Pediatric Update

LAS VEGAS – If a child presents with ash-leaf spots or small hypopigmented “confetti” lesions, think tuberous sclerosis, a neurocutaneous disorder that affects an estimated 1:6,000-10,000 infants and children.

“The neurologic impact of tuberous sclerosis is much higher than it is for neurofibromatosis,” Dr. Thomas K. Koch said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. “These are children that may present to you early on with infantile spasms and/or may have severe psychomotor deficits and difficult seizures. We need to understand the needs of these children across the spectrum as well as what other organ systems can be involved with these kids.”

Dr. Koch, professor of pediatric neurology at the Medical University of South Carolina, Charleston, described tuberous sclerosis (TSC) as an autosomal dominant disorder with variable penetrance. It can affect multiple organs, including the brain, skin, eyes, heart, kidney, and lungs. It involves two different genes on two different chromosomes: the TSC 1 gene on 9q34 called hamartin and the TSC 2 gene on 16p13 called tuberin. “Hamartin and tuberin act together in the Golgi apparatus for regulation of cell division,” he explained. “This leads to the proclivity toward development of abnormal tissue [such as] hamartomas.”

The long-established classical clinical triad to make a diagnosis of TSC was the presence of a seizure disorder, mental retardation, and cutaneous findings, especially adenoma sebaceum. However, that clinical triad occurs in fewer than 50% of patients, Dr. Koch said. According to a 2000 National Institutes of Health consensus conference, definite TSC can be made by the presence of two major features or one major plus two minor features; probable TSC is defined as having one major feature plus one minor feature, while possible TSC is defined as having one major feature or two or more minor features (Arch. Neurol. 2000;57:662-5).

Major features of TSC include cutaneous lesions such as adenoma sebaceum, more than three hypomelanotic macules, shagreen patch, and periungual fibromas; cortical tubers, subependymal nodules, retinal hamartomas, heart rhabdomyomas, renal angiomyolipomas, and lung lymphangiomyomatosis. Minor features include bone cysts, confetti skin lesions, CNS white matter migration abnormalities, dental enamel pits, gingival fibromas, rectal polyps, multiple renal cysts, non-renal hamartomas, and a retinal achromic patch.

One common cutaneous manifestation of TSC is adenoma sebaceum, which usually develops at an age of 4-6 years and is located over the nose, cheeks, chin, and can include the forehead. Another cutaneous manifestation is a shagreen patch: a roughened, raised lesion with an orange-peel consistency almost always located over the lumbosacral region. Approximately 90% of cases have ash leaf spots whose visualization is enhanced by a Woods lamp. “This is one of the first cutaneous manifestations you will see,” Dr. Koch said. “Many of the cutaneous manifestations develop as a function of time. Subungual and periungual fibromas usually arise during adolescence.”

From a central nervous system standpoint, at least 80% of TSC cases have some form of a cognitive or mental disability. Epilepsy is seen in 80%-90% of cases. “If a child presents with infantile spasms, the first thing you have to think about is tuberous sclerosis, because if TSC presents in infancy, it will do so as infantile spasms,” he said.

Dr. Koch reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – If a child presents with ash-leaf spots or small hypopigmented “confetti” lesions, think tuberous sclerosis, a neurocutaneous disorder that affects an estimated 1:6,000-10,000 infants and children.

“The neurologic impact of tuberous sclerosis is much higher than it is for neurofibromatosis,” Dr. Thomas K. Koch said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. “These are children that may present to you early on with infantile spasms and/or may have severe psychomotor deficits and difficult seizures. We need to understand the needs of these children across the spectrum as well as what other organ systems can be involved with these kids.”

Dr. Koch, professor of pediatric neurology at the Medical University of South Carolina, Charleston, described tuberous sclerosis (TSC) as an autosomal dominant disorder with variable penetrance. It can affect multiple organs, including the brain, skin, eyes, heart, kidney, and lungs. It involves two different genes on two different chromosomes: the TSC 1 gene on 9q34 called hamartin and the TSC 2 gene on 16p13 called tuberin. “Hamartin and tuberin act together in the Golgi apparatus for regulation of cell division,” he explained. “This leads to the proclivity toward development of abnormal tissue [such as] hamartomas.”

The long-established classical clinical triad to make a diagnosis of TSC was the presence of a seizure disorder, mental retardation, and cutaneous findings, especially adenoma sebaceum. However, that clinical triad occurs in fewer than 50% of patients, Dr. Koch said. According to a 2000 National Institutes of Health consensus conference, definite TSC can be made by the presence of two major features or one major plus two minor features; probable TSC is defined as having one major feature plus one minor feature, while possible TSC is defined as having one major feature or two or more minor features (Arch. Neurol. 2000;57:662-5).

Major features of TSC include cutaneous lesions such as adenoma sebaceum, more than three hypomelanotic macules, shagreen patch, and periungual fibromas; cortical tubers, subependymal nodules, retinal hamartomas, heart rhabdomyomas, renal angiomyolipomas, and lung lymphangiomyomatosis. Minor features include bone cysts, confetti skin lesions, CNS white matter migration abnormalities, dental enamel pits, gingival fibromas, rectal polyps, multiple renal cysts, non-renal hamartomas, and a retinal achromic patch.

One common cutaneous manifestation of TSC is adenoma sebaceum, which usually develops at an age of 4-6 years and is located over the nose, cheeks, chin, and can include the forehead. Another cutaneous manifestation is a shagreen patch: a roughened, raised lesion with an orange-peel consistency almost always located over the lumbosacral region. Approximately 90% of cases have ash leaf spots whose visualization is enhanced by a Woods lamp. “This is one of the first cutaneous manifestations you will see,” Dr. Koch said. “Many of the cutaneous manifestations develop as a function of time. Subungual and periungual fibromas usually arise during adolescence.”

From a central nervous system standpoint, at least 80% of TSC cases have some form of a cognitive or mental disability. Epilepsy is seen in 80%-90% of cases. “If a child presents with infantile spasms, the first thing you have to think about is tuberous sclerosis, because if TSC presents in infancy, it will do so as infantile spasms,” he said.

Dr. Koch reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – If a child presents with ash-leaf spots or small hypopigmented “confetti” lesions, think tuberous sclerosis, a neurocutaneous disorder that affects an estimated 1:6,000-10,000 infants and children.

“The neurologic impact of tuberous sclerosis is much higher than it is for neurofibromatosis,” Dr. Thomas K. Koch said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. “These are children that may present to you early on with infantile spasms and/or may have severe psychomotor deficits and difficult seizures. We need to understand the needs of these children across the spectrum as well as what other organ systems can be involved with these kids.”

Dr. Koch, professor of pediatric neurology at the Medical University of South Carolina, Charleston, described tuberous sclerosis (TSC) as an autosomal dominant disorder with variable penetrance. It can affect multiple organs, including the brain, skin, eyes, heart, kidney, and lungs. It involves two different genes on two different chromosomes: the TSC 1 gene on 9q34 called hamartin and the TSC 2 gene on 16p13 called tuberin. “Hamartin and tuberin act together in the Golgi apparatus for regulation of cell division,” he explained. “This leads to the proclivity toward development of abnormal tissue [such as] hamartomas.”

The long-established classical clinical triad to make a diagnosis of TSC was the presence of a seizure disorder, mental retardation, and cutaneous findings, especially adenoma sebaceum. However, that clinical triad occurs in fewer than 50% of patients, Dr. Koch said. According to a 2000 National Institutes of Health consensus conference, definite TSC can be made by the presence of two major features or one major plus two minor features; probable TSC is defined as having one major feature plus one minor feature, while possible TSC is defined as having one major feature or two or more minor features (Arch. Neurol. 2000;57:662-5).

Major features of TSC include cutaneous lesions such as adenoma sebaceum, more than three hypomelanotic macules, shagreen patch, and periungual fibromas; cortical tubers, subependymal nodules, retinal hamartomas, heart rhabdomyomas, renal angiomyolipomas, and lung lymphangiomyomatosis. Minor features include bone cysts, confetti skin lesions, CNS white matter migration abnormalities, dental enamel pits, gingival fibromas, rectal polyps, multiple renal cysts, non-renal hamartomas, and a retinal achromic patch.

One common cutaneous manifestation of TSC is adenoma sebaceum, which usually develops at an age of 4-6 years and is located over the nose, cheeks, chin, and can include the forehead. Another cutaneous manifestation is a shagreen patch: a roughened, raised lesion with an orange-peel consistency almost always located over the lumbosacral region. Approximately 90% of cases have ash leaf spots whose visualization is enhanced by a Woods lamp. “This is one of the first cutaneous manifestations you will see,” Dr. Koch said. “Many of the cutaneous manifestations develop as a function of time. Subungual and periungual fibromas usually arise during adolescence.”

From a central nervous system standpoint, at least 80% of TSC cases have some form of a cognitive or mental disability. Epilepsy is seen in 80%-90% of cases. “If a child presents with infantile spasms, the first thing you have to think about is tuberous sclerosis, because if TSC presents in infancy, it will do so as infantile spasms,” he said.

Dr. Koch reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – Skin manifestations of nutritional deficiencies are likely underrecognized, according to Dr. James Treat.

“If you can recognize them, they’re incredibly satisfying and simple to treat,” he said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. “You don’t have to prescribe medications; you simply have to replete in most cases.”

At-risk populations include children and adolescents on restrictive diets for conditions ranging from autism spectrum disorders to extreme or overdiagnosed food allergy, and eating disorders. “There are also kids with metabolic diseases and genetic defects that can lead to nutritional deficiencies,” said Dr. Treat, a pediatric dermatologist at Children’s Hospital of Philadelphia.

Widespread, “flaking paint” dermatitis is a common hallmark of nutritional deficiency. Clinical patterns of typical eczema include antecubital fossae, popliteal fossae, and affected areas of the neck. If only the cheeks are involved in teething, the culprit is most likely irritation from drooling. “I call it drool dermatitis,” Dr. Treat said. “Food allergy leading to skin irritation and breakdown of the skin on the face is not the typical pattern of what food allergy does. Food allergy usually leads to more of a type 1 hypersensitivity where you get urticarial lesions or you get waxing, redness, or swelling.”

Food allergies are more common in children with atopic dermatitis, but they may not be the root cause of the atopic dermatitis. Skin prick testing and IgE food testing have excellent negative predictive value but limited positive predictive value, yielding high false-positive rates. “This matters, because we see kids who are labeled allergic to many foods based on large screening panels,” Dr. Treat said. “Some of them may be false positives, and it is difficult to tell for sure without corroborating parental history.” In fact, children can occasionally develop Kwashiorkor (protein deficiency) from parents restricting what they eat based on allergy-testing results if they are not taught to eat a rounded diet that is nutritionally replete while still avoiding their allergens.

If a child presents with eroded and crusted plaques defined by a “heaped-up” border, think zinc deficiency. The plaques can appear in the diaper area but also in the acral and perioral areas, with relative sparing of the upper lip. He used the mnemonic “diaper” in listing clinical clues: diaper, irritability, acral location, photosensitivity, erosive and crusted appearance, and response to topicals that is poor.

The work-up should consist of measuring zinc and alkaline phosphatase levels in the children. If the child is breastfeeding, Dr. Treat recommended checking zinc levels in the breast. “If mom is missing a zinc transporter in her breast, she can actually have normal zinc levels but not get them into breast milk,” he explained. “You can also have a child who’s missing the zinc transporter in their own gut, or you can have kids who are drinking milk a bit early and some of the zinc-binding proteins in the milk bind the zinc so that it doesn’t get absorbed.” Conditions to consider on your differential include cystic fibrosis or fructose/sucrose malabsorption.

“Kids with severe atopic dermatitis may need a little extra zinc,” he said. “We don’t usually replete it by giving them zinc, but we make sure they’re using appropriate formula or breast milk or that they’re taking a multivitamin with a little zinc in it. Anytime you turn the skin over consistently, you often need a lot of zinc.” Mimickers of zinc deficiency include biotinidase deficiency, methylmalonic acidemia, propionic acidemia, maple syrup urine disease, citrullinemia, and ornithine transcarbamylase deficiency.

Dr. Treat reported having no relevant financial disclosures.

LAS VEGAS – Skin manifestations of nutritional deficiencies are likely underrecognized, according to Dr. James Treat.

“If you can recognize them, they’re incredibly satisfying and simple to treat,” he said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. “You don’t have to prescribe medications; you simply have to replete in most cases.”

At-risk populations include children and adolescents on restrictive diets for conditions ranging from autism spectrum disorders to extreme or overdiagnosed food allergy, and eating disorders. “There are also kids with metabolic diseases and genetic defects that can lead to nutritional deficiencies,” said Dr. Treat, a pediatric dermatologist at Children’s Hospital of Philadelphia.

Widespread, “flaking paint” dermatitis is a common hallmark of nutritional deficiency. Clinical patterns of typical eczema include antecubital fossae, popliteal fossae, and affected areas of the neck. If only the cheeks are involved in teething, the culprit is most likely irritation from drooling. “I call it drool dermatitis,” Dr. Treat said. “Food allergy leading to skin irritation and breakdown of the skin on the face is not the typical pattern of what food allergy does. Food allergy usually leads to more of a type 1 hypersensitivity where you get urticarial lesions or you get waxing, redness, or swelling.”

Food allergies are more common in children with atopic dermatitis, but they may not be the root cause of the atopic dermatitis. Skin prick testing and IgE food testing have excellent negative predictive value but limited positive predictive value, yielding high false-positive rates. “This matters, because we see kids who are labeled allergic to many foods based on large screening panels,” Dr. Treat said. “Some of them may be false positives, and it is difficult to tell for sure without corroborating parental history.” In fact, children can occasionally develop Kwashiorkor (protein deficiency) from parents restricting what they eat based on allergy-testing results if they are not taught to eat a rounded diet that is nutritionally replete while still avoiding their allergens.

If a child presents with eroded and crusted plaques defined by a “heaped-up” border, think zinc deficiency. The plaques can appear in the diaper area but also in the acral and perioral areas, with relative sparing of the upper lip. He used the mnemonic “diaper” in listing clinical clues: diaper, irritability, acral location, photosensitivity, erosive and crusted appearance, and response to topicals that is poor.

The work-up should consist of measuring zinc and alkaline phosphatase levels in the children. If the child is breastfeeding, Dr. Treat recommended checking zinc levels in the breast. “If mom is missing a zinc transporter in her breast, she can actually have normal zinc levels but not get them into breast milk,” he explained. “You can also have a child who’s missing the zinc transporter in their own gut, or you can have kids who are drinking milk a bit early and some of the zinc-binding proteins in the milk bind the zinc so that it doesn’t get absorbed.” Conditions to consider on your differential include cystic fibrosis or fructose/sucrose malabsorption.

“Kids with severe atopic dermatitis may need a little extra zinc,” he said. “We don’t usually replete it by giving them zinc, but we make sure they’re using appropriate formula or breast milk or that they’re taking a multivitamin with a little zinc in it. Anytime you turn the skin over consistently, you often need a lot of zinc.” Mimickers of zinc deficiency include biotinidase deficiency, methylmalonic acidemia, propionic acidemia, maple syrup urine disease, citrullinemia, and ornithine transcarbamylase deficiency.

Dr. Treat reported having no relevant financial disclosures.

LAS VEGAS – Skin manifestations of nutritional deficiencies are likely underrecognized, according to Dr. James Treat.

“If you can recognize them, they’re incredibly satisfying and simple to treat,” he said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. “You don’t have to prescribe medications; you simply have to replete in most cases.”

At-risk populations include children and adolescents on restrictive diets for conditions ranging from autism spectrum disorders to extreme or overdiagnosed food allergy, and eating disorders. “There are also kids with metabolic diseases and genetic defects that can lead to nutritional deficiencies,” said Dr. Treat, a pediatric dermatologist at Children’s Hospital of Philadelphia.

Widespread, “flaking paint” dermatitis is a common hallmark of nutritional deficiency. Clinical patterns of typical eczema include antecubital fossae, popliteal fossae, and affected areas of the neck. If only the cheeks are involved in teething, the culprit is most likely irritation from drooling. “I call it drool dermatitis,” Dr. Treat said. “Food allergy leading to skin irritation and breakdown of the skin on the face is not the typical pattern of what food allergy does. Food allergy usually leads to more of a type 1 hypersensitivity where you get urticarial lesions or you get waxing, redness, or swelling.”

Food allergies are more common in children with atopic dermatitis, but they may not be the root cause of the atopic dermatitis. Skin prick testing and IgE food testing have excellent negative predictive value but limited positive predictive value, yielding high false-positive rates. “This matters, because we see kids who are labeled allergic to many foods based on large screening panels,” Dr. Treat said. “Some of them may be false positives, and it is difficult to tell for sure without corroborating parental history.” In fact, children can occasionally develop Kwashiorkor (protein deficiency) from parents restricting what they eat based on allergy-testing results if they are not taught to eat a rounded diet that is nutritionally replete while still avoiding their allergens.

If a child presents with eroded and crusted plaques defined by a “heaped-up” border, think zinc deficiency. The plaques can appear in the diaper area but also in the acral and perioral areas, with relative sparing of the upper lip. He used the mnemonic “diaper” in listing clinical clues: diaper, irritability, acral location, photosensitivity, erosive and crusted appearance, and response to topicals that is poor.

The work-up should consist of measuring zinc and alkaline phosphatase levels in the children. If the child is breastfeeding, Dr. Treat recommended checking zinc levels in the breast. “If mom is missing a zinc transporter in her breast, she can actually have normal zinc levels but not get them into breast milk,” he explained. “You can also have a child who’s missing the zinc transporter in their own gut, or you can have kids who are drinking milk a bit early and some of the zinc-binding proteins in the milk bind the zinc so that it doesn’t get absorbed.” Conditions to consider on your differential include cystic fibrosis or fructose/sucrose malabsorption.

“Kids with severe atopic dermatitis may need a little extra zinc,” he said. “We don’t usually replete it by giving them zinc, but we make sure they’re using appropriate formula or breast milk or that they’re taking a multivitamin with a little zinc in it. Anytime you turn the skin over consistently, you often need a lot of zinc.” Mimickers of zinc deficiency include biotinidase deficiency, methylmalonic acidemia, propionic acidemia, maple syrup urine disease, citrullinemia, and ornithine transcarbamylase deficiency.

Dr. Treat reported having no relevant financial disclosures.

LAS VEGAS – Skin manifestations of nutritional deficiencies are likely underrecognized, according to Dr. James Treat.

“If you can recognize them, they’re incredibly satisfying and simple to treat,” he said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. “You don’t have to prescribe medications; you simply have to replete in most cases.”

At-risk populations include children and adolescents on restrictive diets for conditions ranging from autism spectrum disorders to extreme or overdiagnosed food allergy, and eating disorders. “There are also kids with metabolic diseases and genetic defects that can lead to nutritional deficiencies,” said Dr. Treat, a pediatric dermatologist at Children’s Hospital of Philadelphia.

Widespread, “flaking paint” dermatitis is a common hallmark of nutritional deficiency. Clinical patterns of typical eczema include antecubital fossae, popliteal fossae, and affected areas of the neck. If only the cheeks are involved in teething, the culprit is most likely irritation from drooling. “I call it drool dermatitis,” Dr. Treat said. “Food allergy leading to skin irritation and breakdown of the skin on the face is not the typical pattern of what food allergy does. Food allergy usually leads to more of a type 1 hypersensitivity where you get urticarial lesions or you get waxing, redness, or swelling.”

Food allergies are more common in children with atopic dermatitis, but they may not be the root cause of the atopic dermatitis. Skin prick testing and IgE food testing have excellent negative predictive value but limited positive predictive value, yielding high false-positive rates. “This matters, because we see kids who are labeled allergic to many foods based on large screening panels,” Dr. Treat said. “Some of them may be false positives, and it is difficult to tell for sure without corroborating parental history.” In fact, children can occasionally develop Kwashiorkor (protein deficiency) from parents restricting what they eat based on allergy-testing results if they are not taught to eat a rounded diet that is nutritionally replete while still avoiding their allergens.

If a child presents with eroded and crusted plaques defined by a “heaped-up” border, think zinc deficiency. The plaques can appear in the diaper area but also in the acral and perioral areas, with relative sparing of the upper lip. He used the mnemonic “diaper” in listing clinical clues: diaper, irritability, acral location, photosensitivity, erosive and crusted appearance, and response to topicals that is poor.

The work-up should consist of measuring zinc and alkaline phosphatase levels in the children. If the child is breastfeeding, Dr. Treat recommended checking zinc levels in the breast. “If mom is missing a zinc transporter in her breast, she can actually have normal zinc levels but not get them into breast milk,” he explained. “You can also have a child who’s missing the zinc transporter in their own gut, or you can have kids who are drinking milk a bit early and some of the zinc-binding proteins in the milk bind the zinc so that it doesn’t get absorbed.” Conditions to consider on your differential include cystic fibrosis or fructose/sucrose malabsorption.

“Kids with severe atopic dermatitis may need a little extra zinc,” he said. “We don’t usually replete it by giving them zinc, but we make sure they’re using appropriate formula or breast milk or that they’re taking a multivitamin with a little zinc in it. Anytime you turn the skin over consistently, you often need a lot of zinc.” Mimickers of zinc deficiency include biotinidase deficiency, methylmalonic acidemia, propionic acidemia, maple syrup urine disease, citrullinemia, and ornithine transcarbamylase deficiency.

Dr. Treat reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – Skin manifestations of nutritional deficiencies are likely underrecognized, according to Dr. James Treat.

“If you can recognize them, they’re incredibly satisfying and simple to treat,” he said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. “You don’t have to prescribe medications; you simply have to replete in most cases.”

At-risk populations include children and adolescents on restrictive diets for conditions ranging from autism spectrum disorders to extreme or overdiagnosed food allergy, and eating disorders. “There are also kids with metabolic diseases and genetic defects that can lead to nutritional deficiencies,” said Dr. Treat, a pediatric dermatologist at Children’s Hospital of Philadelphia.

Widespread, “flaking paint” dermatitis is a common hallmark of nutritional deficiency. Clinical patterns of typical eczema include antecubital fossae, popliteal fossae, and affected areas of the neck. If only the cheeks are involved in teething, the culprit is most likely irritation from drooling. “I call it drool dermatitis,” Dr. Treat said. “Food allergy leading to skin irritation and breakdown of the skin on the face is not the typical pattern of what food allergy does. Food allergy usually leads to more of a type 1 hypersensitivity where you get urticarial lesions or you get waxing, redness, or swelling.”

Food allergies are more common in children with atopic dermatitis, but they may not be the root cause of the atopic dermatitis. Skin prick testing and IgE food testing have excellent negative predictive value but limited positive predictive value, yielding high false-positive rates. “This matters, because we see kids who are labeled allergic to many foods based on large screening panels,” Dr. Treat said. “Some of them may be false positives, and it is difficult to tell for sure without corroborating parental history.” In fact, children can occasionally develop Kwashiorkor (protein deficiency) from parents restricting what they eat based on allergy-testing results if they are not taught to eat a rounded diet that is nutritionally replete while still avoiding their allergens.

If a child presents with eroded and crusted plaques defined by a “heaped-up” border, think zinc deficiency. The plaques can appear in the diaper area but also in the acral and perioral areas, with relative sparing of the upper lip. He used the mnemonic “diaper” in listing clinical clues: diaper, irritability, acral location, photosensitivity, erosive and crusted appearance, and response to topicals that is poor.

The work-up should consist of measuring zinc and alkaline phosphatase levels in the children. If the child is breastfeeding, Dr. Treat recommended checking zinc levels in the breast. “If mom is missing a zinc transporter in her breast, she can actually have normal zinc levels but not get them into breast milk,” he explained. “You can also have a child who’s missing the zinc transporter in their own gut, or you can have kids who are drinking milk a bit early and some of the zinc-binding proteins in the milk bind the zinc so that it doesn’t get absorbed.” Conditions to consider on your differential include cystic fibrosis or fructose/sucrose malabsorption.

“Kids with severe atopic dermatitis may need a little extra zinc,” he said. “We don’t usually replete it by giving them zinc, but we make sure they’re using appropriate formula or breast milk or that they’re taking a multivitamin with a little zinc in it. Anytime you turn the skin over consistently, you often need a lot of zinc.” Mimickers of zinc deficiency include biotinidase deficiency, methylmalonic acidemia, propionic acidemia, maple syrup urine disease, citrullinemia, and ornithine transcarbamylase deficiency.

Dr. Treat reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – Skin manifestations of nutritional deficiencies are likely underrecognized, according to Dr. James Treat.

“If you can recognize them, they’re incredibly satisfying and simple to treat,” he said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. “You don’t have to prescribe medications; you simply have to replete in most cases.”

At-risk populations include children and adolescents on restrictive diets for conditions ranging from autism spectrum disorders to extreme or overdiagnosed food allergy, and eating disorders. “There are also kids with metabolic diseases and genetic defects that can lead to nutritional deficiencies,” said Dr. Treat, a pediatric dermatologist at Children’s Hospital of Philadelphia.

Widespread, “flaking paint” dermatitis is a common hallmark of nutritional deficiency. Clinical patterns of typical eczema include antecubital fossae, popliteal fossae, and affected areas of the neck. If only the cheeks are involved in teething, the culprit is most likely irritation from drooling. “I call it drool dermatitis,” Dr. Treat said. “Food allergy leading to skin irritation and breakdown of the skin on the face is not the typical pattern of what food allergy does. Food allergy usually leads to more of a type 1 hypersensitivity where you get urticarial lesions or you get waxing, redness, or swelling.”

Food allergies are more common in children with atopic dermatitis, but they may not be the root cause of the atopic dermatitis. Skin prick testing and IgE food testing have excellent negative predictive value but limited positive predictive value, yielding high false-positive rates. “This matters, because we see kids who are labeled allergic to many foods based on large screening panels,” Dr. Treat said. “Some of them may be false positives, and it is difficult to tell for sure without corroborating parental history.” In fact, children can occasionally develop Kwashiorkor (protein deficiency) from parents restricting what they eat based on allergy-testing results if they are not taught to eat a rounded diet that is nutritionally replete while still avoiding their allergens.

If a child presents with eroded and crusted plaques defined by a “heaped-up” border, think zinc deficiency. The plaques can appear in the diaper area but also in the acral and perioral areas, with relative sparing of the upper lip. He used the mnemonic “diaper” in listing clinical clues: diaper, irritability, acral location, photosensitivity, erosive and crusted appearance, and response to topicals that is poor.

The work-up should consist of measuring zinc and alkaline phosphatase levels in the children. If the child is breastfeeding, Dr. Treat recommended checking zinc levels in the breast. “If mom is missing a zinc transporter in her breast, she can actually have normal zinc levels but not get them into breast milk,” he explained. “You can also have a child who’s missing the zinc transporter in their own gut, or you can have kids who are drinking milk a bit early and some of the zinc-binding proteins in the milk bind the zinc so that it doesn’t get absorbed.” Conditions to consider on your differential include cystic fibrosis or fructose/sucrose malabsorption.

“Kids with severe atopic dermatitis may need a little extra zinc,” he said. “We don’t usually replete it by giving them zinc, but we make sure they’re using appropriate formula or breast milk or that they’re taking a multivitamin with a little zinc in it. Anytime you turn the skin over consistently, you often need a lot of zinc.” Mimickers of zinc deficiency include biotinidase deficiency, methylmalonic acidemia, propionic acidemia, maple syrup urine disease, citrullinemia, and ornithine transcarbamylase deficiency.

Dr. Treat reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – In the clinical opinion of Dr. Andi L. Shane, tuberculin skin testing and interferon gamma release assay diagnostics and surveillance for Mycobacterium tuberculosis infection are game-changers in the ongoing effort to reduce the rates of TB infection nationwide.

“From 1982 to 2013, we’ve had a very nice decline in the number of TB cases. However, we still have quite a bit of work to do,” Dr. Shane said at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

Reported case rates are especially high in California, Nevada, Texas, Florida, New York, Washington, New Jersey, and the District of Columbia. By age group, those under 5 years old and those aged 15-24 years are more likely to be affected.

“It’s really important to identify TB as soon as possible, especially in children,” said Dr. Shane of the department of pediatrics, division of infectious diseases, Emory University, Atlanta. “An interferon gamma release assay (IGRA) or a tuberculin skin test (TST) may be used in situation where assessment for MTB [M. tuberculosis] exposure is indicated. IGRA is preferred in persons who received BCG vaccine and who have low rates of test completion, while TST is preferred for testing of children younger than age 5.”

TB disease in people younger than age 15 years is a marker for transmission of TB, usually from an adult. “So when we identify a case of TB in children, that requires a contact investigation,” she said. “We’re more concerned with children under the age of 5 with TB because they are more likely to have disseminated disease.”

Latent TB means that the patient has been exposed to the disease but that his or her body has been able to control the infection; no systemic manifestations of infection are present. “It’s very important to identify the difference between latent tuberculosis infection (LTBI) and actual tuberculosis disease,” she said. “This is one of the most challenging aspects to explain to families when you’re giving your diagnosis. The reason this is important is that children or adults who have LTBI are not infectious to other people, whereas someone who has pulmonary or laryngeal TB is considered to be an infectious risk to other individuals.”

Dr. Shane went on to discuss limitations of the TST in diagnosing TB. For one, the test may be placed incorrectly, resulting in an inflammatory response or no response, “and there is reader variability,” she said. “The other issue is that the reading needs to occur 48-72 hours after placement of the test. So, if you place it on a Thursday, that means you really are not going to read it at the optimal time unless the child comes to you on a weekend or the test is read by somebody else.”

As an alternative, two IGRAs have been developed that measure how the immune system reacts to MTB. One is QuantiFERON, which is widely used in the United States; the other is the T-SPOT.TB test, which is widely used in Europe. A positive result on either test indicates that there has been interaction with MTB bacteria but it does not differentiate between LTBI and active TB disease.

“A negative IGRA tells you there is no reaction to the test and MTB is not likely, while an indeterminate result is when you’re unable to interpret the result due to low positive [mitogen] or increased negative control [nil] compared to TB response,” Dr. Shane said. “This usually indicates that there’s some problem with the assay itself. It can also indicate that the individual may not have an immune system that can respond to and produce the interferon gamma that’s needed.”

Assessment of IGRA accuracy is challenged by a lack of a standard for the diagnosis of LTBI and active TB, especially in children. “The reason is, we just don’t have a lot of good data from resource-endowed settings,” Dr. Shane explained. “We have good data from areas where TB is prevalent.” According to the Centers for Disease Control and Prevention and the AAP, IGRAs are probably reliable in children over the age of 5 years, but a TST is still recommended in children under the age of 5.

“The nice thing about the IGRAs is that their specificity is much higher” than TSTs, Dr. Shane said. “However, in some cases a TST might be more sensitive for detecting more remote MTB infections than an IGRA, but IGRAs may be better at detecting a recent infection. Like the TST, an IGRA also shows that if you’re infected with TB you have 5-10% chance of developing active TB in your lifetime.”

She also pointed out that a significant amount of blood is required to perform an IGRA. “That might not always be optimal, especially in a young child,” Dr. Shane said. “Low CD4 counts and other immunodeficiencies have also been associated with false-negative TST and indeterminate/false-negative IGRA results.”

For contact investigations, IGRAs offer increased specificity, are completed during a single visit, and their response is not boosted if an additional evaluation is needed 8-10 weeks after exposure. For periodic screening of health care workers, IGRA offers “technical and logistical advantages, and two-step testing is not required,” she said.

If the TST or IGRA is positive, additional diagnostic efforts are needed “to differentiate between LTBI and active MTB,” said Dr. Shane, who recommended the Curry International Tuberculosis Center as a resource for clinicians. “Your clinical history, chest radiography, [and results of] sputum/gastric aspirates will help,” she added.

If the TST or IGRA is negative, “it’s not sufficient to exclude MTB infection. If you have a discordant TST and IGRA result, consider history and epidemiologic risk factors. Treat with clinical suspicion or risk of a poor outcome (those younger than age 5 and those infected with HIV).”

Dr. Shane reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – In the clinical opinion of Dr. Andi L. Shane, tuberculin skin testing and interferon gamma release assay diagnostics and surveillance for Mycobacterium tuberculosis infection are game-changers in the ongoing effort to reduce the rates of TB infection nationwide.

“From 1982 to 2013, we’ve had a very nice decline in the number of TB cases. However, we still have quite a bit of work to do,” Dr. Shane said at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

Reported case rates are especially high in California, Nevada, Texas, Florida, New York, Washington, New Jersey, and the District of Columbia. By age group, those under 5 years old and those aged 15-24 years are more likely to be affected.

“It’s really important to identify TB as soon as possible, especially in children,” said Dr. Shane of the department of pediatrics, division of infectious diseases, Emory University, Atlanta. “An interferon gamma release assay (IGRA) or a tuberculin skin test (TST) may be used in situation where assessment for MTB [M. tuberculosis] exposure is indicated. IGRA is preferred in persons who received BCG vaccine and who have low rates of test completion, while TST is preferred for testing of children younger than age 5.”

TB disease in people younger than age 15 years is a marker for transmission of TB, usually from an adult. “So when we identify a case of TB in children, that requires a contact investigation,” she said. “We’re more concerned with children under the age of 5 with TB because they are more likely to have disseminated disease.”

Latent TB means that the patient has been exposed to the disease but that his or her body has been able to control the infection; no systemic manifestations of infection are present. “It’s very important to identify the difference between latent tuberculosis infection (LTBI) and actual tuberculosis disease,” she said. “This is one of the most challenging aspects to explain to families when you’re giving your diagnosis. The reason this is important is that children or adults who have LTBI are not infectious to other people, whereas someone who has pulmonary or laryngeal TB is considered to be an infectious risk to other individuals.”

Dr. Shane went on to discuss limitations of the TST in diagnosing TB. For one, the test may be placed incorrectly, resulting in an inflammatory response or no response, “and there is reader variability,” she said. “The other issue is that the reading needs to occur 48-72 hours after placement of the test. So, if you place it on a Thursday, that means you really are not going to read it at the optimal time unless the child comes to you on a weekend or the test is read by somebody else.”

As an alternative, two IGRAs have been developed that measure how the immune system reacts to MTB. One is QuantiFERON, which is widely used in the United States; the other is the T-SPOT.TB test, which is widely used in Europe. A positive result on either test indicates that there has been interaction with MTB bacteria but it does not differentiate between LTBI and active TB disease.

“A negative IGRA tells you there is no reaction to the test and MTB is not likely, while an indeterminate result is when you’re unable to interpret the result due to low positive [mitogen] or increased negative control [nil] compared to TB response,” Dr. Shane said. “This usually indicates that there’s some problem with the assay itself. It can also indicate that the individual may not have an immune system that can respond to and produce the interferon gamma that’s needed.”

Assessment of IGRA accuracy is challenged by a lack of a standard for the diagnosis of LTBI and active TB, especially in children. “The reason is, we just don’t have a lot of good data from resource-endowed settings,” Dr. Shane explained. “We have good data from areas where TB is prevalent.” According to the Centers for Disease Control and Prevention and the AAP, IGRAs are probably reliable in children over the age of 5 years, but a TST is still recommended in children under the age of 5.

“The nice thing about the IGRAs is that their specificity is much higher” than TSTs, Dr. Shane said. “However, in some cases a TST might be more sensitive for detecting more remote MTB infections than an IGRA, but IGRAs may be better at detecting a recent infection. Like the TST, an IGRA also shows that if you’re infected with TB you have 5-10% chance of developing active TB in your lifetime.”

She also pointed out that a significant amount of blood is required to perform an IGRA. “That might not always be optimal, especially in a young child,” Dr. Shane said. “Low CD4 counts and other immunodeficiencies have also been associated with false-negative TST and indeterminate/false-negative IGRA results.”

For contact investigations, IGRAs offer increased specificity, are completed during a single visit, and their response is not boosted if an additional evaluation is needed 8-10 weeks after exposure. For periodic screening of health care workers, IGRA offers “technical and logistical advantages, and two-step testing is not required,” she said.

If the TST or IGRA is positive, additional diagnostic efforts are needed “to differentiate between LTBI and active MTB,” said Dr. Shane, who recommended the Curry International Tuberculosis Center as a resource for clinicians. “Your clinical history, chest radiography, [and results of] sputum/gastric aspirates will help,” she added.

If the TST or IGRA is negative, “it’s not sufficient to exclude MTB infection. If you have a discordant TST and IGRA result, consider history and epidemiologic risk factors. Treat with clinical suspicion or risk of a poor outcome (those younger than age 5 and those infected with HIV).”

Dr. Shane reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – In the clinical opinion of Dr. Andi L. Shane, tuberculin skin testing and interferon gamma release assay diagnostics and surveillance for Mycobacterium tuberculosis infection are game-changers in the ongoing effort to reduce the rates of TB infection nationwide.

“From 1982 to 2013, we’ve had a very nice decline in the number of TB cases. However, we still have quite a bit of work to do,” Dr. Shane said at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

Reported case rates are especially high in California, Nevada, Texas, Florida, New York, Washington, New Jersey, and the District of Columbia. By age group, those under 5 years old and those aged 15-24 years are more likely to be affected.

“It’s really important to identify TB as soon as possible, especially in children,” said Dr. Shane of the department of pediatrics, division of infectious diseases, Emory University, Atlanta. “An interferon gamma release assay (IGRA) or a tuberculin skin test (TST) may be used in situation where assessment for MTB [M. tuberculosis] exposure is indicated. IGRA is preferred in persons who received BCG vaccine and who have low rates of test completion, while TST is preferred for testing of children younger than age 5.”

TB disease in people younger than age 15 years is a marker for transmission of TB, usually from an adult. “So when we identify a case of TB in children, that requires a contact investigation,” she said. “We’re more concerned with children under the age of 5 with TB because they are more likely to have disseminated disease.”

Latent TB means that the patient has been exposed to the disease but that his or her body has been able to control the infection; no systemic manifestations of infection are present. “It’s very important to identify the difference between latent tuberculosis infection (LTBI) and actual tuberculosis disease,” she said. “This is one of the most challenging aspects to explain to families when you’re giving your diagnosis. The reason this is important is that children or adults who have LTBI are not infectious to other people, whereas someone who has pulmonary or laryngeal TB is considered to be an infectious risk to other individuals.”

Dr. Shane went on to discuss limitations of the TST in diagnosing TB. For one, the test may be placed incorrectly, resulting in an inflammatory response or no response, “and there is reader variability,” she said. “The other issue is that the reading needs to occur 48-72 hours after placement of the test. So, if you place it on a Thursday, that means you really are not going to read it at the optimal time unless the child comes to you on a weekend or the test is read by somebody else.”

As an alternative, two IGRAs have been developed that measure how the immune system reacts to MTB. One is QuantiFERON, which is widely used in the United States; the other is the T-SPOT.TB test, which is widely used in Europe. A positive result on either test indicates that there has been interaction with MTB bacteria but it does not differentiate between LTBI and active TB disease.

“A negative IGRA tells you there is no reaction to the test and MTB is not likely, while an indeterminate result is when you’re unable to interpret the result due to low positive [mitogen] or increased negative control [nil] compared to TB response,” Dr. Shane said. “This usually indicates that there’s some problem with the assay itself. It can also indicate that the individual may not have an immune system that can respond to and produce the interferon gamma that’s needed.”

Assessment of IGRA accuracy is challenged by a lack of a standard for the diagnosis of LTBI and active TB, especially in children. “The reason is, we just don’t have a lot of good data from resource-endowed settings,” Dr. Shane explained. “We have good data from areas where TB is prevalent.” According to the Centers for Disease Control and Prevention and the AAP, IGRAs are probably reliable in children over the age of 5 years, but a TST is still recommended in children under the age of 5.

“The nice thing about the IGRAs is that their specificity is much higher” than TSTs, Dr. Shane said. “However, in some cases a TST might be more sensitive for detecting more remote MTB infections than an IGRA, but IGRAs may be better at detecting a recent infection. Like the TST, an IGRA also shows that if you’re infected with TB you have 5-10% chance of developing active TB in your lifetime.”

She also pointed out that a significant amount of blood is required to perform an IGRA. “That might not always be optimal, especially in a young child,” Dr. Shane said. “Low CD4 counts and other immunodeficiencies have also been associated with false-negative TST and indeterminate/false-negative IGRA results.”

For contact investigations, IGRAs offer increased specificity, are completed during a single visit, and their response is not boosted if an additional evaluation is needed 8-10 weeks after exposure. For periodic screening of health care workers, IGRA offers “technical and logistical advantages, and two-step testing is not required,” she said.

If the TST or IGRA is positive, additional diagnostic efforts are needed “to differentiate between LTBI and active MTB,” said Dr. Shane, who recommended the Curry International Tuberculosis Center as a resource for clinicians. “Your clinical history, chest radiography, [and results of] sputum/gastric aspirates will help,” she added.

If the TST or IGRA is negative, “it’s not sufficient to exclude MTB infection. If you have a discordant TST and IGRA result, consider history and epidemiologic risk factors. Treat with clinical suspicion or risk of a poor outcome (those younger than age 5 and those infected with HIV).”

Dr. Shane reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – In the clinical opinion of Dr. Andi L. Shane, tuberculin skin testing and interferon gamma release assay diagnostics and surveillance for Mycobacterium tuberculosis infection are game-changers in the ongoing effort to reduce the rates of TB infection nationwide.

“From 1982 to 2013, we’ve had a very nice decline in the number of TB cases. However, we still have quite a bit of work to do,” Dr. Shane said at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

Reported case rates are especially high in California, Nevada, Texas, Florida, New York, Washington, New Jersey, and the District of Columbia. By age group, those under 5 years old and those aged 15-24 years are more likely to be affected.

“It’s really important to identify TB as soon as possible, especially in children,” said Dr. Shane of the department of pediatrics, division of infectious diseases, Emory University, Atlanta. “An interferon gamma release assay (IGRA) or a tuberculin skin test (TST) may be used in situation where assessment for MTB [M. tuberculosis] exposure is indicated. IGRA is preferred in persons who received BCG vaccine and who have low rates of test completion, while TST is preferred for testing of children younger than age 5.”

TB disease in people younger than age 15 years is a marker for transmission of TB, usually from an adult. “So when we identify a case of TB in children, that requires a contact investigation,” she said. “We’re more concerned with children under the age of 5 with TB because they are more likely to have disseminated disease.”

Latent TB means that the patient has been exposed to the disease but that his or her body has been able to control the infection; no systemic manifestations of infection are present. “It’s very important to identify the difference between latent tuberculosis infection (LTBI) and actual tuberculosis disease,” she said. “This is one of the most challenging aspects to explain to families when you’re giving your diagnosis. The reason this is important is that children or adults who have LTBI are not infectious to other people, whereas someone who has pulmonary or laryngeal TB is considered to be an infectious risk to other individuals.”

Dr. Shane went on to discuss limitations of the TST in diagnosing TB. For one, the test may be placed incorrectly, resulting in an inflammatory response or no response, “and there is reader variability,” she said. “The other issue is that the reading needs to occur 48-72 hours after placement of the test. So, if you place it on a Thursday, that means you really are not going to read it at the optimal time unless the child comes to you on a weekend or the test is read by somebody else.”

As an alternative, two IGRAs have been developed that measure how the immune system reacts to MTB. One is QuantiFERON, which is widely used in the United States; the other is the T-SPOT.TB test, which is widely used in Europe. A positive result on either test indicates that there has been interaction with MTB bacteria but it does not differentiate between LTBI and active TB disease.

“A negative IGRA tells you there is no reaction to the test and MTB is not likely, while an indeterminate result is when you’re unable to interpret the result due to low positive [mitogen] or increased negative control [nil] compared to TB response,” Dr. Shane said. “This usually indicates that there’s some problem with the assay itself. It can also indicate that the individual may not have an immune system that can respond to and produce the interferon gamma that’s needed.”

Assessment of IGRA accuracy is challenged by a lack of a standard for the diagnosis of LTBI and active TB, especially in children. “The reason is, we just don’t have a lot of good data from resource-endowed settings,” Dr. Shane explained. “We have good data from areas where TB is prevalent.” According to the Centers for Disease Control and Prevention and the AAP, IGRAs are probably reliable in children over the age of 5 years, but a TST is still recommended in children under the age of 5.

“The nice thing about the IGRAs is that their specificity is much higher” than TSTs, Dr. Shane said. “However, in some cases a TST might be more sensitive for detecting more remote MTB infections than an IGRA, but IGRAs may be better at detecting a recent infection. Like the TST, an IGRA also shows that if you’re infected with TB you have 5-10% chance of developing active TB in your lifetime.”

She also pointed out that a significant amount of blood is required to perform an IGRA. “That might not always be optimal, especially in a young child,” Dr. Shane said. “Low CD4 counts and other immunodeficiencies have also been associated with false-negative TST and indeterminate/false-negative IGRA results.”

For contact investigations, IGRAs offer increased specificity, are completed during a single visit, and their response is not boosted if an additional evaluation is needed 8-10 weeks after exposure. For periodic screening of health care workers, IGRA offers “technical and logistical advantages, and two-step testing is not required,” she said.

If the TST or IGRA is positive, additional diagnostic efforts are needed “to differentiate between LTBI and active MTB,” said Dr. Shane, who recommended the Curry International Tuberculosis Center as a resource for clinicians. “Your clinical history, chest radiography, [and results of] sputum/gastric aspirates will help,” she added.

If the TST or IGRA is negative, “it’s not sufficient to exclude MTB infection. If you have a discordant TST and IGRA result, consider history and epidemiologic risk factors. Treat with clinical suspicion or risk of a poor outcome (those younger than age 5 and those infected with HIV).”

Dr. Shane reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – In the clinical opinion of Dr. Andi L. Shane, tuberculin skin testing and interferon gamma release assay diagnostics and surveillance for Mycobacterium tuberculosis infection are game-changers in the ongoing effort to reduce the rates of TB infection nationwide.

“From 1982 to 2013, we’ve had a very nice decline in the number of TB cases. However, we still have quite a bit of work to do,” Dr. Shane said at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

Reported case rates are especially high in California, Nevada, Texas, Florida, New York, Washington, New Jersey, and the District of Columbia. By age group, those under 5 years old and those aged 15-24 years are more likely to be affected.

“It’s really important to identify TB as soon as possible, especially in children,” said Dr. Shane of the department of pediatrics, division of infectious diseases, Emory University, Atlanta. “An interferon gamma release assay (IGRA) or a tuberculin skin test (TST) may be used in situation where assessment for MTB [M. tuberculosis] exposure is indicated. IGRA is preferred in persons who received BCG vaccine and who have low rates of test completion, while TST is preferred for testing of children younger than age 5.”

TB disease in people younger than age 15 years is a marker for transmission of TB, usually from an adult. “So when we identify a case of TB in children, that requires a contact investigation,” she said. “We’re more concerned with children under the age of 5 with TB because they are more likely to have disseminated disease.”

Latent TB means that the patient has been exposed to the disease but that his or her body has been able to control the infection; no systemic manifestations of infection are present. “It’s very important to identify the difference between latent tuberculosis infection (LTBI) and actual tuberculosis disease,” she said. “This is one of the most challenging aspects to explain to families when you’re giving your diagnosis. The reason this is important is that children or adults who have LTBI are not infectious to other people, whereas someone who has pulmonary or laryngeal TB is considered to be an infectious risk to other individuals.”

Dr. Shane went on to discuss limitations of the TST in diagnosing TB. For one, the test may be placed incorrectly, resulting in an inflammatory response or no response, “and there is reader variability,” she said. “The other issue is that the reading needs to occur 48-72 hours after placement of the test. So, if you place it on a Thursday, that means you really are not going to read it at the optimal time unless the child comes to you on a weekend or the test is read by somebody else.”

As an alternative, two IGRAs have been developed that measure how the immune system reacts to MTB. One is QuantiFERON, which is widely used in the United States; the other is the T-SPOT.TB test, which is widely used in Europe. A positive result on either test indicates that there has been interaction with MTB bacteria but it does not differentiate between LTBI and active TB disease.

“A negative IGRA tells you there is no reaction to the test and MTB is not likely, while an indeterminate result is when you’re unable to interpret the result due to low positive [mitogen] or increased negative control [nil] compared to TB response,” Dr. Shane said. “This usually indicates that there’s some problem with the assay itself. It can also indicate that the individual may not have an immune system that can respond to and produce the interferon gamma that’s needed.”

Assessment of IGRA accuracy is challenged by a lack of a standard for the diagnosis of LTBI and active TB, especially in children. “The reason is, we just don’t have a lot of good data from resource-endowed settings,” Dr. Shane explained. “We have good data from areas where TB is prevalent.” According to the Centers for Disease Control and Prevention and the AAP, IGRAs are probably reliable in children over the age of 5 years, but a TST is still recommended in children under the age of 5.

“The nice thing about the IGRAs is that their specificity is much higher” than TSTs, Dr. Shane said. “However, in some cases a TST might be more sensitive for detecting more remote MTB infections than an IGRA, but IGRAs may be better at detecting a recent infection. Like the TST, an IGRA also shows that if you’re infected with TB you have 5-10% chance of developing active TB in your lifetime.”

She also pointed out that a significant amount of blood is required to perform an IGRA. “That might not always be optimal, especially in a young child,” Dr. Shane said. “Low CD4 counts and other immunodeficiencies have also been associated with false-negative TST and indeterminate/false-negative IGRA results.”

For contact investigations, IGRAs offer increased specificity, are completed during a single visit, and their response is not boosted if an additional evaluation is needed 8-10 weeks after exposure. For periodic screening of health care workers, IGRA offers “technical and logistical advantages, and two-step testing is not required,” she said.

If the TST or IGRA is positive, additional diagnostic efforts are needed “to differentiate between LTBI and active MTB,” said Dr. Shane, who recommended the Curry International Tuberculosis Center as a resource for clinicians. “Your clinical history, chest radiography, [and results of] sputum/gastric aspirates will help,” she added.

If the TST or IGRA is negative, “it’s not sufficient to exclude MTB infection. If you have a discordant TST and IGRA result, consider history and epidemiologic risk factors. Treat with clinical suspicion or risk of a poor outcome (those younger than age 5 and those infected with HIV).”

Dr. Shane reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – In the clinical opinion of Dr. Andi L. Shane, tuberculin skin testing and interferon gamma release assay diagnostics and surveillance for Mycobacterium tuberculosis infection are game-changers in the ongoing effort to reduce the rates of TB infection nationwide.

“From 1982 to 2013, we’ve had a very nice decline in the number of TB cases. However, we still have quite a bit of work to do,” Dr. Shane said at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

Reported case rates are especially high in California, Nevada, Texas, Florida, New York, Washington, New Jersey, and the District of Columbia. By age group, those under 5 years old and those aged 15-24 years are more likely to be affected.

“It’s really important to identify TB as soon as possible, especially in children,” said Dr. Shane of the department of pediatrics, division of infectious diseases, Emory University, Atlanta. “An interferon gamma release assay (IGRA) or a tuberculin skin test (TST) may be used in situation where assessment for MTB [M. tuberculosis] exposure is indicated. IGRA is preferred in persons who received BCG vaccine and who have low rates of test completion, while TST is preferred for testing of children younger than age 5.”

TB disease in people younger than age 15 years is a marker for transmission of TB, usually from an adult. “So when we identify a case of TB in children, that requires a contact investigation,” she said. “We’re more concerned with children under the age of 5 with TB because they are more likely to have disseminated disease.”

Latent TB means that the patient has been exposed to the disease but that his or her body has been able to control the infection; no systemic manifestations of infection are present. “It’s very important to identify the difference between latent tuberculosis infection (LTBI) and actual tuberculosis disease,” she said. “This is one of the most challenging aspects to explain to families when you’re giving your diagnosis. The reason this is important is that children or adults who have LTBI are not infectious to other people, whereas someone who has pulmonary or laryngeal TB is considered to be an infectious risk to other individuals.”

Dr. Shane went on to discuss limitations of the TST in diagnosing TB. For one, the test may be placed incorrectly, resulting in an inflammatory response or no response, “and there is reader variability,” she said. “The other issue is that the reading needs to occur 48-72 hours after placement of the test. So, if you place it on a Thursday, that means you really are not going to read it at the optimal time unless the child comes to you on a weekend or the test is read by somebody else.”

As an alternative, two IGRAs have been developed that measure how the immune system reacts to MTB. One is QuantiFERON, which is widely used in the United States; the other is the T-SPOT.TB test, which is widely used in Europe. A positive result on either test indicates that there has been interaction with MTB bacteria but it does not differentiate between LTBI and active TB disease.

“A negative IGRA tells you there is no reaction to the test and MTB is not likely, while an indeterminate result is when you’re unable to interpret the result due to low positive [mitogen] or increased negative control [nil] compared to TB response,” Dr. Shane said. “This usually indicates that there’s some problem with the assay itself. It can also indicate that the individual may not have an immune system that can respond to and produce the interferon gamma that’s needed.”

Assessment of IGRA accuracy is challenged by a lack of a standard for the diagnosis of LTBI and active TB, especially in children. “The reason is, we just don’t have a lot of good data from resource-endowed settings,” Dr. Shane explained. “We have good data from areas where TB is prevalent.” According to the Centers for Disease Control and Prevention and the AAP, IGRAs are probably reliable in children over the age of 5 years, but a TST is still recommended in children under the age of 5.

“The nice thing about the IGRAs is that their specificity is much higher” than TSTs, Dr. Shane said. “However, in some cases a TST might be more sensitive for detecting more remote MTB infections than an IGRA, but IGRAs may be better at detecting a recent infection. Like the TST, an IGRA also shows that if you’re infected with TB you have 5-10% chance of developing active TB in your lifetime.”

She also pointed out that a significant amount of blood is required to perform an IGRA. “That might not always be optimal, especially in a young child,” Dr. Shane said. “Low CD4 counts and other immunodeficiencies have also been associated with false-negative TST and indeterminate/false-negative IGRA results.”

For contact investigations, IGRAs offer increased specificity, are completed during a single visit, and their response is not boosted if an additional evaluation is needed 8-10 weeks after exposure. For periodic screening of health care workers, IGRA offers “technical and logistical advantages, and two-step testing is not required,” she said.

If the TST or IGRA is positive, additional diagnostic efforts are needed “to differentiate between LTBI and active MTB,” said Dr. Shane, who recommended the Curry International Tuberculosis Center as a resource for clinicians. “Your clinical history, chest radiography, [and results of] sputum/gastric aspirates will help,” she added.

If the TST or IGRA is negative, “it’s not sufficient to exclude MTB infection. If you have a discordant TST and IGRA result, consider history and epidemiologic risk factors. Treat with clinical suspicion or risk of a poor outcome (those younger than age 5 and those infected with HIV).”

Dr. Shane reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – Few conditions worry parents or school nurses more than when a child develops red eye, but how do you as the treating clinician know when to worry?

“Our challenge is to make the right diagnosis, not to worsen the problem, to figure when to refer, and to make that mother who had to take off from work to bring her child into the office – somehow we have to make her happy,” Dr. David B. Granet said at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

Concomitant pain or photophobia typically means that something other than bacterial conjunctivitis is at play, said Dr. Granet, professor of ophthalmology and pediatrics at the University of California, San Diego. “Is there contact lens use?” he asked. “Is there proptosis or a history of trauma or injury? How long has it been going on? Most bacterial and viral infections will eventually go away. Is there a corneal opacity? Is there cellulitis, loss of vision, or herpes simplex virus?”

If parents call in suspecting that their child’s eye has been contaminated with a chemical, instruct them to irrigate the eye before they head to the emergency department, he advised. “Whoever’s answering the phone in your office ought to be able to separate out what’s worrisome and what’s not,” he said. “Like everything else we do, the history matters.”

For children who present to your office, consider “anything that can go wrong to make the eye red,” he continued, including nasolacrimal duct obstruction, adnexal disease, foreign body/trauma, uveitis, neoplasm, structural change, or conjunctivitis. “Has the vision changed? If so, that’s your vital sign for referral,” he said. “It’s generally a better sign to have both eyes involved with redness than just one. One eye involved means herpes simplex virus, uveitis, or trauma. Both eyes involved usually means infective or allergic conjunctivitis.”

The three most common conditions that cause a red or pink eye are allergic, bacterial, and viral conjunctivitis. Allergic conjunctivitis “is not just itching; that’s the symptom,” Dr. Granet said. “You get redness, swelling of the conjunctiva, lid edema, mucous discharge, and tearing. All of these occur when the patient rubs their eye. The best treatment for allergic conjunctivitis is avoidance of the allergen.”

He also recommended that affected children wash their hair before they go to sleep. “If their hair has been catching allergen all day long and they lie down on their pillow and start to roll [their head around in] it, that can cause a reaction,” he said.

Ketotifen fumarate (Zaditor) is an available over-the-counter treatment option, but olopatadine HCl (Pataday) is the most popular prescription written by pediatricians. “If you give any antihistamine, in low doses you start to prevent the release of histamine,” Dr. Granet said. “As the dose increases, you have a catastrophic event and you start to destruct the mast cell.”

Viral conjunctivitis usually affects older children and presents as a unilateral condition, then affects the fellow eye. It may be associated with pharyngitis and preauricular or submandibular adenopathy. Bacterial conjunctivitis, on the other hand, typically affects preschool-aged children, is often bilateral but can be unilateral, and yields mucopurulent discharge with matting. It is not associated with adenopathy, but it may be associated with otitis media, and it’s highly contagious. Topical antibiotic ointment therapy is indicated for bacterial conjunctivitis “not because this is a deadly disease, but because we want to reduce the chance for spread,” Dr. Granet said. “We know that communicable diseases are responsible for loss of 164 million school days each year. Additionally, there is a significant cost to a family when a parent misses work. Finally, if the diagnosis is in doubt, treatment with an antibiotic geared to work within a few days will help identify masquerade diseases early.”

Because of concerns about antibiotic resistance, fluoroquinolones are often the first choice for treating bacterial conjunctivitis. Dr. Granet led a multicenter comparison of moxifloxacin versus polymyxin B sulfate–trimethoprim ophthalmic solution in the speed of clinical efficacy for the treatment of bacterial conjunctivitis (J. Pediatr. Ophthalmol. Strabismus 2008;45:340-9). The investigators found that after day 2 of treatment, clinical cure was achieved by 81% of kids in the moxifloxacin group, compared with 44% of those in the polymyxin B sulfate–trimethoprim group. In addition, only 2.3% of kids in the moxifloxacin group were nonresponders, compared with 19.5% of those in the polymyxin B sulfate–trimethoprim group.

Common treatments for viral conjunctivitis include hygiene-related approaches like hand washing and not sharing towels and glasses. But these only prevent spread and don’t make the disease go away faster. The infection usually resolves in about 2 weeks.

Dr. Granet disclosed that he is a member of the speakers bureau for Alcon Labs and is a consultant for Diopsys.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – Few conditions worry parents or school nurses more than when a child develops red eye, but how do you as the treating clinician know when to worry?

“Our challenge is to make the right diagnosis, not to worsen the problem, to figure when to refer, and to make that mother who had to take off from work to bring her child into the office – somehow we have to make her happy,” Dr. David B. Granet said at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

Concomitant pain or photophobia typically means that something other than bacterial conjunctivitis is at play, said Dr. Granet, professor of ophthalmology and pediatrics at the University of California, San Diego. “Is there contact lens use?” he asked. “Is there proptosis or a history of trauma or injury? How long has it been going on? Most bacterial and viral infections will eventually go away. Is there a corneal opacity? Is there cellulitis, loss of vision, or herpes simplex virus?”

If parents call in suspecting that their child’s eye has been contaminated with a chemical, instruct them to irrigate the eye before they head to the emergency department, he advised. “Whoever’s answering the phone in your office ought to be able to separate out what’s worrisome and what’s not,” he said. “Like everything else we do, the history matters.”

For children who present to your office, consider “anything that can go wrong to make the eye red,” he continued, including nasolacrimal duct obstruction, adnexal disease, foreign body/trauma, uveitis, neoplasm, structural change, or conjunctivitis. “Has the vision changed? If so, that’s your vital sign for referral,” he said. “It’s generally a better sign to have both eyes involved with redness than just one. One eye involved means herpes simplex virus, uveitis, or trauma. Both eyes involved usually means infective or allergic conjunctivitis.”

The three most common conditions that cause a red or pink eye are allergic, bacterial, and viral conjunctivitis. Allergic conjunctivitis “is not just itching; that’s the symptom,” Dr. Granet said. “You get redness, swelling of the conjunctiva, lid edema, mucous discharge, and tearing. All of these occur when the patient rubs their eye. The best treatment for allergic conjunctivitis is avoidance of the allergen.”

He also recommended that affected children wash their hair before they go to sleep. “If their hair has been catching allergen all day long and they lie down on their pillow and start to roll [their head around in] it, that can cause a reaction,” he said.

Ketotifen fumarate (Zaditor) is an available over-the-counter treatment option, but olopatadine HCl (Pataday) is the most popular prescription written by pediatricians. “If you give any antihistamine, in low doses you start to prevent the release of histamine,” Dr. Granet said. “As the dose increases, you have a catastrophic event and you start to destruct the mast cell.”

Viral conjunctivitis usually affects older children and presents as a unilateral condition, then affects the fellow eye. It may be associated with pharyngitis and preauricular or submandibular adenopathy. Bacterial conjunctivitis, on the other hand, typically affects preschool-aged children, is often bilateral but can be unilateral, and yields mucopurulent discharge with matting. It is not associated with adenopathy, but it may be associated with otitis media, and it’s highly contagious. Topical antibiotic ointment therapy is indicated for bacterial conjunctivitis “not because this is a deadly disease, but because we want to reduce the chance for spread,” Dr. Granet said. “We know that communicable diseases are responsible for loss of 164 million school days each year. Additionally, there is a significant cost to a family when a parent misses work. Finally, if the diagnosis is in doubt, treatment with an antibiotic geared to work within a few days will help identify masquerade diseases early.”

Because of concerns about antibiotic resistance, fluoroquinolones are often the first choice for treating bacterial conjunctivitis. Dr. Granet led a multicenter comparison of moxifloxacin versus polymyxin B sulfate–trimethoprim ophthalmic solution in the speed of clinical efficacy for the treatment of bacterial conjunctivitis (J. Pediatr. Ophthalmol. Strabismus 2008;45:340-9). The investigators found that after day 2 of treatment, clinical cure was achieved by 81% of kids in the moxifloxacin group, compared with 44% of those in the polymyxin B sulfate–trimethoprim group. In addition, only 2.3% of kids in the moxifloxacin group were nonresponders, compared with 19.5% of those in the polymyxin B sulfate–trimethoprim group.

Common treatments for viral conjunctivitis include hygiene-related approaches like hand washing and not sharing towels and glasses. But these only prevent spread and don’t make the disease go away faster. The infection usually resolves in about 2 weeks.

Dr. Granet disclosed that he is a member of the speakers bureau for Alcon Labs and is a consultant for Diopsys.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – Few conditions worry parents or school nurses more than when a child develops red eye, but how do you as the treating clinician know when to worry?

“Our challenge is to make the right diagnosis, not to worsen the problem, to figure when to refer, and to make that mother who had to take off from work to bring her child into the office – somehow we have to make her happy,” Dr. David B. Granet said at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

Concomitant pain or photophobia typically means that something other than bacterial conjunctivitis is at play, said Dr. Granet, professor of ophthalmology and pediatrics at the University of California, San Diego. “Is there contact lens use?” he asked. “Is there proptosis or a history of trauma or injury? How long has it been going on? Most bacterial and viral infections will eventually go away. Is there a corneal opacity? Is there cellulitis, loss of vision, or herpes simplex virus?”

If parents call in suspecting that their child’s eye has been contaminated with a chemical, instruct them to irrigate the eye before they head to the emergency department, he advised. “Whoever’s answering the phone in your office ought to be able to separate out what’s worrisome and what’s not,” he said. “Like everything else we do, the history matters.”

For children who present to your office, consider “anything that can go wrong to make the eye red,” he continued, including nasolacrimal duct obstruction, adnexal disease, foreign body/trauma, uveitis, neoplasm, structural change, or conjunctivitis. “Has the vision changed? If so, that’s your vital sign for referral,” he said. “It’s generally a better sign to have both eyes involved with redness than just one. One eye involved means herpes simplex virus, uveitis, or trauma. Both eyes involved usually means infective or allergic conjunctivitis.”

The three most common conditions that cause a red or pink eye are allergic, bacterial, and viral conjunctivitis. Allergic conjunctivitis “is not just itching; that’s the symptom,” Dr. Granet said. “You get redness, swelling of the conjunctiva, lid edema, mucous discharge, and tearing. All of these occur when the patient rubs their eye. The best treatment for allergic conjunctivitis is avoidance of the allergen.”

He also recommended that affected children wash their hair before they go to sleep. “If their hair has been catching allergen all day long and they lie down on their pillow and start to roll [their head around in] it, that can cause a reaction,” he said.

Ketotifen fumarate (Zaditor) is an available over-the-counter treatment option, but olopatadine HCl (Pataday) is the most popular prescription written by pediatricians. “If you give any antihistamine, in low doses you start to prevent the release of histamine,” Dr. Granet said. “As the dose increases, you have a catastrophic event and you start to destruct the mast cell.”

Viral conjunctivitis usually affects older children and presents as a unilateral condition, then affects the fellow eye. It may be associated with pharyngitis and preauricular or submandibular adenopathy. Bacterial conjunctivitis, on the other hand, typically affects preschool-aged children, is often bilateral but can be unilateral, and yields mucopurulent discharge with matting. It is not associated with adenopathy, but it may be associated with otitis media, and it’s highly contagious. Topical antibiotic ointment therapy is indicated for bacterial conjunctivitis “not because this is a deadly disease, but because we want to reduce the chance for spread,” Dr. Granet said. “We know that communicable diseases are responsible for loss of 164 million school days each year. Additionally, there is a significant cost to a family when a parent misses work. Finally, if the diagnosis is in doubt, treatment with an antibiotic geared to work within a few days will help identify masquerade diseases early.”

Because of concerns about antibiotic resistance, fluoroquinolones are often the first choice for treating bacterial conjunctivitis. Dr. Granet led a multicenter comparison of moxifloxacin versus polymyxin B sulfate–trimethoprim ophthalmic solution in the speed of clinical efficacy for the treatment of bacterial conjunctivitis (J. Pediatr. Ophthalmol. Strabismus 2008;45:340-9). The investigators found that after day 2 of treatment, clinical cure was achieved by 81% of kids in the moxifloxacin group, compared with 44% of those in the polymyxin B sulfate–trimethoprim group. In addition, only 2.3% of kids in the moxifloxacin group were nonresponders, compared with 19.5% of those in the polymyxin B sulfate–trimethoprim group.

Common treatments for viral conjunctivitis include hygiene-related approaches like hand washing and not sharing towels and glasses. But these only prevent spread and don’t make the disease go away faster. The infection usually resolves in about 2 weeks.

Dr. Granet disclosed that he is a member of the speakers bureau for Alcon Labs and is a consultant for Diopsys.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – Beware the diagnosis of tendinitis in children and adolescents who present with varying degrees of knee or foot pain.

“If you make the diagnosis of tendinitis, you’re probably wrong,” Dr. Sally S. Harris said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. “Tendinitis rarely occurs in the pediatric and adolescent age group because tendinitis is a degenerative condition. So think of other things, especially apophysitis.”

An apophysis is a secondary center of ossification that contributes to the peripheral prominences around bones, such as around the ankles, elbows, pelvis, and knees: “The bumps, so to speak,” said Dr. Harris, who practices in the departments of sports medicine and pediatrics at Palo Alto (Calif.) Medical Foundation. “It’s a bone-related pain, an inflammation of that softer cartilage turning to bone that isn’t completely formed.”

Osgood-Schlatter disease ranks as the most-common apophysitis injury. This occurs during midpuberty and is marked by a prominent swollen bump on the front of the knee, just below the knee cap, where the patellar tendon attaches to the tibial tubercle, explained Dr. Harris, who founded the AAP section on sports medicine. “It’s a secondary center of ossification that appears at ages 10-12 years and fuses at ages 14-18.” Telltale signs are tenderness with or without swelling at the tibial tubercle that worsens with running, jumping, or impact activities. “If you ask [patients] to extend their knee against the resistance of your hand, you’ll probably reproduce the pain,” she said.

X-rays usually are not required. “You might do it to confirm the presence of an open apophysitis or to rule out other pathology, but other pathology is almost always unheard of at that area.”

Recommended treatment involves decreasing running and jumping activity as needed to keep symptoms manageable, and decreasing inflammation with ice and possibly nonsteroidal anti-inflammatory drugs. Wearing protective knee pads also can help. “Anytime the bump gets hit, kicked, or kneeled on, it will be more irritated,” she said. “Stretching quadriceps and especially hamstrings can help offload this problem.”.

Dr. Harris described the condition as self-limited although it can last 2-3 years. Potential complications considered minor include enlargement of the tibial tubercle, ununited ossicles in the patellar tendon, and avulsion of the tibial tubercle (rare). “Generally, Osgood-Schlatter is a harmless condition that you just want to manage,” she said.

Another common injury is Sinding-Larsen-Johansson syndrome, which is an apophysitis of the inferior pole of the patella that occurs in prepubescent boys and girls. “This is going to be knee pain, but there won’t be anything obvious for you to see or for them to point at,” Dr. Harris said. “You will focus on the inferior pole of the patella and palpate where the patellar tendon attaches to the knee cap. It’s analogous to jumper’s knee in adults.”

Lateral x-rays will reveal a small ossific fragment at the distal portion of the patella. Sinding-Larsen-Johansson disease typically resolves within 1 year. “It rarely interferes with activity; they just need an explanation of what’s going on,” she said.

Severs disease, which occurs in early puberty, is an apophysitis injury that affects the heels of children who participate in soccer and gymnastics. It’s marked by a traction/impact apophysitis at the site of insertion of the Achilles’ tendon at the posterior calcaneus. “At times, it can last for 2-3 years, but it is a self-limited condition,” Dr. Harris said. “Nothing ever bad comes from this other than the ups and downs of the pain. It’s pain at the base of the heel, not the Achilles’ tendon area, but patients will come in and some of them have been told they have Achilles’ tendinitis.”

Telltale signs include pain with heel walking and positive lateral squeeze test of the posterior calcaneus. “That reproduces the symptoms,” she said. “If they’re not symptomatic when you see them in the office, you can ask them to try this test after their next [sports] practice, and this will confirm the diagnosis. X-rays are not needed.”

Treatment involves modifying physical activity to keep symptoms manageable. Insertion of silicone heel cups can help, as can wearing shoes with good padding.

If a child of pubertal age presents with pain localized to the inner side of the arching foot, think tarsal navicular bone apophysitis, which is due to the presence of accessory navicular or open apophysitis. “It doesn’t really matter what the anatomy is; it’s all treated the same way, which is to support pronation with arch support,” Dr. Harris said. “If this doesn’t alleviate symptoms well enough, they need custom orthotics made.”

The final injury Dr. Harris discussed was Iselin’s disease, which is a secondary center of ossification at the site of insertion of the peroneal tendon at the base of the 5th metatarsal. Pain in the region is exacerbated by excessive lateral ankle movement. “On an x-ray, this looks like a small crescent of bone growing that hasn’t completely fused yet,” she said. “It’s often misread as a fracture, but it’s normal development.” Treatment consists of activity modification, icing, and NSAIDs as needed, and an ankle brace to provide lateral ankle support. She described Iselin’s as “harmless and short lived, from 6-10 months at the most.”

Dr. Harris reported having no financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – Beware the diagnosis of tendinitis in children and adolescents who present with varying degrees of knee or foot pain.

“If you make the diagnosis of tendinitis, you’re probably wrong,” Dr. Sally S. Harris said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. “Tendinitis rarely occurs in the pediatric and adolescent age group because tendinitis is a degenerative condition. So think of other things, especially apophysitis.”

An apophysis is a secondary center of ossification that contributes to the peripheral prominences around bones, such as around the ankles, elbows, pelvis, and knees: “The bumps, so to speak,” said Dr. Harris, who practices in the departments of sports medicine and pediatrics at Palo Alto (Calif.) Medical Foundation. “It’s a bone-related pain, an inflammation of that softer cartilage turning to bone that isn’t completely formed.”

Osgood-Schlatter disease ranks as the most-common apophysitis injury. This occurs during midpuberty and is marked by a prominent swollen bump on the front of the knee, just below the knee cap, where the patellar tendon attaches to the tibial tubercle, explained Dr. Harris, who founded the AAP section on sports medicine. “It’s a secondary center of ossification that appears at ages 10-12 years and fuses at ages 14-18.” Telltale signs are tenderness with or without swelling at the tibial tubercle that worsens with running, jumping, or impact activities. “If you ask [patients] to extend their knee against the resistance of your hand, you’ll probably reproduce the pain,” she said.

X-rays usually are not required. “You might do it to confirm the presence of an open apophysitis or to rule out other pathology, but other pathology is almost always unheard of at that area.”

Recommended treatment involves decreasing running and jumping activity as needed to keep symptoms manageable, and decreasing inflammation with ice and possibly nonsteroidal anti-inflammatory drugs. Wearing protective knee pads also can help. “Anytime the bump gets hit, kicked, or kneeled on, it will be more irritated,” she said. “Stretching quadriceps and especially hamstrings can help offload this problem.”.

Dr. Harris described the condition as self-limited although it can last 2-3 years. Potential complications considered minor include enlargement of the tibial tubercle, ununited ossicles in the patellar tendon, and avulsion of the tibial tubercle (rare). “Generally, Osgood-Schlatter is a harmless condition that you just want to manage,” she said.

Another common injury is Sinding-Larsen-Johansson syndrome, which is an apophysitis of the inferior pole of the patella that occurs in prepubescent boys and girls. “This is going to be knee pain, but there won’t be anything obvious for you to see or for them to point at,” Dr. Harris said. “You will focus on the inferior pole of the patella and palpate where the patellar tendon attaches to the knee cap. It’s analogous to jumper’s knee in adults.”

Lateral x-rays will reveal a small ossific fragment at the distal portion of the patella. Sinding-Larsen-Johansson disease typically resolves within 1 year. “It rarely interferes with activity; they just need an explanation of what’s going on,” she said.

Severs disease, which occurs in early puberty, is an apophysitis injury that affects the heels of children who participate in soccer and gymnastics. It’s marked by a traction/impact apophysitis at the site of insertion of the Achilles’ tendon at the posterior calcaneus. “At times, it can last for 2-3 years, but it is a self-limited condition,” Dr. Harris said. “Nothing ever bad comes from this other than the ups and downs of the pain. It’s pain at the base of the heel, not the Achilles’ tendon area, but patients will come in and some of them have been told they have Achilles’ tendinitis.”

Telltale signs include pain with heel walking and positive lateral squeeze test of the posterior calcaneus. “That reproduces the symptoms,” she said. “If they’re not symptomatic when you see them in the office, you can ask them to try this test after their next [sports] practice, and this will confirm the diagnosis. X-rays are not needed.”

Treatment involves modifying physical activity to keep symptoms manageable. Insertion of silicone heel cups can help, as can wearing shoes with good padding.

If a child of pubertal age presents with pain localized to the inner side of the arching foot, think tarsal navicular bone apophysitis, which is due to the presence of accessory navicular or open apophysitis. “It doesn’t really matter what the anatomy is; it’s all treated the same way, which is to support pronation with arch support,” Dr. Harris said. “If this doesn’t alleviate symptoms well enough, they need custom orthotics made.”

The final injury Dr. Harris discussed was Iselin’s disease, which is a secondary center of ossification at the site of insertion of the peroneal tendon at the base of the 5th metatarsal. Pain in the region is exacerbated by excessive lateral ankle movement. “On an x-ray, this looks like a small crescent of bone growing that hasn’t completely fused yet,” she said. “It’s often misread as a fracture, but it’s normal development.” Treatment consists of activity modification, icing, and NSAIDs as needed, and an ankle brace to provide lateral ankle support. She described Iselin’s as “harmless and short lived, from 6-10 months at the most.”

Dr. Harris reported having no financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – Beware the diagnosis of tendinitis in children and adolescents who present with varying degrees of knee or foot pain.

“If you make the diagnosis of tendinitis, you’re probably wrong,” Dr. Sally S. Harris said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. “Tendinitis rarely occurs in the pediatric and adolescent age group because tendinitis is a degenerative condition. So think of other things, especially apophysitis.”

An apophysis is a secondary center of ossification that contributes to the peripheral prominences around bones, such as around the ankles, elbows, pelvis, and knees: “The bumps, so to speak,” said Dr. Harris, who practices in the departments of sports medicine and pediatrics at Palo Alto (Calif.) Medical Foundation. “It’s a bone-related pain, an inflammation of that softer cartilage turning to bone that isn’t completely formed.”

Osgood-Schlatter disease ranks as the most-common apophysitis injury. This occurs during midpuberty and is marked by a prominent swollen bump on the front of the knee, just below the knee cap, where the patellar tendon attaches to the tibial tubercle, explained Dr. Harris, who founded the AAP section on sports medicine. “It’s a secondary center of ossification that appears at ages 10-12 years and fuses at ages 14-18.” Telltale signs are tenderness with or without swelling at the tibial tubercle that worsens with running, jumping, or impact activities. “If you ask [patients] to extend their knee against the resistance of your hand, you’ll probably reproduce the pain,” she said.

X-rays usually are not required. “You might do it to confirm the presence of an open apophysitis or to rule out other pathology, but other pathology is almost always unheard of at that area.”

Recommended treatment involves decreasing running and jumping activity as needed to keep symptoms manageable, and decreasing inflammation with ice and possibly nonsteroidal anti-inflammatory drugs. Wearing protective knee pads also can help. “Anytime the bump gets hit, kicked, or kneeled on, it will be more irritated,” she said. “Stretching quadriceps and especially hamstrings can help offload this problem.”.

Dr. Harris described the condition as self-limited although it can last 2-3 years. Potential complications considered minor include enlargement of the tibial tubercle, ununited ossicles in the patellar tendon, and avulsion of the tibial tubercle (rare). “Generally, Osgood-Schlatter is a harmless condition that you just want to manage,” she said.

Another common injury is Sinding-Larsen-Johansson syndrome, which is an apophysitis of the inferior pole of the patella that occurs in prepubescent boys and girls. “This is going to be knee pain, but there won’t be anything obvious for you to see or for them to point at,” Dr. Harris said. “You will focus on the inferior pole of the patella and palpate where the patellar tendon attaches to the knee cap. It’s analogous to jumper’s knee in adults.”

Lateral x-rays will reveal a small ossific fragment at the distal portion of the patella. Sinding-Larsen-Johansson disease typically resolves within 1 year. “It rarely interferes with activity; they just need an explanation of what’s going on,” she said.

Severs disease, which occurs in early puberty, is an apophysitis injury that affects the heels of children who participate in soccer and gymnastics. It’s marked by a traction/impact apophysitis at the site of insertion of the Achilles’ tendon at the posterior calcaneus. “At times, it can last for 2-3 years, but it is a self-limited condition,” Dr. Harris said. “Nothing ever bad comes from this other than the ups and downs of the pain. It’s pain at the base of the heel, not the Achilles’ tendon area, but patients will come in and some of them have been told they have Achilles’ tendinitis.”

Telltale signs include pain with heel walking and positive lateral squeeze test of the posterior calcaneus. “That reproduces the symptoms,” she said. “If they’re not symptomatic when you see them in the office, you can ask them to try this test after their next [sports] practice, and this will confirm the diagnosis. X-rays are not needed.”

Treatment involves modifying physical activity to keep symptoms manageable. Insertion of silicone heel cups can help, as can wearing shoes with good padding.

If a child of pubertal age presents with pain localized to the inner side of the arching foot, think tarsal navicular bone apophysitis, which is due to the presence of accessory navicular or open apophysitis. “It doesn’t really matter what the anatomy is; it’s all treated the same way, which is to support pronation with arch support,” Dr. Harris said. “If this doesn’t alleviate symptoms well enough, they need custom orthotics made.”

The final injury Dr. Harris discussed was Iselin’s disease, which is a secondary center of ossification at the site of insertion of the peroneal tendon at the base of the 5th metatarsal. Pain in the region is exacerbated by excessive lateral ankle movement. “On an x-ray, this looks like a small crescent of bone growing that hasn’t completely fused yet,” she said. “It’s often misread as a fracture, but it’s normal development.” Treatment consists of activity modification, icing, and NSAIDs as needed, and an ankle brace to provide lateral ankle support. She described Iselin’s as “harmless and short lived, from 6-10 months at the most.”

Dr. Harris reported having no financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – In the opinion of Dr. Sally S. Harris, there are at least three myths associated with strength training by children and adolescents. One is that the practice is dangerous to the immature skeleton.

In fact, strength training is no riskier for injuries than are contact sports, such as soccer, football, and basketball, Dr. Harris said at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

“There’s a theoretical concern than heavy weights are going to injure open growth plates,” she said. “That’s why one of the main restrictions is that kids do sets of multiple repetitions of weights 10-12 times as opposed to maximal lifts – something that you can lift only once. Proper equipment, supervision, and design are important to prevent injury.”

A second myth is that strength training “will somehow bulk you up and you’ll lose flexibility, which is primarily a concern of coaches,” said Dr. Harris, who practices in the departments of sports medicine and pediatrics at Palo Alto (Calif.) Medical Foundation. “This is not true; flexibility is actually improved if you incorporate stretching with a strength-training program.”

A third myth is that no improvement in strength can occur until adolescence. This is false, Dr. Harris said, referring to published studies demonstrating that strength gains of 30%-50% can occur in preadolescence. “Prepubescent children make the same relative strength gains as teenagers and adults do, it’s just that the absolute strength gains are less, because they’re starting with less muscle,” she explained.

General guidelines for weight training prior to skeletal maturity include no one-repetition maximal lifts because of the theoretical risk of overloading growth plates, and no ballistic maneuvers or Olympic-style lifts. “These are the jerky, bouncy things like dead lifts – competitive weight-training maneuvers,” she said. “It’s not recommended that children do competitive strength training although there are young body builders, and there don’t seem to be any medical issues with that.”

Dr. Harris, who founded the AAP section on sports medicine, listed several potential benefits of strength training, including improved self-esteem, cardiovascular fitness, increased bone density, improved lipid profiles, increased lean body mass, possible improved sports performance, and possible injury prevention. However, whether strength training directly translates to improved sports performance is a matter of debate.

“There’s no compelling evidence that’s shown that general sports performance is enhanced, but we do know that if you strengthen the quadriceps, for example, you’ll improve your vertical jump,” Dr. Harris said. “You would think that might correlate to sports that involve jumping, but it’s hard to demonstrate that it enhances sports performance itself.”

According the guidelines from the AAP (Pediatrics 2008;121:835-40), proper strength training involves six to eight exercises, including core musculature and all major muscle groups, done in sets of multiple repetitions, increasing resistance in increments of 5%-10%. The recommended frequency is two to three times per week for 20- to 30-minute sessions over a course of 8 weeks, with 10-minute warm-up and cool-down periods.

Common sense guidelines include the use of proper techniques such as a straight back and slightly flexed extremities, and a spotter for heavy lifts or free weights. “Most of the serious weight-training injuries have occurred in the home setting with kids dropping barbells on their chest using their parents’ equipment,” Dr. Harris. “That’s preventable.” She went on to note that strength-training exercises should be performed in slow, controlled motions in shoes with good traction. Participants should avoid hyperventilation, Valsalva maneuvers, and the use of anabolic steroids or hormone precursors.

Dr. Harris said that parents often ask her if it’s safe for their adolescent to use creatine, a source of protein energy containing glycine, arginine, and methionine. Theoretically, the more creatine available for immediate use in muscles, the more peak power produced, “so there’s potential benefit for short bursts of exercise lasting 30 seconds or less,” she said. “You spare yourself a lactate-generating mechanism, and you have an increase in lean tissue, which allows you to train longer and more intensely.”

Humans produce creatine naturally via the liver and kidneys, but the idea is that if you supply your body with extra creatine, “you’re going to reap benefits that creatine has on generating adenosine triphosphate (ATP),” she said. The creatine “donates its phosphors to adenosine diphosphate (ADP) to make ATP, which is what muscles use for energy. The ATP in a muscle is used for the first 30 seconds of energy, so it’s beneficial for things that last less than 30 seconds like a sprint, a power lift, or a tackle. It’s not helpful for endurance activities.”

Creatine is available in many forms, including as a pill, a chew, a powder, and as an ingredient in energy bars, sports drinks, and chewing gum. “The cellular uptake is enhanced if it’s in a liquid form with glucose in combination,” Dr. Harris said. “Uptake is decreased by caffeine.”

A loading dose of 5 g every 6 hours for 5 days is recommended. This increases creatine stores in muscles by 15%-30% and remains elevated for 2 weeks to 2 months. “That sounds impressive,” Dr. Harris said. “The problem is, most people don’t do a loading dose. There are a lot of GI side effects associated with that, so they just skip to the maintenance dose of 3-6 g per day. But slowly over time creatine decreases despite the supplementation, so you need to have times off, which is why you cycle. You go on for 5-8 weeks and off the 2-4 weeks.”

According to limited surveys of creatine use by high schoolers, 55% don’t know the dose they’re taking, and 23% report taking doses higher than recommended. Moreover, 13%-30% of people who take creatine are nonresponders, “so a lot of people are taking this and it’s no benefit to them,” Dr. Harris said.

Side effects include weight gain from water retention, anecdotal reports of muscle cramps, stiffness, muscle tension injury, dehydration, and heat illness. “The biggest concern is renal function, but we don’t know the long-term effects,” she said. “There are no effects on blood pressure, liver enzymes, electrolytes, uric acid, hematologic parameters, muscle enzymes, and lipid profiles. That’s reassuring.”

Even so, the use of creatine by adolescents hasn’t been formally studied, and its effects on the brain, cardiac muscle, testes, and other creatine-containing tissues is unknown, “so most medical organizations recommend against it, including the AAP and the American College of Sports Medicine,” Dr. Harris said.

Another concern about creatine is that adolescents “may assume that supplements can substitute for proper nutrition or good athletic training,” Dr. Harris said. “Some feel that it’s a slippery slope to the use of steroids and other harmful and banned substances. On the other hand, it’s not banned by any group and it’s not drug- tested because it’s a source of energy in the diet. It’s not an anabolic agent. Some liken it to caffeine; it’s part of the diet so only high levels should be banned.”

Dr. Harris reported having no financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – In the opinion of Dr. Sally S. Harris, there are at least three myths associated with strength training by children and adolescents. One is that the practice is dangerous to the immature skeleton.

In fact, strength training is no riskier for injuries than are contact sports, such as soccer, football, and basketball, Dr. Harris said at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

“There’s a theoretical concern than heavy weights are going to injure open growth plates,” she said. “That’s why one of the main restrictions is that kids do sets of multiple repetitions of weights 10-12 times as opposed to maximal lifts – something that you can lift only once. Proper equipment, supervision, and design are important to prevent injury.”

A second myth is that strength training “will somehow bulk you up and you’ll lose flexibility, which is primarily a concern of coaches,” said Dr. Harris, who practices in the departments of sports medicine and pediatrics at Palo Alto (Calif.) Medical Foundation. “This is not true; flexibility is actually improved if you incorporate stretching with a strength-training program.”

A third myth is that no improvement in strength can occur until adolescence. This is false, Dr. Harris said, referring to published studies demonstrating that strength gains of 30%-50% can occur in preadolescence. “Prepubescent children make the same relative strength gains as teenagers and adults do, it’s just that the absolute strength gains are less, because they’re starting with less muscle,” she explained.

General guidelines for weight training prior to skeletal maturity include no one-repetition maximal lifts because of the theoretical risk of overloading growth plates, and no ballistic maneuvers or Olympic-style lifts. “These are the jerky, bouncy things like dead lifts – competitive weight-training maneuvers,” she said. “It’s not recommended that children do competitive strength training although there are young body builders, and there don’t seem to be any medical issues with that.”

Dr. Harris, who founded the AAP section on sports medicine, listed several potential benefits of strength training, including improved self-esteem, cardiovascular fitness, increased bone density, improved lipid profiles, increased lean body mass, possible improved sports performance, and possible injury prevention. However, whether strength training directly translates to improved sports performance is a matter of debate.

“There’s no compelling evidence that’s shown that general sports performance is enhanced, but we do know that if you strengthen the quadriceps, for example, you’ll improve your vertical jump,” Dr. Harris said. “You would think that might correlate to sports that involve jumping, but it’s hard to demonstrate that it enhances sports performance itself.”

According the guidelines from the AAP (Pediatrics 2008;121:835-40), proper strength training involves six to eight exercises, including core musculature and all major muscle groups, done in sets of multiple repetitions, increasing resistance in increments of 5%-10%. The recommended frequency is two to three times per week for 20- to 30-minute sessions over a course of 8 weeks, with 10-minute warm-up and cool-down periods.

Common sense guidelines include the use of proper techniques such as a straight back and slightly flexed extremities, and a spotter for heavy lifts or free weights. “Most of the serious weight-training injuries have occurred in the home setting with kids dropping barbells on their chest using their parents’ equipment,” Dr. Harris. “That’s preventable.” She went on to note that strength-training exercises should be performed in slow, controlled motions in shoes with good traction. Participants should avoid hyperventilation, Valsalva maneuvers, and the use of anabolic steroids or hormone precursors.

Dr. Harris said that parents often ask her if it’s safe for their adolescent to use creatine, a source of protein energy containing glycine, arginine, and methionine. Theoretically, the more creatine available for immediate use in muscles, the more peak power produced, “so there’s potential benefit for short bursts of exercise lasting 30 seconds or less,” she said. “You spare yourself a lactate-generating mechanism, and you have an increase in lean tissue, which allows you to train longer and more intensely.”

Humans produce creatine naturally via the liver and kidneys, but the idea is that if you supply your body with extra creatine, “you’re going to reap benefits that creatine has on generating adenosine triphosphate (ATP),” she said. The creatine “donates its phosphors to adenosine diphosphate (ADP) to make ATP, which is what muscles use for energy. The ATP in a muscle is used for the first 30 seconds of energy, so it’s beneficial for things that last less than 30 seconds like a sprint, a power lift, or a tackle. It’s not helpful for endurance activities.”

Creatine is available in many forms, including as a pill, a chew, a powder, and as an ingredient in energy bars, sports drinks, and chewing gum. “The cellular uptake is enhanced if it’s in a liquid form with glucose in combination,” Dr. Harris said. “Uptake is decreased by caffeine.”

A loading dose of 5 g every 6 hours for 5 days is recommended. This increases creatine stores in muscles by 15%-30% and remains elevated for 2 weeks to 2 months. “That sounds impressive,” Dr. Harris said. “The problem is, most people don’t do a loading dose. There are a lot of GI side effects associated with that, so they just skip to the maintenance dose of 3-6 g per day. But slowly over time creatine decreases despite the supplementation, so you need to have times off, which is why you cycle. You go on for 5-8 weeks and off the 2-4 weeks.”

According to limited surveys of creatine use by high schoolers, 55% don’t know the dose they’re taking, and 23% report taking doses higher than recommended. Moreover, 13%-30% of people who take creatine are nonresponders, “so a lot of people are taking this and it’s no benefit to them,” Dr. Harris said.

Side effects include weight gain from water retention, anecdotal reports of muscle cramps, stiffness, muscle tension injury, dehydration, and heat illness. “The biggest concern is renal function, but we don’t know the long-term effects,” she said. “There are no effects on blood pressure, liver enzymes, electrolytes, uric acid, hematologic parameters, muscle enzymes, and lipid profiles. That’s reassuring.”

Even so, the use of creatine by adolescents hasn’t been formally studied, and its effects on the brain, cardiac muscle, testes, and other creatine-containing tissues is unknown, “so most medical organizations recommend against it, including the AAP and the American College of Sports Medicine,” Dr. Harris said.

Another concern about creatine is that adolescents “may assume that supplements can substitute for proper nutrition or good athletic training,” Dr. Harris said. “Some feel that it’s a slippery slope to the use of steroids and other harmful and banned substances. On the other hand, it’s not banned by any group and it’s not drug- tested because it’s a source of energy in the diet. It’s not an anabolic agent. Some liken it to caffeine; it’s part of the diet so only high levels should be banned.”

Dr. Harris reported having no financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – In the opinion of Dr. Sally S. Harris, there are at least three myths associated with strength training by children and adolescents. One is that the practice is dangerous to the immature skeleton.

In fact, strength training is no riskier for injuries than are contact sports, such as soccer, football, and basketball, Dr. Harris said at a pediatric update sponsored by the American Academy of Pediatrics California District 9.

“There’s a theoretical concern than heavy weights are going to injure open growth plates,” she said. “That’s why one of the main restrictions is that kids do sets of multiple repetitions of weights 10-12 times as opposed to maximal lifts – something that you can lift only once. Proper equipment, supervision, and design are important to prevent injury.”

A second myth is that strength training “will somehow bulk you up and you’ll lose flexibility, which is primarily a concern of coaches,” said Dr. Harris, who practices in the departments of sports medicine and pediatrics at Palo Alto (Calif.) Medical Foundation. “This is not true; flexibility is actually improved if you incorporate stretching with a strength-training program.”

A third myth is that no improvement in strength can occur until adolescence. This is false, Dr. Harris said, referring to published studies demonstrating that strength gains of 30%-50% can occur in preadolescence. “Prepubescent children make the same relative strength gains as teenagers and adults do, it’s just that the absolute strength gains are less, because they’re starting with less muscle,” she explained.

General guidelines for weight training prior to skeletal maturity include no one-repetition maximal lifts because of the theoretical risk of overloading growth plates, and no ballistic maneuvers or Olympic-style lifts. “These are the jerky, bouncy things like dead lifts – competitive weight-training maneuvers,” she said. “It’s not recommended that children do competitive strength training although there are young body builders, and there don’t seem to be any medical issues with that.”

Dr. Harris, who founded the AAP section on sports medicine, listed several potential benefits of strength training, including improved self-esteem, cardiovascular fitness, increased bone density, improved lipid profiles, increased lean body mass, possible improved sports performance, and possible injury prevention. However, whether strength training directly translates to improved sports performance is a matter of debate.

“There’s no compelling evidence that’s shown that general sports performance is enhanced, but we do know that if you strengthen the quadriceps, for example, you’ll improve your vertical jump,” Dr. Harris said. “You would think that might correlate to sports that involve jumping, but it’s hard to demonstrate that it enhances sports performance itself.”

According the guidelines from the AAP (Pediatrics 2008;121:835-40), proper strength training involves six to eight exercises, including core musculature and all major muscle groups, done in sets of multiple repetitions, increasing resistance in increments of 5%-10%. The recommended frequency is two to three times per week for 20- to 30-minute sessions over a course of 8 weeks, with 10-minute warm-up and cool-down periods.

Common sense guidelines include the use of proper techniques such as a straight back and slightly flexed extremities, and a spotter for heavy lifts or free weights. “Most of the serious weight-training injuries have occurred in the home setting with kids dropping barbells on their chest using their parents’ equipment,” Dr. Harris. “That’s preventable.” She went on to note that strength-training exercises should be performed in slow, controlled motions in shoes with good traction. Participants should avoid hyperventilation, Valsalva maneuvers, and the use of anabolic steroids or hormone precursors.

Dr. Harris said that parents often ask her if it’s safe for their adolescent to use creatine, a source of protein energy containing glycine, arginine, and methionine. Theoretically, the more creatine available for immediate use in muscles, the more peak power produced, “so there’s potential benefit for short bursts of exercise lasting 30 seconds or less,” she said. “You spare yourself a lactate-generating mechanism, and you have an increase in lean tissue, which allows you to train longer and more intensely.”

Humans produce creatine naturally via the liver and kidneys, but the idea is that if you supply your body with extra creatine, “you’re going to reap benefits that creatine has on generating adenosine triphosphate (ATP),” she said. The creatine “donates its phosphors to adenosine diphosphate (ADP) to make ATP, which is what muscles use for energy. The ATP in a muscle is used for the first 30 seconds of energy, so it’s beneficial for things that last less than 30 seconds like a sprint, a power lift, or a tackle. It’s not helpful for endurance activities.”

Creatine is available in many forms, including as a pill, a chew, a powder, and as an ingredient in energy bars, sports drinks, and chewing gum. “The cellular uptake is enhanced if it’s in a liquid form with glucose in combination,” Dr. Harris said. “Uptake is decreased by caffeine.”

A loading dose of 5 g every 6 hours for 5 days is recommended. This increases creatine stores in muscles by 15%-30% and remains elevated for 2 weeks to 2 months. “That sounds impressive,” Dr. Harris said. “The problem is, most people don’t do a loading dose. There are a lot of GI side effects associated with that, so they just skip to the maintenance dose of 3-6 g per day. But slowly over time creatine decreases despite the supplementation, so you need to have times off, which is why you cycle. You go on for 5-8 weeks and off the 2-4 weeks.”

According to limited surveys of creatine use by high schoolers, 55% don’t know the dose they’re taking, and 23% report taking doses higher than recommended. Moreover, 13%-30% of people who take creatine are nonresponders, “so a lot of people are taking this and it’s no benefit to them,” Dr. Harris said.

Side effects include weight gain from water retention, anecdotal reports of muscle cramps, stiffness, muscle tension injury, dehydration, and heat illness. “The biggest concern is renal function, but we don’t know the long-term effects,” she said. “There are no effects on blood pressure, liver enzymes, electrolytes, uric acid, hematologic parameters, muscle enzymes, and lipid profiles. That’s reassuring.”

Even so, the use of creatine by adolescents hasn’t been formally studied, and its effects on the brain, cardiac muscle, testes, and other creatine-containing tissues is unknown, “so most medical organizations recommend against it, including the AAP and the American College of Sports Medicine,” Dr. Harris said.

Another concern about creatine is that adolescents “may assume that supplements can substitute for proper nutrition or good athletic training,” Dr. Harris said. “Some feel that it’s a slippery slope to the use of steroids and other harmful and banned substances. On the other hand, it’s not banned by any group and it’s not drug- tested because it’s a source of energy in the diet. It’s not an anabolic agent. Some liken it to caffeine; it’s part of the diet so only high levels should be banned.”

Dr. Harris reported having no financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – Although molluscum contagiosum is harmless, it can be confused with warts or lesions commonly related to herpes and various types of acne.

“Molluscum contagiosum really is one of the great imitators,” Dr. James Treat said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. “They can be great big cysts, and they can be tiny ditzels; you can barely tell they’re there. They also can be more classic, umbilicated papules.”

Clinicians can make a quick diagnosis by angling an otoscope to the side of the lesion, said Dr. Treat. Once illuminated, “You’ll see this tiny white spicule at the center of the lesion. That’s a great way of diagnosing it.”

Children and adolescents often present with inflamed, painful lesions, prompting concern from parents. In fact, Dr. Treat identified a recent article naming inflamed molluscum lesions as the BOTE sign: the beginning of the end (Pediatrics 2013; 131:e1650-3). “If your spots are getting red, your body knows the virus is there,” he said. “You don’t have to do anything else about it. They’re almost never infected. It’s just like an ingrown hair. It can look like a pus bump; you get inflammation; it’s a little bit painful. They’re usually just inflamed. If you think someone truly has cellulitis, of course, give them antibiotics. But the majority [of lesions] are not infected.”

When in doubt, culture the lesion. “If you grow streptococcus or staphylococcus, then you know you need to treat them,” he said. “If you grow normal skin flora, though, don’t be surprised. That’s what’s most commonly going to happen. It’s similar to acne or an ingrown hair.”

The time course for complete clearance of molluscum is usually 1-2 years. “It’s probably a bit shorter than that, but it’s better to underpromise,” said Dr. Treat, a pediatric dermatologist at Children’s Hospital of Philadelphia.

No Food and Drug Administration–approved treatment options for molluscum exist, Dr. Treat noted. For lesions under the armpit, for example, he often recommends treating associated dermatitis with hydrocortisone and applying moisturizer to the lesions until they resolve, he said. However, most parents want other treatment options, especially if their child competes in wrestling or other contact sports. His preferred treatment is cantharone, also known as “beetle juice.” Clinicians apply the liquid cantharone solution directly to the lesions in the office, and instruct the parents to help the child wash off the solution after 2 hours. The treatment causes blistering and ultimate breakdown of the molluscum.

“Some centers are not allowing clinicians to use cantharone, because it never went through FDA approval,” Dr. Treat said. “I never use it on the face, around the eye, or inside the diaper area. I put a tiny drop on, and instruct them to wash it off after 2 hours.”

Cryotherapy is another option, though Dr. Treat advised caution. “I think you can do it if you have a motivated teenager who wants their five spots gone very quickly, or if you have a young child that has a couple of spots on the cheek and you can hold them very still and freeze very lightly to get those spots to go away,” he said. “I would not perform cryotherapy around the eye. You have to be careful with cryotherapy because it hurts, and you can cause more inflammation than you really expected, or a blister, for something that’s benign and is going to go away on its own. But there’s definitely a role for cryotherapy for a kid who needs to wrestle very soon or get back to sports, or has lesions in areas where you can’t control the cantharone.”

Curettage also may be used, Dr. Treat said, although “it’s not something we commonly do unless you have a very motivated 10-, 12-, or 14-year-old who can stay still, or unless you have a child that has one or two spots located in a difficult area to treat otherwise,” he noted. Topical options include tretinoin. “I don’t think it works very well, but it’s something to do, and it’s been used on the faces of children,” said Dr. Treat. He recommended using a Q-tip swab to apply a pinhead-sized amount of tretinoin to individual lesions. “Try not to treat the skin around it,” he advised. “Your goal is irritation of the lesion; you are trying to irritate the skin to get the immune system to notice the molluscum.” He characterized sinecatechins as “expensive and often irritating” and considers oral cimetidine as a “last-ditch effort” for patients with molluscum lesions all over the body. “It works 20-30% of the time,” he said. “You have to take it two to three times a day, and you have to take it at the high end of the normal dosing range. But there are some data that show that in patients with bad atopic dermatitis who have terrible molluscum, it might work.”

Dr. Treat reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – Although molluscum contagiosum is harmless, it can be confused with warts or lesions commonly related to herpes and various types of acne.

“Molluscum contagiosum really is one of the great imitators,” Dr. James Treat said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. “They can be great big cysts, and they can be tiny ditzels; you can barely tell they’re there. They also can be more classic, umbilicated papules.”

Clinicians can make a quick diagnosis by angling an otoscope to the side of the lesion, said Dr. Treat. Once illuminated, “You’ll see this tiny white spicule at the center of the lesion. That’s a great way of diagnosing it.”

Children and adolescents often present with inflamed, painful lesions, prompting concern from parents. In fact, Dr. Treat identified a recent article naming inflamed molluscum lesions as the BOTE sign: the beginning of the end (Pediatrics 2013; 131:e1650-3). “If your spots are getting red, your body knows the virus is there,” he said. “You don’t have to do anything else about it. They’re almost never infected. It’s just like an ingrown hair. It can look like a pus bump; you get inflammation; it’s a little bit painful. They’re usually just inflamed. If you think someone truly has cellulitis, of course, give them antibiotics. But the majority [of lesions] are not infected.”

When in doubt, culture the lesion. “If you grow streptococcus or staphylococcus, then you know you need to treat them,” he said. “If you grow normal skin flora, though, don’t be surprised. That’s what’s most commonly going to happen. It’s similar to acne or an ingrown hair.”

The time course for complete clearance of molluscum is usually 1-2 years. “It’s probably a bit shorter than that, but it’s better to underpromise,” said Dr. Treat, a pediatric dermatologist at Children’s Hospital of Philadelphia.

No Food and Drug Administration–approved treatment options for molluscum exist, Dr. Treat noted. For lesions under the armpit, for example, he often recommends treating associated dermatitis with hydrocortisone and applying moisturizer to the lesions until they resolve, he said. However, most parents want other treatment options, especially if their child competes in wrestling or other contact sports. His preferred treatment is cantharone, also known as “beetle juice.” Clinicians apply the liquid cantharone solution directly to the lesions in the office, and instruct the parents to help the child wash off the solution after 2 hours. The treatment causes blistering and ultimate breakdown of the molluscum.

“Some centers are not allowing clinicians to use cantharone, because it never went through FDA approval,” Dr. Treat said. “I never use it on the face, around the eye, or inside the diaper area. I put a tiny drop on, and instruct them to wash it off after 2 hours.”

Cryotherapy is another option, though Dr. Treat advised caution. “I think you can do it if you have a motivated teenager who wants their five spots gone very quickly, or if you have a young child that has a couple of spots on the cheek and you can hold them very still and freeze very lightly to get those spots to go away,” he said. “I would not perform cryotherapy around the eye. You have to be careful with cryotherapy because it hurts, and you can cause more inflammation than you really expected, or a blister, for something that’s benign and is going to go away on its own. But there’s definitely a role for cryotherapy for a kid who needs to wrestle very soon or get back to sports, or has lesions in areas where you can’t control the cantharone.”

Curettage also may be used, Dr. Treat said, although “it’s not something we commonly do unless you have a very motivated 10-, 12-, or 14-year-old who can stay still, or unless you have a child that has one or two spots located in a difficult area to treat otherwise,” he noted. Topical options include tretinoin. “I don’t think it works very well, but it’s something to do, and it’s been used on the faces of children,” said Dr. Treat. He recommended using a Q-tip swab to apply a pinhead-sized amount of tretinoin to individual lesions. “Try not to treat the skin around it,” he advised. “Your goal is irritation of the lesion; you are trying to irritate the skin to get the immune system to notice the molluscum.” He characterized sinecatechins as “expensive and often irritating” and considers oral cimetidine as a “last-ditch effort” for patients with molluscum lesions all over the body. “It works 20-30% of the time,” he said. “You have to take it two to three times a day, and you have to take it at the high end of the normal dosing range. But there are some data that show that in patients with bad atopic dermatitis who have terrible molluscum, it might work.”

Dr. Treat reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

LAS VEGAS – Although molluscum contagiosum is harmless, it can be confused with warts or lesions commonly related to herpes and various types of acne.

“Molluscum contagiosum really is one of the great imitators,” Dr. James Treat said at a pediatric update sponsored by the American Academy of Pediatrics California District 9. “They can be great big cysts, and they can be tiny ditzels; you can barely tell they’re there. They also can be more classic, umbilicated papules.”

Clinicians can make a quick diagnosis by angling an otoscope to the side of the lesion, said Dr. Treat. Once illuminated, “You’ll see this tiny white spicule at the center of the lesion. That’s a great way of diagnosing it.”

Children and adolescents often present with inflamed, painful lesions, prompting concern from parents. In fact, Dr. Treat identified a recent article naming inflamed molluscum lesions as the BOTE sign: the beginning of the end (Pediatrics 2013; 131:e1650-3). “If your spots are getting red, your body knows the virus is there,” he said. “You don’t have to do anything else about it. They’re almost never infected. It’s just like an ingrown hair. It can look like a pus bump; you get inflammation; it’s a little bit painful. They’re usually just inflamed. If you think someone truly has cellulitis, of course, give them antibiotics. But the majority [of lesions] are not infected.”

When in doubt, culture the lesion. “If you grow streptococcus or staphylococcus, then you know you need to treat them,” he said. “If you grow normal skin flora, though, don’t be surprised. That’s what’s most commonly going to happen. It’s similar to acne or an ingrown hair.”

The time course for complete clearance of molluscum is usually 1-2 years. “It’s probably a bit shorter than that, but it’s better to underpromise,” said Dr. Treat, a pediatric dermatologist at Children’s Hospital of Philadelphia.

No Food and Drug Administration–approved treatment options for molluscum exist, Dr. Treat noted. For lesions under the armpit, for example, he often recommends treating associated dermatitis with hydrocortisone and applying moisturizer to the lesions until they resolve, he said. However, most parents want other treatment options, especially if their child competes in wrestling or other contact sports. His preferred treatment is cantharone, also known as “beetle juice.” Clinicians apply the liquid cantharone solution directly to the lesions in the office, and instruct the parents to help the child wash off the solution after 2 hours. The treatment causes blistering and ultimate breakdown of the molluscum.

“Some centers are not allowing clinicians to use cantharone, because it never went through FDA approval,” Dr. Treat said. “I never use it on the face, around the eye, or inside the diaper area. I put a tiny drop on, and instruct them to wash it off after 2 hours.”

Cryotherapy is another option, though Dr. Treat advised caution. “I think you can do it if you have a motivated teenager who wants their five spots gone very quickly, or if you have a young child that has a couple of spots on the cheek and you can hold them very still and freeze very lightly to get those spots to go away,” he said. “I would not perform cryotherapy around the eye. You have to be careful with cryotherapy because it hurts, and you can cause more inflammation than you really expected, or a blister, for something that’s benign and is going to go away on its own. But there’s definitely a role for cryotherapy for a kid who needs to wrestle very soon or get back to sports, or has lesions in areas where you can’t control the cantharone.”

Curettage also may be used, Dr. Treat said, although “it’s not something we commonly do unless you have a very motivated 10-, 12-, or 14-year-old who can stay still, or unless you have a child that has one or two spots located in a difficult area to treat otherwise,” he noted. Topical options include tretinoin. “I don’t think it works very well, but it’s something to do, and it’s been used on the faces of children,” said Dr. Treat. He recommended using a Q-tip swab to apply a pinhead-sized amount of tretinoin to individual lesions. “Try not to treat the skin around it,” he advised. “Your goal is irritation of the lesion; you are trying to irritate the skin to get the immune system to notice the molluscum.” He characterized sinecatechins as “expensive and often irritating” and considers oral cimetidine as a “last-ditch effort” for patients with molluscum lesions all over the body. “It works 20-30% of the time,” he said. “You have to take it two to three times a day, and you have to take it at the high end of the normal dosing range. But there are some data that show that in patients with bad atopic dermatitis who have terrible molluscum, it might work.”

Dr. Treat reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk