Houston Area Pediatric Specialists

Independent pediatric specialists aim to serve our community. We want to share news and analysis regarding our specialties and our practices.

Monday, December 2, 2013

Is your child still resting? Caution recommended when treating concussion with cognitive or physical rest

  1. Caution recommended when treating concussion with cognit

    The paper by Halstead et al brings welcomed attention to the medical- academic needs of children with concussion. However, with respect to brain and body "rest", several recommendations for management are presented without a balanced appraisal of conflicting data or solid evidentiary support. We fear that these recommendations, presented as a standard, may contribute both to sub-optimal individual outcomes as well as to counter-productive policies. The authors recommend cognitive and physical rest after concussion. However, there is no evidence that the brain can be "put to rest" volitionally. Rest recommendations are based on conjecture from animal data demonstrating a "metabolic mismatch" in a vulnerable period occurring after brain trauma. Even if human pathophysiology matches lab-models in rodents and even if we had clinical markers of a vulnerable period, it is hard to imagine how "avoiding concentration" could supersede reparative mechanisms of brain recovery. Continuing this line of reasoning of a metabolic vulnerability, should we deprive concussed humans of sleep? REM sleep maintains nearly the same overall metabolic rate as wakefulness (even greater in certain regions such as the cingulate cortex).
    Cognitive rest remains ill-defined from a practical standpoint - a rest "dosage" for activities does not exist. Suddenly, students and families are now being told to avoid exercise, television, texting, and even spicy foods. When there is no evidence that using technology "stresses" the brain more than any other activity, should professionals really be advising parents that their role on a "team" is to enforce this advice? Enforced rest does not appear to improve recovery from many medical and neurologic conditions.1 And, regarding concussion, growing evidence suggests that cognitive rest does not result in hastened recovery.2 Of greater concern, there is evidence that enforced rest may result in deconditioning, and potentially exacerbate or even produce symptoms typically attributed to the post-concussive syndrome itself.3,4 We suggest that the authors are over-cautious when they assert that students should be at their "academic baseline" before a return to activity. Although judgment should be exercised before returning students to high risk physical activities, this recommendation is excessively broad. As noted, there is potential harm in enforcing rest. In practice, we have observed a self-perpetuating cycle: physicians interpret the re- occurrence of post-concussive symptoms to be an indicator of persistent and worsening brain injury and encourage more rest. We applaud the authors' cooperative approach between schools and providers who advocate for rationale accommodations during recovery. Education about concussion and early reassurance appears to reduce the chance of persistent symptoms after mild traumatic brain injury.5 Solid expert advice about the "known" and rational admission of "knowable unknowns" may ease patient and parental anxiety. Consequently, we agree that pediatric specialists should be engaged in prolonged or atypical cases. Appreciating the merits of this statement and its contribution to practice, we join the authors to stress an individualized patient-centered approach to the prescription of cognitive or physical rest.
    1 McLean SA, Clauw DJ. Predicting chronic symptoms after an acute "stressor" - lessons learned from 3 medical conditions. Med Hypotheses. 2004;63:653-658.
    2 Gibson S, Nigrovic LE, O'Brien M, Meehan WP 3rd. The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Inj. 2013;27:839-42.
    3 Silverberg ND, Iverson GL. Is rest after concussion "the best medicine?": recommendations for activity resumption following concussion in athletes, civilians, and military service members. J Head Trauma Rehabil. 2013;28:250-9.
    4 Kirkwood MW, Randolph C, Yeates KO. Sport-related concussion: a call for evidence and perspective amidst the alarms. Clin J Sport Med. 2012;22:383-4.
    5 Ponsford J, Willmott C, Rothwell A, Cameron P, Ayton G, Nelms R, Curran C, Ng K. Impact of early intervention on outcome after mild traumatic brain injury in children. Pediatrics. 2001;108:1297-303.

    Conflict of Interest:

    None declared
  2. ive or physical rest

Tuesday, October 15, 2013

Sixth-grader dies from asthma complications, no school nurse on duty

Sixth-grader dies from asthma complications, no school nurse on duty

The father of sixth-grader Laporshia Massey says that she died from asthma complications that went untreated while she was at Bryant Elementary School in Philadelphia on the afternoon of Sept. 25.
According to Daniel Burch, he rushed Massey to the emergency room as soon as she got home from school, but it wasn’t soon enough. She collapsed in the car on the way to Children’s Hospital of Philadelphia, where she later passed away.
Burch did receive a call from someone who he assumed to be a nurse during the day alerting him that his daughter was feeling ill, but neither he, nor his fianceƩ, Sherri Mitchell, realized the seriousness of the situation.
Whoever called Burch and Mitchell, it wasn’t a nurse. Bryant Elementary School only has a nurse on staff two days a week and Sept. 25 was not one of those days.
Burch believes that a trained professional would have seen the danger. "Why," he asked, "didn’t [the school] take her to the hospital? If she had problems throughout the day, why … didn’t [the school] call me sooner?"
A source within the School District of Philadelphia believes that Laporshia’s life could have been saved. "If they had called rescue, she would still be here today," the source said. "They told her school was almost out, and she’d get out of school and go straight home. She went to the teacher, who told her ‘there’s no nurse' and just to 'be calm.'"
Jerry Jordan, president of the Philadelphia Federation of Teachers, believes the shortage of nurses is dangerous.
"We will never know whether or not having had a full-time nurse in the building would of been able to save her life. But what we do know is that there was not a nurse at the time of her illness to -- based on the training nurses have -- determine whether or not the child was in crisis, and seek medical attention from a hospital," Jordan said.

Read article here.

Wednesday, October 9, 2013


There is NO data to support using marijuana for epilepsy. And its illegal. 

Anecdotes are interesting. 

Observation is the basis for medical progress, after all.  But there is a 13% placebo response rate in epilepsy trials. -  JR

From the AES....


Nearly 3 million people in the United States live with epilepsy, a neurological problem that includes recurring seizures. While 6 in 10 people with epilepsy may respond to medical treatment, over 1 million people live with uncontrolled seizures. Some of these people may be helped by surgery or other non-drug treatments, but for many, no answers have been found yet. People with uncontrolled epilepsy live with the continued risk of seizures, side effects of medication, injuries and other medical problems.
Recently CNN's chief medical correspondent, Dr. Sanjay Gupta, hosted a special report on medical marijuana. One of the families profiled was the Figis of Colorado. Their daughter, Charlotte, lives with Dravet Syndrome – a rare and severe form of epilepsy with seizures that cannot be controlled by medication. Matt and Paige Figi, after many failed treatments, turned to medical marijuana as a potential treatment for their 5-year-old daughter. The Epilepsy Foundation is excited to hear the results for Charlotte were very positive.
The Epilepsy Foundation is open and committed to exploring and advocating for all potential treatment options for epilepsy -- assuming they are proven safe and effective. This includes medical marijuana (cannabis). However, research into medical marijuana and seizure control is not complete. We are in favor of research that evaluates cannabis's effectiveness so as to better inform and help the millions of individuals who live with epilepsy. We need to help the many children and adults with epilepsy who have no other options but to resort to cannabis.
What to do about the medical use of marijuana (cannabis) as a potential treatment for a number of neurologic conditions, including epilepsy, is a hotly debated issue. There are legal issues surrounding its dispensing and prescription, as well as a lack of scientific research on the usefulness and safety of marijuana as a treatment for seizures. Here are four commonly asked questions about this dilemma:
Does marijuana help seizures?
Evidence from laboratory studies, anecdotal reports, and a small clinical study from a number of years ago suggests that cannabidiol, a non-psychoactive compound of cannabis, could potentially be helpful in controlling seizures. However, there are conflicting reports in the literature. So far, no clear, definitive, solid evidence exists to show marijuana helps seizures.
Does marijuana have side effects on seizures?
Marijuana has a number of effects depending on how it is ingested:
  • If smoked, the risk factors associated with smoking apply to marijuana.
  • If one takes marijuana preparations that are not smoked, side effects are similar to ones that would be seen with inhaled varieties of the drug. These include appetite stimulation and memory problems.
  • It is difficult to assess the adverse effects of the drug since there is no controlled amount of the medication that has been studied. Therefore, other side effects could occur that are simply not known yet to practicing physicians.
What are the laws governing medical marijuana?
A number of states in the U.S. have statutes allowing for dispensation and prescription of this substance. However, the federal government also has a law that is contradictory and fundamentally criminalizes its use. Therefore, if physicians choose to follow the state laws on the medical use of marijuana, it does not guarantee that they will be immunized against federal prosecution for prescribing the medication if the federal government were to decide to enforce these laws. Therefore, physicians must be aware of both federal and state laws and the potential implications. A clearer understanding of the laws governing this issue is needed.
Should one pursue medical marijuana if all other medications do not work?
The goal of epilepsy treatment is to stop seizures with minimal or no side effects. There are receptors in the brain for marijuana, otherwise known as cannabinoid receptors, in areas that are commonly known to cause seizures (such as the hippocampus and amygdala). There is very little understanding as to what roles these receptors play in seizures. Given the legal issues, the lack of clarity on side effects, and risks associated with the use of the medication, there are better options one could try for epilepsy before resorting to marijuana.
Perhaps a clinical drug trial for a new medication or alternatively a new device may be more appropriate and—to some degree— a bit safer. For new medicines or devices, there are federal governing agencies monitoring the safety of the compound and/or device.
To date, there is very little to no monitoring of street-based marijuana. Therefore, one takes risks into their own hands and sometimes this can lead to terrible consequences. But since medical marijuana is now legal in many states, suppliers are working hard to develop dependable branded product, even mixes carefully controlled to offer specific percentages of THC or CBD.
The Epilepsy Foundation supports research on the potential antiepileptic effects of CBD or other marijuana.  While there is experimental evidence that CBD can work to stop seizures in animal models and that there are reports that it may be effective in patients with epilepsy, there is a lack of scientific data in humans.  The Epilepsy Foundation urges anyone exploring  epilepsy treatments, as permitted under their state law, to work with their treating physician to make the best decisions for their own care
More about the studies on marijuana and epilepsy:
There are current ongoing trials involving cannabis for epilepsy such as one at NYU which is sponsored by the Epilepsy Foundation.
While there are no studies finding that either marijuana or its active metabolite, tetrahydrocannabinol, may worsen seizures, there is no scientific basis to justify such studies.
One case-controlled study was designed to evaluate illicit drug use and the risk of a first seizure. Investigators concluded that marijuana is protective against the first-time seizure in men but not women.
  • This study compared 308 individuals who had been admitted to a hospital after their first seizure with a control group of 294 patients. The control group was made up of patients who had not had seizures and were admitted for emergency surgery such as appendicitis, etc.
  • Compared to men who did not use marijuana, the odds of a first seizure for men who had used marijuana within 90 days of hospital admission were roughly 3.6 out of 10.
  • The results for women were not statistically significant. Nevertheless, the study was weak, because it did not include measures of health status prior to hospital admission for the patients' serious conditions.
The potential anti-epilepsy activity of marijuana and its metabolites has been investigated, but so far, the data has not been promising.
  • There have been 3 controlled trials in which marijuana substances were given orally to patients who had had generalized grand mal seizures or focal seizures. These studies were small and the largest study involved 12 patients. One study was a double-blind, placebo-controlled trial in which 8 patients with epilepsy were given marijuana in addition to their standard therapy. Another was a double-blind, placebo-controlled trial in which 12 patients with epilepsy were given marijuana along with their standard anti-epileptic therapy, and then a third one was a double-blind, placebo-controlled add-on crossover trial with 10 patients.
  • In two of the studies, marijuana had no effect on seizure frequency; however, in one of the studies, four of eight patients had significant improvement.
  • Two of the studies were never published and one was presented as an abstract. The studies are so small that one cannot make any definite conclusion about the effect of marijuana as a seizure treatment.

Thursday, September 26, 2013

Winter Viruses, Not Asthma, Culprit Behind Sleep-Disordered Breathing in Children

Pediatric sleep medicine includes the practice of evaluating and treating children with sleep related breathing disorders like obstructive sleep apnea.  This disorder, according to new research, may have a seasonal variation that worsens significantly during the virus season.  Dr. Susarla

Winter Viruses, Not Asthma, Culprit Behind Sleep-Disordered Breathing in Children

A new study reveals that during the winter and spring months, viruses alone — not allergies or asthma — can lead to an increased risk for sleepbreathing disorders in children that can impair their mental and physical development.
Over time, sleep-disordered breathing in children can cause stunted growth, heart disease, and neurocognitive problems associated with poor academic performance, impaired language development, and behavioral problems.
Until now, researchers believed that asthma, allergies, and viral respiratory infections, such as the flu, contributed to disorders that affect children’s breathing during sleep.  Now, however, they have found that viruses alone contribute to these breathing problems.
Lead researcher Dr. Riva Tauman and her colleagues at Tel Aviv University say the study has broad implications for the treatment of sleep-breathing disorders in children.
“We knew from research and clinical practice that sleep-disordered breathing in children gets worse during the colder months,” Tauman said. “What we didn’t expect is that the trend has nothing to do with asthma or allergies.”
During the study, researchers statistically analyzed data of more than 2,000 children and adolescents who were referred to the sleep center to be tested for suspected sleep-disordered breathing between 2008 and 2010.
The researchers found that pediatric sleep-disordered breathing is worse in the winter months than in the summer. The seasonal variability is most apparent in children less than five years old, they found.
The researchers also found that wheezing and asthma do not contribute to these problems.  Based on their findings, the researchers speculate that viral respiratory infections — which are more common in younger children during colder months — are the main reason behind the seasonal variability found in pediatric sleep-disordered breathing.
The researchers estimate that seven percent fewer children would have been diagnosed with sleep-disordered breathing if all the tests had been done in the summer.
“Our study suggests that if a child comes into the sleep laboratory in the winter with a mild case, I may consider not treating him. I can assume he will be better in the summer,” said Tauman.
“But if he has only mild symptoms in the summer, I can assume they are more severe in the winter.”

Monday, September 16, 2013

Autism resources


Wrightslaw -- Special Education law website
The Council of Parent Attorneys and Advocates
Disability Rights Texas
The Autism Society of America
The Brain Connection -- Excellent autism resource
Families for Early Autism Treatment
Tony Attwood site -- Excellent information on Asperger's Syndrome.
Future Horizons -- World leader in Autism/Asperger's Syndrome Publications
The National Learning Disabilities Association
The International Dyslexia Association
The Williams Syndrome Association
Children and Adults with Attention Deficit/Hyperactivity Disorder
The Texas Education Agency Special Education Website
The Office of Special Education and Rehabilitative Services
PBIS website. Information on Positive Behavioral Supports
American Music Therapy Association
Travel Training Information
The Texas Organization of Parent Attorneys and Advocates
The law offices of Purcell and Saucedo
The law offices of Dorene Philpot
Focus Initiative:  Assisting individual’s with ASD’S, with social cognitive differences
ASPIE of Houston: Asperger's Syndrome parent-Professional Information exchange

Infant Wheezing Episodes Impact Lungs Later

Having bronchiolitis in infancy, a wheezy illness associated with viral infections, seems to leave its footprint in the lungs for years to come including adulthood.  Dr Susarla

Infant Wheezing Episodes Impact Lungs Later

BARCELONA -- Children who suffer through a bout of bronchiolitis can end up with lungs early in adulthood that look like those of patients with chronic obstructive pulmonary disease (COPD), researchers reported here.
Thirty years after being hospitalized for bronchiolitis when they were younger than 2 years of age, 11% of the patients exhibited lung function that fell below the 0.7 FEV (forced expiratory volume in one second)/FCV (forced vital capacity) ratio that is threshold for the definition of COPD, said Katri Backman, MD, a researcher in pediatrics at Kuopio University Hospital in Finland.
"We found that [about] 30 years after first being hospitalized for bronchiolitis, many of these patients exhibited irreversible airway obstruction -- even though [they] were 28 to 31 years of age," Backman told MedPage Today. She reported her results in a late-breaking poster abstract session at the annual meeting of the European Respiratory Society.
"Irreversible airway obstruction is present 30 years after infantile bronchiolitis for more than 20% of former bronchiolitis patients, suggesting permanent structural changes in airways," Backman said.
Backman and colleagues determined that these patients' airways had been permanently damaged by performing lung function tests before and after administration of bronchodilating medications. But there were no differences in lung function among the bronchiolitis patients, compared with controls or with patients who had been hospitalized with pneumonia in childhood.
"The lack of effect among the bronchiolitis patients of these medicines leads us to believe that the disease has irreversibly damaged their lungs," she said.
In the study, Backman and colleagues identified 83 children hospitalized for bronchiolitis and 44 who were hospitalized for pneumonia at Kuopio University Hospital in 1981-82. All the children in the study were under 2 years of age. "All these children had viral infections in their lungs," she said. "What differentiates bronchiolitis and pneumonia is that the bronchiolitis children have their illness accompanied by this wheezing."
In 2010, the researchers tracked down 47 of the bronchiolitis patients and 22 of the pneumonia patients and compared them with controls who had avoided hospitals as youths. The researchers also recruited 138 healthy, matched controls. All the subjects then underwent multiple lung function tests, such as forced vital capacity, FEV1, the FVC-FEV-1ratio and the FVC/FEV1-ratio % of predicted (FEV%).
They found irreversible airway obstruction that could be considered COPD in five of the bronchiolitis patients (P=0.012); in one of the pneumonia patients (P=0.360), and in two of the controls. "I think that if we had more pneumonia patients, then that number would be statistically significant too. These are both serious diseases in infancy."
Irreversible airway obstruction -- defined as an FEV % of less than 88% -- was observed in 21% of bronchiolitis patients (P=0.001); in 9% of pneumonia patients (P=0.247), and in 4% of controls.
Backman said making comparisons between the bronchiolitis patients and pneumonia patients was difficult because there were few pneumonia patients.
"These findings are similar to what we are finding in our children," Guilia Cangiano, MD, resident in pediatrics at Sapienza University in Rome, told MedPage Today. "Our children have reached the age of 6 and we are seeing these kinds of long-term problems." She did not participate in Backman's study.

Saturday, September 7, 2013

Non-pharmacological sleep interventions for youth with chronic health conditions

In children with chronic health problems, sleep problems are common, UNRECOGNIZED by most professionals and have a negative IMPACT on recovery.

Many sleep problems can  treatable with non-pharmacologic means. 

Bottom line: If your child has a sleep problem, parents should seek the help of a SPECIALIST (e.g neurologist or pulmonologist) who is knowledgeable in sleep disorders to maximize treatment and recovery. 


Non-pharmacological sleep interventions for youth with chronic health conditions: A critical review of the methodological quality of the evidence
July 2013, Vol. 35, No. 15 , Pages 1221-1255 (doi:10.3109/09638288.2012.723788)

1Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta,
Edmonton, Alberta
2Department of Public Health, Faculty of Professional Education, Concordia University College of Alberta
Correspondence: Cary A. Brown, FHEA, PhD, Associate Professor, Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta,
Edmonton, Alberta
Canada. T6G 2G4. Tel: (780) 492–9545. Fax: (780) 492–4628. E-mail: 

Purpose: Restorative sleep is clearly linked with well-being in youth with chronic health conditions. This review addresses the methodological quality of non-pharmacological sleep intervention (NPSI) research for youth with chronic health conditions. Method: The Guidelines for Critical Review (GCR) and the Effective Public Health Practice Project Quality Assessment Tool (EPHPP) were used in the review. Results: The search yielded 31 behavioural and 10 non-behavioural NPSI for review. Most studies had less than 10 participants. Autism spectrum disorders, attention deficit/hyperactivity disorders, down syndrome, intellectual disabilities, and visual impairments were the conditions that most studies focused upon. The global EPHPP scores indicated most reviewed studies were of weak quality. Only 7 studies were rated as moderate, none were strong. Studies rated as weak quality frequently had recruitment issues; non-blinded participants/parents and/or researchers; and used outcome measures without sound psychometric properties. Conclusions: Little conclusive evidence exists for NPSIs in this population. However, NPSIs are widely used and these preliminary studies demonstrate promising outcomes. There have not been any published reports of negative outcomes that would preclude application of the different NPSIs on a case-by-case basis guided by clinical judgement. These findings support the need for more rigorous, applied research.
Implications for Rehabilitation
  • Methodological Quality of Sleep Research
  • Disordered sleep (DS) in youth with chronic health conditions is pervasive and is important to rehabilitation therapists because DS contributes to significant functional problems across psychological, physical and emotional domains.
  • Rehabilitation therapists and other healthcare providers receive little education about disordered sleep and are largely unaware of the range of assessment and non-pharmacological intervention strategies that exist. 
    An evidence-based website of pediatric sleep resources can be found at http://www.SleepRight.ualberta.ca
The current research on non-pharmacological sleep interventions (NPSI) for youth with health conditions is methodologically weak. 

However, consistently positive outcomes reported in the literature demonstrate that pragmatic interventions such as:
  •  bright light therapy, 
  • activity, 
  • massage and 
  • behavioral interventions are promising areas. 

  • No studies found reasons that a trail of a NPSI matched to the youth’s context and condition should not attempted. More rigorous clinically relevant study of pragmatic non-pharmacological interventions appropriate for therapists’ and parents’ needs is required.

Read More: http://informahealthcare.com/doi/abs/10.3109/09638288.2012.723788

Thursday, August 22, 2013

New Biomarkers for Asthma on the Horizon

A biomarker is any measurable substance used to measure the state or presence of a disease.  A typical source for such a test might be a patient's blood or urine.  For asthma, markers of disease are being measured in exhaled breath condensate, which is the air you breathe out into a specialized collection device.  One known biomarker in asthma is exhaled nitric oxide, which can easily be measured in the doctor's office.  Other markers are being researched for use in the future. Dr. Susarla

Asymmetric Dimethylarginine in Exhaled Breath Condensate and Serum of Children With Asthma

Background:  Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor and uncoupler of nitric oxide synthase. By promoting the formation of peroxynitrite, ADMA is believed to contribute to several aspects of asthma pathogenesis (ie, airway inflammation, oxidative stress, bronchial hyperresponsiveness, and collagen deposition). The aim of the present study was to compare this mediator in healthy children and children with asthma using the completely noninvasive exhaled breath condensate (EBC) technique.
Methods:  We recruited 77 children with asthma (5-16 years of age) and 65 healthy children (5-15 years of age) who underwent EBC collection and spirometry. Serum ADMA levels and fractional exhaled nitric oxide levels were measured on the same day in a subgroup of children with asthma. EBC was collected using the Turbo-Deccs (Medivac). ADMA levels were measured using the ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) technique.
Results:  ADMA could be detected in the EBC of 71 subjects with asthma and 64 healthy subjects. ADMA levels in the EBC of children with asthma were significantly higher than in the healthy control subjects (median, 0.12 [interquartile range, 0.05-0.3] vs 0.07 [0.05-0.12]; P = .017), whereas no difference emerged between the children with asthma who were or were not receiving inhaled steroid treatment. No correlation was found between serum and EBC ADMA levels (P > .5).
Conclusions:  We measured ADMA in EBC by UPLC-MS/MS, a reference analytical technique. Higher ADMA levels were found in children with asthma, supporting a role for this mediator in asthma pathogenesis. This oxidative stress-related mediator also seems to be scarcely affected by steroid therapy. We speculate that ADMA might be a target for new therapeutic strategies designed to control oxidative stress in asthma.

Tuesday, August 20, 2013

Houston Area Seizure Action Plans for Children With Epilepsy

Make sure your child has an action plan...please contact me with a link if I missed your school. 

As a child neurologist / specialist in epilepsy, I fill out may of these forms.  Schools should be aware and prepared. JR

Selected Houston Area Seizure ACTION Plans for Schools

Houston ISD Seizure and Asthma action Plans

Katy ISD
Fort Bend ISD ( Sugar Land, Stafford ) Seizure, Asthma and Allergy ACTION PLAN

Spring Branch ISD ACTION PLAN for seizures, asthma, allergies & Diabetes

Conroe ISD ( The Woodlands)  Seizure information form 

Lamar Consolidated ISD ( Richmond Rosenberg Fulshear Pleak Greatwood Weston Lakes Simonton ) ACTION PLAN

Generic Forms from the EPILEPSY FOUNDATION

Wednesday, August 14, 2013

Children With Allergy, Asthma May Be at Higher Risk for ADHD

Why might this be? Children with allergies and asthma are known to have elevated risk of sleep disturbance, which could manifest with snoring in those with allergies, increased cough and respiratory symptoms during sleep for poorly controlled asthma. And finally, poor sleep quality can lead to symptoms of ADHD. Dr. Susarla

Children With Allergy, Asthma May Be at Higher Risk for ADHD

 The number of children being diagnosed with attention-deficit disorder (ADHD), allergy and asthma is increasing in the United States. And according to a new study, there might be a link between the growth of these three conditions.

The study, published in the August issue of Annals of Allergy, Asthma & Immunology, the scientific journal of the American College of Allergy, Asthma and Immunology (ACAAI), found there is an increased risk of ADHD in boys that have a history of allergy or asthma.
"ADHD, a chronic mental health disorder, is most commonly found in males, while asthma is also more common in young boys than girls," said Eelko Hak, lead study author. "We found there is an increased risk of ADHD in boys with a history of asthma and an even stronger risk associated with milk intolerance."
Researchers in the Netherlands and Boston studied 884 boys with ADHD and 3,536 boys without the disorder. Of the children with ADHD, 34 percent had asthma and 35 percent had an allergic disorder. The study suggests medications used to treat these conditions may be associated with an increased ADHD risk.
"Further research is needed to understand why there appears to be an increased risk of developing ADHD in children with allergy and asthma," said Gailen Marshall, MD, editor-in-chief of Annals of Allergy, Asthma & Immunology. "Medications for these conditions far outweigh the risks, and can be life-saving in some conditions. Treatment should not be stopped, unless advised by a board-certified allergist."
According to the ACAAI, allergy and asthma often run in families. If both parents have an allergy a child has a 75 percent chance of being allergic. If neither parent has allergy, the chance of a child developing an allergy is only 10 to 15 percent. Allergists also know allergies and asthma are linked. An estimated 60 to 80 percent of children with asthma also have an allergy. While the cause of ADHD is unknown, this disorder is also thought to run in families

Monday, August 12, 2013

Really? Breathing Exercises Can Relieve Asthma

There is undoubtedly a role for non-pharmacologic treatment of asthma and other kinds of respiratory disorders.  While they may not replace medication per se, a well conditioned, exercised lung probably manages inflammation and other forms of impairment better than an under utilized, poorly conditioned lung. Dr. Susarla

Really? Breathing Exercises Can Relieve Asthma

Breathing exercises are among the most popular alternative therapies for asthmatics. But do they work?
According to a recent report by the Agency for Healthcare Research and Quality, the answer depends on the technique. Some appear effective in reducing asthma severity, but there is little evidence to support others.
In the exhaustive, 219-page report, researchers examined 22 randomized studies of breathing techniques. Among the most common are hyperventilation-reduction techniques like the Buteyko method, which instructs asthmatics to breathe shallowly and slowly through the nose when short of breath. The report also looked at yoga breathing exercises and so-called inspiratory-muscle training, which involves exercises and devices that make inhaling more difficult in order to strengthen muscles.
The researchers found the most robust body of evidence supported hyperventilation-reduction breathing techniques, which achieved “medium to large improvements in asthma symptoms and reductions in reliever medication use of approximately 1.5 to 2.5 puffs per day.”
Looking at inspiratory training approaches, the researchers could not find enough credible research to draw any firm conclusions. They did find some evidence for yoga exercises, which typically require deep breaths — usually through the nose — with extended exhalation. But most of the evidence came from studies in India, where yoga exercises are more intensive and frequent than in the United States.
Still, the authors said, “Patients with asthma who are students of yoga and willing to undertake intensive training may find benefits of asthma-targeted practice with a trained yoga practitioner.”
Breathing exercises may help relieve asthma, though the efficacy varies.

Effects of Exercise Training on Airway Hyperreactivity in Asthma: A Systematic Review and Meta-Analysis.



Although physical exercise is recommended for asthmatics, evidence on the effects of exercise on clinical key factors is still missing.


We performed a systematic review and meta-analysis to determine the effect of exercise training (EXT) on quality of life (QoL), bronchial hyperresponsiveness (BHR), exercise-induced bronchoconstriction (EIB), lung function and exercise capacity, plus the factors affecting changes in QoL and exercise capacity in asthmatics after a period of EXT.


A computerized search was conducted in MEDLINE, EMBASE, and CINAHL (last search on 15 November 2012), without language restriction, and references of original studies and reviews were searched for further relevant studies.


Two independent investigators screened full-text studies with asthmatic subjects undertaking EXT (defined as training for ≥7 days, ≥2 times per week, ≥5 training sessions in total) that assessed at least one of the following outcomes: QoL, airway hyperreactivity, forced expiratory volume in one second (FEV1), peak expiratory flow (PEF), inflammatory parameters, exercise capacity, or exercise endurance. Potentially relevant studies were excluded if only respiratory muscle training, breathing exercises or yoga was performed, if asthmatic subjects with co-morbidities were investigated, if only data of mixed patient groups without separate results for asthmatics were presented, if training regimens were not sufficiently specified, if no numerical outcome data were presented, and if new long-term medication was introduced in addition to physical training. Of 500 potentially relevant articles, 13.4 % (67 studies including 2,059 subjects) met the eligibility criteria and were included for further analyses.


Data extraction and risk of bias assessment was performed according to the Cochrane Handbook for Systematic Reviews of Interventions. A meta-analysis of all randomized controlled trials (RCTs) was performed to determine the effect of EXT on asthma symptoms, BHR, EIB, FEV1, exercise capacity and exercise endurance compared with control training. In addition, relative pre/post changes were analysed in all RCTs and controlled trials. Finally, multiple linear regression models were used to identify effects of relative changes in airway hyperreactivity (BHR or EIB), lung function (FEV1 or PEF) and training hours on QoL and exercise performance.


In a total of 17 studies including 599 subjects, meta-analyses showed a significant improvement in days without asthma symptoms, FEV1and exercise capacity while BHR only tended to improve. The analysis of relative within-group changes after EXT showed, however, significant improvements in QoL (17 %), BHR (53 %), EIB (9 %), and FEV1 (3 %) compared with control conditions. Multiple linear regression models revealed that changes in airway hyperreactivity and lung function significantly contributed to the change in QoL, while mainly the changes in airway hyperreactivity contributed to the change in exercise capacity.


EXT was shown to improve asthma symptoms, QoL, exercise capacity, BHR, EIB, and FEV1 in asthmatics and improvements in BHR explained part of the improvement in QoL and exercise capacity. Thus, physical activity should be recommended as a supplementary therapy to medication. However, more well controlled studies should be performed assessing the relationship of physical activity, QoL, airway hyperreactivity, lung function and especially airway inflammation as well as medication intake.