Damian McNamara

The CDC's “Protect Yourself from Mosquito Bites and Dengue” patient brochure can be downloaded free of charge at www.cdc.gov/ncidod/dvbid/dengue

MIAMI — From 1977 to 2004, there were 3,806 suspected cases of dengue imported to the United States, according to the Centers for Disease Control and Prevention.

“Many more cases probably go unreported each year because surveillance in the United States is passive and relies on physicians to recognize the disease, inquire about the patient's travel history, obtain proper diagnostic samples, and report the case,” according to the CDC. “We are starting to see more and more cases of dengue fever,” said Dr. Christian C. Patrick at a pediatric update sponsored by Miami Children's Hospital, “particularly in south Texas.”

Following a case report of a woman in Brownsville, Tex., infected with dengue without traveling in July 2005 and an outbreak of 1,251 reported cases in Tamaulipas, Mexico, an investigation identified 24 additional cases in Texas in October, including 2 more infections not associated with travel (MMWR 2007;56:785–9). A review of hospitalization records in December revealed that 16 of 25 (64%) eventual infections in Texas developed the more serious dengue hemorrhagic fever, compared with 34 of 104 cases (33%) identified in Mexico.

Results of another study suggest dengue is endemic along the southern Texas-Mexico border (Emerg. Infect. Dis. 2007;13:1477–83). Investigators found 2% of Brownsville residents had serologic evidence of recent dengue infection, compared with 7.3% of residents in the bordering city of Matamoros in Tamaulipas in 2004. The cross-sectional survey with 600 participants also showed that 40% of Brownsville residents and 78% of Matamoros residents had a past dengue infection. Relevant mosquito larvae were found in 30% of households in both cities, they reported.

The emergence of dengue is a particular problem in the Americas. “We are starting to see an increase in Central America, Puerto Rico, and Cuba,” Dr. Patrick said. The Aedes aegypti mosquito that spreads this disease is now found throughout the central and southern United States, he said.

Dr. David Morens and Dr. Anthony Fauci also described dengue and hemorrhagic fever as a potential public health threat to residents of the continental United States in a commentary in JAMA (2008;299:214–6). Dr. Fauci is the director of the National Institute of Allergy and Infectious Diseases, where Dr. Morens is the dengue program officer.

“The range of Aedes albopictus (the Asian tiger mosquito), a secondary dengue vector related to the classical vector, Aedes aegypti, has been expanding globally at an alarming rate. Since its introduction into the United States in 1985, Aedes albopictus has spread to 36 states,” they wrote. “Worldwide, dengue is among the most important reemerging infectious diseases with an estimated 50 million to 100 million annual cases and, by WHO estimates, 22,000 deaths, mostly in children.”

“We don't talk much about [dengue] in the United States, but we have it in our differential,” said Dr. Patrick, chief medical officer and senior vice president for medical and academic affairs, Miami Children's Hospital.

In 1997–1998, there were 18 cases of confirmed imported dengue reported in Florida, higher than the previously reported 10-year mean of 1.3 cases per year (MMWR 1999;48:1150–2).

The incubation period for dengue fever generally is 4–7 days after a mosquito bite (range, 3–14 days) with a characteristic high fever. “Temperature and the virus go hand in hand,” Dr. Patrick said.

Infected patients also typically experience abrupt headaches, retrobulbar eye pain, marked muscle and joint pain, and a variety of rashes, both macular and maculopapular. Respiratory symptoms include cough, sore throat, and congestion; each is observed in approximately one-third of patients, he said.

A meeting attendee asked how Dr. Patrick would decide which patients to test. “There are a lot of patients who do not have dengue fever. But the retrobulbar pain is pretty distinctive.” Epidemiology also is helpful, he said, and recommended testing any patient with a febrile illness who has traveled to a high-risk region within 2 weeks of presentation. The differential diagnosis includes influenza, typhoid fever, malaria, measles, and rubella.

Diagnosis of dengue is mainly serology based. An IgM immunoassay is recommended, although the timing can be tricky. Most people present while acutely febrile, a time when the IgM serology usually is negative, Dr. Patrick said.

Leucopenia and thrombocytopenia also indicate dengue infection, as does transaminase values 2–5 times the upper limit of normal.

Dengue fever is the most common mosquito-borne viral disease. The A. aegypti mosquito is a daytime biter that resides near domestic areas. A secondary vector, the A. albopictus mosquito, is a more aggressive biter and is better adapted to colder environments. This characteristic may portend a shift in the epidemiology of dengue northward, Dr. Patrick said.

Vaccines to prevent dengue infection are in preclinical trials. Although an immunized person could have lifelong protection, dengue is an RNA virus with four distinct subtypes. “And there is no crossover immunity if a person is infected with a [different] strain,” Dr. Patrick said. There is a trivalent vaccine being investigated now in field trials, he added.

The CDC's “Protect Yourself from Mosquito Bites and Dengue” patient brochure can be downloaded free of charge at www.cdc.gov/ncidod/dvbid/dengue

MIAMI — From 1977 to 2004, there were 3,806 suspected cases of dengue imported to the United States, according to the Centers for Disease Control and Prevention.

“Many more cases probably go unreported each year because surveillance in the United States is passive and relies on physicians to recognize the disease, inquire about the patient's travel history, obtain proper diagnostic samples, and report the case,” according to the CDC. “We are starting to see more and more cases of dengue fever,” said Dr. Christian C. Patrick at a pediatric update sponsored by Miami Children's Hospital, “particularly in south Texas.”

Following a case report of a woman in Brownsville, Tex., infected with dengue without traveling in July 2005 and an outbreak of 1,251 reported cases in Tamaulipas, Mexico, an investigation identified 24 additional cases in Texas in October, including 2 more infections not associated with travel (MMWR 2007;56:785–9). A review of hospitalization records in December revealed that 16 of 25 (64%) eventual infections in Texas developed the more serious dengue hemorrhagic fever, compared with 34 of 104 cases (33%) identified in Mexico.

Results of another study suggest dengue is endemic along the southern Texas-Mexico border (Emerg. Infect. Dis. 2007;13:1477–83). Investigators found 2% of Brownsville residents had serologic evidence of recent dengue infection, compared with 7.3% of residents in the bordering city of Matamoros in Tamaulipas in 2004. The cross-sectional survey with 600 participants also showed that 40% of Brownsville residents and 78% of Matamoros residents had a past dengue infection. Relevant mosquito larvae were found in 30% of households in both cities, they reported.

The emergence of dengue is a particular problem in the Americas. “We are starting to see an increase in Central America, Puerto Rico, and Cuba,” Dr. Patrick said. The Aedes aegypti mosquito that spreads this disease is now found throughout the central and southern United States, he said.

Dr. David Morens and Dr. Anthony Fauci also described dengue and hemorrhagic fever as a potential public health threat to residents of the continental United States in a commentary in JAMA (2008;299:214–6). Dr. Fauci is the director of the National Institute of Allergy and Infectious Diseases, where Dr. Morens is the dengue program officer.

“The range of Aedes albopictus (the Asian tiger mosquito), a secondary dengue vector related to the classical vector, Aedes aegypti, has been expanding globally at an alarming rate. Since its introduction into the United States in 1985, Aedes albopictus has spread to 36 states,” they wrote. “Worldwide, dengue is among the most important reemerging infectious diseases with an estimated 50 million to 100 million annual cases and, by WHO estimates, 22,000 deaths, mostly in children.”

“We don't talk much about [dengue] in the United States, but we have it in our differential,” said Dr. Patrick, chief medical officer and senior vice president for medical and academic affairs, Miami Children's Hospital.

In 1997–1998, there were 18 cases of confirmed imported dengue reported in Florida, higher than the previously reported 10-year mean of 1.3 cases per year (MMWR 1999;48:1150–2).

The incubation period for dengue fever generally is 4–7 days after a mosquito bite (range, 3–14 days) with a characteristic high fever. “Temperature and the virus go hand in hand,” Dr. Patrick said.

Infected patients also typically experience abrupt headaches, retrobulbar eye pain, marked muscle and joint pain, and a variety of rashes, both macular and maculopapular. Respiratory symptoms include cough, sore throat, and congestion; each is observed in approximately one-third of patients, he said.

A meeting attendee asked how Dr. Patrick would decide which patients to test. “There are a lot of patients who do not have dengue fever. But the retrobulbar pain is pretty distinctive.” Epidemiology also is helpful, he said, and recommended testing any patient with a febrile illness who has traveled to a high-risk region within 2 weeks of presentation. The differential diagnosis includes influenza, typhoid fever, malaria, measles, and rubella.

Diagnosis of dengue is mainly serology based. An IgM immunoassay is recommended, although the timing can be tricky. Most people present while acutely febrile, a time when the IgM serology usually is negative, Dr. Patrick said.

Leucopenia and thrombocytopenia also indicate dengue infection, as does transaminase values 2–5 times the upper limit of normal.

Dengue fever is the most common mosquito-borne viral disease. The A. aegypti mosquito is a daytime biter that resides near domestic areas. A secondary vector, the A. albopictus mosquito, is a more aggressive biter and is better adapted to colder environments. This characteristic may portend a shift in the epidemiology of dengue northward, Dr. Patrick said.

Vaccines to prevent dengue infection are in preclinical trials. Although an immunized person could have lifelong protection, dengue is an RNA virus with four distinct subtypes. “And there is no crossover immunity if a person is infected with a [different] strain,” Dr. Patrick said. There is a trivalent vaccine being investigated now in field trials, he added.

The CDC's “Protect Yourself from Mosquito Bites and Dengue” patient brochure can be downloaded free of charge at www.cdc.gov/ncidod/dvbid/dengue

MIAMI — From 1977 to 2004, there were 3,806 suspected cases of dengue imported to the United States, according to the Centers for Disease Control and Prevention.

“Many more cases probably go unreported each year because surveillance in the United States is passive and relies on physicians to recognize the disease, inquire about the patient's travel history, obtain proper diagnostic samples, and report the case,” according to the CDC. “We are starting to see more and more cases of dengue fever,” said Dr. Christian C. Patrick at a pediatric update sponsored by Miami Children's Hospital, “particularly in south Texas.”

Following a case report of a woman in Brownsville, Tex., infected with dengue without traveling in July 2005 and an outbreak of 1,251 reported cases in Tamaulipas, Mexico, an investigation identified 24 additional cases in Texas in October, including 2 more infections not associated with travel (MMWR 2007;56:785–9). A review of hospitalization records in December revealed that 16 of 25 (64%) eventual infections in Texas developed the more serious dengue hemorrhagic fever, compared with 34 of 104 cases (33%) identified in Mexico.

Results of another study suggest dengue is endemic along the southern Texas-Mexico border (Emerg. Infect. Dis. 2007;13:1477–83). Investigators found 2% of Brownsville residents had serologic evidence of recent dengue infection, compared with 7.3% of residents in the bordering city of Matamoros in Tamaulipas in 2004. The cross-sectional survey with 600 participants also showed that 40% of Brownsville residents and 78% of Matamoros residents had a past dengue infection. Relevant mosquito larvae were found in 30% of households in both cities, they reported.

The emergence of dengue is a particular problem in the Americas. “We are starting to see an increase in Central America, Puerto Rico, and Cuba,” Dr. Patrick said. The Aedes aegypti mosquito that spreads this disease is now found throughout the central and southern United States, he said.

Dr. David Morens and Dr. Anthony Fauci also described dengue and hemorrhagic fever as a potential public health threat to residents of the continental United States in a commentary in JAMA (2008;299:214–6). Dr. Fauci is the director of the National Institute of Allergy and Infectious Diseases, where Dr. Morens is the dengue program officer.

“The range of Aedes albopictus (the Asian tiger mosquito), a secondary dengue vector related to the classical vector, Aedes aegypti, has been expanding globally at an alarming rate. Since its introduction into the United States in 1985, Aedes albopictus has spread to 36 states,” they wrote. “Worldwide, dengue is among the most important reemerging infectious diseases with an estimated 50 million to 100 million annual cases and, by WHO estimates, 22,000 deaths, mostly in children.”

“We don't talk much about [dengue] in the United States, but we have it in our differential,” said Dr. Patrick, chief medical officer and senior vice president for medical and academic affairs, Miami Children's Hospital.

In 1997–1998, there were 18 cases of confirmed imported dengue reported in Florida, higher than the previously reported 10-year mean of 1.3 cases per year (MMWR 1999;48:1150–2).

The incubation period for dengue fever generally is 4–7 days after a mosquito bite (range, 3–14 days) with a characteristic high fever. “Temperature and the virus go hand in hand,” Dr. Patrick said.

Infected patients also typically experience abrupt headaches, retrobulbar eye pain, marked muscle and joint pain, and a variety of rashes, both macular and maculopapular. Respiratory symptoms include cough, sore throat, and congestion; each is observed in approximately one-third of patients, he said.

A meeting attendee asked how Dr. Patrick would decide which patients to test. “There are a lot of patients who do not have dengue fever. But the retrobulbar pain is pretty distinctive.” Epidemiology also is helpful, he said, and recommended testing any patient with a febrile illness who has traveled to a high-risk region within 2 weeks of presentation. The differential diagnosis includes influenza, typhoid fever, malaria, measles, and rubella.

Diagnosis of dengue is mainly serology based. An IgM immunoassay is recommended, although the timing can be tricky. Most people present while acutely febrile, a time when the IgM serology usually is negative, Dr. Patrick said.

Leucopenia and thrombocytopenia also indicate dengue infection, as does transaminase values 2–5 times the upper limit of normal.

Dengue fever is the most common mosquito-borne viral disease. The A. aegypti mosquito is a daytime biter that resides near domestic areas. A secondary vector, the A. albopictus mosquito, is a more aggressive biter and is better adapted to colder environments. This characteristic may portend a shift in the epidemiology of dengue northward, Dr. Patrick said.

Vaccines to prevent dengue infection are in preclinical trials. Although an immunized person could have lifelong protection, dengue is an RNA virus with four distinct subtypes. “And there is no crossover immunity if a person is infected with a [different] strain,” Dr. Patrick said. There is a trivalent vaccine being investigated now in field trials, he added.

MIAMI — When meeting with elected officials to advocate on behalf of children in your community, build rapport with the legislator, know your topic—including the positive and negative aspects—and leave a brief written summary of your position.

These are among the tips for successful advocacy outlined by Florida pediatrician Joseph J. Chiaro.

“Speaking about children's issues can be very empowering, and I recommend it to all of you,” Dr. Chiaro said at a pediatric update sponsored by Miami Children's Hospital. Provision of medical insurance from the moment of birth, bicycle helmet use, and swimming pool protections are examples of issues for which advocacy by pediatricians made a difference in Florida and elsewhere.

Advocacy is not always easy, however, such as calling for pool safety requirements. “You can imagine how strong the opposition was from home builders and the pool industry,” Dr. Chiaro said. “Despite our efforts … Florida still leads the country in drowning deaths of children under age 4 [years].”

“I am not here to tell you how to advocate within your community. But I submit to you it's important to speak up,” said Dr. Chiaro, deputy secretary of Health and Children's Medical Services, Florida Department of Health, Tallahassee.

Before you meet with elected officials, Google them, he suggested. “There is no excuse for not knowing your elected officials.” Are they lawyers, for example, or physicians, or married to a physician? In addition, get to know their staff. Frequently, staff members understand the system far better than many elected officials, and they often remain beyond the next election cycle.

Meet with legislators in their local offices whenever possible. “Most people think most advocacy happens in [the] state capitol. That is not true. They are very busy when they are in the capitol,” Dr. Chiaro said.

When you enter a legislator's office, begin with observation. Are there diplomas on the wall? Where did he or she graduate from? “Take a clue from [the] office—any kind of rapport you can build with this individual can be key.”

Then disclose whom you represent, Dr. Chiaro said. Are you there as a pediatrician, a parent, and/or on behalf of a medical society?

Know your topic thoroughly. To get a little training or practice, find people you know who disagree with you strongly, he suggested. Try to persuade them, and they will show you the fallacies in your argument. “Trust me, more often than not, legislators or elected officials will know how to counter your arguments.”

If you get a question you don't know how to answer correctly, “don't fake it,” Dr. Chiaro said. “Say 'Sir or Madam, I don't know the answer to that question, but I will get back to you with an answer in a day or two.' And do so.”

Remember your Latin—quid pro quo. This means “you are not getting something for nothing,” he said. Most elected officials want to be reelected. What does it take? Money, recognition. If you have the opportunity to support an elected official, do so.” Also, know which lawmakers tend to vote for legislation favorable to children.

“Never get angry or threaten,” Dr. Chiaro said. “If you are advocating for children, you will cross paths with these same people again.”

Prepare a written summary of your position. Half a page of large print written at a fourth-grade English level is recommended. Be willing to negotiate when you advocate. “We advocated last year for $4 million for abused and neglected kids in the state.” Florida did not give $4 million—it gave $400,000, Dr. Chiaro said. “Some folks were disappointed, but be happy for what you get. You might get legislators to at least start changing their minds.”

After the meeting, send a thank-you note. “This is a skill many people have forgotten. Make it on personal or business stationery, and make sure it's handwritten,” he recommended.

MIAMI — When meeting with elected officials to advocate on behalf of children in your community, build rapport with the legislator, know your topic—including the positive and negative aspects—and leave a brief written summary of your position.

These are among the tips for successful advocacy outlined by Florida pediatrician Joseph J. Chiaro.

“Speaking about children's issues can be very empowering, and I recommend it to all of you,” Dr. Chiaro said at a pediatric update sponsored by Miami Children's Hospital. Provision of medical insurance from the moment of birth, bicycle helmet use, and swimming pool protections are examples of issues for which advocacy by pediatricians made a difference in Florida and elsewhere.

Advocacy is not always easy, however, such as calling for pool safety requirements. “You can imagine how strong the opposition was from home builders and the pool industry,” Dr. Chiaro said. “Despite our efforts … Florida still leads the country in drowning deaths of children under age 4 [years].”

“I am not here to tell you how to advocate within your community. But I submit to you it's important to speak up,” said Dr. Chiaro, deputy secretary of Health and Children's Medical Services, Florida Department of Health, Tallahassee.

Before you meet with elected officials, Google them, he suggested. “There is no excuse for not knowing your elected officials.” Are they lawyers, for example, or physicians, or married to a physician? In addition, get to know their staff. Frequently, staff members understand the system far better than many elected officials, and they often remain beyond the next election cycle.

Meet with legislators in their local offices whenever possible. “Most people think most advocacy happens in [the] state capitol. That is not true. They are very busy when they are in the capitol,” Dr. Chiaro said.

When you enter a legislator's office, begin with observation. Are there diplomas on the wall? Where did he or she graduate from? “Take a clue from [the] office—any kind of rapport you can build with this individual can be key.”

Then disclose whom you represent, Dr. Chiaro said. Are you there as a pediatrician, a parent, and/or on behalf of a medical society?

Know your topic thoroughly. To get a little training or practice, find people you know who disagree with you strongly, he suggested. Try to persuade them, and they will show you the fallacies in your argument. “Trust me, more often than not, legislators or elected officials will know how to counter your arguments.”

If you get a question you don't know how to answer correctly, “don't fake it,” Dr. Chiaro said. “Say 'Sir or Madam, I don't know the answer to that question, but I will get back to you with an answer in a day or two.' And do so.”

Remember your Latin—quid pro quo. This means “you are not getting something for nothing,” he said. Most elected officials want to be reelected. What does it take? Money, recognition. If you have the opportunity to support an elected official, do so.” Also, know which lawmakers tend to vote for legislation favorable to children.

“Never get angry or threaten,” Dr. Chiaro said. “If you are advocating for children, you will cross paths with these same people again.”

Prepare a written summary of your position. Half a page of large print written at a fourth-grade English level is recommended. Be willing to negotiate when you advocate. “We advocated last year for $4 million for abused and neglected kids in the state.” Florida did not give $4 million—it gave $400,000, Dr. Chiaro said. “Some folks were disappointed, but be happy for what you get. You might get legislators to at least start changing their minds.”

After the meeting, send a thank-you note. “This is a skill many people have forgotten. Make it on personal or business stationery, and make sure it's handwritten,” he recommended.

MIAMI — When meeting with elected officials to advocate on behalf of children in your community, build rapport with the legislator, know your topic—including the positive and negative aspects—and leave a brief written summary of your position.

These are among the tips for successful advocacy outlined by Florida pediatrician Joseph J. Chiaro.

“Speaking about children's issues can be very empowering, and I recommend it to all of you,” Dr. Chiaro said at a pediatric update sponsored by Miami Children's Hospital. Provision of medical insurance from the moment of birth, bicycle helmet use, and swimming pool protections are examples of issues for which advocacy by pediatricians made a difference in Florida and elsewhere.

Advocacy is not always easy, however, such as calling for pool safety requirements. “You can imagine how strong the opposition was from home builders and the pool industry,” Dr. Chiaro said. “Despite our efforts … Florida still leads the country in drowning deaths of children under age 4 [years].”

“I am not here to tell you how to advocate within your community. But I submit to you it's important to speak up,” said Dr. Chiaro, deputy secretary of Health and Children's Medical Services, Florida Department of Health, Tallahassee.

Before you meet with elected officials, Google them, he suggested. “There is no excuse for not knowing your elected officials.” Are they lawyers, for example, or physicians, or married to a physician? In addition, get to know their staff. Frequently, staff members understand the system far better than many elected officials, and they often remain beyond the next election cycle.

Meet with legislators in their local offices whenever possible. “Most people think most advocacy happens in [the] state capitol. That is not true. They are very busy when they are in the capitol,” Dr. Chiaro said.

When you enter a legislator's office, begin with observation. Are there diplomas on the wall? Where did he or she graduate from? “Take a clue from [the] office—any kind of rapport you can build with this individual can be key.”

Then disclose whom you represent, Dr. Chiaro said. Are you there as a pediatrician, a parent, and/or on behalf of a medical society?

Know your topic thoroughly. To get a little training or practice, find people you know who disagree with you strongly, he suggested. Try to persuade them, and they will show you the fallacies in your argument. “Trust me, more often than not, legislators or elected officials will know how to counter your arguments.”

If you get a question you don't know how to answer correctly, “don't fake it,” Dr. Chiaro said. “Say 'Sir or Madam, I don't know the answer to that question, but I will get back to you with an answer in a day or two.' And do so.”

Remember your Latin—quid pro quo. This means “you are not getting something for nothing,” he said. Most elected officials want to be reelected. What does it take? Money, recognition. If you have the opportunity to support an elected official, do so.” Also, know which lawmakers tend to vote for legislation favorable to children.

“Never get angry or threaten,” Dr. Chiaro said. “If you are advocating for children, you will cross paths with these same people again.”

Prepare a written summary of your position. Half a page of large print written at a fourth-grade English level is recommended. Be willing to negotiate when you advocate. “We advocated last year for $4 million for abused and neglected kids in the state.” Florida did not give $4 million—it gave $400,000, Dr. Chiaro said. “Some folks were disappointed, but be happy for what you get. You might get legislators to at least start changing their minds.”

After the meeting, send a thank-you note. “This is a skill many people have forgotten. Make it on personal or business stationery, and make sure it's handwritten,” he recommended.

MIAMI — Two recent outbreaks of measles in the United States highlight the need for vaccination and vigilance for infections imported from overseas, including Europe, according to Dr. Carol J. Baker.

“How could this happen in 2008? We need to be aware of the importations from Europe,” Dr. Baker said. “Most people do not think of MMR as a travel vaccine. There is a lot of measles in Europe now, and people think of going to Europe as the same as [traveling within] the U.S.”

The Centers for Disease Control and Prevention reported both outbreaks in February 2008. In one instance, 11 cases in San Diego County in January and February of this year were linked to a 7-year-old unvaccinated boy who was infected during a family trip to Switzerland (MMWR 2008;57:203–6). None of the eight children he subsequently infected was vaccinated, including two siblings, two playmates from school, and four children exposed in a pediatrician's office (three were infants younger than the immunization age). Another three students at the school were secondarily infected. About 10% of the children at his school, including those infected, were vaccine personal belief exemptors (PEDIATRIC NEWS, March 2008, p. 14).

“If you have more and more vaccine exemptors, you will be as a community more susceptible to measles,” Dr. Baker said during a pediatric update sponsored by Miami Children's Hospital. No vaccinated child exposed to the San Diego index case became infected.

Suspect measles infection for all patients who have traveled overseas and present with a fever and rash, Dr. Baker advised. In addition, “separate a suspected case from the waiting room. You will need to clean the room very well and wait a few hours [before reentering].”

An earlier outbreak of measles in August-September 2007 also was imported and associated with an unvaccinated youth. The index case was a 12-year-old boy from Japan attending an International Youth event in Pennsylvania (MMWR 2008;57:169–73). A multistate investigation identified seven additional measles infections in Pennsylvania, Michigan, and Texas, including six confirmed from the index case using genetic sequencing.

Estimated attendance at the event was 265,000 and included teams from Canada, Chinese Taipei, Curaçao, Japan, the Netherlands, Mexico, Saudi Arabia, and Venezuela. The coaches and boys aged 10–13 years were housed in the same compound during the event, according to the CDC report.

“If you hear one of your patients is going to one of these events, make sure they are vaccinated,” said Dr. Baker, professor of pediatrics and molecular neurology and microbiology at Baylor College of Medicine, Houston.

“This outbreak highlights the need to maintain the highest possible vaccination coverage in the United States, along with disease surveillance and outbreak-containment capabilities,” the CDC investigators wrote.

One of the lessons learned from the outbreaks is that unvaccinated people are at high risk, Dr. Baker said. Measles spreads rapidly in susceptible populations and is still endemic throughout the world, including Europe.

A meeting attendee asked for advice regarding parents who refuse immunizations. “Personal exemptors are a big problem for pediatricians and family physicians. Look to the academy for advice. The child's parents in the case I presented had refused to vaccinate,” said Dr. Baker, who is also associate editor of the Red Book 2006: Report of the Committee on Infectious Diseases.

Another editor of the Red Book, Dr. David W. Kimberlin, responded during a panel discussion at the meeting. “There is a growing voice from parents whose children have died of vaccine-preventable diseases,” said Dr. Kimberlin, professor of pediatrics at the University of Alabama at Birmingham.

These groups can be a good resource, he said.

Measles is no longer endemic in the United States. In 2006, there were fewer than 100 cases reported to the CDC, and all were imported, primarily from India and Japan, with some cases from Europe.

At press time, the CDC reported that from January through April 25, 2008, 64 reports of confirmed measles cases were received from nine states, in which outbreaks were ongoing in four (Arizona, Michigan, New York, and Wisconsin). A total of 59 cases occurred among U.S. residents, and 54 were associated with the importation of measles from other countries. In all but one case, patients were unvaccinated or had unknown vaccination status. In all, 43 (67%) of the patients were less than 19 years of age and 32 (50%) were less than 4 years old.

When the San Diego boy presented on Jan. 25, 2008, with rash, fever, yellow discharge, and red lips, his family physician and pediatrician suspected scarlet fever. This diagnosis was ruled out on the basis of a negative rapid test for streptococcus. “If you've seen measles, it can be clearly differentiated, [but] younger physicians do not recognize this diagnosis in the United States,” Dr. Baker said.

The boy was correctly diagnosed the following day based on laboratory tests and his presentation at a children's hospital emergency department with a 104° F fever and generalized rash.

Measles is a very contagious disease that can spread airborne and through physical contact. In fact, a 53-year-old woman who sat one row ahead of the Japanese boy on a Detroit-to-Baltimore flight prior to the event developed measles; she could not recall being immunized.

More than 90% of “susceptibles” will be infected, Dr. Baker said. Despite receiving two doses of MMR, 1% of vaccinated people can develop measles, as well as some persons born before 1957, she added. “Very few vaccines are 100%.”

MIAMI — Two recent outbreaks of measles in the United States highlight the need for vaccination and vigilance for infections imported from overseas, including Europe, according to Dr. Carol J. Baker.

“How could this happen in 2008? We need to be aware of the importations from Europe,” Dr. Baker said. “Most people do not think of MMR as a travel vaccine. There is a lot of measles in Europe now, and people think of going to Europe as the same as [traveling within] the U.S.”

The Centers for Disease Control and Prevention reported both outbreaks in February 2008. In one instance, 11 cases in San Diego County in January and February of this year were linked to a 7-year-old unvaccinated boy who was infected during a family trip to Switzerland (MMWR 2008;57:203–6). None of the eight children he subsequently infected was vaccinated, including two siblings, two playmates from school, and four children exposed in a pediatrician's office (three were infants younger than the immunization age). Another three students at the school were secondarily infected. About 10% of the children at his school, including those infected, were vaccine personal belief exemptors (PEDIATRIC NEWS, March 2008, p. 14).

“If you have more and more vaccine exemptors, you will be as a community more susceptible to measles,” Dr. Baker said during a pediatric update sponsored by Miami Children's Hospital. No vaccinated child exposed to the San Diego index case became infected.

Suspect measles infection for all patients who have traveled overseas and present with a fever and rash, Dr. Baker advised. In addition, “separate a suspected case from the waiting room. You will need to clean the room very well and wait a few hours [before reentering].”

An earlier outbreak of measles in August-September 2007 also was imported and associated with an unvaccinated youth. The index case was a 12-year-old boy from Japan attending an International Youth event in Pennsylvania (MMWR 2008;57:169–73). A multistate investigation identified seven additional measles infections in Pennsylvania, Michigan, and Texas, including six confirmed from the index case using genetic sequencing.

Estimated attendance at the event was 265,000 and included teams from Canada, Chinese Taipei, Curaçao, Japan, the Netherlands, Mexico, Saudi Arabia, and Venezuela. The coaches and boys aged 10–13 years were housed in the same compound during the event, according to the CDC report.

“If you hear one of your patients is going to one of these events, make sure they are vaccinated,” said Dr. Baker, professor of pediatrics and molecular neurology and microbiology at Baylor College of Medicine, Houston.

“This outbreak highlights the need to maintain the highest possible vaccination coverage in the United States, along with disease surveillance and outbreak-containment capabilities,” the CDC investigators wrote.

One of the lessons learned from the outbreaks is that unvaccinated people are at high risk, Dr. Baker said. Measles spreads rapidly in susceptible populations and is still endemic throughout the world, including Europe.

A meeting attendee asked for advice regarding parents who refuse immunizations. “Personal exemptors are a big problem for pediatricians and family physicians. Look to the academy for advice. The child's parents in the case I presented had refused to vaccinate,” said Dr. Baker, who is also associate editor of the Red Book 2006: Report of the Committee on Infectious Diseases.

Another editor of the Red Book, Dr. David W. Kimberlin, responded during a panel discussion at the meeting. “There is a growing voice from parents whose children have died of vaccine-preventable diseases,” said Dr. Kimberlin, professor of pediatrics at the University of Alabama at Birmingham.

These groups can be a good resource, he said.

Measles is no longer endemic in the United States. In 2006, there were fewer than 100 cases reported to the CDC, and all were imported, primarily from India and Japan, with some cases from Europe.

At press time, the CDC reported that from January through April 25, 2008, 64 reports of confirmed measles cases were received from nine states, in which outbreaks were ongoing in four (Arizona, Michigan, New York, and Wisconsin). A total of 59 cases occurred among U.S. residents, and 54 were associated with the importation of measles from other countries. In all but one case, patients were unvaccinated or had unknown vaccination status. In all, 43 (67%) of the patients were less than 19 years of age and 32 (50%) were less than 4 years old.

When the San Diego boy presented on Jan. 25, 2008, with rash, fever, yellow discharge, and red lips, his family physician and pediatrician suspected scarlet fever. This diagnosis was ruled out on the basis of a negative rapid test for streptococcus. “If you've seen measles, it can be clearly differentiated, [but] younger physicians do not recognize this diagnosis in the United States,” Dr. Baker said.

The boy was correctly diagnosed the following day based on laboratory tests and his presentation at a children's hospital emergency department with a 104° F fever and generalized rash.

Measles is a very contagious disease that can spread airborne and through physical contact. In fact, a 53-year-old woman who sat one row ahead of the Japanese boy on a Detroit-to-Baltimore flight prior to the event developed measles; she could not recall being immunized.

More than 90% of “susceptibles” will be infected, Dr. Baker said. Despite receiving two doses of MMR, 1% of vaccinated people can develop measles, as well as some persons born before 1957, she added. “Very few vaccines are 100%.”

MIAMI — Two recent outbreaks of measles in the United States highlight the need for vaccination and vigilance for infections imported from overseas, including Europe, according to Dr. Carol J. Baker.

“How could this happen in 2008? We need to be aware of the importations from Europe,” Dr. Baker said. “Most people do not think of MMR as a travel vaccine. There is a lot of measles in Europe now, and people think of going to Europe as the same as [traveling within] the U.S.”

The Centers for Disease Control and Prevention reported both outbreaks in February 2008. In one instance, 11 cases in San Diego County in January and February of this year were linked to a 7-year-old unvaccinated boy who was infected during a family trip to Switzerland (MMWR 2008;57:203–6). None of the eight children he subsequently infected was vaccinated, including two siblings, two playmates from school, and four children exposed in a pediatrician's office (three were infants younger than the immunization age). Another three students at the school were secondarily infected. About 10% of the children at his school, including those infected, were vaccine personal belief exemptors (PEDIATRIC NEWS, March 2008, p. 14).

“If you have more and more vaccine exemptors, you will be as a community more susceptible to measles,” Dr. Baker said during a pediatric update sponsored by Miami Children's Hospital. No vaccinated child exposed to the San Diego index case became infected.

Suspect measles infection for all patients who have traveled overseas and present with a fever and rash, Dr. Baker advised. In addition, “separate a suspected case from the waiting room. You will need to clean the room very well and wait a few hours [before reentering].”

An earlier outbreak of measles in August-September 2007 also was imported and associated with an unvaccinated youth. The index case was a 12-year-old boy from Japan attending an International Youth event in Pennsylvania (MMWR 2008;57:169–73). A multistate investigation identified seven additional measles infections in Pennsylvania, Michigan, and Texas, including six confirmed from the index case using genetic sequencing.

Estimated attendance at the event was 265,000 and included teams from Canada, Chinese Taipei, Curaçao, Japan, the Netherlands, Mexico, Saudi Arabia, and Venezuela. The coaches and boys aged 10–13 years were housed in the same compound during the event, according to the CDC report.

“If you hear one of your patients is going to one of these events, make sure they are vaccinated,” said Dr. Baker, professor of pediatrics and molecular neurology and microbiology at Baylor College of Medicine, Houston.

“This outbreak highlights the need to maintain the highest possible vaccination coverage in the United States, along with disease surveillance and outbreak-containment capabilities,” the CDC investigators wrote.

One of the lessons learned from the outbreaks is that unvaccinated people are at high risk, Dr. Baker said. Measles spreads rapidly in susceptible populations and is still endemic throughout the world, including Europe.

A meeting attendee asked for advice regarding parents who refuse immunizations. “Personal exemptors are a big problem for pediatricians and family physicians. Look to the academy for advice. The child's parents in the case I presented had refused to vaccinate,” said Dr. Baker, who is also associate editor of the Red Book 2006: Report of the Committee on Infectious Diseases.

Another editor of the Red Book, Dr. David W. Kimberlin, responded during a panel discussion at the meeting. “There is a growing voice from parents whose children have died of vaccine-preventable diseases,” said Dr. Kimberlin, professor of pediatrics at the University of Alabama at Birmingham.

These groups can be a good resource, he said.

Measles is no longer endemic in the United States. In 2006, there were fewer than 100 cases reported to the CDC, and all were imported, primarily from India and Japan, with some cases from Europe.

At press time, the CDC reported that from January through April 25, 2008, 64 reports of confirmed measles cases were received from nine states, in which outbreaks were ongoing in four (Arizona, Michigan, New York, and Wisconsin). A total of 59 cases occurred among U.S. residents, and 54 were associated with the importation of measles from other countries. In all but one case, patients were unvaccinated or had unknown vaccination status. In all, 43 (67%) of the patients were less than 19 years of age and 32 (50%) were less than 4 years old.

When the San Diego boy presented on Jan. 25, 2008, with rash, fever, yellow discharge, and red lips, his family physician and pediatrician suspected scarlet fever. This diagnosis was ruled out on the basis of a negative rapid test for streptococcus. “If you've seen measles, it can be clearly differentiated, [but] younger physicians do not recognize this diagnosis in the United States,” Dr. Baker said.

The boy was correctly diagnosed the following day based on laboratory tests and his presentation at a children's hospital emergency department with a 104° F fever and generalized rash.

Measles is a very contagious disease that can spread airborne and through physical contact. In fact, a 53-year-old woman who sat one row ahead of the Japanese boy on a Detroit-to-Baltimore flight prior to the event developed measles; she could not recall being immunized.

More than 90% of “susceptibles” will be infected, Dr. Baker said. Despite receiving two doses of MMR, 1% of vaccinated people can develop measles, as well as some persons born before 1957, she added. “Very few vaccines are 100%.”

MIAMI BEACH — Your diagnosis and management of infectious diseases in children should have changed following the publication of 10 articles in 2006 and 2007, according to Dr. Russell W. Steele.

The reports range from antimicrobial therapy for methicillin-resistant Staphylococcus aureus infections to an update on cat scratch disease to the well-published alterations to antibacterial prophylaxis prior to dental and gastrointestinal procedures.

Dr. Steele explained why these reports are important for optimal pediatric practice at the annual Masters of Pediatrics conference sponsored by the University of Miami.

“These are all about infectious diseases, and [are] things that have a practical impact immediately—things that might change your practice,” Dr. Steele, division head of pediatric infectious diseases at Ochsner Children's Health Center and Tulane University in New Orleans, said in an interview. He was not an author of any of the articles and had no relevant financial disclosures.

Dr. Steele does a lot of journal reading and scanning. “When something is of obvious practical value—will change someone's practice—I make note of that.” Sometimes colleagues recommend a study to him or ask him questions about it. “Someone will call me when something comes out, and sometimes I haven't even seen it yet. For example, a cardiologist called me about the endocarditis article and it wasn't even out yet.”

Dr. Steele selected the following articles of import:

1. Community-onset methicillin-resistant Staphylococcus aureus skin and soft-tissue infections: impact of antimicrobial therapy on outcome (Clin. Infect. Dis. 2007;44:777–84). Dr. Jörg J. Ruhe of the University of Arkansas for Medical Sciences, Little Rock, and associates determined that use of an antimicrobial with activity against uncomplicated community-onset methicillin-resistant S. aureus (MRSA) skin and soft-tissue infections successfully treated 296 of 312 (95%) episodes. In contrast, treatment was successful for 190 of 219 (87%) cases in patients who did not receive an active antimicrobial. The researchers conducted the retrospective cohort study to address the conflicting data in the literature regarding the role of antimicrobials for these uncomplicated MRSA infections. Use of an inactive antimicrobial agent was an independent predictor of treatment failure, the authors noted. There were 45 treatment failures among the 531 infectious episodes experienced by the 492 adult patients.

2. Is Epstein-Barr virus transmitted sexually? (J. Infect. Dis. 2007;195:469–73). Dr. Joseph S. Pagano, in this editorial commentary, provides perspective on a report in the same issue by Craig D. Higgins of the Institute of Cancer Research, Surrey, England, and associates that demonstrates sexual transmission is possible for Epstein-Barr virus (J. Infect. Dis. 2007;195:474–82).

The retrospective study of 2,006 college students in Edinburgh is among the first to provide seroepidemiologic evidence of sexual transmission, wrote Dr. Pagano of the Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill. He pointed out that nonsexual contact, however, remains responsible for more cases of transmission of EBV and the other three well-established human herpesviruses transmitted sexually: herpes simplex virus type 2, cytomegalovirus, and Kaposi's sarcoma-associated herpesvirus.

Dr. Steele commented, “This article offers additional information as how [Epstein-Barr virus] might be transmitted. If you get an adolescent with Epstein-Barr virus, you might do a lot more history regarding sexual activity and more counseling.”

3. Specific real-time polymerase chain reaction places Kingella kingae as the most common cause of osteoarticular infections in young children (Pediatr. Infect. Dis. J. 2007;26:377–81). This prospective study identified Kingella kingae as the causative pathogen for 39 out of 87 (45%) children admitted to a pediatric unit for an osteoarticular infection. S. aureus was the second leading cause, identified in 25 (29%) children. Dr. Sylvia Chometon and the other French researchers implicated K. kingae as the leading pathogen at their institution using a real-time polymerase chain reaction assay they developed.

4. Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology (Neurology 2007;69:91–102). There are sufficient data to conclude that, in both adults and children, nervous system Lyme disease infection responds well to penicillin, ceftriaxone, cefotaxime, and doxycycline, according to panel recommendations following a review of 37 articles in the literature. In addition, the subcommittee found no compelling evidence of a beneficial effect from prolonged antibiotic treatment in patients with post-Lyme syndrome. The number of children in the studies is limited, but available data indicate that findings are comparable to those in adults, they noted.

5. The clinical assessment, treatment and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Disease Society of America (Clin. Infect. Dis. 2006;43:1089–134). Updated evidence-based guidelines for the management of patients with Lyme disease, human granulocytic anaplasmosis (formerly known as human granulocytic ehrlichiosis), and babesiosis replace guidelines from 2000. An Infectious Diseases Society of America expert panel provided information about prevention, epidemiology, clinical manifestations, diagnosis, and treatment for each of these Ixodes tickborne infections. The guidelines recommended antimicrobial therapy regimens for Lyme disease prevention and treatment, and include a partial list of therapies to be avoided.

6. How reliable is a negative blood culture result? Volume of blood submitted for culture in routine practice in a children's hospital (Pediatrics 2007;119:891–6) “In routine clinical practice, a negative blood culture result is almost inevitable for a large proportion of blood cultures because of the submission of an inadequate volume of blood,” wrote Dr. Thomas G. Connell of the University of Melbourne, Parkville, Australia, and his associates. They assessed blood samples submitted for culture over 6 months at a children's hospital for adequate volume and use of proper culture bottles. Before an educational intervention to improve these parameters, they found 491 of 1,067 (46%) blood cultures had an adequate volume and 378 (35%) were submitted in the correct bottle type. After the intervention, there were significant improvements in the number of submission with adequate volume, 186 of 291 (64%) and use of the correct vial, 149 of 291 (51%) cultures.

7. Etiology of severe sensorineural hearing loss in children: independent impact of congenital cytomegalovirus infection and GJB2 mutations (J. Infect. Dis. 2007;195:782–8). In this study, Dr. Hiroshi Ogawa of Fukushima Medical University, Fukushima City, Japan, and associates demonstrated that congenital cytomegalovirus (CMV) infections are an important cause of severe sensorineural hearing loss. In addition, the incidence from this etiology is comparable to one of the major genetic causes of the condition, GJB2 gene mutations. These findings come from an assessment of DNA samples from 67 affected children born in Japan.

A total of 15% had congenital CMV infection and 24% had GJB2 mutations. All participants with CMV infection developed the severe hearing loss before age 2 years, and most had no clinically obvious abnormality at birth.

8. Surgical excision versus antibiotic treatment for nontuberculous mycobacterial cervicofacial lymphadenitis in children: a multicenter, randomized, controlled trial (Clin. Infect. Dis. 2007;44:1057–64.). Dr. Jerome A. Lindeboom of the University of Amsterdam and associates determined that surgery was more effective than antibiotics for children with nontuberculous mycobacterial cervicofacial lymphadenitis. Although surgery is considered standard treatment, increasing reports of successful antibiotic treatment spurred the study. The investigators randomized 100 children with the condition to surgical excision of the involved lymph nodes or to clarithromycin and rifabutin treatment for at least 12 weeks. Surgery was more effective with a cure rate of 96%, compared with the antibiotic therapy cure rate of 66%. Treatment failures were not associated with resistance to or noncompliance with the antibiotic regimens.

9. Lymph node biopsy specimens and diagnosis of cat-scratch disease (Emerg. Infect. Dis. 2006;12:1338–44). A diagnosis of cat scratch disease does not rule out a diagnosis of mycobacteriosis or neoplasm, according to this report. Dr. Jean-Marc Rolain, professor at the Unité des Rickettsies in Marseille, France, and associates performed microbiologic assessment of lymph node biopsies from 786 patients with suspected cat-scratch disease. The most common infectious agent was Bartonella henselae, found in 245 patients (31%). Mycobacteriosis was diagnosed in 54 patients (7%) by culture, and neoplasm was detected in 181 (26%) specimens suitable for histologic analysis from 47 patients. Of note, 13 patients with confirmed B. henselae infections had concurrent mycobacteriosis (10 cases) or neoplasm (3 cases). This suggests routine histologic testing of lymph node biopsy specimens is indicated because some patients might have a concurrent malignant disease or mycobacteriosis, the authors wrote.

10. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group (Circulation 2007;116:1736–54). This is an update to American Heart Association recommendations for prevention of infectious endocarditis, last released in 1997. The recommendations are based on literature reports of procedure-related bacteremia and infective endocarditis, in vitro susceptibility data for infective endocarditis microorganisms, prophylaxis findings from animal studies, and retrospective and prospective studies of prevention in humans.

Only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures, even if such prophylactic therapy were 100% effective, the writing committee found. In addition, prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. The recommendations also state that administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure.

These 10 articles have the potential to alter infectious disease practice, Dr. Steele said. “This article on endocarditis is the most dramatic example. We are using a lot less prophylaxis before dental procedures now.”

MIAMI BEACH — Your diagnosis and management of infectious diseases in children should have changed following the publication of 10 articles in 2006 and 2007, according to Dr. Russell W. Steele.

The reports range from antimicrobial therapy for methicillin-resistant Staphylococcus aureus infections to an update on cat scratch disease to the well-published alterations to antibacterial prophylaxis prior to dental and gastrointestinal procedures.

Dr. Steele explained why these reports are important for optimal pediatric practice at the annual Masters of Pediatrics conference sponsored by the University of Miami.

“These are all about infectious diseases, and [are] things that have a practical impact immediately—things that might change your practice,” Dr. Steele, division head of pediatric infectious diseases at Ochsner Children's Health Center and Tulane University in New Orleans, said in an interview. He was not an author of any of the articles and had no relevant financial disclosures.

Dr. Steele does a lot of journal reading and scanning. “When something is of obvious practical value—will change someone's practice—I make note of that.” Sometimes colleagues recommend a study to him or ask him questions about it. “Someone will call me when something comes out, and sometimes I haven't even seen it yet. For example, a cardiologist called me about the endocarditis article and it wasn't even out yet.”

Dr. Steele selected the following articles of import:

1. Community-onset methicillin-resistant Staphylococcus aureus skin and soft-tissue infections: impact of antimicrobial therapy on outcome (Clin. Infect. Dis. 2007;44:777–84). Dr. Jörg J. Ruhe of the University of Arkansas for Medical Sciences, Little Rock, and associates determined that use of an antimicrobial with activity against uncomplicated community-onset methicillin-resistant S. aureus (MRSA) skin and soft-tissue infections successfully treated 296 of 312 (95%) episodes. In contrast, treatment was successful for 190 of 219 (87%) cases in patients who did not receive an active antimicrobial. The researchers conducted the retrospective cohort study to address the conflicting data in the literature regarding the role of antimicrobials for these uncomplicated MRSA infections. Use of an inactive antimicrobial agent was an independent predictor of treatment failure, the authors noted. There were 45 treatment failures among the 531 infectious episodes experienced by the 492 adult patients.

2. Is Epstein-Barr virus transmitted sexually? (J. Infect. Dis. 2007;195:469–73). Dr. Joseph S. Pagano, in this editorial commentary, provides perspective on a report in the same issue by Craig D. Higgins of the Institute of Cancer Research, Surrey, England, and associates that demonstrates sexual transmission is possible for Epstein-Barr virus (J. Infect. Dis. 2007;195:474–82).

The retrospective study of 2,006 college students in Edinburgh is among the first to provide seroepidemiologic evidence of sexual transmission, wrote Dr. Pagano of the Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill. He pointed out that nonsexual contact, however, remains responsible for more cases of transmission of EBV and the other three well-established human herpesviruses transmitted sexually: herpes simplex virus type 2, cytomegalovirus, and Kaposi's sarcoma-associated herpesvirus.

Dr. Steele commented, “This article offers additional information as how [Epstein-Barr virus] might be transmitted. If you get an adolescent with Epstein-Barr virus, you might do a lot more history regarding sexual activity and more counseling.”

3. Specific real-time polymerase chain reaction places Kingella kingae as the most common cause of osteoarticular infections in young children (Pediatr. Infect. Dis. J. 2007;26:377–81). This prospective study identified Kingella kingae as the causative pathogen for 39 out of 87 (45%) children admitted to a pediatric unit for an osteoarticular infection. S. aureus was the second leading cause, identified in 25 (29%) children. Dr. Sylvia Chometon and the other French researchers implicated K. kingae as the leading pathogen at their institution using a real-time polymerase chain reaction assay they developed.

4. Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology (Neurology 2007;69:91–102). There are sufficient data to conclude that, in both adults and children, nervous system Lyme disease infection responds well to penicillin, ceftriaxone, cefotaxime, and doxycycline, according to panel recommendations following a review of 37 articles in the literature. In addition, the subcommittee found no compelling evidence of a beneficial effect from prolonged antibiotic treatment in patients with post-Lyme syndrome. The number of children in the studies is limited, but available data indicate that findings are comparable to those in adults, they noted.

5. The clinical assessment, treatment and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Disease Society of America (Clin. Infect. Dis. 2006;43:1089–134). Updated evidence-based guidelines for the management of patients with Lyme disease, human granulocytic anaplasmosis (formerly known as human granulocytic ehrlichiosis), and babesiosis replace guidelines from 2000. An Infectious Diseases Society of America expert panel provided information about prevention, epidemiology, clinical manifestations, diagnosis, and treatment for each of these Ixodes tickborne infections. The guidelines recommended antimicrobial therapy regimens for Lyme disease prevention and treatment, and include a partial list of therapies to be avoided.

6. How reliable is a negative blood culture result? Volume of blood submitted for culture in routine practice in a children's hospital (Pediatrics 2007;119:891–6) “In routine clinical practice, a negative blood culture result is almost inevitable for a large proportion of blood cultures because of the submission of an inadequate volume of blood,” wrote Dr. Thomas G. Connell of the University of Melbourne, Parkville, Australia, and his associates. They assessed blood samples submitted for culture over 6 months at a children's hospital for adequate volume and use of proper culture bottles. Before an educational intervention to improve these parameters, they found 491 of 1,067 (46%) blood cultures had an adequate volume and 378 (35%) were submitted in the correct bottle type. After the intervention, there were significant improvements in the number of submission with adequate volume, 186 of 291 (64%) and use of the correct vial, 149 of 291 (51%) cultures.

7. Etiology of severe sensorineural hearing loss in children: independent impact of congenital cytomegalovirus infection and GJB2 mutations (J. Infect. Dis. 2007;195:782–8). In this study, Dr. Hiroshi Ogawa of Fukushima Medical University, Fukushima City, Japan, and associates demonstrated that congenital cytomegalovirus (CMV) infections are an important cause of severe sensorineural hearing loss. In addition, the incidence from this etiology is comparable to one of the major genetic causes of the condition, GJB2 gene mutations. These findings come from an assessment of DNA samples from 67 affected children born in Japan.

A total of 15% had congenital CMV infection and 24% had GJB2 mutations. All participants with CMV infection developed the severe hearing loss before age 2 years, and most had no clinically obvious abnormality at birth.

8. Surgical excision versus antibiotic treatment for nontuberculous mycobacterial cervicofacial lymphadenitis in children: a multicenter, randomized, controlled trial (Clin. Infect. Dis. 2007;44:1057–64.). Dr. Jerome A. Lindeboom of the University of Amsterdam and associates determined that surgery was more effective than antibiotics for children with nontuberculous mycobacterial cervicofacial lymphadenitis. Although surgery is considered standard treatment, increasing reports of successful antibiotic treatment spurred the study. The investigators randomized 100 children with the condition to surgical excision of the involved lymph nodes or to clarithromycin and rifabutin treatment for at least 12 weeks. Surgery was more effective with a cure rate of 96%, compared with the antibiotic therapy cure rate of 66%. Treatment failures were not associated with resistance to or noncompliance with the antibiotic regimens.

9. Lymph node biopsy specimens and diagnosis of cat-scratch disease (Emerg. Infect. Dis. 2006;12:1338–44). A diagnosis of cat scratch disease does not rule out a diagnosis of mycobacteriosis or neoplasm, according to this report. Dr. Jean-Marc Rolain, professor at the Unité des Rickettsies in Marseille, France, and associates performed microbiologic assessment of lymph node biopsies from 786 patients with suspected cat-scratch disease. The most common infectious agent was Bartonella henselae, found in 245 patients (31%). Mycobacteriosis was diagnosed in 54 patients (7%) by culture, and neoplasm was detected in 181 (26%) specimens suitable for histologic analysis from 47 patients. Of note, 13 patients with confirmed B. henselae infections had concurrent mycobacteriosis (10 cases) or neoplasm (3 cases). This suggests routine histologic testing of lymph node biopsy specimens is indicated because some patients might have a concurrent malignant disease or mycobacteriosis, the authors wrote.

10. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group (Circulation 2007;116:1736–54). This is an update to American Heart Association recommendations for prevention of infectious endocarditis, last released in 1997. The recommendations are based on literature reports of procedure-related bacteremia and infective endocarditis, in vitro susceptibility data for infective endocarditis microorganisms, prophylaxis findings from animal studies, and retrospective and prospective studies of prevention in humans.

Only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures, even if such prophylactic therapy were 100% effective, the writing committee found. In addition, prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. The recommendations also state that administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure.

These 10 articles have the potential to alter infectious disease practice, Dr. Steele said. “This article on endocarditis is the most dramatic example. We are using a lot less prophylaxis before dental procedures now.”

MIAMI BEACH — Your diagnosis and management of infectious diseases in children should have changed following the publication of 10 articles in 2006 and 2007, according to Dr. Russell W. Steele.

The reports range from antimicrobial therapy for methicillin-resistant Staphylococcus aureus infections to an update on cat scratch disease to the well-published alterations to antibacterial prophylaxis prior to dental and gastrointestinal procedures.

Dr. Steele explained why these reports are important for optimal pediatric practice at the annual Masters of Pediatrics conference sponsored by the University of Miami.

“These are all about infectious diseases, and [are] things that have a practical impact immediately—things that might change your practice,” Dr. Steele, division head of pediatric infectious diseases at Ochsner Children's Health Center and Tulane University in New Orleans, said in an interview. He was not an author of any of the articles and had no relevant financial disclosures.

Dr. Steele does a lot of journal reading and scanning. “When something is of obvious practical value—will change someone's practice—I make note of that.” Sometimes colleagues recommend a study to him or ask him questions about it. “Someone will call me when something comes out, and sometimes I haven't even seen it yet. For example, a cardiologist called me about the endocarditis article and it wasn't even out yet.”

Dr. Steele selected the following articles of import:

1. Community-onset methicillin-resistant Staphylococcus aureus skin and soft-tissue infections: impact of antimicrobial therapy on outcome (Clin. Infect. Dis. 2007;44:777–84). Dr. Jörg J. Ruhe of the University of Arkansas for Medical Sciences, Little Rock, and associates determined that use of an antimicrobial with activity against uncomplicated community-onset methicillin-resistant S. aureus (MRSA) skin and soft-tissue infections successfully treated 296 of 312 (95%) episodes. In contrast, treatment was successful for 190 of 219 (87%) cases in patients who did not receive an active antimicrobial. The researchers conducted the retrospective cohort study to address the conflicting data in the literature regarding the role of antimicrobials for these uncomplicated MRSA infections. Use of an inactive antimicrobial agent was an independent predictor of treatment failure, the authors noted. There were 45 treatment failures among the 531 infectious episodes experienced by the 492 adult patients.

2. Is Epstein-Barr virus transmitted sexually? (J. Infect. Dis. 2007;195:469–73). Dr. Joseph S. Pagano, in this editorial commentary, provides perspective on a report in the same issue by Craig D. Higgins of the Institute of Cancer Research, Surrey, England, and associates that demonstrates sexual transmission is possible for Epstein-Barr virus (J. Infect. Dis. 2007;195:474–82).

The retrospective study of 2,006 college students in Edinburgh is among the first to provide seroepidemiologic evidence of sexual transmission, wrote Dr. Pagano of the Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill. He pointed out that nonsexual contact, however, remains responsible for more cases of transmission of EBV and the other three well-established human herpesviruses transmitted sexually: herpes simplex virus type 2, cytomegalovirus, and Kaposi's sarcoma-associated herpesvirus.

Dr. Steele commented, “This article offers additional information as how [Epstein-Barr virus] might be transmitted. If you get an adolescent with Epstein-Barr virus, you might do a lot more history regarding sexual activity and more counseling.”

3. Specific real-time polymerase chain reaction places Kingella kingae as the most common cause of osteoarticular infections in young children (Pediatr. Infect. Dis. J. 2007;26:377–81). This prospective study identified Kingella kingae as the causative pathogen for 39 out of 87 (45%) children admitted to a pediatric unit for an osteoarticular infection. S. aureus was the second leading cause, identified in 25 (29%) children. Dr. Sylvia Chometon and the other French researchers implicated K. kingae as the leading pathogen at their institution using a real-time polymerase chain reaction assay they developed.

4. Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology (Neurology 2007;69:91–102). There are sufficient data to conclude that, in both adults and children, nervous system Lyme disease infection responds well to penicillin, ceftriaxone, cefotaxime, and doxycycline, according to panel recommendations following a review of 37 articles in the literature. In addition, the subcommittee found no compelling evidence of a beneficial effect from prolonged antibiotic treatment in patients with post-Lyme syndrome. The number of children in the studies is limited, but available data indicate that findings are comparable to those in adults, they noted.

5. The clinical assessment, treatment and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Disease Society of America (Clin. Infect. Dis. 2006;43:1089–134). Updated evidence-based guidelines for the management of patients with Lyme disease, human granulocytic anaplasmosis (formerly known as human granulocytic ehrlichiosis), and babesiosis replace guidelines from 2000. An Infectious Diseases Society of America expert panel provided information about prevention, epidemiology, clinical manifestations, diagnosis, and treatment for each of these Ixodes tickborne infections. The guidelines recommended antimicrobial therapy regimens for Lyme disease prevention and treatment, and include a partial list of therapies to be avoided.

6. How reliable is a negative blood culture result? Volume of blood submitted for culture in routine practice in a children's hospital (Pediatrics 2007;119:891–6) “In routine clinical practice, a negative blood culture result is almost inevitable for a large proportion of blood cultures because of the submission of an inadequate volume of blood,” wrote Dr. Thomas G. Connell of the University of Melbourne, Parkville, Australia, and his associates. They assessed blood samples submitted for culture over 6 months at a children's hospital for adequate volume and use of proper culture bottles. Before an educational intervention to improve these parameters, they found 491 of 1,067 (46%) blood cultures had an adequate volume and 378 (35%) were submitted in the correct bottle type. After the intervention, there were significant improvements in the number of submission with adequate volume, 186 of 291 (64%) and use of the correct vial, 149 of 291 (51%) cultures.

7. Etiology of severe sensorineural hearing loss in children: independent impact of congenital cytomegalovirus infection and GJB2 mutations (J. Infect. Dis. 2007;195:782–8). In this study, Dr. Hiroshi Ogawa of Fukushima Medical University, Fukushima City, Japan, and associates demonstrated that congenital cytomegalovirus (CMV) infections are an important cause of severe sensorineural hearing loss. In addition, the incidence from this etiology is comparable to one of the major genetic causes of the condition, GJB2 gene mutations. These findings come from an assessment of DNA samples from 67 affected children born in Japan.

A total of 15% had congenital CMV infection and 24% had GJB2 mutations. All participants with CMV infection developed the severe hearing loss before age 2 years, and most had no clinically obvious abnormality at birth.

8. Surgical excision versus antibiotic treatment for nontuberculous mycobacterial cervicofacial lymphadenitis in children: a multicenter, randomized, controlled trial (Clin. Infect. Dis. 2007;44:1057–64.). Dr. Jerome A. Lindeboom of the University of Amsterdam and associates determined that surgery was more effective than antibiotics for children with nontuberculous mycobacterial cervicofacial lymphadenitis. Although surgery is considered standard treatment, increasing reports of successful antibiotic treatment spurred the study. The investigators randomized 100 children with the condition to surgical excision of the involved lymph nodes or to clarithromycin and rifabutin treatment for at least 12 weeks. Surgery was more effective with a cure rate of 96%, compared with the antibiotic therapy cure rate of 66%. Treatment failures were not associated with resistance to or noncompliance with the antibiotic regimens.

9. Lymph node biopsy specimens and diagnosis of cat-scratch disease (Emerg. Infect. Dis. 2006;12:1338–44). A diagnosis of cat scratch disease does not rule out a diagnosis of mycobacteriosis or neoplasm, according to this report. Dr. Jean-Marc Rolain, professor at the Unité des Rickettsies in Marseille, France, and associates performed microbiologic assessment of lymph node biopsies from 786 patients with suspected cat-scratch disease. The most common infectious agent was Bartonella henselae, found in 245 patients (31%). Mycobacteriosis was diagnosed in 54 patients (7%) by culture, and neoplasm was detected in 181 (26%) specimens suitable for histologic analysis from 47 patients. Of note, 13 patients with confirmed B. henselae infections had concurrent mycobacteriosis (10 cases) or neoplasm (3 cases). This suggests routine histologic testing of lymph node biopsy specimens is indicated because some patients might have a concurrent malignant disease or mycobacteriosis, the authors wrote.

10. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group (Circulation 2007;116:1736–54). This is an update to American Heart Association recommendations for prevention of infectious endocarditis, last released in 1997. The recommendations are based on literature reports of procedure-related bacteremia and infective endocarditis, in vitro susceptibility data for infective endocarditis microorganisms, prophylaxis findings from animal studies, and retrospective and prospective studies of prevention in humans.

Only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures, even if such prophylactic therapy were 100% effective, the writing committee found. In addition, prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. The recommendations also state that administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure.

These 10 articles have the potential to alter infectious disease practice, Dr. Steele said. “This article on endocarditis is the most dramatic example. We are using a lot less prophylaxis before dental procedures now.”

FORT LAUDERDALE, FLA. — Although adenotonsillectomy remains the first-line treatment for children with obstructive sleep apnea syndrome, only about 25%–30% will experience complete resolution of symptoms, according to a prospective study.

Another 25% or so of children will still have apnea severe enough to warrant continuous positive airway pressure (CPAP) therapy. Management of the rest, who end up better but not cured after tonsillectomy and adenoidectomy (T&A), remains unclear. About 45% of children won't be cured, but won't be worse “somewhere in the middle,” said Dr. David Gozal, director of the division of pediatric sleep medicine, Kosair Children's Hospital Research Institute, University of Louisville (Ky.).

That figure comes from a prospective study of 110 consecutive children with obstructive sleep apnea assessed with poly- somnography before and after T&A (J. Pediatr. 2006;149:803–8). Mean age was almost 7 years; 62% of patients were boys. A total of 37% was obese, mean body mass index was 24 kg/m

Outcome was measured as change in the obstructive apnea/hypopnea index (OAHI), defined as the number of instances of apnea and hypopnea per hour of total sleep time.

The overall OAHI before T&A was 24, and at a second polysomnography, it was 5.3. Although that was a statistically significant improvement, “it was not normal at all—don't expect it to normalize,” Dr. Gozal said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians.

“It is very difficult to predict results in individual patients, but, globally, the percentage who had a normal respiratory pattern after T&A was less than 30%. That is a jolt [and] not the 80%–85% success rate from ENTs that we quote for parents,” he said.

In the study, 28% of children scored an OAHI of 1 or less after surgery. Another 27% scored a postoperative OAHI of 5 or greater and were recommended for CPAP.

Because treatment options for the group with residual, mild sleep-disordered breathing after T&A are unclear, Dr. Gozal and colleagues launched another investigation (Pediatrics 2006;117:e61–6). They identified 22 children who had incomplete resolution of sleep apnea postoperatively on polysomnography at 10–14 weeks (an OAHI greater than 1 and less than 5) and treated them for 12 weeks with anti-inflammatory combination therapy. An additional 14 children not treated served as controls.

Patients received oral montelukast, because leukotriene modifiers have been demonstrated as effective for mild sleep-disordered breathing (Am. J. Respir. Crit. Care Med. 2005;172:364–70). They also received intranasal budesonide. Upper airway collapsibility and presence of mild sleep-disordered breathing after T&A might indicate residual upper airway inflammation that could respond to anti-inflammatory treatment, Dr. Gozal said.

Parameters measured during the polysomnography prior to anti-inflammatory therapy were not statistically different between treated and control children. The mean OAHI was 3.9 per hour of total sleep time (TST) in the treatment group and 3.6 per hour of TST in control patients. Researchers also noted similar nadir arterial oxygen saturations (87.3%) and respiratory arousal index findings (4.6 per hour of TST) for both groups. “Sleep fragmentation seems common in these children,” Dr. Gozal said.

The posttreatment polysomnography, however, indicated some significant improvements in the treated group, compared with controls. In fact, 21 out of the 24 patients in the treated group normalized their sleep apnea, Dr. Gozal said. The treatment group showed significant improvements in OAHI (0.3 per hour of TST), in nadir arterial oxygen saturation (92.5%), and in respiratory arousal index (0.8 per hour of TST), whereas no significant changes were seen over time in the control group children.

“Although randomized, double-blind, placebo-controlled trials are needed to confirm the current findings, the present study clearly establishes the beneficial role of anti-inflammatory approaches for asymptomatic children with mild sleep-disordered breathing after T&A,” said Dr. Gozal, who disclosed he is on the national speakers bureau for Merck & Co.

FORT LAUDERDALE, FLA. — Although adenotonsillectomy remains the first-line treatment for children with obstructive sleep apnea syndrome, only about 25%–30% will experience complete resolution of symptoms, according to a prospective study.

Another 25% or so of children will still have apnea severe enough to warrant continuous positive airway pressure (CPAP) therapy. Management of the rest, who end up better but not cured after tonsillectomy and adenoidectomy (T&A), remains unclear. About 45% of children won't be cured, but won't be worse “somewhere in the middle,” said Dr. David Gozal, director of the division of pediatric sleep medicine, Kosair Children's Hospital Research Institute, University of Louisville (Ky.).

That figure comes from a prospective study of 110 consecutive children with obstructive sleep apnea assessed with poly- somnography before and after T&A (J. Pediatr. 2006;149:803–8). Mean age was almost 7 years; 62% of patients were boys. A total of 37% was obese, mean body mass index was 24 kg/m

Outcome was measured as change in the obstructive apnea/hypopnea index (OAHI), defined as the number of instances of apnea and hypopnea per hour of total sleep time.

The overall OAHI before T&A was 24, and at a second polysomnography, it was 5.3. Although that was a statistically significant improvement, “it was not normal at all—don't expect it to normalize,” Dr. Gozal said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians.

“It is very difficult to predict results in individual patients, but, globally, the percentage who had a normal respiratory pattern after T&A was less than 30%. That is a jolt [and] not the 80%–85% success rate from ENTs that we quote for parents,” he said.

In the study, 28% of children scored an OAHI of 1 or less after surgery. Another 27% scored a postoperative OAHI of 5 or greater and were recommended for CPAP.

Because treatment options for the group with residual, mild sleep-disordered breathing after T&A are unclear, Dr. Gozal and colleagues launched another investigation (Pediatrics 2006;117:e61–6). They identified 22 children who had incomplete resolution of sleep apnea postoperatively on polysomnography at 10–14 weeks (an OAHI greater than 1 and less than 5) and treated them for 12 weeks with anti-inflammatory combination therapy. An additional 14 children not treated served as controls.

Patients received oral montelukast, because leukotriene modifiers have been demonstrated as effective for mild sleep-disordered breathing (Am. J. Respir. Crit. Care Med. 2005;172:364–70). They also received intranasal budesonide. Upper airway collapsibility and presence of mild sleep-disordered breathing after T&A might indicate residual upper airway inflammation that could respond to anti-inflammatory treatment, Dr. Gozal said.

Parameters measured during the polysomnography prior to anti-inflammatory therapy were not statistically different between treated and control children. The mean OAHI was 3.9 per hour of total sleep time (TST) in the treatment group and 3.6 per hour of TST in control patients. Researchers also noted similar nadir arterial oxygen saturations (87.3%) and respiratory arousal index findings (4.6 per hour of TST) for both groups. “Sleep fragmentation seems common in these children,” Dr. Gozal said.

The posttreatment polysomnography, however, indicated some significant improvements in the treated group, compared with controls. In fact, 21 out of the 24 patients in the treated group normalized their sleep apnea, Dr. Gozal said. The treatment group showed significant improvements in OAHI (0.3 per hour of TST), in nadir arterial oxygen saturation (92.5%), and in respiratory arousal index (0.8 per hour of TST), whereas no significant changes were seen over time in the control group children.

“Although randomized, double-blind, placebo-controlled trials are needed to confirm the current findings, the present study clearly establishes the beneficial role of anti-inflammatory approaches for asymptomatic children with mild sleep-disordered breathing after T&A,” said Dr. Gozal, who disclosed he is on the national speakers bureau for Merck & Co.

FORT LAUDERDALE, FLA. — Although adenotonsillectomy remains the first-line treatment for children with obstructive sleep apnea syndrome, only about 25%–30% will experience complete resolution of symptoms, according to a prospective study.

Another 25% or so of children will still have apnea severe enough to warrant continuous positive airway pressure (CPAP) therapy. Management of the rest, who end up better but not cured after tonsillectomy and adenoidectomy (T&A), remains unclear. About 45% of children won't be cured, but won't be worse “somewhere in the middle,” said Dr. David Gozal, director of the division of pediatric sleep medicine, Kosair Children's Hospital Research Institute, University of Louisville (Ky.).

That figure comes from a prospective study of 110 consecutive children with obstructive sleep apnea assessed with poly- somnography before and after T&A (J. Pediatr. 2006;149:803–8). Mean age was almost 7 years; 62% of patients were boys. A total of 37% was obese, mean body mass index was 24 kg/m

Outcome was measured as change in the obstructive apnea/hypopnea index (OAHI), defined as the number of instances of apnea and hypopnea per hour of total sleep time.

The overall OAHI before T&A was 24, and at a second polysomnography, it was 5.3. Although that was a statistically significant improvement, “it was not normal at all—don't expect it to normalize,” Dr. Gozal said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians.

“It is very difficult to predict results in individual patients, but, globally, the percentage who had a normal respiratory pattern after T&A was less than 30%. That is a jolt [and] not the 80%–85% success rate from ENTs that we quote for parents,” he said.

In the study, 28% of children scored an OAHI of 1 or less after surgery. Another 27% scored a postoperative OAHI of 5 or greater and were recommended for CPAP.

Because treatment options for the group with residual, mild sleep-disordered breathing after T&A are unclear, Dr. Gozal and colleagues launched another investigation (Pediatrics 2006;117:e61–6). They identified 22 children who had incomplete resolution of sleep apnea postoperatively on polysomnography at 10–14 weeks (an OAHI greater than 1 and less than 5) and treated them for 12 weeks with anti-inflammatory combination therapy. An additional 14 children not treated served as controls.

Patients received oral montelukast, because leukotriene modifiers have been demonstrated as effective for mild sleep-disordered breathing (Am. J. Respir. Crit. Care Med. 2005;172:364–70). They also received intranasal budesonide. Upper airway collapsibility and presence of mild sleep-disordered breathing after T&A might indicate residual upper airway inflammation that could respond to anti-inflammatory treatment, Dr. Gozal said.

Parameters measured during the polysomnography prior to anti-inflammatory therapy were not statistically different between treated and control children. The mean OAHI was 3.9 per hour of total sleep time (TST) in the treatment group and 3.6 per hour of TST in control patients. Researchers also noted similar nadir arterial oxygen saturations (87.3%) and respiratory arousal index findings (4.6 per hour of TST) for both groups. “Sleep fragmentation seems common in these children,” Dr. Gozal said.

The posttreatment polysomnography, however, indicated some significant improvements in the treated group, compared with controls. In fact, 21 out of the 24 patients in the treated group normalized their sleep apnea, Dr. Gozal said. The treatment group showed significant improvements in OAHI (0.3 per hour of TST), in nadir arterial oxygen saturation (92.5%), and in respiratory arousal index (0.8 per hour of TST), whereas no significant changes were seen over time in the control group children.

“Although randomized, double-blind, placebo-controlled trials are needed to confirm the current findings, the present study clearly establishes the beneficial role of anti-inflammatory approaches for asymptomatic children with mild sleep-disordered breathing after T&A,” said Dr. Gozal, who disclosed he is on the national speakers bureau for Merck & Co.

MIAMI — Ataxia, peripheral neuropathy, and epilepsy are among the extraintestinal manifestations of celiac disease when it presents in a child over age 15 months. The bowel symptoms of diarrhea, nausea, and abdominal pain are more common in younger children.

Other extraintestinal or atypical symptoms include dermatitis herpetiformis and other skin disorders, osteopenia and osteoporosis, iron-deficient anemia resistant to oral iron treatment, liver and biliary tract disease, and delayed puberty. Also, short stature can be a presenting sign. “In fact, 10% of children who walk into endocrinologist's office for short stature have celiac disease,” Dr. Stefano Guandalini said during a pediatric update sponsored by Miami Children's Hospital.

A meeting attendee asked Dr. Guandalini if celiac serology should be routine in the work-up of patients with failure to thrive. “Yes, that is a big presentation for celiac disease, as long as the child has gluten in their diet,” he said. “Residents sometimes will suggest this in a 3-month-old who has never had solid food.”

There is even growing recognition that dental enamel defects in permanent teeth are a sign of the condition, Dr. Guandalini said.

“All the specialties are touched by this condition, even general pediatrics,” said Dr. Guandalini, pediatric gastroenterologist and professor of pediatrics at the University of Chicago.

Celiac disease also can present with other autoimmune conditions, Dr. Guandalini said. For example, an estimated 4%–10% of patients with type 1 diabetes mellitus also have celiac disease, as do 4%–8% of those with thyroiditis, and 2%–8% of those with arthritis.

“We tested one individual who had type 1 diabetes and found six relatives in the extended family with celiac disease,” Dr. Guandalini said. “Celiac disease is much more prevalent if you are related to a celiac disease patient.”

A child will, on average, visit eight pediatricians before being diagnosed, according to the Celiac Disease Center at the University of Chicago Web site, www.celiacdisease.net

A meeting attendee asked if screening asymptomatic relatives of people with celiac disease is worthwhile. “Yes,” Dr. Guandalini said. “The prevalence in first-degree relatives is between 10% and 25%. [These are] very high numbers.”

A negative genetic test rules out celiac disease for life because it features a 100% negative predictive value. However, the test only has a 5% positive predictive value, so “a positive test means nothing,” Dr. Guandalini said.

This “fascinating autoimmune disease” is triggered in genetically susceptible individuals by ingestion of gluten, the protein in wheat, rye, and barley. “We think that many, if not all celiac disease individuals, might have a problem with how they regulate their intestinal permeability,” Dr. Guandalini said. Increased intestinal permeability allows more gluten to enter, attach to receptors, and present as antigens (non-self) to the immune system. This process can lead to damage of intestines, primarily the small intestines, including duodenal mucosa. Multiple childhood infections also are implicated in the possible etiology, he added.

In the early 1980s, diagnosis primarily was based on GI symptoms such as diarrhea, vomiting, and weight loss, but currently, only about 8% of patients are diagnosed with these symptoms alone, Dr. Guandalini said. Diagnosis has changed over time toward more asymptomatic adults being detected through screening (Am. J. Med. 2006;119:e9–14).

“Every time you screen for celiac disease, test for [tissue transglutaminase] antibodies and total serum IgA, and confirm with a biopsy,” Dr. Guandalini said. Some suggest that direct visualization of intestinal damage, including villous atrophy or blunting, is diagnostic. However, he said, “You cannot distinguish by visual findings if someone has celiac disease or not. You need to take a biopsy to an experienced pathologist—changes can be subtle.” Dr. Guandalini had no relevant disclosures.

Early introduction of gluten into the diet of children at risk might be protective. For example, the timing of gluten introduction made a difference in a prospective study of 1,560 children at risk (JAMA 2005;293:2410–2). Specifically, the researchers found a protective window between 4 and 6 months of age.

Another study demonstrated that breast-feeding is beneficial to prevent or delay celiac disease (Arch. Dis. Child. 2006;91:39–43). Only one study included in this meta-analysis report showed no protective effect, Dr. Guandalini said.

“So you can recommend breast-feeding, and introduce gluten at 4–6 months along with breast-feeding in children at risk to minimize risk of celiac disease,” he commented.

The only treatment for celiac disease is a diet free of gluten. However, “research is ongoing to find ways to remove gluten from wheat, degrade the enzyme, or to keep the gates tight,” Dr. Guandalini said. “So there is hope that someday they will be able to eat at least some gluten.”

'You cannot distinguish [celiac disease] by visual findings … takea biopsy to an experienced pathologist.' DR. GUANDALINI

MIAMI — Ataxia, peripheral neuropathy, and epilepsy are among the extraintestinal manifestations of celiac disease when it presents in a child over age 15 months. The bowel symptoms of diarrhea, nausea, and abdominal pain are more common in younger children.

Other extraintestinal or atypical symptoms include dermatitis herpetiformis and other skin disorders, osteopenia and osteoporosis, iron-deficient anemia resistant to oral iron treatment, liver and biliary tract disease, and delayed puberty. Also, short stature can be a presenting sign. “In fact, 10% of children who walk into endocrinologist's office for short stature have celiac disease,” Dr. Stefano Guandalini said during a pediatric update sponsored by Miami Children's Hospital.

A meeting attendee asked Dr. Guandalini if celiac serology should be routine in the work-up of patients with failure to thrive. “Yes, that is a big presentation for celiac disease, as long as the child has gluten in their diet,” he said. “Residents sometimes will suggest this in a 3-month-old who has never had solid food.”

There is even growing recognition that dental enamel defects in permanent teeth are a sign of the condition, Dr. Guandalini said.

“All the specialties are touched by this condition, even general pediatrics,” said Dr. Guandalini, pediatric gastroenterologist and professor of pediatrics at the University of Chicago.

Celiac disease also can present with other autoimmune conditions, Dr. Guandalini said. For example, an estimated 4%–10% of patients with type 1 diabetes mellitus also have celiac disease, as do 4%–8% of those with thyroiditis, and 2%–8% of those with arthritis.

“We tested one individual who had type 1 diabetes and found six relatives in the extended family with celiac disease,” Dr. Guandalini said. “Celiac disease is much more prevalent if you are related to a celiac disease patient.”

A child will, on average, visit eight pediatricians before being diagnosed, according to the Celiac Disease Center at the University of Chicago Web site, www.celiacdisease.net

A meeting attendee asked if screening asymptomatic relatives of people with celiac disease is worthwhile. “Yes,” Dr. Guandalini said. “The prevalence in first-degree relatives is between 10% and 25%. [These are] very high numbers.”

A negative genetic test rules out celiac disease for life because it features a 100% negative predictive value. However, the test only has a 5% positive predictive value, so “a positive test means nothing,” Dr. Guandalini said.

This “fascinating autoimmune disease” is triggered in genetically susceptible individuals by ingestion of gluten, the protein in wheat, rye, and barley. “We think that many, if not all celiac disease individuals, might have a problem with how they regulate their intestinal permeability,” Dr. Guandalini said. Increased intestinal permeability allows more gluten to enter, attach to receptors, and present as antigens (non-self) to the immune system. This process can lead to damage of intestines, primarily the small intestines, including duodenal mucosa. Multiple childhood infections also are implicated in the possible etiology, he added.

In the early 1980s, diagnosis primarily was based on GI symptoms such as diarrhea, vomiting, and weight loss, but currently, only about 8% of patients are diagnosed with these symptoms alone, Dr. Guandalini said. Diagnosis has changed over time toward more asymptomatic adults being detected through screening (Am. J. Med. 2006;119:e9–14).

“Every time you screen for celiac disease, test for [tissue transglutaminase] antibodies and total serum IgA, and confirm with a biopsy,” Dr. Guandalini said. Some suggest that direct visualization of intestinal damage, including villous atrophy or blunting, is diagnostic. However, he said, “You cannot distinguish by visual findings if someone has celiac disease or not. You need to take a biopsy to an experienced pathologist—changes can be subtle.” Dr. Guandalini had no relevant disclosures.

Early introduction of gluten into the diet of children at risk might be protective. For example, the timing of gluten introduction made a difference in a prospective study of 1,560 children at risk (JAMA 2005;293:2410–2). Specifically, the researchers found a protective window between 4 and 6 months of age.

Another study demonstrated that breast-feeding is beneficial to prevent or delay celiac disease (Arch. Dis. Child. 2006;91:39–43). Only one study included in this meta-analysis report showed no protective effect, Dr. Guandalini said.

“So you can recommend breast-feeding, and introduce gluten at 4–6 months along with breast-feeding in children at risk to minimize risk of celiac disease,” he commented.

The only treatment for celiac disease is a diet free of gluten. However, “research is ongoing to find ways to remove gluten from wheat, degrade the enzyme, or to keep the gates tight,” Dr. Guandalini said. “So there is hope that someday they will be able to eat at least some gluten.”

'You cannot distinguish [celiac disease] by visual findings … takea biopsy to an experienced pathologist.' DR. GUANDALINI

MIAMI — Ataxia, peripheral neuropathy, and epilepsy are among the extraintestinal manifestations of celiac disease when it presents in a child over age 15 months. The bowel symptoms of diarrhea, nausea, and abdominal pain are more common in younger children.

Other extraintestinal or atypical symptoms include dermatitis herpetiformis and other skin disorders, osteopenia and osteoporosis, iron-deficient anemia resistant to oral iron treatment, liver and biliary tract disease, and delayed puberty. Also, short stature can be a presenting sign. “In fact, 10% of children who walk into endocrinologist's office for short stature have celiac disease,” Dr. Stefano Guandalini said during a pediatric update sponsored by Miami Children's Hospital.

A meeting attendee asked Dr. Guandalini if celiac serology should be routine in the work-up of patients with failure to thrive. “Yes, that is a big presentation for celiac disease, as long as the child has gluten in their diet,” he said. “Residents sometimes will suggest this in a 3-month-old who has never had solid food.”

There is even growing recognition that dental enamel defects in permanent teeth are a sign of the condition, Dr. Guandalini said.

“All the specialties are touched by this condition, even general pediatrics,” said Dr. Guandalini, pediatric gastroenterologist and professor of pediatrics at the University of Chicago.

Celiac disease also can present with other autoimmune conditions, Dr. Guandalini said. For example, an estimated 4%–10% of patients with type 1 diabetes mellitus also have celiac disease, as do 4%–8% of those with thyroiditis, and 2%–8% of those with arthritis.

“We tested one individual who had type 1 diabetes and found six relatives in the extended family with celiac disease,” Dr. Guandalini said. “Celiac disease is much more prevalent if you are related to a celiac disease patient.”

A child will, on average, visit eight pediatricians before being diagnosed, according to the Celiac Disease Center at the University of Chicago Web site, www.celiacdisease.net

A meeting attendee asked if screening asymptomatic relatives of people with celiac disease is worthwhile. “Yes,” Dr. Guandalini said. “The prevalence in first-degree relatives is between 10% and 25%. [These are] very high numbers.”

A negative genetic test rules out celiac disease for life because it features a 100% negative predictive value. However, the test only has a 5% positive predictive value, so “a positive test means nothing,” Dr. Guandalini said.

This “fascinating autoimmune disease” is triggered in genetically susceptible individuals by ingestion of gluten, the protein in wheat, rye, and barley. “We think that many, if not all celiac disease individuals, might have a problem with how they regulate their intestinal permeability,” Dr. Guandalini said. Increased intestinal permeability allows more gluten to enter, attach to receptors, and present as antigens (non-self) to the immune system. This process can lead to damage of intestines, primarily the small intestines, including duodenal mucosa. Multiple childhood infections also are implicated in the possible etiology, he added.

In the early 1980s, diagnosis primarily was based on GI symptoms such as diarrhea, vomiting, and weight loss, but currently, only about 8% of patients are diagnosed with these symptoms alone, Dr. Guandalini said. Diagnosis has changed over time toward more asymptomatic adults being detected through screening (Am. J. Med. 2006;119:e9–14).

“Every time you screen for celiac disease, test for [tissue transglutaminase] antibodies and total serum IgA, and confirm with a biopsy,” Dr. Guandalini said. Some suggest that direct visualization of intestinal damage, including villous atrophy or blunting, is diagnostic. However, he said, “You cannot distinguish by visual findings if someone has celiac disease or not. You need to take a biopsy to an experienced pathologist—changes can be subtle.” Dr. Guandalini had no relevant disclosures.

Early introduction of gluten into the diet of children at risk might be protective. For example, the timing of gluten introduction made a difference in a prospective study of 1,560 children at risk (JAMA 2005;293:2410–2). Specifically, the researchers found a protective window between 4 and 6 months of age.

Another study demonstrated that breast-feeding is beneficial to prevent or delay celiac disease (Arch. Dis. Child. 2006;91:39–43). Only one study included in this meta-analysis report showed no protective effect, Dr. Guandalini said.

“So you can recommend breast-feeding, and introduce gluten at 4–6 months along with breast-feeding in children at risk to minimize risk of celiac disease,” he commented.

The only treatment for celiac disease is a diet free of gluten. However, “research is ongoing to find ways to remove gluten from wheat, degrade the enzyme, or to keep the gates tight,” Dr. Guandalini said. “So there is hope that someday they will be able to eat at least some gluten.”

'You cannot distinguish [celiac disease] by visual findings … takea biopsy to an experienced pathologist.' DR. GUANDALINI

MIAMI BEACH — To avoid mistakes in the management of a child with attention-deficit/hyperactivity disorder, consider the patient's receptive language age, comorbidities such as depression, and medication to protect a young child when a parent is very intolerant of their behavior, Dr. David O. Childers recommended at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Attention-deficit/hyperactivity disorder (ADHD) is complex and not a stand-alone diagnosis, said Dr. Childers, a neurodevelopmental pediatrician. Look for a grouping of social, behavioral, and attention issues, as well as immaturity of fine and gross motor skills, judgment, and/or learning.

Begin with assessment of receptive language age. “Receptive language is critical to just about everything we do in developmental pediatrics. Our receptive language defines our behavior,” he said. “We all have conversations in our heads. If the conversation in your head is at the 3-year-old level, your behavior will be like a 3-year-old,” said Dr. Childers, chief of the section of developmental pediatrics, University of Florida College of Medicine in Jacksonville.

Medications make a difference, he said, “But they are a Band-Aid approach—they do not make the problem go away.” Dr. Childers outlined the following possible mistakes in management of ADHD:

▸ Mistake 1: Automatic prescription of stimulants for a hyperactive 3-year-old. A physician might want to dose “the hyperactive child who is jumping off the chair and up on the exam table … but is it the right thing to do?” Dr. Childers asked. The medication will allow the young child to focus their attention where they want to, and “a 3-year-old is nothing but a walking 'id.' They want it, they want it, they want it now,” he said, whether it's a toy or their own personal needs met.

▸ Mistake 2: Not dosing a young child for protection. A possible exception to the first mistake is the scenario of a “really, really hyperactive 3-year-old with a really intolerant parent. There is a subset of children who have a desperate need for protection,” he said. “Sometimes the stimulant is important at this age” in such cases.

▸ Mistake 3: Inappropriate initial dosing. There can be, for example, a 5-year-old who is extremely emotional, a zombie, or absolutely intolerable after starting a particular medication. A prescription of 5 mg of methylphenidate is 2.5 mg of the L isomer and 2.5 mg D isomer, or 2.5 mg total of active isomer.

“Part of the problem is we start frequently with the mixed amphetamine salts 5 mg,” he said. This is 5 mg of active isomer. “So starting them on mixed salts is double the dose [we give with methylphenidate]. This is not the ideal [starting] dose for the average 4- to 6-year-old. I'm not saying you're not going to get there anyway, but do you want to start there?”

▸ Mistake 4: Confusing the first effective dose with an ideal dose. “We find a dose that is effective, and we leave it there. We make the mistake of settling for lowest effective dose, not the best dose,” Dr. Childers said. Parents in this situation might say, “He tried the medicine—it didn't work” or “The medicine worked for a little while, but then his body got used to it.”

▸ Mistake 5: Neglecting comorbidities. “This is where some people start to make mistakes,” he noted. ADHD might be primary, or it might be secondary. Learning disabilities, oppositional defiant disorder, conduct disorder, anxiety, depression, encopresis/enuresis, and poor self-esteem are among possible comorbidities.

“Childhood depression can look like ADHD in many cases.” ADHD incidence is 6%–10%, childhood depression incidence is 10%, and they can be comorbid. “You think it's hard to talk to a parent about putting a child on a stimulant, try to talk to them about putting a child on Prozac.”

▸ Mistake 6: Not detecting drug diversion. “ADHD is inherited. It is one of the most heritable conditions we know of,” Dr. Childers said. “You find a child with ADHD, the likelihood you'll find a parent with ADHD is 0.8.” He added that there are exceptions, but sometimes “my goal is to see how fast I can make the diagnosis in the parent.”

Keep in mind that maybe the child is not the only one who sees the value of the medication. “Parents can divert.” A drug-seeking parent might say, “I need to change my child from the long-acting to the short-acting.” Long-acting agents, in general, have much less abuse potential. In contrast, short-acting stimulants can be divided, and there can be enough to get a child through school and a parent through work.

▸ Mistake 7: Confusing ADHD with an undiagnosed learning disability. Learning disabilities are more common, with an incidence of 15%–20%, compared with 6%–10% for ADHD, he said.

The physician might, for example, see a young boy who got all As and Bs in school, and, then all of sudden, starts getting Ds in third grade. It could be a learning disability arising at a time when children have to read to learn. Or it could manifest later, such as an inattentive 13- or 14-year-old girl who sits quietly in the back of class and just makes passing grades.

“Be careful of what you call it before you diagnose it,” Dr. Childers said. “Once you label the kid as 'ADHD,' the school will not be looking for anything else.”

The Federal Individuals with Disability Education Act (IDEA) requires schools to test for a learning disability at the parent's request, he added.

▸ Mistake 8: Undiagnosed ADHD in an adolescent. Sometimes it is easy to miss the adolescent with ADHD, inattentive subtype, Dr. Childers said. “We get so programmatic in our approach that the differential list of problems in adolescence doesn't place ADHD high on the index of suspicion.” He added, “Just because ADHD was not diagnosed in childhood doesn't mean it is not there.”

▸ Mistake 9: Insufficient dosing. Rebound and insomnia are not subtle. “The problem isn't the medicine, the problem is the medicine wearing off.” If a stimulant wears off at 4 p.m. and bedtime is at 8 p.m., a small dose in the evening “can make a huge difference. Kids will be more stable and be able to fall asleep.”

It is important to note if the insomnia predated the stimulant use. Get a basal sleep history, Dr. Childers advised. Also recommend proper sleep hygiene. “My first question is: Is there a TV in the bedroom? The answer is always yes, and I ask them “Why?” They can't answer it.” Remove the television forever, and give the child a bath and warm milk before bedtime, he said. “That is enough for most kids.”

▸ Mistake 10: Overdiagnosis of bipolar disorder. More and more parents are coming in and saying, “My teacher, aunt, therapist, neighbor, etc. said my child has 'bipolar disorder,'” Dr. Childers remarked.

The adult prevalence of bipolar disorder is 1%–1.6%, according to a National Alliance of Mental Illness Fact Sheet, January 2004. “It's not a curable illness. Bipolar is a lifelong diagnosis. So how can 7% of children have bipolar disorder?” A much more common diagnosis is a combination of ADHD and oppositional defiant disorder (ODD). “The one big difference I always look for is a trigger to the behavior. If a parent says, 'Every time I tell him 'no,' he has a tantrum, it is unlikely it's bipolar disorder, and more often it's ODD.”

Dr. Childers tells parents they should have three goals for their child that appropriate management of ADHD can help to achieve: a happy childhood, a successful academic experience, and out the door and independent by age 18.

Dr. Childers had no relevant financial disclosures.

MIAMI BEACH — To avoid mistakes in the management of a child with attention-deficit/hyperactivity disorder, consider the patient's receptive language age, comorbidities such as depression, and medication to protect a young child when a parent is very intolerant of their behavior, Dr. David O. Childers recommended at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Attention-deficit/hyperactivity disorder (ADHD) is complex and not a stand-alone diagnosis, said Dr. Childers, a neurodevelopmental pediatrician. Look for a grouping of social, behavioral, and attention issues, as well as immaturity of fine and gross motor skills, judgment, and/or learning.

Begin with assessment of receptive language age. “Receptive language is critical to just about everything we do in developmental pediatrics. Our receptive language defines our behavior,” he said. “We all have conversations in our heads. If the conversation in your head is at the 3-year-old level, your behavior will be like a 3-year-old,” said Dr. Childers, chief of the section of developmental pediatrics, University of Florida College of Medicine in Jacksonville.

Medications make a difference, he said, “But they are a Band-Aid approach—they do not make the problem go away.” Dr. Childers outlined the following possible mistakes in management of ADHD:

▸ Mistake 1: Automatic prescription of stimulants for a hyperactive 3-year-old. A physician might want to dose “the hyperactive child who is jumping off the chair and up on the exam table … but is it the right thing to do?” Dr. Childers asked. The medication will allow the young child to focus their attention where they want to, and “a 3-year-old is nothing but a walking 'id.' They want it, they want it, they want it now,” he said, whether it's a toy or their own personal needs met.

▸ Mistake 2: Not dosing a young child for protection. A possible exception to the first mistake is the scenario of a “really, really hyperactive 3-year-old with a really intolerant parent. There is a subset of children who have a desperate need for protection,” he said. “Sometimes the stimulant is important at this age” in such cases.

▸ Mistake 3: Inappropriate initial dosing. There can be, for example, a 5-year-old who is extremely emotional, a zombie, or absolutely intolerable after starting a particular medication. A prescription of 5 mg of methylphenidate is 2.5 mg of the L isomer and 2.5 mg D isomer, or 2.5 mg total of active isomer.

“Part of the problem is we start frequently with the mixed amphetamine salts 5 mg,” he said. This is 5 mg of active isomer. “So starting them on mixed salts is double the dose [we give with methylphenidate]. This is not the ideal [starting] dose for the average 4- to 6-year-old. I'm not saying you're not going to get there anyway, but do you want to start there?”

▸ Mistake 4: Confusing the first effective dose with an ideal dose. “We find a dose that is effective, and we leave it there. We make the mistake of settling for lowest effective dose, not the best dose,” Dr. Childers said. Parents in this situation might say, “He tried the medicine—it didn't work” or “The medicine worked for a little while, but then his body got used to it.”

▸ Mistake 5: Neglecting comorbidities. “This is where some people start to make mistakes,” he noted. ADHD might be primary, or it might be secondary. Learning disabilities, oppositional defiant disorder, conduct disorder, anxiety, depression, encopresis/enuresis, and poor self-esteem are among possible comorbidities.

“Childhood depression can look like ADHD in many cases.” ADHD incidence is 6%–10%, childhood depression incidence is 10%, and they can be comorbid. “You think it's hard to talk to a parent about putting a child on a stimulant, try to talk to them about putting a child on Prozac.”

▸ Mistake 6: Not detecting drug diversion. “ADHD is inherited. It is one of the most heritable conditions we know of,” Dr. Childers said. “You find a child with ADHD, the likelihood you'll find a parent with ADHD is 0.8.” He added that there are exceptions, but sometimes “my goal is to see how fast I can make the diagnosis in the parent.”

Keep in mind that maybe the child is not the only one who sees the value of the medication. “Parents can divert.” A drug-seeking parent might say, “I need to change my child from the long-acting to the short-acting.” Long-acting agents, in general, have much less abuse potential. In contrast, short-acting stimulants can be divided, and there can be enough to get a child through school and a parent through work.

▸ Mistake 7: Confusing ADHD with an undiagnosed learning disability. Learning disabilities are more common, with an incidence of 15%–20%, compared with 6%–10% for ADHD, he said.

The physician might, for example, see a young boy who got all As and Bs in school, and, then all of sudden, starts getting Ds in third grade. It could be a learning disability arising at a time when children have to read to learn. Or it could manifest later, such as an inattentive 13- or 14-year-old girl who sits quietly in the back of class and just makes passing grades.

“Be careful of what you call it before you diagnose it,” Dr. Childers said. “Once you label the kid as 'ADHD,' the school will not be looking for anything else.”

The Federal Individuals with Disability Education Act (IDEA) requires schools to test for a learning disability at the parent's request, he added.

▸ Mistake 8: Undiagnosed ADHD in an adolescent. Sometimes it is easy to miss the adolescent with ADHD, inattentive subtype, Dr. Childers said. “We get so programmatic in our approach that the differential list of problems in adolescence doesn't place ADHD high on the index of suspicion.” He added, “Just because ADHD was not diagnosed in childhood doesn't mean it is not there.”

▸ Mistake 9: Insufficient dosing. Rebound and insomnia are not subtle. “The problem isn't the medicine, the problem is the medicine wearing off.” If a stimulant wears off at 4 p.m. and bedtime is at 8 p.m., a small dose in the evening “can make a huge difference. Kids will be more stable and be able to fall asleep.”

It is important to note if the insomnia predated the stimulant use. Get a basal sleep history, Dr. Childers advised. Also recommend proper sleep hygiene. “My first question is: Is there a TV in the bedroom? The answer is always yes, and I ask them “Why?” They can't answer it.” Remove the television forever, and give the child a bath and warm milk before bedtime, he said. “That is enough for most kids.”

▸ Mistake 10: Overdiagnosis of bipolar disorder. More and more parents are coming in and saying, “My teacher, aunt, therapist, neighbor, etc. said my child has 'bipolar disorder,'” Dr. Childers remarked.

The adult prevalence of bipolar disorder is 1%–1.6%, according to a National Alliance of Mental Illness Fact Sheet, January 2004. “It's not a curable illness. Bipolar is a lifelong diagnosis. So how can 7% of children have bipolar disorder?” A much more common diagnosis is a combination of ADHD and oppositional defiant disorder (ODD). “The one big difference I always look for is a trigger to the behavior. If a parent says, 'Every time I tell him 'no,' he has a tantrum, it is unlikely it's bipolar disorder, and more often it's ODD.”

Dr. Childers tells parents they should have three goals for their child that appropriate management of ADHD can help to achieve: a happy childhood, a successful academic experience, and out the door and independent by age 18.

Dr. Childers had no relevant financial disclosures.

MIAMI BEACH — To avoid mistakes in the management of a child with attention-deficit/hyperactivity disorder, consider the patient's receptive language age, comorbidities such as depression, and medication to protect a young child when a parent is very intolerant of their behavior, Dr. David O. Childers recommended at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Attention-deficit/hyperactivity disorder (ADHD) is complex and not a stand-alone diagnosis, said Dr. Childers, a neurodevelopmental pediatrician. Look for a grouping of social, behavioral, and attention issues, as well as immaturity of fine and gross motor skills, judgment, and/or learning.

Begin with assessment of receptive language age. “Receptive language is critical to just about everything we do in developmental pediatrics. Our receptive language defines our behavior,” he said. “We all have conversations in our heads. If the conversation in your head is at the 3-year-old level, your behavior will be like a 3-year-old,” said Dr. Childers, chief of the section of developmental pediatrics, University of Florida College of Medicine in Jacksonville.

Medications make a difference, he said, “But they are a Band-Aid approach—they do not make the problem go away.” Dr. Childers outlined the following possible mistakes in management of ADHD:

▸ Mistake 1: Automatic prescription of stimulants for a hyperactive 3-year-old. A physician might want to dose “the hyperactive child who is jumping off the chair and up on the exam table … but is it the right thing to do?” Dr. Childers asked. The medication will allow the young child to focus their attention where they want to, and “a 3-year-old is nothing but a walking 'id.' They want it, they want it, they want it now,” he said, whether it's a toy or their own personal needs met.

▸ Mistake 2: Not dosing a young child for protection. A possible exception to the first mistake is the scenario of a “really, really hyperactive 3-year-old with a really intolerant parent. There is a subset of children who have a desperate need for protection,” he said. “Sometimes the stimulant is important at this age” in such cases.

▸ Mistake 3: Inappropriate initial dosing. There can be, for example, a 5-year-old who is extremely emotional, a zombie, or absolutely intolerable after starting a particular medication. A prescription of 5 mg of methylphenidate is 2.5 mg of the L isomer and 2.5 mg D isomer, or 2.5 mg total of active isomer.

“Part of the problem is we start frequently with the mixed amphetamine salts 5 mg,” he said. This is 5 mg of active isomer. “So starting them on mixed salts is double the dose [we give with methylphenidate]. This is not the ideal [starting] dose for the average 4- to 6-year-old. I'm not saying you're not going to get there anyway, but do you want to start there?”

▸ Mistake 4: Confusing the first effective dose with an ideal dose. “We find a dose that is effective, and we leave it there. We make the mistake of settling for lowest effective dose, not the best dose,” Dr. Childers said. Parents in this situation might say, “He tried the medicine—it didn't work” or “The medicine worked for a little while, but then his body got used to it.”

▸ Mistake 5: Neglecting comorbidities. “This is where some people start to make mistakes,” he noted. ADHD might be primary, or it might be secondary. Learning disabilities, oppositional defiant disorder, conduct disorder, anxiety, depression, encopresis/enuresis, and poor self-esteem are among possible comorbidities.

“Childhood depression can look like ADHD in many cases.” ADHD incidence is 6%–10%, childhood depression incidence is 10%, and they can be comorbid. “You think it's hard to talk to a parent about putting a child on a stimulant, try to talk to them about putting a child on Prozac.”

▸ Mistake 6: Not detecting drug diversion. “ADHD is inherited. It is one of the most heritable conditions we know of,” Dr. Childers said. “You find a child with ADHD, the likelihood you'll find a parent with ADHD is 0.8.” He added that there are exceptions, but sometimes “my goal is to see how fast I can make the diagnosis in the parent.”

Keep in mind that maybe the child is not the only one who sees the value of the medication. “Parents can divert.” A drug-seeking parent might say, “I need to change my child from the long-acting to the short-acting.” Long-acting agents, in general, have much less abuse potential. In contrast, short-acting stimulants can be divided, and there can be enough to get a child through school and a parent through work.

▸ Mistake 7: Confusing ADHD with an undiagnosed learning disability. Learning disabilities are more common, with an incidence of 15%–20%, compared with 6%–10% for ADHD, he said.

The physician might, for example, see a young boy who got all As and Bs in school, and, then all of sudden, starts getting Ds in third grade. It could be a learning disability arising at a time when children have to read to learn. Or it could manifest later, such as an inattentive 13- or 14-year-old girl who sits quietly in the back of class and just makes passing grades.

“Be careful of what you call it before you diagnose it,” Dr. Childers said. “Once you label the kid as 'ADHD,' the school will not be looking for anything else.”

The Federal Individuals with Disability Education Act (IDEA) requires schools to test for a learning disability at the parent's request, he added.

▸ Mistake 8: Undiagnosed ADHD in an adolescent. Sometimes it is easy to miss the adolescent with ADHD, inattentive subtype, Dr. Childers said. “We get so programmatic in our approach that the differential list of problems in adolescence doesn't place ADHD high on the index of suspicion.” He added, “Just because ADHD was not diagnosed in childhood doesn't mean it is not there.”

▸ Mistake 9: Insufficient dosing. Rebound and insomnia are not subtle. “The problem isn't the medicine, the problem is the medicine wearing off.” If a stimulant wears off at 4 p.m. and bedtime is at 8 p.m., a small dose in the evening “can make a huge difference. Kids will be more stable and be able to fall asleep.”

It is important to note if the insomnia predated the stimulant use. Get a basal sleep history, Dr. Childers advised. Also recommend proper sleep hygiene. “My first question is: Is there a TV in the bedroom? The answer is always yes, and I ask them “Why?” They can't answer it.” Remove the television forever, and give the child a bath and warm milk before bedtime, he said. “That is enough for most kids.”

▸ Mistake 10: Overdiagnosis of bipolar disorder. More and more parents are coming in and saying, “My teacher, aunt, therapist, neighbor, etc. said my child has 'bipolar disorder,'” Dr. Childers remarked.

The adult prevalence of bipolar disorder is 1%–1.6%, according to a National Alliance of Mental Illness Fact Sheet, January 2004. “It's not a curable illness. Bipolar is a lifelong diagnosis. So how can 7% of children have bipolar disorder?” A much more common diagnosis is a combination of ADHD and oppositional defiant disorder (ODD). “The one big difference I always look for is a trigger to the behavior. If a parent says, 'Every time I tell him 'no,' he has a tantrum, it is unlikely it's bipolar disorder, and more often it's ODD.”

Dr. Childers tells parents they should have three goals for their child that appropriate management of ADHD can help to achieve: a happy childhood, a successful academic experience, and out the door and independent by age 18.

Dr. Childers had no relevant financial disclosures.

FORT LAUDERDALE, FLA. – Pain catastrophizing and pain-related fear are associated with increased disability and worse physical functioning among overweight patients with osteoarthritis, according to a study presented at the World Congress on Osteoarthritis.

“In the cognitive-behavioral area, what people are thinking about pain while they are having it can have a significant effect,” said Francis J. Keefe, Ph.D. “We need to be thinking about pain-related cognitions. These can increase the patient perception of pain.”

Researchers assessed pain among 106 patients with knee osteoarthritis. They also evaluated psychological disability, physical impairment, and walking velocity while controlling for pain levels. They measured walking velocity, stride length, and knee range of motion. Mean body mass index was 35 kg/m

Dr. Keefe and his associates sought to assess how pain catastrophizing and pain-related fear might affect psychological and physical functioning in this patient population. It already is well accepted that increased body weight can increase severity of knee osteoarthritis, he said.

People who catastrophize focus on their pain and magnify it. They can misinterpret pain as more threatening than it is and underestimate their ability to manage it. “Pain catastrophizing tends to increase the pain experience and disability. The reason people do this is it tends to pull other people into their situation,” said Dr. Keefe, who is with the medical psychology division, psychiatry and behavioral sciences department, Duke University, Durham, N.C.

Pain-related fear includes excessive fear of experiencing pain during movement, or kinesiophobia. This phenomenon “is especially important in the obese with osteoarthritis if they are afraid to move,” Dr. Keefe said at the meeting, which was sponsored by Osteoarthritis Research Society International.

“Clinicians need to be aware of the effects of pain catastrophizing,” he said.

All participants completed the Coping Strategies Questionnaire to assess pain catastrophizing, the Tampa Scale for Kinesiophobia to measure pain-related fear, and the Arthritis Self-Efficacy Scale. Self-efficacy for pain management was associated with improved physical functioning in the study.

Catastrophizing and pain-related fear were associated with higher psychological distress and lower pain self-efficacy. Pain-related fear, but not catastrophizing, was associated with worse physical functioning.

“Pain cognition, even after controlling for demographics and medical severity, does contribute significantly to pain,” Dr. Keefe said. “The degree of catastrophizing was among the greatest we've seen. We've also studied this in oncology.”

Addressing pain catastrophizing among overweight people with knee osteoarthritis might improve psychological functioning, Dr. Keefe said. An intervention aimed at improving pain-related fear could improve physical functioning as well. “Coping skills training or cognitive-behavioral therapy could improve these cognitions, but they are challenging to do.”

Dr. Keefe and his associates plan to launch a new study that will randomize obese patients with osteoarthritis to behavioral weight management, pain coping skills training, both interventions, or control group.

FORT LAUDERDALE, FLA. – Pain catastrophizing and pain-related fear are associated with increased disability and worse physical functioning among overweight patients with osteoarthritis, according to a study presented at the World Congress on Osteoarthritis.

“In the cognitive-behavioral area, what people are thinking about pain while they are having it can have a significant effect,” said Francis J. Keefe, Ph.D. “We need to be thinking about pain-related cognitions. These can increase the patient perception of pain.”

Researchers assessed pain among 106 patients with knee osteoarthritis. They also evaluated psychological disability, physical impairment, and walking velocity while controlling for pain levels. They measured walking velocity, stride length, and knee range of motion. Mean body mass index was 35 kg/m

Dr. Keefe and his associates sought to assess how pain catastrophizing and pain-related fear might affect psychological and physical functioning in this patient population. It already is well accepted that increased body weight can increase severity of knee osteoarthritis, he said.

People who catastrophize focus on their pain and magnify it. They can misinterpret pain as more threatening than it is and underestimate their ability to manage it. “Pain catastrophizing tends to increase the pain experience and disability. The reason people do this is it tends to pull other people into their situation,” said Dr. Keefe, who is with the medical psychology division, psychiatry and behavioral sciences department, Duke University, Durham, N.C.

Pain-related fear includes excessive fear of experiencing pain during movement, or kinesiophobia. This phenomenon “is especially important in the obese with osteoarthritis if they are afraid to move,” Dr. Keefe said at the meeting, which was sponsored by Osteoarthritis Research Society International.

“Clinicians need to be aware of the effects of pain catastrophizing,” he said.

All participants completed the Coping Strategies Questionnaire to assess pain catastrophizing, the Tampa Scale for Kinesiophobia to measure pain-related fear, and the Arthritis Self-Efficacy Scale. Self-efficacy for pain management was associated with improved physical functioning in the study.

Catastrophizing and pain-related fear were associated with higher psychological distress and lower pain self-efficacy. Pain-related fear, but not catastrophizing, was associated with worse physical functioning.

“Pain cognition, even after controlling for demographics and medical severity, does contribute significantly to pain,” Dr. Keefe said. “The degree of catastrophizing was among the greatest we've seen. We've also studied this in oncology.”

Addressing pain catastrophizing among overweight people with knee osteoarthritis might improve psychological functioning, Dr. Keefe said. An intervention aimed at improving pain-related fear could improve physical functioning as well. “Coping skills training or cognitive-behavioral therapy could improve these cognitions, but they are challenging to do.”

Dr. Keefe and his associates plan to launch a new study that will randomize obese patients with osteoarthritis to behavioral weight management, pain coping skills training, both interventions, or control group.

FORT LAUDERDALE, FLA. – Pain catastrophizing and pain-related fear are associated with increased disability and worse physical functioning among overweight patients with osteoarthritis, according to a study presented at the World Congress on Osteoarthritis.

“In the cognitive-behavioral area, what people are thinking about pain while they are having it can have a significant effect,” said Francis J. Keefe, Ph.D. “We need to be thinking about pain-related cognitions. These can increase the patient perception of pain.”

Researchers assessed pain among 106 patients with knee osteoarthritis. They also evaluated psychological disability, physical impairment, and walking velocity while controlling for pain levels. They measured walking velocity, stride length, and knee range of motion. Mean body mass index was 35 kg/m

Dr. Keefe and his associates sought to assess how pain catastrophizing and pain-related fear might affect psychological and physical functioning in this patient population. It already is well accepted that increased body weight can increase severity of knee osteoarthritis, he said.

People who catastrophize focus on their pain and magnify it. They can misinterpret pain as more threatening than it is and underestimate their ability to manage it. “Pain catastrophizing tends to increase the pain experience and disability. The reason people do this is it tends to pull other people into their situation,” said Dr. Keefe, who is with the medical psychology division, psychiatry and behavioral sciences department, Duke University, Durham, N.C.

Pain-related fear includes excessive fear of experiencing pain during movement, or kinesiophobia. This phenomenon “is especially important in the obese with osteoarthritis if they are afraid to move,” Dr. Keefe said at the meeting, which was sponsored by Osteoarthritis Research Society International.

“Clinicians need to be aware of the effects of pain catastrophizing,” he said.

All participants completed the Coping Strategies Questionnaire to assess pain catastrophizing, the Tampa Scale for Kinesiophobia to measure pain-related fear, and the Arthritis Self-Efficacy Scale. Self-efficacy for pain management was associated with improved physical functioning in the study.

Catastrophizing and pain-related fear were associated with higher psychological distress and lower pain self-efficacy. Pain-related fear, but not catastrophizing, was associated with worse physical functioning.

“Pain cognition, even after controlling for demographics and medical severity, does contribute significantly to pain,” Dr. Keefe said. “The degree of catastrophizing was among the greatest we've seen. We've also studied this in oncology.”

Addressing pain catastrophizing among overweight people with knee osteoarthritis might improve psychological functioning, Dr. Keefe said. An intervention aimed at improving pain-related fear could improve physical functioning as well. “Coping skills training or cognitive-behavioral therapy could improve these cognitions, but they are challenging to do.”

Dr. Keefe and his associates plan to launch a new study that will randomize obese patients with osteoarthritis to behavioral weight management, pain coping skills training, both interventions, or control group.

MIAMI BEACH – It is important to confront parents about their parenting style when conveying a diagnosis of oppositional defiant disorder, a developmental pediatrics specialist advises.

It is difficult to address a parenting issue, particularly in a 15-minute visit and when you want to keep a relationship with the family, Dr. David O. Childers, chief of the developmental pediatrics section at the University of Florida, Jacksonville, told the annual Masters of Pediatrics conference. Instead, ask them to return for a more comprehensive discussion, perhaps as the last appointment on a day in the near future. “When I make the diagnosis, I don't just throw them out the door. I spend 45 minutes to an hour to speak with parents about options and things they could do better,” Dr. Childers said.

Parenting class is an important strategy regarding oppositional defiant disorder (ODD), one that Dr. Childers knows from personal experience. “A parenting class is essential. In the world of behavioral medicine, good parenting style is very important. When I walked out of my parenting class, I said, 'Man, I didn't know what I was doing.' My wife and I were not good parents when our son was 5 years old,” he said.

Dr. Childers typically tells parents three things about ODD. “No. 1–my son got diagnosed with ODD at age 5 and it was a good, valid diagnosis. No. 2–you're going to hate my third thing. And No. 3–it's a mismatch between the parents and the child … when the parenting abilities suck.”

Discipline and consistency are critical to improve life for a family affected by ODD, Dr. Childers said at the conference sponsored by the University of Miami.

Discipline is also important for parents, he said. They “have to be consistent over time. Kids are screaming for boundaries and rules. They don't know this is what they want, but they do. Kids get irritable when the boundaries are shifting all the time.”

A short period of negative reinforcement helps parents gain control over the inappropriate behavior so they can implement positive changes over time. Dr. Childers said, “I tell parents it's going to be 1 or 2 months of miserable existence to buy the next 10 or 15 years of happiness.”

“For most children who are coming to my level of care,” he added, “it takes a few weeks to a month or two for the child to realize the parent is not going to break.”

Sending a child to the corner for a “time out” is a component of the negative reinforcement. “The 'corner' is available everywhere you go. You can take them out of a restaurant and put their nose to the side of the building, or if you are driving you can pull into the next parking lot,” Dr. Childers said. This strategy will alter future behavior for a majority of children.

In some rare cases, he added, medications to reduce the child's irritability are warranted to give parents a better opportunity to address the bad behaviors.

If a child ever says “no” or argues with a parent, they get an automatic time out, Dr. Childers said. In addition, if they show any kind of disrespect, such as ignoring parents or rolling their eyes, “they go right to the corner.” Any type of aggressive behavior likewise is not tolerated.

Advise parents not to count to three because it implies the child has time to think about it. “I tell the parents if they want to count to three, start with three and then go right to time out,” Dr. Childers said.

Warn parents that during the negative reinforcement phase, the child's behaviors will escalate and continue to escalate until the moment they realize the parent is not going to back down, he said.

Empathizing with parents can help. “I tell parents it is not easy but they will end up with a dramatically calmer and happier child. I know that sometimes children will wear them down, or they are stressed out, and they will give the child a 'fine, whatever.' The 'fine, whatever' could be 'go ahead, have a chocolate bar for dinner' or 'go ahead, go play video games.' However, it is essential not to back down no matter how challenging the situation. They know they will get 10 more 'fine, whatevers' from the parent if they keep up the behavior. Parents have to be absolutely consistent … and they will be able to move from negative reinforcement to a positive behavior.”

“I tell parents it may take 1–2 months to gain control. However, it usually takes 1–2 weeks. I prepare them for the longer haul so they won't give up in case they have one of the outlier children who really do take several months. So, in general, families who come to see me can move pretty rapidly to a positive reward system, which should be the heart of any behavior program,” he said.

Then, “I start with the precept that children should basically have no real privileges,” whether they have ODD or not. “Children should earn their privileges daily through their completion of daily requirements,” Dr. Childers said.

“However, I also believe in 'bonuses.' “For example, when parents come home with groceries and ask the kids to help unload the car, this isn't part of the daily list of jobs. If they come and do it willingly, they get 30–40 minutes of “bonus time” for their privileges. “The next time parents come home with groceries, they shouldn't have to even call them,” he said. “Or if one child helps a brother or sister with a homework problem or with a chore, reward that behavior with some bonus privilege time.”

“I do limit 'screen time' to 2 hours, as part of the privilege package,” Dr. Childers said.

These tips for improving ODD behavior and the quality of life for the child and the rest of the family are effective, Dr. Childers said. “This works–if the parents will do it. If you don't have a buy-in from parents, it won't work.”

MIAMI BEACH – It is important to confront parents about their parenting style when conveying a diagnosis of oppositional defiant disorder, a developmental pediatrics specialist advises.

It is difficult to address a parenting issue, particularly in a 15-minute visit and when you want to keep a relationship with the family, Dr. David O. Childers, chief of the developmental pediatrics section at the University of Florida, Jacksonville, told the annual Masters of Pediatrics conference. Instead, ask them to return for a more comprehensive discussion, perhaps as the last appointment on a day in the near future. “When I make the diagnosis, I don't just throw them out the door. I spend 45 minutes to an hour to speak with parents about options and things they could do better,” Dr. Childers said.

Parenting class is an important strategy regarding oppositional defiant disorder (ODD), one that Dr. Childers knows from personal experience. “A parenting class is essential. In the world of behavioral medicine, good parenting style is very important. When I walked out of my parenting class, I said, 'Man, I didn't know what I was doing.' My wife and I were not good parents when our son was 5 years old,” he said.

Dr. Childers typically tells parents three things about ODD. “No. 1–my son got diagnosed with ODD at age 5 and it was a good, valid diagnosis. No. 2–you're going to hate my third thing. And No. 3–it's a mismatch between the parents and the child … when the parenting abilities suck.”

Discipline and consistency are critical to improve life for a family affected by ODD, Dr. Childers said at the conference sponsored by the University of Miami.

Discipline is also important for parents, he said. They “have to be consistent over time. Kids are screaming for boundaries and rules. They don't know this is what they want, but they do. Kids get irritable when the boundaries are shifting all the time.”

A short period of negative reinforcement helps parents gain control over the inappropriate behavior so they can implement positive changes over time. Dr. Childers said, “I tell parents it's going to be 1 or 2 months of miserable existence to buy the next 10 or 15 years of happiness.”

“For most children who are coming to my level of care,” he added, “it takes a few weeks to a month or two for the child to realize the parent is not going to break.”

Sending a child to the corner for a “time out” is a component of the negative reinforcement. “The 'corner' is available everywhere you go. You can take them out of a restaurant and put their nose to the side of the building, or if you are driving you can pull into the next parking lot,” Dr. Childers said. This strategy will alter future behavior for a majority of children.

In some rare cases, he added, medications to reduce the child's irritability are warranted to give parents a better opportunity to address the bad behaviors.

If a child ever says “no” or argues with a parent, they get an automatic time out, Dr. Childers said. In addition, if they show any kind of disrespect, such as ignoring parents or rolling their eyes, “they go right to the corner.” Any type of aggressive behavior likewise is not tolerated.

Advise parents not to count to three because it implies the child has time to think about it. “I tell the parents if they want to count to three, start with three and then go right to time out,” Dr. Childers said.

Warn parents that during the negative reinforcement phase, the child's behaviors will escalate and continue to escalate until the moment they realize the parent is not going to back down, he said.

Empathizing with parents can help. “I tell parents it is not easy but they will end up with a dramatically calmer and happier child. I know that sometimes children will wear them down, or they are stressed out, and they will give the child a 'fine, whatever.' The 'fine, whatever' could be 'go ahead, have a chocolate bar for dinner' or 'go ahead, go play video games.' However, it is essential not to back down no matter how challenging the situation. They know they will get 10 more 'fine, whatevers' from the parent if they keep up the behavior. Parents have to be absolutely consistent … and they will be able to move from negative reinforcement to a positive behavior.”

“I tell parents it may take 1–2 months to gain control. However, it usually takes 1–2 weeks. I prepare them for the longer haul so they won't give up in case they have one of the outlier children who really do take several months. So, in general, families who come to see me can move pretty rapidly to a positive reward system, which should be the heart of any behavior program,” he said.

Then, “I start with the precept that children should basically have no real privileges,” whether they have ODD or not. “Children should earn their privileges daily through their completion of daily requirements,” Dr. Childers said.

“However, I also believe in 'bonuses.' “For example, when parents come home with groceries and ask the kids to help unload the car, this isn't part of the daily list of jobs. If they come and do it willingly, they get 30–40 minutes of “bonus time” for their privileges. “The next time parents come home with groceries, they shouldn't have to even call them,” he said. “Or if one child helps a brother or sister with a homework problem or with a chore, reward that behavior with some bonus privilege time.”

“I do limit 'screen time' to 2 hours, as part of the privilege package,” Dr. Childers said.

These tips for improving ODD behavior and the quality of life for the child and the rest of the family are effective, Dr. Childers said. “This works–if the parents will do it. If you don't have a buy-in from parents, it won't work.”

MIAMI BEACH – It is important to confront parents about their parenting style when conveying a diagnosis of oppositional defiant disorder, a developmental pediatrics specialist advises.

It is difficult to address a parenting issue, particularly in a 15-minute visit and when you want to keep a relationship with the family, Dr. David O. Childers, chief of the developmental pediatrics section at the University of Florida, Jacksonville, told the annual Masters of Pediatrics conference. Instead, ask them to return for a more comprehensive discussion, perhaps as the last appointment on a day in the near future. “When I make the diagnosis, I don't just throw them out the door. I spend 45 minutes to an hour to speak with parents about options and things they could do better,” Dr. Childers said.

Parenting class is an important strategy regarding oppositional defiant disorder (ODD), one that Dr. Childers knows from personal experience. “A parenting class is essential. In the world of behavioral medicine, good parenting style is very important. When I walked out of my parenting class, I said, 'Man, I didn't know what I was doing.' My wife and I were not good parents when our son was 5 years old,” he said.

Dr. Childers typically tells parents three things about ODD. “No. 1–my son got diagnosed with ODD at age 5 and it was a good, valid diagnosis. No. 2–you're going to hate my third thing. And No. 3–it's a mismatch between the parents and the child … when the parenting abilities suck.”

Discipline and consistency are critical to improve life for a family affected by ODD, Dr. Childers said at the conference sponsored by the University of Miami.

Discipline is also important for parents, he said. They “have to be consistent over time. Kids are screaming for boundaries and rules. They don't know this is what they want, but they do. Kids get irritable when the boundaries are shifting all the time.”

A short period of negative reinforcement helps parents gain control over the inappropriate behavior so they can implement positive changes over time. Dr. Childers said, “I tell parents it's going to be 1 or 2 months of miserable existence to buy the next 10 or 15 years of happiness.”

“For most children who are coming to my level of care,” he added, “it takes a few weeks to a month or two for the child to realize the parent is not going to break.”

Sending a child to the corner for a “time out” is a component of the negative reinforcement. “The 'corner' is available everywhere you go. You can take them out of a restaurant and put their nose to the side of the building, or if you are driving you can pull into the next parking lot,” Dr. Childers said. This strategy will alter future behavior for a majority of children.

In some rare cases, he added, medications to reduce the child's irritability are warranted to give parents a better opportunity to address the bad behaviors.

If a child ever says “no” or argues with a parent, they get an automatic time out, Dr. Childers said. In addition, if they show any kind of disrespect, such as ignoring parents or rolling their eyes, “they go right to the corner.” Any type of aggressive behavior likewise is not tolerated.

Advise parents not to count to three because it implies the child has time to think about it. “I tell the parents if they want to count to three, start with three and then go right to time out,” Dr. Childers said.

Warn parents that during the negative reinforcement phase, the child's behaviors will escalate and continue to escalate until the moment they realize the parent is not going to back down, he said.

Empathizing with parents can help. “I tell parents it is not easy but they will end up with a dramatically calmer and happier child. I know that sometimes children will wear them down, or they are stressed out, and they will give the child a 'fine, whatever.' The 'fine, whatever' could be 'go ahead, have a chocolate bar for dinner' or 'go ahead, go play video games.' However, it is essential not to back down no matter how challenging the situation. They know they will get 10 more 'fine, whatevers' from the parent if they keep up the behavior. Parents have to be absolutely consistent … and they will be able to move from negative reinforcement to a positive behavior.”

“I tell parents it may take 1–2 months to gain control. However, it usually takes 1–2 weeks. I prepare them for the longer haul so they won't give up in case they have one of the outlier children who really do take several months. So, in general, families who come to see me can move pretty rapidly to a positive reward system, which should be the heart of any behavior program,” he said.

Then, “I start with the precept that children should basically have no real privileges,” whether they have ODD or not. “Children should earn their privileges daily through their completion of daily requirements,” Dr. Childers said.

“However, I also believe in 'bonuses.' “For example, when parents come home with groceries and ask the kids to help unload the car, this isn't part of the daily list of jobs. If they come and do it willingly, they get 30–40 minutes of “bonus time” for their privileges. “The next time parents come home with groceries, they shouldn't have to even call them,” he said. “Or if one child helps a brother or sister with a homework problem or with a chore, reward that behavior with some bonus privilege time.”

“I do limit 'screen time' to 2 hours, as part of the privilege package,” Dr. Childers said.

These tips for improving ODD behavior and the quality of life for the child and the rest of the family are effective, Dr. Childers said. “This works–if the parents will do it. If you don't have a buy-in from parents, it won't work.”

The new recommendation calling for electrocardiogram screening for children with attention-deficit/hyperactivity disorder before initiating pharmacologic treatment is not based on data, according to an expert in child and adolescent psychiatry.

Dr. David Fassler said that at this point, there is no evidence that such screening would enhance safety or reduce the risk of rare but potentially serious heart-related problems.

“The best advice is for parents to talk to their child's doctor,” Dr. Fassler, clinical professor of psychiatry at the University of Vermont, Burlington, said when asked about the recommendations. “They can then decide together what, if any, additional evaluation may be warranted.”

Under the recommendations, issued in April by the American Heart Association, if patient history, family history, clinical examination, and/or ECG results suggest a higher risk, a referral to a pediatric cardiologist is warranted.

For patients currently taking methylphenidate, amphetamine, or another treatment for ADHD, a comprehensive assessment of cardiac risk is reasonable if deemed necessary, according to the AHA scientific statement published in Circulation, available at circ.ahajournals.org

The AHA recommendations, offered by Dr. Victoria L. Vetter of the Children's Hospital of Philadelphia and her colleagues, say it is important to pay particular attention to symptoms such as palpitations, near syncope, or syncope that might indicate a cardiac condition.

Consider all other medications taken by a pediatric patient, including over-the-counter agents, according to the recommendations, titled “Cardiovascular Monitoring of Children and Adolescents With Heart Disease Receiving Stimulant Drugs.”

Cardiac risk assessment of all children before prescribing ADHD medications, ongoing monitoring, and specific guidelines for children with known structural heart disease or other heart conditions are outlined in the statement.

In 1999, the AHA addressed concerns about potential adverse cardiac effects of psychotropic medications in children, but made no specific recommendations about stimulants. However, “since that time, a constellation of circumstances has come together, necessitating a second look at this complicated issue,” the authors of the current statement wrote.

The authors note that ADHD might be more prevalent among children with heart disease than the estimated 4%–16% of the general population. One study, for example, indicated that 45% of children with heart disease had abnormal attention scores and 39% had abnormal hyperactivity scores (Pediatrics 2000;105:1082–9).

The recommendation for selective ECG screening is new. The writing group suggested the testing will increase the likelihood of identifying significant cardiac conditions such as hypertrophic cardiomyopathy, long QT syndrome, and Wolff-Parkinson-White syndrome that might place the child at risk.

“We recognize that the ECG cannot identify all children with these conditions but will increase the probability,” wrote Dr. Vetter and the six other experts on the American Heart Association Congenital Cardiac Defects Committee of the Council on Cardiovascular Disease in the Young and the Council on Cardiovascular Nursing.

“The use of selective ECG screening in this population is thought to be medically indicated and of reasonable cost.” Dr. Vetter, the majority of writing group members, and the four physician reviewers had no relevant financial disclosures.

A physician familiar with interpretation of pediatric ECG should assess results, according to the recommendations. A repeat ECG might be useful after initiation of ADHD medication if there is a change in relevant family history or, if the first ECG was performed before the age of 12, after the child turns 12 years old.

Initial assessment of a child with ADHD should include personal history of fainting or dizziness, particularly with exercise; seizures; rheumatic fever; chest pain or shortness of breath with exercise; an unexplained, noticeable change in exercise tolerance; palpitations, increased heart rate, or extra/skipped heartbeats; history of hypertension; and other factors.

Relevant family history includes sudden or unexplained death of someone young, sudden cardiac death or myocardial infarction before age 35 years, sudden death during exercise, and cardiac arrhythmias.

During physical examination, assess the child for an abnormal heart murmur and other cardiovascular abnormalities, including hypertension. It also is important to assess the child for irregular or rapid heart rhythm, as well as findings suggestive of Marfan syndrome.

Refer any patient with significant findings to a pediatric cardiologist for further evaluation, because a routine physician examination might miss some conditions associated with sudden cardiac death, the authors recommended. Pediatricians should perform ongoing assessment of patients identified at risk at each subsequent visit, according to the guidelines. A physical examination including blood pressure and pulse assessment is suggested. “There are no clinical studies or data indicating that children with most types of congenital heart disease are at significant risk for sudden cardiac death while on these [ADHD] medications,” the authors wrote. Nevertheless, the authors addressed cardiovascular monitoring of children with known structural heart disease or other heart conditions.

“It is reasonable to consider the use of stimulant medication in patients with congenital heart disease that is not repaired or repaired but without current hemodynamic or arrhythmic concerns or congenital heart disease that is considered to be stable by the patient's pediatric cardiologist unless the patient's pediatric cardiologist has specific concerns.”

Dr. Fassler thinks that more large-scale, long-term research on stimulants and other medications used to treat child and adolescent psychiatric disorders are needed. “Such studies will ultimately help us determine who is most likely to respond to specific interventions, and if there are particular groups of kids who may be at increased risk for certain side effects,” he said.

Future studies are warranted, the authors wrote, to assess the true risk of sudden cardiac death associated with use of stimulant drugs in children and adolescents with and without heart disease.

The new recommendation calling for electrocardiogram screening for children with attention-deficit/hyperactivity disorder before initiating pharmacologic treatment is not based on data, according to an expert in child and adolescent psychiatry.

Dr. David Fassler said that at this point, there is no evidence that such screening would enhance safety or reduce the risk of rare but potentially serious heart-related problems.

“The best advice is for parents to talk to their child's doctor,” Dr. Fassler, clinical professor of psychiatry at the University of Vermont, Burlington, said when asked about the recommendations. “They can then decide together what, if any, additional evaluation may be warranted.”

Under the recommendations, issued in April by the American Heart Association, if patient history, family history, clinical examination, and/or ECG results suggest a higher risk, a referral to a pediatric cardiologist is warranted.

For patients currently taking methylphenidate, amphetamine, or another treatment for ADHD, a comprehensive assessment of cardiac risk is reasonable if deemed necessary, according to the AHA scientific statement published in Circulation, available at circ.ahajournals.org

The AHA recommendations, offered by Dr. Victoria L. Vetter of the Children's Hospital of Philadelphia and her colleagues, say it is important to pay particular attention to symptoms such as palpitations, near syncope, or syncope that might indicate a cardiac condition.

Consider all other medications taken by a pediatric patient, including over-the-counter agents, according to the recommendations, titled “Cardiovascular Monitoring of Children and Adolescents With Heart Disease Receiving Stimulant Drugs.”

Cardiac risk assessment of all children before prescribing ADHD medications, ongoing monitoring, and specific guidelines for children with known structural heart disease or other heart conditions are outlined in the statement.

In 1999, the AHA addressed concerns about potential adverse cardiac effects of psychotropic medications in children, but made no specific recommendations about stimulants. However, “since that time, a constellation of circumstances has come together, necessitating a second look at this complicated issue,” the authors of the current statement wrote.

The authors note that ADHD might be more prevalent among children with heart disease than the estimated 4%–16% of the general population. One study, for example, indicated that 45% of children with heart disease had abnormal attention scores and 39% had abnormal hyperactivity scores (Pediatrics 2000;105:1082–9).

The recommendation for selective ECG screening is new. The writing group suggested the testing will increase the likelihood of identifying significant cardiac conditions such as hypertrophic cardiomyopathy, long QT syndrome, and Wolff-Parkinson-White syndrome that might place the child at risk.

“We recognize that the ECG cannot identify all children with these conditions but will increase the probability,” wrote Dr. Vetter and the six other experts on the American Heart Association Congenital Cardiac Defects Committee of the Council on Cardiovascular Disease in the Young and the Council on Cardiovascular Nursing.

“The use of selective ECG screening in this population is thought to be medically indicated and of reasonable cost.” Dr. Vetter, the majority of writing group members, and the four physician reviewers had no relevant financial disclosures.

A physician familiar with interpretation of pediatric ECG should assess results, according to the recommendations. A repeat ECG might be useful after initiation of ADHD medication if there is a change in relevant family history or, if the first ECG was performed before the age of 12, after the child turns 12 years old.

Initial assessment of a child with ADHD should include personal history of fainting or dizziness, particularly with exercise; seizures; rheumatic fever; chest pain or shortness of breath with exercise; an unexplained, noticeable change in exercise tolerance; palpitations, increased heart rate, or extra/skipped heartbeats; history of hypertension; and other factors.

Relevant family history includes sudden or unexplained death of someone young, sudden cardiac death or myocardial infarction before age 35 years, sudden death during exercise, and cardiac arrhythmias.

During physical examination, assess the child for an abnormal heart murmur and other cardiovascular abnormalities, including hypertension. It also is important to assess the child for irregular or rapid heart rhythm, as well as findings suggestive of Marfan syndrome.

Refer any patient with significant findings to a pediatric cardiologist for further evaluation, because a routine physician examination might miss some conditions associated with sudden cardiac death, the authors recommended. Pediatricians should perform ongoing assessment of patients identified at risk at each subsequent visit, according to the guidelines. A physical examination including blood pressure and pulse assessment is suggested. “There are no clinical studies or data indicating that children with most types of congenital heart disease are at significant risk for sudden cardiac death while on these [ADHD] medications,” the authors wrote. Nevertheless, the authors addressed cardiovascular monitoring of children with known structural heart disease or other heart conditions.

“It is reasonable to consider the use of stimulant medication in patients with congenital heart disease that is not repaired or repaired but without current hemodynamic or arrhythmic concerns or congenital heart disease that is considered to be stable by the patient's pediatric cardiologist unless the patient's pediatric cardiologist has specific concerns.”

Dr. Fassler thinks that more large-scale, long-term research on stimulants and other medications used to treat child and adolescent psychiatric disorders are needed. “Such studies will ultimately help us determine who is most likely to respond to specific interventions, and if there are particular groups of kids who may be at increased risk for certain side effects,” he said.

Future studies are warranted, the authors wrote, to assess the true risk of sudden cardiac death associated with use of stimulant drugs in children and adolescents with and without heart disease.

The new recommendation calling for electrocardiogram screening for children with attention-deficit/hyperactivity disorder before initiating pharmacologic treatment is not based on data, according to an expert in child and adolescent psychiatry.

Dr. David Fassler said that at this point, there is no evidence that such screening would enhance safety or reduce the risk of rare but potentially serious heart-related problems.

“The best advice is for parents to talk to their child's doctor,” Dr. Fassler, clinical professor of psychiatry at the University of Vermont, Burlington, said when asked about the recommendations. “They can then decide together what, if any, additional evaluation may be warranted.”

Under the recommendations, issued in April by the American Heart Association, if patient history, family history, clinical examination, and/or ECG results suggest a higher risk, a referral to a pediatric cardiologist is warranted.

For patients currently taking methylphenidate, amphetamine, or another treatment for ADHD, a comprehensive assessment of cardiac risk is reasonable if deemed necessary, according to the AHA scientific statement published in Circulation, available at circ.ahajournals.org

The AHA recommendations, offered by Dr. Victoria L. Vetter of the Children's Hospital of Philadelphia and her colleagues, say it is important to pay particular attention to symptoms such as palpitations, near syncope, or syncope that might indicate a cardiac condition.

Consider all other medications taken by a pediatric patient, including over-the-counter agents, according to the recommendations, titled “Cardiovascular Monitoring of Children and Adolescents With Heart Disease Receiving Stimulant Drugs.”

Cardiac risk assessment of all children before prescribing ADHD medications, ongoing monitoring, and specific guidelines for children with known structural heart disease or other heart conditions are outlined in the statement.

In 1999, the AHA addressed concerns about potential adverse cardiac effects of psychotropic medications in children, but made no specific recommendations about stimulants. However, “since that time, a constellation of circumstances has come together, necessitating a second look at this complicated issue,” the authors of the current statement wrote.

The authors note that ADHD might be more prevalent among children with heart disease than the estimated 4%–16% of the general population. One study, for example, indicated that 45% of children with heart disease had abnormal attention scores and 39% had abnormal hyperactivity scores (Pediatrics 2000;105:1082–9).

The recommendation for selective ECG screening is new. The writing group suggested the testing will increase the likelihood of identifying significant cardiac conditions such as hypertrophic cardiomyopathy, long QT syndrome, and Wolff-Parkinson-White syndrome that might place the child at risk.

“We recognize that the ECG cannot identify all children with these conditions but will increase the probability,” wrote Dr. Vetter and the six other experts on the American Heart Association Congenital Cardiac Defects Committee of the Council on Cardiovascular Disease in the Young and the Council on Cardiovascular Nursing.

“The use of selective ECG screening in this population is thought to be medically indicated and of reasonable cost.” Dr. Vetter, the majority of writing group members, and the four physician reviewers had no relevant financial disclosures.

A physician familiar with interpretation of pediatric ECG should assess results, according to the recommendations. A repeat ECG might be useful after initiation of ADHD medication if there is a change in relevant family history or, if the first ECG was performed before the age of 12, after the child turns 12 years old.

Initial assessment of a child with ADHD should include personal history of fainting or dizziness, particularly with exercise; seizures; rheumatic fever; chest pain or shortness of breath with exercise; an unexplained, noticeable change in exercise tolerance; palpitations, increased heart rate, or extra/skipped heartbeats; history of hypertension; and other factors.

Relevant family history includes sudden or unexplained death of someone young, sudden cardiac death or myocardial infarction before age 35 years, sudden death during exercise, and cardiac arrhythmias.

During physical examination, assess the child for an abnormal heart murmur and other cardiovascular abnormalities, including hypertension. It also is important to assess the child for irregular or rapid heart rhythm, as well as findings suggestive of Marfan syndrome.

Refer any patient with significant findings to a pediatric cardiologist for further evaluation, because a routine physician examination might miss some conditions associated with sudden cardiac death, the authors recommended. Pediatricians should perform ongoing assessment of patients identified at risk at each subsequent visit, according to the guidelines. A physical examination including blood pressure and pulse assessment is suggested. “There are no clinical studies or data indicating that children with most types of congenital heart disease are at significant risk for sudden cardiac death while on these [ADHD] medications,” the authors wrote. Nevertheless, the authors addressed cardiovascular monitoring of children with known structural heart disease or other heart conditions.

“It is reasonable to consider the use of stimulant medication in patients with congenital heart disease that is not repaired or repaired but without current hemodynamic or arrhythmic concerns or congenital heart disease that is considered to be stable by the patient's pediatric cardiologist unless the patient's pediatric cardiologist has specific concerns.”

Dr. Fassler thinks that more large-scale, long-term research on stimulants and other medications used to treat child and adolescent psychiatric disorders are needed. “Such studies will ultimately help us determine who is most likely to respond to specific interventions, and if there are particular groups of kids who may be at increased risk for certain side effects,” he said.

Future studies are warranted, the authors wrote, to assess the true risk of sudden cardiac death associated with use of stimulant drugs in children and adolescents with and without heart disease.