Heidi Splete

Preschoolers Tolerate Methylphenidate

Adverse events were well tolerated in a majority of 3− to 5-year-olds who took methylphenidate for ADHD, based on data from 183 children, said Tim Wigal, Ph.D., of the University of California, Irvine, and his colleagues.

Although methylphenidate's safety had been studied in school-aged children, studies of its effects on preschoolers are limited, they noted.

Overall, 21 (11%) of the 183 children discontinued as a result of adverse events that were rated moderate to severe. During the initial treatment and randomized study phases, nine children discontinued the study because of emotionality/irritability and one each discontinued because of tics, tactile hallucinations, possible seizure, rash, and insomnia (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1294–303).

Adverse effects associated with discontinuation during the maintenance phase of the study included appetite loss, irritability, tics, weight loss, depression, anxiety, and social isolation. No cardiovascular-related adverse events were reported in any of the study phases.

The 11% rate of adverse events in this study of preschoolers is high, compared with the rates of less than 1% that have been reported among school-aged children. Rates of the most common adverse events, however, including irritability and emotionality, decreased significantly during the maintenance phase, which suggests that young children's tolerance of methylphenidate may improve with time, the researchers said.

Dr. Wigal has received financial support from several companies that manufacture and market methylphenidate, including Cephalon, Eli Lilly & Co., McNeil, and Shire.

ADHD and Tourette's: All in the Family

Tourette's disorder and ADHD may not have the same genetic cause, but cases in which the two conditions occur comorbidly tend to run in families, said Dr. S. Evelyn Stewart of Harvard University, Boston, and her associates.

To determine the possible connection between ADHD and TD in families, Dr. Stewart and her colleagues interviewed 239 patients aged 7–18 years and 692 relatives of various ages. The patients were divided into four case groups: 75 individuals with comorbid ADHD and TD, 74 with TD only, 41 with ADHD only, and 49 controls (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1354–62).

Comorbid rates of ADHD and TD were significantly higher among relatives of patients in all four case groups, compared with either condition alone. The age-corrected rates of ADHD were significantly higher in relatives with TD than in relatives without TD (48% vs. 13%). Similarly, the rates of TD were significantly higher among relatives with ADHD than in relatives without ADHD (27% vs. 5%). The ages of onset for ADHD and TD were not significantly different in relatives among the four case groups.

The presence of either the combined or the inattentive subtype of ADHD was a significant predictor of TD in relatives of study patients in all the case groups. Also, most cases of ADHD in relatives of study patients with TD were either the combined or the inattentive subtypes, suggesting that TD symptoms were probably not misdiagnosed as ADHD, the researchers noted.

Externalization in Daytime Wetters

Children aged 7–9 years who wet their pants during the day have significantly more parent-reported psychological problems than do children with no daytime wetting, based on data collected from 8,213 children as part of a longitudinal study.

The clinical implication is that early intervention for children who have frequent problems with daytime wetting may prevent psychological problems once they start school, reported Carol Joinson, Ph.D., of the University of Bristol (England).

Overall, 643 children (7.8%)–291 boys and 352 girls–reported daytime wetting, based on a parent questionnaire (Pediatrics 2006;118:1985–93). Children with daytime wetting were twice as likely as those with no daytime wetting to demonstrate attention and activity problems (24.8%), oppositional behavior (10.9%), and conduct problems (11.8%).

An adjustment for developmental delay, which was identified in 276 children, significantly reduced the odds of oppositional behavior or attention and activity problems, but there was still a strong association between these problems and daytime wetting. An adjustment for comorbid soiling also reduced the odds ratios for externalizing behavior problems, but an independent association persisted, the researchers noted.

The rate of externalizing problems (attention/activity problems, oppositional disorder, and conduct disorder) was higher in the 82 (12.8%) children whose severe daytime wetting met the DSM-IV criteria.

Preschoolers Tolerate Methylphenidate

Adverse events were well tolerated in a majority of 3− to 5-year-olds who took methylphenidate for ADHD, based on data from 183 children, said Tim Wigal, Ph.D., of the University of California, Irvine, and his colleagues.

Although methylphenidate's safety had been studied in school-aged children, studies of its effects on preschoolers are limited, they noted.

Overall, 21 (11%) of the 183 children discontinued as a result of adverse events that were rated moderate to severe. During the initial treatment and randomized study phases, nine children discontinued the study because of emotionality/irritability and one each discontinued because of tics, tactile hallucinations, possible seizure, rash, and insomnia (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1294–303).

Adverse effects associated with discontinuation during the maintenance phase of the study included appetite loss, irritability, tics, weight loss, depression, anxiety, and social isolation. No cardiovascular-related adverse events were reported in any of the study phases.

The 11% rate of adverse events in this study of preschoolers is high, compared with the rates of less than 1% that have been reported among school-aged children. Rates of the most common adverse events, however, including irritability and emotionality, decreased significantly during the maintenance phase, which suggests that young children's tolerance of methylphenidate may improve with time, the researchers said.

Dr. Wigal has received financial support from several companies that manufacture and market methylphenidate, including Cephalon, Eli Lilly & Co., McNeil, and Shire.

ADHD and Tourette's: All in the Family

Tourette's disorder and ADHD may not have the same genetic cause, but cases in which the two conditions occur comorbidly tend to run in families, said Dr. S. Evelyn Stewart of Harvard University, Boston, and her associates.

To determine the possible connection between ADHD and TD in families, Dr. Stewart and her colleagues interviewed 239 patients aged 7–18 years and 692 relatives of various ages. The patients were divided into four case groups: 75 individuals with comorbid ADHD and TD, 74 with TD only, 41 with ADHD only, and 49 controls (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1354–62).

Comorbid rates of ADHD and TD were significantly higher among relatives of patients in all four case groups, compared with either condition alone. The age-corrected rates of ADHD were significantly higher in relatives with TD than in relatives without TD (48% vs. 13%). Similarly, the rates of TD were significantly higher among relatives with ADHD than in relatives without ADHD (27% vs. 5%). The ages of onset for ADHD and TD were not significantly different in relatives among the four case groups.

The presence of either the combined or the inattentive subtype of ADHD was a significant predictor of TD in relatives of study patients in all the case groups. Also, most cases of ADHD in relatives of study patients with TD were either the combined or the inattentive subtypes, suggesting that TD symptoms were probably not misdiagnosed as ADHD, the researchers noted.

Externalization in Daytime Wetters

Children aged 7–9 years who wet their pants during the day have significantly more parent-reported psychological problems than do children with no daytime wetting, based on data collected from 8,213 children as part of a longitudinal study.

The clinical implication is that early intervention for children who have frequent problems with daytime wetting may prevent psychological problems once they start school, reported Carol Joinson, Ph.D., of the University of Bristol (England).

Overall, 643 children (7.8%)–291 boys and 352 girls–reported daytime wetting, based on a parent questionnaire (Pediatrics 2006;118:1985–93). Children with daytime wetting were twice as likely as those with no daytime wetting to demonstrate attention and activity problems (24.8%), oppositional behavior (10.9%), and conduct problems (11.8%).

An adjustment for developmental delay, which was identified in 276 children, significantly reduced the odds of oppositional behavior or attention and activity problems, but there was still a strong association between these problems and daytime wetting. An adjustment for comorbid soiling also reduced the odds ratios for externalizing behavior problems, but an independent association persisted, the researchers noted.

The rate of externalizing problems (attention/activity problems, oppositional disorder, and conduct disorder) was higher in the 82 (12.8%) children whose severe daytime wetting met the DSM-IV criteria.

Preschoolers Tolerate Methylphenidate

Adverse events were well tolerated in a majority of 3− to 5-year-olds who took methylphenidate for ADHD, based on data from 183 children, said Tim Wigal, Ph.D., of the University of California, Irvine, and his colleagues.

Although methylphenidate's safety had been studied in school-aged children, studies of its effects on preschoolers are limited, they noted.

Overall, 21 (11%) of the 183 children discontinued as a result of adverse events that were rated moderate to severe. During the initial treatment and randomized study phases, nine children discontinued the study because of emotionality/irritability and one each discontinued because of tics, tactile hallucinations, possible seizure, rash, and insomnia (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1294–303).

Adverse effects associated with discontinuation during the maintenance phase of the study included appetite loss, irritability, tics, weight loss, depression, anxiety, and social isolation. No cardiovascular-related adverse events were reported in any of the study phases.

The 11% rate of adverse events in this study of preschoolers is high, compared with the rates of less than 1% that have been reported among school-aged children. Rates of the most common adverse events, however, including irritability and emotionality, decreased significantly during the maintenance phase, which suggests that young children's tolerance of methylphenidate may improve with time, the researchers said.

Dr. Wigal has received financial support from several companies that manufacture and market methylphenidate, including Cephalon, Eli Lilly & Co., McNeil, and Shire.

ADHD and Tourette's: All in the Family

Tourette's disorder and ADHD may not have the same genetic cause, but cases in which the two conditions occur comorbidly tend to run in families, said Dr. S. Evelyn Stewart of Harvard University, Boston, and her associates.

To determine the possible connection between ADHD and TD in families, Dr. Stewart and her colleagues interviewed 239 patients aged 7–18 years and 692 relatives of various ages. The patients were divided into four case groups: 75 individuals with comorbid ADHD and TD, 74 with TD only, 41 with ADHD only, and 49 controls (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1354–62).

Comorbid rates of ADHD and TD were significantly higher among relatives of patients in all four case groups, compared with either condition alone. The age-corrected rates of ADHD were significantly higher in relatives with TD than in relatives without TD (48% vs. 13%). Similarly, the rates of TD were significantly higher among relatives with ADHD than in relatives without ADHD (27% vs. 5%). The ages of onset for ADHD and TD were not significantly different in relatives among the four case groups.

The presence of either the combined or the inattentive subtype of ADHD was a significant predictor of TD in relatives of study patients in all the case groups. Also, most cases of ADHD in relatives of study patients with TD were either the combined or the inattentive subtypes, suggesting that TD symptoms were probably not misdiagnosed as ADHD, the researchers noted.

Externalization in Daytime Wetters

Children aged 7–9 years who wet their pants during the day have significantly more parent-reported psychological problems than do children with no daytime wetting, based on data collected from 8,213 children as part of a longitudinal study.

The clinical implication is that early intervention for children who have frequent problems with daytime wetting may prevent psychological problems once they start school, reported Carol Joinson, Ph.D., of the University of Bristol (England).

Overall, 643 children (7.8%)–291 boys and 352 girls–reported daytime wetting, based on a parent questionnaire (Pediatrics 2006;118:1985–93). Children with daytime wetting were twice as likely as those with no daytime wetting to demonstrate attention and activity problems (24.8%), oppositional behavior (10.9%), and conduct problems (11.8%).

An adjustment for developmental delay, which was identified in 276 children, significantly reduced the odds of oppositional behavior or attention and activity problems, but there was still a strong association between these problems and daytime wetting. An adjustment for comorbid soiling also reduced the odds ratios for externalizing behavior problems, but an independent association persisted, the researchers noted.

The rate of externalizing problems (attention/activity problems, oppositional disorder, and conduct disorder) was higher in the 82 (12.8%) children whose severe daytime wetting met the DSM-IV criteria.

LAS VEGAS — An endoscopic device that has been used to detect lesions in the bladder and lung was able to detect unusual and inconspicuous endometrial lesions during laparoscopy that cannot be seen under white light, Dr. Steven F. Palter said in his award-winning presentation at the annual meeting of the American Association of Gynecologic Laparoscopists.

Dr. Palter and his colleagues conducted a pilot study using the D-Light system to detect lesions in patients suspected of having endometriosis because of pelvic pain or infertility. All suspected lesions were biopsied and excised for pathologic confirmation. Eight of 10 women were diagnosed with endometriosis, and 34 biopsies were reviewed.

Overall, 79% of the lesions diagnosed with autofluorescence were confirmed to be endometriosis. And the new technique revealed additional lesions in 75% of the patients who had endometriosis. As a result, 10 additional biopsies were taken, and 90% of these new lesions were confirmed.

“Therefore, 5 of 6 patients with suspected additional disease were confirmed,” Dr. Palter said. In other words, the autofluorescent technology identified additional disease in 62.5% of the patients studied.

“Our pilot study demonstrated the ability to visualize the endometriosis, and further studies are ongoing on clinical outcomes,” noted Dr. Palter, medical and scientific director of Gold Coast IVF, Syosset, N.Y. He disclosed that he serves as a consultant to Karl Storz Endoscopy-America, which makes the D-Light system.

“This was the first complete use of the system in the pelvis without drug dyes for the diagnosis of endometriosis in the United States,” said Dr. Palter. “Further studies are obviously required to determine the clinical outcome” of pain-free survival in patients who undergo a more complete excision of diseased tissue as a result of the imaging system.

The D-Light system has not been approved for pelvic use by the Food and Drug Administration, but it received IRB approval for the study. It's not yet known whether autofluorescence endoscopy will provide enough information on the depth of the lesion to know whether ablative or surgical excision will be the most appropriate treatment, he said.

In contrast to the classical dark, black, hemosiderin-like endometrial lesions that can be seen with normal white light, there are subtle and atypical clear, red, and white endometrial lesions with high metabolic activity that are now recognized as earlier forms of the disease. These atypical forms are found in most patients. The new autofluorescence endoscope system could improve the ability to see these lesions and render their detection less dependent on the ability and experience of the user, he said.

The standard method for the diagnosis of endometriosis is by direct, white-light illumination of lesions during laparoscopy with confirmation by biopsy.

Under normal white light illumination, most light is reflected back from the tissue at the same wavelength. A small percentage of photons are absorbed by the tissue and released at another wavelength in the process of autofluorescence. In regular endoscopy, the autofluorescent light is present but cannot be seen, since it is overpowered by the large amount of white light, Dr. Palter said.

An autofluorescence endoscope differs from a regular endoscope by the use of two additional colored filters that enhance the visualization of autofluorescent light. The first one filters the light illuminating the tissue from the wavelength range in a normal white light mode into a narrower, blue-light range, which intensifies the amount of fluorescent light that is released from the tissue at a higher wavelength. Another filter blocks reflected light with a wavelength shorter than 450 nm. This second filter blocks more than 99.5% of the reflected blue light, enhancing the small amount of fluorescent light emitted from the tissue so that it can be visualized. Endometrial lesions may appear dark blue if they block the green background fluorescence or they may be hyperfluorescent with an increased level of fluorescence, compared with the background.

Further details of the studies, including photos and videos of the system, are available on Dr. Palter's Web site and blog about future technology and medicine at http://docinthemachine.com/afendo

An autofluorescence endoscope differs from a regular endoscope by the use of two additional colored filters. Images courtesy Dr. Steven F. Palter

In regular endoscopy, white light is used (A). The light is filtered from white into a narrower, blue range (B). Reflected blue light is filtered; endometrial lesions may appear dark blue if they block the green background fluorescence, now visible (C).

LAS VEGAS — An endoscopic device that has been used to detect lesions in the bladder and lung was able to detect unusual and inconspicuous endometrial lesions during laparoscopy that cannot be seen under white light, Dr. Steven F. Palter said in his award-winning presentation at the annual meeting of the American Association of Gynecologic Laparoscopists.

Dr. Palter and his colleagues conducted a pilot study using the D-Light system to detect lesions in patients suspected of having endometriosis because of pelvic pain or infertility. All suspected lesions were biopsied and excised for pathologic confirmation. Eight of 10 women were diagnosed with endometriosis, and 34 biopsies were reviewed.

Overall, 79% of the lesions diagnosed with autofluorescence were confirmed to be endometriosis. And the new technique revealed additional lesions in 75% of the patients who had endometriosis. As a result, 10 additional biopsies were taken, and 90% of these new lesions were confirmed.

“Therefore, 5 of 6 patients with suspected additional disease were confirmed,” Dr. Palter said. In other words, the autofluorescent technology identified additional disease in 62.5% of the patients studied.

“Our pilot study demonstrated the ability to visualize the endometriosis, and further studies are ongoing on clinical outcomes,” noted Dr. Palter, medical and scientific director of Gold Coast IVF, Syosset, N.Y. He disclosed that he serves as a consultant to Karl Storz Endoscopy-America, which makes the D-Light system.

“This was the first complete use of the system in the pelvis without drug dyes for the diagnosis of endometriosis in the United States,” said Dr. Palter. “Further studies are obviously required to determine the clinical outcome” of pain-free survival in patients who undergo a more complete excision of diseased tissue as a result of the imaging system.

The D-Light system has not been approved for pelvic use by the Food and Drug Administration, but it received IRB approval for the study. It's not yet known whether autofluorescence endoscopy will provide enough information on the depth of the lesion to know whether ablative or surgical excision will be the most appropriate treatment, he said.

In contrast to the classical dark, black, hemosiderin-like endometrial lesions that can be seen with normal white light, there are subtle and atypical clear, red, and white endometrial lesions with high metabolic activity that are now recognized as earlier forms of the disease. These atypical forms are found in most patients. The new autofluorescence endoscope system could improve the ability to see these lesions and render their detection less dependent on the ability and experience of the user, he said.

The standard method for the diagnosis of endometriosis is by direct, white-light illumination of lesions during laparoscopy with confirmation by biopsy.

Under normal white light illumination, most light is reflected back from the tissue at the same wavelength. A small percentage of photons are absorbed by the tissue and released at another wavelength in the process of autofluorescence. In regular endoscopy, the autofluorescent light is present but cannot be seen, since it is overpowered by the large amount of white light, Dr. Palter said.

An autofluorescence endoscope differs from a regular endoscope by the use of two additional colored filters that enhance the visualization of autofluorescent light. The first one filters the light illuminating the tissue from the wavelength range in a normal white light mode into a narrower, blue-light range, which intensifies the amount of fluorescent light that is released from the tissue at a higher wavelength. Another filter blocks reflected light with a wavelength shorter than 450 nm. This second filter blocks more than 99.5% of the reflected blue light, enhancing the small amount of fluorescent light emitted from the tissue so that it can be visualized. Endometrial lesions may appear dark blue if they block the green background fluorescence or they may be hyperfluorescent with an increased level of fluorescence, compared with the background.

Further details of the studies, including photos and videos of the system, are available on Dr. Palter's Web site and blog about future technology and medicine at http://docinthemachine.com/afendo

An autofluorescence endoscope differs from a regular endoscope by the use of two additional colored filters. Images courtesy Dr. Steven F. Palter

In regular endoscopy, white light is used (A). The light is filtered from white into a narrower, blue range (B). Reflected blue light is filtered; endometrial lesions may appear dark blue if they block the green background fluorescence, now visible (C).

LAS VEGAS — An endoscopic device that has been used to detect lesions in the bladder and lung was able to detect unusual and inconspicuous endometrial lesions during laparoscopy that cannot be seen under white light, Dr. Steven F. Palter said in his award-winning presentation at the annual meeting of the American Association of Gynecologic Laparoscopists.

Dr. Palter and his colleagues conducted a pilot study using the D-Light system to detect lesions in patients suspected of having endometriosis because of pelvic pain or infertility. All suspected lesions were biopsied and excised for pathologic confirmation. Eight of 10 women were diagnosed with endometriosis, and 34 biopsies were reviewed.

Overall, 79% of the lesions diagnosed with autofluorescence were confirmed to be endometriosis. And the new technique revealed additional lesions in 75% of the patients who had endometriosis. As a result, 10 additional biopsies were taken, and 90% of these new lesions were confirmed.

“Therefore, 5 of 6 patients with suspected additional disease were confirmed,” Dr. Palter said. In other words, the autofluorescent technology identified additional disease in 62.5% of the patients studied.

“Our pilot study demonstrated the ability to visualize the endometriosis, and further studies are ongoing on clinical outcomes,” noted Dr. Palter, medical and scientific director of Gold Coast IVF, Syosset, N.Y. He disclosed that he serves as a consultant to Karl Storz Endoscopy-America, which makes the D-Light system.

“This was the first complete use of the system in the pelvis without drug dyes for the diagnosis of endometriosis in the United States,” said Dr. Palter. “Further studies are obviously required to determine the clinical outcome” of pain-free survival in patients who undergo a more complete excision of diseased tissue as a result of the imaging system.

The D-Light system has not been approved for pelvic use by the Food and Drug Administration, but it received IRB approval for the study. It's not yet known whether autofluorescence endoscopy will provide enough information on the depth of the lesion to know whether ablative or surgical excision will be the most appropriate treatment, he said.

In contrast to the classical dark, black, hemosiderin-like endometrial lesions that can be seen with normal white light, there are subtle and atypical clear, red, and white endometrial lesions with high metabolic activity that are now recognized as earlier forms of the disease. These atypical forms are found in most patients. The new autofluorescence endoscope system could improve the ability to see these lesions and render their detection less dependent on the ability and experience of the user, he said.

The standard method for the diagnosis of endometriosis is by direct, white-light illumination of lesions during laparoscopy with confirmation by biopsy.

Under normal white light illumination, most light is reflected back from the tissue at the same wavelength. A small percentage of photons are absorbed by the tissue and released at another wavelength in the process of autofluorescence. In regular endoscopy, the autofluorescent light is present but cannot be seen, since it is overpowered by the large amount of white light, Dr. Palter said.

An autofluorescence endoscope differs from a regular endoscope by the use of two additional colored filters that enhance the visualization of autofluorescent light. The first one filters the light illuminating the tissue from the wavelength range in a normal white light mode into a narrower, blue-light range, which intensifies the amount of fluorescent light that is released from the tissue at a higher wavelength. Another filter blocks reflected light with a wavelength shorter than 450 nm. This second filter blocks more than 99.5% of the reflected blue light, enhancing the small amount of fluorescent light emitted from the tissue so that it can be visualized. Endometrial lesions may appear dark blue if they block the green background fluorescence or they may be hyperfluorescent with an increased level of fluorescence, compared with the background.

Further details of the studies, including photos and videos of the system, are available on Dr. Palter's Web site and blog about future technology and medicine at http://docinthemachine.com/afendo

An autofluorescence endoscope differs from a regular endoscope by the use of two additional colored filters. Images courtesy Dr. Steven F. Palter

In regular endoscopy, white light is used (A). The light is filtered from white into a narrower, blue range (B). Reflected blue light is filtered; endometrial lesions may appear dark blue if they block the green background fluorescence, now visible (C).

CHARLESTON, S.C. — Give breast-feeding women enough vitamin D and you may supplement their babies, too, according to the results of a small but promising pilot study presented at a pediatric meeting sponsored by the Medical University of South Carolina.

“Our question was: 'Would direct vitamin D supplementation meet the needs of both the mother and her nursing infant?'” said Dr. Carol L. Wagner of the department of neonatology at the university, in Charleston.

Insufficient vitamin D causes many problems, primarily a lack of calcium absorption that can lead to bone loss. In addition, recent research suggests a link between insufficient vitamin D and immune system disorders such as diabetes, Dr. Wagner said.

People in the developed world are at risk for vitamin D deficiency because of a primarily indoor lifestyle that has limited adequate vitamin D intake from sunlight, she added.

Data from several recent studies suggest that doses of vitamin D that are significantly higher than the current recommended daily allowance will not cause toxicity and are in fact needed for adequate circulating 25-hydroxyvitamin D concentrations (25[OH]D).

To determine whether giving mothers high doses of vitamin D provides adequate 25(OH)D for both mothers and infants without toxicity to either, Dr. Wagner and colleagues randomized 18 breast-feeding women to receive 400 IU or 6,400 IU of vitamin D₃ as a daily pill for 6 months starting at 1 month post partum.

The mothers who were randomized to 6,400 IU of vitamin D₃ showed a substantial increase in circulating calcium levels with no adverse effects.

In addition, compliance rates were more than 90% because the mothers said that they were more likely to remember to take a pill themselves than to give supplements to their babies.

The infants whose mothers took 400 IU received their own supplement of 300 IU daily, while the infants whose mothers took 6,400 IU received a placebo supplement.

“What we found was a wonderful increase,” in infant 25(OH)D levels from breast milk alone, Dr. Wagner said.

After 6 months, the average 25(OH)D level was 47 ng/mL in the mothers who received 6,400 IU and 46 ng/mL in their babies. By comparison, the average 25(OH)D level was 38 ng/mL in the mothers who received 400 IU and 43 ng/mL in their babies. There were no adverse events in either mother or infant related to vitamin D toxicity.

“Supplementing the mom with high-dose vitamin D is still considered unproven,” Dr. Wagner said. “We think it is safe, but we have to study it in large numbers.” A study of 389 lactating women at sites in Charleston, S.C., and Rochester, N.Y., is planned, and the researchers will assess factors including bone mineral density and immune function.

For now, Dr. Wagner encourages physicians to recommend vitamin D supplementation for breast-feeding infants, but if the circulating vitamin D levels in the mothers are 50 ng/mL or higher, the infants are probably getting enough, too. Strive for circulating 25(OH)D levels of at least 30 ng/mL in all patients, she emphasized.

The American Academy of Pediatrics currently recommends vitamin D supplementation for all breast-fed infants because mother's milk is generally deficient in vitamin D. But 25% of the vitamin D in lactating women goes into breast milk, and it seems that increasing vitamin D in mothers results in adequate vitamin D for the breast-fed infant, Dr. Wagner explained.

Because a mother is the only source of vitamin D for her developing fetus and the primary source for a breast-feeding infant, more research is needed on whether increasing maternal vitamin D will help infants, too.

CHARLESTON, S.C. — Give breast-feeding women enough vitamin D and you may supplement their babies, too, according to the results of a small but promising pilot study presented at a pediatric meeting sponsored by the Medical University of South Carolina.

“Our question was: 'Would direct vitamin D supplementation meet the needs of both the mother and her nursing infant?'” said Dr. Carol L. Wagner of the department of neonatology at the university, in Charleston.

Insufficient vitamin D causes many problems, primarily a lack of calcium absorption that can lead to bone loss. In addition, recent research suggests a link between insufficient vitamin D and immune system disorders such as diabetes, Dr. Wagner said.

People in the developed world are at risk for vitamin D deficiency because of a primarily indoor lifestyle that has limited adequate vitamin D intake from sunlight, she added.

Data from several recent studies suggest that doses of vitamin D that are significantly higher than the current recommended daily allowance will not cause toxicity and are in fact needed for adequate circulating 25-hydroxyvitamin D concentrations (25[OH]D).

To determine whether giving mothers high doses of vitamin D provides adequate 25(OH)D for both mothers and infants without toxicity to either, Dr. Wagner and colleagues randomized 18 breast-feeding women to receive 400 IU or 6,400 IU of vitamin D₃ as a daily pill for 6 months starting at 1 month post partum.

The mothers who were randomized to 6,400 IU of vitamin D₃ showed a substantial increase in circulating calcium levels with no adverse effects.

In addition, compliance rates were more than 90% because the mothers said that they were more likely to remember to take a pill themselves than to give supplements to their babies.

The infants whose mothers took 400 IU received their own supplement of 300 IU daily, while the infants whose mothers took 6,400 IU received a placebo supplement.

“What we found was a wonderful increase,” in infant 25(OH)D levels from breast milk alone, Dr. Wagner said.

After 6 months, the average 25(OH)D level was 47 ng/mL in the mothers who received 6,400 IU and 46 ng/mL in their babies. By comparison, the average 25(OH)D level was 38 ng/mL in the mothers who received 400 IU and 43 ng/mL in their babies. There were no adverse events in either mother or infant related to vitamin D toxicity.

“Supplementing the mom with high-dose vitamin D is still considered unproven,” Dr. Wagner said. “We think it is safe, but we have to study it in large numbers.” A study of 389 lactating women at sites in Charleston, S.C., and Rochester, N.Y., is planned, and the researchers will assess factors including bone mineral density and immune function.

For now, Dr. Wagner encourages physicians to recommend vitamin D supplementation for breast-feeding infants, but if the circulating vitamin D levels in the mothers are 50 ng/mL or higher, the infants are probably getting enough, too. Strive for circulating 25(OH)D levels of at least 30 ng/mL in all patients, she emphasized.

The American Academy of Pediatrics currently recommends vitamin D supplementation for all breast-fed infants because mother's milk is generally deficient in vitamin D. But 25% of the vitamin D in lactating women goes into breast milk, and it seems that increasing vitamin D in mothers results in adequate vitamin D for the breast-fed infant, Dr. Wagner explained.

Because a mother is the only source of vitamin D for her developing fetus and the primary source for a breast-feeding infant, more research is needed on whether increasing maternal vitamin D will help infants, too.

CHARLESTON, S.C. — Give breast-feeding women enough vitamin D and you may supplement their babies, too, according to the results of a small but promising pilot study presented at a pediatric meeting sponsored by the Medical University of South Carolina.

“Our question was: 'Would direct vitamin D supplementation meet the needs of both the mother and her nursing infant?'” said Dr. Carol L. Wagner of the department of neonatology at the university, in Charleston.

Insufficient vitamin D causes many problems, primarily a lack of calcium absorption that can lead to bone loss. In addition, recent research suggests a link between insufficient vitamin D and immune system disorders such as diabetes, Dr. Wagner said.

People in the developed world are at risk for vitamin D deficiency because of a primarily indoor lifestyle that has limited adequate vitamin D intake from sunlight, she added.

Data from several recent studies suggest that doses of vitamin D that are significantly higher than the current recommended daily allowance will not cause toxicity and are in fact needed for adequate circulating 25-hydroxyvitamin D concentrations (25[OH]D).

To determine whether giving mothers high doses of vitamin D provides adequate 25(OH)D for both mothers and infants without toxicity to either, Dr. Wagner and colleagues randomized 18 breast-feeding women to receive 400 IU or 6,400 IU of vitamin D₃ as a daily pill for 6 months starting at 1 month post partum.

The mothers who were randomized to 6,400 IU of vitamin D₃ showed a substantial increase in circulating calcium levels with no adverse effects.

In addition, compliance rates were more than 90% because the mothers said that they were more likely to remember to take a pill themselves than to give supplements to their babies.

The infants whose mothers took 400 IU received their own supplement of 300 IU daily, while the infants whose mothers took 6,400 IU received a placebo supplement.

“What we found was a wonderful increase,” in infant 25(OH)D levels from breast milk alone, Dr. Wagner said.

After 6 months, the average 25(OH)D level was 47 ng/mL in the mothers who received 6,400 IU and 46 ng/mL in their babies. By comparison, the average 25(OH)D level was 38 ng/mL in the mothers who received 400 IU and 43 ng/mL in their babies. There were no adverse events in either mother or infant related to vitamin D toxicity.

“Supplementing the mom with high-dose vitamin D is still considered unproven,” Dr. Wagner said. “We think it is safe, but we have to study it in large numbers.” A study of 389 lactating women at sites in Charleston, S.C., and Rochester, N.Y., is planned, and the researchers will assess factors including bone mineral density and immune function.

For now, Dr. Wagner encourages physicians to recommend vitamin D supplementation for breast-feeding infants, but if the circulating vitamin D levels in the mothers are 50 ng/mL or higher, the infants are probably getting enough, too. Strive for circulating 25(OH)D levels of at least 30 ng/mL in all patients, she emphasized.

The American Academy of Pediatrics currently recommends vitamin D supplementation for all breast-fed infants because mother's milk is generally deficient in vitamin D. But 25% of the vitamin D in lactating women goes into breast milk, and it seems that increasing vitamin D in mothers results in adequate vitamin D for the breast-fed infant, Dr. Wagner explained.

Because a mother is the only source of vitamin D for her developing fetus and the primary source for a breast-feeding infant, more research is needed on whether increasing maternal vitamin D will help infants, too.

WASHINGTON — One way to develop a research project in family medicine would be to contact a local network that keeps an inventory of clinical research projects taking place in primary care, Dr. Donya Powers said at the annual meeting of the American Academy of Family Physicians.

“It's hard for any one family doctor to have enough cases to say enough statistically about them,” said Dr. Powers of Brown University, Providence, R.I. Local research networks often have ongoing projects that are already funded but need more patients, she added.

The Federation of Practice-Based Research Networks (FPBRN) is an umbrella organization that addresses national issues faced by the networks, including rules related to consent and Institutional Review Board approval.

Patient consent and IRB approval are crucial if a study involves a patient intervention, although the rules of a quality improvement study may be more lenient than the rules for a study sponsored by a drug company, Dr. Powers explained.

For more information, visit the FPBRN Web site, which can been accessed through the AAFP site: www.aafp.org/online/en/home/clinical/research/fpbrn.html

WASHINGTON — One way to develop a research project in family medicine would be to contact a local network that keeps an inventory of clinical research projects taking place in primary care, Dr. Donya Powers said at the annual meeting of the American Academy of Family Physicians.

“It's hard for any one family doctor to have enough cases to say enough statistically about them,” said Dr. Powers of Brown University, Providence, R.I. Local research networks often have ongoing projects that are already funded but need more patients, she added.

The Federation of Practice-Based Research Networks (FPBRN) is an umbrella organization that addresses national issues faced by the networks, including rules related to consent and Institutional Review Board approval.

Patient consent and IRB approval are crucial if a study involves a patient intervention, although the rules of a quality improvement study may be more lenient than the rules for a study sponsored by a drug company, Dr. Powers explained.

For more information, visit the FPBRN Web site, which can been accessed through the AAFP site: www.aafp.org/online/en/home/clinical/research/fpbrn.html

WASHINGTON — One way to develop a research project in family medicine would be to contact a local network that keeps an inventory of clinical research projects taking place in primary care, Dr. Donya Powers said at the annual meeting of the American Academy of Family Physicians.

“It's hard for any one family doctor to have enough cases to say enough statistically about them,” said Dr. Powers of Brown University, Providence, R.I. Local research networks often have ongoing projects that are already funded but need more patients, she added.

The Federation of Practice-Based Research Networks (FPBRN) is an umbrella organization that addresses national issues faced by the networks, including rules related to consent and Institutional Review Board approval.

Patient consent and IRB approval are crucial if a study involves a patient intervention, although the rules of a quality improvement study may be more lenient than the rules for a study sponsored by a drug company, Dr. Powers explained.

For more information, visit the FPBRN Web site, which can been accessed through the AAFP site: www.aafp.org/online/en/home/clinical/research/fpbrn.html

Rapid Flu Test Trims Further Tests, Tx

Rapid viral testing for influenza as part of the routine care plan for febrile infants reduced antibiotic use, emergency department visits, and the use of additional tests, based on data from a prospective study of 206 infants during the course of two flu seasons.

Nonspecific fevers without obvious signs of infection send many infants to the pediatric emergency department, and rapid flu testing in these settings can help triage patients more effectively and reduce unnecessary tests and treatment, wrote Dr. Javier Benito-Fernandez of the pediatric emergency department in Hospital de Cruces, Barakaldo, Spain, and colleagues.

Overall, 84 of 206 (41%) infants aged 0–36 months tested positive based on commercially available rapid flu tests. The influenza-positive infants were significantly less likely than influenza-negative infants to undergo blood tests (33% vs. 100%), urinalysis (81% vs. 100%), chest radiographs (14% vs. 32%), and lumbar punctures for cerebrospinal fluid analysis (2% vs. 21%). In addition, none of the influenza-positive infants received antibiotics at the time of diagnosis, compared with 39% of the influenza-negative infants (Pediatr. Infect. Dis. J. 2006;25:1153–7).

Only two influenza-positive infants (2%) required hospital stays for observation, compared with 20 influenza-negative infants (16%) admitted for diagnoses including pneumonia, meningitis, urinary tract infection, and bacteremia. All influenza-positive patients had a favorable clinical course, the investigators said.

New Coronavirus Subtypes on Rise

Two recently discovered coronavirus subtypes, NL63 and HKU1, accounted for a majority of the 66 coronaviruses identified in a review of 1,043 samples from children with acute respiratory illness.

Overall, coronavirus subtypes HKU1, OC43, NL63, and 229E were identified in 28, 19, 11, and 8 specimens, respectively, reported Jane Kuypers, Ph.D., of the University of Washington, Seattle, and her colleagues (Pediatrics 2007;119:e70–6 [doi:10.1542/peds.2006–1406]).

The researchers collected specimens from patients aged 0–19 years who presented to a children's hospital with upper respiratory illness from October 2003 through September 2004. The acute clinical features experienced by the children were not significantly different based on the virus type.

A coronavirus was the only respiratory viral pathogen identified in 32 (57%) of the 56 children for whom complete clinical data were available, including 14 patients with HKU1, 11 with OC43, 5 with NL63, and 2 with 229E. Of these, children infected only with a coronavirus were significantly more likely to have underlying medical conditions, compared with children who were infected with more than one respiratory virus.

Three children (one each infected with HKU1, OC43, and 229E) were treated in the intensive care unit, and two of them needed ventilators. In addition, six immunocompromised children had coronavirus as the sole pathogen, including five children with acute lymphocytic leukemia and one renal transplant patient. Three of the children with leukemia and the transplant patient required hospital stays ranging from 2 to 12 days.

The findings diverge from previous coronavirus research by showing that the viruses were present year-round; specimens from at least one virus were collected during each month, although the monthly specimen total peaked at 218 in December 2003.

Levofloxacin Succeeds vs. AOM

Treatment with oral levofloxacin is safe and effective against bacteria in the middle-ear fluid of children with recurrent or persistent acute otitis media, based on data from children aged 6 months to 5 years.

The open-label study, sponsored by Johnson and Johnson Pharmaceutical Research and Development, included 204 children with confirmed acute otitis media who received at least one 10-mg/kg dose of the study medication (Pediatr. Infect. Dis. J. 2006;25:1102–9). The full course of therapy was 10 mg/kg of levofloxacin twice daily for 10 days.

A total of 105 pathogens were recovered from the middle-ear fluid of 89 bacteriologically evaluable children using tympanocentesis. Haemophilus influenzae, the most common pathogen, was identified in 54 children, either alone or along with Streptococcus pneumoniae or Moraxella catarrhalis.

All of the H. influenzae and S. pneumoniae isolates were susceptible to levofloxacin, and the eradication rates for these pathogens were 100% and 84%, respectively. The eradication rate for M. catarrhalis was 100%, wrote Dr. Adriano Arguedas of the Universidad de Ciencias Médicas, in San José, Costa Rica, and colleagues. No cartilage damage was reported in any patients.

Rapid Flu Test Trims Further Tests, Tx

Rapid viral testing for influenza as part of the routine care plan for febrile infants reduced antibiotic use, emergency department visits, and the use of additional tests, based on data from a prospective study of 206 infants during the course of two flu seasons.

Nonspecific fevers without obvious signs of infection send many infants to the pediatric emergency department, and rapid flu testing in these settings can help triage patients more effectively and reduce unnecessary tests and treatment, wrote Dr. Javier Benito-Fernandez of the pediatric emergency department in Hospital de Cruces, Barakaldo, Spain, and colleagues.

Overall, 84 of 206 (41%) infants aged 0–36 months tested positive based on commercially available rapid flu tests. The influenza-positive infants were significantly less likely than influenza-negative infants to undergo blood tests (33% vs. 100%), urinalysis (81% vs. 100%), chest radiographs (14% vs. 32%), and lumbar punctures for cerebrospinal fluid analysis (2% vs. 21%). In addition, none of the influenza-positive infants received antibiotics at the time of diagnosis, compared with 39% of the influenza-negative infants (Pediatr. Infect. Dis. J. 2006;25:1153–7).

Only two influenza-positive infants (2%) required hospital stays for observation, compared with 20 influenza-negative infants (16%) admitted for diagnoses including pneumonia, meningitis, urinary tract infection, and bacteremia. All influenza-positive patients had a favorable clinical course, the investigators said.

New Coronavirus Subtypes on Rise

Two recently discovered coronavirus subtypes, NL63 and HKU1, accounted for a majority of the 66 coronaviruses identified in a review of 1,043 samples from children with acute respiratory illness.

Overall, coronavirus subtypes HKU1, OC43, NL63, and 229E were identified in 28, 19, 11, and 8 specimens, respectively, reported Jane Kuypers, Ph.D., of the University of Washington, Seattle, and her colleagues (Pediatrics 2007;119:e70–6 [doi:10.1542/peds.2006–1406]).

The researchers collected specimens from patients aged 0–19 years who presented to a children's hospital with upper respiratory illness from October 2003 through September 2004. The acute clinical features experienced by the children were not significantly different based on the virus type.

A coronavirus was the only respiratory viral pathogen identified in 32 (57%) of the 56 children for whom complete clinical data were available, including 14 patients with HKU1, 11 with OC43, 5 with NL63, and 2 with 229E. Of these, children infected only with a coronavirus were significantly more likely to have underlying medical conditions, compared with children who were infected with more than one respiratory virus.

Three children (one each infected with HKU1, OC43, and 229E) were treated in the intensive care unit, and two of them needed ventilators. In addition, six immunocompromised children had coronavirus as the sole pathogen, including five children with acute lymphocytic leukemia and one renal transplant patient. Three of the children with leukemia and the transplant patient required hospital stays ranging from 2 to 12 days.

The findings diverge from previous coronavirus research by showing that the viruses were present year-round; specimens from at least one virus were collected during each month, although the monthly specimen total peaked at 218 in December 2003.

Levofloxacin Succeeds vs. AOM

Treatment with oral levofloxacin is safe and effective against bacteria in the middle-ear fluid of children with recurrent or persistent acute otitis media, based on data from children aged 6 months to 5 years.

The open-label study, sponsored by Johnson and Johnson Pharmaceutical Research and Development, included 204 children with confirmed acute otitis media who received at least one 10-mg/kg dose of the study medication (Pediatr. Infect. Dis. J. 2006;25:1102–9). The full course of therapy was 10 mg/kg of levofloxacin twice daily for 10 days.

A total of 105 pathogens were recovered from the middle-ear fluid of 89 bacteriologically evaluable children using tympanocentesis. Haemophilus influenzae, the most common pathogen, was identified in 54 children, either alone or along with Streptococcus pneumoniae or Moraxella catarrhalis.

All of the H. influenzae and S. pneumoniae isolates were susceptible to levofloxacin, and the eradication rates for these pathogens were 100% and 84%, respectively. The eradication rate for M. catarrhalis was 100%, wrote Dr. Adriano Arguedas of the Universidad de Ciencias Médicas, in San José, Costa Rica, and colleagues. No cartilage damage was reported in any patients.

Rapid Flu Test Trims Further Tests, Tx

Rapid viral testing for influenza as part of the routine care plan for febrile infants reduced antibiotic use, emergency department visits, and the use of additional tests, based on data from a prospective study of 206 infants during the course of two flu seasons.

Nonspecific fevers without obvious signs of infection send many infants to the pediatric emergency department, and rapid flu testing in these settings can help triage patients more effectively and reduce unnecessary tests and treatment, wrote Dr. Javier Benito-Fernandez of the pediatric emergency department in Hospital de Cruces, Barakaldo, Spain, and colleagues.

Overall, 84 of 206 (41%) infants aged 0–36 months tested positive based on commercially available rapid flu tests. The influenza-positive infants were significantly less likely than influenza-negative infants to undergo blood tests (33% vs. 100%), urinalysis (81% vs. 100%), chest radiographs (14% vs. 32%), and lumbar punctures for cerebrospinal fluid analysis (2% vs. 21%). In addition, none of the influenza-positive infants received antibiotics at the time of diagnosis, compared with 39% of the influenza-negative infants (Pediatr. Infect. Dis. J. 2006;25:1153–7).

Only two influenza-positive infants (2%) required hospital stays for observation, compared with 20 influenza-negative infants (16%) admitted for diagnoses including pneumonia, meningitis, urinary tract infection, and bacteremia. All influenza-positive patients had a favorable clinical course, the investigators said.

New Coronavirus Subtypes on Rise

Two recently discovered coronavirus subtypes, NL63 and HKU1, accounted for a majority of the 66 coronaviruses identified in a review of 1,043 samples from children with acute respiratory illness.

Overall, coronavirus subtypes HKU1, OC43, NL63, and 229E were identified in 28, 19, 11, and 8 specimens, respectively, reported Jane Kuypers, Ph.D., of the University of Washington, Seattle, and her colleagues (Pediatrics 2007;119:e70–6 [doi:10.1542/peds.2006–1406]).

The researchers collected specimens from patients aged 0–19 years who presented to a children's hospital with upper respiratory illness from October 2003 through September 2004. The acute clinical features experienced by the children were not significantly different based on the virus type.

A coronavirus was the only respiratory viral pathogen identified in 32 (57%) of the 56 children for whom complete clinical data were available, including 14 patients with HKU1, 11 with OC43, 5 with NL63, and 2 with 229E. Of these, children infected only with a coronavirus were significantly more likely to have underlying medical conditions, compared with children who were infected with more than one respiratory virus.

Three children (one each infected with HKU1, OC43, and 229E) were treated in the intensive care unit, and two of them needed ventilators. In addition, six immunocompromised children had coronavirus as the sole pathogen, including five children with acute lymphocytic leukemia and one renal transplant patient. Three of the children with leukemia and the transplant patient required hospital stays ranging from 2 to 12 days.

The findings diverge from previous coronavirus research by showing that the viruses were present year-round; specimens from at least one virus were collected during each month, although the monthly specimen total peaked at 218 in December 2003.

Levofloxacin Succeeds vs. AOM

Treatment with oral levofloxacin is safe and effective against bacteria in the middle-ear fluid of children with recurrent or persistent acute otitis media, based on data from children aged 6 months to 5 years.

The open-label study, sponsored by Johnson and Johnson Pharmaceutical Research and Development, included 204 children with confirmed acute otitis media who received at least one 10-mg/kg dose of the study medication (Pediatr. Infect. Dis. J. 2006;25:1102–9). The full course of therapy was 10 mg/kg of levofloxacin twice daily for 10 days.

A total of 105 pathogens were recovered from the middle-ear fluid of 89 bacteriologically evaluable children using tympanocentesis. Haemophilus influenzae, the most common pathogen, was identified in 54 children, either alone or along with Streptococcus pneumoniae or Moraxella catarrhalis.

All of the H. influenzae and S. pneumoniae isolates were susceptible to levofloxacin, and the eradication rates for these pathogens were 100% and 84%, respectively. The eradication rate for M. catarrhalis was 100%, wrote Dr. Adriano Arguedas of the Universidad de Ciencias Médicas, in San José, Costa Rica, and colleagues. No cartilage damage was reported in any patients.

CHARLESTON, S.C. — Primary care physicians should provide brief, focused advice to parents whose school-aged children are on the brink of overweight and by doing so, they can make a real difference, Dr. Stephen Cook said at a pediatric meeting sponsored by the Medical University of South Carolina.

“Only 20% of overweight kids aged 5–11 years are identified in the primary care office,” said Dr. Cook, a pediatrician at the University of Rochester (N.Y.).

One should start with a body mass index (BMI) measurement. “The BMI is a great first trigger point at a well-child visit,” Dr. Cook said.

“The BMI is going to open your eyes to kids in the problem range.” But be sure to review correct BMI measurement with your staff, he added. The children can be clothed, but ask them to remove shoes, jackets, and hats.

Although the BMI is not perfect, it is a simple tool that fairly accurately assesses weight status in prepubertal children, Dr. Cook said. If the child's BMI is on the cusp or indicates just slight overweight, use a motivational interviewing tactic and ask the parent and child whether they think weight is a problem.

“I ask, 'On a scale of 1 to 10, how important is it to you right now that the child's weight status might be unhealthy?'” he said.

“There is enough to do in a well-child visit that extensive counseling for obesity” may not be possible during that time, Dr. Cook said. But you can identify that weight is a potential problem, make the family aware of it, and document it in the record.

In some families, the child's weight simply is not a priority. If the family is not interested in talking about weight, then offer a nonjudgmental response, suggest a reasonable time for a follow-up visit, and move on, Dr. Cook advised. But if families do express some concern about weight, listen to their responses to the following question: “The BMI shows that your child is overweight; what do you think about that?” After you have listened, briefly share some tips about how simple changes—such as cutting down on juice and moving the TV out of the bedroom—can make the difference in keeping children within a healthy weight range. Invite the family for a follow-up visit as soon as possible for positive reinforcement and more tips on keeping the child's weight in the healthy range.

The calorie shift in prepubertal children is very small, only about 150 calories a day, Dr. Cook noted. That's equivalent to one juice box or one can of regular (nondiet) soda.

Behavior changes for a prepubertal child with a motivated family can be explained in depth by a nurse or other nonphysician provider in a follow-up visit. In some cases, a second visit is the time to identify barriers to behavior change and how to address them.

Identify problems related to diet and exercise habits, such as caretakers who give children high-calorie or junk foods and excessive snacks. Ask about opportunities for exercise and play, such as school recess and gym class; options for walking or biking to school; and ways to replace some “screen time” with physical activity, either indoors or outdoors.

One should also remember that medical statistics do not motivate children. Children are motivated by peer approval, a sense of accomplishment, and a desire to please a parent or other adult, Dr. Cook pointed out.

“The small steps we can make in these younger age groups can really effect some change, and the parents feel enabled,” he noted.

A primary care physician may not be able to do much for the morbidly obese 5-year-old who needs a referral, but doctors who stay alert to changes in BMI and listen to patients and families can make a difference for a 5-year-old who was normal weight last year but slightly overweight this year, Dr. Cook said.

A brief office visit is not the best time for the doctor to overwhelm a family with information about rising childhood obesity rates and the increased risk of health problems that could arise later in life.

Instead, one should try creating a single-page handout that focuses on a few practical points, such as “Children who watch more than 2 hours of TV daily or have more than two sweetened drinks a day are more likely to become overweight or obese.”

The handout should be given to the family, and that may be as far as you are able to go that day in discussing weight. The handout may go directly into the trash, or it may give children and families food for thought.

CHARLESTON, S.C. — Primary care physicians should provide brief, focused advice to parents whose school-aged children are on the brink of overweight and by doing so, they can make a real difference, Dr. Stephen Cook said at a pediatric meeting sponsored by the Medical University of South Carolina.

“Only 20% of overweight kids aged 5–11 years are identified in the primary care office,” said Dr. Cook, a pediatrician at the University of Rochester (N.Y.).

One should start with a body mass index (BMI) measurement. “The BMI is a great first trigger point at a well-child visit,” Dr. Cook said.

“The BMI is going to open your eyes to kids in the problem range.” But be sure to review correct BMI measurement with your staff, he added. The children can be clothed, but ask them to remove shoes, jackets, and hats.

Although the BMI is not perfect, it is a simple tool that fairly accurately assesses weight status in prepubertal children, Dr. Cook said. If the child's BMI is on the cusp or indicates just slight overweight, use a motivational interviewing tactic and ask the parent and child whether they think weight is a problem.

“I ask, 'On a scale of 1 to 10, how important is it to you right now that the child's weight status might be unhealthy?'” he said.

“There is enough to do in a well-child visit that extensive counseling for obesity” may not be possible during that time, Dr. Cook said. But you can identify that weight is a potential problem, make the family aware of it, and document it in the record.

In some families, the child's weight simply is not a priority. If the family is not interested in talking about weight, then offer a nonjudgmental response, suggest a reasonable time for a follow-up visit, and move on, Dr. Cook advised. But if families do express some concern about weight, listen to their responses to the following question: “The BMI shows that your child is overweight; what do you think about that?” After you have listened, briefly share some tips about how simple changes—such as cutting down on juice and moving the TV out of the bedroom—can make the difference in keeping children within a healthy weight range. Invite the family for a follow-up visit as soon as possible for positive reinforcement and more tips on keeping the child's weight in the healthy range.

The calorie shift in prepubertal children is very small, only about 150 calories a day, Dr. Cook noted. That's equivalent to one juice box or one can of regular (nondiet) soda.

Behavior changes for a prepubertal child with a motivated family can be explained in depth by a nurse or other nonphysician provider in a follow-up visit. In some cases, a second visit is the time to identify barriers to behavior change and how to address them.

Identify problems related to diet and exercise habits, such as caretakers who give children high-calorie or junk foods and excessive snacks. Ask about opportunities for exercise and play, such as school recess and gym class; options for walking or biking to school; and ways to replace some “screen time” with physical activity, either indoors or outdoors.

One should also remember that medical statistics do not motivate children. Children are motivated by peer approval, a sense of accomplishment, and a desire to please a parent or other adult, Dr. Cook pointed out.

“The small steps we can make in these younger age groups can really effect some change, and the parents feel enabled,” he noted.

A primary care physician may not be able to do much for the morbidly obese 5-year-old who needs a referral, but doctors who stay alert to changes in BMI and listen to patients and families can make a difference for a 5-year-old who was normal weight last year but slightly overweight this year, Dr. Cook said.

A brief office visit is not the best time for the doctor to overwhelm a family with information about rising childhood obesity rates and the increased risk of health problems that could arise later in life.

Instead, one should try creating a single-page handout that focuses on a few practical points, such as “Children who watch more than 2 hours of TV daily or have more than two sweetened drinks a day are more likely to become overweight or obese.”

The handout should be given to the family, and that may be as far as you are able to go that day in discussing weight. The handout may go directly into the trash, or it may give children and families food for thought.

CHARLESTON, S.C. — Primary care physicians should provide brief, focused advice to parents whose school-aged children are on the brink of overweight and by doing so, they can make a real difference, Dr. Stephen Cook said at a pediatric meeting sponsored by the Medical University of South Carolina.

“Only 20% of overweight kids aged 5–11 years are identified in the primary care office,” said Dr. Cook, a pediatrician at the University of Rochester (N.Y.).

One should start with a body mass index (BMI) measurement. “The BMI is a great first trigger point at a well-child visit,” Dr. Cook said.

“The BMI is going to open your eyes to kids in the problem range.” But be sure to review correct BMI measurement with your staff, he added. The children can be clothed, but ask them to remove shoes, jackets, and hats.

Although the BMI is not perfect, it is a simple tool that fairly accurately assesses weight status in prepubertal children, Dr. Cook said. If the child's BMI is on the cusp or indicates just slight overweight, use a motivational interviewing tactic and ask the parent and child whether they think weight is a problem.

“I ask, 'On a scale of 1 to 10, how important is it to you right now that the child's weight status might be unhealthy?'” he said.

“There is enough to do in a well-child visit that extensive counseling for obesity” may not be possible during that time, Dr. Cook said. But you can identify that weight is a potential problem, make the family aware of it, and document it in the record.

In some families, the child's weight simply is not a priority. If the family is not interested in talking about weight, then offer a nonjudgmental response, suggest a reasonable time for a follow-up visit, and move on, Dr. Cook advised. But if families do express some concern about weight, listen to their responses to the following question: “The BMI shows that your child is overweight; what do you think about that?” After you have listened, briefly share some tips about how simple changes—such as cutting down on juice and moving the TV out of the bedroom—can make the difference in keeping children within a healthy weight range. Invite the family for a follow-up visit as soon as possible for positive reinforcement and more tips on keeping the child's weight in the healthy range.

The calorie shift in prepubertal children is very small, only about 150 calories a day, Dr. Cook noted. That's equivalent to one juice box or one can of regular (nondiet) soda.

Behavior changes for a prepubertal child with a motivated family can be explained in depth by a nurse or other nonphysician provider in a follow-up visit. In some cases, a second visit is the time to identify barriers to behavior change and how to address them.

Identify problems related to diet and exercise habits, such as caretakers who give children high-calorie or junk foods and excessive snacks. Ask about opportunities for exercise and play, such as school recess and gym class; options for walking or biking to school; and ways to replace some “screen time” with physical activity, either indoors or outdoors.

One should also remember that medical statistics do not motivate children. Children are motivated by peer approval, a sense of accomplishment, and a desire to please a parent or other adult, Dr. Cook pointed out.

“The small steps we can make in these younger age groups can really effect some change, and the parents feel enabled,” he noted.

A primary care physician may not be able to do much for the morbidly obese 5-year-old who needs a referral, but doctors who stay alert to changes in BMI and listen to patients and families can make a difference for a 5-year-old who was normal weight last year but slightly overweight this year, Dr. Cook said.

A brief office visit is not the best time for the doctor to overwhelm a family with information about rising childhood obesity rates and the increased risk of health problems that could arise later in life.

Instead, one should try creating a single-page handout that focuses on a few practical points, such as “Children who watch more than 2 hours of TV daily or have more than two sweetened drinks a day are more likely to become overweight or obese.”

The handout should be given to the family, and that may be as far as you are able to go that day in discussing weight. The handout may go directly into the trash, or it may give children and families food for thought.

OTTAWA — The smart compression technique using short stretch bandages facilitates healing by extruding edema and lymphedema from a wound, Dr. John MacDonald said at the annual conference of the Canadian Association of Wound Care.

"Lymphedema is a major impediment to wound healing," said Dr. MacDonald, a retired cardiovascular surgeon who is now with the department of dermatology and cutaneous surgery at the University of Miami.

"If you have a bandage that moves as the muscles move, nothing happens," Dr. MacDonald explained. "But if you have a bandage that gives resistance to the motion of the muscle, there is pressure on the tissue that stimulates pressure on the lymphatic fluid and pushes it out of the limb."

"Every chronic wound has a lymphatic pathology," he explained. The lymphatic system accounts for 10%–15% of cardiac output, so be sure to consider what could be wrong with the lymphatic system in any chronic wound.

Lymphatic vessels are easily injured, and they can't move fluid to and from a chronic wound without help; but if the external pressure from a compression bandage is high enough, the lymphatic capillaries start to fill with fluid and the fluid moves away from the wound and back toward the heart. "It is external pressure from the compression bandage that is moving this fluid," Dr. MacDonald said. The steady, constant pressure (5–10 mm Hg) on the delicate lymphatic vessels can propel the fluid back into the cardiovascular system.

Smart compression takes into account both resting pressure and working pressure on the affected area. Resting pressure is the pressure applied by a bandage to a body part, such as a leg, when that part is at rest. Working pressure develops when the muscles contract and push against the compressing bandage; there is a dynamic pulsation between the muscles and the bandage. Working pressure develops internally and has a positive effect on the deeper muscles when the bandage restrains muscle expansion, he said.

Smart compression is uniform, not like squeezing a tube of toothpaste, and short stretch bandages are the best way to achieve it.

The short bandage creates a lower resting pressure and a higher working pressure, which is the safest treatment option for a compromised limb, Dr. MacDonald noted. External compression is extremely important in controlling edema and lymphedema because it promotes fluid absorption, which is critical to the healing of any chronic wound.

To treat a patient with smart compression, Dr. MacDonald recommends using inelastic short stretch bandages that are left on 24 hours a day, 7 days a week. Although the bandages on the wound itself are to be changed regularly, the patient doesn't get a break from the compression for more than the time needed to change the dressing. The steady, constant compression helps move the lymphatic fluid out of the swollen, wounded area.

Padding is needed underneath the bandage to fill in crevices and to equalize pressure over the area to be treated, he added.

Adding smart compression does not detract from the principles of basic wound care. "It was the missing link," Dr. MacDonald said. Healing is restricted when debris in a wound can't drain via the lymphatic system. Smart compression is "like sending your patient home with their own massage therapist 24 hours a day," he said.

Smart compression with short stretch bandages also can be used to treat lymphedema in patients with metastatic lesions, as well as wounds in obese patients or patients with cellulitis or diabetes.

"There has never been a study to show that using compression will shorten the life of someone with metastatic disease," said Dr. MacDonald.

Smart compression should be used to treat lymphedema in obese patients with wounds below the knee, which is the site of most wounds in these patients. "You can't do anything about their weight, but if you use continuous sustained compression, you will stop that drainage and heal the wounds," he explained.

This wound in patient with grade three lymphedema is shown before treatment.

The patient is shown approximately 21/2 months after treatment. Photos courtesy Dr. John MacDonald

OTTAWA — The smart compression technique using short stretch bandages facilitates healing by extruding edema and lymphedema from a wound, Dr. John MacDonald said at the annual conference of the Canadian Association of Wound Care.

"Lymphedema is a major impediment to wound healing," said Dr. MacDonald, a retired cardiovascular surgeon who is now with the department of dermatology and cutaneous surgery at the University of Miami.

"If you have a bandage that moves as the muscles move, nothing happens," Dr. MacDonald explained. "But if you have a bandage that gives resistance to the motion of the muscle, there is pressure on the tissue that stimulates pressure on the lymphatic fluid and pushes it out of the limb."

"Every chronic wound has a lymphatic pathology," he explained. The lymphatic system accounts for 10%–15% of cardiac output, so be sure to consider what could be wrong with the lymphatic system in any chronic wound.

Lymphatic vessels are easily injured, and they can't move fluid to and from a chronic wound without help; but if the external pressure from a compression bandage is high enough, the lymphatic capillaries start to fill with fluid and the fluid moves away from the wound and back toward the heart. "It is external pressure from the compression bandage that is moving this fluid," Dr. MacDonald said. The steady, constant pressure (5–10 mm Hg) on the delicate lymphatic vessels can propel the fluid back into the cardiovascular system.

Smart compression takes into account both resting pressure and working pressure on the affected area. Resting pressure is the pressure applied by a bandage to a body part, such as a leg, when that part is at rest. Working pressure develops when the muscles contract and push against the compressing bandage; there is a dynamic pulsation between the muscles and the bandage. Working pressure develops internally and has a positive effect on the deeper muscles when the bandage restrains muscle expansion, he said.

Smart compression is uniform, not like squeezing a tube of toothpaste, and short stretch bandages are the best way to achieve it.

The short bandage creates a lower resting pressure and a higher working pressure, which is the safest treatment option for a compromised limb, Dr. MacDonald noted. External compression is extremely important in controlling edema and lymphedema because it promotes fluid absorption, which is critical to the healing of any chronic wound.

To treat a patient with smart compression, Dr. MacDonald recommends using inelastic short stretch bandages that are left on 24 hours a day, 7 days a week. Although the bandages on the wound itself are to be changed regularly, the patient doesn't get a break from the compression for more than the time needed to change the dressing. The steady, constant compression helps move the lymphatic fluid out of the swollen, wounded area.

Padding is needed underneath the bandage to fill in crevices and to equalize pressure over the area to be treated, he added.

Adding smart compression does not detract from the principles of basic wound care. "It was the missing link," Dr. MacDonald said. Healing is restricted when debris in a wound can't drain via the lymphatic system. Smart compression is "like sending your patient home with their own massage therapist 24 hours a day," he said.

Smart compression with short stretch bandages also can be used to treat lymphedema in patients with metastatic lesions, as well as wounds in obese patients or patients with cellulitis or diabetes.

"There has never been a study to show that using compression will shorten the life of someone with metastatic disease," said Dr. MacDonald.

Smart compression should be used to treat lymphedema in obese patients with wounds below the knee, which is the site of most wounds in these patients. "You can't do anything about their weight, but if you use continuous sustained compression, you will stop that drainage and heal the wounds," he explained.

This wound in patient with grade three lymphedema is shown before treatment.

The patient is shown approximately 21/2 months after treatment. Photos courtesy Dr. John MacDonald

OTTAWA — The smart compression technique using short stretch bandages facilitates healing by extruding edema and lymphedema from a wound, Dr. John MacDonald said at the annual conference of the Canadian Association of Wound Care.

"Lymphedema is a major impediment to wound healing," said Dr. MacDonald, a retired cardiovascular surgeon who is now with the department of dermatology and cutaneous surgery at the University of Miami.

"If you have a bandage that moves as the muscles move, nothing happens," Dr. MacDonald explained. "But if you have a bandage that gives resistance to the motion of the muscle, there is pressure on the tissue that stimulates pressure on the lymphatic fluid and pushes it out of the limb."

"Every chronic wound has a lymphatic pathology," he explained. The lymphatic system accounts for 10%–15% of cardiac output, so be sure to consider what could be wrong with the lymphatic system in any chronic wound.

Lymphatic vessels are easily injured, and they can't move fluid to and from a chronic wound without help; but if the external pressure from a compression bandage is high enough, the lymphatic capillaries start to fill with fluid and the fluid moves away from the wound and back toward the heart. "It is external pressure from the compression bandage that is moving this fluid," Dr. MacDonald said. The steady, constant pressure (5–10 mm Hg) on the delicate lymphatic vessels can propel the fluid back into the cardiovascular system.

Smart compression takes into account both resting pressure and working pressure on the affected area. Resting pressure is the pressure applied by a bandage to a body part, such as a leg, when that part is at rest. Working pressure develops when the muscles contract and push against the compressing bandage; there is a dynamic pulsation between the muscles and the bandage. Working pressure develops internally and has a positive effect on the deeper muscles when the bandage restrains muscle expansion, he said.

Smart compression is uniform, not like squeezing a tube of toothpaste, and short stretch bandages are the best way to achieve it.

The short bandage creates a lower resting pressure and a higher working pressure, which is the safest treatment option for a compromised limb, Dr. MacDonald noted. External compression is extremely important in controlling edema and lymphedema because it promotes fluid absorption, which is critical to the healing of any chronic wound.

To treat a patient with smart compression, Dr. MacDonald recommends using inelastic short stretch bandages that are left on 24 hours a day, 7 days a week. Although the bandages on the wound itself are to be changed regularly, the patient doesn't get a break from the compression for more than the time needed to change the dressing. The steady, constant compression helps move the lymphatic fluid out of the swollen, wounded area.

Padding is needed underneath the bandage to fill in crevices and to equalize pressure over the area to be treated, he added.

Adding smart compression does not detract from the principles of basic wound care. "It was the missing link," Dr. MacDonald said. Healing is restricted when debris in a wound can't drain via the lymphatic system. Smart compression is "like sending your patient home with their own massage therapist 24 hours a day," he said.

Smart compression with short stretch bandages also can be used to treat lymphedema in patients with metastatic lesions, as well as wounds in obese patients or patients with cellulitis or diabetes.

"There has never been a study to show that using compression will shorten the life of someone with metastatic disease," said Dr. MacDonald.

Smart compression should be used to treat lymphedema in obese patients with wounds below the knee, which is the site of most wounds in these patients. "You can't do anything about their weight, but if you use continuous sustained compression, you will stop that drainage and heal the wounds," he explained.

This wound in patient with grade three lymphedema is shown before treatment.

The patient is shown approximately 21/2 months after treatment. Photos courtesy Dr. John MacDonald

PHOENIX — Infants are rarely born with suppressed thyroid function if their mothers have Graves' disease but continue to take lower doses of thyroid medication during pregnancy, based on data from 249 pregnant Graves' disease patients.

Maternal free thyroxine (FT4) levels just above normal (at least 1.9 ng/dL) were associated with normal FT4 levels in the newborn, Dr. Naoko Momotani said at the annual meeting of the American Thyroid Association.

Although previous research has suggested that a mother's thyroid hormone level is linked to her newborn's health, this study is the first to show such a relationship, said Dr. Momotani of the Tokyo Health Service Association in Tokyo.

Graves' disease involves overactivity of the entire thyroid gland, which can cause underactivity of the thyroid in the developing fetus. When a pregnant woman with Graves' disease takes antithyroid medication, the TSH receptor antibodies are transferred to the fetus, which prevents fetal hypothyroidism.

“But the drug doses that are ideal for the mother might be too much for the fetus,” Dr. Momotani said.

Keeping pregnant Graves' disease patients in a mild hyperthyroid state may be a noninvasive way to care for these women and prevent thyroid problems in the fetus, she said.

The women in the study took antithyroid drugs throughout pregnancy. The highest reported maternal FT4 level was 4.1 ng/dL. Overall, 41 fetuses had elevated TSH, but none had a visible goiter at birth.

There were no cases of below-normal fetal FT4 levels and only one case of elevated TSH in a fetus among women whose FT4 levels were greater than 1.9 ng/dL (that is, higher than the upper normal range of 1.2–1.9 ng/dL).

By contrast, a total of 102 mothers had normal free T4 levels (0.6–1.2 ng/dL) at the time of delivery, and 23 of their infants had low FT4 and/or high TSH levels at birth. But only 1 of these 23 infants had an elevated TSH level when the infants were screened for congenital hypothyroidism. One infant had both suppressed TSH and normal free T4 levels at birth, which suggested central hypothyroidism, and the mother's FT4 in this case was 2.1 ng/dL.

It is important to remember that the range of FT4 values in women with Graves' disease varies, and some infants may have initial suppressed thyroid function, but most of these infants do well with close follow-up, Dr. Momotani said.

PHOENIX — Infants are rarely born with suppressed thyroid function if their mothers have Graves' disease but continue to take lower doses of thyroid medication during pregnancy, based on data from 249 pregnant Graves' disease patients.

Maternal free thyroxine (FT4) levels just above normal (at least 1.9 ng/dL) were associated with normal FT4 levels in the newborn, Dr. Naoko Momotani said at the annual meeting of the American Thyroid Association.

Although previous research has suggested that a mother's thyroid hormone level is linked to her newborn's health, this study is the first to show such a relationship, said Dr. Momotani of the Tokyo Health Service Association in Tokyo.

Graves' disease involves overactivity of the entire thyroid gland, which can cause underactivity of the thyroid in the developing fetus. When a pregnant woman with Graves' disease takes antithyroid medication, the TSH receptor antibodies are transferred to the fetus, which prevents fetal hypothyroidism.

“But the drug doses that are ideal for the mother might be too much for the fetus,” Dr. Momotani said.

Keeping pregnant Graves' disease patients in a mild hyperthyroid state may be a noninvasive way to care for these women and prevent thyroid problems in the fetus, she said.

The women in the study took antithyroid drugs throughout pregnancy. The highest reported maternal FT4 level was 4.1 ng/dL. Overall, 41 fetuses had elevated TSH, but none had a visible goiter at birth.

There were no cases of below-normal fetal FT4 levels and only one case of elevated TSH in a fetus among women whose FT4 levels were greater than 1.9 ng/dL (that is, higher than the upper normal range of 1.2–1.9 ng/dL).

By contrast, a total of 102 mothers had normal free T4 levels (0.6–1.2 ng/dL) at the time of delivery, and 23 of their infants had low FT4 and/or high TSH levels at birth. But only 1 of these 23 infants had an elevated TSH level when the infants were screened for congenital hypothyroidism. One infant had both suppressed TSH and normal free T4 levels at birth, which suggested central hypothyroidism, and the mother's FT4 in this case was 2.1 ng/dL.

It is important to remember that the range of FT4 values in women with Graves' disease varies, and some infants may have initial suppressed thyroid function, but most of these infants do well with close follow-up, Dr. Momotani said.

PHOENIX — Infants are rarely born with suppressed thyroid function if their mothers have Graves' disease but continue to take lower doses of thyroid medication during pregnancy, based on data from 249 pregnant Graves' disease patients.

Maternal free thyroxine (FT4) levels just above normal (at least 1.9 ng/dL) were associated with normal FT4 levels in the newborn, Dr. Naoko Momotani said at the annual meeting of the American Thyroid Association.

Although previous research has suggested that a mother's thyroid hormone level is linked to her newborn's health, this study is the first to show such a relationship, said Dr. Momotani of the Tokyo Health Service Association in Tokyo.

Graves' disease involves overactivity of the entire thyroid gland, which can cause underactivity of the thyroid in the developing fetus. When a pregnant woman with Graves' disease takes antithyroid medication, the TSH receptor antibodies are transferred to the fetus, which prevents fetal hypothyroidism.

“But the drug doses that are ideal for the mother might be too much for the fetus,” Dr. Momotani said.

Keeping pregnant Graves' disease patients in a mild hyperthyroid state may be a noninvasive way to care for these women and prevent thyroid problems in the fetus, she said.

The women in the study took antithyroid drugs throughout pregnancy. The highest reported maternal FT4 level was 4.1 ng/dL. Overall, 41 fetuses had elevated TSH, but none had a visible goiter at birth.

There were no cases of below-normal fetal FT4 levels and only one case of elevated TSH in a fetus among women whose FT4 levels were greater than 1.9 ng/dL (that is, higher than the upper normal range of 1.2–1.9 ng/dL).

By contrast, a total of 102 mothers had normal free T4 levels (0.6–1.2 ng/dL) at the time of delivery, and 23 of their infants had low FT4 and/or high TSH levels at birth. But only 1 of these 23 infants had an elevated TSH level when the infants were screened for congenital hypothyroidism. One infant had both suppressed TSH and normal free T4 levels at birth, which suggested central hypothyroidism, and the mother's FT4 in this case was 2.1 ng/dL.

It is important to remember that the range of FT4 values in women with Graves' disease varies, and some infants may have initial suppressed thyroid function, but most of these infants do well with close follow-up, Dr. Momotani said.

PHOENIX — Infants of women with Graves' disease are rarely born with suppressed thyroid function, but their mothers should continue taking lower doses of thyroid medication during pregnancy, according to data presented at the annual meeting of the American Thyroid Association.

Maternal free thyroxine (FT₄) levels just above normal (at least 1.9 ng/dL) were associated with normal FT₄ levels in the newborn, Dr. Naoko Momotani of the Tokyo Health Service Association in Tokyo.

This study of 249 pregnant Graves' disease patients is the first to show that a mother's thyroid hormone level is linked to her newborn's health, said Dr. Momotani.

Graves' disease can cause underactivity of the thyroid in the developing fetus. When a pregnant woman with Graves' disease takes antithyroid medication, the TSH receptor antibodies are transferred to the fetus. “But the drug doses that are ideal for the mother might be too much for the fetus,” she said.

The women in the study took antithyroid drugs throughout pregnancy. The highest reported maternal FT₄ level was 4.1 ng/dL. Overall, 41 fetuses had elevated TSH, but none had a visible goiter at birth. There were no cases of below-normal fetal FT₄ levels and only one case of elevated TSH in a fetus among women whose FT₄ levels were greater than 1.9 ng/dL (that is, higher than the upper normal range of 1.2–1.9 ng/dL). By contrast, 102 mothers had normal free T₄ levels (0.6–1.2 ng/dL) at the time of delivery, and 23 of their infants had low FT₄ and/or high TSH levels at birth. Only 1 of these 23 infants had an elevated TSH level when the infants were screened for congenital hypothyroidism.

One infant had both suppressed TSH and normal free T₄ levels at birth, which suggested central hypothyroidism, and the mother's FT₄ in this case was 2.1 ng/dL.

PHOENIX — Infants of women with Graves' disease are rarely born with suppressed thyroid function, but their mothers should continue taking lower doses of thyroid medication during pregnancy, according to data presented at the annual meeting of the American Thyroid Association.

Maternal free thyroxine (FT₄) levels just above normal (at least 1.9 ng/dL) were associated with normal FT₄ levels in the newborn, Dr. Naoko Momotani of the Tokyo Health Service Association in Tokyo.

This study of 249 pregnant Graves' disease patients is the first to show that a mother's thyroid hormone level is linked to her newborn's health, said Dr. Momotani.

Graves' disease can cause underactivity of the thyroid in the developing fetus. When a pregnant woman with Graves' disease takes antithyroid medication, the TSH receptor antibodies are transferred to the fetus. “But the drug doses that are ideal for the mother might be too much for the fetus,” she said.

The women in the study took antithyroid drugs throughout pregnancy. The highest reported maternal FT₄ level was 4.1 ng/dL. Overall, 41 fetuses had elevated TSH, but none had a visible goiter at birth. There were no cases of below-normal fetal FT₄ levels and only one case of elevated TSH in a fetus among women whose FT₄ levels were greater than 1.9 ng/dL (that is, higher than the upper normal range of 1.2–1.9 ng/dL). By contrast, 102 mothers had normal free T₄ levels (0.6–1.2 ng/dL) at the time of delivery, and 23 of their infants had low FT₄ and/or high TSH levels at birth. Only 1 of these 23 infants had an elevated TSH level when the infants were screened for congenital hypothyroidism.

One infant had both suppressed TSH and normal free T₄ levels at birth, which suggested central hypothyroidism, and the mother's FT₄ in this case was 2.1 ng/dL.

PHOENIX — Infants of women with Graves' disease are rarely born with suppressed thyroid function, but their mothers should continue taking lower doses of thyroid medication during pregnancy, according to data presented at the annual meeting of the American Thyroid Association.

Maternal free thyroxine (FT₄) levels just above normal (at least 1.9 ng/dL) were associated with normal FT₄ levels in the newborn, Dr. Naoko Momotani of the Tokyo Health Service Association in Tokyo.

This study of 249 pregnant Graves' disease patients is the first to show that a mother's thyroid hormone level is linked to her newborn's health, said Dr. Momotani.

Graves' disease can cause underactivity of the thyroid in the developing fetus. When a pregnant woman with Graves' disease takes antithyroid medication, the TSH receptor antibodies are transferred to the fetus. “But the drug doses that are ideal for the mother might be too much for the fetus,” she said.

The women in the study took antithyroid drugs throughout pregnancy. The highest reported maternal FT₄ level was 4.1 ng/dL. Overall, 41 fetuses had elevated TSH, but none had a visible goiter at birth. There were no cases of below-normal fetal FT₄ levels and only one case of elevated TSH in a fetus among women whose FT₄ levels were greater than 1.9 ng/dL (that is, higher than the upper normal range of 1.2–1.9 ng/dL). By contrast, 102 mothers had normal free T₄ levels (0.6–1.2 ng/dL) at the time of delivery, and 23 of their infants had low FT₄ and/or high TSH levels at birth. Only 1 of these 23 infants had an elevated TSH level when the infants were screened for congenital hypothyroidism.

One infant had both suppressed TSH and normal free T₄ levels at birth, which suggested central hypothyroidism, and the mother's FT₄ in this case was 2.1 ng/dL.

Vitamin A deficiency due to malabsorption after intestinal surgery should be suspected in patients with unexplained vision loss, based on data from several cases seen in one neuro-ophthalmic practice between January and December 2005.

Dr. Teresa Chae and Dr. Rod Foroozan of Baylor College of Medicine in Houston described three cases where past intestinal surgery was linked to vision loss. All surgeries took place more than 18 years before onset of symptoms. The patients were older than 65 years, and their vitamin A deficiencies were confirmed with blood tests (Br. J. Ophthalmol. 2006;90:955–6).

Patient 1, a 69-year-old man, presented with a 4-month history of night blindness. He had undergone intestinal bypass sur-gery 20 years earlier, and had a history of childhood hepatitis. Patient 2, an 80-year-old man, reported 4 months of decreased vision in one eye that worsened at night. His history included Crohn's disease and a partial small- and large-bowel resection for a ruptured ileum at age 44 years.

Patient 3, a 79-year-old woman, reported several months of decreased vision, and her history included cholecystectomy with subsequent surgeries to manage complications. Her surgeries occurred 18–20 years before her vision problems began.

Patients 1 and 2 were treated successfully with vitamin A therapy (200,000 IU per day), administered by intramuscular injection. Patient 3 declined vitamin A therapy and had no additional follow-up care.

Vitamin A deficiency due to malabsorption after intestinal surgery should be suspected in patients with unexplained vision loss, based on data from several cases seen in one neuro-ophthalmic practice between January and December 2005.

Dr. Teresa Chae and Dr. Rod Foroozan of Baylor College of Medicine in Houston described three cases where past intestinal surgery was linked to vision loss. All surgeries took place more than 18 years before onset of symptoms. The patients were older than 65 years, and their vitamin A deficiencies were confirmed with blood tests (Br. J. Ophthalmol. 2006;90:955–6).

Patient 1, a 69-year-old man, presented with a 4-month history of night blindness. He had undergone intestinal bypass sur-gery 20 years earlier, and had a history of childhood hepatitis. Patient 2, an 80-year-old man, reported 4 months of decreased vision in one eye that worsened at night. His history included Crohn's disease and a partial small- and large-bowel resection for a ruptured ileum at age 44 years.

Patient 3, a 79-year-old woman, reported several months of decreased vision, and her history included cholecystectomy with subsequent surgeries to manage complications. Her surgeries occurred 18–20 years before her vision problems began.

Patients 1 and 2 were treated successfully with vitamin A therapy (200,000 IU per day), administered by intramuscular injection. Patient 3 declined vitamin A therapy and had no additional follow-up care.

Vitamin A deficiency due to malabsorption after intestinal surgery should be suspected in patients with unexplained vision loss, based on data from several cases seen in one neuro-ophthalmic practice between January and December 2005.

Dr. Teresa Chae and Dr. Rod Foroozan of Baylor College of Medicine in Houston described three cases where past intestinal surgery was linked to vision loss. All surgeries took place more than 18 years before onset of symptoms. The patients were older than 65 years, and their vitamin A deficiencies were confirmed with blood tests (Br. J. Ophthalmol. 2006;90:955–6).

Patient 1, a 69-year-old man, presented with a 4-month history of night blindness. He had undergone intestinal bypass sur-gery 20 years earlier, and had a history of childhood hepatitis. Patient 2, an 80-year-old man, reported 4 months of decreased vision in one eye that worsened at night. His history included Crohn's disease and a partial small- and large-bowel resection for a ruptured ileum at age 44 years.

Patient 3, a 79-year-old woman, reported several months of decreased vision, and her history included cholecystectomy with subsequent surgeries to manage complications. Her surgeries occurred 18–20 years before her vision problems began.

Patients 1 and 2 were treated successfully with vitamin A therapy (200,000 IU per day), administered by intramuscular injection. Patient 3 declined vitamin A therapy and had no additional follow-up care.