, detailed in the journal Pediatrics, has broad implications when considering recent data suggesting that exposure to repeated or severe pain in early life can subsequently affect development of the central nervous system and possibly have long-lasting effects on neurologic function and behavior. In the study, 100 infants receiving routine immunizations received either a weight-controlled amount of sugar water or a placebo. Then, they were observed for pain responses such as crying, facial expression, and body posture. Pain response measurements were taken immediately after each shot. The group receiving sugar water had lower pain scores and took E-mail: [email protected]. 1527-3369/08/0802-0245$34.00/0 doi:10.1053/j.nainr.2008.03.003
less time to return to normal than those in the control group. Over the course of 9 minutes, the sugar water group had an average of 78% lower pain scores than the control group. The authors conclude that oral sucrose is an inexpensive, shortacting, nonsedating, easily administered method of reducing pain for infants undergoing minor invasive procedures. Medical staff can easily administer sugar water to infants with no additional training, and the treatment presents no additional risk to the children. Although the sugar water did not completely eliminate pain during the immunization process, the researchers suggest that other measures— acetaminophen, distraction, holding, feeding—in conjunction with sugar water may provide additional comfort. Sugar water has been studied for use as a pain relief and comforting measure in preterm infants. The Penn State Hershey study is the first to compare a controlled dosage of sugar water as a comforting measure to full-term babies during routine, follow-up procedures and care. For more information, refer to http:// live.psu.edu/story/28789.
First Quadrivalent Meningococcal Vaccine Promises to Protect Infants Menveo, a vaccine in development by Novartis, may protect infants using a schedule beginning at 2 months of age against four of the most common causes of meningococcal disease. Menveo is the only meningococcal vaccine shown to generate protection against a broad range of serogroups in infants. New data published in the Journal of the American Medical Association show that the drug was well tolerated and generated high levels of immunogenicity in infants against meningococcal serogroups A, C, W-135, and Y with a standard infant vaccination dosing schedule. Infants have the highest rate of meningococcal disease, a potentially deadly bacterial infection. However, no currently available quadrivalent vaccine,
including Menomune and Menactra, has demonstrated a strong and lasting immune response for this age group. These results build on numerous other clinical trial findings, which support that Menveo generates a strong immune response across all age groups. Novartis plans regulatory submissions for Menveo in the United States this year, although the drug would not be available before 2009. Go to http://www.novartis.com/ newsroom/media-releases/en/2008/ 1180471.shtml for details.
Women With Psychiatric Illness More Likely to Experience Adverse Pregnancy Outcomes New findings in Elsevier's International Journal of Gynecology & Obstetrics support a growing body of research that links maternal psychiatric illness and adverse pregnancy outcomes. Of 181 479 deliveries that occurred at a hospital in Israel between 1988 and 2005, 607 women reported psychiatric illness ranging from anxiety disorders to schizophrenia. Although the psychiatric patients were significantly older, with a higher prevalence of diabetes and hypertensive disorders, the analysis revealed that even after controlling these variables, these women had higher perinatal mortality rates and their babies had more congenital malformations and lower Apgar scores and birth weights. The data conclude that psychiatric illness is an independent risk factor for congenital malformations and perinatal mortality, and as a result, prenatal care should be adjusted accordingly.
MRI Seen as Alternative to Chest X-Rays in Children With Lung Disease Optimized low-field magnetic resonance imaging has the potential to
replace plain chest radiographs in the assessment of lung disease in children, according to results of a poster study presented at the annual meeting of the Radiological Society of North America. As reported by Mosby's Nursing Consult on January 25, 2008, “The goal is to reduce radiation exposure for these very young patients—many with cystic fibrosis—while visualizing pathologies such as pneumonia and atelectasis,” Dr Joachim Bernhardt, lead author, said in an interview. “We achieved that goal in about half of the 12 children involved in our study.” A total of 48 examinations were conducted in 9 boys and 3 girls, mean age 4 years, with pathologic lung alterations using a Magnetom open 0.2-T scanner (Siemens, Germany). Images were acquired with interleaved multislice 2- and 3-dimensional gradient echo sequences in combination with standard steady-state MRI, said Bernhardt of the University of Wurzburg (Germany). Imaging allowed an exact localization of presented pathologies and resulted in a modification of the therapeutic regimen in 5 of 12 patients. In addition, the researchers were able to dispense with bronchoscopy in 5 of 12 patients, and antibiotic therapy was changed in four of those five children because magnetic resonance images could differentiate between atelectasis and pneumonia, said Dr Maynard Beer, senior investigator, who outlined the distinct advantages of low-field MRI. “For example, image artifacts are reduced when field strength is reduced, so we get more reliable images. For these children, we don't need the sharper image because we're looking for larger pathologies rather than small nodules, and our clinicians are very satisfied with these images,” Beer, also of the University of Wurzburg, said in an interview. Because the images are acquired so quickly and the open machine allows a parent to sit next to the child in full view, sedation is unnecessary, Beer said, adding that even when the baby or child is crying and moving, image integration produces good clinical results. “We get a stack of 10-15 coronal images in 10 seconds, and we choose those that are most important.”
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The use of the magnet resulted in a relevant influence on clinical therapy in nearly half of this small group of patients, the investigators concluded. “MRI demonstrated multiple additional pathologies compared to plain chest radiographs and in our institution is now the primary chest imaging modality for infants,” Beer concluded.
Review Offers Primer for Infant Skin Conditions According to a review article published in the January 1 issue of American Family Physician, pediatric clinicians should be able to identify and treat common skin conditions, in addition to reassuring concerned parents. The researchers summarize the presentation, prognosis, and treatment of the rashes most often presenting during the first month of a baby's life. Nina R. O'Connor, MD, with Chestnut Hill Hospital Family Practice Residency Program in Philadelphia, wrote, “A newborn's skin may exhibit a variety of changes during the first 4 weeks of life. Most of these changes are benign and self-limited, but others require further work-up for infectious etiologies or underlying systemic disorders.” A Medscape summary of the article says, “The most common pustular eruption during the first month of life is erythema toxicum neonatorum, affecting 40% to 70% of newborns. Typical lesions are erythematous, 2- to 3-mm macules and papules that evolve into pustules on the face, trunk, and proximal part of the limbs. When rashes are accompanied by signs of systemic illness or unusual presentations, infants should be evaluated for Candida, viral, and bacterial infections.” Among the review's clinical recommendations in the Medscape article: • “Infants who have vesiculopustular rashes and who appear ill should be tested for Candida, viral, and bacterial infections. • Although acne neonatorum usually resolves within 4 months without scarring, resolution of severe cases may be facilitated by 2.5% benzoyl peroxide lotion.
NEWBORN
& INFANT NURSING REVIEWS
• Miliaria rubra, or heat rash, typically resolves with avoidance of overheating, removal of excess clothing, and treatment with cool baths and air conditioning. • Infantile seborrheic dermatitis generally resolves with conservative treatment, such as petrolatum, soft brushes, and tarcontaining shampoo. • Topical antifungals or mild corticosteroids may be used to treat seborrheic dermatitis that is refractory to conservative management.” The bottom line? “Management of most transient newborn rashes is observation with no treatment, whereas rashes resulting from infection should be excluded for atypical or systemic presentations.” Check out the article at http://www.medscape.com/viewarticle/ 568652.
Some Bacterial Infections Predispose Kids to Asthma Infants whose airways are colonized by one or more of three bacterial species are significantly more likely to develop asthma by 5 years of age than are other children. Dr Hans Bisgaard and his colleagues from the Copenhagen University Hospital found that colonization with Streptococcus pneumoniae, Haemophilus influenzae, and/or Moraxella catarrhalis in 1-month-old infants also was associated with significant increases in the risk of the later development of certain asthma precursors, including persistent wheeze (hazard ratio [HR], 2.01), acute severe exacerbation of wheeze (HR 3.14), and hospitalization for wheeze (HR 3.57). Colonization by Staphylococcus aureus at 1 month of age, on the other hand, was not associated with an increased risk of asthma or its precursors, nor was colonization with any of the organisms at 12 months of age (N Engl J Med. 2007;357:1487-95). It is unlikely that this association is causal, Dr Erika von Mutius wrote in an accompanying editorial (N Engl J Med. 2007;357:1545). Instead, early colonization with those three organisms may signal a defective innate immune response, and it
is that defective immune response that promotes the development of asthma. The investigators followed 321 infants as part of the Copenhagen Prospective Study on Asthma in Childhood (COPSAC). All infants were born to mothers with current or previous asthma. Physicians aspirated samples from the asymptomatic infants' hypopharyngeal region at 1 and 12 months of age, and these samples were cultured for the presence of the four bacterial species. At 1 month, 21% of the infants were found to be colonized with S. pneumoniae, H. influenzae, and/or M. catarrhalis, and 61% were colonized with S. aureus. At 12 months, 71% were colonized with the first three organisms and only 13% were colonized with S. aureus. Children colonized at 1 month of age who were available for testing at 5 years had a 33% (17/52) prevalence of asthma at that age compared with 10% (20 of 208) in those not colonized. Total immunoglobulin E was increased by 47% in colonized children; there was no significant increase in specific immunoglobulin E. Whereas Bisgaard and his colleagues proposed that bacterial colonization may induce neutrophilic inflammation of the airways and thereby cause asthma, von Mutius, professor of pediatrics at Munich University Children's Hospital and head of the outpatient clinic for asthma and allergy, disagreed. Colonization may indicate a defective clearance of those flora. The impaired innate immune response also might be expected to decrease a child's resistance to viruses, and studies have recognized that people with asthma are unable to limit viral infections to the upper respiratory tract. It is possible, Dr von Mutius wrote, that exposure to certain bacterial strains may contribute to the development of asthma by inducing inflammatory responses in a child's airway. But, if that were the case, treatment with antibiotics during the first weeks of life should protect children from developing asthma. Although no clinical trial has examined this question, several population-based cohort studies have failed to find an association between early antibiotic therapies and the risk of asthma.
“Early Asthma Tied to Bacteria in Neonatal Airways,” Family Practice News, February 2008, vol 38, page 41). Reprinted with permission from Elsevier.
Health Groups Release 2008 Immunization Schedules Updated immunization recommendations for childhood influenza are included in the 2008 Childhood and Adolescent Immunization Schedules by the Centers for Disease Control and Prevention, the American Academy of Pediatrics, and the American Academy of Family Physicians. The childhood schedule expands the recommendation for the nasal spray influenza vaccine, FluMist, to include children from 2 to 4 years of age who do not have a history of asthma or wheezing. The vaccine, which contains a weakened form of the live virus and is sprayed in the nose, had previously been limited to healthy children 5 years of age and older and healthy adults up to 50 years of age. The new schedule also clarifies and updates recommendations for use of pneumococcal vaccine. Healthy children 24 through 59 months of age who are incompletely vaccinated should receive one dose of pneumococcal conjugate vaccine (PCV7). Children 2 years and older with underlying medical conditions should receive pneumococcal polysaccharide vaccine (PPV). The 2008 immunization schedule can be found at Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report at http://www.cdc.gov/ mmwr or http://www.cdc.gov/vaccines/ recs/schedules/child-schedule.htm.
ence less stress, regardless of income, sex, or other known asthma risk factors. Kozyrskyj and her colleagues studied medical records of almost 14 000 children born in Manitoba in 1995 until the children were 7 years old in 2003. After controlling for known risk factors, longterm maternal stress was associated with an increase of nearly a third in the prevalence of childhood asthma. A curious finding from the study is that the risk of asthma associated with maternal stress was greater in high-income households or if there was more than one sibling in the household. Kozyrskyj suggests that, in low-income households, more factors could contribute to asthma, whereas many of these will be absent in higher-income homes. This would thus overemphasize the contribution of stress as a factor in the latter situation. Kozyrskyj cautions that exactly how maternal distress causes asthma is not well understood. Depressed mothers are more likely to smoke and less likely to breastfeed, actions associated with asthma development. However, research has also suggested that depressed mothers are also less likely to interact with their infants. “Our findings may be limited to more severe depression and anxiety,” said Kozyrskyj. “We plan to do further studies linking health care records and public health nurse assessments of depression and anxiety. This will enable us to assess the effects of less severe depression and anxiety during the postpartum period.” The findings appeared in the American Journal of Respiratory and Critical Care Medicine. Go to http://myuminfo. umanitoba.ca/index.asp?sec=209& too=100&eve=1000&id=14741 for additional details.
Maternal Stress Can Antiplatelet Therapy for Increase Child Asthma Risk Kids Looks Promising Mothers who are chronically stressed may unwittingly increase the likelihood of asthma in their children, according to a new study published by a University of Manitoba researcher. Lead researcher for the study, Anita Kozyrskyj in the faculty of Pharmacy, says children from stressedout mothers are more likely to have asthma than those whose moms experi-
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Dr Jennifer Li, a pediatric cardiologist at Duke University Medical Center, and colleagues from 22 research centers around the world have completed the first study examining an anticlotting drug called clopidogrel, also known as Plavix, in children younger than 2 years. The study, known as the PICOLO Trial, appeared in the January 29 issue of Circulation.
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Clopidogrel, like aspirin, is useful in keeping platelets from sticking together and forming blood clots. Studies show it can reduce the risk of myocardial infarction, stroke, or death in adults who are at high risk for cardiovascular problems. However, children with heart disease can benefit from clopidogrel, too, says Li. It is just not been clear what the optimal dose should be. “Just because a kid is one-eighth the size of an adult doesn't mean you give them one-eighth the amount of medicine,” says Li, who is chief of cardiovascular research in the division of pediatric cardiology. “Kids are not just small adults. Their bodies are changing faster; they metabolize drugs differently; they are just biologically different.” Li recruited 92 participants with heart disease that put them at high risk of developing life-threatening blood clots. Most had been diagnosed with hypoplastic left heart syndrome, a disorder involving a poorly performing, small ventricle that left them weak and blue. Others had problems with floppy or imperfect valves and one had Kawasaki disease, a condition that causes inflammation in coronary arteries. Many of the children were facing multiple surgeries to correct the defects, and three quarters of them had already had shunts implanted in their hearts to keep their blood flowing properly. The patients received either clopidogrel or a placebo. Those in the treatment group were given one of four doses of clopidogrel, ranging from 0.01 to 0.20 milligrams per kilogram of weight over a period of 1 to 4 weeks. Li notes that adults, with an average weight of 75 kilograms, are typically given 75 milligrams of clopidogrel per day to inhibit clot formation. When extrapolated, would predict an optimal dose of about 1 milligram per day for children younger than 2 years. However, the study showed that the optimal dose for infants and toddlers up to 24 months was actually only 0.2 milligrams per day—about a fifth of that amount. Bristol-Myers Squibb and sanofiaventis, the makers of Plavix, sponsored the study. Visit http://www.dukemednews.org/news/article.php?id=10221 for more information.
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Mosby's Nursing Skills Launches Pediatric Collection In the ever-evolving field of pediatric nursing, practitioners must have easy access to the latest clinical information. Mosby's Nursing Skills—Pediatric Collection provides a comprehensive online system to monitor training and learning. More than 320 topics are covered, from how to clean and treat traumatic wounds to the procedure for performing a lumbar puncture. The Pediatric Collection was created from two peer-reviewed references—the current editions of the American Association of Critical Care Nursing Procedure Manual for Pediatric Acute and Critical Care and Wong's Nursing Care of Infants and Children. These two references provide more breadth and depth of coverage than available anywhere else online. The product is endorsed by the American Association of Critical Care Nursing and has been adopted by several high-profile institutions, including the entire Kaiser Permanente provider network. Go to http://eresourcesonline.com/ pedskills for more information.
Survey Highlights Progress and Barriers to Care for Premature Infants A recent survey of 202 neonatologists and pediatricians that examined current attitudes and practices when caring for the specialized health needs of preterm infants revealed that 70% of respondents think the US health care system does not place enough emphasis on or dedicate enough resources to preventive health care for premature infants. The incidence of preterm birth, when infants are born at less than 36 weeks' gestation, has increased steadily in the United States since the mid-1990s. Because preterm babies lack the usual complement of antibodies, which are supplied by the mother in late gestation, they are at high risk of getting a host of infectious diseases, including respiratory syncytial virus, the leading cause of infant respiratory hospitalization. That risk can be even greater among infants that have an array of complex health problems,
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including immune deficiencies, chronic lung disease, congenital heart disease, and neurologic disorders. Additional key survey findings shed light on reasons why premature infants may not receive the specialized care they require: • More than half (53%) of pediatricians with 10 years of experience or less relied on parents to find out if a patient was born prematurely, compared with just 14% of pediatricians with 21-plus years of experience. The more experienced pediatricians favored the hospital discharge summary (43%) or communication with the child's neonatologist for this information (36%). • Twenty-one percent of neonatologists with more than 10 years of experience said providing parents with a copy of their child's discharge plan is the most important step when discharging a preemie from the hospital. Only 3% of neonatologists with fewer years of experience named this as the most important step. • Most pediatricians (56%) with 10 years of experience or less said they stop working with a preemie's neonatologist immediately after discharge, whereas most pediatricians (54%) with 21-plus years of experience keep working with the neonatologist until their patient is at least 3 months old. • Fifty-eight percent of 34- to 35week infants are perceived by their surveyed physicians as healthy (not at high-risk), although they are premature and at high risk for respiratory syncytial virus disease. The survey was sponsored by MedImmune, Inc. An independent research company surveyed a random sample of 202 neonatologists and pediatricians in September 2007. Respondents had to have spent at least 50% of their time in a clinical setting, with neonatologists treating at least three preemies per month and pediatricians treating at least three preemies in the past 4 months. Ninety-seven neonatologists participated in the survey: 32 had 10 years of experience or less, 37 had between 11 and 20 years, and 28 had
at least 21 years. A total of 105 pediatricians participated in the survey: 12 were pediatric pulmonologists and 15 were pediatric cardiologists. Thirty-two pediatricians had 10 years of experience or less, 45 had between 11 and 20 years, and 28 pediatricians had at least 21 years.
French Study Finds Breast Milk May Protect Against Asthma Research from the French INSERM institute indicated that lactating mice can transmit ovalbumin, an allergen protein found in egg whites, to their newborns through their milk, and the newborns develop an immunologic tolerance to it. A BBC report on the study said, “However, in humans, the link between breastfeeding and reduced asthma risk remains unproven, say experts.” For more information, go to http:// news.bbc.co.uk/2/hi/health/7208941.stm.
Nutrition Programs Dramatically Improve Child Survival and Health A landmark series of research articles on maternal and child undernutrition published in The Lancet in January
shows that children will have irreversible damage into their adult life if proper nutrition interventions are not delivered before the 24 months of age. The Lancet's Series on Maternal and Child Undernutrition reviews and analyzes the effectiveness and potential impact of nutrition-related interventions and policies in developing countries and recommends actions to accelerate efforts to improve maternal and child undernutrition. The five-part series aims to draw international attention to the critical role of early nutrition in the health and development of children and the economic growth of nations. The articles quantify the prevalence of maternal and child undernutrition and consider the short-term consequences in terms of deaths and disease burden, as measured by disability-adjusted life years and long-term educational and economic effects and associations with adult chronic diseases. Undernutrition includes a wide array of effects, including: • Intrauterine growth restriction (IUGR), resulting in low birth-weight • Stunting, a chronic restriction of growth in height indicated by a low height for age • Wasting, an acute weight loss indicated by a low weight for height
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• Less visible micronutrient deficiencies This research shows that nutrition in first 2 years of life is more critical to longterm health than previously thought. Conditions such as stunting, severe wasting, and low birth weight in the first 2 years of life cause irreparable harm by impeding physical growth and—if followed by rapid weight gain in the 3- to 5-year age range—increasing the risk of chronic disease later in life. Children who are stunted or underweight at birth are also shown to complete fewer years of schooling and earn less income as adults. To help address nutrition in this critical age group, the Global Alliance for Improved Nutrition has announced a new initiative to strengthen private sector engagement in the fight against malnutrition in children younger than 2 years. GAIN, with support from a US $38 million grant from the Bill & Melinda Gates Foundation, will provide loans, grants, and technical advice to help develop and distribute low-cost, easyto-use, nutritious foods. • The full articles plus accompanying materials are also available for download free of charge at http:// www.globalnutritionseries.org/ and at http://www.thelancet.com/.
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