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.

Thursday, December 25, 2014

Enriched environments could heal brain injuries - An argument against brain rest?

Hmm...perhaps "brain rest" is not a good idea. - JR

Enriched environments could heal brain injuries

One of the greatest risks in contact sports such as boxing and football is a violent blow to the head, which can cause mild to severe traumatic brain injury leading to debilitating and even fatal consequences. And despite great strides made in recent years in the area of brain science, there still aren’t any effective medical or cognitive treatments for patients with this type of injury.
But a new Israeli study points to an “enriched environment” — specially enhanced surroundings — as a promising path for the rehabilitation of mild traumatic brain injury (mTBI) patients.
The research study using a model of mTBI in mice, published in Behavioural Brain Research...

The scientists put one group of the mice into standard cages, while they moved a second group to larger cages outfitted with additional stimuli, running wheels, food and water.
Using the Novel Object Recognition task, in which mice exhibit different levels of curiosity about new objects placed in their cages and run different mazes to establish navigation abilities, the researchers looked at differences in the mice’s level of functioning in each of the environments.
Results of their behavioral and cognitive evaluation showed that the mice exposed to the enriched environment showed a marked improvement in recovery from brain injuries.

Hidden effects of brain injury
Pick emphasized that the consequences of traumatic brain injury can remain hidden for years after the trauma, but they eventually will surface. These can include various degrees of amnesia, difficulty concentrating, depression, apathy, anxiety and even a prominent personality change.
“A house may survive an earthquake, but up close you will see cracks in the walls. This is what may happen following traumatic brain injury,” said Pick.

“An MRI might determine that the brain looks normal, but fast forward two years and the patient, who was married and successful, is suddenly unemployed, divorced, and miserable — without any awareness or understanding that new and lasting cognitive and emotional difficulties emerged due to a car accident two years earlier.”

When a patient comes to the emergency room following a blow to the head, doctors generally use the Glasgow Coma Scale to assess the extent of brain trauma, he explained.
“In the majority of cases, doctors determine minimal damage according to the symptoms that appear over a very short period of monitoring — just 30 minutes. In 85 percent of cases, this is accurate, but in 15% of cases, a cascade of serious damage has just begun, and we don’t really know why. But this is what we are trying to figure out.”

If the phenomenon they saw in mice translates to humans, the Israeli study may encourage the use of some kind of enriched environment to minimize this long-term damage.

“We have shown that just six weeks in an enriched environment can help animals recover from cognitive dysfunctions after traumatic brain injury,” Pick said.

“Possible clinical implications indicate the importance of adapting elements of enriched environments to humans, such as prolonged and intensive physical activity, possibly combined with intensive cognitive stimulation. Through proper exercise, stimuli and diet, we can improve a patient’s condition. No one is promising a cure, but now we have evidence that this can help.”


Friday, September 12, 2014

Biologic Eases Subset of Severe Asthma

For severe eosinophilic asthma, the novel monoclonal antibody mepolizumab cut exacerbations whether given as an injection or infusion and reduced steroid use in patients dependent on them, two trials showed.
The drug, which targets interleukin-5 (IL-5) to inhibit eosinophilic inflammation,cut exacerbations by 47% with intravenous dosing and by 53% with subcutaneous dosing when compared with placebo (0.93 and 0.81 versus 1.75 per year, both P<0.001), Hector G. Ortega, MD, ScD, of GlaxoSmithKline, found in the MENSA trial.
Mepolizumab injections more than doubled the likelihood of glucocorticoid dose strata reduction compared with placebo, with a median 50% dose reduction from baseline versus none with placebo (P=0.007), Elisabeth H. Bel, MD, PhD, of the University of Amsterdam, and colleagues found in a second study, dubbed SIRIUS. Investigators in both trials said that safety issues with the drug were no different from placebo.
Both trials were reported online in the New England Journal of Medicine in conjunction with presentation at the European Respiratory Society meeting in Munich.
Three prior trials had already shown that anti-IL-5 drugs helped in asthma cases targeted by sputum eosinophil levels, Parameswaran Nair, MD, PhD, of McMaster University in Hamilton, Ontario, noted in an accompanying editorial.
The two new trials provided some clinical observations with "important practical applications," though, he wrote.
"First, the subcutaneous administration of a lower dose of the drug (100 mg) than was previously reported was shown to be efficacious," he noted.
"Second, characterization of the eosinophilic phenotype on the basis of a blood eosinophil count of more than 300 cells per microliter despite concurrent treatment with high doses of glucocorticoids was sufficient to select patients who were likely to have a response to this therapy.
"Both these observations make it potentially simple and easy for practitioners to identify patients who are likely to benefit and administer the drug to them."
Some previous studies that had tried to identify candidates for treatment based on clinical characteristics alone had failed.
Sputum eosinophil counts have been used since, but their greater sensitivity to change than blood eosinophil levels comes at a cost in convenience.
"Although persistent blood eosinophilia may be sufficient to identify patients who are likely to have a response to this treatment, whether this biomarker is sufficient or is as effective as airway eosinophilia in monitoring the response to treatment remains to be seen," Nair pointed out.

Singulair Doesn't Ease Wheeze in Most Kids

Intermittent montelukast (Singulair) didn't alleviate wheezing in children, except possibly for those with a specific genetic mutation, a trial showed.
Giving the leukotriene receptor blocker at the onset of wheezing didn't cut down on unscheduled medical visits for those episodes compared with placebo (mean 2.0 versus 2.3 over 12 months, incidence rate ratio 0.88, P=0.06), Jonathan Grigg, MD, of the Queen Mary University of London, and colleagues found.
However, the subgroup of children with the 5/5 ALOX5 promoter genotype associated with montelukast response in adults did have a 20% relative reduction in unscheduled wheeze-related medical visits with the drug (2.0 versus 2.4 over 12 months, P=0.01).
No effect was seen with other genotypes (P=0.79), the researchers reported at the European Respiratory Society meeting in Munich and simultaneously online in the Lancet Respiratory Medicine.
"These data do not support the routine use of intermittent montelukast for wheeze in children aged 10 months to 5 years," the group concluded. "Further data from stratified trials are needed before treatment is targeted to a responsive subgroup."
Their Wheeze And Intermittent Treatment (WAIT) trial included 1,358 children in the age range of 10 months to 5 years, who were seen at 21 primary care sites and 41 secondary care sites in England and Scotland. They had two or more wheeze episodes (at least one recent).
After stratification by genotype, the kids were randomized to montelukast or placebo given by parents at each wheeze episode over a 12-month period.
Overall, montelukast increased the time to first hospital admission (P=0.04) but without changing the rate of emergency department visits.
Also, montelukast-treated kids received fewer courses of rescue oral corticosteroids, but without reducing the proportion of children getting at least one course of those rescue meds.
And, "in the context of present U.K. prescribing practice, the clinical significance of a change in this indirect marker of wheeze severity is unclear," the researchers cautioned.
The number and duration of wheeze episodes didn't differ between treatment groups.
The only serious adverse event -- a skin reaction -- occurred in the placebo group.
Meta-analysis of the findings of those of three prior trials of montelukast in young children, yielded results similar to those of the trial by Grigg and colleagues, supporting no overall benefit from intermittent dosing.

Tuesday, September 9, 2014

Enterovirus Triggering Respiratory Problems in Children

Enterovirus is one of many viruses capable of triggering airway problems in children similar to asthma.  As such, children with asthma are especially high risk for exacerbations.  A child with poorly controlled asthma would be especially high risk.  At this time, there does not appear to be an easy way to test for the virus. Dr Susarla

What is Enterovirus 68, the mysterious illness that may be sickening hundreds of children?

Health officials in at least 10 states have reported hundreds of cases of a respiratory illness that has sent scores of children to emergency rooms and, in some cases, even to intensive care units.
The culprit is believed to be Enterovirus 68 (also known as EVD-68 or Eentrovirus D68), a fairly rare viral infection that can cause symptoms such as coughing, wheezing and low blood oxygen levels (also known as hypoxemia). In some cases, however, the symptoms can be severe — particularly for children who already suffer from asthma or other respiratory problems.
Jennifer Cornejo of Colorado told Denver's ABC affiliate that her 13-year-old son, William, had cold symptoms that developed overnight into a life-threatening illness. "He was in really bad shape," she told the station. "He came really close to death. He was unconscious at our house and white as a ghost with blue lips — he just passed out."
Here is how William Cornejo described it: "My head started hurting. And after that my lungs started closing up. It felt different."
Until recently, Enterovirus 68 was only thought to cause sporadic infections, but there have been reports of more widespread outbreaks in Georgia, Pennsylvania and Arizona between 2008 and 2010.
Only Missouri and Illinois have confirmed cases of EV-D68, but cases with similar symptoms have been reported in Colorado, Georgia, Iowa, Kansas, Kentucky, North Carolina, Ohio and Oklahoma as well.
Because of how rare Enterovirus 68 is, scientists are still learning about it. But here is what you should know now:
Why is it called Enterovirus 68?
Enterovirus is the name used to describe a group of more than 100 of the most common viruses that affect humans and other mammals. Most people might interact with an enterovirus by way of the common cold, which can be caused by enteroviruses as well as rhinoviruses.

Thursday, July 17, 2014

Scientific review finds asthma drugs suppress child growth

This is a well known potential side effect of inhaled corticosteroids, the most commonly prescribed asthma controller medication.  As indicated in this article, the effect seems "small and non-cumulative".  Moreover, this effect is not seen in all children.  It is critical to re-evaluate asthma periodically to be sure medication is still needed, and to reduce dosing when appropriate.  Dr. Susarla

Scientific review finds asthma drugs suppress child growth

(Reuters) - Corticosteroid drugs given via inhalers to children with asthma may suppress their growth, according to two systematic reviews of scientific studies on the issue.
Health experts who conducted the review and published it in The Cochrane Library journal found that children's growth slowed in the first year of treatment, although the effects were minimized by using lower doses.
Steroid-containing inhalers are prescribed as first-line treatments for adults and children with persistent asthma.
They are the most effective asthma control drugs and have been shown to reduce asthma deaths, hospital visits and improve quality of life by cutting the number and severity of attacks.
Yet their potential effect on children's growth is a source of worry for parents and doctors - a factor which prompted the Cochrane reviewers to analyze the evidence more closely.
"The evidence... suggests that children treated daily with inhaled corticosteroids may grow approximately half a centimeter less during the first year of treatment," said Linjie Zhang at the Federal University of Rio Grande in Brazil, who led the review. "But this effect is less pronounced in subsequent years, is not cumulative, and seems minor compared to the known benefits of the drugs for controlling asthma."
According to data from the World Health Organization (WHO), some 235 million people worldwide suffer from asthma, a chronic disease which inflames and narrows the air passages of the lungs. The disease is common among children.
The first of the two systematic reviews focused on 25 trials involving 8,471 children up to 18 years old with mild to moderate persistent asthma. These trials tested almost all the available inhaled corticosteroids and showed they suppressed growth rates when compared to placebos or non-steroidal drugs.
Fourteen of the trials reported growth over a year and found the average growth rate, which was around 6 to 9 centimeters (2.4 to 3.5 inches)per year in control groups, was about 0.5 cm (0.2 inch) less in the groups of children being treated with inhaled steroids for asthma.
In the second review, researchers looked at data from 22 trials in which children were treated with low or medium doses of inhaled corticosteroids.
Only three trials followed 728 children for a year or more and the reviewers said they showed that using lower doses of inhaled corticosteroids, by about one puff per day, improved growth by around a quarter of a centimeter (0.1 inch) at one year.
Francine Ducharme of the University of Montreal in Canada, who worked on both reviews, said the findings were important and should prompt more frequent and detailed tracking of childhood asthma patients' growth.
"Only 14 percent of the trials we looked at monitored growth in a systematic way for over a year," she said. "This is a matter of major concern given the importance of this topic."
She said her team would recommend the minimal effective dose be used in children with asthma until further data becomes available. "Growth should be carefully documented in all children treated with inhaled corticosteroids, as well in all future trials testing (them) in children," she said.
Experts not directly involved in the reviews cautioned, however, that the growth effects were minimal and should not prompt asthma patients to stop taking their medication.
"These studies confirm what many have suspected, that inhaled steroids can suppress growth in children," said Jon Ayres, a professor of environmental and respiratory medicine at Britain's Birmingham University.
"However, the effect seems... small and non-cumulative and many may consider this a risk worth taking compared to the alternative, which is poorly controlled and therefore potentially life threatening asthma." 

Thursday, June 5, 2014

Scuba, flying trauma, ear infections ... What is a ruptured eardrum? How do you treat a ruptured ear drum?

Scuba, flying trauma, ear infections ...
What is a ruptured eardrum?

Ruptured eardrum

A ruptured eardrum is an opening or hole in the eardrum. The eardrum is a thin piece of tissue that separates the outer and middle ear. Damage to the eardrum may harm hearing.


Ear infections may cause a ruptured eardrum. This occurs more often in children. The infection causes pus or fluid to build up behind the eardrum. As the pressure increases, the eardrum may break open (rupture).
Damage to the eardrum can also occur from:


Ear pain may suddenly decrease right after your eardrum ruptures.
After the rupture, you may have:

Exams and Tests

The doctor will look in your ear with an instrument called an otoscope. If the eardrum is ruptured, the doctor will see an opening in it. The bones of the middle ear may also be visible.
Pus draining from the ear may make it harder for the doctor to see the eardrum.
Audiology testing can measure how much hearing has been lost.


You can take steps at home to treat ear pain.
  • Put warm compresses on the ear to help relieve discomfort.
  • Use medicines such as ibuprofen or acetaminophen to ease pain.
Keep the ear clean and dry while it is healing.
  • Place cotton balls in the ear while showering or shampooing to prevent water from entering the ear.
  • Avoid swimming or putting your head underneath the water.
Your health care provider may prescribe antibiotics (oral or ear drops) to prevent or treat an infection.
Sometimes the health care provider may place a patch over the eardrum to speed healing. Surgical repair of the eardrum (tympanoplasty) may be needed if the eardrum does not heal on its own.

Outlook (Prognosis)

The opening in the eardrum usually heals by itself within 2 months. Any hearing loss is most often short-term.
Rarely, other problems may occur, such as:
  • Long-term hearing loss
  • Spread of infection to the bone behind the ear (mastoiditis)
  • Long-term vertigo and dizziness

When to Contact a Medical Professional

If your pain and symptoms improve after your eardrum ruptures, you may wait until the next day to see your health care provider.
Call your health care provider right away after your eardrum ruptures if you:
  • Are very dizzy
  • Have a fever, general ill feeling, or hearing loss
  • Have very bad pain or a loud ringing in your ear
  • Have an object in your ear that does not come out
  • Have any symptoms that last longer than 2 months after treatment


Do not insert objects into the ear canal, even to clean it. Objects stuck in the ear should only be removed by a health care provider. Have ear infections treated promptly.

Alternative Names

Tympanic membrane perforation; Eardrum - ruptured or perforated; Perforated eardrum


Buttaravoli P, Leffler SM. Perforated tympanic membrane (ruptured eardrum). In: Buttaravoli P, Leffler SM, eds. Minor Emergencies. 3rd ed. Philadelphia, Pa: Mosby Elsevier; 2012:chap 37.
Kerschner JE. Otitis media. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 632.

Update Date: 5/21/2013

Updated by: Ashutosh Kacker, MD, BS, Associate Professor of Otolaryngology, Weill Cornell Medical College, and Associate Attending Otolaryngologist, New York-Presbyterian Hospital, New York, NY. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Bethanne Black, and the A.D.A.M. Editorial team.

Sunday, May 25, 2014

Congratulations to Dr. Rotenberg, Pediatric Neurologist, and Dr. Susarla, Pediatric Pulmonologist, named as Houston Top Docs for 2014

Congratulations to Houston Specialists nominated for recognition by their colleagues!

Dr. Rotenberg, Pediatric Neurologist, Sleep Specialist, Epileptologist &

Dr. Susarla, Pediatric Pulmonologist, Sleep Specialist

named as Houston Top Docs for 2014

Read the article here

Monday, April 21, 2014

What does access to adequate botox treatment do for children with CP? Reduces the need for surgery from 40 to 15%!

I do not understand why I see kids in clinic who have leg or arm spasticity and the families are content to get treatment every year or every 6 months...or worse...not at all!?!  - JR

 2005 Jul;14(4):269-73.

Prevention of severe contractures might replace multilevel surgery in cerebral palsy: results of a population-based health care programme and new techniques to reduce spasticity.

Erratum in

  • J Pediatr Orthop B. 2005 Sep;14(5):388. Pedertsen, Henrik Lauge [corrected to Lauge-Pedersen, Henrik].


During the 1990s three new techniques to reduce spasticity and dystonia in children with cerebral palsy (CP) were introduced in southern Sweden: selective dorsal rhizotomy, continuous intrathecal baclofen infusion and botulinum toxin treatment. In 1994 a CP register and a health care programme, aimed to prevent hip dislocation and severe contractures, were initiated in the area. The total population of children with CP born 1990-1991, 1992-1993 and 1994-1995 was evaluated and compared at 8 years of age. In non-ambulant children the passive range of motion in hip, knee and ankle improved significantly from the first to the later age groups. Ambulant children had similar range of motion in the three age groups, with almost no severe contractures. The proportion of children treated with orthopaedic surgery for contracture or skeletal torsion deformity decreased from 40 to 15% (P = 0.0019). One-fifth of the children with spastic diplegia had been treated with selective dorsal rhizotomy. One-third of the children born 1994-1995 had been treated with botulinum toxin before 8 years of age. With early treatment of spasticity, early non-operative treatment of contracture and prevention of hip dislocation, the need for orthopaedic surgery for contracture or torsion deformity is reduced, and the need for multilevel procedures seems to be eliminated.
[PubMed - indexed for MEDLINE]

Cut through the fog: An evidence-based review of treatments for children with cerebral palsy

As a parent, I am also subject to all kinds of claims of efficacy for treatment. 

How can you cut through the fog?

As a member of the Academy of CP and Developmental medicine, I suggest this very readable article for parents of children with CP to educate themselves on best practices.

- Dr. Rotenberg

New Clinical and Research Trends in Lower Extremity Management for Ambulatory Children with Cerebral Palsy


Cerebral palsy is the most prevalent physical disability in childhood and includes a group of disorders with varying manifestations and levels of capability in individuals given this diagnosis. This chapter will focus on current and future intervention strategies for improving mobility and participation over the lifespan for ambulatory children with cerebral palsy (CP). The provision and integration of physical therapy, medical and orthopedic surgery management focused primarily on the lower extremities will be discussed here. Some of the newer trends are: more intense and task-related exercise strategies, greater precision in tone identification and management, and a shift towards musculoskeletal surgery that focuses more on promoting dynamic bony alignment and less on releasing or lengthening tendons. Advances in basic and clinical science and technology development are changing existing paradigms and offering renewed hope for improved functioning for children with CP who are currently facing a lifelong disability with unique challenges at each stage in life.

"... it is the intensity of walking practice, rather than the use of a device, that produces the positive functional outcomes"

Wednesday, April 9, 2014

Does Childhood Asthma Lead to COPD?

Early childhood asthma, particularly when severe, seems to impart risk of COPD - an adult condition associated with abnormal lung function that declines over time faster than the general population.  Can controlling asthma early prevent this? Dr. Susarla

The association between childhood asthma and adult chronic obstructive pulmonary disease.


There is epidemiological evidence to suggest that events in childhood influence lung growth and constitute a significant risk for adult COPD. The aim of the study is to evaluate for an association between childhood asthma and adult COPD.


This longitudinal, prospective study of 6-7-year-old children with asthma has been regularly reviewed every 7 years to the current analysis at 50 years of age. Participants completed respiratory questionnaires and lung function spirometry with postbronchodilator response. At the age of 50, subjects were classified to the following subgroups: non-asthmatics, asthma remission, current asthma and COPD which was defined by FEV1 to FVC ratio postbronchodilator of less than 0.7.


Of the remaining survivors, 346 participated in the current study (participation rate of 76%) of whom 197 completed both questionnaire and lung function testing. As compared with children without symptoms of wheeze to the age of 7, (non-asthmatics) children with severe asthma had an adjusted 32 times higher risk for developing COPD (95% CI 3.4 to 269). In this cohort, 43% of the COPD group had never smoked. There was no evidence of a difference in the rate of decline in FEV1 (mL/year, 95th CI) between the COPD group (17, 10 to 23) and the other groups: non-asthmatics (16, 12 to 21), asthma remission (20, 16 to 24) and current asthma (19, 13 to 25).


Children with severe asthma are at increased risk of developing COPD.