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, April 21, 2014

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

Synopsis

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.


INTRODUCTION:

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.

METHODS:

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.

RESULTS:

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).

CONCLUSIONS:

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

Wednesday, April 2, 2014

Roche drug cuts asthma attacks, improves lung function -study

"Biological therapies" are the new frontier in asthma treatment, especially for patients with more severe disease. These antibody based medications provide a more targeted  strategy in asthma treatment compared to conventional asthma medications.  Dr. Susarla



Roche drug cuts asthma attacks, improves lung function -study

(Reuters) - An experimental drug reduced asthma attacks in patients with severe uncontrolled asthma by 60 percent and helped improve lung function in certain patients, indicating that the drug could offer the first personalized approach to treatment, according to data from a clinical trial released on Tuesday.
The biotech drug lebrikizumab, which was developed by Roche Holding's Genentech unit, was tested at three doses in patients whose asthma was not sufficiently controlled even with high-dose, inhaled corticosteroids and a second asthma-controlling therapy.
In the 463-patient Phase IIb study, lebrikizumab reduced asthma attacks by a statistically significant 60 percent more than a placebo in patients found to have a high level of the protein periostin, according to pooled data from the three doses tested - 37.5 milligrams, 125 mg and 250 mg. That compared with a 5 percent reduction versus placebo over 28 to 52 weeks of treatment in those with low levels of periostin.
"If this drug gets approved we would have for the first time a personalized approach other than just blanket therapy for everyone with uncontrolled disease," Dr Nicola Hanania, one of the study's lead investigators, said in a telephone interview.
Lebrikizumab works by blocking interleukin-13, or IL-13, which contributes to airway inflammation and mucous production. Periostin is believed to be a biomarker for IL-13 activity and a likely predictor of how well the Roche drug will work.
Roche is also developing a blood test for periostin in order to identify the patients most likely to benefit from lebrikizumab, which is injected once every four weeks.
Hanania, who is director of the Asthma Clinical Research Center at Baylor College of Medicine in Houston, called the data from the study "very exciting."
In those with severe asthma receiving existing treatments, "we still see patients who still have symptoms, who still have exacerbations, hospital admissions, and this is the type of patient this study was targeting," he said.
Curiously, the greatest level of asthma attack reduction, at 81 percent, was seen with the lowest dose of lebrikizumab, something that Hanania called surprising. Hanania, who presented the data at the American Academy of Allergy, Asthma and Immunology (AAAAI) meeting in San Diego, noted, "Higher is not always the better."
Fifteen percent of the estimated 25 million Americans with asthma suffer from severe asthma, according to the National Institutes of Health. About half of severe asthmatics are believed to have high periostin levels.
Among patients with high level periostin, the drug improved lung function by 9.1 percent after 12 weeks, compared with an improvement of just 2.6 percent in the low periostin group.
Lung function was tested by change in FEV1, a measure of the maximum amount of air that can be forcibly exhaled in one second. The greatest improvement in FEV1, of 10.7 percent, was seen with the 125 mg dose of lebrikizumab.
"Statistically it's significant, and I believe it is clinically significant because it goes hand in hand with reduction in exacerbations," Hanania said of the lung function improvement seen in the high periostin group.
The incidence of serious adverse side effects was low and similar in the lebrikizumab and placebo arms of the study, researchers said.
"The safety profile was very reassuring. Nothing really stood out as major side effect or major serious adverse effect," Hanania said.
If the results are replicated in large, ongoing Phase III trials that will include more than 2,000 patients, Roche said it expects to seek approval for the drug in 2016.

"As a clinician, this is important because there is a great need for additional therapy for those with poorly controlled asthma," Hanania said. "It's a light at the end of the tunnel."

Monday, March 31, 2014

Diuretic may treat autism, study in rodents suggests

While this is a rat model, it offers some biologic evidence for an earlier treatment trial in humans. Interestingly, there are many papers about using diuretics in seizures in infants. JR

Diuretic may treat autism, study in rodents suggests

Drug that affects brain chloride levels staves off symptoms in mice and rats
Curbing chloride in nerve cells could combat symptoms of autism, a study of rats and mice suggests. The results may explain why a small group of children with autism seemed to improve after taking the common diuretic bumetanide in an earlier study.
The new details of how bumetanide works, published in the Feb. 7 Science, provide important clues about how autism spectrum disorders arise in a developing brain, says Susan Connors, an autism specialist at Massachusetts General Hospital for Children in Boston ....
article here

Here is the abstract of the human study....

Transl Psychiatry. Dec 2012; 2(12): e202.

PMCID: PMC3565189
A randomised controlled trial of bumetanide in the treatment of autism in children
E Lemonnier,1,2,* C Degrez,1 M Phelep,1 R Tyzio,3 F Josse,1 M Grandgeorge,1,2 N Hadjikhani,4,5 and Y Ben-Ari3,*

Go to:
Abstract
Gamma aminobutyric acid (GABA)-mediated synapses and the oscillations they orchestrate are altered in autism. GABA-acting benzodiazepines exert in some patients with autism paradoxical effects, raising the possibility that like in epilepsies, GABA excites neurons because of elevated intracellular concentrations of chloride. Following a successful pilot study,1 we have now performed a double-blind clinical trial using the diuretic, chloride-importer antagonist bumetanide that reduces intracellular chloride reinforcing GABAergic inhibition. Sixty children with autism or Asperger syndrome (3–11 years old) received for 3 months placebo or bumetanide (1 mg daily), followed by 1-month wash out. Determination of the severity of autism was made with video films at day 0 (D0) and D90 by blind, independent evaluators. Bumetanide reduced significantly the Childhood Autism Rating Scale (CARS) (D90−D0; P<0 .004="" a="" above="" accuracy="" activation="" adjikhani="" agent="" al.="" an="" and="" are="" areas="" autism.="" autism="" best="" better="" brain="" bumetanide="" cases="" chronic="" clinical="" companion="" determine="" diagnostic="" effects="" emotional="" et="" facial="" for="" global="" hypokalaemia="" ilcoxon="" impressions="" improved="" in="" increased="" involved="" is="" k="" l="" labelling="" larger="" mean="" mild="" mm="" most="" n="9)" novel="" observation="" occasional="" p-value="0.017)." p="" perception="" placebo="" population="" potassium.="" promising="" removed="" restricted="" s.d.="" s="" schedule="" severe="" side="" significantly="" social="" student="" study="" submitted="" suited="" supplemental="" t-test:="" test:="" that="" the="" therapeutic="" therefore="" this="" to="" treat="" treated="" treatment.="" treatment="" trials="" values="" vs="" warranted="" was="" were="" when="" with="">
Keywords: autism, bumetanide, clinical trial, diuretics, GABA

Sugar doesn’t make kids hyper, and other parenting myths

Sugar, shoes, sleep, baby Mozart....parenting is hard enough without added "wisdom". Our oldest has come to understand that we have a
learning curve. JR

Baby shoes didn’t feature prominently into Baby V’s wardrobe for quite some time. Tiny Chuck Taylors are adorable, obviously, but I questioned their utility for a baby who didn’t use her feet except as wiggly pacifiers. So Baby V spent a lot of time barefoot — a fashion statement that I didn’t really consider until she started toddling around in public. 

Well-meaning observers were quick to tell me that I needed to get that baby some nice stiff shoes. Hard soles will help her get the hang of walking and protect her delicate baby feet, I was told. But when I started looking into this advice, I actually found the opposite is true: These days, people recommend that babies learning to walk wear soft, flexible shoes, or better yet, go barefoot. The minimalist footwear allows the nascent walkers the most sensory feedback from their sweet little feet as they move across the earth.

I offer the shoe advice as just one tiny glimpse into the life of a parent of a young kid. Over the last year, I’ve come to learn that much of the advice I’ve heard, while well-intentioned, might just be wrong. Or at the very least, questionable. So here are my top five parenting myths (shoes didn’t make the cut), with a little dash of science.

1. Sugar makes kids hyper.

Lots of parents swear that a single hit of birthday cake holds the power to morph their well-behaved, polite youngster into a sticky hot mess that careens around a room while emitting eardrum-piercing shrieks. Anyone who has had the pleasure to attend a 5-year-old’s birthday party knows that the hypothesis sounds reasonable, except that science has found that it’s not true.
Sugar doesn’t change kids’ behavior, a double-blind research study found way back in 1994. A sugary diet didn’t affect behavior or cognitive skills, the researchers report. Sugar does change one important thing, though: parents’ expectations. After hearing that their children had just consumed a big sugar fix, parents were more likely to say their child was hyperactive, even when the big sugar fix was a placebo, another study found.
Of course, there are plenty of good reasons not to feed your kids a bunch of sugar, but fear of a little crazed sugar monster isn’t one of them.

2. Listening to Mozart makes babies smarter.

My colleague Rachel Ehrenberg busted this “Mozart Effect” myth in her 2010 feature. The original observation, that 10 minutes of classical music made college students briefly perform better on a paper-folding task, was twisted so out of context that the governor of Georgia used tax money to buy a classical music CD for every baby born in the state.
Many babies adore music, and there’s evidence that suggests music might help soothe babies. There’s also evidence that playing an instrument might be beneficial to brain development, as Ehrenberg points out. But scientists haven’t found that classical music makes your baby smarter. So play music to your child because she loves it and you love it, not because you’re looking to grub a few extra IQ points.

3. Feeding a baby solid food will help her sleep through the night.

Your baby is waking up in the night? Just put some rice cereal in the last bottle before bed, well-intentioned observers urge. The solid food will fill baby’s tummy and keep her satisfied longer, which translates to fewer wakeups. Except that it doesn’t.

Babies fed rice cereal before bedtime slept no better than babies fed only breast milk or formula, a study found. In fact, early introduction to solid food (before 4 months) has been associated with worse infant sleep.  The magical cure of feeding a baby solids before bedtime belongs at the top of the heaping pile of sleep miracles that sound great but don’t really work. And speaking of rice cereal…


Thursday, March 27, 2014

BIG NEWS! Autism begins in pregnancy, according to study: Cortical layers disrupted during brain development in autism

Autism begins in pregnancy, according to study: Cortical layers disrupted during brain development in autism

Date:
March 26, 2014
Source:
University of California, San Diego Health Sciences
Postmortem analysis of autistic brain tissue revealed patch-like areas of disorganized neurons. Arrows show a patch of decreased or absent expression of genetic markers across multiple layers of the dorsolateral prefrontal cortex.
Credit: Rich Stoner, Ph.D., University of California, San Diego
Researchers at the University of California, San Diego School of Medicine and the Allen Institute for Brain Science have published a study that gives clear and direct new evidence that autism begins during pregnancy.
The study will be published in the March 27 online edition of the New England Journal of Medicine.
The researchers -- Eric Courchesne, PhD, professor of neurosciences and director of the Autism Center of Excellence at UC San Diego, Ed S. Lein, PhD, of the Allen Institute for Brain Science in Seattle, and first author Rich Stoner, PhD, of the UC San Diego Autism Center of Excellence -- analyzed 25 genes in post-mortem brain tissue of children with and without autism. These included genes that serve as biomarkers for brain cell types in different layers of the cortex, genes implicated in autism and several control genes.
"Building a baby's brain during pregnancy involves creating a cortex that contains six layers," Courchesne said. "We discovered focal patches of disrupted development of these cortical layers in the majority of children with autism." Stoner created the first three-dimensional model visualizing brain locations where patches of cortex had failed to develop the normal cell-layering pattern.
"The most surprising finding was the similar early developmental pathology across nearly all of the autistic brains, especially given the diversity of symptoms in patients with autism, as well as the extremely complex genetics behind the disorder," explained Lein.
During early brain development, each cortical layer develops its own specific types of brain cells, each with specific patterns of brain connectivity that perform unique and important roles in processing information. As a brain cell develops into a specific type in a specific layer with specific connections, it acquires a distinct genetic signature or "marker" that can be observed.
The study found that in the brains of children with autism, key genetic markers were absent in brain cells in multiple layers. "This defect," Courchesne said, "indicates that the crucial early developmental step of creating six distinct layers with specific types of brain cells -- something that begins in prenatal life -- had been disrupted."



Tongue tied infant? Nursing? Randomized controlled trial of early frenotomy in breastfed infants.

Tongue tied? Nursing? Considering clipping procedure known as "frenotomy"?
Who is getting treatment? It appears that the babies all work out nursing. Early frenotomy results in a better "self-efficacy" and less bottle feeding in the first 5 days. "...over 80% of both groups were still feeding at the breast at 8 weeks."
Hmm. Tough one. JR


 2013 Nov 18. doi: 10.1136/archdischild-2013-305031. [Epub ahead of print]

Randomised controlled trial of early frenotomy in breastfed infants with mild-moderate tongue-tie.

Abstract

Trial design A randomised, parallel group, pragmatic trial.
Setting A large UK maternity hospital.
Participants Term infants <2 a="" and="" breastfeeding.="" degree="" difficulties="" having="" mild="" moderate="" mothers="" of="" old="" or="" p="" their="" tongue-tie="" weeks="" were="" who="" with="">
Objectives To determine if immediate frenotomy was better than standard breastfeeding support.
Interventions Participants were randomised to an early frenotomy intervention group or a ‘standard care’ comparison group.
Outcomes Primary outcome was breastfeeding at 5 days, with secondary outcomes of breastfeeding self-efficacy and pain on feeding. Final assessment was at 8 weeks; 20 also had qualitative interviews. Researchers assessing outcomes, but not participants, were blinded to group assignment.
Results 107 infants were randomised, 55 to the intervention group and 52 to the comparison group. 
Five-day outcome measures were available for 53 (96%) of the intervention group and 52 (100%) of the comparison group, and intention-to-treat analysis showed no difference in the primary outcome—Latch, Audible swallowing, nipple Type, Comfort, Hold score. 
Frenotomy did improve the tongue-tie and increased maternal breastfeeding self-efficacy. 
At 5 days, there was a 15.5% increase in bottle feeding in the comparison group compared with a 7.5% increase in the intervention group.
After the 5-day clinic, 44 of the comparison group had requested a frenotomy; 
by 8 weeks only 6 (12%) were breastfeeding without a frenotomy. 
At 8 weeks, there were no differences between groups in the breastfeeding measures or in the infant weight. No adverse events were observed.
Conclusions Early frenotomy did not result in an objective improvement in breastfeeding but was associated with improved self-efficacy. The majority in the comparison arm opted for the intervention after 5 days.
KEYWORDS:

Infant Feeding, Neonatology, Nutrition


What is known on this topic

  • Tongue-tie (ankyloglossia) is a common congenital condition which can interfere with breastfeeding.
  • Tongue-tie release (frenotomy) is a well-tolerated procedure that can provide objective and subjective benefits in breast feeding.
  • Evidence from randomised trials supports early frenotomy in severe cases of tongue-tie, but debate continues about management of mild–moderate degrees of tongue-tie resulting in wide variations in clinical practice.

What this study adds

  • A randomised, parallel group, pragmatic trial comparing early frenotomy with usual care in mild–moderate tongue-tie showed that mothers could sustain breastfeeding of infants with tongue-tie for 5 days without a frenotomy.
  • Early frenotomy did not result in an objective improvement in breastfeeding at 5 days.
  • Early frenotomy did improve maternal breastfeeding self-efficacy and resulted in fewer mothers switching to bottle feeding before 5 days.

Wednesday, March 26, 2014

Preemies Aren't Little Term Babies

Disorders of feeding and swallowing, and the risk of aspiration are increased in premie infants.  This study highlights that a routine surgery performed for a common pediatric disorder known as as laryngomalacia (floppy airway) may significantly raise risk for aspiration more so than in term infants. Dr. Susarla



The effects of prematurity on incidence of aspiration following supraglottoplasty for laryngomalacia.

Abstract

OBJECTIVES:

To determine if patients who were born premature have a higher incidence of aspiration following supraglottoplasty compared to patients born full term.

STUDY DESIGN:

Retrospective study.

METHODS:

Two thousand three hundred sixty (2360) patient charts from Riley Hospital for Children were reviewed retrospectively. Patients had already been treated for laryngomalacia with supraglottoplasty by Dr. Bruce Matt. Estimated weeks gestational age at birth was recorded for each patient. Prematurity was stratified as mild (32-36 weeks gestational age [WGA]), very (28-31 WGA), or extremely (<28 WGA). Patients were excluded from the study if they had suspected aspiration with chronic cough, pneumonia, chronic lung disease, or documented aspiration prior to supraglottoplasty.

RESULTS:

As previously shown, 75 patients (3.2%) had aspiration following supraglottoplasty. Twenty of these patients were preterm infants at birth. The rate for aspiration following supraglottoplasty for former premature infants was statistically significant (5.9%, odds ratio = 2.3, P = .0032).

CONCLUSIONS:

Children who were born premature have a higher rate of postoperative aspiration following supraglottoplasty; however, supraglottoplasty should still be considered as treatment for laryngomalacia as the rate is still relatively low (5.9%).

Monday, March 24, 2014

White Noise Might Be Too Noisy

See below.  Not all "infant sleep machines" are safe for infant ears. Dr. Susarla

Caution urged for infant sleep machines

Infant sleep machines have become a popular aid for parents with a baby getting inadequate sleep because of a busy household, loud neighbors or other noise disturbances.
But a new study says parents should be cautious with the devices because they can generate sound levels that could place infants at risk of developing noise-induced hearing loss. In addition, they are often sold with limited or no instructions for safe use, says the study published online Monday by the journal Pediatrics.
The machines -- which can be used to mask environmental noises or provide ambient noise designed to soothe an infant during sleep -- "are capable of producing levels that may be damaging to babies' hearing," says Blake Papsin, otolaryngologist-in-chief at the Hospital for Sick Children in Toronto and senior author of the study.
Using a sound level meter, Papsin and colleagues tested the maximum noise levels of 65 sounds in 14 different infant sleep machines when placed at three distances: 30 centimeters (11.7 inches -- simulating placement on a crib rail): 100 centimeters (39 inches -- simulating placement on a table near a crib); and 200 centimeters (78 inches -- simulating placement across the room from a crib.) Calculations were added to account for the size and development of a 6-month-old's ear canal.
The sounds included white noise, nature sounds (rain, thunder, wind, ocean, river, campfire, insect and bird sounds), mechanical sounds (including traffic, train, airplane and machinery sounds) and heartbeat sounds.
When set to their maximum volume:
-- All 14 sleep machines exceeded 50 decibels at 30 cm and 100 cm, the current recommended noise limit for infants in hospital nurseries.
-- All but one machine exceeded that recommended noise limit even when placed across the room, 200 centimeters away.
--Three machines produced outputs greater than 85 decibels when placed 30 cm away. If played continuously, as recommended on several parenting websites, infants would be exposed to sound pressure levels that exceed the occupational noise limits for an 8-hour period endorsed by the National Institute for Occupational Safety and Health and the Canadian Centre for Occupational Health and Safety
Regular exposure to white noise through an infant sleep machine on a nightly basis is of particular concern, Papsin says, because an infant's brain needs the stimulation it receives from a range of sounds in order to develop properly. "Completely removing all informational content at a loud, potentially damaging level is the worst," he says.
Most of the devices studied featured a volume control, which suggests that safer use is possible and that the machines can be used in accordance with recommendations for hospital nursery noise, Papsin says.
With that in mind, the study says manufacturers should be required to limit maximum output levels; print warnings about noise-induced hearing loss on the machine's packaging; and include a mandatory timer on machines marketed primarily for infants that would make them automatically shut off after a predetermined period of time.
Families can more safely use the machines if they place them as far away as possible from the infant and never in the crib or on a crib rail; play the the devices at a low volume; and operate them for a short duration of time.
â??Parents "can feel desperate and want to try anything" when a baby has difficulty sleeping, says Nanci Yuan, pulmonologist and sleep medicine specialist at Lucile Packard Children's Hospital Stanford.
She was not involved in the study.
But this research highlights the potential for a previously "unknown harm that can occur," Yuan says. "We're getting more and more concerned about issues related to sound and noise and hearing-loss in children because it's progressive."
Given today's very industrial lifestyle, "there's a lot of noise around, so it's always good, especially with young children, to really know what types of exposures they're getting and the effects they can have long term," adds Linda Hazard, an audiologist certified by the American Speech-Language-Hearing Association â?? and director of the Vermont Early Hearing Detection and Intervention Program.
"It's important to recognize that the authors are not saying not to use (the machines)," says Hazard, who was not involved in the study. "They're saying use them judiciously and get information about how they're performing." The recommendation that manufacturers include instructions about how the devices should be used is equally important, she says.
The paper "intentionally" does not identify any specific brands, models or manufacturers, Papsin says, "because the point is to start the conversation that every one of these is capable of damage if used inappropriately."