Heidi Splete

SAN DIEGO — Some closures may be too complex for inexperienced Mohs surgeons, but even novices can successfully close most of their cases if they have an understanding of how skin flaps move and a willingness to see the possibilities in the two simple skin movements—the fusiform and the z-plasty—that underlie all flap closures, Dr. Kenneth G. Gross said at a meeting sponsored by the American Society for Mohs Surgery.

It helps to think of flap movement as occurring in two dimensions.

"The majority of skin flaps can be explained simply by exploring what makes a fusiform work," Dr. Gross said.

Fusiform flaps generally have 30-degree angles at their tips, based on principles of plane geometry, but the skin is not a flat plane, and whether a lesion will close with 30-degree angles depends on the anatomic location.

"The purpose of making 30-degree angles at the ends of the fusiform is to allow closure without a standing cone," said Dr. Gross, a dermatologic surgeon in private practice in San Diego.

The fusiform consists of three components: the central defect to be closed (depicted as a circle) and two Burow's triangles.

The short axis of the defect usually forms the short axis of the fusiform. The surgeon uses the Burow's triangles at each end of the fusiform to bring the defect to 30-degree angles or to the angles necessary to close the wound without creating a standing cone at the ends of the excision.

The Burow's triangles also can be rotated at the ends of the fusiform as needed to achieve the best cosmetic result. "The Burow's triangle can even be rotated 90 degrees," Dr. Gross pointed out. "You should do whatever type of Burow's triangle is needed to make the best possible closure."

If the location of the defect prevents the use of a Burow's triangle at one or both ends of the fusiform, the surgeon can offset the Burow's triangles, Dr. Gross explained.

"This will result in the creation of what we call an advancement or a rotation flap. If the Burow's triangle is offset to two sides, the result will be a bilateral flap, such as the bilateral advancement or the A to T flap," he commented.

"If the surgeon is in doubt about how to close a wound, he or she may start by drawing a fusiform and then [assessing] whether the fusiform lies in the relaxed skin tension lines and whether it causes distortion of surrounding important anatomic structures," Dr. Gross advised.

If the fusiform does interfere with important anatomy, the surgeon must decide where to offset the Burow's triangles at one or both ends of the fusiform—thereby creating an advancement or rotation flap that doesn't interfere with important anatomy or degrade the cosmetic result.

He noted that about 90% of his Mohs closures are variations of rotation flaps.

Although rotation flaps are generally larger than other types of flaps, Dr. Gross believes that they yield better cosmetic results than transposition flaps because the resulting scar lines can usually be placed in junctions between anatomic units.

Transposition flaps are based primarily on z-plasty movement.

"If you understand the movement of a z-plasty, you will understand how all transposition flaps move and why they move the way they do," Dr. Gross said at the meeting.

Think of a z-plasty as two Burow's triangles sharing a common side, called the central limb. When planning a z-plasty, think about using imaginary skin hooks to pull the central limb longer, Dr. Gross said.

While the central limb lengthens and rotates, there is concomitant shortening of tissue approximately 90 degrees from the axis of the central limb.

The amount of central limb lengthening, and the amount of rotation and shortening in the other axis, is determined by the total of both angles of the Burow's triangles in the z-plasty.

"You can combine 45-degree and 90-degree angles in the same z-plasty, and in fact the Burow's triangles of transposition flaps never have the same-sized angles," Dr. Gross said.

This is the reason some surgeons don't recognize the z-plasties that lie at the heart of all transposition flaps: They are accustomed to seeing z-plasties in textbooks that are drawn with equal angles.

As long as there is sufficient tissue in the opposite direction to allow for shortening without disrupting the surrounding anatomy, as well as enough skin laxity, the surgeon can use whatever size z-plasty angles are needed to produce the amount of central limb lengthening that will close the defect.

The three transposition flaps most often discussed and used by dermatologic surgeons are the Limberg, Webster, and Dufourmentel flaps.

The only difference among them is the total angle of the z-plasties used to create the flaps. The larger the sum of the total angles of the z-plasty of the transposition flap, the greater the lengthening and degree of rotation of the central limb and the greater the shortening of tissue in the opposite axis.

These actions result in the movement of tissue into the defect known as a transposition flap closure. Overall, the amount of tissue that is "wasted" is similar in both a z-plasty and a rotation flap, Dr. Gross said.

SAN DIEGO — Some closures may be too complex for inexperienced Mohs surgeons, but even novices can successfully close most of their cases if they have an understanding of how skin flaps move and a willingness to see the possibilities in the two simple skin movements—the fusiform and the z-plasty—that underlie all flap closures, Dr. Kenneth G. Gross said at a meeting sponsored by the American Society for Mohs Surgery.

It helps to think of flap movement as occurring in two dimensions.

"The majority of skin flaps can be explained simply by exploring what makes a fusiform work," Dr. Gross said.

Fusiform flaps generally have 30-degree angles at their tips, based on principles of plane geometry, but the skin is not a flat plane, and whether a lesion will close with 30-degree angles depends on the anatomic location.

"The purpose of making 30-degree angles at the ends of the fusiform is to allow closure without a standing cone," said Dr. Gross, a dermatologic surgeon in private practice in San Diego.

The fusiform consists of three components: the central defect to be closed (depicted as a circle) and two Burow's triangles.

The short axis of the defect usually forms the short axis of the fusiform. The surgeon uses the Burow's triangles at each end of the fusiform to bring the defect to 30-degree angles or to the angles necessary to close the wound without creating a standing cone at the ends of the excision.

The Burow's triangles also can be rotated at the ends of the fusiform as needed to achieve the best cosmetic result. "The Burow's triangle can even be rotated 90 degrees," Dr. Gross pointed out. "You should do whatever type of Burow's triangle is needed to make the best possible closure."

If the location of the defect prevents the use of a Burow's triangle at one or both ends of the fusiform, the surgeon can offset the Burow's triangles, Dr. Gross explained.

"This will result in the creation of what we call an advancement or a rotation flap. If the Burow's triangle is offset to two sides, the result will be a bilateral flap, such as the bilateral advancement or the A to T flap," he commented.

"If the surgeon is in doubt about how to close a wound, he or she may start by drawing a fusiform and then [assessing] whether the fusiform lies in the relaxed skin tension lines and whether it causes distortion of surrounding important anatomic structures," Dr. Gross advised.

If the fusiform does interfere with important anatomy, the surgeon must decide where to offset the Burow's triangles at one or both ends of the fusiform—thereby creating an advancement or rotation flap that doesn't interfere with important anatomy or degrade the cosmetic result.

He noted that about 90% of his Mohs closures are variations of rotation flaps.

Although rotation flaps are generally larger than other types of flaps, Dr. Gross believes that they yield better cosmetic results than transposition flaps because the resulting scar lines can usually be placed in junctions between anatomic units.

Transposition flaps are based primarily on z-plasty movement.

"If you understand the movement of a z-plasty, you will understand how all transposition flaps move and why they move the way they do," Dr. Gross said at the meeting.

Think of a z-plasty as two Burow's triangles sharing a common side, called the central limb. When planning a z-plasty, think about using imaginary skin hooks to pull the central limb longer, Dr. Gross said.

While the central limb lengthens and rotates, there is concomitant shortening of tissue approximately 90 degrees from the axis of the central limb.

The amount of central limb lengthening, and the amount of rotation and shortening in the other axis, is determined by the total of both angles of the Burow's triangles in the z-plasty.

"You can combine 45-degree and 90-degree angles in the same z-plasty, and in fact the Burow's triangles of transposition flaps never have the same-sized angles," Dr. Gross said.

This is the reason some surgeons don't recognize the z-plasties that lie at the heart of all transposition flaps: They are accustomed to seeing z-plasties in textbooks that are drawn with equal angles.

As long as there is sufficient tissue in the opposite direction to allow for shortening without disrupting the surrounding anatomy, as well as enough skin laxity, the surgeon can use whatever size z-plasty angles are needed to produce the amount of central limb lengthening that will close the defect.

The three transposition flaps most often discussed and used by dermatologic surgeons are the Limberg, Webster, and Dufourmentel flaps.

The only difference among them is the total angle of the z-plasties used to create the flaps. The larger the sum of the total angles of the z-plasty of the transposition flap, the greater the lengthening and degree of rotation of the central limb and the greater the shortening of tissue in the opposite axis.

These actions result in the movement of tissue into the defect known as a transposition flap closure. Overall, the amount of tissue that is "wasted" is similar in both a z-plasty and a rotation flap, Dr. Gross said.

SAN DIEGO — Some closures may be too complex for inexperienced Mohs surgeons, but even novices can successfully close most of their cases if they have an understanding of how skin flaps move and a willingness to see the possibilities in the two simple skin movements—the fusiform and the z-plasty—that underlie all flap closures, Dr. Kenneth G. Gross said at a meeting sponsored by the American Society for Mohs Surgery.

It helps to think of flap movement as occurring in two dimensions.

"The majority of skin flaps can be explained simply by exploring what makes a fusiform work," Dr. Gross said.

Fusiform flaps generally have 30-degree angles at their tips, based on principles of plane geometry, but the skin is not a flat plane, and whether a lesion will close with 30-degree angles depends on the anatomic location.

"The purpose of making 30-degree angles at the ends of the fusiform is to allow closure without a standing cone," said Dr. Gross, a dermatologic surgeon in private practice in San Diego.

The fusiform consists of three components: the central defect to be closed (depicted as a circle) and two Burow's triangles.

The short axis of the defect usually forms the short axis of the fusiform. The surgeon uses the Burow's triangles at each end of the fusiform to bring the defect to 30-degree angles or to the angles necessary to close the wound without creating a standing cone at the ends of the excision.

The Burow's triangles also can be rotated at the ends of the fusiform as needed to achieve the best cosmetic result. "The Burow's triangle can even be rotated 90 degrees," Dr. Gross pointed out. "You should do whatever type of Burow's triangle is needed to make the best possible closure."

If the location of the defect prevents the use of a Burow's triangle at one or both ends of the fusiform, the surgeon can offset the Burow's triangles, Dr. Gross explained.

"This will result in the creation of what we call an advancement or a rotation flap. If the Burow's triangle is offset to two sides, the result will be a bilateral flap, such as the bilateral advancement or the A to T flap," he commented.

"If the surgeon is in doubt about how to close a wound, he or she may start by drawing a fusiform and then [assessing] whether the fusiform lies in the relaxed skin tension lines and whether it causes distortion of surrounding important anatomic structures," Dr. Gross advised.

If the fusiform does interfere with important anatomy, the surgeon must decide where to offset the Burow's triangles at one or both ends of the fusiform—thereby creating an advancement or rotation flap that doesn't interfere with important anatomy or degrade the cosmetic result.

He noted that about 90% of his Mohs closures are variations of rotation flaps.

Although rotation flaps are generally larger than other types of flaps, Dr. Gross believes that they yield better cosmetic results than transposition flaps because the resulting scar lines can usually be placed in junctions between anatomic units.

Transposition flaps are based primarily on z-plasty movement.

"If you understand the movement of a z-plasty, you will understand how all transposition flaps move and why they move the way they do," Dr. Gross said at the meeting.

Think of a z-plasty as two Burow's triangles sharing a common side, called the central limb. When planning a z-plasty, think about using imaginary skin hooks to pull the central limb longer, Dr. Gross said.

While the central limb lengthens and rotates, there is concomitant shortening of tissue approximately 90 degrees from the axis of the central limb.

The amount of central limb lengthening, and the amount of rotation and shortening in the other axis, is determined by the total of both angles of the Burow's triangles in the z-plasty.

"You can combine 45-degree and 90-degree angles in the same z-plasty, and in fact the Burow's triangles of transposition flaps never have the same-sized angles," Dr. Gross said.

This is the reason some surgeons don't recognize the z-plasties that lie at the heart of all transposition flaps: They are accustomed to seeing z-plasties in textbooks that are drawn with equal angles.

As long as there is sufficient tissue in the opposite direction to allow for shortening without disrupting the surrounding anatomy, as well as enough skin laxity, the surgeon can use whatever size z-plasty angles are needed to produce the amount of central limb lengthening that will close the defect.

The three transposition flaps most often discussed and used by dermatologic surgeons are the Limberg, Webster, and Dufourmentel flaps.

The only difference among them is the total angle of the z-plasties used to create the flaps. The larger the sum of the total angles of the z-plasty of the transposition flap, the greater the lengthening and degree of rotation of the central limb and the greater the shortening of tissue in the opposite axis.

These actions result in the movement of tissue into the defect known as a transposition flap closure. Overall, the amount of tissue that is "wasted" is similar in both a z-plasty and a rotation flap, Dr. Gross said.

WASHINGTON — Behavior modification can reduce the level of medication needed in school-aged children with attention-deficit hyperactivity disorder, William E. Pelham Jr., Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Few studies have addressed the issue of how behavioral and pharmacologic therapies should be sequenced in children, said Dr. Pelham, a professor of pediatrics and psychiatry at the State University of New York, Buffalo.

Dr. Pelham, who is also a professor of psychology at the university, and his colleagues have completed two studies funded by the National Institutes of Health that examined dosing and sequencing of behavior modification and medication.

The first study included 154 children aged 5–12 years (130 boys and 24 girls) who participated in a summer day camp program. They were divided for 3 weeks into three behavior modification groups—no behavior modification, low-intensity behavior modification, and high-intensity behavior modification. In addition, the children were divided into four dosage groups for methylphenidate.

Medication was randomized each day, and the program counselors recorded the children's behavior in areas such as failing to comply with staff requests, following activity rules, and exhibiting conduct problems.

When the data were reviewed at summer's end, the lowest dose of medication—0.15 mg/kg three times daily—had a surprising and substantial effect on reducing ADHD impairment. In fact, the maximum incremental value of medication to behavior modification occurred at this low dose.

“There was no incremental value for most children beyond the 0.15 mg/kg dose in combination with behavior modification, but the highest dose—0.6 mg/kg—produced the largest effects in the absence of behavior modification,” Dr. Pelham said. This dosage normalized the largest number of children when combined with behavior modification. The effects of behavior modification alone and medication alone were comparable.

“Medication alone does not normalize the children's performance,” he explained. “Even at the highest dose of 0.6 m g/kg three times daily, many children were not normalized; the effect of behavior modification is as strong as the effect of medication.” Lower doses produce a substantially lower level of side effects—a benefit of using behavior modification as the first-line intervention.

Parents also evaluated the treatment conditions; they ranked a high level of behavior modification therapy, either alone or in combination with medication, as their first choice for managing ADHD.

The investigators conducted a follow-up study to assess the effectiveness of sequencing medication and behavior modification in a school setting. The primary outcome measure was the maintenance of acceptable behavior without medication after summer exposure to both medication and behavioral therapy.

The study included 128 of the children from the summer program who were randomly assigned to one of three groups. A total of 44 children received high behavior modification treatment, 43 received low behavior modification treatment, and 41 received no behavior modification treatment.

Overall, nearly twice the number of children who received behavior modification remained off medication at school during the fall semester, compared with children who received none (60% vs. 30%).

In addition, about 80% of children who had received behavior modification remained off medication at home. A caveat, however, was that almost all the children (75%) had been taking medication before enrollment in the summer study, which influenced their ability to remain unmedicated, Dr. Pelham noted.

Children who received no behavior modification started taking medication during the school day after 13 weeks, compared with 19 weeks for the low-intensity behavioral therapy group and 20 weeks for the high-intensity behavioral therapy group. Similarly, children who received no behavior modification therapy started taking medication at home after 27 weeks, compared with 38 weeks for the low behavior modification group and 32 weeks for the high behavior modification group.

Dr. Pelham has been a consultant, scientific adviser, speaker, and grant recipient for the following companies: McNeil Consumer Healthcare/ALZA (developers and marketers of the methylphenidate product Concerta), Abbott, Shire, Noven, Eli Lilly, and Cephalon.

WASHINGTON — Behavior modification can reduce the level of medication needed in school-aged children with attention-deficit hyperactivity disorder, William E. Pelham Jr., Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Few studies have addressed the issue of how behavioral and pharmacologic therapies should be sequenced in children, said Dr. Pelham, a professor of pediatrics and psychiatry at the State University of New York, Buffalo.

Dr. Pelham, who is also a professor of psychology at the university, and his colleagues have completed two studies funded by the National Institutes of Health that examined dosing and sequencing of behavior modification and medication.

The first study included 154 children aged 5–12 years (130 boys and 24 girls) who participated in a summer day camp program. They were divided for 3 weeks into three behavior modification groups—no behavior modification, low-intensity behavior modification, and high-intensity behavior modification. In addition, the children were divided into four dosage groups for methylphenidate.

Medication was randomized each day, and the program counselors recorded the children's behavior in areas such as failing to comply with staff requests, following activity rules, and exhibiting conduct problems.

When the data were reviewed at summer's end, the lowest dose of medication—0.15 mg/kg three times daily—had a surprising and substantial effect on reducing ADHD impairment. In fact, the maximum incremental value of medication to behavior modification occurred at this low dose.

“There was no incremental value for most children beyond the 0.15 mg/kg dose in combination with behavior modification, but the highest dose—0.6 mg/kg—produced the largest effects in the absence of behavior modification,” Dr. Pelham said. This dosage normalized the largest number of children when combined with behavior modification. The effects of behavior modification alone and medication alone were comparable.

“Medication alone does not normalize the children's performance,” he explained. “Even at the highest dose of 0.6 m g/kg three times daily, many children were not normalized; the effect of behavior modification is as strong as the effect of medication.” Lower doses produce a substantially lower level of side effects—a benefit of using behavior modification as the first-line intervention.

Parents also evaluated the treatment conditions; they ranked a high level of behavior modification therapy, either alone or in combination with medication, as their first choice for managing ADHD.

The investigators conducted a follow-up study to assess the effectiveness of sequencing medication and behavior modification in a school setting. The primary outcome measure was the maintenance of acceptable behavior without medication after summer exposure to both medication and behavioral therapy.

The study included 128 of the children from the summer program who were randomly assigned to one of three groups. A total of 44 children received high behavior modification treatment, 43 received low behavior modification treatment, and 41 received no behavior modification treatment.

Overall, nearly twice the number of children who received behavior modification remained off medication at school during the fall semester, compared with children who received none (60% vs. 30%).

In addition, about 80% of children who had received behavior modification remained off medication at home. A caveat, however, was that almost all the children (75%) had been taking medication before enrollment in the summer study, which influenced their ability to remain unmedicated, Dr. Pelham noted.

Children who received no behavior modification started taking medication during the school day after 13 weeks, compared with 19 weeks for the low-intensity behavioral therapy group and 20 weeks for the high-intensity behavioral therapy group. Similarly, children who received no behavior modification therapy started taking medication at home after 27 weeks, compared with 38 weeks for the low behavior modification group and 32 weeks for the high behavior modification group.

Dr. Pelham has been a consultant, scientific adviser, speaker, and grant recipient for the following companies: McNeil Consumer Healthcare/ALZA (developers and marketers of the methylphenidate product Concerta), Abbott, Shire, Noven, Eli Lilly, and Cephalon.

WASHINGTON — Behavior modification can reduce the level of medication needed in school-aged children with attention-deficit hyperactivity disorder, William E. Pelham Jr., Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Few studies have addressed the issue of how behavioral and pharmacologic therapies should be sequenced in children, said Dr. Pelham, a professor of pediatrics and psychiatry at the State University of New York, Buffalo.

Dr. Pelham, who is also a professor of psychology at the university, and his colleagues have completed two studies funded by the National Institutes of Health that examined dosing and sequencing of behavior modification and medication.

The first study included 154 children aged 5–12 years (130 boys and 24 girls) who participated in a summer day camp program. They were divided for 3 weeks into three behavior modification groups—no behavior modification, low-intensity behavior modification, and high-intensity behavior modification. In addition, the children were divided into four dosage groups for methylphenidate.

Medication was randomized each day, and the program counselors recorded the children's behavior in areas such as failing to comply with staff requests, following activity rules, and exhibiting conduct problems.

When the data were reviewed at summer's end, the lowest dose of medication—0.15 mg/kg three times daily—had a surprising and substantial effect on reducing ADHD impairment. In fact, the maximum incremental value of medication to behavior modification occurred at this low dose.

“There was no incremental value for most children beyond the 0.15 mg/kg dose in combination with behavior modification, but the highest dose—0.6 mg/kg—produced the largest effects in the absence of behavior modification,” Dr. Pelham said. This dosage normalized the largest number of children when combined with behavior modification. The effects of behavior modification alone and medication alone were comparable.

“Medication alone does not normalize the children's performance,” he explained. “Even at the highest dose of 0.6 m g/kg three times daily, many children were not normalized; the effect of behavior modification is as strong as the effect of medication.” Lower doses produce a substantially lower level of side effects—a benefit of using behavior modification as the first-line intervention.

Parents also evaluated the treatment conditions; they ranked a high level of behavior modification therapy, either alone or in combination with medication, as their first choice for managing ADHD.

The investigators conducted a follow-up study to assess the effectiveness of sequencing medication and behavior modification in a school setting. The primary outcome measure was the maintenance of acceptable behavior without medication after summer exposure to both medication and behavioral therapy.

The study included 128 of the children from the summer program who were randomly assigned to one of three groups. A total of 44 children received high behavior modification treatment, 43 received low behavior modification treatment, and 41 received no behavior modification treatment.

Overall, nearly twice the number of children who received behavior modification remained off medication at school during the fall semester, compared with children who received none (60% vs. 30%).

In addition, about 80% of children who had received behavior modification remained off medication at home. A caveat, however, was that almost all the children (75%) had been taking medication before enrollment in the summer study, which influenced their ability to remain unmedicated, Dr. Pelham noted.

Children who received no behavior modification started taking medication during the school day after 13 weeks, compared with 19 weeks for the low-intensity behavioral therapy group and 20 weeks for the high-intensity behavioral therapy group. Similarly, children who received no behavior modification therapy started taking medication at home after 27 weeks, compared with 38 weeks for the low behavior modification group and 32 weeks for the high behavior modification group.

Dr. Pelham has been a consultant, scientific adviser, speaker, and grant recipient for the following companies: McNeil Consumer Healthcare/ALZA (developers and marketers of the methylphenidate product Concerta), Abbott, Shire, Noven, Eli Lilly, and Cephalon.

WASHINGTON — Diabetic patients with severe skin infections had greater improvement when treated with meropenem than with imipenem-cilastatin, Dr. John M. Embil reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Skin and skin-structure infections are a perpetual problem for many diabetic patients, and may require surgical intervention if left untreated, wrote Dr. Embil of the University of Manitoba, Winnipeg, Canada.

The international, randomized, double-blind study included 1,037 hospitalized patients with complicated skin infections, 398 of whom were diabetic.

The clinical cure rate was 86% among the 204 diabetic patients who received a 500-mg intravenous dose of meropenem every 8 hours, compared with 72% among the 194 diabetic patients who received the same dosing regimen of imipenem-cilastatin. The cure rate among the nondiabetic patients treated with meropenem (87%) was similar to the rate in those treated with imipenem-cilastatin (89%).

Overall, meropenem was associated with slightly higher cure rates for all groups of pathogens—aerobic gram-negative, aerobic gram-positive, anaerobic, and polymicrobial—compared with imipenem-cilastatin, but the differences were not statistically significant. More than 40% of the pathogens were gram-negative aerobic or anaerobic organisms, and 29% of the Staphylococcus aureus isolates showed methicillin resistance. A similar spectrum of pathogens appeared in both diabetic and nondiabetic patients.

The study was sponsored in part by AstraZeneca, and the meeting was sponsored by the American Society for Microbiology.

WASHINGTON — Diabetic patients with severe skin infections had greater improvement when treated with meropenem than with imipenem-cilastatin, Dr. John M. Embil reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Skin and skin-structure infections are a perpetual problem for many diabetic patients, and may require surgical intervention if left untreated, wrote Dr. Embil of the University of Manitoba, Winnipeg, Canada.

The international, randomized, double-blind study included 1,037 hospitalized patients with complicated skin infections, 398 of whom were diabetic.

The clinical cure rate was 86% among the 204 diabetic patients who received a 500-mg intravenous dose of meropenem every 8 hours, compared with 72% among the 194 diabetic patients who received the same dosing regimen of imipenem-cilastatin. The cure rate among the nondiabetic patients treated with meropenem (87%) was similar to the rate in those treated with imipenem-cilastatin (89%).

Overall, meropenem was associated with slightly higher cure rates for all groups of pathogens—aerobic gram-negative, aerobic gram-positive, anaerobic, and polymicrobial—compared with imipenem-cilastatin, but the differences were not statistically significant. More than 40% of the pathogens were gram-negative aerobic or anaerobic organisms, and 29% of the Staphylococcus aureus isolates showed methicillin resistance. A similar spectrum of pathogens appeared in both diabetic and nondiabetic patients.

The study was sponsored in part by AstraZeneca, and the meeting was sponsored by the American Society for Microbiology.

WASHINGTON — Diabetic patients with severe skin infections had greater improvement when treated with meropenem than with imipenem-cilastatin, Dr. John M. Embil reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Skin and skin-structure infections are a perpetual problem for many diabetic patients, and may require surgical intervention if left untreated, wrote Dr. Embil of the University of Manitoba, Winnipeg, Canada.

The international, randomized, double-blind study included 1,037 hospitalized patients with complicated skin infections, 398 of whom were diabetic.

The clinical cure rate was 86% among the 204 diabetic patients who received a 500-mg intravenous dose of meropenem every 8 hours, compared with 72% among the 194 diabetic patients who received the same dosing regimen of imipenem-cilastatin. The cure rate among the nondiabetic patients treated with meropenem (87%) was similar to the rate in those treated with imipenem-cilastatin (89%).

Overall, meropenem was associated with slightly higher cure rates for all groups of pathogens—aerobic gram-negative, aerobic gram-positive, anaerobic, and polymicrobial—compared with imipenem-cilastatin, but the differences were not statistically significant. More than 40% of the pathogens were gram-negative aerobic or anaerobic organisms, and 29% of the Staphylococcus aureus isolates showed methicillin resistance. A similar spectrum of pathogens appeared in both diabetic and nondiabetic patients.

The study was sponsored in part by AstraZeneca, and the meeting was sponsored by the American Society for Microbiology.

BAL HARBOUR, FLA. — Tracking the cause of allergic contact dermatitis in children requires investigation of all possible avenues of exposure, from toys and clothes to personal hygiene products and foods.

“Patients can receive a dose of allergen in many different ways,” Dr. Sharon E. Jacob said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Allergic contact dermatitis hypersensitivity reactions proceed through three phases: sensitization, challenge, and resolution, said Dr. Jacob, director of the contact dermatitis clinic at the university.

Sensitization occurs when the patient is first exposed to the allergen, but it takes about 21 days.

“Most people don't have a reaction on immediate exposure to an allergen,” Dr. Jacob said. After the patient is sensitized and rechallenged, or reexposed, it takes about 48–96 hours for the skin to react.

“This is important, because patients often won't remember what they did 2–3 days before a rash appeared,” she noted.

The first step in evaluating a child for allergic contact dermatitis is to take an in-depth history. “Look for temporal relationships; ask when the child gets better or worse,” Dr. Jacob said. Consider the child's age, gender, and demographics. Examine the distribution pattern of the rash, which may provide a clue to its origin. For example, a pattern of perioral dermatitis may suggest an allergy to fragrances or balsam of Peru, whereas earlobe dermatitis in a young girl with pierced ears suggests a metal allergy. Also ask about the child's activities, including day care and travel, and even what jewelry he or she wears.

Next, select the most likely allergens for patch testing given the patient's history. Be sure to use allergen concentrations that are safe in children. There are currently no commercially available allergy testing kits designed for the pediatric population, Dr. Jacob noted.

The most common sources of contact dermatitis in children include nickel, fragrances/flavorings, thimerosal, chromium, formaldehyde, cobalt, lanolin, paraphenylenediamine, neomycin, bacitracin, and cocamidopropyl betaine.

Nickel remains the most prevalent contact allergen among children. Nickel exposure can come from many sources, including paper clips, jewelry, front snaps on jeans, and foods. Certain foods—including chocolate, asparagus, soy, and oatmeal—contain high amounts of nickel.

“Allergic contact dermatitis is a dose-dependent phenomenon, and trigger foods may contribute a significant dose,” Dr. Jacob explained.

For example, a 12-year-old girl might wear jeans and earrings, eat both chocolate and oatmeal, and touch paper clips in a single day. These seemingly unrelated items all contain nickel and have the potential to exacerbate contact dermatitis in a sensitized patient. “It's a bit like being Sherlock Holmes and putting the puzzle pieces together—once you know the allergens—to figure out the exposures,” Dr. Jacob said.

Fragrances and flavorings are common causes of contact dermatitis, and they appear in many products that patients routinely use. “We need to remind patients that 'unscented' is in fact a blocking fragrance. Many parents believe that unscented is the same as 'fragrance free,'” Dr. Jacob noted. Two common fragrance allergens, cinnamic alcohol and cinnamic aldehyde, are components of balsam of Peru. These substances can be ingredients in soaps and shampoos, as well as in many foods, including tomato-based products such as ketchup, and artificially flavored soft drinks. Thimerosal is a preservative found in some vaccines and some medications, such as Neo-Synephrine pediatric formula and L'Oreal Miracle Wear mascara, Dr. Jacob noted.

Chromium is another metal salt that appears in products ranging from cement to leather to match heads. People who keep matchbooks in their pockets can have an allergic reaction to chromate in the shape of a patch on the leg where the matchbook was placed, Dr. Jacob noted. Again, food can increase the dose of the allergen. Orthodontic braces or dental fillings may contain chromium, as do apples (especially the peels); a combination of these items can exacerbate contact dermatitis in an allergic patient.

Bacitracin is another common allergen in the United States. It is one of the components of Neosporin, and this over-the-counter antibiotic ointment has been associated with anaphylaxis in allergic patients, Dr. Jacob warned.

Paraphenylenediamine is an oxidation chemical ingredient that often is used as a hair dye. More recently, it has been used in henna tattoo dyes to make them last longer, despite a Food and Drug Administration warning against the use of this chemical on the skin, Dr. Jacob said.

Formaldehyde and formaldehyde-releasing preservatives are common allergens for children. They are present in many child care products, including Johnson & Johnson baby shampoo, Baby Magic wash, and Water Babies sunscreen, as well as other cosmetics, baby wipes, and personal hygiene products. Aspartame, or NutraSweet, degrades into methanol, which in turn is metabolized in the liver and releases formaldehyde, Dr. Jacob noted. Children with a formaldehyde allergy may find that their condition resolves when they eliminate diet sodas containing NutraSweet and other NutraSweet-containing products from their diets, she said.

Cocamidopropyl betaine is a detergent that appears in many soaps, shampoos, and toothpastes, including Cetaphil and Dove products, and Colgate toothpaste. Patients with this allergy may present with dermatitis behind the ear, where shampoo tends to collect; this allergen should be suspected in children with persistent hand dermatitis.

When treating children with allergic contact dermatitis, allowing time for questions and patient education after the patch test is paramount, Dr. Jacob emphasized. Also, recognize the discomfort and frustration children may feel about the patch test process, and about the elimination or reduction of favorite foods, jewelry, or other products. Provide information about safe alternatives. “I can't stress this enough,” she said.

Databases such as the Contact Allergen Replacement Database, available through the American Contact Dermatitis Society (www.contactderm.org

Allergic contact dermatitis can be caused by anything from toys to food. Courtesy Dr. Sharon E. Jacob

BAL HARBOUR, FLA. — Tracking the cause of allergic contact dermatitis in children requires investigation of all possible avenues of exposure, from toys and clothes to personal hygiene products and foods.

“Patients can receive a dose of allergen in many different ways,” Dr. Sharon E. Jacob said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Allergic contact dermatitis hypersensitivity reactions proceed through three phases: sensitization, challenge, and resolution, said Dr. Jacob, director of the contact dermatitis clinic at the university.

Sensitization occurs when the patient is first exposed to the allergen, but it takes about 21 days.

“Most people don't have a reaction on immediate exposure to an allergen,” Dr. Jacob said. After the patient is sensitized and rechallenged, or reexposed, it takes about 48–96 hours for the skin to react.

“This is important, because patients often won't remember what they did 2–3 days before a rash appeared,” she noted.

The first step in evaluating a child for allergic contact dermatitis is to take an in-depth history. “Look for temporal relationships; ask when the child gets better or worse,” Dr. Jacob said. Consider the child's age, gender, and demographics. Examine the distribution pattern of the rash, which may provide a clue to its origin. For example, a pattern of perioral dermatitis may suggest an allergy to fragrances or balsam of Peru, whereas earlobe dermatitis in a young girl with pierced ears suggests a metal allergy. Also ask about the child's activities, including day care and travel, and even what jewelry he or she wears.

Next, select the most likely allergens for patch testing given the patient's history. Be sure to use allergen concentrations that are safe in children. There are currently no commercially available allergy testing kits designed for the pediatric population, Dr. Jacob noted.

The most common sources of contact dermatitis in children include nickel, fragrances/flavorings, thimerosal, chromium, formaldehyde, cobalt, lanolin, paraphenylenediamine, neomycin, bacitracin, and cocamidopropyl betaine.

Nickel remains the most prevalent contact allergen among children. Nickel exposure can come from many sources, including paper clips, jewelry, front snaps on jeans, and foods. Certain foods—including chocolate, asparagus, soy, and oatmeal—contain high amounts of nickel.

“Allergic contact dermatitis is a dose-dependent phenomenon, and trigger foods may contribute a significant dose,” Dr. Jacob explained.

For example, a 12-year-old girl might wear jeans and earrings, eat both chocolate and oatmeal, and touch paper clips in a single day. These seemingly unrelated items all contain nickel and have the potential to exacerbate contact dermatitis in a sensitized patient. “It's a bit like being Sherlock Holmes and putting the puzzle pieces together—once you know the allergens—to figure out the exposures,” Dr. Jacob said.

Fragrances and flavorings are common causes of contact dermatitis, and they appear in many products that patients routinely use. “We need to remind patients that 'unscented' is in fact a blocking fragrance. Many parents believe that unscented is the same as 'fragrance free,'” Dr. Jacob noted. Two common fragrance allergens, cinnamic alcohol and cinnamic aldehyde, are components of balsam of Peru. These substances can be ingredients in soaps and shampoos, as well as in many foods, including tomato-based products such as ketchup, and artificially flavored soft drinks. Thimerosal is a preservative found in some vaccines and some medications, such as Neo-Synephrine pediatric formula and L'Oreal Miracle Wear mascara, Dr. Jacob noted.

Chromium is another metal salt that appears in products ranging from cement to leather to match heads. People who keep matchbooks in their pockets can have an allergic reaction to chromate in the shape of a patch on the leg where the matchbook was placed, Dr. Jacob noted. Again, food can increase the dose of the allergen. Orthodontic braces or dental fillings may contain chromium, as do apples (especially the peels); a combination of these items can exacerbate contact dermatitis in an allergic patient.

Bacitracin is another common allergen in the United States. It is one of the components of Neosporin, and this over-the-counter antibiotic ointment has been associated with anaphylaxis in allergic patients, Dr. Jacob warned.

Paraphenylenediamine is an oxidation chemical ingredient that often is used as a hair dye. More recently, it has been used in henna tattoo dyes to make them last longer, despite a Food and Drug Administration warning against the use of this chemical on the skin, Dr. Jacob said.

Formaldehyde and formaldehyde-releasing preservatives are common allergens for children. They are present in many child care products, including Johnson & Johnson baby shampoo, Baby Magic wash, and Water Babies sunscreen, as well as other cosmetics, baby wipes, and personal hygiene products. Aspartame, or NutraSweet, degrades into methanol, which in turn is metabolized in the liver and releases formaldehyde, Dr. Jacob noted. Children with a formaldehyde allergy may find that their condition resolves when they eliminate diet sodas containing NutraSweet and other NutraSweet-containing products from their diets, she said.

Cocamidopropyl betaine is a detergent that appears in many soaps, shampoos, and toothpastes, including Cetaphil and Dove products, and Colgate toothpaste. Patients with this allergy may present with dermatitis behind the ear, where shampoo tends to collect; this allergen should be suspected in children with persistent hand dermatitis.

When treating children with allergic contact dermatitis, allowing time for questions and patient education after the patch test is paramount, Dr. Jacob emphasized. Also, recognize the discomfort and frustration children may feel about the patch test process, and about the elimination or reduction of favorite foods, jewelry, or other products. Provide information about safe alternatives. “I can't stress this enough,” she said.

Databases such as the Contact Allergen Replacement Database, available through the American Contact Dermatitis Society (www.contactderm.org

Allergic contact dermatitis can be caused by anything from toys to food. Courtesy Dr. Sharon E. Jacob

BAL HARBOUR, FLA. — Tracking the cause of allergic contact dermatitis in children requires investigation of all possible avenues of exposure, from toys and clothes to personal hygiene products and foods.

“Patients can receive a dose of allergen in many different ways,” Dr. Sharon E. Jacob said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Allergic contact dermatitis hypersensitivity reactions proceed through three phases: sensitization, challenge, and resolution, said Dr. Jacob, director of the contact dermatitis clinic at the university.

Sensitization occurs when the patient is first exposed to the allergen, but it takes about 21 days.

“Most people don't have a reaction on immediate exposure to an allergen,” Dr. Jacob said. After the patient is sensitized and rechallenged, or reexposed, it takes about 48–96 hours for the skin to react.

“This is important, because patients often won't remember what they did 2–3 days before a rash appeared,” she noted.

The first step in evaluating a child for allergic contact dermatitis is to take an in-depth history. “Look for temporal relationships; ask when the child gets better or worse,” Dr. Jacob said. Consider the child's age, gender, and demographics. Examine the distribution pattern of the rash, which may provide a clue to its origin. For example, a pattern of perioral dermatitis may suggest an allergy to fragrances or balsam of Peru, whereas earlobe dermatitis in a young girl with pierced ears suggests a metal allergy. Also ask about the child's activities, including day care and travel, and even what jewelry he or she wears.

Next, select the most likely allergens for patch testing given the patient's history. Be sure to use allergen concentrations that are safe in children. There are currently no commercially available allergy testing kits designed for the pediatric population, Dr. Jacob noted.

The most common sources of contact dermatitis in children include nickel, fragrances/flavorings, thimerosal, chromium, formaldehyde, cobalt, lanolin, paraphenylenediamine, neomycin, bacitracin, and cocamidopropyl betaine.

Nickel remains the most prevalent contact allergen among children. Nickel exposure can come from many sources, including paper clips, jewelry, front snaps on jeans, and foods. Certain foods—including chocolate, asparagus, soy, and oatmeal—contain high amounts of nickel.

“Allergic contact dermatitis is a dose-dependent phenomenon, and trigger foods may contribute a significant dose,” Dr. Jacob explained.

For example, a 12-year-old girl might wear jeans and earrings, eat both chocolate and oatmeal, and touch paper clips in a single day. These seemingly unrelated items all contain nickel and have the potential to exacerbate contact dermatitis in a sensitized patient. “It's a bit like being Sherlock Holmes and putting the puzzle pieces together—once you know the allergens—to figure out the exposures,” Dr. Jacob said.

Fragrances and flavorings are common causes of contact dermatitis, and they appear in many products that patients routinely use. “We need to remind patients that 'unscented' is in fact a blocking fragrance. Many parents believe that unscented is the same as 'fragrance free,'” Dr. Jacob noted. Two common fragrance allergens, cinnamic alcohol and cinnamic aldehyde, are components of balsam of Peru. These substances can be ingredients in soaps and shampoos, as well as in many foods, including tomato-based products such as ketchup, and artificially flavored soft drinks. Thimerosal is a preservative found in some vaccines and some medications, such as Neo-Synephrine pediatric formula and L'Oreal Miracle Wear mascara, Dr. Jacob noted.

Chromium is another metal salt that appears in products ranging from cement to leather to match heads. People who keep matchbooks in their pockets can have an allergic reaction to chromate in the shape of a patch on the leg where the matchbook was placed, Dr. Jacob noted. Again, food can increase the dose of the allergen. Orthodontic braces or dental fillings may contain chromium, as do apples (especially the peels); a combination of these items can exacerbate contact dermatitis in an allergic patient.

Bacitracin is another common allergen in the United States. It is one of the components of Neosporin, and this over-the-counter antibiotic ointment has been associated with anaphylaxis in allergic patients, Dr. Jacob warned.

Paraphenylenediamine is an oxidation chemical ingredient that often is used as a hair dye. More recently, it has been used in henna tattoo dyes to make them last longer, despite a Food and Drug Administration warning against the use of this chemical on the skin, Dr. Jacob said.

Formaldehyde and formaldehyde-releasing preservatives are common allergens for children. They are present in many child care products, including Johnson & Johnson baby shampoo, Baby Magic wash, and Water Babies sunscreen, as well as other cosmetics, baby wipes, and personal hygiene products. Aspartame, or NutraSweet, degrades into methanol, which in turn is metabolized in the liver and releases formaldehyde, Dr. Jacob noted. Children with a formaldehyde allergy may find that their condition resolves when they eliminate diet sodas containing NutraSweet and other NutraSweet-containing products from their diets, she said.

Cocamidopropyl betaine is a detergent that appears in many soaps, shampoos, and toothpastes, including Cetaphil and Dove products, and Colgate toothpaste. Patients with this allergy may present with dermatitis behind the ear, where shampoo tends to collect; this allergen should be suspected in children with persistent hand dermatitis.

When treating children with allergic contact dermatitis, allowing time for questions and patient education after the patch test is paramount, Dr. Jacob emphasized. Also, recognize the discomfort and frustration children may feel about the patch test process, and about the elimination or reduction of favorite foods, jewelry, or other products. Provide information about safe alternatives. “I can't stress this enough,” she said.

Databases such as the Contact Allergen Replacement Database, available through the American Contact Dermatitis Society (www.contactderm.org

Allergic contact dermatitis can be caused by anything from toys to food. Courtesy Dr. Sharon E. Jacob

WASHINGTON — Depressed patients with infections who were treated concomitantly with linezolid and antidepressants showed no evidence of developing serotonin syndrome due to drug interactions, compared with similar patients taking other antibiotics, Dr. Meryl H. Mendelson of Pfizer Global Pharmaceuticals, New York, and colleagues reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Despite this evidence against dangerous drug interactions, data from postmarketing case reports suggest the need to closely observe patients on linezolid and concomitant antidepressants. Physicians should consider discontinuing one or both if patients show signs or symptoms of serotonin syndrome, the investigators said.

Limited clinical evidence suggests that linezolid may weakly inhibit monoamine oxidase and may interact with adrenergic or serotonergic agents, they noted.

A total of 117 adults who received SSRIs and linezolid were matched with 127 patients who received SSRIs and non-linezolid antibiotics—including amoxicillin-clavulanate, cefadroxil, and vancomycin—in phase III and IV drug comparison trials.

Among additional patients being treated with tricyclic or other non-SSRI antidepressants, 112 patients receiving linezolid were matched with 115 patients receiving non-linezolid antibiotics. Both groups were treated concomitantly with antibiotics for approximately 8 days.

Symptoms were classified in three groups based on directly observed or patient-reported adverse events. (See chart.) Adverse event rates were similar among patients on linezolid and other antibiotics.

The study was sponsored by Pfizer, and the meeting was sponsored by the American Society for Microbiology.

WASHINGTON — Depressed patients with infections who were treated concomitantly with linezolid and antidepressants showed no evidence of developing serotonin syndrome due to drug interactions, compared with similar patients taking other antibiotics, Dr. Meryl H. Mendelson of Pfizer Global Pharmaceuticals, New York, and colleagues reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Despite this evidence against dangerous drug interactions, data from postmarketing case reports suggest the need to closely observe patients on linezolid and concomitant antidepressants. Physicians should consider discontinuing one or both if patients show signs or symptoms of serotonin syndrome, the investigators said.

Limited clinical evidence suggests that linezolid may weakly inhibit monoamine oxidase and may interact with adrenergic or serotonergic agents, they noted.

A total of 117 adults who received SSRIs and linezolid were matched with 127 patients who received SSRIs and non-linezolid antibiotics—including amoxicillin-clavulanate, cefadroxil, and vancomycin—in phase III and IV drug comparison trials.

Among additional patients being treated with tricyclic or other non-SSRI antidepressants, 112 patients receiving linezolid were matched with 115 patients receiving non-linezolid antibiotics. Both groups were treated concomitantly with antibiotics for approximately 8 days.

Symptoms were classified in three groups based on directly observed or patient-reported adverse events. (See chart.) Adverse event rates were similar among patients on linezolid and other antibiotics.

The study was sponsored by Pfizer, and the meeting was sponsored by the American Society for Microbiology.

WASHINGTON — Depressed patients with infections who were treated concomitantly with linezolid and antidepressants showed no evidence of developing serotonin syndrome due to drug interactions, compared with similar patients taking other antibiotics, Dr. Meryl H. Mendelson of Pfizer Global Pharmaceuticals, New York, and colleagues reported in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Despite this evidence against dangerous drug interactions, data from postmarketing case reports suggest the need to closely observe patients on linezolid and concomitant antidepressants. Physicians should consider discontinuing one or both if patients show signs or symptoms of serotonin syndrome, the investigators said.

Limited clinical evidence suggests that linezolid may weakly inhibit monoamine oxidase and may interact with adrenergic or serotonergic agents, they noted.

A total of 117 adults who received SSRIs and linezolid were matched with 127 patients who received SSRIs and non-linezolid antibiotics—including amoxicillin-clavulanate, cefadroxil, and vancomycin—in phase III and IV drug comparison trials.

Among additional patients being treated with tricyclic or other non-SSRI antidepressants, 112 patients receiving linezolid were matched with 115 patients receiving non-linezolid antibiotics. Both groups were treated concomitantly with antibiotics for approximately 8 days.

Symptoms were classified in three groups based on directly observed or patient-reported adverse events. (See chart.) Adverse event rates were similar among patients on linezolid and other antibiotics.

The study was sponsored by Pfizer, and the meeting was sponsored by the American Society for Microbiology.

A combination MMR-varicella vaccine can be substituted for the second dose of the MMR vaccine or for the second doses of coadministered MMR and varicella vaccines in children aged 4–6 years, reported Dr. Keith S. Reisinger of Primary Physicians Research in Pittsburgh, and his associates.

Dr. Reisinger and his colleagues found postvaccination seropositivity rates of nearly 100% for the combination measles, mumps, rubella, and varicella vaccine (ProQuad) in a randomized, double-blind multicenter study sponsored by Merck & Co., including 799 healthy children (Pediatrics 2006;117:265–72).

Dr. Reisinger serves as a speaker for Merck and receives research money from the company.

The children had received their primary doses of the measles, mumps, and rubella vaccine (Merck-brand MMRII vaccine) and the varicella vaccine (Varivax) at age 12 months or older at least 1 month before their enrollment in the study.

A total of 399 children received ProQuad as a single injection, plus a placebo, while 205 children received the standard MMRII plus a placebo, and 195 received MMRII plus Varivax. About half the children (53%) were male, most (79%) were white, and their mean age was 4 years.

Overall, the immune responses to all four viruses, as measured by geometric mean titers (GMTs), in children who received ProQuad were statistically similar to those in children who received the other vaccines, although there were differences in GMTs with respect to the individual viruses. The GMTs of antibodies to mumps alone were statistically lower in the ProQuad group, compared with the other groups, but the GMTs of antibodies to rubella and varicella in the ProQuad group were higher, compared with the other groups, Dr. Reisinger and hisassociates wrote.

No severe vaccine-related adverse events were reported, and the percentages of any adverse events were similar among the groups. The most common problems were fever, nasopharyngitis, and cough. There were no significant differences in injection-site adverse experiences in the ProQuad group, compared with the other groups.

The concentration of varicella vaccine virus was higher in the ProQuad vaccine than in the current Varivax varicella vaccine, but the concentrations of measles, mumps, and rubella viruses were the same as those in the current MMRII vaccine.

“The use of [measles, mumps, rubella, and varicella] MMRV will increase varicella protection in a similar fashion that MMR did for lagging mumps and rubella vaccine utilization in the early ′70s,” Dr. Reisinger said. Secondly, some parents and physicians are concerned about the high number of injections that infants receive in the first 2 years of life. The use of MMRV will be helpful in reducing the number of shots.

“Although the above factors are important, the largest issue to me is the need [for the United States] to move toward a two-dose varicella policy. Every vaccine has a primary failure rate. For MMR this primary failure rate is corrected through the recommendation of two doses.

“If the United States adopts a second varicella dose recommendation (as surely it must), the combined MMRV administered at 4–6 years of age will be the vaccine of choice to accomplish this,” he said.

A combination MMR-varicella vaccine can be substituted for the second dose of the MMR vaccine or for the second doses of coadministered MMR and varicella vaccines in children aged 4–6 years, reported Dr. Keith S. Reisinger of Primary Physicians Research in Pittsburgh, and his associates.

Dr. Reisinger and his colleagues found postvaccination seropositivity rates of nearly 100% for the combination measles, mumps, rubella, and varicella vaccine (ProQuad) in a randomized, double-blind multicenter study sponsored by Merck & Co., including 799 healthy children (Pediatrics 2006;117:265–72).

Dr. Reisinger serves as a speaker for Merck and receives research money from the company.

The children had received their primary doses of the measles, mumps, and rubella vaccine (Merck-brand MMRII vaccine) and the varicella vaccine (Varivax) at age 12 months or older at least 1 month before their enrollment in the study.

A total of 399 children received ProQuad as a single injection, plus a placebo, while 205 children received the standard MMRII plus a placebo, and 195 received MMRII plus Varivax. About half the children (53%) were male, most (79%) were white, and their mean age was 4 years.

Overall, the immune responses to all four viruses, as measured by geometric mean titers (GMTs), in children who received ProQuad were statistically similar to those in children who received the other vaccines, although there were differences in GMTs with respect to the individual viruses. The GMTs of antibodies to mumps alone were statistically lower in the ProQuad group, compared with the other groups, but the GMTs of antibodies to rubella and varicella in the ProQuad group were higher, compared with the other groups, Dr. Reisinger and hisassociates wrote.

No severe vaccine-related adverse events were reported, and the percentages of any adverse events were similar among the groups. The most common problems were fever, nasopharyngitis, and cough. There were no significant differences in injection-site adverse experiences in the ProQuad group, compared with the other groups.

The concentration of varicella vaccine virus was higher in the ProQuad vaccine than in the current Varivax varicella vaccine, but the concentrations of measles, mumps, and rubella viruses were the same as those in the current MMRII vaccine.

“The use of [measles, mumps, rubella, and varicella] MMRV will increase varicella protection in a similar fashion that MMR did for lagging mumps and rubella vaccine utilization in the early ′70s,” Dr. Reisinger said. Secondly, some parents and physicians are concerned about the high number of injections that infants receive in the first 2 years of life. The use of MMRV will be helpful in reducing the number of shots.

“Although the above factors are important, the largest issue to me is the need [for the United States] to move toward a two-dose varicella policy. Every vaccine has a primary failure rate. For MMR this primary failure rate is corrected through the recommendation of two doses.

“If the United States adopts a second varicella dose recommendation (as surely it must), the combined MMRV administered at 4–6 years of age will be the vaccine of choice to accomplish this,” he said.

A combination MMR-varicella vaccine can be substituted for the second dose of the MMR vaccine or for the second doses of coadministered MMR and varicella vaccines in children aged 4–6 years, reported Dr. Keith S. Reisinger of Primary Physicians Research in Pittsburgh, and his associates.

Dr. Reisinger and his colleagues found postvaccination seropositivity rates of nearly 100% for the combination measles, mumps, rubella, and varicella vaccine (ProQuad) in a randomized, double-blind multicenter study sponsored by Merck & Co., including 799 healthy children (Pediatrics 2006;117:265–72).

Dr. Reisinger serves as a speaker for Merck and receives research money from the company.

The children had received their primary doses of the measles, mumps, and rubella vaccine (Merck-brand MMRII vaccine) and the varicella vaccine (Varivax) at age 12 months or older at least 1 month before their enrollment in the study.

A total of 399 children received ProQuad as a single injection, plus a placebo, while 205 children received the standard MMRII plus a placebo, and 195 received MMRII plus Varivax. About half the children (53%) were male, most (79%) were white, and their mean age was 4 years.

Overall, the immune responses to all four viruses, as measured by geometric mean titers (GMTs), in children who received ProQuad were statistically similar to those in children who received the other vaccines, although there were differences in GMTs with respect to the individual viruses. The GMTs of antibodies to mumps alone were statistically lower in the ProQuad group, compared with the other groups, but the GMTs of antibodies to rubella and varicella in the ProQuad group were higher, compared with the other groups, Dr. Reisinger and hisassociates wrote.

No severe vaccine-related adverse events were reported, and the percentages of any adverse events were similar among the groups. The most common problems were fever, nasopharyngitis, and cough. There were no significant differences in injection-site adverse experiences in the ProQuad group, compared with the other groups.

The concentration of varicella vaccine virus was higher in the ProQuad vaccine than in the current Varivax varicella vaccine, but the concentrations of measles, mumps, and rubella viruses were the same as those in the current MMRII vaccine.

“The use of [measles, mumps, rubella, and varicella] MMRV will increase varicella protection in a similar fashion that MMR did for lagging mumps and rubella vaccine utilization in the early ′70s,” Dr. Reisinger said. Secondly, some parents and physicians are concerned about the high number of injections that infants receive in the first 2 years of life. The use of MMRV will be helpful in reducing the number of shots.

“Although the above factors are important, the largest issue to me is the need [for the United States] to move toward a two-dose varicella policy. Every vaccine has a primary failure rate. For MMR this primary failure rate is corrected through the recommendation of two doses.

“If the United States adopts a second varicella dose recommendation (as surely it must), the combined MMRV administered at 4–6 years of age will be the vaccine of choice to accomplish this,” he said.

A “medical home” for children means primary care as a combination of the place where care is provided, the process of care in that place, and the team of people delivering the care.

A medical home is not only about improving health and health care, but also about improving the experience of receiving and providing health care, said Dr. W. Carl Cooley, codirector of the Center for Medical Home Improvement in Greenfield, N.H.

“A medical home is not simply a program within a primary care practice, nor is it only for children with special health needs,” Dr. Cooley said. Creating a medical home for children is about practice-wide improvement that depends on being open to change and committed to listening to families and working with them to improve care. That said, children with special health issues account for about 80% of pediatric health care costs.

The model that has emerged in 21st century health care involves chronic condition management as the third leg of a primary care stool, along with preventive care and acute illness management, said Dr. Cooley. An efficient and effective process of chronic condition management in the general practice will benefit all patients in terms of office organization and quality of care.

The first step in providing chronic condition management in a medical home is to identify children with chronic conditions and special needs. If a practice creates a registry of these patients and flags their charts, their conditions are known each time the child comes in or a parent or caregiver calls. Some practices stratify patients by the severity and complexity of the child's condition. For example, on a scale of 1 to 4, 1 might be a child with mild asthma, and 4 might be a child with multiple system complications or home care services.

This type of structure ensures that children with chronic conditions are scheduled for separate visits to discuss specific issues related to chronic conditions. These visits create an opportunity to plan comanagement of the child with specialists and coordinate other aspects of care and services. The visits in the medical home might complement visits to a specialist and reinforce patient education and care strategies, Dr. Cooley said.

For example, a child with diabetes might visit a general practice regularly, alternating with visits to a diabetes clinic every 3 months. Data from the regular medical home visits could be forwarded to the specialty clinic.

In addition, a planned chronic condition management visit creates time for a nurse or nurse coordinator to update the medical history, which makes other preventive and acute visits more useful and productive.

These chronic care visits are among the easiest to bill, Dr. Cooley noted. The visit is a prolonged encounter with an established patient, and codes 99214 and 99215 are almost uniformly accepted as long as the documentation is consistent with this type of visit. “Many pediatricians underutilize the longer visit codes,” he said.

Scheduling longer visits can be difficult in a busy practice accustomed to rapid patient flow. Dr. Cooley recommends gradually blocking out certain times, such as the first hour or two after lunch on certain days, for chronic care visits. “Start with two or three patients a month and enroll them in a chronic conditions management program,” he suggested.

Grants are available to help general practices become more efficient as medical homes for children. Grantors include the Maternal and Child Health Bureau (MCHB) (www.mchb.hrsa.gov/grants/default.htmwww.ntlf.com/html/grants/122256.htm

Dr. H. Garry Gardner and his colleagues received a CATCH grant in 2004 for their primary care pediatric practice. The CATCH grants are geared toward physicians who are interested in community pediatrics. Physicians develop proposals for how they might make their practices become more community oriented and serve as medical homes for patients.

An important part of Dr. Gardner's grant proposal was the inclusion of the cost of a facilitator from the Division of Specialized Care for Children (DSCC), which is administered by the University of Illinois at Chicago, to help organize a program of caring for children with special needs. DSCC is the Title V federally funded Illinois state program for children with special health needs and disabilities. Similar programs exist under other names in other states.

“We learned through working with the facilitator that many of our patients qualified for Title V funding and they didn't know it,” Dr. Gardner said. After receiving the grant, Dr. Gardner, a pediatrician in private practice in Darien, Ill., formed an office quality improvement team. He serves as the physician representative on behalf of the physicians in the practice. The office manager, a nurse, a receptionist, and two patients' mothers complete the team, which meets monthly to discuss ways to improve the quality of care in the office.

The team established a complexity score to define children with special needs. They opted not to designate all children with ADHD or asthma as having chronic conditions. Instead, they reserved this definition for more severe problems, including diabetes, cerebral palsy, and autism.

“We literally labeled the kids by putting a sticker on the front of the chart, and an identifier on the computer screen that comes up when the name is entered,” he explained. “That identification process was important because it helped us know who the child was whenever the parent called with a question or to make an appointment,” he added. Dr. Gardner's practice currently includes 90 children with chronic conditions for whom they serve as a medical home.

Another successful project was creating a telephone script for use by the receptionist when the parent of a special needs child calls. The receptionist has a specific set of questions to ask, such as whether the visit will take extra time, or whether the child prefers to wait in a quiet exam room rather than a crowded waiting room. The office manager of the practice serves as a “care coordinator,” for these patients, and helps manage referral letters, letters of medical necessity, and insurance coverage, which removes some of the paperwork burden from the physicians. Feedback from the parents on the quality improvement team in Dr. Gardner's practice led to the creation of two additional features.

First, the office has a picture guidebook available for nonverbal patients, which includes pictures of the front door, the waiting room, the different doctors, and the different pieces of equipment. Pictures in this format, also known as picture exchange cards, are often used by parents of nonverbal autistic children, and such pictures have been shown to reassure children who might be anxious about the office visit, Dr. Gardner explained.

Second, children with chronic conditions or special needs have a written care plan, condensed to both sides of a single sheet of paper, that lists all of the child's diagnoses, medications, recent hospitalizations, therapist visits—“everything that goes on with this child,” Dr. Gardner said. “We put this page in the front of the chart, and parents have a copy that they can keep with them.”

For more information about the medical home concept and ideas for incorporating its strategies into your practice, visit www.medicalhomeimprovement.org

Creating a medical home is about practice-wide improvement and being open to change. DR. COOLEY

The definition 'chronic conditions' is for problems such as diabetes, cerebral palsy, and autism. Dr. gardner

A “medical home” for children means primary care as a combination of the place where care is provided, the process of care in that place, and the team of people delivering the care.

A medical home is not only about improving health and health care, but also about improving the experience of receiving and providing health care, said Dr. W. Carl Cooley, codirector of the Center for Medical Home Improvement in Greenfield, N.H.

“A medical home is not simply a program within a primary care practice, nor is it only for children with special health needs,” Dr. Cooley said. Creating a medical home for children is about practice-wide improvement that depends on being open to change and committed to listening to families and working with them to improve care. That said, children with special health issues account for about 80% of pediatric health care costs.

The model that has emerged in 21st century health care involves chronic condition management as the third leg of a primary care stool, along with preventive care and acute illness management, said Dr. Cooley. An efficient and effective process of chronic condition management in the general practice will benefit all patients in terms of office organization and quality of care.

The first step in providing chronic condition management in a medical home is to identify children with chronic conditions and special needs. If a practice creates a registry of these patients and flags their charts, their conditions are known each time the child comes in or a parent or caregiver calls. Some practices stratify patients by the severity and complexity of the child's condition. For example, on a scale of 1 to 4, 1 might be a child with mild asthma, and 4 might be a child with multiple system complications or home care services.

This type of structure ensures that children with chronic conditions are scheduled for separate visits to discuss specific issues related to chronic conditions. These visits create an opportunity to plan comanagement of the child with specialists and coordinate other aspects of care and services. The visits in the medical home might complement visits to a specialist and reinforce patient education and care strategies, Dr. Cooley said.

For example, a child with diabetes might visit a general practice regularly, alternating with visits to a diabetes clinic every 3 months. Data from the regular medical home visits could be forwarded to the specialty clinic.

In addition, a planned chronic condition management visit creates time for a nurse or nurse coordinator to update the medical history, which makes other preventive and acute visits more useful and productive.

These chronic care visits are among the easiest to bill, Dr. Cooley noted. The visit is a prolonged encounter with an established patient, and codes 99214 and 99215 are almost uniformly accepted as long as the documentation is consistent with this type of visit. “Many pediatricians underutilize the longer visit codes,” he said.

Scheduling longer visits can be difficult in a busy practice accustomed to rapid patient flow. Dr. Cooley recommends gradually blocking out certain times, such as the first hour or two after lunch on certain days, for chronic care visits. “Start with two or three patients a month and enroll them in a chronic conditions management program,” he suggested.

Grants are available to help general practices become more efficient as medical homes for children. Grantors include the Maternal and Child Health Bureau (MCHB) (www.mchb.hrsa.gov/grants/default.htmwww.ntlf.com/html/grants/122256.htm

Dr. H. Garry Gardner and his colleagues received a CATCH grant in 2004 for their primary care pediatric practice. The CATCH grants are geared toward physicians who are interested in community pediatrics. Physicians develop proposals for how they might make their practices become more community oriented and serve as medical homes for patients.

An important part of Dr. Gardner's grant proposal was the inclusion of the cost of a facilitator from the Division of Specialized Care for Children (DSCC), which is administered by the University of Illinois at Chicago, to help organize a program of caring for children with special needs. DSCC is the Title V federally funded Illinois state program for children with special health needs and disabilities. Similar programs exist under other names in other states.

“We learned through working with the facilitator that many of our patients qualified for Title V funding and they didn't know it,” Dr. Gardner said. After receiving the grant, Dr. Gardner, a pediatrician in private practice in Darien, Ill., formed an office quality improvement team. He serves as the physician representative on behalf of the physicians in the practice. The office manager, a nurse, a receptionist, and two patients' mothers complete the team, which meets monthly to discuss ways to improve the quality of care in the office.

The team established a complexity score to define children with special needs. They opted not to designate all children with ADHD or asthma as having chronic conditions. Instead, they reserved this definition for more severe problems, including diabetes, cerebral palsy, and autism.

“We literally labeled the kids by putting a sticker on the front of the chart, and an identifier on the computer screen that comes up when the name is entered,” he explained. “That identification process was important because it helped us know who the child was whenever the parent called with a question or to make an appointment,” he added. Dr. Gardner's practice currently includes 90 children with chronic conditions for whom they serve as a medical home.

Another successful project was creating a telephone script for use by the receptionist when the parent of a special needs child calls. The receptionist has a specific set of questions to ask, such as whether the visit will take extra time, or whether the child prefers to wait in a quiet exam room rather than a crowded waiting room. The office manager of the practice serves as a “care coordinator,” for these patients, and helps manage referral letters, letters of medical necessity, and insurance coverage, which removes some of the paperwork burden from the physicians. Feedback from the parents on the quality improvement team in Dr. Gardner's practice led to the creation of two additional features.

First, the office has a picture guidebook available for nonverbal patients, which includes pictures of the front door, the waiting room, the different doctors, and the different pieces of equipment. Pictures in this format, also known as picture exchange cards, are often used by parents of nonverbal autistic children, and such pictures have been shown to reassure children who might be anxious about the office visit, Dr. Gardner explained.

Second, children with chronic conditions or special needs have a written care plan, condensed to both sides of a single sheet of paper, that lists all of the child's diagnoses, medications, recent hospitalizations, therapist visits—“everything that goes on with this child,” Dr. Gardner said. “We put this page in the front of the chart, and parents have a copy that they can keep with them.”

For more information about the medical home concept and ideas for incorporating its strategies into your practice, visit www.medicalhomeimprovement.org

Creating a medical home is about practice-wide improvement and being open to change. DR. COOLEY

The definition 'chronic conditions' is for problems such as diabetes, cerebral palsy, and autism. Dr. gardner

A “medical home” for children means primary care as a combination of the place where care is provided, the process of care in that place, and the team of people delivering the care.

A medical home is not only about improving health and health care, but also about improving the experience of receiving and providing health care, said Dr. W. Carl Cooley, codirector of the Center for Medical Home Improvement in Greenfield, N.H.

“A medical home is not simply a program within a primary care practice, nor is it only for children with special health needs,” Dr. Cooley said. Creating a medical home for children is about practice-wide improvement that depends on being open to change and committed to listening to families and working with them to improve care. That said, children with special health issues account for about 80% of pediatric health care costs.

The model that has emerged in 21st century health care involves chronic condition management as the third leg of a primary care stool, along with preventive care and acute illness management, said Dr. Cooley. An efficient and effective process of chronic condition management in the general practice will benefit all patients in terms of office organization and quality of care.

The first step in providing chronic condition management in a medical home is to identify children with chronic conditions and special needs. If a practice creates a registry of these patients and flags their charts, their conditions are known each time the child comes in or a parent or caregiver calls. Some practices stratify patients by the severity and complexity of the child's condition. For example, on a scale of 1 to 4, 1 might be a child with mild asthma, and 4 might be a child with multiple system complications or home care services.

This type of structure ensures that children with chronic conditions are scheduled for separate visits to discuss specific issues related to chronic conditions. These visits create an opportunity to plan comanagement of the child with specialists and coordinate other aspects of care and services. The visits in the medical home might complement visits to a specialist and reinforce patient education and care strategies, Dr. Cooley said.

For example, a child with diabetes might visit a general practice regularly, alternating with visits to a diabetes clinic every 3 months. Data from the regular medical home visits could be forwarded to the specialty clinic.

In addition, a planned chronic condition management visit creates time for a nurse or nurse coordinator to update the medical history, which makes other preventive and acute visits more useful and productive.

These chronic care visits are among the easiest to bill, Dr. Cooley noted. The visit is a prolonged encounter with an established patient, and codes 99214 and 99215 are almost uniformly accepted as long as the documentation is consistent with this type of visit. “Many pediatricians underutilize the longer visit codes,” he said.

Scheduling longer visits can be difficult in a busy practice accustomed to rapid patient flow. Dr. Cooley recommends gradually blocking out certain times, such as the first hour or two after lunch on certain days, for chronic care visits. “Start with two or three patients a month and enroll them in a chronic conditions management program,” he suggested.

Grants are available to help general practices become more efficient as medical homes for children. Grantors include the Maternal and Child Health Bureau (MCHB) (www.mchb.hrsa.gov/grants/default.htmwww.ntlf.com/html/grants/122256.htm

Dr. H. Garry Gardner and his colleagues received a CATCH grant in 2004 for their primary care pediatric practice. The CATCH grants are geared toward physicians who are interested in community pediatrics. Physicians develop proposals for how they might make their practices become more community oriented and serve as medical homes for patients.

An important part of Dr. Gardner's grant proposal was the inclusion of the cost of a facilitator from the Division of Specialized Care for Children (DSCC), which is administered by the University of Illinois at Chicago, to help organize a program of caring for children with special needs. DSCC is the Title V federally funded Illinois state program for children with special health needs and disabilities. Similar programs exist under other names in other states.

“We learned through working with the facilitator that many of our patients qualified for Title V funding and they didn't know it,” Dr. Gardner said. After receiving the grant, Dr. Gardner, a pediatrician in private practice in Darien, Ill., formed an office quality improvement team. He serves as the physician representative on behalf of the physicians in the practice. The office manager, a nurse, a receptionist, and two patients' mothers complete the team, which meets monthly to discuss ways to improve the quality of care in the office.

The team established a complexity score to define children with special needs. They opted not to designate all children with ADHD or asthma as having chronic conditions. Instead, they reserved this definition for more severe problems, including diabetes, cerebral palsy, and autism.

“We literally labeled the kids by putting a sticker on the front of the chart, and an identifier on the computer screen that comes up when the name is entered,” he explained. “That identification process was important because it helped us know who the child was whenever the parent called with a question or to make an appointment,” he added. Dr. Gardner's practice currently includes 90 children with chronic conditions for whom they serve as a medical home.

Another successful project was creating a telephone script for use by the receptionist when the parent of a special needs child calls. The receptionist has a specific set of questions to ask, such as whether the visit will take extra time, or whether the child prefers to wait in a quiet exam room rather than a crowded waiting room. The office manager of the practice serves as a “care coordinator,” for these patients, and helps manage referral letters, letters of medical necessity, and insurance coverage, which removes some of the paperwork burden from the physicians. Feedback from the parents on the quality improvement team in Dr. Gardner's practice led to the creation of two additional features.

First, the office has a picture guidebook available for nonverbal patients, which includes pictures of the front door, the waiting room, the different doctors, and the different pieces of equipment. Pictures in this format, also known as picture exchange cards, are often used by parents of nonverbal autistic children, and such pictures have been shown to reassure children who might be anxious about the office visit, Dr. Gardner explained.

Second, children with chronic conditions or special needs have a written care plan, condensed to both sides of a single sheet of paper, that lists all of the child's diagnoses, medications, recent hospitalizations, therapist visits—“everything that goes on with this child,” Dr. Gardner said. “We put this page in the front of the chart, and parents have a copy that they can keep with them.”

For more information about the medical home concept and ideas for incorporating its strategies into your practice, visit www.medicalhomeimprovement.org

Creating a medical home is about practice-wide improvement and being open to change. DR. COOLEY

The definition 'chronic conditions' is for problems such as diabetes, cerebral palsy, and autism. Dr. gardner

Flu Pneumonia Rare, Mild in Children

Pneumonia was found in 14% of 936 children aged younger than 16 years with influenza, reported Dr. Elina Lahti of Turku (Finland) University Hospital and her colleagues. Nearly half (47%) of the children with both illnesses showed no specific clinical symptoms of pneumonia, and the impact of the influenza virus on the cause of pneumonia remains uncertain (Pediatr. Infect. Dis. J. 2006;25:160–4). The researchers reviewed the chest radiographs of children treated as both inpatients and outpatients in a university hospital from 1980 to 2003, including 743 cases of influenza A and 193 cases of influenza B. Pneumonia was found in 111 (15%) of children with influenza A and in 23 children (12%) with influenza B. There were no significant differences in laboratory or radiologic findings between the influenza A and B groups. Overall, 89% of the children with influenza and pneumonia had white blood cell counts below 15.0 × 109/L and 55% had C-reactive protein concentrations at normal levels or slightly increased (to less than 20 mg/L). About half of the chest radiographs showed alveolar infiltrates, which suggests viral pneumonia, the researchers noted. Almost all of the children recovered without severe adverse events, although four children required ventilator care and one 12-year-old girl with congenital muscular dystrophy died due to severe pneumonia. The findings suggest that influenza pneumonia usually is benign in children and that influenza does not significantly increase the overall burden of pneumonia in previously healthy children, Dr. Lahti and her colleagues said. However, the disease burden was greater among young children—nearly two-thirds of the children in the study were aged younger than 3 years and 75% of these children were hospitalized for their illnesses.

Climate Change Shortens RSV Season

Global warming could be curtailing the respiratory syncytial virus season in England and Wales, according to a study by Dr. Gavin C. Donaldson of University College London. The seasons associated with both respiratory syncytial virus (RSV) isolation rates in laboratories and with RSV-related emergency department admission rates in England and Wales were significantly shorter—3.1 weeks and 2.5 weeks, respectively—during 1981–2004 for laboratory RSV and 1990–2004 for patients admitted to the emergency department with bronchiolitis, compared with rates in previous years (Clin. Infect. Dis. 2006;42:677–9). Dr. Donaldson reviewed the annual mean daily temperatures recorded at four locations in order to calculate the average temperatures for central England during the study periods. Overall, the average temperature increased from 9.2° C in 1981 to 10.5° C in 2004. The start of the RSV season was defined as the first week in the year in which the number of viral isolations and hospital admissions topped an established threshold, and the end of the season was the first week of the year in which the numbers fell below that threshold. The threshold was set at 60% of each year's average weekly number of isolations and hospital admissions. The findings were essentially similar if the threshold was set at 50% or 70%, although the relationship between hospital admission and temperature was not statistically significant when the threshold was set at 50%. Despite these findings, data on the association between RSV and temperature remain contradictory.

Strep Changes Cut Rheumatic Fever

Nonrheumatogenic types of group A streptococcus may be replacing rheumatogenic types in cases of acute streptococcal pharyngitis in children, said Dr. Stanford T. Shulman of Northwestern University and his colleagues. This change could be contributing to the decline of acute rheumatic fever among children in the United States, based on a comparison of data on M-type isolates from children in Chicago during 1961–1968 with data from children from Chicago and nationwide during 2000–2004 (CID 2006;42:441–7). Several rheumatic types of group A streptococcus—3, 5, 6, 14, 18, 19, and 29—were present in nearly 50% of 468 pharyngeal isolates from the 1961–1968 period, but comprised only 11% of 450 isolates from the Chicago area and 18% of 3,969 isolates nationwide during the 2000–2004 period. In contrast, the proportion of several nonrheumatogenic types—2, 4, 22, and 28—increased significantly between the study periods, from about 5% to nearly 28% of isolates, both in Chicago and nationwide. Rheumatic types 14, 18, 19, and 29 essentially vanished during the years between the two study periods. The other most significant decreases occurred in rheumatic types 3, 5, and 6, which comprised 35% of the Chicago isolates during the first study period, when acute rheumatic fever was still prevalent, but only 10% of Chicago isolates during the second study period, when acute rheumatic fever had become rare.

Flu Pneumonia Rare, Mild in Children

Pneumonia was found in 14% of 936 children aged younger than 16 years with influenza, reported Dr. Elina Lahti of Turku (Finland) University Hospital and her colleagues. Nearly half (47%) of the children with both illnesses showed no specific clinical symptoms of pneumonia, and the impact of the influenza virus on the cause of pneumonia remains uncertain (Pediatr. Infect. Dis. J. 2006;25:160–4). The researchers reviewed the chest radiographs of children treated as both inpatients and outpatients in a university hospital from 1980 to 2003, including 743 cases of influenza A and 193 cases of influenza B. Pneumonia was found in 111 (15%) of children with influenza A and in 23 children (12%) with influenza B. There were no significant differences in laboratory or radiologic findings between the influenza A and B groups. Overall, 89% of the children with influenza and pneumonia had white blood cell counts below 15.0 × 109/L and 55% had C-reactive protein concentrations at normal levels or slightly increased (to less than 20 mg/L). About half of the chest radiographs showed alveolar infiltrates, which suggests viral pneumonia, the researchers noted. Almost all of the children recovered without severe adverse events, although four children required ventilator care and one 12-year-old girl with congenital muscular dystrophy died due to severe pneumonia. The findings suggest that influenza pneumonia usually is benign in children and that influenza does not significantly increase the overall burden of pneumonia in previously healthy children, Dr. Lahti and her colleagues said. However, the disease burden was greater among young children—nearly two-thirds of the children in the study were aged younger than 3 years and 75% of these children were hospitalized for their illnesses.

Climate Change Shortens RSV Season

Global warming could be curtailing the respiratory syncytial virus season in England and Wales, according to a study by Dr. Gavin C. Donaldson of University College London. The seasons associated with both respiratory syncytial virus (RSV) isolation rates in laboratories and with RSV-related emergency department admission rates in England and Wales were significantly shorter—3.1 weeks and 2.5 weeks, respectively—during 1981–2004 for laboratory RSV and 1990–2004 for patients admitted to the emergency department with bronchiolitis, compared with rates in previous years (Clin. Infect. Dis. 2006;42:677–9). Dr. Donaldson reviewed the annual mean daily temperatures recorded at four locations in order to calculate the average temperatures for central England during the study periods. Overall, the average temperature increased from 9.2° C in 1981 to 10.5° C in 2004. The start of the RSV season was defined as the first week in the year in which the number of viral isolations and hospital admissions topped an established threshold, and the end of the season was the first week of the year in which the numbers fell below that threshold. The threshold was set at 60% of each year's average weekly number of isolations and hospital admissions. The findings were essentially similar if the threshold was set at 50% or 70%, although the relationship between hospital admission and temperature was not statistically significant when the threshold was set at 50%. Despite these findings, data on the association between RSV and temperature remain contradictory.

Strep Changes Cut Rheumatic Fever

Nonrheumatogenic types of group A streptococcus may be replacing rheumatogenic types in cases of acute streptococcal pharyngitis in children, said Dr. Stanford T. Shulman of Northwestern University and his colleagues. This change could be contributing to the decline of acute rheumatic fever among children in the United States, based on a comparison of data on M-type isolates from children in Chicago during 1961–1968 with data from children from Chicago and nationwide during 2000–2004 (CID 2006;42:441–7). Several rheumatic types of group A streptococcus—3, 5, 6, 14, 18, 19, and 29—were present in nearly 50% of 468 pharyngeal isolates from the 1961–1968 period, but comprised only 11% of 450 isolates from the Chicago area and 18% of 3,969 isolates nationwide during the 2000–2004 period. In contrast, the proportion of several nonrheumatogenic types—2, 4, 22, and 28—increased significantly between the study periods, from about 5% to nearly 28% of isolates, both in Chicago and nationwide. Rheumatic types 14, 18, 19, and 29 essentially vanished during the years between the two study periods. The other most significant decreases occurred in rheumatic types 3, 5, and 6, which comprised 35% of the Chicago isolates during the first study period, when acute rheumatic fever was still prevalent, but only 10% of Chicago isolates during the second study period, when acute rheumatic fever had become rare.

Flu Pneumonia Rare, Mild in Children

Pneumonia was found in 14% of 936 children aged younger than 16 years with influenza, reported Dr. Elina Lahti of Turku (Finland) University Hospital and her colleagues. Nearly half (47%) of the children with both illnesses showed no specific clinical symptoms of pneumonia, and the impact of the influenza virus on the cause of pneumonia remains uncertain (Pediatr. Infect. Dis. J. 2006;25:160–4). The researchers reviewed the chest radiographs of children treated as both inpatients and outpatients in a university hospital from 1980 to 2003, including 743 cases of influenza A and 193 cases of influenza B. Pneumonia was found in 111 (15%) of children with influenza A and in 23 children (12%) with influenza B. There were no significant differences in laboratory or radiologic findings between the influenza A and B groups. Overall, 89% of the children with influenza and pneumonia had white blood cell counts below 15.0 × 109/L and 55% had C-reactive protein concentrations at normal levels or slightly increased (to less than 20 mg/L). About half of the chest radiographs showed alveolar infiltrates, which suggests viral pneumonia, the researchers noted. Almost all of the children recovered without severe adverse events, although four children required ventilator care and one 12-year-old girl with congenital muscular dystrophy died due to severe pneumonia. The findings suggest that influenza pneumonia usually is benign in children and that influenza does not significantly increase the overall burden of pneumonia in previously healthy children, Dr. Lahti and her colleagues said. However, the disease burden was greater among young children—nearly two-thirds of the children in the study were aged younger than 3 years and 75% of these children were hospitalized for their illnesses.

Climate Change Shortens RSV Season

Global warming could be curtailing the respiratory syncytial virus season in England and Wales, according to a study by Dr. Gavin C. Donaldson of University College London. The seasons associated with both respiratory syncytial virus (RSV) isolation rates in laboratories and with RSV-related emergency department admission rates in England and Wales were significantly shorter—3.1 weeks and 2.5 weeks, respectively—during 1981–2004 for laboratory RSV and 1990–2004 for patients admitted to the emergency department with bronchiolitis, compared with rates in previous years (Clin. Infect. Dis. 2006;42:677–9). Dr. Donaldson reviewed the annual mean daily temperatures recorded at four locations in order to calculate the average temperatures for central England during the study periods. Overall, the average temperature increased from 9.2° C in 1981 to 10.5° C in 2004. The start of the RSV season was defined as the first week in the year in which the number of viral isolations and hospital admissions topped an established threshold, and the end of the season was the first week of the year in which the numbers fell below that threshold. The threshold was set at 60% of each year's average weekly number of isolations and hospital admissions. The findings were essentially similar if the threshold was set at 50% or 70%, although the relationship between hospital admission and temperature was not statistically significant when the threshold was set at 50%. Despite these findings, data on the association between RSV and temperature remain contradictory.

Strep Changes Cut Rheumatic Fever

Nonrheumatogenic types of group A streptococcus may be replacing rheumatogenic types in cases of acute streptococcal pharyngitis in children, said Dr. Stanford T. Shulman of Northwestern University and his colleagues. This change could be contributing to the decline of acute rheumatic fever among children in the United States, based on a comparison of data on M-type isolates from children in Chicago during 1961–1968 with data from children from Chicago and nationwide during 2000–2004 (CID 2006;42:441–7). Several rheumatic types of group A streptococcus—3, 5, 6, 14, 18, 19, and 29—were present in nearly 50% of 468 pharyngeal isolates from the 1961–1968 period, but comprised only 11% of 450 isolates from the Chicago area and 18% of 3,969 isolates nationwide during the 2000–2004 period. In contrast, the proportion of several nonrheumatogenic types—2, 4, 22, and 28—increased significantly between the study periods, from about 5% to nearly 28% of isolates, both in Chicago and nationwide. Rheumatic types 14, 18, 19, and 29 essentially vanished during the years between the two study periods. The other most significant decreases occurred in rheumatic types 3, 5, and 6, which comprised 35% of the Chicago isolates during the first study period, when acute rheumatic fever was still prevalent, but only 10% of Chicago isolates during the second study period, when acute rheumatic fever had become rare.

A combination MMR-varicella vaccine can be substituted for the second dose of the MMR vaccine or for the second doses of coadministered MMR and varicella vaccines in children aged 4–6 years, reported Dr. Keith S. Reisinger of Primary Physicians Research in Pittsburgh, and his associates.

Dr. Reisinger and his colleagues found postvaccination seropositivity rates of nearly 100% for the combination measles, mumps, rubella, and varicella vaccine (ProQuad) in a randomized, double-blind multicenter study sponsored by Merck & Co., including 799 healthy children (Pediatrics 2006;117:265–72).

Dr. Reisinger serves as a speaker for Merck and receives research money from the company.

The children had received their primary doses of the measles, mumps, and rubella vaccine (Merck-brand MMRII vaccine) and the varicella vaccine (Varivax) at age 12 months or older at least 1 month before their enrollment in the study.

A total of 399 children received ProQuad as a single injection, plus a placebo, while 205 children received the standard MMRII plus a placebo, and 195 received MMRII plus Varivax. About half the children (53%) were male, most (79%) were white, and their mean age was 4 years.

Overall, the immune responses to all four viruses, as measured by geometric mean titers (GMTs), in children who received ProQuad were statistically similar to those in children who received the other vaccines, although there were differences in GMTs with respect to the individual viruses. The GMTs of antibodies to mumps alone were statistically lower in the ProQuad group, compared with the other groups, but the GMTs of antibodies to rubella and varicella in the ProQuad group were higher, compared with the other groups, Dr. Reisinger and his associates wrote.

No severe vaccine-related adverse events were reported, and the percentages of any adverse events were similar among the groups. The most common problems were fever, nasopharyngitis, and cough. There were no significant differences in injection-site adverse experiences in the ProQuad group, compared with the other groups.

The concentration of varicella vaccine virus was higher in the ProQuad vaccine than in the current Varivax varicella vaccine, but the concentrations of measles, mumps, and rubella viruses were the same as those in the current MMRII vaccine.

Dr. Reisinger said in an interview that the development of a combined vaccine to provide protection against four diseases—measles, mumps, rubella, and varicella (MMRV)—is an important step in children's health for a number of reasons. Although the utilization rates for MMR are approximately 93%, the rates for varicella vaccination have been significantly lower.

“The use of MMRV will increase varicella protection in a similar fashion that MMR did for lagging mumps and rubella vaccine utilization in the early ′70s. Secondly, some parents and physicians are concerned about the high number of injections that infants receive in the first 2 years of life. The use of MMRV will be helpful in reducing the number of shots,” he said.

“Although the above factors are important, the largest issue to me is the need [for the United States] to move toward a two-dose varicella policy. Every vaccine has a primary failure rate. For MMR this primary failure rate is corrected through the recommendation of two doses.

“The combination of lower utilization rates of varicella with the primary vaccine failure rate may allow many children to reach adulthood with susceptibility to varicella. Adults have a much higher rate of morbidity and mortality from a varicella infection.

“If the United States adopts a second varicella dose recommendation (as surely it must), then the combined MMRV administered at 4–6 years of age will be the vaccine of choice to accomplish this,” he said.

A combination MMR-varicella vaccine can be substituted for the second dose of the MMR vaccine or for the second doses of coadministered MMR and varicella vaccines in children aged 4–6 years, reported Dr. Keith S. Reisinger of Primary Physicians Research in Pittsburgh, and his associates.

Dr. Reisinger and his colleagues found postvaccination seropositivity rates of nearly 100% for the combination measles, mumps, rubella, and varicella vaccine (ProQuad) in a randomized, double-blind multicenter study sponsored by Merck & Co., including 799 healthy children (Pediatrics 2006;117:265–72).

Dr. Reisinger serves as a speaker for Merck and receives research money from the company.

The children had received their primary doses of the measles, mumps, and rubella vaccine (Merck-brand MMRII vaccine) and the varicella vaccine (Varivax) at age 12 months or older at least 1 month before their enrollment in the study.

A total of 399 children received ProQuad as a single injection, plus a placebo, while 205 children received the standard MMRII plus a placebo, and 195 received MMRII plus Varivax. About half the children (53%) were male, most (79%) were white, and their mean age was 4 years.

Overall, the immune responses to all four viruses, as measured by geometric mean titers (GMTs), in children who received ProQuad were statistically similar to those in children who received the other vaccines, although there were differences in GMTs with respect to the individual viruses. The GMTs of antibodies to mumps alone were statistically lower in the ProQuad group, compared with the other groups, but the GMTs of antibodies to rubella and varicella in the ProQuad group were higher, compared with the other groups, Dr. Reisinger and his associates wrote.

No severe vaccine-related adverse events were reported, and the percentages of any adverse events were similar among the groups. The most common problems were fever, nasopharyngitis, and cough. There were no significant differences in injection-site adverse experiences in the ProQuad group, compared with the other groups.

The concentration of varicella vaccine virus was higher in the ProQuad vaccine than in the current Varivax varicella vaccine, but the concentrations of measles, mumps, and rubella viruses were the same as those in the current MMRII vaccine.

Dr. Reisinger said in an interview that the development of a combined vaccine to provide protection against four diseases—measles, mumps, rubella, and varicella (MMRV)—is an important step in children's health for a number of reasons. Although the utilization rates for MMR are approximately 93%, the rates for varicella vaccination have been significantly lower.

“The use of MMRV will increase varicella protection in a similar fashion that MMR did for lagging mumps and rubella vaccine utilization in the early ′70s. Secondly, some parents and physicians are concerned about the high number of injections that infants receive in the first 2 years of life. The use of MMRV will be helpful in reducing the number of shots,” he said.

“Although the above factors are important, the largest issue to me is the need [for the United States] to move toward a two-dose varicella policy. Every vaccine has a primary failure rate. For MMR this primary failure rate is corrected through the recommendation of two doses.

“The combination of lower utilization rates of varicella with the primary vaccine failure rate may allow many children to reach adulthood with susceptibility to varicella. Adults have a much higher rate of morbidity and mortality from a varicella infection.

“If the United States adopts a second varicella dose recommendation (as surely it must), then the combined MMRV administered at 4–6 years of age will be the vaccine of choice to accomplish this,” he said.

A combination MMR-varicella vaccine can be substituted for the second dose of the MMR vaccine or for the second doses of coadministered MMR and varicella vaccines in children aged 4–6 years, reported Dr. Keith S. Reisinger of Primary Physicians Research in Pittsburgh, and his associates.

Dr. Reisinger and his colleagues found postvaccination seropositivity rates of nearly 100% for the combination measles, mumps, rubella, and varicella vaccine (ProQuad) in a randomized, double-blind multicenter study sponsored by Merck & Co., including 799 healthy children (Pediatrics 2006;117:265–72).

Dr. Reisinger serves as a speaker for Merck and receives research money from the company.

The children had received their primary doses of the measles, mumps, and rubella vaccine (Merck-brand MMRII vaccine) and the varicella vaccine (Varivax) at age 12 months or older at least 1 month before their enrollment in the study.

A total of 399 children received ProQuad as a single injection, plus a placebo, while 205 children received the standard MMRII plus a placebo, and 195 received MMRII plus Varivax. About half the children (53%) were male, most (79%) were white, and their mean age was 4 years.

Overall, the immune responses to all four viruses, as measured by geometric mean titers (GMTs), in children who received ProQuad were statistically similar to those in children who received the other vaccines, although there were differences in GMTs with respect to the individual viruses. The GMTs of antibodies to mumps alone were statistically lower in the ProQuad group, compared with the other groups, but the GMTs of antibodies to rubella and varicella in the ProQuad group were higher, compared with the other groups, Dr. Reisinger and his associates wrote.

No severe vaccine-related adverse events were reported, and the percentages of any adverse events were similar among the groups. The most common problems were fever, nasopharyngitis, and cough. There were no significant differences in injection-site adverse experiences in the ProQuad group, compared with the other groups.

The concentration of varicella vaccine virus was higher in the ProQuad vaccine than in the current Varivax varicella vaccine, but the concentrations of measles, mumps, and rubella viruses were the same as those in the current MMRII vaccine.

Dr. Reisinger said in an interview that the development of a combined vaccine to provide protection against four diseases—measles, mumps, rubella, and varicella (MMRV)—is an important step in children's health for a number of reasons. Although the utilization rates for MMR are approximately 93%, the rates for varicella vaccination have been significantly lower.

“The use of MMRV will increase varicella protection in a similar fashion that MMR did for lagging mumps and rubella vaccine utilization in the early ′70s. Secondly, some parents and physicians are concerned about the high number of injections that infants receive in the first 2 years of life. The use of MMRV will be helpful in reducing the number of shots,” he said.

“Although the above factors are important, the largest issue to me is the need [for the United States] to move toward a two-dose varicella policy. Every vaccine has a primary failure rate. For MMR this primary failure rate is corrected through the recommendation of two doses.

“The combination of lower utilization rates of varicella with the primary vaccine failure rate may allow many children to reach adulthood with susceptibility to varicella. Adults have a much higher rate of morbidity and mortality from a varicella infection.

“If the United States adopts a second varicella dose recommendation (as surely it must), then the combined MMRV administered at 4–6 years of age will be the vaccine of choice to accomplish this,” he said.

WASHINGTON — Recognize parenting strategies that hinder or support the development of healthy eating patterns, and you can help prevent obesity in toddlers, Jennifer Orlet Fisher, Ph.D., and Susan L. Johnson, Ph.D., said in a presentation at the annual meeting of the American Academy of Pediatrics.

Approximately 11% of American infants aged 0–23 months are above the 95th percentile for weight, said Dr. Fisher of Baylor College of Medicine in Houston.

Few studies of activity levels in toddlers exist, she said. The best data come from a recent study of 100 Scottish children. These data revealed that toddlers spend a majority of their time in sedentary activity followed by light activity, and surprisingly very little time is spent in moderate to vigorous activity. However, moderate to vigorous activity did not predict total energy expenditure, which suggests that light activity is the primary contributor to total energy expenditure. There was little daily variation or weekday/weekend variation.

Television watching contributes to increased sedentary time for toddlers. A national longitudinal study showed that nearly half of toddlers are watching more than 2 hours daily, and children who watched more than 2 hours as toddlers were almost three times more likely to watch more than 2 hours at age 6 years, Dr. Fisher said.

The other side of the equation is what foods toddlers eat, and where and how they eat. Toddlerhood is a time of transition to a modified adult diet, Dr. Fisher explained. “In a relatively short time you see a huge increase in the energy from table food.”

“On average, a 2-year-old's intake is 1,249 calories, which is 32% higher than the estimated daily requirement,” said Dr. Fisher.

Data from the Feeding Infants & Toddlers Study (FITS), a 2003 survey of eating patterns in more than 3,000 children aged 4–24 months conducted by Gerber, indicated that toddlers average seven eating occasions per day. Also, nearly 25% of 19- to 24-year-olds did not eat vegetables daily, and French fries were the most commonly consumed vegetable by children aged 15–24 months.

Some research has examined whether young children can adequately regulate their own energy intake. Dr. Fisher and colleagues conducted an observational study in which young children expressed preferences for the flavored beverage that had the highest energy, suggesting that energy content influenced preferences for flavor.

Data from another study of preschool children showed that children adjusted their energy intake by consuming less high-density drink when left to choose for themselves. Children are much better than adults in regulating energy intake, Dr. Fisher said.

“Opportunities to positively influence food preference begin at the earliest point in development,” she noted. She cited a study in which pregnant women consumed carrot juice during the last trimester and during early breast-feeding. Infants exposed to carrots showed better acceptance of carrot-flavored cereals on first introduction to those foods.

The influence of the environment on eating is a huge area of study; the increase in pediatric overweight can't be explained by genetics alone.

Parents have a very influential role on toddlers' eating habits, and food exposure is related to intake. If something is available and accessible in the home, children are more likely to eat it, but parents have to make the nutritious food available.

Often, well-meaning parents will reduce the variety of foods offered to children; they conclude after 3 or so presentations and rejections that the child doesn't like a particular food. In fact, evidence shows that it takes 5–10 exposures for a child to accept a novel food, Dr. Fisher said, and the number of foods liked in toddlerhood predicts the number liked at age 6–8 years.

Parents, take note: a study in 2000 showed that when adults enthusiastically modeled food, children were more likely to eat it. In addition, parents can be mindful of their feeding strategies for toddlers, including pressuring them to eat, or restricting specific foods. Some parents are controlling, while others provide minimal structure or supervision.

“We actually know very little about best practices for feeding children,” Dr. Fisher said, “but what we do know is that authoritarian feeding practices usually backfire.” Pressure to eat can create a dislike for certain foods and disrupt children's ability to regulate energy intake, and food restriction can encourage children to eat when they aren't hungry.

Doctors are strapped for time, but there are some points they can make in the office that might help parents prevent or control overweight and obesity in toddlers, said Dr. Johnson, director of the Children's Eating Laboratory at the University of Colorado, Denver.

Suggestions for parents, which may not be met with enthusiasm, include cutting down on sweetened drinks and making an effort to create a safe space in the home for toddlers to move freely, or to visit places, such as zoos, parks, or indoor play areas.

However, many physicians feel uncomfortable raising the issue of weight. No one wants to hear that their child is overweight, and especially not obese, said Dr. Johnson, who works with extremely obese pediatric patients and families in a tertiary care center. Also, in some cultures, plump babies are considered healthy, and parents don't recognize that they might be laying a foundation for childhood obesity by overfeeding their infants and toddlers.

It's also important to phrase questions about a young child's weight in a nonaccusatory way, Dr. Johnson said. Instead of saying “Your child needs to lose weight,” try asking, “Do you have any concerns about your child's weight?” Depending on the parent's response, offer some tips for reducing energy intake and increasing activity, or you may have to drop the subject for that particular visit if the family is not receptive or willing to make any changes.

A child who has exceeded the 95th percentile on growth charts can be a conversation starter. Dr. Johnson said that when she uses phrases such as “your child is growing faster than 95 of 100 children,” she can make an impact on parents. Use of sensitive language is important, however, because parents don't want to hear their children labeled as overweight or obese. Dr. Johnson uses phrases such as “Your child seems to be getting ahead of himself,” which sounds less accusatory than “your child is overweight.”

Ask parents, “What do you think is going to happen if this growth rate keeps up?” If the parent comes up with an answer, the doctor is taken out of the role of accuser, she noted. If parents get the idea at that point that their child needs to stop gaining weight so rapidly, the doctor can introduce some ways to “slow things down a bit.” If the parents don't recognize the problem, offer some information about potential health risks: “If your child continues to go on this way, here's what can happen.”

“I often start with 'is your child being teased?'” Dr. Johnson said. That gets people's attention because it's not a number or a percent; it is a painful situation for the child. Ask the parents what they want to do to mitigate the weight problem and thus cut down on the teasing. Listen to what the parents think is important, and have concrete strategies on hand to offer them.

Parents can't see how much food goes into the baby when they are breast-feeding, and some parents find security in “just topping it off” with some formula, because they can see an empty bottle. “It is important to stress that breast-feeding is enough, because the infant's growth is proceeding fine,” Dr. Johnson said.

Tips for Controlling Calories, Increasing Activity Levels

Dr. Johnson shared her tips for families about how to control calorie intake and keep toddlers from “getting ahead of themselves” in terms of weight:

▸ Cut down on sugar by avoiding sweetened beverages, except on special days.

▸ Limit juice to one-half cup per day of 100% fruit juice.

▸ Don't put juice in bottles. Promote children to a cup (not a sippy cup) by age 18 months.

▸ Find other ways to console a child besides candy. (Note to parents: granola bars are more like candy bars than “health food.”)

▸ Keep offering vegetables. Young children reject most foods on the first few tries; this behavior is not a poor reflection on parents.

▸ Choose foods in which whole grain is the first ingredient.

▸ Encourage breakfast. Breakfast provides children with cognitive benefits and prevents overweight. The number of toddlers reportedly consuming breakfast has dropped during the past two decades.

▸ Limit eating in the car. “I don't consider the car to be an eating environment,” Dr. Johnson said. It promotes overconsumption because parents can't keep track of what the child is eating, and it is unsafe, since parents behind the wheel can't help a child who starts to choke.

▸ Ask parents how many fruits and vegetables their child eats in a day, and which ones he or she likes. Help parents to focus on the ones that the child likes, and make sure these fruits and vegetables are available.

▸ Ask about both over- and underconsumption of milk. Current guidelines call for toddlers to consume 15–24 oz/day of milk; some children drink as much as 60 oz/day. You can have too much of a good thing.

▸ Teach children to serve themselves. When they do so, they tend to consume child-sized portions. This requires more patience and guidance from parents at the outset.

Dr. Johnson also offered several guidelines for promoting physical activity in toddlers:

▸ Make sure parents know about developmental milestones, such as standing and walking.

▸ Praise activity in children, and give them an opportunity to be active. Toddlers love routines; consider structured active time at a specific time during the day.

▸ Toddlers should not be sedentary for more than an hour at a time, unless they are sleeping.

▸ Create a safe area in the house where toddlers can be free to move, or take them to the zoo, park, or an indoor play area.

▸ Encourage dancing and play that is active.

Here are some questions for parents that serve as reminders:

▸ Do you, the parent, eat fruits and vegetables in front of your child? A parent's modeling of healthy eating can have a significant impact on a child's eating.

▸ Do you participate in active play with your child?

▸ Do you have family meals, in which the parents and children together eat healthy foods?

▸ Do you hide food from your children? Do they find it? All parents hide food from children, but it often doesn't work.

Sources: Susan L. Johnson, Ph.D.; Circulation 2005;112:2061–75; National Association for Sport and Physical Education Guidelines for Infants and Toddlers (

http://www.aahperd.org/NASPE/template.cfm?template=toddlers.html

WASHINGTON — Recognize parenting strategies that hinder or support the development of healthy eating patterns, and you can help prevent obesity in toddlers, Jennifer Orlet Fisher, Ph.D., and Susan L. Johnson, Ph.D., said in a presentation at the annual meeting of the American Academy of Pediatrics.

Approximately 11% of American infants aged 0–23 months are above the 95th percentile for weight, said Dr. Fisher of Baylor College of Medicine in Houston.

Few studies of activity levels in toddlers exist, she said. The best data come from a recent study of 100 Scottish children. These data revealed that toddlers spend a majority of their time in sedentary activity followed by light activity, and surprisingly very little time is spent in moderate to vigorous activity. However, moderate to vigorous activity did not predict total energy expenditure, which suggests that light activity is the primary contributor to total energy expenditure. There was little daily variation or weekday/weekend variation.

Television watching contributes to increased sedentary time for toddlers. A national longitudinal study showed that nearly half of toddlers are watching more than 2 hours daily, and children who watched more than 2 hours as toddlers were almost three times more likely to watch more than 2 hours at age 6 years, Dr. Fisher said.

The other side of the equation is what foods toddlers eat, and where and how they eat. Toddlerhood is a time of transition to a modified adult diet, Dr. Fisher explained. “In a relatively short time you see a huge increase in the energy from table food.”

“On average, a 2-year-old's intake is 1,249 calories, which is 32% higher than the estimated daily requirement,” said Dr. Fisher.

Data from the Feeding Infants & Toddlers Study (FITS), a 2003 survey of eating patterns in more than 3,000 children aged 4–24 months conducted by Gerber, indicated that toddlers average seven eating occasions per day. Also, nearly 25% of 19- to 24-year-olds did not eat vegetables daily, and French fries were the most commonly consumed vegetable by children aged 15–24 months.

Some research has examined whether young children can adequately regulate their own energy intake. Dr. Fisher and colleagues conducted an observational study in which young children expressed preferences for the flavored beverage that had the highest energy, suggesting that energy content influenced preferences for flavor.

Data from another study of preschool children showed that children adjusted their energy intake by consuming less high-density drink when left to choose for themselves. Children are much better than adults in regulating energy intake, Dr. Fisher said.

“Opportunities to positively influence food preference begin at the earliest point in development,” she noted. She cited a study in which pregnant women consumed carrot juice during the last trimester and during early breast-feeding. Infants exposed to carrots showed better acceptance of carrot-flavored cereals on first introduction to those foods.

The influence of the environment on eating is a huge area of study; the increase in pediatric overweight can't be explained by genetics alone.

Parents have a very influential role on toddlers' eating habits, and food exposure is related to intake. If something is available and accessible in the home, children are more likely to eat it, but parents have to make the nutritious food available.

Often, well-meaning parents will reduce the variety of foods offered to children; they conclude after 3 or so presentations and rejections that the child doesn't like a particular food. In fact, evidence shows that it takes 5–10 exposures for a child to accept a novel food, Dr. Fisher said, and the number of foods liked in toddlerhood predicts the number liked at age 6–8 years.

Parents, take note: a study in 2000 showed that when adults enthusiastically modeled food, children were more likely to eat it. In addition, parents can be mindful of their feeding strategies for toddlers, including pressuring them to eat, or restricting specific foods. Some parents are controlling, while others provide minimal structure or supervision.

“We actually know very little about best practices for feeding children,” Dr. Fisher said, “but what we do know is that authoritarian feeding practices usually backfire.” Pressure to eat can create a dislike for certain foods and disrupt children's ability to regulate energy intake, and food restriction can encourage children to eat when they aren't hungry.

Doctors are strapped for time, but there are some points they can make in the office that might help parents prevent or control overweight and obesity in toddlers, said Dr. Johnson, director of the Children's Eating Laboratory at the University of Colorado, Denver.

Suggestions for parents, which may not be met with enthusiasm, include cutting down on sweetened drinks and making an effort to create a safe space in the home for toddlers to move freely, or to visit places, such as zoos, parks, or indoor play areas.

However, many physicians feel uncomfortable raising the issue of weight. No one wants to hear that their child is overweight, and especially not obese, said Dr. Johnson, who works with extremely obese pediatric patients and families in a tertiary care center. Also, in some cultures, plump babies are considered healthy, and parents don't recognize that they might be laying a foundation for childhood obesity by overfeeding their infants and toddlers.

It's also important to phrase questions about a young child's weight in a nonaccusatory way, Dr. Johnson said. Instead of saying “Your child needs to lose weight,” try asking, “Do you have any concerns about your child's weight?” Depending on the parent's response, offer some tips for reducing energy intake and increasing activity, or you may have to drop the subject for that particular visit if the family is not receptive or willing to make any changes.

A child who has exceeded the 95th percentile on growth charts can be a conversation starter. Dr. Johnson said that when she uses phrases such as “your child is growing faster than 95 of 100 children,” she can make an impact on parents. Use of sensitive language is important, however, because parents don't want to hear their children labeled as overweight or obese. Dr. Johnson uses phrases such as “Your child seems to be getting ahead of himself,” which sounds less accusatory than “your child is overweight.”

Ask parents, “What do you think is going to happen if this growth rate keeps up?” If the parent comes up with an answer, the doctor is taken out of the role of accuser, she noted. If parents get the idea at that point that their child needs to stop gaining weight so rapidly, the doctor can introduce some ways to “slow things down a bit.” If the parents don't recognize the problem, offer some information about potential health risks: “If your child continues to go on this way, here's what can happen.”

“I often start with 'is your child being teased?'” Dr. Johnson said. That gets people's attention because it's not a number or a percent; it is a painful situation for the child. Ask the parents what they want to do to mitigate the weight problem and thus cut down on the teasing. Listen to what the parents think is important, and have concrete strategies on hand to offer them.

Parents can't see how much food goes into the baby when they are breast-feeding, and some parents find security in “just topping it off” with some formula, because they can see an empty bottle. “It is important to stress that breast-feeding is enough, because the infant's growth is proceeding fine,” Dr. Johnson said.

Tips for Controlling Calories, Increasing Activity Levels

Dr. Johnson shared her tips for families about how to control calorie intake and keep toddlers from “getting ahead of themselves” in terms of weight:

▸ Cut down on sugar by avoiding sweetened beverages, except on special days.

▸ Limit juice to one-half cup per day of 100% fruit juice.

▸ Don't put juice in bottles. Promote children to a cup (not a sippy cup) by age 18 months.

▸ Find other ways to console a child besides candy. (Note to parents: granola bars are more like candy bars than “health food.”)

▸ Keep offering vegetables. Young children reject most foods on the first few tries; this behavior is not a poor reflection on parents.

▸ Choose foods in which whole grain is the first ingredient.

▸ Encourage breakfast. Breakfast provides children with cognitive benefits and prevents overweight. The number of toddlers reportedly consuming breakfast has dropped during the past two decades.

▸ Limit eating in the car. “I don't consider the car to be an eating environment,” Dr. Johnson said. It promotes overconsumption because parents can't keep track of what the child is eating, and it is unsafe, since parents behind the wheel can't help a child who starts to choke.

▸ Ask parents how many fruits and vegetables their child eats in a day, and which ones he or she likes. Help parents to focus on the ones that the child likes, and make sure these fruits and vegetables are available.

▸ Ask about both over- and underconsumption of milk. Current guidelines call for toddlers to consume 15–24 oz/day of milk; some children drink as much as 60 oz/day. You can have too much of a good thing.

▸ Teach children to serve themselves. When they do so, they tend to consume child-sized portions. This requires more patience and guidance from parents at the outset.

Dr. Johnson also offered several guidelines for promoting physical activity in toddlers:

▸ Make sure parents know about developmental milestones, such as standing and walking.

▸ Praise activity in children, and give them an opportunity to be active. Toddlers love routines; consider structured active time at a specific time during the day.

▸ Toddlers should not be sedentary for more than an hour at a time, unless they are sleeping.

▸ Create a safe area in the house where toddlers can be free to move, or take them to the zoo, park, or an indoor play area.

▸ Encourage dancing and play that is active.

Here are some questions for parents that serve as reminders:

▸ Do you, the parent, eat fruits and vegetables in front of your child? A parent's modeling of healthy eating can have a significant impact on a child's eating.

▸ Do you participate in active play with your child?

▸ Do you have family meals, in which the parents and children together eat healthy foods?

▸ Do you hide food from your children? Do they find it? All parents hide food from children, but it often doesn't work.

Sources: Susan L. Johnson, Ph.D.; Circulation 2005;112:2061–75; National Association for Sport and Physical Education Guidelines for Infants and Toddlers (

http://www.aahperd.org/NASPE/template.cfm?template=toddlers.html

WASHINGTON — Recognize parenting strategies that hinder or support the development of healthy eating patterns, and you can help prevent obesity in toddlers, Jennifer Orlet Fisher, Ph.D., and Susan L. Johnson, Ph.D., said in a presentation at the annual meeting of the American Academy of Pediatrics.

Approximately 11% of American infants aged 0–23 months are above the 95th percentile for weight, said Dr. Fisher of Baylor College of Medicine in Houston.

Few studies of activity levels in toddlers exist, she said. The best data come from a recent study of 100 Scottish children. These data revealed that toddlers spend a majority of their time in sedentary activity followed by light activity, and surprisingly very little time is spent in moderate to vigorous activity. However, moderate to vigorous activity did not predict total energy expenditure, which suggests that light activity is the primary contributor to total energy expenditure. There was little daily variation or weekday/weekend variation.

Television watching contributes to increased sedentary time for toddlers. A national longitudinal study showed that nearly half of toddlers are watching more than 2 hours daily, and children who watched more than 2 hours as toddlers were almost three times more likely to watch more than 2 hours at age 6 years, Dr. Fisher said.

The other side of the equation is what foods toddlers eat, and where and how they eat. Toddlerhood is a time of transition to a modified adult diet, Dr. Fisher explained. “In a relatively short time you see a huge increase in the energy from table food.”

“On average, a 2-year-old's intake is 1,249 calories, which is 32% higher than the estimated daily requirement,” said Dr. Fisher.

Data from the Feeding Infants & Toddlers Study (FITS), a 2003 survey of eating patterns in more than 3,000 children aged 4–24 months conducted by Gerber, indicated that toddlers average seven eating occasions per day. Also, nearly 25% of 19- to 24-year-olds did not eat vegetables daily, and French fries were the most commonly consumed vegetable by children aged 15–24 months.

Some research has examined whether young children can adequately regulate their own energy intake. Dr. Fisher and colleagues conducted an observational study in which young children expressed preferences for the flavored beverage that had the highest energy, suggesting that energy content influenced preferences for flavor.

Data from another study of preschool children showed that children adjusted their energy intake by consuming less high-density drink when left to choose for themselves. Children are much better than adults in regulating energy intake, Dr. Fisher said.

“Opportunities to positively influence food preference begin at the earliest point in development,” she noted. She cited a study in which pregnant women consumed carrot juice during the last trimester and during early breast-feeding. Infants exposed to carrots showed better acceptance of carrot-flavored cereals on first introduction to those foods.

The influence of the environment on eating is a huge area of study; the increase in pediatric overweight can't be explained by genetics alone.

Parents have a very influential role on toddlers' eating habits, and food exposure is related to intake. If something is available and accessible in the home, children are more likely to eat it, but parents have to make the nutritious food available.

Often, well-meaning parents will reduce the variety of foods offered to children; they conclude after 3 or so presentations and rejections that the child doesn't like a particular food. In fact, evidence shows that it takes 5–10 exposures for a child to accept a novel food, Dr. Fisher said, and the number of foods liked in toddlerhood predicts the number liked at age 6–8 years.

Parents, take note: a study in 2000 showed that when adults enthusiastically modeled food, children were more likely to eat it. In addition, parents can be mindful of their feeding strategies for toddlers, including pressuring them to eat, or restricting specific foods. Some parents are controlling, while others provide minimal structure or supervision.

“We actually know very little about best practices for feeding children,” Dr. Fisher said, “but what we do know is that authoritarian feeding practices usually backfire.” Pressure to eat can create a dislike for certain foods and disrupt children's ability to regulate energy intake, and food restriction can encourage children to eat when they aren't hungry.

Doctors are strapped for time, but there are some points they can make in the office that might help parents prevent or control overweight and obesity in toddlers, said Dr. Johnson, director of the Children's Eating Laboratory at the University of Colorado, Denver.

Suggestions for parents, which may not be met with enthusiasm, include cutting down on sweetened drinks and making an effort to create a safe space in the home for toddlers to move freely, or to visit places, such as zoos, parks, or indoor play areas.

However, many physicians feel uncomfortable raising the issue of weight. No one wants to hear that their child is overweight, and especially not obese, said Dr. Johnson, who works with extremely obese pediatric patients and families in a tertiary care center. Also, in some cultures, plump babies are considered healthy, and parents don't recognize that they might be laying a foundation for childhood obesity by overfeeding their infants and toddlers.

It's also important to phrase questions about a young child's weight in a nonaccusatory way, Dr. Johnson said. Instead of saying “Your child needs to lose weight,” try asking, “Do you have any concerns about your child's weight?” Depending on the parent's response, offer some tips for reducing energy intake and increasing activity, or you may have to drop the subject for that particular visit if the family is not receptive or willing to make any changes.

A child who has exceeded the 95th percentile on growth charts can be a conversation starter. Dr. Johnson said that when she uses phrases such as “your child is growing faster than 95 of 100 children,” she can make an impact on parents. Use of sensitive language is important, however, because parents don't want to hear their children labeled as overweight or obese. Dr. Johnson uses phrases such as “Your child seems to be getting ahead of himself,” which sounds less accusatory than “your child is overweight.”

Ask parents, “What do you think is going to happen if this growth rate keeps up?” If the parent comes up with an answer, the doctor is taken out of the role of accuser, she noted. If parents get the idea at that point that their child needs to stop gaining weight so rapidly, the doctor can introduce some ways to “slow things down a bit.” If the parents don't recognize the problem, offer some information about potential health risks: “If your child continues to go on this way, here's what can happen.”

“I often start with 'is your child being teased?'” Dr. Johnson said. That gets people's attention because it's not a number or a percent; it is a painful situation for the child. Ask the parents what they want to do to mitigate the weight problem and thus cut down on the teasing. Listen to what the parents think is important, and have concrete strategies on hand to offer them.

Parents can't see how much food goes into the baby when they are breast-feeding, and some parents find security in “just topping it off” with some formula, because they can see an empty bottle. “It is important to stress that breast-feeding is enough, because the infant's growth is proceeding fine,” Dr. Johnson said.

Tips for Controlling Calories, Increasing Activity Levels

Dr. Johnson shared her tips for families about how to control calorie intake and keep toddlers from “getting ahead of themselves” in terms of weight:

▸ Cut down on sugar by avoiding sweetened beverages, except on special days.

▸ Limit juice to one-half cup per day of 100% fruit juice.

▸ Don't put juice in bottles. Promote children to a cup (not a sippy cup) by age 18 months.

▸ Find other ways to console a child besides candy. (Note to parents: granola bars are more like candy bars than “health food.”)

▸ Keep offering vegetables. Young children reject most foods on the first few tries; this behavior is not a poor reflection on parents.

▸ Choose foods in which whole grain is the first ingredient.

▸ Encourage breakfast. Breakfast provides children with cognitive benefits and prevents overweight. The number of toddlers reportedly consuming breakfast has dropped during the past two decades.

▸ Limit eating in the car. “I don't consider the car to be an eating environment,” Dr. Johnson said. It promotes overconsumption because parents can't keep track of what the child is eating, and it is unsafe, since parents behind the wheel can't help a child who starts to choke.

▸ Ask parents how many fruits and vegetables their child eats in a day, and which ones he or she likes. Help parents to focus on the ones that the child likes, and make sure these fruits and vegetables are available.

▸ Ask about both over- and underconsumption of milk. Current guidelines call for toddlers to consume 15–24 oz/day of milk; some children drink as much as 60 oz/day. You can have too much of a good thing.

▸ Teach children to serve themselves. When they do so, they tend to consume child-sized portions. This requires more patience and guidance from parents at the outset.

Dr. Johnson also offered several guidelines for promoting physical activity in toddlers:

▸ Make sure parents know about developmental milestones, such as standing and walking.

▸ Praise activity in children, and give them an opportunity to be active. Toddlers love routines; consider structured active time at a specific time during the day.

▸ Toddlers should not be sedentary for more than an hour at a time, unless they are sleeping.

▸ Create a safe area in the house where toddlers can be free to move, or take them to the zoo, park, or an indoor play area.

▸ Encourage dancing and play that is active.

Here are some questions for parents that serve as reminders:

▸ Do you, the parent, eat fruits and vegetables in front of your child? A parent's modeling of healthy eating can have a significant impact on a child's eating.

▸ Do you participate in active play with your child?

▸ Do you have family meals, in which the parents and children together eat healthy foods?

▸ Do you hide food from your children? Do they find it? All parents hide food from children, but it often doesn't work.

Sources: Susan L. Johnson, Ph.D.; Circulation 2005;112:2061–75; National Association for Sport and Physical Education Guidelines for Infants and Toddlers (

http://www.aahperd.org/NASPE/template.cfm?template=toddlers.html