M. Alexander Otto

PORTLAND, ORE. – Fecal transplants are proving useful for pediatric ulcerative colitis, and enteral feedings are already well established in Europe to help kids with Crohn’s disease; together, the findings suggest that gut flora is more important to pediatric gastrointestinal health than previously thought, according to Dr. Linda Muir.

In both cases, "they think a lot of [the effect] has to do with modification of bowel flora. I think we are all starting to realize that the bacteria we carry around in our bodies drive and determine a lot of our health and illness. A lot of autoimmune disorders may be related to [imbalances in our] gut microbiome," said Dr. Muir, chief of pediatric gastroenterology at the Oregon Health and Science University in Portland.

Although it’s unclear at the moment if donor stool is best delivered by nasogastric tube, colonoscope, or enema, it’s easy to understand how fecal transplants might correct such an imbalance. They’ve proven remarkably effective for Clostridium difficile infections, and now "good studies are being published for [their] application in [inflammatory bowel disease]. They’re very promising" for pediatric ulcerative colitis (UC), she said at a conference sponsored by the North Pacific Pediatric Society.

In one study from Michigan State and Emory universities, 10 children (aged 7-21 years) with mild to moderate UC received fecal enemas, 165 mL on average, for 5 days. Seven of nine (78%) – the 10th couldn’t retain the enema – showed a significant clinical response within a week, including three remissions. Six (67%) maintained their response at 1 month. There were no serious adverse events (J. Pediatr. Gastroenterol. Nutr. 2013;56:597-601).

If other studies have results like that, "I think [fecal transplants] may become more common in our practice. [Perhaps] we can turn around kids who are not responding to medication," Dr. Muir said.

It’s less clear how enteral feedings might rebalance the gut flora in Crohn’s kids. Typically, a child gets 100% of his or her nutrition for a period of time from milk-based products such as Ensure, Boost, or Nutren delivered by nasogastric tube at home; older children often learn to place the tube themselves. Dr. Muir favors products that pack the most calories in the least volume so kids don’t have to get up in the middle of the night to urinate; she uses enteral therapy as a supplement to the more usual Crohn’s approaches.

"Why does this make them better? We don’t know. Is it because of the nutrients? Are you removing food protein antigens? It may tie together with what we are seeing with fecal transplant, somehow modifying the fecal flora to allow mucosal healing. [Kids] obviously have much improved growth and they actually get true mucosal healing" on enteral feeding, unlike with steroids, Dr. Muir said.

Whatever the reason, pediatric gastroenterologists in Europe have been using the technique for years and touting its benefits. "They don’t use nearly the steroids U.S. physicians use," she said. In 2012, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition noted that enteral feeding offers "an alternative to corticosteroids to induce remission in pediatric CD [Crohn’s disease] and should be supported as a first-line induction therapy in pediatric CD" (J. Pediatr. Gastroenterol. Nutr. 2012;54:298-305). And it just might be the case that CD kids don’t need to get all their calories through a tube. Researchers at the Children’s Hospital of Philadelphia recently reviewed the charts of 23 kids who got 80%-90% of their calories by enteral feedings and found that 20 (87%) had a clinical response, and 15 (65%) went into remission after a mean of 2 months (Inflamm. Bowel Dis. 2013;19:1374-8).

Even though they were on the tube at home, they could pull it out in the morning and have lunch with their friends at school just like any other kid, Dr. Muir said.

She said she had no relevant financial disclosures.

[email protected]

PORTLAND, ORE. – Fecal transplants are proving useful for pediatric ulcerative colitis, and enteral feedings are already well established in Europe to help kids with Crohn’s disease; together, the findings suggest that gut flora is more important to pediatric gastrointestinal health than previously thought, according to Dr. Linda Muir.

In both cases, "they think a lot of [the effect] has to do with modification of bowel flora. I think we are all starting to realize that the bacteria we carry around in our bodies drive and determine a lot of our health and illness. A lot of autoimmune disorders may be related to [imbalances in our] gut microbiome," said Dr. Muir, chief of pediatric gastroenterology at the Oregon Health and Science University in Portland.

Although it’s unclear at the moment if donor stool is best delivered by nasogastric tube, colonoscope, or enema, it’s easy to understand how fecal transplants might correct such an imbalance. They’ve proven remarkably effective for Clostridium difficile infections, and now "good studies are being published for [their] application in [inflammatory bowel disease]. They’re very promising" for pediatric ulcerative colitis (UC), she said at a conference sponsored by the North Pacific Pediatric Society.

In one study from Michigan State and Emory universities, 10 children (aged 7-21 years) with mild to moderate UC received fecal enemas, 165 mL on average, for 5 days. Seven of nine (78%) – the 10th couldn’t retain the enema – showed a significant clinical response within a week, including three remissions. Six (67%) maintained their response at 1 month. There were no serious adverse events (J. Pediatr. Gastroenterol. Nutr. 2013;56:597-601).

If other studies have results like that, "I think [fecal transplants] may become more common in our practice. [Perhaps] we can turn around kids who are not responding to medication," Dr. Muir said.

It’s less clear how enteral feedings might rebalance the gut flora in Crohn’s kids. Typically, a child gets 100% of his or her nutrition for a period of time from milk-based products such as Ensure, Boost, or Nutren delivered by nasogastric tube at home; older children often learn to place the tube themselves. Dr. Muir favors products that pack the most calories in the least volume so kids don’t have to get up in the middle of the night to urinate; she uses enteral therapy as a supplement to the more usual Crohn’s approaches.

"Why does this make them better? We don’t know. Is it because of the nutrients? Are you removing food protein antigens? It may tie together with what we are seeing with fecal transplant, somehow modifying the fecal flora to allow mucosal healing. [Kids] obviously have much improved growth and they actually get true mucosal healing" on enteral feeding, unlike with steroids, Dr. Muir said.

Whatever the reason, pediatric gastroenterologists in Europe have been using the technique for years and touting its benefits. "They don’t use nearly the steroids U.S. physicians use," she said. In 2012, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition noted that enteral feeding offers "an alternative to corticosteroids to induce remission in pediatric CD [Crohn’s disease] and should be supported as a first-line induction therapy in pediatric CD" (J. Pediatr. Gastroenterol. Nutr. 2012;54:298-305). And it just might be the case that CD kids don’t need to get all their calories through a tube. Researchers at the Children’s Hospital of Philadelphia recently reviewed the charts of 23 kids who got 80%-90% of their calories by enteral feedings and found that 20 (87%) had a clinical response, and 15 (65%) went into remission after a mean of 2 months (Inflamm. Bowel Dis. 2013;19:1374-8).

Even though they were on the tube at home, they could pull it out in the morning and have lunch with their friends at school just like any other kid, Dr. Muir said.

She said she had no relevant financial disclosures.

[email protected]

PORTLAND, ORE. – Fecal transplants are proving useful for pediatric ulcerative colitis, and enteral feedings are already well established in Europe to help kids with Crohn’s disease; together, the findings suggest that gut flora is more important to pediatric gastrointestinal health than previously thought, according to Dr. Linda Muir.

In both cases, "they think a lot of [the effect] has to do with modification of bowel flora. I think we are all starting to realize that the bacteria we carry around in our bodies drive and determine a lot of our health and illness. A lot of autoimmune disorders may be related to [imbalances in our] gut microbiome," said Dr. Muir, chief of pediatric gastroenterology at the Oregon Health and Science University in Portland.

Although it’s unclear at the moment if donor stool is best delivered by nasogastric tube, colonoscope, or enema, it’s easy to understand how fecal transplants might correct such an imbalance. They’ve proven remarkably effective for Clostridium difficile infections, and now "good studies are being published for [their] application in [inflammatory bowel disease]. They’re very promising" for pediatric ulcerative colitis (UC), she said at a conference sponsored by the North Pacific Pediatric Society.

In one study from Michigan State and Emory universities, 10 children (aged 7-21 years) with mild to moderate UC received fecal enemas, 165 mL on average, for 5 days. Seven of nine (78%) – the 10th couldn’t retain the enema – showed a significant clinical response within a week, including three remissions. Six (67%) maintained their response at 1 month. There were no serious adverse events (J. Pediatr. Gastroenterol. Nutr. 2013;56:597-601).

If other studies have results like that, "I think [fecal transplants] may become more common in our practice. [Perhaps] we can turn around kids who are not responding to medication," Dr. Muir said.

It’s less clear how enteral feedings might rebalance the gut flora in Crohn’s kids. Typically, a child gets 100% of his or her nutrition for a period of time from milk-based products such as Ensure, Boost, or Nutren delivered by nasogastric tube at home; older children often learn to place the tube themselves. Dr. Muir favors products that pack the most calories in the least volume so kids don’t have to get up in the middle of the night to urinate; she uses enteral therapy as a supplement to the more usual Crohn’s approaches.

"Why does this make them better? We don’t know. Is it because of the nutrients? Are you removing food protein antigens? It may tie together with what we are seeing with fecal transplant, somehow modifying the fecal flora to allow mucosal healing. [Kids] obviously have much improved growth and they actually get true mucosal healing" on enteral feeding, unlike with steroids, Dr. Muir said.

Whatever the reason, pediatric gastroenterologists in Europe have been using the technique for years and touting its benefits. "They don’t use nearly the steroids U.S. physicians use," she said. In 2012, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition noted that enteral feeding offers "an alternative to corticosteroids to induce remission in pediatric CD [Crohn’s disease] and should be supported as a first-line induction therapy in pediatric CD" (J. Pediatr. Gastroenterol. Nutr. 2012;54:298-305). And it just might be the case that CD kids don’t need to get all their calories through a tube. Researchers at the Children’s Hospital of Philadelphia recently reviewed the charts of 23 kids who got 80%-90% of their calories by enteral feedings and found that 20 (87%) had a clinical response, and 15 (65%) went into remission after a mean of 2 months (Inflamm. Bowel Dis. 2013;19:1374-8).

Even though they were on the tube at home, they could pull it out in the morning and have lunch with their friends at school just like any other kid, Dr. Muir said.

She said she had no relevant financial disclosures.

[email protected]

LAS VEGAS – Vancomycin is as safe on the kidneys of critically ill patients as linezolid, so long as trough levels don’t exceed the recommended upper limit of 20 mcg/mL, according to researchers from the University of Virginia in Charlottesville.

"When correct dosing is performed, the use of alternative agents to treat Gram-positive infections – specifically to avoid [vancomycin] nephrotoxicity – is unnecessary. Vancomycin use in critically ill patients is no different than linezolid use regarding nephrotoxicity or new-onset need for hemodialysis," said lead investigator Stephen Davies, a resident in the department of surgery, said at the annual meeting of the Surgical Infection Society.

The kidney safety of vancomycin has been in doubt, with mixed results from prior studies. To shed light on the issue, Dr. Davies and his team compared renal outcomes in 298 critically ill patients treated with vancomycin for 571 Gram-positive infections with outcomes in 247 patients treated with linezolid for 475 Gram-positive infections.

Infection sites included the lungs, peritoneum, blood stream, and urinary tract, among others, and isolates included Staphylococcus aureus (77 methicillin-resistant S. aureus), Enterococcus faecium (67 vancomycin-resistant Enterococcus), E. faecalis, and Streptococcus species. Vancomycin patients were dosed at 15-20 mg/kg, with serial trough monitoring, and treated for a mean of 16.2 days, vs. 14.3 days for linezolid. Patients were on no other nephrotoxic agents.

In the end, "there were no [statistically significant] differences between the two groups regarding maximum creatinine during treatment, final creatinine after treatment, change in creatinine maximum and initial values, and final and initial creatinine values." There were also no differences "in new-onset hemodialysis or death," Dr. Davies said.

APACHE II (Acute Physiology and Chronic Health Evaluation II) scores above 30 and initial creatinine levels above 1.2 mg/dL both predicted the need for new-onset hemodialysis, but antibiotic choice did not.

Those same two variables also predicted an increase in creatinine of more than 1.0 mg/dl during treatment; vancomycin use did, as well (relative risk, vancomycin 0.49; 95% confidence interval: 0.25-0.94). Concerned, the team looked into the issue. "What we found was that a rise in creatinine was typically not encountered until trough levels greater than 20 mg/dL were reached. As long as you stay within the recommended doses, you should be safe," Dr. Davies said.

There were no statistically significant baseline differences between the two groups in renal function, hemodialysis, creatinine levels, or APACHE II scores.

Despite the results, Dr. Philip Barie, who helped moderate Dr. Davies’ talk, said in an interview that he’s still concerned about vancomycin kidney safety.

"We are having to use higher doses to treat tougher bugs, and whereas nephrotoxicity pretty much went away with vancomycin after they purified the drug [decades ago], now we are having to use higher doses more, and nephrotoxicity is beginning to creep back into the picture. You have to dose really carefully, and if you have an organism that is among the more resistant to vancomycin, the safest thing to do with vancomycin is to use linezolid," said Dr. Barie, a professor of surgery and public heath at Cornell University, New York.

Dr. Davies and Dr. Barie reported no relevant disclosures.

[email protected]

LAS VEGAS – Vancomycin is as safe on the kidneys of critically ill patients as linezolid, so long as trough levels don’t exceed the recommended upper limit of 20 mcg/mL, according to researchers from the University of Virginia in Charlottesville.

"When correct dosing is performed, the use of alternative agents to treat Gram-positive infections – specifically to avoid [vancomycin] nephrotoxicity – is unnecessary. Vancomycin use in critically ill patients is no different than linezolid use regarding nephrotoxicity or new-onset need for hemodialysis," said lead investigator Stephen Davies, a resident in the department of surgery, said at the annual meeting of the Surgical Infection Society.

The kidney safety of vancomycin has been in doubt, with mixed results from prior studies. To shed light on the issue, Dr. Davies and his team compared renal outcomes in 298 critically ill patients treated with vancomycin for 571 Gram-positive infections with outcomes in 247 patients treated with linezolid for 475 Gram-positive infections.

Infection sites included the lungs, peritoneum, blood stream, and urinary tract, among others, and isolates included Staphylococcus aureus (77 methicillin-resistant S. aureus), Enterococcus faecium (67 vancomycin-resistant Enterococcus), E. faecalis, and Streptococcus species. Vancomycin patients were dosed at 15-20 mg/kg, with serial trough monitoring, and treated for a mean of 16.2 days, vs. 14.3 days for linezolid. Patients were on no other nephrotoxic agents.

In the end, "there were no [statistically significant] differences between the two groups regarding maximum creatinine during treatment, final creatinine after treatment, change in creatinine maximum and initial values, and final and initial creatinine values." There were also no differences "in new-onset hemodialysis or death," Dr. Davies said.

APACHE II (Acute Physiology and Chronic Health Evaluation II) scores above 30 and initial creatinine levels above 1.2 mg/dL both predicted the need for new-onset hemodialysis, but antibiotic choice did not.

Those same two variables also predicted an increase in creatinine of more than 1.0 mg/dl during treatment; vancomycin use did, as well (relative risk, vancomycin 0.49; 95% confidence interval: 0.25-0.94). Concerned, the team looked into the issue. "What we found was that a rise in creatinine was typically not encountered until trough levels greater than 20 mg/dL were reached. As long as you stay within the recommended doses, you should be safe," Dr. Davies said.

There were no statistically significant baseline differences between the two groups in renal function, hemodialysis, creatinine levels, or APACHE II scores.

Despite the results, Dr. Philip Barie, who helped moderate Dr. Davies’ talk, said in an interview that he’s still concerned about vancomycin kidney safety.

"We are having to use higher doses to treat tougher bugs, and whereas nephrotoxicity pretty much went away with vancomycin after they purified the drug [decades ago], now we are having to use higher doses more, and nephrotoxicity is beginning to creep back into the picture. You have to dose really carefully, and if you have an organism that is among the more resistant to vancomycin, the safest thing to do with vancomycin is to use linezolid," said Dr. Barie, a professor of surgery and public heath at Cornell University, New York.

Dr. Davies and Dr. Barie reported no relevant disclosures.

[email protected]

LAS VEGAS – Vancomycin is as safe on the kidneys of critically ill patients as linezolid, so long as trough levels don’t exceed the recommended upper limit of 20 mcg/mL, according to researchers from the University of Virginia in Charlottesville.

"When correct dosing is performed, the use of alternative agents to treat Gram-positive infections – specifically to avoid [vancomycin] nephrotoxicity – is unnecessary. Vancomycin use in critically ill patients is no different than linezolid use regarding nephrotoxicity or new-onset need for hemodialysis," said lead investigator Stephen Davies, a resident in the department of surgery, said at the annual meeting of the Surgical Infection Society.

The kidney safety of vancomycin has been in doubt, with mixed results from prior studies. To shed light on the issue, Dr. Davies and his team compared renal outcomes in 298 critically ill patients treated with vancomycin for 571 Gram-positive infections with outcomes in 247 patients treated with linezolid for 475 Gram-positive infections.

Infection sites included the lungs, peritoneum, blood stream, and urinary tract, among others, and isolates included Staphylococcus aureus (77 methicillin-resistant S. aureus), Enterococcus faecium (67 vancomycin-resistant Enterococcus), E. faecalis, and Streptococcus species. Vancomycin patients were dosed at 15-20 mg/kg, with serial trough monitoring, and treated for a mean of 16.2 days, vs. 14.3 days for linezolid. Patients were on no other nephrotoxic agents.

In the end, "there were no [statistically significant] differences between the two groups regarding maximum creatinine during treatment, final creatinine after treatment, change in creatinine maximum and initial values, and final and initial creatinine values." There were also no differences "in new-onset hemodialysis or death," Dr. Davies said.

APACHE II (Acute Physiology and Chronic Health Evaluation II) scores above 30 and initial creatinine levels above 1.2 mg/dL both predicted the need for new-onset hemodialysis, but antibiotic choice did not.

Those same two variables also predicted an increase in creatinine of more than 1.0 mg/dl during treatment; vancomycin use did, as well (relative risk, vancomycin 0.49; 95% confidence interval: 0.25-0.94). Concerned, the team looked into the issue. "What we found was that a rise in creatinine was typically not encountered until trough levels greater than 20 mg/dL were reached. As long as you stay within the recommended doses, you should be safe," Dr. Davies said.

There were no statistically significant baseline differences between the two groups in renal function, hemodialysis, creatinine levels, or APACHE II scores.

Despite the results, Dr. Philip Barie, who helped moderate Dr. Davies’ talk, said in an interview that he’s still concerned about vancomycin kidney safety.

"We are having to use higher doses to treat tougher bugs, and whereas nephrotoxicity pretty much went away with vancomycin after they purified the drug [decades ago], now we are having to use higher doses more, and nephrotoxicity is beginning to creep back into the picture. You have to dose really carefully, and if you have an organism that is among the more resistant to vancomycin, the safest thing to do with vancomycin is to use linezolid," said Dr. Barie, a professor of surgery and public heath at Cornell University, New York.

Dr. Davies and Dr. Barie reported no relevant disclosures.

[email protected]

LAS VEGAS – Although inpatient glucose levels in critically ill adults are generally kept between 140 and 180 mg/dL, Toronto investigators have found that it might be best to keep pediatric burn patients between 130 and 140 mg/dL.

Morbidity and mortality outcomes were better in that range when 760 children – the majority boys under 10 years old burned over half their bodies, usually by flame – were followed for 2 months after ICU admission.

"We used about 300,000 glucose measurements" during the study "to determine the ideal glucose target. For burn patients, the range of 130-140 mg/dL should be targeted. You avoid hyperglycemia as well as hypoglycemia. [Also,] a major factor to be considered" in burns "is that protein glycosylation starts at around 150 mg/dL; we burn surgeons try to be below that," said lead researcher Dr. Marc Jeschke, director of the burn center at Toronto’s Sunnybrook Health Sciences Centre.

Dr. Jeschke’s study isn’t the first to suggest that range for critically ill children. "There seems to be a signal [across] studies that this is the range we should target in order to see the benefits of glucose control," he said (e.g., J. Pediatr. 2009;155:734-9).

It’s been known that burns cause a hyperglycemic response, especially those in excess of 40% of the body. When not reined in, "you lose more grafts, you have more infections, and you [are more likely to] die," Dr. Jeschke said at the annual meeting of the Surgical Infection Society.

In its investigation, however, his team also found that, as in critically ill adults, hypoglycemia must also be avoided in pediatric burn patients.

Eighty-five patients had one hypoglycemia episode in the study, defined as blood glucose below 60?mg/dL, and 107 had two or more. The remaining 568 children had no episodes.

Twenty-one percent of patients who had hypoglycemic episodes – versus 6.5% of those who did not – developed sepsis; 47.9%, versus 10%, developed multiple organ failure, and a quarter died. Mortality was 3.3% in the nonhypoglycemic group. The differences were statistically significant.

"We [also] found that hypoglycemic patients are more inflammatory and hypermetabolic," Dr. Jeschke said.

Hypoglycemia was associated with larger burns and more inhalation injuries, so the team did a propensity analysis comparing 166 children who had hypoglycemic episodes to 166 with similar injury severities who did not.

Among those matched patients, children were 2.67 more likely to die (95% confidence interval 1.15-6.20) if they had one hypoglycemic episode, 5.58 more likely to die if they had two (95% CI 2.26-13.81), and 9.25 times more likely if they had three (95% CI 4.30-19.88).

Hypoglycemia during sepsis or at time of death was excluded in the analysis. Even so, "we don’t know" if hypoglycemia was the cause of death or a marker for another fatal process, Dr. Jeschke noted.

Whatever the case, the results indicate that just as in sick adults, "glycemic control in [pediatric] burns is an integral part of good clinical outcomes," he said.

Dr. Jeschke said he has no conflicts of interest.

[email protected]

LAS VEGAS – Although inpatient glucose levels in critically ill adults are generally kept between 140 and 180 mg/dL, Toronto investigators have found that it might be best to keep pediatric burn patients between 130 and 140 mg/dL.

Morbidity and mortality outcomes were better in that range when 760 children – the majority boys under 10 years old burned over half their bodies, usually by flame – were followed for 2 months after ICU admission.

"We used about 300,000 glucose measurements" during the study "to determine the ideal glucose target. For burn patients, the range of 130-140 mg/dL should be targeted. You avoid hyperglycemia as well as hypoglycemia. [Also,] a major factor to be considered" in burns "is that protein glycosylation starts at around 150 mg/dL; we burn surgeons try to be below that," said lead researcher Dr. Marc Jeschke, director of the burn center at Toronto’s Sunnybrook Health Sciences Centre.

Dr. Jeschke’s study isn’t the first to suggest that range for critically ill children. "There seems to be a signal [across] studies that this is the range we should target in order to see the benefits of glucose control," he said (e.g., J. Pediatr. 2009;155:734-9).

It’s been known that burns cause a hyperglycemic response, especially those in excess of 40% of the body. When not reined in, "you lose more grafts, you have more infections, and you [are more likely to] die," Dr. Jeschke said at the annual meeting of the Surgical Infection Society.

In its investigation, however, his team also found that, as in critically ill adults, hypoglycemia must also be avoided in pediatric burn patients.

Eighty-five patients had one hypoglycemia episode in the study, defined as blood glucose below 60?mg/dL, and 107 had two or more. The remaining 568 children had no episodes.

Twenty-one percent of patients who had hypoglycemic episodes – versus 6.5% of those who did not – developed sepsis; 47.9%, versus 10%, developed multiple organ failure, and a quarter died. Mortality was 3.3% in the nonhypoglycemic group. The differences were statistically significant.

"We [also] found that hypoglycemic patients are more inflammatory and hypermetabolic," Dr. Jeschke said.

Hypoglycemia was associated with larger burns and more inhalation injuries, so the team did a propensity analysis comparing 166 children who had hypoglycemic episodes to 166 with similar injury severities who did not.

Among those matched patients, children were 2.67 more likely to die (95% confidence interval 1.15-6.20) if they had one hypoglycemic episode, 5.58 more likely to die if they had two (95% CI 2.26-13.81), and 9.25 times more likely if they had three (95% CI 4.30-19.88).

Hypoglycemia during sepsis or at time of death was excluded in the analysis. Even so, "we don’t know" if hypoglycemia was the cause of death or a marker for another fatal process, Dr. Jeschke noted.

Whatever the case, the results indicate that just as in sick adults, "glycemic control in [pediatric] burns is an integral part of good clinical outcomes," he said.

Dr. Jeschke said he has no conflicts of interest.

[email protected]

LAS VEGAS – Although inpatient glucose levels in critically ill adults are generally kept between 140 and 180 mg/dL, Toronto investigators have found that it might be best to keep pediatric burn patients between 130 and 140 mg/dL.

Morbidity and mortality outcomes were better in that range when 760 children – the majority boys under 10 years old burned over half their bodies, usually by flame – were followed for 2 months after ICU admission.

"We used about 300,000 glucose measurements" during the study "to determine the ideal glucose target. For burn patients, the range of 130-140 mg/dL should be targeted. You avoid hyperglycemia as well as hypoglycemia. [Also,] a major factor to be considered" in burns "is that protein glycosylation starts at around 150 mg/dL; we burn surgeons try to be below that," said lead researcher Dr. Marc Jeschke, director of the burn center at Toronto’s Sunnybrook Health Sciences Centre.

Dr. Jeschke’s study isn’t the first to suggest that range for critically ill children. "There seems to be a signal [across] studies that this is the range we should target in order to see the benefits of glucose control," he said (e.g., J. Pediatr. 2009;155:734-9).

It’s been known that burns cause a hyperglycemic response, especially those in excess of 40% of the body. When not reined in, "you lose more grafts, you have more infections, and you [are more likely to] die," Dr. Jeschke said at the annual meeting of the Surgical Infection Society.

In its investigation, however, his team also found that, as in critically ill adults, hypoglycemia must also be avoided in pediatric burn patients.

Eighty-five patients had one hypoglycemia episode in the study, defined as blood glucose below 60?mg/dL, and 107 had two or more. The remaining 568 children had no episodes.

Twenty-one percent of patients who had hypoglycemic episodes – versus 6.5% of those who did not – developed sepsis; 47.9%, versus 10%, developed multiple organ failure, and a quarter died. Mortality was 3.3% in the nonhypoglycemic group. The differences were statistically significant.

"We [also] found that hypoglycemic patients are more inflammatory and hypermetabolic," Dr. Jeschke said.

Hypoglycemia was associated with larger burns and more inhalation injuries, so the team did a propensity analysis comparing 166 children who had hypoglycemic episodes to 166 with similar injury severities who did not.

Among those matched patients, children were 2.67 more likely to die (95% confidence interval 1.15-6.20) if they had one hypoglycemic episode, 5.58 more likely to die if they had two (95% CI 2.26-13.81), and 9.25 times more likely if they had three (95% CI 4.30-19.88).

Hypoglycemia during sepsis or at time of death was excluded in the analysis. Even so, "we don’t know" if hypoglycemia was the cause of death or a marker for another fatal process, Dr. Jeschke noted.

Whatever the case, the results indicate that just as in sick adults, "glycemic control in [pediatric] burns is an integral part of good clinical outcomes," he said.

Dr. Jeschke said he has no conflicts of interest.

[email protected]

LAS VEGAS – It’s a good idea to swab both the throat and nose when looking for Staphylococcus aureus colonization; doing so picks up cases missed by swabbing the nares alone, according to researchers from the Baylor College of Medicine in Houston.

That holds true whether testing is by culture or PCR [polymerase chain reaction], said the lead investigator, Dr. Meredith Knofsky, a surgery resident there.

The team swabbed both areas preoperatively and on the day of surgery in patients undergoing operations involving hardware implants, such as new knees or hips. The 109 samples they obtained were then tested for methicillin-sensitive (MSSA) and methicillin-resistant (MRSA) S. aureus by both MRSA select media culture and the GeneXpert PCR system.

By culture, 7 throat swabs and 18 nares swabs were positive for MRSA; 20 throat and 40 nares swabs were positive for MSSA.

Courtesy Janice Haney Carr/CDC

By PCR, 7 throat and 21 nares samples were MRSA positive; 33 throat and 51 nares swabs were positive for MSSA.

The detection rate differences weren’t surprising; PCR is known to be more accurate and the results confirm its greater sensitivity, Dr. Knofsky said at the annual meeting of the Surgical Infection Society.

The bigger finding is that "throat screening identifies additional patients missed by screening the nares alone," she said.

Adding PCR throat testing to PCR nasal screening picked up one additional MRSA and 14 additional MSSA carriers. Similarly, the addition of throat cultures to nares cultures picked up an additional MRSA and eight additional MSSA carriers.

Not infrequently, patients were positive in one location, such as the throat, but not in the other. Although "nasal carrier status of Staphylococcus aureus is an important risk factor for surgical site infections," it’s not known at the moment if that’s also true for carriage limited to the throat, Dr. Knofsky said.

"We have plans to go back and evaluate which of these patients colonized only in the oropharynx actually developed a surgical site infection. It’s important that we invest in evaluating pharyngeal carriage," she said.

In the meantime, session moderator and surgeon Dr. E. Patchen Dellinger of the University of Washington in Seattle, noted that MSSA in the study "was two to three times more common than MRSA; an MSSA infection of implanted hardware is just as devastating to the patient as an MRSA infection. I would like to urge that we not focus on MRSA alone, but consider at least in selected surgical populations seeking and suppressing any Staph that colonizes our surgical patients."

PCR could help with that because it "has the advantage of very rapid answers. The logistics of getting [colonization] information in time to do something [before an operation] is very difficult for us. PCR could make that better, [but it] isn’t standard of care mostly because it costs a lot more" than does culture, he said.

Dr. Knofsky and Dr. Dellinger said they have no relevant disclosures.

[email protected]

LAS VEGAS – It’s a good idea to swab both the throat and nose when looking for Staphylococcus aureus colonization; doing so picks up cases missed by swabbing the nares alone, according to researchers from the Baylor College of Medicine in Houston.

That holds true whether testing is by culture or PCR [polymerase chain reaction], said the lead investigator, Dr. Meredith Knofsky, a surgery resident there.

The team swabbed both areas preoperatively and on the day of surgery in patients undergoing operations involving hardware implants, such as new knees or hips. The 109 samples they obtained were then tested for methicillin-sensitive (MSSA) and methicillin-resistant (MRSA) S. aureus by both MRSA select media culture and the GeneXpert PCR system.

By culture, 7 throat swabs and 18 nares swabs were positive for MRSA; 20 throat and 40 nares swabs were positive for MSSA.

Courtesy Janice Haney Carr/CDC

By PCR, 7 throat and 21 nares samples were MRSA positive; 33 throat and 51 nares swabs were positive for MSSA.

The detection rate differences weren’t surprising; PCR is known to be more accurate and the results confirm its greater sensitivity, Dr. Knofsky said at the annual meeting of the Surgical Infection Society.

The bigger finding is that "throat screening identifies additional patients missed by screening the nares alone," she said.

Adding PCR throat testing to PCR nasal screening picked up one additional MRSA and 14 additional MSSA carriers. Similarly, the addition of throat cultures to nares cultures picked up an additional MRSA and eight additional MSSA carriers.

Not infrequently, patients were positive in one location, such as the throat, but not in the other. Although "nasal carrier status of Staphylococcus aureus is an important risk factor for surgical site infections," it’s not known at the moment if that’s also true for carriage limited to the throat, Dr. Knofsky said.

"We have plans to go back and evaluate which of these patients colonized only in the oropharynx actually developed a surgical site infection. It’s important that we invest in evaluating pharyngeal carriage," she said.

In the meantime, session moderator and surgeon Dr. E. Patchen Dellinger of the University of Washington in Seattle, noted that MSSA in the study "was two to three times more common than MRSA; an MSSA infection of implanted hardware is just as devastating to the patient as an MRSA infection. I would like to urge that we not focus on MRSA alone, but consider at least in selected surgical populations seeking and suppressing any Staph that colonizes our surgical patients."

PCR could help with that because it "has the advantage of very rapid answers. The logistics of getting [colonization] information in time to do something [before an operation] is very difficult for us. PCR could make that better, [but it] isn’t standard of care mostly because it costs a lot more" than does culture, he said.

Dr. Knofsky and Dr. Dellinger said they have no relevant disclosures.

[email protected]

LAS VEGAS – It’s a good idea to swab both the throat and nose when looking for Staphylococcus aureus colonization; doing so picks up cases missed by swabbing the nares alone, according to researchers from the Baylor College of Medicine in Houston.

That holds true whether testing is by culture or PCR [polymerase chain reaction], said the lead investigator, Dr. Meredith Knofsky, a surgery resident there.

The team swabbed both areas preoperatively and on the day of surgery in patients undergoing operations involving hardware implants, such as new knees or hips. The 109 samples they obtained were then tested for methicillin-sensitive (MSSA) and methicillin-resistant (MRSA) S. aureus by both MRSA select media culture and the GeneXpert PCR system.

By culture, 7 throat swabs and 18 nares swabs were positive for MRSA; 20 throat and 40 nares swabs were positive for MSSA.

Courtesy Janice Haney Carr/CDC

By PCR, 7 throat and 21 nares samples were MRSA positive; 33 throat and 51 nares swabs were positive for MSSA.

The detection rate differences weren’t surprising; PCR is known to be more accurate and the results confirm its greater sensitivity, Dr. Knofsky said at the annual meeting of the Surgical Infection Society.

The bigger finding is that "throat screening identifies additional patients missed by screening the nares alone," she said.

Adding PCR throat testing to PCR nasal screening picked up one additional MRSA and 14 additional MSSA carriers. Similarly, the addition of throat cultures to nares cultures picked up an additional MRSA and eight additional MSSA carriers.

Not infrequently, patients were positive in one location, such as the throat, but not in the other. Although "nasal carrier status of Staphylococcus aureus is an important risk factor for surgical site infections," it’s not known at the moment if that’s also true for carriage limited to the throat, Dr. Knofsky said.

"We have plans to go back and evaluate which of these patients colonized only in the oropharynx actually developed a surgical site infection. It’s important that we invest in evaluating pharyngeal carriage," she said.

In the meantime, session moderator and surgeon Dr. E. Patchen Dellinger of the University of Washington in Seattle, noted that MSSA in the study "was two to three times more common than MRSA; an MSSA infection of implanted hardware is just as devastating to the patient as an MRSA infection. I would like to urge that we not focus on MRSA alone, but consider at least in selected surgical populations seeking and suppressing any Staph that colonizes our surgical patients."

PCR could help with that because it "has the advantage of very rapid answers. The logistics of getting [colonization] information in time to do something [before an operation] is very difficult for us. PCR could make that better, [but it] isn’t standard of care mostly because it costs a lot more" than does culture, he said.

Dr. Knofsky and Dr. Dellinger said they have no relevant disclosures.

[email protected]

PORTLAND, ORE. – Joint pain isn’t usually part of the clinical picture when children have juvenile idiopathic arthritis, according to pediatric rheumatologist Victoria Cartwright.

"In fact, it helps you discount that juvenile arthritis is going on," she said at a conference sponsored by the North Pacific Pediatric Society.

Pain as an isolated complaint has a negative predictive value for pediatric rheumatic disease of 0.99 and, as one of several reasons for a rheumatology referral, a negative predictive value of 0.91 (Pediatrics 2002;110:354-9).

"That’s better than any lab test or x-ray [and] about as good as MRI. [So] if you’re calling me saying that Johnny has knee pain, I’m not as worried about JIA [juvenile idiopathic arthritis]. I may be worried about [Henoch-Schönlein purpura (HSP)] or a mechanical issue or something else ... but [not] JIA," said Dr. Cartwright of Randall Children’s Hospital at Legacy Emanuel in Portland, Ore.

On the other hand, "labs really don’t help one way or the other to make the diagnosis of arthritis. Rheumatoid factor doesn’t help. [Erythrocyte sedimentation rate] is helpful if it’s abnormal, but only kind of. I can have a kid who has 20 inflamed joints and their sed rate is 2; I can have another kid with one swollen knee, and their sed rate is 30. [However,] if the sed rate is over 100, I worry about other stuff," such as systemic disease, lupus, HSP, vasculitis, or malignancy, she said.

If those problems have been ruled out, Dr. Cartwright said she usually waits until kids have been on NSAIDs – she favors weight-dosed ibuprofen or naproxen – for a month before getting a complete blood count, a liver enzyme panel, and an antinuclear antibody (ANA) test. "I’m not a big fan of labs up front" for JIA "because we end up chasing the lab illness a little bit," she said. JIA kids also need a referral to an ophthalmologist to check for iritis. If this condition is present, ANA testing helps tell how aggressive it is.

As for assessment, Dr. Cartwright noted that obesity makes it tough to check the ankle for swelling; extra pounds obscure the Achilles tendon and the divots to either side. "It’s one of the joints I image a lot with MRI because I [often] can’t see it very well," she said.

Swelling can be hard to detect in kids with polyarticular disease because it can be more or less even on either side of the body, and, thus, less noticeable. One trick, especially helpful with the hands, is to compare the skin folds and wrinkles around corresponding joints. If they aren’t symmetrical, it could be due to swelling.

Check for jaw arthritis, too, Dr. Cartwright said. A lot of children don’t even know there’s a problem because it’s painless, but left unchecked, jaw arthritis can cause growth abnormalities – associated asymmetries are most obvious when the head’s tilted back – and make it difficult to fully open the mouth.

Patients should be able to insert their three middle fingers vertically into their mouth. When they can’t, "we do some dynamic stretching. We’ll stack tongue blades" to reach the appropriate thickness and have patients place them in their mouth to "stretch the muscles out, kind of like doing [physical therapy]," Dr. Cartwright said.

She said she has no relevant financial disclosures.

[email protected]

PORTLAND, ORE. – Joint pain isn’t usually part of the clinical picture when children have juvenile idiopathic arthritis, according to pediatric rheumatologist Victoria Cartwright.

"In fact, it helps you discount that juvenile arthritis is going on," she said at a conference sponsored by the North Pacific Pediatric Society.

Pain as an isolated complaint has a negative predictive value for pediatric rheumatic disease of 0.99 and, as one of several reasons for a rheumatology referral, a negative predictive value of 0.91 (Pediatrics 2002;110:354-9).

"That’s better than any lab test or x-ray [and] about as good as MRI. [So] if you’re calling me saying that Johnny has knee pain, I’m not as worried about JIA [juvenile idiopathic arthritis]. I may be worried about [Henoch-Schönlein purpura (HSP)] or a mechanical issue or something else ... but [not] JIA," said Dr. Cartwright of Randall Children’s Hospital at Legacy Emanuel in Portland, Ore.

On the other hand, "labs really don’t help one way or the other to make the diagnosis of arthritis. Rheumatoid factor doesn’t help. [Erythrocyte sedimentation rate] is helpful if it’s abnormal, but only kind of. I can have a kid who has 20 inflamed joints and their sed rate is 2; I can have another kid with one swollen knee, and their sed rate is 30. [However,] if the sed rate is over 100, I worry about other stuff," such as systemic disease, lupus, HSP, vasculitis, or malignancy, she said.

If those problems have been ruled out, Dr. Cartwright said she usually waits until kids have been on NSAIDs – she favors weight-dosed ibuprofen or naproxen – for a month before getting a complete blood count, a liver enzyme panel, and an antinuclear antibody (ANA) test. "I’m not a big fan of labs up front" for JIA "because we end up chasing the lab illness a little bit," she said. JIA kids also need a referral to an ophthalmologist to check for iritis. If this condition is present, ANA testing helps tell how aggressive it is.

As for assessment, Dr. Cartwright noted that obesity makes it tough to check the ankle for swelling; extra pounds obscure the Achilles tendon and the divots to either side. "It’s one of the joints I image a lot with MRI because I [often] can’t see it very well," she said.

Swelling can be hard to detect in kids with polyarticular disease because it can be more or less even on either side of the body, and, thus, less noticeable. One trick, especially helpful with the hands, is to compare the skin folds and wrinkles around corresponding joints. If they aren’t symmetrical, it could be due to swelling.

Check for jaw arthritis, too, Dr. Cartwright said. A lot of children don’t even know there’s a problem because it’s painless, but left unchecked, jaw arthritis can cause growth abnormalities – associated asymmetries are most obvious when the head’s tilted back – and make it difficult to fully open the mouth.

Patients should be able to insert their three middle fingers vertically into their mouth. When they can’t, "we do some dynamic stretching. We’ll stack tongue blades" to reach the appropriate thickness and have patients place them in their mouth to "stretch the muscles out, kind of like doing [physical therapy]," Dr. Cartwright said.

She said she has no relevant financial disclosures.

[email protected]

PORTLAND, ORE. – Joint pain isn’t usually part of the clinical picture when children have juvenile idiopathic arthritis, according to pediatric rheumatologist Victoria Cartwright.

"In fact, it helps you discount that juvenile arthritis is going on," she said at a conference sponsored by the North Pacific Pediatric Society.

Pain as an isolated complaint has a negative predictive value for pediatric rheumatic disease of 0.99 and, as one of several reasons for a rheumatology referral, a negative predictive value of 0.91 (Pediatrics 2002;110:354-9).

"That’s better than any lab test or x-ray [and] about as good as MRI. [So] if you’re calling me saying that Johnny has knee pain, I’m not as worried about JIA [juvenile idiopathic arthritis]. I may be worried about [Henoch-Schönlein purpura (HSP)] or a mechanical issue or something else ... but [not] JIA," said Dr. Cartwright of Randall Children’s Hospital at Legacy Emanuel in Portland, Ore.

On the other hand, "labs really don’t help one way or the other to make the diagnosis of arthritis. Rheumatoid factor doesn’t help. [Erythrocyte sedimentation rate] is helpful if it’s abnormal, but only kind of. I can have a kid who has 20 inflamed joints and their sed rate is 2; I can have another kid with one swollen knee, and their sed rate is 30. [However,] if the sed rate is over 100, I worry about other stuff," such as systemic disease, lupus, HSP, vasculitis, or malignancy, she said.

If those problems have been ruled out, Dr. Cartwright said she usually waits until kids have been on NSAIDs – she favors weight-dosed ibuprofen or naproxen – for a month before getting a complete blood count, a liver enzyme panel, and an antinuclear antibody (ANA) test. "I’m not a big fan of labs up front" for JIA "because we end up chasing the lab illness a little bit," she said. JIA kids also need a referral to an ophthalmologist to check for iritis. If this condition is present, ANA testing helps tell how aggressive it is.

As for assessment, Dr. Cartwright noted that obesity makes it tough to check the ankle for swelling; extra pounds obscure the Achilles tendon and the divots to either side. "It’s one of the joints I image a lot with MRI because I [often] can’t see it very well," she said.

Swelling can be hard to detect in kids with polyarticular disease because it can be more or less even on either side of the body, and, thus, less noticeable. One trick, especially helpful with the hands, is to compare the skin folds and wrinkles around corresponding joints. If they aren’t symmetrical, it could be due to swelling.

Check for jaw arthritis, too, Dr. Cartwright said. A lot of children don’t even know there’s a problem because it’s painless, but left unchecked, jaw arthritis can cause growth abnormalities – associated asymmetries are most obvious when the head’s tilted back – and make it difficult to fully open the mouth.

Patients should be able to insert their three middle fingers vertically into their mouth. When they can’t, "we do some dynamic stretching. We’ll stack tongue blades" to reach the appropriate thickness and have patients place them in their mouth to "stretch the muscles out, kind of like doing [physical therapy]," Dr. Cartwright said.

She said she has no relevant financial disclosures.

[email protected]

PORTLAND, ORE. – When time-outs don’t work, it’s often because they aren’t being done right, according to Dr. Barbara J. Howard.

Time-outs are "the best evidence-based consequence to change unwanted behavior," effective from as early as 9 months old – when some children are already hitting – and most effective between ages 2-6 years, said Dr. Howard, an assistant professor of pediatrics at Johns Hopkins University in Baltimore.

But parents first need to be taught how to do time-outs right, and practice them; that’s best done before they’re ever needed.

They should know that time-outs should be reserved for just a few serious offenses, such as hitting, kicking, or swearing, and that they are not a substitute for good parenting. If "the kid’s in time-out more than once a day, they are probably not getting enough positive attention for positive behaviors," Dr. Howard said at a conference sponsored by the North Pacific Pediatric Society.

Time-outs for aggressive behavior shouldn’t come with a warning beforehand. Instead, the child should get a brief statement of the offense – for instance, " ‘No hitting, hitting hurts, you’re in time-out.’ Then put [the child] in an uninteresting, but not-scary place." There should be no interaction while the sentence is served. Restraints are an option if the child squirms out of the chair, as is restarting the clock if they act up, said the pediatric developmental and behavioral specialist.

The general rule is 1 minute for each year of age, but if a child with attention-deficit/hyperactivity disorder (ADHD) is unable to sit for a few minutes, even 15 seconds can work. "Have the parent sort of watch them out of the corner of their eye. As soon as the child gives in to the fact that they are sitting there" – lets out a sigh, for example – "that’s the time to [let] them out," she said.

There shouldn’t be a discussion or lecture about what they did wrong when the time’s up. "They are so delicate when they come out of being given a consequence that they fall apart very easily, so it’s better not to talk about it at that moment because they can’t [hear] the lesson." A discussion is just likely to rekindle the situation, Dr. Howard said.

Instead, "return to the scene of the crime and distract them onto some new activity that they can be praised for. Find something positive about their behavior to talk about, or at least give them neutral attention," she said.

And "don’t ask them to apologize. First of all, are they sorry? No. So, if you force them to apologize, you are telling them to lie. That’s not good. [However,] it is appropriate for the adult to apologize to the victim" by saying something like "Oh, I’m sorry you got hurt. That must hurt a lot." The offender just might incorporate the example into their own behavior, she said.

It’s time to revisit the offense later on, after the storm’s passed. The child can be asked what they could have done differently, and given some different options. Role-playing helps.

Parents also need to know that "it’s quite common" for children to go back and do the exact same thing that got them into trouble in the first place, "but that doesn’t mean that the time-out didn’t work; the same thing is true if they get [spanked]. So you can reassure parents they aren’t crazy if they see [that time-outs are] not immediately effective. Tell them to hang in there, and expect change over time," Dr. Howard said.

Dr. Howard is the creator of CHADIS and president of Total Child Health, the management company that licenses its use.

[email protected]

PORTLAND, ORE. – When time-outs don’t work, it’s often because they aren’t being done right, according to Dr. Barbara J. Howard.

Time-outs are "the best evidence-based consequence to change unwanted behavior," effective from as early as 9 months old – when some children are already hitting – and most effective between ages 2-6 years, said Dr. Howard, an assistant professor of pediatrics at Johns Hopkins University in Baltimore.

But parents first need to be taught how to do time-outs right, and practice them; that’s best done before they’re ever needed.

They should know that time-outs should be reserved for just a few serious offenses, such as hitting, kicking, or swearing, and that they are not a substitute for good parenting. If "the kid’s in time-out more than once a day, they are probably not getting enough positive attention for positive behaviors," Dr. Howard said at a conference sponsored by the North Pacific Pediatric Society.

Time-outs for aggressive behavior shouldn’t come with a warning beforehand. Instead, the child should get a brief statement of the offense – for instance, " ‘No hitting, hitting hurts, you’re in time-out.’ Then put [the child] in an uninteresting, but not-scary place." There should be no interaction while the sentence is served. Restraints are an option if the child squirms out of the chair, as is restarting the clock if they act up, said the pediatric developmental and behavioral specialist.

The general rule is 1 minute for each year of age, but if a child with attention-deficit/hyperactivity disorder (ADHD) is unable to sit for a few minutes, even 15 seconds can work. "Have the parent sort of watch them out of the corner of their eye. As soon as the child gives in to the fact that they are sitting there" – lets out a sigh, for example – "that’s the time to [let] them out," she said.

There shouldn’t be a discussion or lecture about what they did wrong when the time’s up. "They are so delicate when they come out of being given a consequence that they fall apart very easily, so it’s better not to talk about it at that moment because they can’t [hear] the lesson." A discussion is just likely to rekindle the situation, Dr. Howard said.

Instead, "return to the scene of the crime and distract them onto some new activity that they can be praised for. Find something positive about their behavior to talk about, or at least give them neutral attention," she said.

And "don’t ask them to apologize. First of all, are they sorry? No. So, if you force them to apologize, you are telling them to lie. That’s not good. [However,] it is appropriate for the adult to apologize to the victim" by saying something like "Oh, I’m sorry you got hurt. That must hurt a lot." The offender just might incorporate the example into their own behavior, she said.

It’s time to revisit the offense later on, after the storm’s passed. The child can be asked what they could have done differently, and given some different options. Role-playing helps.

Parents also need to know that "it’s quite common" for children to go back and do the exact same thing that got them into trouble in the first place, "but that doesn’t mean that the time-out didn’t work; the same thing is true if they get [spanked]. So you can reassure parents they aren’t crazy if they see [that time-outs are] not immediately effective. Tell them to hang in there, and expect change over time," Dr. Howard said.

Dr. Howard is the creator of CHADIS and president of Total Child Health, the management company that licenses its use.

[email protected]

PORTLAND, ORE. – When time-outs don’t work, it’s often because they aren’t being done right, according to Dr. Barbara J. Howard.

Time-outs are "the best evidence-based consequence to change unwanted behavior," effective from as early as 9 months old – when some children are already hitting – and most effective between ages 2-6 years, said Dr. Howard, an assistant professor of pediatrics at Johns Hopkins University in Baltimore.

But parents first need to be taught how to do time-outs right, and practice them; that’s best done before they’re ever needed.

They should know that time-outs should be reserved for just a few serious offenses, such as hitting, kicking, or swearing, and that they are not a substitute for good parenting. If "the kid’s in time-out more than once a day, they are probably not getting enough positive attention for positive behaviors," Dr. Howard said at a conference sponsored by the North Pacific Pediatric Society.

Time-outs for aggressive behavior shouldn’t come with a warning beforehand. Instead, the child should get a brief statement of the offense – for instance, " ‘No hitting, hitting hurts, you’re in time-out.’ Then put [the child] in an uninteresting, but not-scary place." There should be no interaction while the sentence is served. Restraints are an option if the child squirms out of the chair, as is restarting the clock if they act up, said the pediatric developmental and behavioral specialist.

The general rule is 1 minute for each year of age, but if a child with attention-deficit/hyperactivity disorder (ADHD) is unable to sit for a few minutes, even 15 seconds can work. "Have the parent sort of watch them out of the corner of their eye. As soon as the child gives in to the fact that they are sitting there" – lets out a sigh, for example – "that’s the time to [let] them out," she said.

There shouldn’t be a discussion or lecture about what they did wrong when the time’s up. "They are so delicate when they come out of being given a consequence that they fall apart very easily, so it’s better not to talk about it at that moment because they can’t [hear] the lesson." A discussion is just likely to rekindle the situation, Dr. Howard said.

Instead, "return to the scene of the crime and distract them onto some new activity that they can be praised for. Find something positive about their behavior to talk about, or at least give them neutral attention," she said.

And "don’t ask them to apologize. First of all, are they sorry? No. So, if you force them to apologize, you are telling them to lie. That’s not good. [However,] it is appropriate for the adult to apologize to the victim" by saying something like "Oh, I’m sorry you got hurt. That must hurt a lot." The offender just might incorporate the example into their own behavior, she said.

It’s time to revisit the offense later on, after the storm’s passed. The child can be asked what they could have done differently, and given some different options. Role-playing helps.

Parents also need to know that "it’s quite common" for children to go back and do the exact same thing that got them into trouble in the first place, "but that doesn’t mean that the time-out didn’t work; the same thing is true if they get [spanked]. So you can reassure parents they aren’t crazy if they see [that time-outs are] not immediately effective. Tell them to hang in there, and expect change over time," Dr. Howard said.

Dr. Howard is the creator of CHADIS and president of Total Child Health, the management company that licenses its use.

[email protected]

LAS VEGAS – The development of euglycemic insulin resistance soon after intubation may herald the onset of ventilator-associated pneumonia, a study by investigators at Vanderbilt University in Nashville, Tenn., has shown.

Researchers compared 92 critically injured trauma patients who developed VAP (ventilator-associated pneumonia) 3-4 days after intubation with 2,162 who did not. All the subjects had their blood glucose levels kept mostly between 80 and 150 mg/dL with the help of a computer-assisted protocol that adjusted insulin drip rates as necessary, lead investigator Dr. Kaushik Mukherjee reported at the annual meeting of the Surgical Infection Society.

There were no differences in baseline demographics between the two groups, but compared with controls, patients who developed VAP needed significantly higher insulin drip rates to stay in that range the day before and the first and third days after they met clinical criteria for VAP diagnosis (maximum difference, 1.1 U/hr [95% CI, 0.8-1.5; P less than .001]).

The M multiplier, a surrogate for insulin resistance calculated from blood glucose levels and insulin drip rates, was significantly higher 2 days before VAP was diagnosed, and remained so for 10 days afterward.

If the findings hold up with further investigation, the Vanderbilt team believes they may one day help predict who’s at risk for VAP so that preventative measures can be taken. Among other things, the model will need to incorporate body mass index, steroid use, tube-feeding schedule, and other confounders that impact insulin requirements, and be put through a prospective trial.

Even so, "these data indicate euglycemic insulin resistance may be an important new indicator for VAP in the era of strict glycemic control. [This] may be valuable moving forward," said Dr. Mukherjee of Vanderbilt’s division of trauma and surgical critical care.

"We believe that critically injured patients with VAP show euglycemic insulin resistance as measured by the multiplier, and we think [that] could be predictive of infection. We are hoping to turn this into an insulin resistance–based screening tool for VAP that would help us decide when we should obtain a [bronchoalveolar lavage]. Earlier detection of pneumonias could result in earlier antibiotic therapy and survival," he said.

Patients in the study were at least 16 years old, and had been ventilated for at least 48 hours.

Both VAP and control patients needed increasing amounts of insulin in the 10 days following intubation, probably "due to added nutrition, but [the VAP group required] a more rapid increase in their insulin infusion rates" starting about 3 days before VAP was diagnosed.

Overall, VAP patients had lower blood glucose levels both before and after diagnosis and were less likely to exceed the target range. "We think it’s because their innate ability to control glucose [was more] impaired, [so] there was less variability from the patient’s own system," Dr. Mukherjee said.

He said he had no relevant financial disclosures.

[email protected]

LAS VEGAS – The development of euglycemic insulin resistance soon after intubation may herald the onset of ventilator-associated pneumonia, a study by investigators at Vanderbilt University in Nashville, Tenn., has shown.

Researchers compared 92 critically injured trauma patients who developed VAP (ventilator-associated pneumonia) 3-4 days after intubation with 2,162 who did not. All the subjects had their blood glucose levels kept mostly between 80 and 150 mg/dL with the help of a computer-assisted protocol that adjusted insulin drip rates as necessary, lead investigator Dr. Kaushik Mukherjee reported at the annual meeting of the Surgical Infection Society.

There were no differences in baseline demographics between the two groups, but compared with controls, patients who developed VAP needed significantly higher insulin drip rates to stay in that range the day before and the first and third days after they met clinical criteria for VAP diagnosis (maximum difference, 1.1 U/hr [95% CI, 0.8-1.5; P less than .001]).

The M multiplier, a surrogate for insulin resistance calculated from blood glucose levels and insulin drip rates, was significantly higher 2 days before VAP was diagnosed, and remained so for 10 days afterward.

If the findings hold up with further investigation, the Vanderbilt team believes they may one day help predict who’s at risk for VAP so that preventative measures can be taken. Among other things, the model will need to incorporate body mass index, steroid use, tube-feeding schedule, and other confounders that impact insulin requirements, and be put through a prospective trial.

Even so, "these data indicate euglycemic insulin resistance may be an important new indicator for VAP in the era of strict glycemic control. [This] may be valuable moving forward," said Dr. Mukherjee of Vanderbilt’s division of trauma and surgical critical care.

"We believe that critically injured patients with VAP show euglycemic insulin resistance as measured by the multiplier, and we think [that] could be predictive of infection. We are hoping to turn this into an insulin resistance–based screening tool for VAP that would help us decide when we should obtain a [bronchoalveolar lavage]. Earlier detection of pneumonias could result in earlier antibiotic therapy and survival," he said.

Patients in the study were at least 16 years old, and had been ventilated for at least 48 hours.

Both VAP and control patients needed increasing amounts of insulin in the 10 days following intubation, probably "due to added nutrition, but [the VAP group required] a more rapid increase in their insulin infusion rates" starting about 3 days before VAP was diagnosed.

Overall, VAP patients had lower blood glucose levels both before and after diagnosis and were less likely to exceed the target range. "We think it’s because their innate ability to control glucose [was more] impaired, [so] there was less variability from the patient’s own system," Dr. Mukherjee said.

He said he had no relevant financial disclosures.

[email protected]

LAS VEGAS – The development of euglycemic insulin resistance soon after intubation may herald the onset of ventilator-associated pneumonia, a study by investigators at Vanderbilt University in Nashville, Tenn., has shown.

Researchers compared 92 critically injured trauma patients who developed VAP (ventilator-associated pneumonia) 3-4 days after intubation with 2,162 who did not. All the subjects had their blood glucose levels kept mostly between 80 and 150 mg/dL with the help of a computer-assisted protocol that adjusted insulin drip rates as necessary, lead investigator Dr. Kaushik Mukherjee reported at the annual meeting of the Surgical Infection Society.

There were no differences in baseline demographics between the two groups, but compared with controls, patients who developed VAP needed significantly higher insulin drip rates to stay in that range the day before and the first and third days after they met clinical criteria for VAP diagnosis (maximum difference, 1.1 U/hr [95% CI, 0.8-1.5; P less than .001]).

The M multiplier, a surrogate for insulin resistance calculated from blood glucose levels and insulin drip rates, was significantly higher 2 days before VAP was diagnosed, and remained so for 10 days afterward.

If the findings hold up with further investigation, the Vanderbilt team believes they may one day help predict who’s at risk for VAP so that preventative measures can be taken. Among other things, the model will need to incorporate body mass index, steroid use, tube-feeding schedule, and other confounders that impact insulin requirements, and be put through a prospective trial.

Even so, "these data indicate euglycemic insulin resistance may be an important new indicator for VAP in the era of strict glycemic control. [This] may be valuable moving forward," said Dr. Mukherjee of Vanderbilt’s division of trauma and surgical critical care.

"We believe that critically injured patients with VAP show euglycemic insulin resistance as measured by the multiplier, and we think [that] could be predictive of infection. We are hoping to turn this into an insulin resistance–based screening tool for VAP that would help us decide when we should obtain a [bronchoalveolar lavage]. Earlier detection of pneumonias could result in earlier antibiotic therapy and survival," he said.

Patients in the study were at least 16 years old, and had been ventilated for at least 48 hours.

Both VAP and control patients needed increasing amounts of insulin in the 10 days following intubation, probably "due to added nutrition, but [the VAP group required] a more rapid increase in their insulin infusion rates" starting about 3 days before VAP was diagnosed.

Overall, VAP patients had lower blood glucose levels both before and after diagnosis and were less likely to exceed the target range. "We think it’s because their innate ability to control glucose [was more] impaired, [so] there was less variability from the patient’s own system," Dr. Mukherjee said.

He said he had no relevant financial disclosures.

[email protected]

Plan B One-Step can now be purchased without a prescription by young women aged 15-16 years so long as they can verify their age, the Food and Drug Administration announced April 30.

Previously, only women 17 years or older could purchase Teva’s one-dose levonorgestrel emergency contraceptive under those conditions; others needed a prescription.

Plan B One-Step (levonorgestrel tablet, 1.5 mg, for oral use) "will be packaged with a product code prompting a cashier to request and verify the customer’s age. A customer who cannot provide age verification will not be able to purchase the product," according to the FDA announcement.

The product will be available in the family planning or women’s health aisles of stores that have a pharmacy and will be accessible "whether the pharmacy is open or not," the statement continued.

The agency also said that this approval is unrelated to an April 5 U.S. District Court order that gave it 30 days to grant emergency contraception full OTC status.

Specifically, the court ordered the FDA "to grant a 2001 citizen’s petition ... that sought to allow over-the-counter access to Plan B [a two dose levonorgestrel product] for women of all ages and/or make Plan B One-Step available without age or point of sale restrictions," the agency said.

However, Teva had a pending application to market Plan B One-Step to women 15 years and older prior to the ruling. According to the FDA, approval of the Plan B One-Step "is independent of that litigation and this decision is not intended to address the judge’s ruling. The Department of Justice is considering next steps in the litigation. In the meantime, the FDA took independent action to approve the pending application on Plan B One-Step."

The Center for Reproductive Rights, a plaintiff to the lawsuit that led to the ruling, said in a statement that "lowering the age restriction to 15 for over-the-counter access to Plan B One-Step may reduce delays for some young women, but it does nothing to address the significant barriers that far too many women of all ages will still find if they arrive at the drugstore without identification or after the pharmacy gates have been closed for the night or weekend."

Planned Parenthood noted in its statement, "While we fully support this expansion of access to birth control, we continue to believe that the administration should lift all unnecessary restrictions to emergency contraception, consistent with the prevailing science and medicine."

"We really would like no age restriction," said spokeswoman Kristen Glundberg-Prossor. "If you really need [emergency contraception], you need to have easy access to it. Anytime you have these age restrictions on a drug, they create a lot of confusion."

The confusion could get worse since Plan B One-Step and the original Plan B now have different age requirements for OTC access, in addition to different dosing schedules despite similar-sounding names. The original product remains indicated without a prescription for women aged 17 years or older.

Meanwhile, it’s unknown if the Department of Health and Human Services will contest the court ruling, and there’s a third emergency contraceptive, Ella, that is available only by prescription.

"Confusion usually winds up reducing access" as pharmacists, unsure of the rules, err on the side of caution, said Dr. Eve Espey, associate professor of obstetrics and gynecology at the University of New Mexico, Albuquerque.

But it’s important to remember that, overall, "access to emergency contraception is being liberalized and hopefully will continue to get easier for women. Talking to women about emergency contraception and continuing to advocate for increased access [both] remain really important," she said.

Teva plans an education campaign to bring consumers, pharmacy staff, and health care providers up to speed with Plan B One-Step’s new age rules, the FDA said.

Dr. Espey said that she had no financial conflicts of interest.

[email protected]

Plan B One-Step can now be purchased without a prescription by young women aged 15-16 years so long as they can verify their age, the Food and Drug Administration announced April 30.

Previously, only women 17 years or older could purchase Teva’s one-dose levonorgestrel emergency contraceptive under those conditions; others needed a prescription.

Plan B One-Step (levonorgestrel tablet, 1.5 mg, for oral use) "will be packaged with a product code prompting a cashier to request and verify the customer’s age. A customer who cannot provide age verification will not be able to purchase the product," according to the FDA announcement.

The product will be available in the family planning or women’s health aisles of stores that have a pharmacy and will be accessible "whether the pharmacy is open or not," the statement continued.

The agency also said that this approval is unrelated to an April 5 U.S. District Court order that gave it 30 days to grant emergency contraception full OTC status.

Specifically, the court ordered the FDA "to grant a 2001 citizen’s petition ... that sought to allow over-the-counter access to Plan B [a two dose levonorgestrel product] for women of all ages and/or make Plan B One-Step available without age or point of sale restrictions," the agency said.

However, Teva had a pending application to market Plan B One-Step to women 15 years and older prior to the ruling. According to the FDA, approval of the Plan B One-Step "is independent of that litigation and this decision is not intended to address the judge’s ruling. The Department of Justice is considering next steps in the litigation. In the meantime, the FDA took independent action to approve the pending application on Plan B One-Step."

The Center for Reproductive Rights, a plaintiff to the lawsuit that led to the ruling, said in a statement that "lowering the age restriction to 15 for over-the-counter access to Plan B One-Step may reduce delays for some young women, but it does nothing to address the significant barriers that far too many women of all ages will still find if they arrive at the drugstore without identification or after the pharmacy gates have been closed for the night or weekend."

Planned Parenthood noted in its statement, "While we fully support this expansion of access to birth control, we continue to believe that the administration should lift all unnecessary restrictions to emergency contraception, consistent with the prevailing science and medicine."

"We really would like no age restriction," said spokeswoman Kristen Glundberg-Prossor. "If you really need [emergency contraception], you need to have easy access to it. Anytime you have these age restrictions on a drug, they create a lot of confusion."

The confusion could get worse since Plan B One-Step and the original Plan B now have different age requirements for OTC access, in addition to different dosing schedules despite similar-sounding names. The original product remains indicated without a prescription for women aged 17 years or older.

Meanwhile, it’s unknown if the Department of Health and Human Services will contest the court ruling, and there’s a third emergency contraceptive, Ella, that is available only by prescription.

"Confusion usually winds up reducing access" as pharmacists, unsure of the rules, err on the side of caution, said Dr. Eve Espey, associate professor of obstetrics and gynecology at the University of New Mexico, Albuquerque.

But it’s important to remember that, overall, "access to emergency contraception is being liberalized and hopefully will continue to get easier for women. Talking to women about emergency contraception and continuing to advocate for increased access [both] remain really important," she said.

Teva plans an education campaign to bring consumers, pharmacy staff, and health care providers up to speed with Plan B One-Step’s new age rules, the FDA said.

Dr. Espey said that she had no financial conflicts of interest.

[email protected]

Plan B One-Step can now be purchased without a prescription by young women aged 15-16 years so long as they can verify their age, the Food and Drug Administration announced April 30.

Previously, only women 17 years or older could purchase Teva’s one-dose levonorgestrel emergency contraceptive under those conditions; others needed a prescription.

Plan B One-Step (levonorgestrel tablet, 1.5 mg, for oral use) "will be packaged with a product code prompting a cashier to request and verify the customer’s age. A customer who cannot provide age verification will not be able to purchase the product," according to the FDA announcement.

The product will be available in the family planning or women’s health aisles of stores that have a pharmacy and will be accessible "whether the pharmacy is open or not," the statement continued.

The agency also said that this approval is unrelated to an April 5 U.S. District Court order that gave it 30 days to grant emergency contraception full OTC status.

Specifically, the court ordered the FDA "to grant a 2001 citizen’s petition ... that sought to allow over-the-counter access to Plan B [a two dose levonorgestrel product] for women of all ages and/or make Plan B One-Step available without age or point of sale restrictions," the agency said.

However, Teva had a pending application to market Plan B One-Step to women 15 years and older prior to the ruling. According to the FDA, approval of the Plan B One-Step "is independent of that litigation and this decision is not intended to address the judge’s ruling. The Department of Justice is considering next steps in the litigation. In the meantime, the FDA took independent action to approve the pending application on Plan B One-Step."

The Center for Reproductive Rights, a plaintiff to the lawsuit that led to the ruling, said in a statement that "lowering the age restriction to 15 for over-the-counter access to Plan B One-Step may reduce delays for some young women, but it does nothing to address the significant barriers that far too many women of all ages will still find if they arrive at the drugstore without identification or after the pharmacy gates have been closed for the night or weekend."

Planned Parenthood noted in its statement, "While we fully support this expansion of access to birth control, we continue to believe that the administration should lift all unnecessary restrictions to emergency contraception, consistent with the prevailing science and medicine."

"We really would like no age restriction," said spokeswoman Kristen Glundberg-Prossor. "If you really need [emergency contraception], you need to have easy access to it. Anytime you have these age restrictions on a drug, they create a lot of confusion."

The confusion could get worse since Plan B One-Step and the original Plan B now have different age requirements for OTC access, in addition to different dosing schedules despite similar-sounding names. The original product remains indicated without a prescription for women aged 17 years or older.

Meanwhile, it’s unknown if the Department of Health and Human Services will contest the court ruling, and there’s a third emergency contraceptive, Ella, that is available only by prescription.

"Confusion usually winds up reducing access" as pharmacists, unsure of the rules, err on the side of caution, said Dr. Eve Espey, associate professor of obstetrics and gynecology at the University of New Mexico, Albuquerque.

But it’s important to remember that, overall, "access to emergency contraception is being liberalized and hopefully will continue to get easier for women. Talking to women about emergency contraception and continuing to advocate for increased access [both] remain really important," she said.

Teva plans an education campaign to bring consumers, pharmacy staff, and health care providers up to speed with Plan B One-Step’s new age rules, the FDA said.

Dr. Espey said that she had no financial conflicts of interest.

[email protected]