Peanut exposure therapy results in desensitization for children with peanut allergies

A British study found that children with peanut allergies who were fed peanut flour, while under supervision of a doctor, over time became desensitized to peanuts.

A British study provides some of the strongest evidence yet that feeding small amounts of peanut flour to children and teens with peanut allergies can help desensitize them to the nuts.

But the approach remains experimental and much too dangerous for anyone to try without medical supervision, experts say.

For the study, published Thursday in the journalLancet, researchers divided 99 children into two groups who took turns undergoing the therapy. The patients ate increasing – but small – amounts of the peanut flour under the watchful eyes of doctors.

In both six-month rounds of therapy, more than half of the treated participants ended up able to eat the equivalent of 10 peanuts at a time. More than 80% could eat the equivalent of five peanuts. The initially untreated children showed no such improvement after the first round.

Some of the treated children did get upset stomachs and one child ended up having an allergic reaction severe enough to require an injection of epinephrine.

The results are "exceptionally promising," but the treatment remains years away from routine use, says an editorial accompanying the study, written by Matthew Greenhawt, a pediatric allergist at the University of Michigan. He also notes that studies have yet to show if patients can develop long-lasting tolerance.

U.S. researchers also are studying the approach – known as oral immunotherapy – for peanuts, walnuts and other allergens, says the non-profit group Food Allergy Research & Education.

For now, the group says, the only proven treatment for peanut allergies is avoidance.

Allergies to peanuts and tree nuts affect 1.4% of U.S. children and rates have been rising, surveys find. Nut allergies are the leading cause of fatal allergic reactions.

Read more here

Pediatric migraines may be caused by environment

Different environmental factors, such as sleep deprivation, diet, and school, could play a role in pediatric migraines.

Environmental stressors play a large role in triggering migraines in children, according to Dr. Eric Pearlman.

"Migraine is definitely a pediatric disorder. It peaks in young adulthood, but it definitely occurs in kids," Dr. Pearlman, chair of the department of pediatrics at Mercer University in Savannah, Ga., said at the annual meeting of the American Academy of Pediatrics.

Epidemiologic data suggest that migraine occurs in 10.5% of 10- to 15-year-old children and 3% of 7-year-olds, and that headaches – possibly including migraines – occur in 4% of 3-year-olds. By about 13 years of age, the prevalence of migraines starts reaching adult levels of about 6% in males, and 18% in females.

Environmental factors such as sleep deprivation, dehydration, dietary factors, school stressors, hidden stressors (like peers), and hormonal fluctuations represent triggers that can be particularly pronounced in children, he noted.

With International Classification of Headache Disorders, third edition (ICHD-III) criteria, migraines can be differentiated from acute, acute recurrent, and chronic progressive or chronic nonprogressive headaches if a child has experienced at least five attacks lasting up to 72 hours (whether untreated or unsuccessfully treated), if nausea and/or vomiting or photophobia and phonophobia are present, and if the child has at least two of four characteristics, including unilateral location, pulsating quality, moderate to severe intensity, and a tendency to be aggravated by – or avoid – routine physical activity.

In children, photophobia and phonophobia can be inferred (if they report having to lie down in a dark, quiet room, for example), as many have difficulty describing or understanding these symptoms

Unilateral headaches are rare in children, Dr. Pearlman noted.

If a diagnosis of migraine is established, it is important to make the diagnosis known to the child, and to educate the child about the condition and treatments.

Consider providing handouts and referring to websites (such as theAmerican Headache Society or the National Headache Foundationsites), to help educate patients and to manage their expectations, as they need to understand you cannot cure their migraine, he advised.

Involving both the patient and their parents in decision making can improve compliance with treatment recommendations, he said.

Pharmacologic interventions can include nonspecific short-term therapies, migraine-specific therapies, and preventive treatment.

Nonspecific short-term therapies may include acetaminophen, nonsteroidal anti-inflammatory drugs, or combination drugs. Migraine-specific therapies include ergotamine and dihydroergotamine, and the "triptans."

Seven triptans are available, including two that are approved for use in children; rizitriptan (Maxalt) is approved for children older than age 6 years, and almitriptan (Axert) is approved for those aged 12-17 years.

Maxalt comes in both an oral and orally disintegrating form, and is available as a generic drug. Generic sumitriptan (Imitrex) also is available.

"There are good data for most of the triptans for adolescents aged 12 and older," Dr. Pearlman said.

Rescue medications for those who have an inadequate response to short-term therapy can include a combination of an analgesic like a nonsteroidal and an antiemetic, or an opiate and an antiemetic if the patient used a nonsteroidal initially. Rescue medications may be needed "because nothing is going to work 100% of the time," he said.

Read more here

Autism's new diagnosis rules may mean a drop in diagnosis numbers

New diagnosis criteria for autism will result in a reduction in the number of new diagnoses due to more strict criteria.

Stricter new criteria for autism may change how frequently the condition is diagnosed, a new study suggests.

The study estimates that if the new diagnostic guidelines had been in place in 2008, they would have lowered the prevalence of the disorder in a nationally representative database to one in 100 children.

The most recent estimate of autism prevalence from this database, according to the U.S. Centers for Disease Control and Prevention, is one in 88 children with the diagnosis.

Researchers say it's hard to tell how quickly the new guidelines will be put into practice. But some fear this change to how the condition is diagnosed may mask true increases in the number of children who develop symptoms that have been consistent with the disorder.

"The trend in the incidence of autism spectrum disorders has been one of pretty steady increases. Whether the switch to DSM-5 would offset that yearly increase remains to be seen," said study author Matthew Maenner, an epidemiologist with the CDC.

But advocates for children with autism say the ramifications of the new guidelines go beyond research. They say they're starting to see signs that children are being reclassified under the new criteria and that some may be losing access to needed services as a result.

In May, the American Psychiatric Association published sweeping new guidelines for the diagnosis of autism spectrum disorders in its Diagnostic and Statistical Manual of Mental Disorders, or DSM-5.

In the past, children who met six of 12 possible criteria could be diagnosed with one of several related conditions including autistic disorder, childhood disintegrative disorder, pervasive developmental disorder not otherwise specified (PDD-NOS) and Asperger disorder, according to study background information.

Now, those categories have been folded into a single condition -- autism spectrum disorders. In order to be diagnosed, kids must demonstrate all of three recognized deficits in social communication, and they have to show two of four different kinds of restricted or repetitive patterns of behavior.

The new study applied the updated criteria to the medical records kept in a database of nearly 645,000 8-year-old children who are being tracked by the Autism and Developmental Disabilities Monitoring Network (ADDM).

Of the 6,577 children who were classified as having an autism spectrum disorder under the old diagnostic criteria, researchers found 5,339, or 81 percent, would have kept their diagnosis under the new guidelines.

"Most of the children who didn't make the cut, they didn't miss by a lot," Maenner said. "They only needed one additional criterion to meet the DSM-5 definition. They had four of the five."

Most kids who wouldn't have met the new definition missed because they didn't show problems with nonverbal communication, which means they didn't have trouble reading or using body language or facial expressions.

The study findings were published online Jan. 22 in the journal JAMA Psychiatry.

Researchers caution that it's still not clear how the changes will play out in the real world. Doctors, for example, could change how they look for symptoms to better fit the new criteria. It's also possible that kids who don't qualify for an autism diagnosis could receive a new designation -- something called social communication disorder.

The latter is what seems to be happening, said Michael Rosanoff, associate director of public health research at Autism Speaks, a nonprofit advocacy group.

Autism Speaks is surveying parents to find out how the changes are affecting their children. Though the results are still early, and it's not a scientifically rigorous sample, he said they are seeing indications that children are being reclassified using the new criteria.

"What we've seen from the first 600 persons participating in the survey, is that there is a percentage of individuals being asked to be re-evaluated by school districts or insurers using DSM-5 criteria," he said.

About one-third of those who were reclassified said they had lost access to services.

"Our sense, from our survey and previous studies that have been published, is that individuals who are losing their autism diagnosis are getting a diagnosis of social communication disorder. The concern is there are no clinical guidelines for how to treat social communication disorder," Rosanoff said, which means that kids who get the diagnosis may not qualify for any services to treat it.

"We're concerned about this," he said.

Read more here

Study claims concussions are common in middle school-aged girls playing soccer

A recent study claims that girls who are middle school-aged and play soccer commonly have concussions.

Girls who play soccer in middle school are vulnerable to concussions, new research shows.

And despite medical advice to the contrary, many play through their injury, increasing the risk of a second concussion, the study found.

Although awareness has increased about sports concussions, little research has been done on middle school athletes, especially girls, noted study co-author Dr. Melissa Schiff, a professor of epidemiology at the University of Washington School of Public Health in Seattle.

In the study, which evaluated 351 soccer players between the ages of 11 and 14, Schiff and her colleagues found 59 concussions. A concussion is defined as a traumatic injury to the brain after a blow, shaking or spinning. In the study, the girls' symptoms included headache, dizziness, drowsiness and concentration problems.

That rate of injuries, Schiff said, is higher than what has been reported at either high school or college level of women's soccer.

Heading the ball was to blame for about 30 percent of the injuries. This involves hitting the ball with your forehead to redirect the ball in play. More than half of the concussions were from contact with another player.

Experts recommend those who have a concussion be evaluated by a doctor or other health care professional trained in the injury, but Schiff found that ''56 percent were never evaluated." Experts also advise that players not return to practice or games until symptoms disappear, but 58 percent of the players in the study continued to play even with symptoms persisting, she said.

The study was published online Jan. 20 in the journal JAMA Pediatrics.

Awareness about the dangers of concussions has increased, Schiff said, beginning with the National Football League's attention to the problem. Research about the problem has slowly increased to encompass college-level, high school, and now middle school players, she said.

In this study, the researchers randomly selected 33 of 72 elite teams from four youth soccer clubs in the Puget Sound region of Washington state. The study continued from 2008 to 2012. Players reported injuries and symptoms.

With so many injuries blamed on heading the ball, should it be banned?

Schiff thinks that is unrealistic. "It's part of the soccer sport," she said. However, it was found to result in concussion 23 times more often in a game than in practice. One suggestion, she said, is to teach middle school athletes heading in practice but tell them not to do it in games until they are older. The researchers speculate that younger players' less mature brains and weaker neck muscles, along with poorer heading technique, may contribute to the number of concussions.

The new study ''calls attention to the high incidence of concussion in this age group," said Dr. John Kuluz, director of traumatic brain injury and neurorehabilitation at Miami Children's Hospital.

The number of injuries blamed on heading the ball, 30 percent, is not surprising, he said. "I see it all the time," Kuluz explained. Often, he noted, a heading injury occurs along with colliding with another player.

Kuluz advises young athletes who have had a concussion to avoid heading the ball.

Parents need to pay attention to their child during and after soccer, he suggested. "In the event of an injury, pay attention to symptoms," Kuluz said. He added that if a concussion is suspected, a young athlete must be evaluated by a doctor or trainer who has experience with concussions.

"Soccer can be done safely," he said, but parents and coaches need to be aware of concussion symptoms and obtain good medical evaluation and care.

Read more here

Effects of sleep deprivation on the pediatric eeg.

Effects of sleep deprivation on the pediatric electroencephalogram.

Steven T DeRoos, Kipp L Chillag, Martina Keeler, Donald L Gilbert

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1. Steven T. DeRoos, MD^a,
2. Kipp L. Chillag, DO^a,
3. Martina Keeler, MD^b,
4. Donald L. Gilbert, MD^c

1. ^aDivisions of Pediatric Neurology
2. ^bPediatric Hospitalists, Helen DeVos Children's Hospital, Grand Rapids, Michigan
3. ^cDivision of Pediatric Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio

Abstract

BACKGROUND. The routine electroencephalogram aids in epilepsy syndrome diagnosis. Unfortunately, routine outpatient electroencephalogram results are normal in roughly half of children with epilepsy. To increase the yield, practice guidelines recommend electroencephalograms with sleep and sleep deprivation. The purpose of this study was to rigorously evaluate this recommendation in children.

METHODS. We conducted a randomized, blinded comparison of routine electroencephalograms versus sleep-deprived electroencephalograms in 206 children aged 0 to 18 years. Electroencephalograms were ordered for standard indications after a neurologist's clinical assessment indicated ≥1 seizure (83%) or unclear spell (17%). The primary outcome was the proportion of normal routine electroencephalogram results versus sleep-deprived electroencephalogram results. Logistic regression modeling was used to assess the influence of sleep, as well as other clinical factors.

RESULTS. Although children with sleep-deprived electroencephalograms had less sleep the night before (4.9 vs 7.9 hours) and more sleep during electroencephalograms (73% vs 55%), the increase in electroencephalogram yield was borderline significant (56% normal sleep-deprived electroencephalogram versus 68% normal routine electroencephalogram). Moreover, sleep during the electroencephalogram did not increase its diagnostic yield. Sleep-deprived electroencephalogram yield tended to be higher in children with preelectroencephalogram clinical diagnosis of seizure(s) and at older ages (>3 years).

CONCLUSIONS. Sleep deprivation, but not sleep during the electroencephalogram, modestly increases the yield of the electroencephalogram in children diagnosed with seizures by neurologists. Compared with a routine electroencephalogram, the number needed to test with sleep-deprived electroencephalogram to identify 1 additional child with epileptiform discharges is ∼11.

Key Words:

• Accepted June 6, 2008.

• Copyright © 2009 by the American Academy of Pediatrics

EEG in Houston Sugar Land Katy Cypress Missouri City

ChestAugust 10, 2013

Sleep-disordered-breathing in Ehlers-Danlos Syndrome (a genetic model of obstructive sleep apnea).

Christian Guilleminault, Michelle Primeau, Yean Hsiao, Kin Min Yuen, Damien Leger, Arnaut Metlaine

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Aims:  Investigation of the presence of sleep-disordered-breathing (SDB) in patients with Ehlers-Danlos(ED) Syndrome. ED is a genetic disorder characterized by cartilaginous defects, including nasal-maxillary cartilages.

Method:  A retrospective series of 34 ED patients presenting to clinic with complaints of fatigue and poor sleep were evaluated via clinical history, physical examination, polysomnography (PSG) and in some cases with anterior rhinomanometry. Additionally, a prospective clinical investigation of 9 ED patients was performed in a specialized medical ED clinic.

Results:  All ED patients evaluated had SDB on PSG. In addition to apneas and hypopneas, SDB included flow limitation. With increasing age, flow limitation decreased in favor of apnea and hypopnea events, but clinical complaints were similar independent of the type of PSG finding. In the subgroup of patients who underwent nasal rhinometry, increased nasal resistance was increased relative to normative values. Nasal CPAP improved patient symptoms. ED patients in medical clinic presented with symptoms and clinical signs of SDB, but they never were referred for evaluation of SDB.

Conclusion:  In ED patients, abnormal breathing during sleep is commonly unrecognized and is responsible for daytime fatigue and poor sleep. ED patients are at particular risk for SDB due to genetically related cartilage defects that lead to the development of facial structures known to cause SDB. ED may be a genetic model for obstructive sleep apnea because of abnormalities of oral-facial growth. Early recognition of SDB may allow treatment with orthodontics and myofacial reeducation.

Relationship between Sleep and Pain in Adolescents with Juvenile Primary Fibromyalgia Syndrome

Sleep disturbance is very common in teens with fibromyalgia and chronic pain. JR

Relationship between Sleep and Pain in Adolescents with Juvenile Primary Fibromyalgia Syndrome 

To investigate sleep quality in adolescents with juvenile primary fibromyalgia syndrome (JPFS) and determine whether sleep abnormalities, including alpha-delta sleep (ADS), correlate with pain intensity. We hypothesized that successful treatment for pain with exercise therapy would reduce ADS and improve sleep quality.

Design:

Single-center preintervention and postintervention (mean = 5.7 ± 1.0 weeks; range = 4.0-7.3 weeks) observational study.

Patients:

Ten female adolescents (mean age = 16.2 ± 0.65 SD yr) who met criteria for JPFS and completed treatment.

Interventions:

Multidisciplinary pain treatment, including intensive exercise therapy.

Measurements and Results:

Pain and disability were measured by a pain visual analog scale (VAS) and the Functional Disability Inventory. Subjective sleep measures included a sleep VAS, an energy VAS, and the School Sleep Habits Survey. Objective sleep measures included actigraphy, polysomnography (PSG), and the Multiple Sleep Latency Test. Baseline PSG was compared with that of healthy age- and sex-matched control patients. At baseline, patients had poorer sleep efficiency, more arousals/awakenings, and more ADS (70.3% of total slow wave sleep [SWS] versus 21.9% SWS, P = 0.002) than controls. ADS was unrelated to pain, disability, or subjective sleep difficulty. After treatment, pain decreased (P = 0.000) and subjective sleep quality improved (P = 0.008). Objective sleep quality, including the amount of ADS, did not change.

Conclusions:

Although perceived sleep quality improved in adolescents with JPFS after treatment, objective measures did not. Our findings do not suggest exercise therapy for pain improves sleep by reducing ADS, nor do they support causal relationships between ADS and chronic pain or subjective sleep quality.

Citation:

Olsen MN; Sherry DD; Boyne K; McCue R; Gallagher PR; Brooks LJ. Relationship between sleep and pain in adolescents with juvenile primary fibromyalgia syndrome. SLEEP 2013;36(4):509-516.

Houston ADD Conference - Strategies for Life with ADHD 26th Annual Conference

Strategies for Life with ADHD

26th Annual Conference

Double Tree by Hilton Hotel Houston Intercontinental Airport

15747 John F Kennedy Blvd, Houston, TX 77032

Saturday, February 22, 2014

2014 Registration Brochure (PDF — 245 KB)

This event is designed for parents, educators, adults with ADD and mental health professionals. The general session speaker will be Dwight Wolfe, M.D. with UTMB in Galveston covering updated trends in ADHD. Author Chris Zeigler Dendy and her husband, Tommy Dendy will present sessions addressing teen issues. They will introduce their new video for dads. Twenty breakout sessions will cover a wide variety of topics including behavior management, life skills, medication, educational laws, related conditions and classroom strategies. TEA approved CPE credits for educators will be available and continuing education credits, including ethics credits, will be available for social workers, psychologists, Type 1 for OTs, LPCs, and LMFTs. Discounts are available for groups of educators. A limited number of scholarships covering registration and hotel are available for individuals or families coping with ADHD. Mark your calendars and join us.

Featured Speaker

Dwight Wolfe, M.D. is a Professor in the Department of Psychiatry, Division of Child and Adolescent Psychiatry at the University of Texas Medical Branch at Galveston.  He earned a Bachelor of Science in Biology from Lamar University in Beaumont, TX and completed medical school and residency training at UTMB.   He is board certified in both Adult and Child and Adolescent Psychiatry.  Dr. Wolf’s responsibilities at UTMB include the medical directorship of the Psychiatry Department’s outpatient clinics, supervision of residents and medical student education.  He is responsible for the clinical supervision of the Child and Adolescent Psychiatry residents in their final year of training.  Dr. Wolf serves as the chairman of one of two Institutional Review Boards which oversees all human subject research at UTMB.   His clinical practice includes a broad based patient population with an emphasis on the treatment of ADHD as well as mood disorders.   His research interests include the study of bipolar disorder, and medical student education with an emphasis on team based learning and the use of film and cinema in psychiatric education.   

More about the Speakers...          More about the Topics...               Stipend Information...

Become a sponsor...                              Exhibitor Information...                            Ads...

Cost of Attendence

Members- $100 (Early Bird $75), Non-Members- $135 (Early Bird $110), Special! (Join now & Attend Conference)- $130 (Early Bird $105)

Early Bird prices end 1/31/2014

Hotel Accommodations DoubleTree by Hilton Hotel Houston Intercontinental Airport 15747 JFK Boulevard, Houston, TX 77032

Go to http://doubletree.hilton.com/en/dt/groups/personalized/H/HOUAPDT-ADD-20140221/index.jhtml to make your reservations. ADDA-SR Conference rate is $89/night. Book by February 8, 2014.

CE Credits

Continuing Education Credits available:

• LPCs                  5.25 Credits

• LMFTs                5.25 Credits

• Social Worker     5.25 Credits

• Educators           5.25 CPE Credits
• OTs                    5.25 Type 1 Credits

Dress Code  Casual Attire.

Schedule

8:00 - 8:45 Special Pre-Conference Session (no credits— please register)

1 ABCs of ADHD

  David Brown, M.D. 

2 Educational Laws Overview, 504 and IDEA

  Rachel Beard, Advocate

3 Developing Self Control in Young Children

  Sue MacHugh, Trainer 

9:00 - 10:30 Conference Welcome General Session—New Developments in ADHD Treatment  

                  Dwight V. Wolf, M.D.                         AEMP       

10:30—10:45 Break 

10:45— 11:45 

1 School Success from Elementary to High School

   Kimberly Harrison, MA, LPC, LPA                      EMP

2 Managing Anxiety in Adult ADHD:  Behavioral Interventions and Self-Management 

   Joel Farb, M.A.                                                 AM         

3 The Nurtured Heart Approach

   Nancy Kling, M.A., LPC                                     EMP

4 Mastering Manipulation

  George Burnetz, M.Ed., NCC-LPC                       EMP

5Co Morbids and Medication Management

   Debra Stokan, M.D.                                          AMP 

11:45 - 1:15 Lunch (on your own) 

12:30 - 1:10 Special Sessions—No CEs—Registration not required 

1 The Doctor Is In, Meds Q & A

  Bernard Rosenberg, M.D.

2 The Advocate Is In, IDEA and 504 Q & A

  Laura Peddicord, Advocate & Robin Rettie, M.Ed.

3 Clips from Video, Father to Father: Expert Advice on ADHD Dad’s Video

  Chris ZeiglerDendy, M.S. & Tommy Dendy, B.S.

4 Organizing and Leading Support Groups for ADHD

  Aaron Fink, M.D. 

1:15 - 2:15 

1 Utilization of New Technology in the Evaluation and Treatment of ADHD (Part 1)          

  Jay D. Tarnow, M.D. & Ron J. Swatzyna, Ph.D., LCSW                                             AEMP  

2 TBA

3 Managing Motivation and Procrastination

  Eddie Rodriguez, B.S., ACT                                 AM

4 Off the Wall Approaches

  George Burnetz, M.Ed., NCC-LPC                       EMP

5 Teaching Strategies to Enhance Executive Functions

  Chris Dendy, M.A.                                               EP 

2:15 - 2:45 Beverage Break 

2:45– 3:45 

1 Utilization of New Technology in the Evaluation and Treatment of ADHD (Part 2)           AEMP   

  Jay D. Tarnow, M.D. & Ron J. Swatzyna, Ph.D., LCSW

2 Sunrise, Sunset – Circadian Rhythms and Learning

  Joshua Rotenberg, M.D                                       AEMP

3 Structured Discipline Communication: Helping Children with Attention Problems 

   Listen,Cooperate and Do!      

   Earl S. Saltzman, Ph.D.                                     EMP

4 Organization and Task Management

  Evan Weinberger, PH.D.                                      AEMP

5 Father to Father: Expert Advice on ADHD

  Chris Zeigler Dendy, M.S                                      AMP

3:45 - 4:00 Break 

4:00 - 5:00

1 Surviving the Ride: Parenting Challenging Teens with ADHD

  Chris Zeigler Dendy, M.S.  & Tommy Dendy, B.S.                                                       EMP

2 Story as a Mode of Social Skill Instruction for Students

 Thomas Merriman, Ed.D.                                      EMP

3 Paper, Paper Everywhere

  Ellen Delap, CPO                                                AEMP

4 Interpersonal Relationships                                 AM

5 Ethical Decision Making

  Robbie Sharp, Ph. D.***

*** qualifies for ethics credits              

A - Adults with ADD, Spouses, Parents of adult children, E - Educators M - Mental Health Professionals P - Parents of Children with ADD/ADHD

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

From the American Academy of Pediatrics:Clinical Report: Returning to Learning Following a Concussion

• Mark E. Halstead, 
• Karen McAvoy, 
• Cynthia D. Devore, 
• Rebecca Carl,
• Michael Lee, 
• Kelsey Logan, 
• Council on Sports Medicine and Fitness,
• and Council on School Health

Pediatrics 2013; 132:5 948-957; published ahead of print October 27, 2013, doi:10.1542/peds.2013-2867

• Abstract
 
• Full Text
 
• Full Text (PDF)

1. Caution recommended when treating concussion with cognit

   • Marc P DiFazio, M.D., Pediatric Neurologist
    
   • Joshua Rotenberg, M.D. Pediatric Neurologist

   Childrens National Medical Center, Washinton, DC
   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.

   References

   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