Linda Little

SCOTTSDALE, ARIZ. — Vaccination for hepatitis A should be extended to children above the age of 2 with catch-up immunization for older children and adolescents, William F. Balistreri, M.D., advised.

“We need to rethink the vaccine strategy to see if we can have a rational plan for hepatitis A that would be more inclusive,” said Dr. Balistreri, director of pediatric gastroenterology, hepatology, and nutrition at Children's Medical Center, Cincinnati.

He advised physicians to vaccinate children over the age of 2 years.

Physicians “need to get beyond these barriers and vaccinate these children. We have a vaccine that works. We have a disease that can kill,” Dr. Balistreri said in an interview.

Major outbreaks of hepatitis A still occur in the United States; the majority of these are food borne, he said at a pediatric update sponsored by the Phoenix Children's Hospital.

Children play a vital role in the spread of hepatitis A virus, which can be transmitted through food, fecal matter, and person-to-person contact.

“Day care is a hotbed for transmission,” he said. “You have lots of children, few caretakers, everything goes in the mouth, caretakers may change the diaper on the same surface where children play, and children excrete the virus longer [than adults].”

To make matters worse, a young child can be infected and have few, if any, symptoms. Usually, outbreaks in day-care centers are detected only after the adult contacts become sick, he said.

While 85% of adults will become jaundiced, only about 10%-15% of children do. Children are likely to have a mild fever, a runny nose, and maybe a little diarrhea, Dr. Balistreri said. “Some children have no symptoms whatsoever.”

In contrast, adults become jaundiced and have nausea, vomiting, anorexia, and abdominal pain. It can be deadly for some adults.

“Children and young adults do fairly well,” he said. “But for anyone over the age of 49, the mortality is up to 3%-4%. This is a disease that can take lives.”

If middle-aged adults are infected, this form of hepatitis can be devastating and costly, he said. There are more than 63,000 symptomatic infections in adults each year, resulting in 8,403 hospitalizations and 255 deaths. The illness results in 829,000 work loss days, 7,466 years of life lost at an annual cost of $489 million.

“The bottom line is the vaccine is cost effective when you look at the implications,” Dr. Balistreri said.

Part of the problem is that 80% of children excrete the virus for 3 weeks, some as long as 6 weeks. This results in adults, who are hit much harder by the symptoms, being susceptible to the virus. “Not only are children not symptomatic, but they continue to excrete the virus,” he said. “No individual is sick at the time they are shedding.”

Something as simple as eating a school lunch can result in an outbreak, as evidence of the Michigan outbreak in 1997 shows, when strawberries contaminated in Mexico and processed in California were then shipped to the school lunch program in Michigan.

“We need to use a vaccine not only to protect the individual but the community, so it can't gain a foothold,” Dr. Balistreri said.

Once an outbreak occurs then immunoglobulin can be given to prevent symptomatic infection in contacts. While there is nothing wrong with this, the timing is off, Dr. Balistreri said. Prevention appears to be the most effective approach.

A Thailand study of 40,119 school-aged children showed the vaccine was effective in immunizing children against hepatitis A. Of the 19,037 children given the vaccine, 94% developed antibodies in 8 months and 99% developed antibodies at 17 months. There were 38 cases of clinical hepatitis A in the control group, compared with only 2 in the vaccinated children, both of whom were probably infected with the virus at time of vaccination.

Currently, hepatitis A vaccination is recommended for those with occupational risks, such as health care and day-care workers, travelers to endemic regions, children in high-rate communities, persons with chronic liver disease, those with high-risk behaviors, and transplant recipients or others who are immune depressed.

When it was found that Native American children had a fourfold higher rate, the children were vaccinated, he said. That rate dramatically dropped after vaccinations were provided in 1996. Three years later, children in 11 Western states—where the incidence of hepatitis A was twice the national average—were targeted.

“It did a great job in those states with a high rate,” he said, but the adjoining states then developed a higher incidence. “The virus shifted east. The virus doesn't respect state lines.” That's the problem in only targeting high-risk groups, he said.

Health officials should learn from the experience of hepatitis B, he said, where targeting the high-risk groups did not result in a substantial reduction in the frequency of hepatitis B. “We lost 10 years because we didn't start off with a universal vaccination program,” he said.

He gave an example of 244 migrant children tested in Florida; on average, half already had been infected. The numbers increased with age, with 34% of the 2- to 5-year-olds testing positive for hepatitis A antibodies and 81% of the 14-year-old and over group testing positive.

“In a community that wasn't targeted, about half of the children already had been infected,” he said. “This is a missed opportunity.”

The biggest impediments to universal hepatitis A vaccination in children include cost, addition of yet another vaccination to a complex schedule, and the rising fear among some parents about vaccination.

But the vaccine has proved both safe and cost effective, he said.

The vaccine costs $11.15 a dose under federal programs and $26 to $30 per patient in private practice. Administration fees are about $12 a dose.

“Children play an important role in the spread of hepatitis A,” said Dr. Balistreri. “There already is an immunization schedule in place for children, whereas trying to get adults immunized is another story.”

One solution may be a combined hepatitis A and B vaccine for children, he said. Currently, the combined vaccine is approved for children in Europe, but approved only for adults in the United States.

SCOTTSDALE, ARIZ. — Vaccination for hepatitis A should be extended to children above the age of 2 with catch-up immunization for older children and adolescents, William F. Balistreri, M.D., advised.

“We need to rethink the vaccine strategy to see if we can have a rational plan for hepatitis A that would be more inclusive,” said Dr. Balistreri, director of pediatric gastroenterology, hepatology, and nutrition at Children's Medical Center, Cincinnati.

He advised physicians to vaccinate children over the age of 2 years.

Physicians “need to get beyond these barriers and vaccinate these children. We have a vaccine that works. We have a disease that can kill,” Dr. Balistreri said in an interview.

Major outbreaks of hepatitis A still occur in the United States; the majority of these are food borne, he said at a pediatric update sponsored by the Phoenix Children's Hospital.

Children play a vital role in the spread of hepatitis A virus, which can be transmitted through food, fecal matter, and person-to-person contact.

“Day care is a hotbed for transmission,” he said. “You have lots of children, few caretakers, everything goes in the mouth, caretakers may change the diaper on the same surface where children play, and children excrete the virus longer [than adults].”

To make matters worse, a young child can be infected and have few, if any, symptoms. Usually, outbreaks in day-care centers are detected only after the adult contacts become sick, he said.

While 85% of adults will become jaundiced, only about 10%-15% of children do. Children are likely to have a mild fever, a runny nose, and maybe a little diarrhea, Dr. Balistreri said. “Some children have no symptoms whatsoever.”

In contrast, adults become jaundiced and have nausea, vomiting, anorexia, and abdominal pain. It can be deadly for some adults.

“Children and young adults do fairly well,” he said. “But for anyone over the age of 49, the mortality is up to 3%-4%. This is a disease that can take lives.”

If middle-aged adults are infected, this form of hepatitis can be devastating and costly, he said. There are more than 63,000 symptomatic infections in adults each year, resulting in 8,403 hospitalizations and 255 deaths. The illness results in 829,000 work loss days, 7,466 years of life lost at an annual cost of $489 million.

“The bottom line is the vaccine is cost effective when you look at the implications,” Dr. Balistreri said.

Part of the problem is that 80% of children excrete the virus for 3 weeks, some as long as 6 weeks. This results in adults, who are hit much harder by the symptoms, being susceptible to the virus. “Not only are children not symptomatic, but they continue to excrete the virus,” he said. “No individual is sick at the time they are shedding.”

Something as simple as eating a school lunch can result in an outbreak, as evidence of the Michigan outbreak in 1997 shows, when strawberries contaminated in Mexico and processed in California were then shipped to the school lunch program in Michigan.

“We need to use a vaccine not only to protect the individual but the community, so it can't gain a foothold,” Dr. Balistreri said.

Once an outbreak occurs then immunoglobulin can be given to prevent symptomatic infection in contacts. While there is nothing wrong with this, the timing is off, Dr. Balistreri said. Prevention appears to be the most effective approach.

A Thailand study of 40,119 school-aged children showed the vaccine was effective in immunizing children against hepatitis A. Of the 19,037 children given the vaccine, 94% developed antibodies in 8 months and 99% developed antibodies at 17 months. There were 38 cases of clinical hepatitis A in the control group, compared with only 2 in the vaccinated children, both of whom were probably infected with the virus at time of vaccination.

Currently, hepatitis A vaccination is recommended for those with occupational risks, such as health care and day-care workers, travelers to endemic regions, children in high-rate communities, persons with chronic liver disease, those with high-risk behaviors, and transplant recipients or others who are immune depressed.

When it was found that Native American children had a fourfold higher rate, the children were vaccinated, he said. That rate dramatically dropped after vaccinations were provided in 1996. Three years later, children in 11 Western states—where the incidence of hepatitis A was twice the national average—were targeted.

“It did a great job in those states with a high rate,” he said, but the adjoining states then developed a higher incidence. “The virus shifted east. The virus doesn't respect state lines.” That's the problem in only targeting high-risk groups, he said.

Health officials should learn from the experience of hepatitis B, he said, where targeting the high-risk groups did not result in a substantial reduction in the frequency of hepatitis B. “We lost 10 years because we didn't start off with a universal vaccination program,” he said.

He gave an example of 244 migrant children tested in Florida; on average, half already had been infected. The numbers increased with age, with 34% of the 2- to 5-year-olds testing positive for hepatitis A antibodies and 81% of the 14-year-old and over group testing positive.

“In a community that wasn't targeted, about half of the children already had been infected,” he said. “This is a missed opportunity.”

The biggest impediments to universal hepatitis A vaccination in children include cost, addition of yet another vaccination to a complex schedule, and the rising fear among some parents about vaccination.

But the vaccine has proved both safe and cost effective, he said.

The vaccine costs $11.15 a dose under federal programs and $26 to $30 per patient in private practice. Administration fees are about $12 a dose.

“Children play an important role in the spread of hepatitis A,” said Dr. Balistreri. “There already is an immunization schedule in place for children, whereas trying to get adults immunized is another story.”

One solution may be a combined hepatitis A and B vaccine for children, he said. Currently, the combined vaccine is approved for children in Europe, but approved only for adults in the United States.

SCOTTSDALE, ARIZ. — Vaccination for hepatitis A should be extended to children above the age of 2 with catch-up immunization for older children and adolescents, William F. Balistreri, M.D., advised.

“We need to rethink the vaccine strategy to see if we can have a rational plan for hepatitis A that would be more inclusive,” said Dr. Balistreri, director of pediatric gastroenterology, hepatology, and nutrition at Children's Medical Center, Cincinnati.

He advised physicians to vaccinate children over the age of 2 years.

Physicians “need to get beyond these barriers and vaccinate these children. We have a vaccine that works. We have a disease that can kill,” Dr. Balistreri said in an interview.

Major outbreaks of hepatitis A still occur in the United States; the majority of these are food borne, he said at a pediatric update sponsored by the Phoenix Children's Hospital.

Children play a vital role in the spread of hepatitis A virus, which can be transmitted through food, fecal matter, and person-to-person contact.

“Day care is a hotbed for transmission,” he said. “You have lots of children, few caretakers, everything goes in the mouth, caretakers may change the diaper on the same surface where children play, and children excrete the virus longer [than adults].”

To make matters worse, a young child can be infected and have few, if any, symptoms. Usually, outbreaks in day-care centers are detected only after the adult contacts become sick, he said.

While 85% of adults will become jaundiced, only about 10%-15% of children do. Children are likely to have a mild fever, a runny nose, and maybe a little diarrhea, Dr. Balistreri said. “Some children have no symptoms whatsoever.”

In contrast, adults become jaundiced and have nausea, vomiting, anorexia, and abdominal pain. It can be deadly for some adults.

“Children and young adults do fairly well,” he said. “But for anyone over the age of 49, the mortality is up to 3%-4%. This is a disease that can take lives.”

If middle-aged adults are infected, this form of hepatitis can be devastating and costly, he said. There are more than 63,000 symptomatic infections in adults each year, resulting in 8,403 hospitalizations and 255 deaths. The illness results in 829,000 work loss days, 7,466 years of life lost at an annual cost of $489 million.

“The bottom line is the vaccine is cost effective when you look at the implications,” Dr. Balistreri said.

Part of the problem is that 80% of children excrete the virus for 3 weeks, some as long as 6 weeks. This results in adults, who are hit much harder by the symptoms, being susceptible to the virus. “Not only are children not symptomatic, but they continue to excrete the virus,” he said. “No individual is sick at the time they are shedding.”

Something as simple as eating a school lunch can result in an outbreak, as evidence of the Michigan outbreak in 1997 shows, when strawberries contaminated in Mexico and processed in California were then shipped to the school lunch program in Michigan.

“We need to use a vaccine not only to protect the individual but the community, so it can't gain a foothold,” Dr. Balistreri said.

Once an outbreak occurs then immunoglobulin can be given to prevent symptomatic infection in contacts. While there is nothing wrong with this, the timing is off, Dr. Balistreri said. Prevention appears to be the most effective approach.

A Thailand study of 40,119 school-aged children showed the vaccine was effective in immunizing children against hepatitis A. Of the 19,037 children given the vaccine, 94% developed antibodies in 8 months and 99% developed antibodies at 17 months. There were 38 cases of clinical hepatitis A in the control group, compared with only 2 in the vaccinated children, both of whom were probably infected with the virus at time of vaccination.

Currently, hepatitis A vaccination is recommended for those with occupational risks, such as health care and day-care workers, travelers to endemic regions, children in high-rate communities, persons with chronic liver disease, those with high-risk behaviors, and transplant recipients or others who are immune depressed.

When it was found that Native American children had a fourfold higher rate, the children were vaccinated, he said. That rate dramatically dropped after vaccinations were provided in 1996. Three years later, children in 11 Western states—where the incidence of hepatitis A was twice the national average—were targeted.

“It did a great job in those states with a high rate,” he said, but the adjoining states then developed a higher incidence. “The virus shifted east. The virus doesn't respect state lines.” That's the problem in only targeting high-risk groups, he said.

Health officials should learn from the experience of hepatitis B, he said, where targeting the high-risk groups did not result in a substantial reduction in the frequency of hepatitis B. “We lost 10 years because we didn't start off with a universal vaccination program,” he said.

He gave an example of 244 migrant children tested in Florida; on average, half already had been infected. The numbers increased with age, with 34% of the 2- to 5-year-olds testing positive for hepatitis A antibodies and 81% of the 14-year-old and over group testing positive.

“In a community that wasn't targeted, about half of the children already had been infected,” he said. “This is a missed opportunity.”

The biggest impediments to universal hepatitis A vaccination in children include cost, addition of yet another vaccination to a complex schedule, and the rising fear among some parents about vaccination.

But the vaccine has proved both safe and cost effective, he said.

The vaccine costs $11.15 a dose under federal programs and $26 to $30 per patient in private practice. Administration fees are about $12 a dose.

“Children play an important role in the spread of hepatitis A,” said Dr. Balistreri. “There already is an immunization schedule in place for children, whereas trying to get adults immunized is another story.”

One solution may be a combined hepatitis A and B vaccine for children, he said. Currently, the combined vaccine is approved for children in Europe, but approved only for adults in the United States.

GRAPEVINE, TEX. — A strong family history of heart disease can increase an individual's future risk for coronary heart disease fourfold, and even a moderate family history can lead to a twofold increase in risk, a population-based study has shown.

“Most clinicians limit family history assessment to the presence of early-onset disease in a first-degree relative,” Maren Scheuner, M.D., said at a meeting sponsored by the American College of Medical Genetics. “However, familial risk is influenced by the number of affected relatives, their degree of relationship and lineage, and age at diagnosis.”

By analyzing data on 4,035 respondents to a national mail survey called HealthStyles, the researchers found that even a moderate history of coronary heart disease (CHD) increased the risk of CHD. Additionally, a strong family history of stroke also increased the CHD risk.

“If you have a family history of CHD, we know that it increases the risk,” said Dr. Scheuner of the department of health services at the University of California School of Public Health, Los Angeles. “We have shown that a family history of stroke also influences the risk of CHD.”

The researchers stratified the survey respondents' family history of CHD and stroke as weak, moderate, or strong. Those with a strong family history had one or more family members with onset of heart disease or stroke at or before age 60. Those with a moderate family history had one or two family members with heart disease or stroke at a later age. Those with a weak family history had no relatives with heart disease or stroke or only one or two affected second-degree relatives. The survey also obtained self-reported information on risk factors such as diabetes, hypertension, high cholesterol, and obesity.

Individuals with strong family histories of CHD were four times as likely to have the disease, compared with those with a weak history. If three or four risk factors are present—such as diabetes, high blood pressure, high cholesterol, and obesity—the risk is increased 27 times given a strong familial CHD risk, compared with those with a weak family history of heart disease and no risk factors. If only two risk factors are present, then the risk is increased 19 times, and if no risk factors are present, then the risk for CHD associated with strong familial CHD is increased only twofold.

Turning to the risk of stroke, a person with a strong family history of CHD has 2.5 times the risk of stroke as a person with a weak family history of CHD. And an individual with a strong family history of stroke has a threefold increase in the risk of a stroke and a twofold increase in the risk of CHD, she reported.

A strong family history of CHD was also associated with a 1.5-fold increased risk of diabetes, high cholesterol, high blood pressure, and obesity. A strong family history of stroke was associated with a twofold increase in diabetes and a 1.5-fold increase in high blood pressure and obesity.

Moderate family histories of CHD resulted in a twofold increase in CHD, but not an increased risk for stroke, diabetes, high cholesterol, high blood pressure, or obesity. If there was a moderate family history of stroke, the risk of stroke was increased, but the risk for the other conditions was not increased.

Survey respondents were 60% female and 72% white, with a mean age of 48 years. Overall, 6.4% had a personal history of CHD, 4.2% had a personal history of stroke, and 12.3% had a personal history of diabetes. More than 15% of the respondents had a family history of all three conditions. Almost one-third of respondents reported a strong family history of CHD, and 15% had a strong family history of stroke.

The data show that familial risk algorithms for CHD and stroke that incorporate factors such as age at diagnosis, number of affected relatives, and their degree of relationship and lineage, can stratify cardiovascular risk as moderate (about a 1.5- to 2.5-fold increase) or strong (about a 2.5- to fivefold increase) Dr. Scheuner said.

Modifiable cardiovascular risk factors such as diabetes, high cholesterol, hypertension, and obesity are associated with strong familial CHD and stroke risk, and when present they substantially increase the cardiovascular risk. The absence of risk factors diminishes the association between familial risk and CHD or stroke, she said.

This suggests that individuals with increased familial risk could benefit considerably from preventive interventions. Familial risk stratification should be included in cardiovascular risk assessment and prevention strategies, Dr. Scheuner said.

GRAPEVINE, TEX. — A strong family history of heart disease can increase an individual's future risk for coronary heart disease fourfold, and even a moderate family history can lead to a twofold increase in risk, a population-based study has shown.

“Most clinicians limit family history assessment to the presence of early-onset disease in a first-degree relative,” Maren Scheuner, M.D., said at a meeting sponsored by the American College of Medical Genetics. “However, familial risk is influenced by the number of affected relatives, their degree of relationship and lineage, and age at diagnosis.”

By analyzing data on 4,035 respondents to a national mail survey called HealthStyles, the researchers found that even a moderate history of coronary heart disease (CHD) increased the risk of CHD. Additionally, a strong family history of stroke also increased the CHD risk.

“If you have a family history of CHD, we know that it increases the risk,” said Dr. Scheuner of the department of health services at the University of California School of Public Health, Los Angeles. “We have shown that a family history of stroke also influences the risk of CHD.”

The researchers stratified the survey respondents' family history of CHD and stroke as weak, moderate, or strong. Those with a strong family history had one or more family members with onset of heart disease or stroke at or before age 60. Those with a moderate family history had one or two family members with heart disease or stroke at a later age. Those with a weak family history had no relatives with heart disease or stroke or only one or two affected second-degree relatives. The survey also obtained self-reported information on risk factors such as diabetes, hypertension, high cholesterol, and obesity.

Individuals with strong family histories of CHD were four times as likely to have the disease, compared with those with a weak history. If three or four risk factors are present—such as diabetes, high blood pressure, high cholesterol, and obesity—the risk is increased 27 times given a strong familial CHD risk, compared with those with a weak family history of heart disease and no risk factors. If only two risk factors are present, then the risk is increased 19 times, and if no risk factors are present, then the risk for CHD associated with strong familial CHD is increased only twofold.

Turning to the risk of stroke, a person with a strong family history of CHD has 2.5 times the risk of stroke as a person with a weak family history of CHD. And an individual with a strong family history of stroke has a threefold increase in the risk of a stroke and a twofold increase in the risk of CHD, she reported.

A strong family history of CHD was also associated with a 1.5-fold increased risk of diabetes, high cholesterol, high blood pressure, and obesity. A strong family history of stroke was associated with a twofold increase in diabetes and a 1.5-fold increase in high blood pressure and obesity.

Moderate family histories of CHD resulted in a twofold increase in CHD, but not an increased risk for stroke, diabetes, high cholesterol, high blood pressure, or obesity. If there was a moderate family history of stroke, the risk of stroke was increased, but the risk for the other conditions was not increased.

Survey respondents were 60% female and 72% white, with a mean age of 48 years. Overall, 6.4% had a personal history of CHD, 4.2% had a personal history of stroke, and 12.3% had a personal history of diabetes. More than 15% of the respondents had a family history of all three conditions. Almost one-third of respondents reported a strong family history of CHD, and 15% had a strong family history of stroke.

The data show that familial risk algorithms for CHD and stroke that incorporate factors such as age at diagnosis, number of affected relatives, and their degree of relationship and lineage, can stratify cardiovascular risk as moderate (about a 1.5- to 2.5-fold increase) or strong (about a 2.5- to fivefold increase) Dr. Scheuner said.

Modifiable cardiovascular risk factors such as diabetes, high cholesterol, hypertension, and obesity are associated with strong familial CHD and stroke risk, and when present they substantially increase the cardiovascular risk. The absence of risk factors diminishes the association between familial risk and CHD or stroke, she said.

This suggests that individuals with increased familial risk could benefit considerably from preventive interventions. Familial risk stratification should be included in cardiovascular risk assessment and prevention strategies, Dr. Scheuner said.

GRAPEVINE, TEX. — A strong family history of heart disease can increase an individual's future risk for coronary heart disease fourfold, and even a moderate family history can lead to a twofold increase in risk, a population-based study has shown.

“Most clinicians limit family history assessment to the presence of early-onset disease in a first-degree relative,” Maren Scheuner, M.D., said at a meeting sponsored by the American College of Medical Genetics. “However, familial risk is influenced by the number of affected relatives, their degree of relationship and lineage, and age at diagnosis.”

By analyzing data on 4,035 respondents to a national mail survey called HealthStyles, the researchers found that even a moderate history of coronary heart disease (CHD) increased the risk of CHD. Additionally, a strong family history of stroke also increased the CHD risk.

“If you have a family history of CHD, we know that it increases the risk,” said Dr. Scheuner of the department of health services at the University of California School of Public Health, Los Angeles. “We have shown that a family history of stroke also influences the risk of CHD.”

The researchers stratified the survey respondents' family history of CHD and stroke as weak, moderate, or strong. Those with a strong family history had one or more family members with onset of heart disease or stroke at or before age 60. Those with a moderate family history had one or two family members with heart disease or stroke at a later age. Those with a weak family history had no relatives with heart disease or stroke or only one or two affected second-degree relatives. The survey also obtained self-reported information on risk factors such as diabetes, hypertension, high cholesterol, and obesity.

Individuals with strong family histories of CHD were four times as likely to have the disease, compared with those with a weak history. If three or four risk factors are present—such as diabetes, high blood pressure, high cholesterol, and obesity—the risk is increased 27 times given a strong familial CHD risk, compared with those with a weak family history of heart disease and no risk factors. If only two risk factors are present, then the risk is increased 19 times, and if no risk factors are present, then the risk for CHD associated with strong familial CHD is increased only twofold.

Turning to the risk of stroke, a person with a strong family history of CHD has 2.5 times the risk of stroke as a person with a weak family history of CHD. And an individual with a strong family history of stroke has a threefold increase in the risk of a stroke and a twofold increase in the risk of CHD, she reported.

A strong family history of CHD was also associated with a 1.5-fold increased risk of diabetes, high cholesterol, high blood pressure, and obesity. A strong family history of stroke was associated with a twofold increase in diabetes and a 1.5-fold increase in high blood pressure and obesity.

Moderate family histories of CHD resulted in a twofold increase in CHD, but not an increased risk for stroke, diabetes, high cholesterol, high blood pressure, or obesity. If there was a moderate family history of stroke, the risk of stroke was increased, but the risk for the other conditions was not increased.

Survey respondents were 60% female and 72% white, with a mean age of 48 years. Overall, 6.4% had a personal history of CHD, 4.2% had a personal history of stroke, and 12.3% had a personal history of diabetes. More than 15% of the respondents had a family history of all three conditions. Almost one-third of respondents reported a strong family history of CHD, and 15% had a strong family history of stroke.

The data show that familial risk algorithms for CHD and stroke that incorporate factors such as age at diagnosis, number of affected relatives, and their degree of relationship and lineage, can stratify cardiovascular risk as moderate (about a 1.5- to 2.5-fold increase) or strong (about a 2.5- to fivefold increase) Dr. Scheuner said.

Modifiable cardiovascular risk factors such as diabetes, high cholesterol, hypertension, and obesity are associated with strong familial CHD and stroke risk, and when present they substantially increase the cardiovascular risk. The absence of risk factors diminishes the association between familial risk and CHD or stroke, she said.

This suggests that individuals with increased familial risk could benefit considerably from preventive interventions. Familial risk stratification should be included in cardiovascular risk assessment and prevention strategies, Dr. Scheuner said.

SCOTTSDALE, ARIZ. — Vaccination for hepatitis A should be extended to children above the age of 2 with catch-up immunization for older children and adolescents, William F. Balistreri, M.D., advised.

“We need to rethink the vaccine strategy to see if we can have a rational plan for hepatitis A that would be more inclusive,” said Dr. Balistreri, director of pediatric gastroenterology, hepatology, and nutrition at Children's Medical Center, Cincinnati.

He advised pediatricians to vaccinate children over the age of 2 years.

“Pediatricians need to get beyond these barriers and vaccinate these children. We have a vaccine that works. We have a disease that can kill,” Dr. Balistreri said in an interview.

Major outbreaks of hepatitis A still occur in the United States; the majority of these are food borne, he said at a pediatric update sponsored by the Phoenix Children's Hospital.

Children play a vital role in the spread of hepatitis A virus, which can be transmitted through food, fecal matter, and person-to-person contact.

“Day care is a hotbed for transmission,” he said. “You have lots of children, few caretakers, everything goes in the mouth, caretakers may change the diaper on the same surface where children play, and children excrete the virus longer [than adults].”

To make matters worse, a young child can be infected and have few, if any, symptoms. Usually, outbreaks in day-care centers are detected only after the adult contacts become sick, he said.

While 85% of adults will become jaundiced, only about 10%-15% of children do. Children are likely to have a mild fever, a runny nose, and maybe a little diarrhea, Dr. Balistreri said. “Some children have no symptoms whatsoever.” In contrast, adults become jaundiced and have nausea, vomiting, anorexia, and abdominal pain. It can be deadly for some adults.

“Children and young adults do fairly well,” he said. “But for anyone over the age of 49, the mortality is up to 3%-4%. This is a disease that can take lives.”

If middle-aged adults are infected, this form of hepatitis can be devastating and costly, he said. There are more than 63,000 symptomatic infections in adults each year, resulting in 8,403 hospitalizations and 255 deaths. The illness results in 829,000 work loss days, 7,466 years of life lost at an annual cost of $489 million.

“The bottom line is the vaccine is cost effective when you look at the implications,” said Dr. Balistreri.

Part of the problem is that 80% of children excrete the virus for 3 weeks, some as long as 6 weeks. This results in adults, who are hit much harder by the symptoms, being susceptible to the virus. “Not only are children not symptomatic, but they continue to excrete the virus,” he said. “No individual is sick at the time they are shedding.”

Something as simple as eating a school lunch can result in an outbreak, as evidence of the Michigan outbreak in 1997 shows, when strawberries contaminated in Mexico and processed in California were then shipped to the school lunch program in Michigan.

“We need to use a vaccine not only to protect the individual but the community, so it can't gain a foothold,” Dr. Balistreri said.

Once an outbreak occurs, then immunoglobulin can be given to prevent symptomatic infection in contacts. While there is nothing wrong with this, the timing is off, Dr. Balistreri said. Prevention appears to be the most effective approach.

A Thailand study of 40,119 school-aged children showed the vaccine was effective in immunizing children against hepatitis A. Of the 19,037 children given the vaccine, 94% developed antibodies in 8 months and 99% developed antibodies at 17 months. There were 38 cases of clinical hepatitis A in the control group, compared with only 2 in the vaccinated children, both of whom were probably infected with the virus at time of vaccination.

Currently, hepatitis A vaccination is recommended for those with occupational risks, such as health care and day-care workers, travelers to endemic regions, children in high-rate communities, persons with chronic liver disease, those with high-risk behaviors, and transplant recipients or others who are immune depressed.

When it was found that Native American children had a fourfold higher rate, the children were vaccinated, he said. That rate dramatically dropped after vaccinations were provided in 1996. Three years later, children in 11 Western states—where the incidence of hepatitis A was twice the national average—were targeted.

“It did a great job in those states with a high rate,” he said, but the adjoining states then developed a higher incidence. “The virus shifted east. The virus doesn't respect state lines.”

That's the problem in only targeting high risk groups, he said.

Health officials should learn from the experience of hepatitis B, he said, where targeting the high-risk groups did not result in a substantial reduction in the frequency of hepatitis B. “We lost 10 years because we didn't start off with a universal vaccination program,” he said.

He gave the example of migrant children in Florida where 244 children were tested and on average half already had been infected. The numbers increased with age with 34% of the 2- to 5-year-olds testing positive for hepatitis A antibodies and 81% of the 14-year-old and over group testing positive.

“In a community that wasn't targeted, about half of the children already had been infected,” he said. “This is a missed opportunity.”

The biggest impediments to universal hepatitis A vaccination in children include cost, addition of yet another vaccination to a complex schedule, and the rising fear among some parents about vaccination.

But the vaccine has proved both safe and cost effective, he said. The cost of the vaccine under federal programs is $11.15 a dose while in private practice the cost is between $26 and $30 per patient. Administration fees are about $12 a dose.

“Children play an important role in the spread of hepatitis A,” said Dr. Balistreri. “There already is an immunization schedule in place for children, whereas trying to get adults immunized is another story. It makes great sense.”

One solution may be a combined hepatitis A and B vaccine for children, he said. Currently, the combined vaccine is approved for children in Europe, but approved only for adults in the United States.

SCOTTSDALE, ARIZ. — Vaccination for hepatitis A should be extended to children above the age of 2 with catch-up immunization for older children and adolescents, William F. Balistreri, M.D., advised.

“We need to rethink the vaccine strategy to see if we can have a rational plan for hepatitis A that would be more inclusive,” said Dr. Balistreri, director of pediatric gastroenterology, hepatology, and nutrition at Children's Medical Center, Cincinnati.

He advised pediatricians to vaccinate children over the age of 2 years.

“Pediatricians need to get beyond these barriers and vaccinate these children. We have a vaccine that works. We have a disease that can kill,” Dr. Balistreri said in an interview.

Major outbreaks of hepatitis A still occur in the United States; the majority of these are food borne, he said at a pediatric update sponsored by the Phoenix Children's Hospital.

Children play a vital role in the spread of hepatitis A virus, which can be transmitted through food, fecal matter, and person-to-person contact.

“Day care is a hotbed for transmission,” he said. “You have lots of children, few caretakers, everything goes in the mouth, caretakers may change the diaper on the same surface where children play, and children excrete the virus longer [than adults].”

To make matters worse, a young child can be infected and have few, if any, symptoms. Usually, outbreaks in day-care centers are detected only after the adult contacts become sick, he said.

While 85% of adults will become jaundiced, only about 10%-15% of children do. Children are likely to have a mild fever, a runny nose, and maybe a little diarrhea, Dr. Balistreri said. “Some children have no symptoms whatsoever.” In contrast, adults become jaundiced and have nausea, vomiting, anorexia, and abdominal pain. It can be deadly for some adults.

“Children and young adults do fairly well,” he said. “But for anyone over the age of 49, the mortality is up to 3%-4%. This is a disease that can take lives.”

If middle-aged adults are infected, this form of hepatitis can be devastating and costly, he said. There are more than 63,000 symptomatic infections in adults each year, resulting in 8,403 hospitalizations and 255 deaths. The illness results in 829,000 work loss days, 7,466 years of life lost at an annual cost of $489 million.

“The bottom line is the vaccine is cost effective when you look at the implications,” said Dr. Balistreri.

Part of the problem is that 80% of children excrete the virus for 3 weeks, some as long as 6 weeks. This results in adults, who are hit much harder by the symptoms, being susceptible to the virus. “Not only are children not symptomatic, but they continue to excrete the virus,” he said. “No individual is sick at the time they are shedding.”

Something as simple as eating a school lunch can result in an outbreak, as evidence of the Michigan outbreak in 1997 shows, when strawberries contaminated in Mexico and processed in California were then shipped to the school lunch program in Michigan.

“We need to use a vaccine not only to protect the individual but the community, so it can't gain a foothold,” Dr. Balistreri said.

Once an outbreak occurs, then immunoglobulin can be given to prevent symptomatic infection in contacts. While there is nothing wrong with this, the timing is off, Dr. Balistreri said. Prevention appears to be the most effective approach.

A Thailand study of 40,119 school-aged children showed the vaccine was effective in immunizing children against hepatitis A. Of the 19,037 children given the vaccine, 94% developed antibodies in 8 months and 99% developed antibodies at 17 months. There were 38 cases of clinical hepatitis A in the control group, compared with only 2 in the vaccinated children, both of whom were probably infected with the virus at time of vaccination.

Currently, hepatitis A vaccination is recommended for those with occupational risks, such as health care and day-care workers, travelers to endemic regions, children in high-rate communities, persons with chronic liver disease, those with high-risk behaviors, and transplant recipients or others who are immune depressed.

When it was found that Native American children had a fourfold higher rate, the children were vaccinated, he said. That rate dramatically dropped after vaccinations were provided in 1996. Three years later, children in 11 Western states—where the incidence of hepatitis A was twice the national average—were targeted.

“It did a great job in those states with a high rate,” he said, but the adjoining states then developed a higher incidence. “The virus shifted east. The virus doesn't respect state lines.”

That's the problem in only targeting high risk groups, he said.

Health officials should learn from the experience of hepatitis B, he said, where targeting the high-risk groups did not result in a substantial reduction in the frequency of hepatitis B. “We lost 10 years because we didn't start off with a universal vaccination program,” he said.

He gave the example of migrant children in Florida where 244 children were tested and on average half already had been infected. The numbers increased with age with 34% of the 2- to 5-year-olds testing positive for hepatitis A antibodies and 81% of the 14-year-old and over group testing positive.

“In a community that wasn't targeted, about half of the children already had been infected,” he said. “This is a missed opportunity.”

The biggest impediments to universal hepatitis A vaccination in children include cost, addition of yet another vaccination to a complex schedule, and the rising fear among some parents about vaccination.

But the vaccine has proved both safe and cost effective, he said. The cost of the vaccine under federal programs is $11.15 a dose while in private practice the cost is between $26 and $30 per patient. Administration fees are about $12 a dose.

“Children play an important role in the spread of hepatitis A,” said Dr. Balistreri. “There already is an immunization schedule in place for children, whereas trying to get adults immunized is another story. It makes great sense.”

One solution may be a combined hepatitis A and B vaccine for children, he said. Currently, the combined vaccine is approved for children in Europe, but approved only for adults in the United States.

SCOTTSDALE, ARIZ. — Vaccination for hepatitis A should be extended to children above the age of 2 with catch-up immunization for older children and adolescents, William F. Balistreri, M.D., advised.

“We need to rethink the vaccine strategy to see if we can have a rational plan for hepatitis A that would be more inclusive,” said Dr. Balistreri, director of pediatric gastroenterology, hepatology, and nutrition at Children's Medical Center, Cincinnati.

He advised pediatricians to vaccinate children over the age of 2 years.

“Pediatricians need to get beyond these barriers and vaccinate these children. We have a vaccine that works. We have a disease that can kill,” Dr. Balistreri said in an interview.

Major outbreaks of hepatitis A still occur in the United States; the majority of these are food borne, he said at a pediatric update sponsored by the Phoenix Children's Hospital.

Children play a vital role in the spread of hepatitis A virus, which can be transmitted through food, fecal matter, and person-to-person contact.

“Day care is a hotbed for transmission,” he said. “You have lots of children, few caretakers, everything goes in the mouth, caretakers may change the diaper on the same surface where children play, and children excrete the virus longer [than adults].”

To make matters worse, a young child can be infected and have few, if any, symptoms. Usually, outbreaks in day-care centers are detected only after the adult contacts become sick, he said.

While 85% of adults will become jaundiced, only about 10%-15% of children do. Children are likely to have a mild fever, a runny nose, and maybe a little diarrhea, Dr. Balistreri said. “Some children have no symptoms whatsoever.” In contrast, adults become jaundiced and have nausea, vomiting, anorexia, and abdominal pain. It can be deadly for some adults.

“Children and young adults do fairly well,” he said. “But for anyone over the age of 49, the mortality is up to 3%-4%. This is a disease that can take lives.”

If middle-aged adults are infected, this form of hepatitis can be devastating and costly, he said. There are more than 63,000 symptomatic infections in adults each year, resulting in 8,403 hospitalizations and 255 deaths. The illness results in 829,000 work loss days, 7,466 years of life lost at an annual cost of $489 million.

“The bottom line is the vaccine is cost effective when you look at the implications,” said Dr. Balistreri.

Part of the problem is that 80% of children excrete the virus for 3 weeks, some as long as 6 weeks. This results in adults, who are hit much harder by the symptoms, being susceptible to the virus. “Not only are children not symptomatic, but they continue to excrete the virus,” he said. “No individual is sick at the time they are shedding.”

Something as simple as eating a school lunch can result in an outbreak, as evidence of the Michigan outbreak in 1997 shows, when strawberries contaminated in Mexico and processed in California were then shipped to the school lunch program in Michigan.

“We need to use a vaccine not only to protect the individual but the community, so it can't gain a foothold,” Dr. Balistreri said.

Once an outbreak occurs, then immunoglobulin can be given to prevent symptomatic infection in contacts. While there is nothing wrong with this, the timing is off, Dr. Balistreri said. Prevention appears to be the most effective approach.

A Thailand study of 40,119 school-aged children showed the vaccine was effective in immunizing children against hepatitis A. Of the 19,037 children given the vaccine, 94% developed antibodies in 8 months and 99% developed antibodies at 17 months. There were 38 cases of clinical hepatitis A in the control group, compared with only 2 in the vaccinated children, both of whom were probably infected with the virus at time of vaccination.

Currently, hepatitis A vaccination is recommended for those with occupational risks, such as health care and day-care workers, travelers to endemic regions, children in high-rate communities, persons with chronic liver disease, those with high-risk behaviors, and transplant recipients or others who are immune depressed.

When it was found that Native American children had a fourfold higher rate, the children were vaccinated, he said. That rate dramatically dropped after vaccinations were provided in 1996. Three years later, children in 11 Western states—where the incidence of hepatitis A was twice the national average—were targeted.

“It did a great job in those states with a high rate,” he said, but the adjoining states then developed a higher incidence. “The virus shifted east. The virus doesn't respect state lines.”

That's the problem in only targeting high risk groups, he said.

Health officials should learn from the experience of hepatitis B, he said, where targeting the high-risk groups did not result in a substantial reduction in the frequency of hepatitis B. “We lost 10 years because we didn't start off with a universal vaccination program,” he said.

He gave the example of migrant children in Florida where 244 children were tested and on average half already had been infected. The numbers increased with age with 34% of the 2- to 5-year-olds testing positive for hepatitis A antibodies and 81% of the 14-year-old and over group testing positive.

“In a community that wasn't targeted, about half of the children already had been infected,” he said. “This is a missed opportunity.”

The biggest impediments to universal hepatitis A vaccination in children include cost, addition of yet another vaccination to a complex schedule, and the rising fear among some parents about vaccination.

But the vaccine has proved both safe and cost effective, he said. The cost of the vaccine under federal programs is $11.15 a dose while in private practice the cost is between $26 and $30 per patient. Administration fees are about $12 a dose.

“Children play an important role in the spread of hepatitis A,” said Dr. Balistreri. “There already is an immunization schedule in place for children, whereas trying to get adults immunized is another story. It makes great sense.”

One solution may be a combined hepatitis A and B vaccine for children, he said. Currently, the combined vaccine is approved for children in Europe, but approved only for adults in the United States.

SCOTTSDALE, ARIZ. — The treatment and diagnosis of urinary tract infections in young children are undergoing dramatic changes, Aaron L. Friedman, M.D., said at a pediatric update sponsored by Phoenix Children's Hospital.

Urinary tract infections affect 3%-4% of young girls and 1% of young boys—making the condition relatively common in children.

Dr. Friedman, chairman of the department of pediatrics at Brown University, Providence, R.I., said the standard treatment today is 7-14 days of antibiotics. However, there is now evidence that this could be shortened to 2-4 days for uncomplicated infections.

He pointed to a compilation of 10 studies of 652 children, aged 3 months to 18 years, comparing the conventional antibiotic course of 7-14 days with a 2- to 4-day treatment. The shorter course was found as effective as the longer course in eradicating lower urinary tract infections in children.

“There is increasing evidence that treatment as short as 2-4 days is sufficient for uncomplicated urinary tract infections in children who don't have bacteria floating in their blood and no kidney involvement,” Dr. Friedman said.

Another change is the amount of work a physician should put into finding the cause of the urinary tract infection. Because of the fear of kidney damage due to ureterovesical reflux in young children, the dogma has been to order imaging studies, such as ultrasound and voiding cystourethrogram (VUCG), after the diagnosis.

Both imaging studies are conventionally done weeks after the diagnosis of urinary tract infection in young children, said Dr. Friedman.

Ultrasound is now considered of little value, and the utility of VCUG—especially in children older than 1 year—is under considerable review, he said.

This applies only to children aged 1 year and older, he said. “Infants should be examined aggressively, but for everyone else, there should be a more nuanced approach.”

A U.S. study of more than 300 children aged 1-24 months showed that ultrasound was normal in 88% of children and that VCUG was positive for reflux in only 39%. Additionally, the nuclear medicine scan was positive for renal scarring in only 9.5% of patients.

“There is very little utility in ultrasound in urinary tract infections in children,” he said. “It doesn't help in early treatment, and it doesn't give you any more information than what you had before.”

There is increasing evidence about the use of VUCG with the first urinary tract infection, he said.

VUCG was thought to be useful in defining the population that needed prophylactic treatment. However, there is increasing skepticism such treatment is advantageous in these children.

“The problem is that we don't know that prophylactic treatment with low-dose antibiotics for an 18-month to 2-year period is useful,” he said. “While it does reduce the recurrences, there is no evidence that it improves the long-term outcome.

“We are in a continuum here, where the conventional approach recommended a voiding study,” Dr. Friedman said.

However, it may be better only to use the voiding study in children who aren't getting better with antibiotics and don't fit the usual pattern of recovery, he said.

In these children, the imaging technique can aid in diagnosing troublesome vesicoureteral reflux.

But even with a diagnosis, it is recommended that only children with high grade (grade 4-5) be treated surgically, he said. “In these children, you won't get anywhere by waiting.”

“Children with lower-grade refluxes, between [grades] 1 and 2, have the likelihood of getting better on their own,” he said. “Grade 3 is right in the middle; some get better, and some don't.”

SCOTTSDALE, ARIZ. — The treatment and diagnosis of urinary tract infections in young children are undergoing dramatic changes, Aaron L. Friedman, M.D., said at a pediatric update sponsored by Phoenix Children's Hospital.

Urinary tract infections affect 3%-4% of young girls and 1% of young boys—making the condition relatively common in children.

Dr. Friedman, chairman of the department of pediatrics at Brown University, Providence, R.I., said the standard treatment today is 7-14 days of antibiotics. However, there is now evidence that this could be shortened to 2-4 days for uncomplicated infections.

He pointed to a compilation of 10 studies of 652 children, aged 3 months to 18 years, comparing the conventional antibiotic course of 7-14 days with a 2- to 4-day treatment. The shorter course was found as effective as the longer course in eradicating lower urinary tract infections in children.

“There is increasing evidence that treatment as short as 2-4 days is sufficient for uncomplicated urinary tract infections in children who don't have bacteria floating in their blood and no kidney involvement,” Dr. Friedman said.

Another change is the amount of work a physician should put into finding the cause of the urinary tract infection. Because of the fear of kidney damage due to ureterovesical reflux in young children, the dogma has been to order imaging studies, such as ultrasound and voiding cystourethrogram (VUCG), after the diagnosis.

Both imaging studies are conventionally done weeks after the diagnosis of urinary tract infection in young children, said Dr. Friedman.

Ultrasound is now considered of little value, and the utility of VCUG—especially in children older than 1 year—is under considerable review, he said.

This applies only to children aged 1 year and older, he said. “Infants should be examined aggressively, but for everyone else, there should be a more nuanced approach.”

A U.S. study of more than 300 children aged 1-24 months showed that ultrasound was normal in 88% of children and that VCUG was positive for reflux in only 39%. Additionally, the nuclear medicine scan was positive for renal scarring in only 9.5% of patients.

“There is very little utility in ultrasound in urinary tract infections in children,” he said. “It doesn't help in early treatment, and it doesn't give you any more information than what you had before.”

There is increasing evidence about the use of VUCG with the first urinary tract infection, he said.

VUCG was thought to be useful in defining the population that needed prophylactic treatment. However, there is increasing skepticism such treatment is advantageous in these children.

“The problem is that we don't know that prophylactic treatment with low-dose antibiotics for an 18-month to 2-year period is useful,” he said. “While it does reduce the recurrences, there is no evidence that it improves the long-term outcome.

“We are in a continuum here, where the conventional approach recommended a voiding study,” Dr. Friedman said.

However, it may be better only to use the voiding study in children who aren't getting better with antibiotics and don't fit the usual pattern of recovery, he said.

In these children, the imaging technique can aid in diagnosing troublesome vesicoureteral reflux.

But even with a diagnosis, it is recommended that only children with high grade (grade 4-5) be treated surgically, he said. “In these children, you won't get anywhere by waiting.”

“Children with lower-grade refluxes, between [grades] 1 and 2, have the likelihood of getting better on their own,” he said. “Grade 3 is right in the middle; some get better, and some don't.”

SCOTTSDALE, ARIZ. — The treatment and diagnosis of urinary tract infections in young children are undergoing dramatic changes, Aaron L. Friedman, M.D., said at a pediatric update sponsored by Phoenix Children's Hospital.

Urinary tract infections affect 3%-4% of young girls and 1% of young boys—making the condition relatively common in children.

Dr. Friedman, chairman of the department of pediatrics at Brown University, Providence, R.I., said the standard treatment today is 7-14 days of antibiotics. However, there is now evidence that this could be shortened to 2-4 days for uncomplicated infections.

He pointed to a compilation of 10 studies of 652 children, aged 3 months to 18 years, comparing the conventional antibiotic course of 7-14 days with a 2- to 4-day treatment. The shorter course was found as effective as the longer course in eradicating lower urinary tract infections in children.

“There is increasing evidence that treatment as short as 2-4 days is sufficient for uncomplicated urinary tract infections in children who don't have bacteria floating in their blood and no kidney involvement,” Dr. Friedman said.

Another change is the amount of work a physician should put into finding the cause of the urinary tract infection. Because of the fear of kidney damage due to ureterovesical reflux in young children, the dogma has been to order imaging studies, such as ultrasound and voiding cystourethrogram (VUCG), after the diagnosis.

Both imaging studies are conventionally done weeks after the diagnosis of urinary tract infection in young children, said Dr. Friedman.

Ultrasound is now considered of little value, and the utility of VCUG—especially in children older than 1 year—is under considerable review, he said.

This applies only to children aged 1 year and older, he said. “Infants should be examined aggressively, but for everyone else, there should be a more nuanced approach.”

A U.S. study of more than 300 children aged 1-24 months showed that ultrasound was normal in 88% of children and that VCUG was positive for reflux in only 39%. Additionally, the nuclear medicine scan was positive for renal scarring in only 9.5% of patients.

“There is very little utility in ultrasound in urinary tract infections in children,” he said. “It doesn't help in early treatment, and it doesn't give you any more information than what you had before.”

There is increasing evidence about the use of VUCG with the first urinary tract infection, he said.

VUCG was thought to be useful in defining the population that needed prophylactic treatment. However, there is increasing skepticism such treatment is advantageous in these children.

“The problem is that we don't know that prophylactic treatment with low-dose antibiotics for an 18-month to 2-year period is useful,” he said. “While it does reduce the recurrences, there is no evidence that it improves the long-term outcome.

“We are in a continuum here, where the conventional approach recommended a voiding study,” Dr. Friedman said.

However, it may be better only to use the voiding study in children who aren't getting better with antibiotics and don't fit the usual pattern of recovery, he said.

In these children, the imaging technique can aid in diagnosing troublesome vesicoureteral reflux.

But even with a diagnosis, it is recommended that only children with high grade (grade 4-5) be treated surgically, he said. “In these children, you won't get anywhere by waiting.”

“Children with lower-grade refluxes, between [grades] 1 and 2, have the likelihood of getting better on their own,” he said. “Grade 3 is right in the middle; some get better, and some don't.”