Pediatric Chronicle Autumn 2014 by Derm City

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PEDIATRIC

CHRONICLE Canada’s National Newspaper of Pediatric Medicine pediatric.chronicle.ca Preview Edition • Autumn 2014

‘Super Lice’?

UTIs in children Canadian Paediatric Society urges improved management

Non-pesticide therapies available to treat strain in Canada by Halvor

R. Kinskela

for Pediatric Chronicle

Study shows many North American lice infestations are resistant to available pesticide-based products

Dear Doctor: We are pleased to introduce you to this new publication, which we describe, with a fair bit of pride and only a trace measure of irony, as the Pediatric Literature’s New Kid on the Block. Metaphors aside, this is a different type of periodical, and emphatically not your father’s (or mother’s) paediatrics journal. Pediatric chroNicLe was designed not to add to the volumes of data regularly presented to the practitioner—but rather to aid in the orderly navigation and consideration of useful clinical information by over-busy pro—please turn to page 3

by Emily

Innes

Pediatric Chronicle Assistant Editor

n response to recent studies that have led to changes in the management of urinary tract infections (Utis) in children, the canadian Paediatric Society released a position statement and practice points on Utis in June. the cPS last released guidelines and recommendations on the management of Utis in 2004, and the authors note in this new statement that since then meta-analytic reviews have investigated the utility of diagnostic tests, radiological assessment and randomized control treatment trials published. as well, in 2011 the american academy of Pediatrics revised its clinical practice guidelines for diagnosing and managing febrile Uti in young children. the cPS investigators recommend that Utis should be ruled out in infants from two to 36 months with a fever higher than 39°c and no other source for fever on history or physical examination. these patients should have urine collected for urinalysis, and if not completely clear then urine should be collected by catheter or SPa to be sent for microscopy and culture before prescribing antibiotics. “the main challenge [in diagnosing Utis in children] is getting a good urine sample . . . in children who are not yet toilet-trained,” said dr. Joan L. robinson, an albertabased pediatrician, chair of the cPS’ infectious diseases and immuniza-

tion committee, and one of the statement authors. She said some physicians and nurses are reluctant to use the recommended method, a catheter, “so sometimes the urine is collected by other means, most commonly by a little plastic bag that has tape on it that is put over the genitals. But the problem with that is that commonly bacteria can end up in that bag that were not actually in the bladder . . . So then fairly often a positive result comes back even if the child does not have a urinary tract infection.” if a physician is uncomfortable using catheters with infants, she suggests referring the patient to a pediatric emergency department, if practical. having the parent catch a urine sample in a sterile container when the child urinates is an alternative, although this can be time-consuming. Antibiotic resistance the problem with over diagnosis of Utis, according to dr. robinson, is the growing concern of antibiotic resistance. there have been relatively few “new classes of antibiotics [in the last decade] and as time goes by we get more and more bacteria that are resistant to the antibiotics that we currently have. “one thing that we know will work is that we can markedly decrease the use of antibiotics, and cer—please turn to page 12

Childhood obesity: Some BMI metrics are superior fat-mass proxies in measuring change see page 6

More awareness and support needed for pediatric patients by Emily

Innes

Pediatric Chronicle Assistant Editor

anadian researchers have identified that availability, cost, and product labelling are major barriers to adherence to a gluten-free (GF) diet for pediatric patients with celiac disease, according to their study published in the journal Paediatrics & Child Health (June/July 2014; 19(6): 305-309). Parents of patients between the ages of two to 12 years with biopsy-confirmed celiac disease were surveyed using a questionnaire to determine factors that affect adherence to a GF diet. adolescents 13 to 18 years of age responded to the survey themselves. overall adherence was high, the authors noted, though it was lower for adolescents. through a ranking system of one (never) to 10 (always) based on how often the issue was problematic, the investigators identified the barriers listed above. “the adherence at home and at school was quite good, but where people struggled was in social activities, in restaurants [and when] eating out, at parties. certainly at sleepovers and camps adherence was not as good,” said Dr. Mohsin Rashid (pictured above right), a pediatric gastroenterologist, and professor in the department of Paediatrics & Medical education at dalhousie University in halifax, and co-lead investigator of the study. “[a gluten-free diet] is a really big lifestyle change. it can be done, and many people do really well with this, but it has its own challenge.”

A different threshold in recent years there has been a trend toward individuals without celiac disease following a GF diet. this, according to dr. rashid, has pros and cons for the pediatric patients with celiac disease. “the thing that we need to be very cautious about is that people with celiac disease cannot take any gluten at all— their threshold for contamination is very different,” said dr. rashid, a member of the national Professional advisory Board of the canadian celiac association. “i think as more people get on GF diets, for whatever reason, the food industry will respond. they are responding, restaurants are offering gluten-free —please turn to page 12

Image courtesy Walter Siegmund

Welcome to Pediatric Chronicle

ccording to some canadian specialists, North americans should not panic about the report published in the journal Entomological Society of America (Mar. 2014; 51(2):450 –457) regarding the growing frequency of knockdown-type resistance allele in human head lice, known as “super lice.” Non-pesticide therapies, not discussed by the researchers, are now available and have high rates of safety and efficacy. Dr. John Kraft (pictured above left), with the Lynde institute for dermatology in Mark ham, ont., says that while the news that lice are becoming resistant to pest icide-based treatment products in the majority of infestations in North america is concerning, “there are other options.” —please turn to page 12

Celiac disease

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Welcome

continued from page 1— fessionals. Please think of this title as a type of medical search engine, utilizing the supremely elegant and convenient delivery technology known as “ink-on-paper.” the launch of a new publication is often taken as an occasion for the lengthy declaration of various individuals’ principles. We will spare you that pretense, in keeping with our intention to allocate time judiciously. No declarations, then. Simply this paragraph: This newspaper aspires to assist in providing information and insights of value, and to be worthy of inclusion in a medical specialist’s information-gathering regimen. We promise never to waste a moment of your time, or to undervalue or in any way fail to respect the vital and essential work you do. that’s all. Please enjoy this Preview issue, and by all means let us know what you think. —Mitch ShaNNoN, Publisher

Pediatrics

Pediatrics observed

In brief

St. Joseph’s Children’s Hospital of tampa, Fla. introduced mobile telemedicine carts to connect with a specialized remote team at childrens’ hospital of Pittsburgh, to assist in providing cardiac care to pediatric icU patients.

Images from the world of Pediatric Medicine: We invite you to submit your photographs for publication in this regular department of Pediatric chroNicLe. Send original high-resolution (2 megapixel and higher) JPGs to: health@chronicle.org

Pediatric mask developed using 3D camera technology

University of alberta pediatric pulmonologist has used 3d technology to develop an inhalation mask that properly fits pediatric patients. Dr. Israel Amirav (left), a faculty member in the department of Pediatrics at the University of alberta in edmonton and in Northern israel, recognized that the inhalation masks his pediatric patients were wearing were only scaled down versions of ones for adults and did not seal properly. this allowed medicine to dissipate in the air rather than be properly administered to the child. dr. amirav discovered that the only children’s mask using children’s measurements is based on an airplane oxygen mask developed over 60 years ago. it was created using measurements from only 30 to 40 children. “i decided to measure infants’ faces and heard about the 3d camera technology the computer science department created at technion israel institue of technology,” said dr. amirav. Using the camera, he took 3d images of the faces of about 300 children between the ages of zero and four. the photo-

graphs were then archived and analysed. the data was grouped into three different sizes: small, medium, and large. Using a mathematical process, each child’s photo of each cluster size was averaged, producing the three average sizes. these sizes were transferred to the design of the mask. dr. amirav also included a hole in the mask so a pacifier could fit to help soothe the child in between taking the medicine. according to dr. amirav, it used to be challenging to get a patient to use ventilators because of the poor fit, but his inhaler has increased patient compliance. “We can now give the mask to the mother to use on the child. they come back to us and say, ‘My child takes the medication and sleeps well now, doesn’t cough, and is developing well.’” the masks have Fda approval and are awaiting canadian approval.

Pediatric

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canadian and irish researchers have discovered that children’s television programs in the U.K. and ireland have a high level of unhealthy food cues such as an overrepresentation of sweet snacks and candy being associated with celebrations and being hungry, according to findings published in the journal Archives of Disease in Childhood (June 30, 2014). More at http://ow.ly/zuVIm emergency departments in alberta are rarely using policies and protocols to manage pediatric pain. in a study, published in Paediatrics & Child Health (apr. 2014; 19(4):190–194), researchers urged canadian pediatricians to advocate for improved analgesia to narrow the knowledge-topractice gap. More at http://ow.ly/zuUf2 case reports of allergic contact dermatitis (adc) in pediatric patients have risen rapidly since 2000 in many different countries. Metal allergens in both cheap and expensive cell phones, notably nickel and chromium, are frequently reported as a trigger for the acd, report authors in a study published in the journal Pediatric Allergy, Immunology, and Pulmonology (June 2014; 27(2):60–69). More at http://ow.ly/zuXeo

Publisher Editorial Director Senior Associate Editor Assistant Editor Assistant Editor Advertising & Partnerships Production & Circulation Comptroller

Mitchell Shannon R. Allan Ryan Lynn Bradshaw John Evans Emily Innes Sandi Leckie, RN Cathy Dusome Rose Arciero

n A NOTE TO OUR READERS: The Chronicle is proud to be the first Canadian publisher to provide its national medical publications printed on 50 per cent post-consumer recycled paper, which is the highest percentage of recycled stock currently commercially available. Pediatric Chronicle is committed to maintaining leadership in environmentally sustainable policies, and to encouraging the adoption of “green-aware” practices in healthcare. We invite your comments via e-mail, at: health@chronicle.org

Contacting Pediatric Chronicle

QUOTED & NOTED © Anita Peppers | Morgueﬁle

“For kids that are maltreated, you can think of it as daily stress, such as being told ‘no’ or peer social interactions that they cannot regulate. they slip more easily into emotional dysregulation, for example a ‘fight or flight’ response,”

—Dr. Benjamin Klein of Hamilton, Ont. (see page 10)

Autumn 2014

n READER SERVICE: to change your address, or for questions about your receipt of the journal, send an e-mail to health@chronicle.org with subject line “circulation,” or call during business hours at 416.916.chron (2476), or toll-free at 866.63.chroN (24766). n CORRESPONDENCE FOR PUBLICATION: We welcome your correspondence by mail, fax (416.352.6199), or e-mail. Kindly use the co-ordinates listed above. n ADVERTISING: For current rates and data, please contact the publisher. n REPRINTS: the content of this journal is copyrighted. Please contact Mitchell Shannon for reprint information.

PEDIATRIC CHRONICLE • 3

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Pain under-treated in pediatric patients Parents may be averse to the idea of administering pain medication to their children by Louise

Gagnon for Pediatric Chronicle

ain is typically under-treated in pediatric patients, and healthcare professionals should educate parents about steps that they can take to reduce their children’s experience with pain on an outpatient basis, according to a presentation at the inaugural Pediatric Wound care Symposium in toronto, organized through the hospital for Sick children. “Provide them with written and verbal advice and point them in the direction of reputable web sites and video clips,” says Dr. Fiona Campbell (left), an anesthesiologist and co-director of the Pain centre at the hospital for Sick children and associate professor at the University of toronto.

PAIN

MANAGEMENT in her presentation, dr. campbell stressed that parents need re-assurance about providing pain control to their children. “they need to know it’s okay [to intervene to reduce their children’s pain],” she said. Few analgesics administered one study involving 132 parents of children aged two to 12 years of age found that despite identifying pain in their children who had undergone surgery, parents administered few doses of analgesics to them in the first 48 hours following hospital discharge. the researchers identified attitudes to pain management that correlated with parents’ administration of fewer doses of analgesia, noting more than half of parents reported they thought analgesics were addictive (Pediatrics 2010; 125(6): e1372–1378).

Nutraceuticals prophylaxis of pediatric migraine? Parents are interested in administering them to their children, therefore side effects, efficacy should be better understood by Emily

Innes for Pediatric Chronicle

Certain nutraceutical agents are showing promising results in the prophylaxis of migraine in pediatric patients, though the quality of evidence for their use is still poor, according to a study published online in the journal Cephalalgia (Jan. 17, 2014). Ottawa researchers reviewed the literature regarding six different nutraceuticals used for treating pediatric patients—including butterbur, riboflavin, ginkgolide B, magnesium, coenzyme Q10 and polyunsaturated fatty acids. “The main impetus [for the study] really was the interest that I was getting from patients and their families,” said Dr. Serena L. Orr (pictured left), a neurology resident at The Children’s Hospital of Eastern Ontario (CHEO) in Ottawa and the study’s lead author. “Either they have heard about it in the media or they have been doing their own reading because they have an interest in it. “I find that some families prefer to try to start with a nutraceutical agent, if possible, prior to prescribing something pharmaceutical. A lot of families feel more comfortable with that, especially if their child has never been on medication before.” Dr. Orr said there is limited research on the subject in adults and even less for pediatric patients, which she added is a common trend across the board. Magnesium, coenzyme q10, and butterbur have demonstrated efficacy and low side effect profile She said that despite the lack of research, she sometimes recommends patients try magnesium, coenzyme Q10 and petadolex—a formulation of butterbur root (pictured right)—based on the preliminary evidence of efficacy and the low side effect profile. “Pretty much with every new migraine patient I mention these as options and I talk about the limitations of the literature, but I also mention that at least those three particular agents seem to be safe based on the preliminary studies,” she said. Promising randomized control trials regarding petadolex for adult migraineurs have led both the Canadian Society Headache and the American Academy of Neurology to strongly recommend its use, said Dr. Orr. The significance of Dr. Orr’s study is recognizing an area that needs to be better studied and understood. She said she hopes her paper acts as an anchor for where researchers might go next with this topic. “I think it is really important to do more research because the reality is that there is a public perception that nutraceuticals are safe because they are ‘natural’,” said Dr. Orr. “[But] nutraceuticals have side effects as well.” Some studies have shown that some formulations of butterbur, other than petadolex, can contain high levels of pyrrolizidine alkaloids, which can cause liver failure. Dr. Orr said this is not the case with petadolex because it is strictly regulated. Other nutraceuticals have been found to have minimal side effects, according to Dr. Orr. The most frequent side effect of coenzyme Q10, for example, is increased burping. “It is true that some are [safer] but not all [are] and I think we owe it to our patients to establish what is safe and what is not and what works and what does not.” An area where Dr. Orr said she would like to see more research is for agents where the levels in patients can be measured, such as magnesium or coenzyme Q10. It would be worthwhile to determine if the nutraceuticals are only effective for those patients who are deficient or if they help non-deficient patients as well. She added that more randomized controlled trials should be conducted in pediatric patients for the nutraceuticals that have shown promise in adults. —Read more information at http://ow.ly/vOidl

4 • PEDIATRIC CHRONICLE

an acknowledgment by parents that their children are having pain is not sufficient, and they should be provided with instructions regarding measures they can implement to provide pain relief, explained dr. campbell. healthcare facilities should have pain assessment policies in place, so that validated tools can be used to assess the prevalence and degree of pain, stressed dr. campbell. Pain under-recognized “everyone needs to have a policy around assessing pain and treating pain to raise the awareness [about pain],” said dr. campbell, noting pain is the fifth vital sign. “if you do not know how much pain [a patient has], how do you treat it?” Pain is typically under-recognized and undertreated in patients in hospital and that phenomenon applies in the pediatric setting, said dr. campbell, noting one study found that adolescents reported that pain was the worst aspect of hospitalization (MCN: The American Journal of Maternal/Child Nursing Sep-oct 2006; 31(5):290–295). children typically receive less medication than what is prescribed to them, regardless of how severe their pain is, and they also receive less analgesia than adults, noted dr. campbell. Several reasons may explain why pain is undertreated in children, including the lack of a diagnostic test for pain and the lack of education that health professionals such as nurses and physicians receive with respect to pain management, said dr. campbell. assessing pain in children consists of three spheres including self-reports such as the Faces scales, Numeric rating Scale or Visual analog Scale, physiological reactions from a child, and behavioural observations such as the Face, Legs, activity, cry, consolability (FLacc) scale, used to measure pain in children between two months and seven years of age or in children who are cognitively impaired and are not able to communicate their pain. Pain management can include physical strategies such as providing ice or heat and massage to patients. it can also include psychological strategies such as using distraction or cognitive behavioural therapy, and pain management can also include pharmacological strategies, such as providing prescription therapies. Tailor meds to patient “the perfect analgesic does not exist,” said dr. campbell. optimal use of analgesia involves following the World health organization recommendations and using more than one class of analgesic or adjuvant, with each therapy working in a different way to achieve improved pain relief and decrease adverse events. initial therapies should include simple analgesia such as acetaminophen and NSaids, said dr. campbell. as pain increases, clinicians can add in opioids; lower doses for moderate pain and higher doses for more severe cases of pain that prove refractory to milder treatments. accurate weight-based dosing is required for safety, she added. “opioids rarely cause addiction when used appropriately for pain relief,” she said, and can be used under medial guidance for children of any age. Pain management related to procedures should be tailored to patients. For example, in infants less than 18 months of age, 24% sucrose administered on the tip of the tongue two minutes prior to a procedure can make the pain related to a procedure more tolerable, said dr. campbell. topical local anesthetics should be used for all skin breaking procedures. it would be advisable for clinicians to keep in mind several goals in procedural pain management such as performing the procedure (whether it is required, and making sure it is done properly), ensuring patient safety, preventing or minimizing discomfort, and, if sedation is used, returning patients to a state such that they can be discharged, added dr. campbell.

PREVIEW EDITION

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Atopic dermatitis and skin barrier dysfunction

Clinical experience with the use of skin care containing colloidal oatmeal and ceramides

Colloidal oatmeal-containing skin care reduces inflammation and itch in

Catherine McCuaig, MD, FRCPC

PEDIATRIC PATIENTS WITH ATOPIC DERMATITIS

About 90% of Atopic Dermatitis (AD) cases present before five years of age, with an estimated prevalence of 17.2% in children aged five to nine years.1 The cause of AD involves both genetic and environmental factors.2 Skin barrier dysfunction in AD is evidenced by increased transepidermal water loss, skin penetration of irritants and allergens, leading to cytokine release, dermal inflammation and itching. In children, itching often leads to scratching, enhancing the risk for secondary infection. Use of colloidal oatmeal-containing skin care to restore skin barrier function Avena sativa extracts are well known for their repairing and soothing properties; the compounds have the potential to help reduce inflammation and irritation, as well as promote skin barrier repair 6 (Table 1). In a randomized, controlled study, Grimalt, et al. (2007) evaluated the effect of an oat-containing moisturizer (AveenoÂŽ (Johnson & Johnson Inc.)) on the amount of topical corticosteroids used in infants with moderate to severe AD.7 In the six-week study, 173 infants under 12 months old were treated for inflammatory AD lesions by moderate- and/or high-potency topical corticosteroids. Only the study group was additionally treated with an oat-containing moisturizer.7 Corticosteroid consumption was evaluated by weighing the tubes. Disease severity was assessed by the Scoring Atopic Dermatitis Index (SCORAD), and quality of life (Infant's Dermatitis Quality of Life Index and Dermatitis Family Impact scores), was scored at baseline, week 21 and week 42.7 In the study group, the amount of corticosteroids used in six weeks decreased by 7.5% and 42% (p<0.05), respectively.7 The SCORAD index and quality of life scores indicated a significant improvement (p<0.0001) in both groups.7 The colloidal oatmeal-containing moisturizer also contains avenanthramides, which were shown to have multifaceted, anti-inflammatory activity that includes inhibition of nuclear factor (NF)-KB activation in keratinocytes and reduction of both the skin immune response and the skin neurogenic inflammatory response6 (Fig. 1). Moisturizers that soothe pruritus, hydrate, protect and restore the skin barrier are essential for the effective management of AD.3-5 Several pediatric atopic dermatitis consensus reports recommend these moisturizers as first-line agents in the treatment of AD.3-5 Daily moisturizers are also used as complementary to prescription medications for enhancement of treatment efficacy and for their steroid-sparing effect.3-5

Table 1: Colloidal oatmeal compounds and their function [6,8] Ingredient

Function

Protein (10%-18%)

Acts as an emulsifier, promotes hydration and promotes antioxidant activity

Polysaccharides (60%-64%)

Î˛-glucan appears to have immunodulatory activity, which could represent a modulating effect on inflammation

Lipids (3%-9%)

Contribute to viscosity to reduce the rate of TEWL

Antioxidant enzymes, saponins, vitamins, flavonoids, and prostaglandin synthesis inhibitors (7%-9%)

All have anti-inflammatory properties

Fig 1: In Vitro Effects of an Oatmeal-Based, Avenanthramide-Containing Moisturizer [6] 100 90 % average improvement

Case presented by

80 70 60 50 40 30

Week 1 Week 2 Week 4

20 10 0 roughness

overall dryness

cracking

scaling

itch

Conclusions â&#x20AC;˘ Colloidal oatmeal is proven to be well-suited for treating inflammatory skin conditions, including atopic dermatitis. â&#x20AC;˘ This natural ingredient moisturizes, helps protect the skin barrier, and has demonstrated anti-inflammatory and anti-pruritic activity. â&#x20AC;˘ Additionally, colloidal oatmeal has been shown to restore skin barrier function and has a central role in the evolution and progression of atopic dermatitis.

References /HUPĂ&#x201E;U 14 9LLK 43 ( WVW\SH[PVU IHZLK Z\Y]L` VM LJaLTH WYL]HSLUJL PU [OL <UP[LK :[H[LZ Dermatitis 1\U" ! *VYR 41 9VIPUZVU +( =HZPSVWV\SVZ @ L[ HS! 5L^ WLYZWLJ[P]LZ VU LWPKLYTHS IHYYPLY K`ZM\UJ[PVU PU H[VWPJ KLYTH[P[PZ! .LUL LU]PYVUTLU[ PU[LYHJ[PVUZ J Allergy Clin Immunol " ! 9\ILS + ;OPY\TVVY[O` ; :VLIHY`V 9> >LUN :* .HIYPLS ;4 =PSSHM\LY[L 33 *O\ *@ +OHY : 7HYPRO + >VUN 3* 3V 22! *VUZLUZ\Z N\PKLSPULZ MVY [OL THUHNLTLU[ VM H[VWPJ KLYTH[P[PZ! HU (ZPH 7HJPĂ&#x201E;J WLYZWLJ[P]L J Dermatol 4HY" ! -V^SLY 1- 5LI\Z 1 >HSSV > ,PJOLUĂ&#x201E;LSK 3-! *VSSVPKHS VH[TLHS MVYT\SH[PVUZ HZ HKQ\UJ[ [YLH[TLU[Z PU H[VWPJ KLYTH[P[PZ J Drugs Dermatol " ! 5LI\Z 1 5`Z[YHUK . -V^SLY 1 >HSSV >! ( KHPS` VH[IHZLK ZRPU JHYL YLNPTL MVY H[VWPJ ZRPU J Am Dermatol " !() >HSSV > 5LI\Z 1 5`Z[YHUK .! (NLU[Z ^P[O HKQ\UJ[P]L WV[LU[PHS PU H[VWPJ KLYTH[P[PZ J Am Acad Dermatol " Z\WWS ! () (IZ[YHJ[ 7 -`OYX\PZ[ =HUUP 5 (SLUP\Z / 3H\LYTH (! *VU[HJ[ KLYTH[P[PZ Dermatol Clin " ! .YPTHS[ 9 4LUNLH\K = *HTIHaHYK -! ;OL Z[LYVPKZWHYPUN LMMLJ[ VM HU LTVSSPLU[ [OLYHW` PU PUMHU[Z ^P[O H[VWPJ KLYTH[P[PZ! H YHUKVTPaLK JVU[YVSSLK Z[\K` Dermatology " ! *OLU *@ 4PSI\Y` 7, *VSSPUZ -> )S\TILYN 1)! (]LUHU[OYHTPKLZ HYL IPVH]HPSHISL HUK OH]L HU[PV_PKHU[ HJ[P]P[` PU O\THUZ HM[LY HJ\[L JVUZ\TW[PVU VM HU LUYPJOLK TP_[\YL MYVT VH[Z J Nutr " ! ÂŠ MMXIV, Chronicle Information Resources Ltd. Editorial feature supported by an unrestricted grant from Johnson & Johnson, which is not responsible for content.

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BMI metrics: Some are superior fat-mass occupational health in Montreal. as part of a study published online in Archives of Disease in Childhood (May 19, 2014), dr. Kakinami and her colleagues looked at data from the

Children’s physical activity: Canada attains poor score in annual report

Walter Siegmund

by John Evans Assistant Editor, Pediatric Chronicle

FITNESS

& Weight MANAGEMENT oth absolute and per cent change in Body Mass index (BMi) appear to be good proxies for change in fat mass (FM) or fat mass index (FMi) in eight- to 10-year old children, while BMi z-score is a good proxy for FM z-score change in the same age group. this finding may help support research into how childhood obesity progresses as the child grows up. While dual-energy X-ray absorptiometry is the gold standard for measuring adiposity, BMi is typically used as a proxy in clinical settings. Yet BMi is age dependent, so identifying the adiposity proxy measure that best maps onto change in actual fat mass in children would be a great benefit for tracking the health of children at risk of obesity as adults, says dr. Lisa Kakinami, a researcher at McGill University’s department of epidemiology, Biostatistics and

Active Healthy Kids Canada has released its 2014 report card, the 10th anniversary edition, and Canada has received a D- for overall physical activity. Other countries with the same score as Canada were Australia, Ireland, and the United States, while only Scotland fell below them with an F. At the top of the chart were Mozambique and New Zealand, each with a B. The authors of the report noted that while Canada ranked well for sophisticated policies, places for activities, and programs, only 4% of children between the ages of 12 and 17 years met the guidelines for physical activity of 60 minutes of moderate- to vigorous-intensity. The researchers commented that it is “encouraging” that 84% of children between the ages of three and four years met the guidelines suggested for their age group—180 minutes of activity at any intensity. However, only 7% of children between the ages of ﬁve and 11 years met the 60-minute guideline. “It seems that we have built it, but they are not coming,” the investigators stated. “Why are our kids sitting more and moving less? The answer requires a hard look at our culture of convenience. For most Canadians, the socially acceptable walking distance to school is less than 1.6 km, and distance between home and school is the single most reported reason why kids do not walk or bike to get there. In Finland, however, 74 per cent of children who live between one and three km from school use active transport, and nearly all children living one km or less from their school commute actively. Finland is a world leader with a B in Active Transportation, in part because its social norms differ dramatically.” In the Organized Sport Participation category, Canada gets a C+, an incomplete for Active Play, a D in Active Transportation, a grade of C in the categories of Family & Peers and Government Strategies & Investments, and a C+ for School. Canada is in second place with a B+ in Community & The Build Environment, and is failing in the category of Sedentary Behaviours, with 61% of parents believing their children spend too much time watching television. “To increase daily physical activity levels for all kids, we must encourage the accumulation of physical activity throughout a child’s day, and consider a mix of opportunities (e.g., sport, active play, active transportation). In some cases, we may need to step back and do less. Developed societies such as Canada must acknowledge that children need room to move,” suggest the authors. More information at http://ow.ly/zv6VA

GOOD NEWS FOR KIDS! BAD NEWS FOR WARTS!

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mass proxies in measuring childhood adiposity change Québec adipose and Lifestyle investigation in Youth cohort—a prospective cohort of 557 children from Québec who were between ages eight and 10 when recruited. height and weight of the cohort children had been recorded once in 2008, and on follow-up in 2010. the researchers compared several metrics of BMi change to fat levels measured through dualenergy X-ray absorptiometry. Metrics included raw change in BMi, adjusted for median BMi, and age-sex-adjusted using the centers for disease control and Prevention’s growth curves, expressed as either centiles or z-scores. “in children when we measure BMi, we can’t just take their height and weight like we would in an adult,” says dr. Kakinami. “We have to use a reference curve for children of same age and same sex, in terms of their height and weight. as we know, children are growing. a BMi of 12 in a child might not indicate they are underweight. it might indicate something else when you take into account their age and their sex.” the first major finding of the study, says dr. Kakinami, is that the BMi centile from the growth curves that doctors normally use do not map very well to direct fat measures when looking at change over time. “even though the BMi centile is developed and is really well validated and is a better measure than a lot of other body composition measures for children at one point in time, our study found that it is really not necessarily the best way to measure changes is [children’s] adipose tissue,” she says. there is some controversy in the literature over what the best way to measure fat mass in children is, says dr. Kakinami, with different researchers looking at fat mass, fat mass as a percentage of the child’s total weight, or adjusting the fat mass for the height of the child. “We found that just changes in [children’s] raw BMi, or changes in their

BMi percentage, mapped on best with changes in the raw value of fat mass,” says dr. Kakinami. and in terms of looking at changes of adiposity over time, the FMi doesn’t map very well with any of the BMi measures, she says. changes in BMi centile only modestly correlated with changes in raw fat mass, percentage fat mass, and the height-adjusted fat mass index, so dr. Kakinami and her team do not recommend it for longitudinal tracking. dr. Kakinami says she would like to redo the study with a larger sample over a wider age range to see whether or not this finding of the BMi centile not mapping well onto dual-energy X-ray absorptiometry holds up. “i think that could be an important lesson for family practitioners as well as families, in terms of knowing if their BMi percentile is changing,” she says. “We found this to be the case especially in very obese children,” says dr. Kakinami. BMi percentile only goes from zero to 100%, so for an individual who is already very obese, their BMi percentile is not going to change as much. “in that instance it is probably better to use a BMi z-score, which is not bounded by zero and 100, and could be a better indicator of how much of a difference you have in your BMi over time.” “it would be nice to identify the fat mass measurement that we want to be using with [dual-energy X-ray absorptiometry]. i think that it is fairly ambiguous right now as to which measurement is best to map onto adiposity,” says dr. Kakinami. “and for that, we really need to measure adiposity in children in terms of their [dual-energy X-ray absorptiometry] values, and then see which ones have what types of health outcomes as adults, for example. that’s really the only way you can best assess it.”

Pediatric weight management: Canadian registry in progress As a result of a three-fold increase of overweight and obese children in Canada over the last decade, the CANadian Pediatric Weight management Registry (CANPWR) is in the process of being developed, according to a study protocol published in the journal BMC Pediatrics (July 24, 2014; 14:161). According to the study authors the three goals of the CANPWR are to document changes in anthropometric, lifestyle, behavioural, and obesity-related comorbidities in children enrolled in Canadian pediatric weight management programs over a three-year period; characterize the individual-, family-, and program-level determinants of change in anthropometric and obesity-related co-morbidities; and to examine the individual-, family-, and program-level determinants of program attrition. A pilot study was completed at ﬁve centres and the researchers stated it aided them in determining the core data set of outcomes and measurement protocols, a harmonized data collection method, and the case report forms.

The 1,600 participants must be between the ages of two and 17 years with a body mass index (BMI) of greater than the 85th percentile. The study will be run at eight different weight management centres afﬁliated with children’s hospitals across the country—including McMaster’s Children Hospital in Hamilton, Ont., BC Children’s Hospital in Vancouver, Stollery Children’s Hospital in Edmonton, The Hospital for Sick Children in Toronto, North York General Hospital in Toronto, Children’s Hospital of Eastern Ontario in Ottawa, Montreal’s Children’s Hospital, and CHU Sainte Justine in Montreal. The study will take place over a three-year period, and the researchers will collect data at presentation and at six-, 12-, 24-, and 36-month follow-up. The primary study outcomes will be the BMI z-scores and their changes over time. The secondary outcomes will include anthropometric, cardiometabolic, lifestyle such as dietary and exercise, and psychosocial variables. The authors noted that they were inﬂuenced by The Canadian Clinical Practice Guidelines for the Management and Prevention of Obesity, which highlighted the

“mismatch between the high prevalence and significance of pediatric obesity and the limited knowledge base from which to inform treatment strategies.” The investigators state that they believe the CANPWR will contribute by being “the first harmonized, evidence-based registry and platform that identifies the key determinants of weight change in eight pediatric weight management centres across Canada. “The registry will contain detailed information regarding individual-,family-, and program-level determinants of change in health outcomes and behaviours. It will make it possible to compare these determinants of change in a large, diverse population of children and their families throughout Canada. The outcomes of this study are expected to contribute important information on the suitability of change in weight status and obesityrelated co-morbidities.” CANPWR could also be helpful in determining subgroups of children who do not respond well to treatment paradigms, the authors noted. For more information visit: http://ow.ly/zuN9k

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Wound care principles of bacteria especially important in pediatric cases Wound swab rarely sufficient to diagnose serious infection by Louise

Gagnon for Pediatric Chronicle

actors such as the host defenses, the number of bacteria, and the virulence of bacteria are important considerations in determining the threat of wound infection, according to an associate professor in the department of Pediatrics at the University of toronto. “any time you are dealing with a wound, you have to think about the vascular supply, the host defence mechanisms, and aggressiveness of the bacteria present,” said Dr. Elena Pope (pictured, left) head, Section of dermatology, division of Pediatric Medicine, the hospital for Sick children in toronto, discussing infection in wounds at the inaugural Pediatric Wound Symposium organized through the hospital for Sick children.

Burns and injuries most common the number of bacteria matters. a small number contaminate each wound, but rarely interfere with wound healing,” said dr. Pope. “if the wound persists,

bacteria multiply and the wound becomes colonized. at some point the balance between host defenses and the bacteria is tipped toward the latter, leading to true infection.” Pediatric wounds have various etiologies, with burns and injuries being the most common. While it’s probably true that children heal faster than adults, wound care is a concern in the pediatric setting. one study found 17% of home healthcare visits for children often involve care for wounds (Ostomy Wound Management 2000; 46(4):36–42). in addition, visits of pediatric patients with open wounds are not uncommon in emergency room departments. the diagnosis of wound infection is a clinical one, stressed dr. Pope. “When an acute wound is infected, it appears red, swollen, and hot,” she said. “if you suspect infection, you have to treat it.”

Clinical clues to watch for For chronic wounds (lasting more than six weeks) other clinical clues that suggest infection are used, such as deterioration of the wound, the presence of exudate, increased size, friable tissue, increased pain, foul odor, discolouration, and a failure to respond to therapy. “chronic wounds can become stuck,” she said. the gold standard for diagnosing a wound infection is a culture from a skin biopsy; a wound swab is rarely sufficient as it may recognize only colonization and contamination, said dr. Pope. When performing a swab, the

WOUND TREATMENT

wound should be cleaned and debrided. dr. Pope added that a wound can look “clean” but colonization could be taking place. When taking a swab, it should be placed on granulation tissue, pressed lightly, and rotated 360 degrees, explained dr. Pope. avoid debris and frank pus when performing the swab, and if the swab is dry, it’s best to moisten it in transport media first. identification and correction of local and systemic factors needs to precede effective wound management in pediatric patients similarly to adult patients, said dr. Pope. Systemic factors such as diabetes are typically not a challenge to face in pediatric wound care, but pediatric patients can experience conditions such as vasculitis or pyoderma gangrenosum, dr. Pope said. Patients should have adequate levels of hemoglobin and good nutritional status to ensure proper wound healing. aspects like immunodeficiency and immunosuppression can influence how wounds heal in patients. these are features that emerge in pediatric oncology in particular. When critical colonization is present, topical antimicrobials and various dressings should be applied. When infection is present, systemic antibiotics should be initiated, taking into consider-

ation concerns like antibiotic resistance, said dr. Pope. “in canada, we do not have to worry as much about MrSa [methicillin-resistant Staphyloccus aureus], but there is a lot of resistance to MrSa in the U.S.,” said dr. Pope, stressing clinicians have to be judicious in their selection of therapeutic antibiotics. Treatment recommendations a panel of the infectious diseases Society of america (idSa) released guidelines on treating patients with MrSa infection in 2011. For minor infections, topical mupirocin 2% is suggested as therapy. For management of major MrSa infections in the pediatric setting, vancomycin is the first-line choice followed by clindamycin and linezolid as second-line choices. the guidelines provide information on vancomycin dosing and monitoring (Clinical Infectious Diseases 2011; 52(3): e8–11). empirical therapy for communityassociated MrSa infection in skin and soft tissue infections is suggested pending results of culture, according to the idSa guidelines. Patients can experience treatment failure with vancomycin, with wounds remaining infected because of strains with decreased susceptibility to vancomycin. dr. Pope cautioned that clinicians should avoid using the same preparation topically and systemically when managing infection in wounds, to prevent potential sensitizers.

Burns often the cause of pediatric wounds Steps can be taken to reduce incidence of potential hypertrophic scarring, skin stripping any of the wounds in the pediatric population are the result of burns, according to a professor of Public Health Sciences and Medicine at the University of Toronto. Speaking at the inaugural Pediatric Wound Care Symposium organized by Toronto’s Hospital for Sick Children, Dr. Gary Sibbald (pictured right) noted that 70% of burn scars occur in the pediatric population. One of the concerns in wound healing is insufficient oxygen and insufficient blood supply, said Dr. Sibbald. “There can be inadequate phagocytosis, and the wound can end up being in the inflammatory stage for some time,” said Dr. Sibbald. “There can be poor quality collagen which leads to skin breakdown and poor epithelialization.”

Stuck in inflammatory stage Indeed, chronic wounds can stall and fail to heal, and they can then become classiﬁed as non-healable wounds, noted Dr. Sibbald. He is director of the Wound Healing Clinic at Women’s College Hospital in Toronto, and a former president of the World Union of Wound Healing Societies. “Chronic wounds often get ‘stuck’ in the inﬂammatory stage,” said Dr. Sibbald. “That can go on for days and

8 • PEDIATRIC CHRONICLE

even into months. They do not advance to the proliferative stage, scar formation, and scar remodelling.” One of the factors that is critical to wound healing is effective wound bed preparation, stressed Dr. Sibbald. “Even with advanced therapies, wound bed preparation needs to be correct,” he said. “That is the most important part of the equation.” Part of effective wound bed preparation is identifying the cause of the wound and determining if systemic factors are interfering with healing or if healthcare system factors are preventing healing, explained Dr. Sibbald (Canadian Association of Wound Care (CAWC) Institute for Wound Management and Prevention. Level 1 workbook: putting knowledge into practice: knowledge learning. Toronto: Canadian Association of Wound Care, 2010). The choice of a dressing is significant in influencing the outcome in wound healing. Wound surfaces, for example, can decrease with the use of silver dressings, noted Dr. Sibbald. Thermometry to ID infection Given the prevalence of burns in the pediatric population, it is important to avoid burn sepsis. One study that looked at a silver dressing to treat burn wounds found burn wound sepsis was reduced in wounds treated with a novel silver-coated dressing. Secondary bacteremias were also less frequent with the use of the novel dressing (Journal of Burn Care Rehabilitation 1998; 19(6): 531–537). Identifying infection is valuable in achieving successful wound healing, and one of the avenues to detecting infection is the use of temperature, said Dr. Sibbald. An increase in temperature can signal a wound infection, so using thermometry may be useful for clinicians. “Not many of you use infrared thermometry in your office,” said Dr. Sibbald.

Referring to a study where temperature emerged as the most important factor in determining deep infection in wounds, Dr. Sibbald stressed that the presence of infection guides the selection of a dressing. “Antimicrobial dressings do not treat infection,” Dr. Sibbald said. “They treat critical colonization.” A paper published in 2013 cited three mechanisms that are signiﬁcant in wound healing in pediatrics: oxygen tension-regulating angiogenesis and revascularization, transforming growth factor-beta kinetics controlling collagen deposition, and mechanical stretch stimulating cellular mitosis and extracellular matrix remodelling (Pediatric Research 2013; 73(4 Pt 2):553–563). Mechanical stretch is a new focus in wound healing, and there are numerous studies examining the impact of mechanical stretch as a means of reducing scarring in wound healing, according to Dr. Sibbald. Some data are indicating that the release of mechanical stress in the wound can reduce the inﬂammatory phase of healing and decrease scarring. Avoidance of scarring key Dr. Sibbald differentiated between pre-natal skin and post-natal skin, noting that pre-natal skin heals such that the skin can be restored to how it was prior to an injury, but that isn’t the case with post-natal skin: the protective barrier function can be restored but a scar is left behind, with different characteristics than the native tissue. One of the particular goals in pediatric wound healing is to avoid the development of hypertrophic scarring, noted Dr. Sibbald. Another consideration in wound healing in children is the use of tape and products that can strip the skin. Where possible, these types of products should be avoided, said Dr. Sibbald.

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ADHD: Portions of the basal ganglia shrink in affected children Ventral striatum generally expand with age, but the opposite was found for ADHD youth

ADHD research by John

Evans

longitudinal brain-imaging study of children with attention deficit hyperactivity disorder (adhd) has found that regions of the ventral striatal surfaces of the basal ganglia, associated with reward processing, shrink progressively in surface area. “the basal ganglia, particularly in the caudate and the ventral striatum, have been very strongly linked with adhd,” says Dr. Philip Shaw (pictured above right), the study’s lead author and the head of the Neurobehavioral clinical research Section of the National human Genome research institute in Bethesda, Md. Not only does it make sense that regions of the brain involved in control of action and attention would be different in brains with adhd on a theoretical level, he says, but a past meta-analysis of adhd imaging studies identified the right and basal ganglia areas as the most consistently affected. Yet dr. Shaw says all prior studies have been cross-sectional. While exPediatric Chronicle Assistant Editor

tremely helpful, cross-sectional data can’t tell the whole story in this condition because adhd is inherently developmental. “the best way to capture such a moving target is to use longitudinal data,” he says. dr. Shaw and his team enrolled 270 youths with diagnostic and Statistical Manual of Mental health-iV-defined adhd as well as 270 age- and sexmatched typically developing controls to undergo neuroanatomic magnetic resonance imaging in order to define the surface morphology of their basal ganglia. of those, 220 were scanned at least twice. in all, the team mapped developmental changes from age four through 19 years at roughly 7,500 surface vertices in the striatum and globus pallidus. the method they used to define the surfaces being studied was developed by canadian colleagues, Mallar chakravarty and his group at the research imaging centre at the centre for addiction and Mental health in toronto, says dr. Shaw. “his group developed this very nice method for mapping the surfaces of these deep structures in the brain.”

dren with adhd it contracted. “it did the direct opposite, and it was really a very marked effect indeed,” says dr. Shaw, noting that cross-sectional data would not have been able to reveal this behaviour. the typically developing group had an estimated rate of increase of 0.54 mm2 per year, while the adhd group showed a decrease of 1.75 mm2 per year. the findings of dr. Shaw and his colleagues are exciting and interesting, and replicate some other findings, says Dr. Isaac Szpindel (pictured left), consultative General Practice in attentional disorders at the S.t.a.r.t. clinic in toronto. “We have some interesting information and some surprising results in some respects, but i do not think these are generalizable enough to be considered diagnostic. i think it raises some reasonable opportunities for etiological and diagnostic speculation and further study.”

Ventral straitum contracted in ADHD patients “What we did, first of all, is ask what happens in typical kids?” says dr. Shaw. in this group they saw that the surface of the basal ganglia generally expands with age. “that was also true for most of the surface in adhd. it also expanded—except for the ventral striatum.” in typical children this area expanded, but in chil-

Must keep researching to make clinically useful dr. Shaw agrees, adding it is important to consider that while this observed difference is highly significant, “this is a group effect. it is something that required a very large sample to detect.” Significant but fixed surface area reductions were also seen in dorsal striatal regions in the adhd group at study

ADHD rates higher in child protection services in Canada The effects of maltreatment of children in protection services can lead to behavioural problems by Emily

Innes

Pediatric Chronicle Assistant Editor

hildren in child protection services are diagnosed with attention deficit hyperactivity disorder (ADHD) at higher rates than the general population, although these children may have other factors contributing to behavioural and attentional regulation difficulties, according to a study published in the journal Child Care Health Day (June 18, 2014). Researchers found the effects of maltreatment in children can lead to problems with attention that overlap or mimic ADHD-like symptoms and co-morbid disorders. The study reports more awareness of the challenges this group faces is needed among caregivers, teachers, and child welfare staff to ensure the mental well-being of these children. “[The effects of maltreatment on the emotional regulatory system] does not even have an accepted formal diagnosis, although it has been referred to as ‘complex trauma’ or the proposed ‘developmental trauma disorder’,” said lead author Dr. Benjamin Klein (pictured left), medical director at Lansdowne Children’s Centre in Brantford, Ont. “When you do not even have a name for something it is hard to communicate it to people, and child protection workers. Many children whose stress regulatory systems are damaged have involuntary behavioural outbursts, which often leads to the diagnosis of oppositional defiant disorder, a label that can be stigmatizing and ultimately not helpful.” The maltreatment—psychological and emotional neglect— causes problems with emotional stress regulation for these children, according to Dr. Klein, an assistant clinical professor in the Department of Pediatrics at McMaster University in Hamilton, Ont. “For kids that are maltreated, you can think of it as daily stress, such as being told ‘no’ or peer social interactions that they cannot regulate. They slip more easily into emotional dysregulation, for example a ‘fight or flight’ response, including involuntarily freezing— inattention—or flighting—hyperactivity. “This can be impossible to distinguish from ADHD for clini-

10 • PEDIATRIC CHRONICLE

cians, who rely heavily on accounts from parents and teachers to make the diagnosis of ADHD.” Children with effects of maltreatment need their environmental stress exposure carefully titrated, such as a low emotional stress environment, he said. That allows them to stay in the “calm-alert thinking brain mode” rather than “fight-flight” mode. Dr. Klein explained that children in child protection services are probably often correctly diagnosed with ADHD, but diagnostic formulation may miss the more global effects of a suboptimal early environment on the emotional stress regulatory system. “The ADHD is often there and ADHD medication often helps the kids,” said Dr. Klein. “But what we see clinically is that it helps somewhat, but it doesn’t take away all the functional problems, of course. [For example] if you have asthma and pneumonia and you take medicine for asthma you are still going to have problems because there is something left untreated.” “Physicians who end up seeing these kids have a much greater access to medication and just have to write a prescription,” said Dr. Klein. “But to get something like parent-child dyadic psychotherapy is problematic. First of all you might not know what that is as a physician because there is a limited amount of training for psychological development issues in medical training, including pediatrics. “But even if you do know about that, or know what agency to refer someone to, it may be a long wait and local agencies may not have the capacity.” Need grerater resources for these children Lack of other resources, according to Dr. Klein, also exacerbates this condition. He advocates for more access to mental health and developmental services for children in child protection services but also for more support for pregnant women, reducing poverty, and improving neighbourhoods. He would also like to see greater access to high quality full time daycare, especially for at risk children. “Prevention of maltreatment is the most key and the most impactful step,” said Dr. Klein. “I would like the system to have a greater capacity to respond to risk.” —More at http://ow.ly/B5sVX

entry, which persisted into adolescence. Further research would be needed to integrate these findings with other aspects of the understanding of adhd to translate into something clinically useful, says dr. Shaw. one area where dr. Szpindel would like to see study of this cohort extended is by collecting additional scans when the patients are older. “the sample size here goes from four to about 18.9 years, which is the borderline between adolescence and adulthood,” says dr. Szpindel. “that means we’re potentially not seeing the neurological changes fully into adulthood, really,” as these brains have roughly six more years of significant neuronal pruning and executive development remaining. Furthermore, Pet studies have suggested that the maturation of the adhd brain may lag that of the normally developing brain by an additional five years or so, he says. “this lag or delay does not account for the involution or reduction in specific anatomical surface areas [in dr. Shaw’s research]. But it does suggest that in a study such as this, we extend the age at endpoint further to better consider normal and adhd neurodevelopment into adulthood,” says dr. Szpindel. “this is a structural study, and it begs the question ‘what’s happening?’ in terms of the ventral striatum’s functioning. So the logical next step is to look at the functioning of the ventral striatum,” says dr. Shaw, noting that he and his team are moving on into this further research. it is also relevant to examine how these shrinkages tie into other aspects of neural structure in adhd, says dr. Shaw, noting that his team is looking at white matter tracks between the ventral striatum and other brain areas. this study compared a cohort with severe adhd to healthy controls, notes dr. Szpindel. expanding the study to contrast to scans of a wider severity range of adhd brains with other overlapping conditions that exhibit executive functioning changes, such as anxiety and depression, would help clarify whether these shrinkages in the basal ganglia may be specific to adhd and therefore of potentially useful diagnostic value. Gaining a comprehensive understanding of adhd will likely involve looking at the condition at an array of levels, says dr. Shaw, from the gene level to environmental factors. Socioeconomic status is a variable that dr. Szpindel agrees is important to examine in any follow-up studies. Looking at predominantly affluent patients, such as those in dr. Shaw’s cohort, “can be particularly problematic, because we know that the low socio-economic status patients are the ones at the highest risk of persistence [of adhd] into adulthood. So if we’re considering adult neurodevelopment trajectories in adhd, this is a key cohort of the sample population that should be included.” dr. Szpindel says “what this study does, very nicely, within its cohort, is confirm that there are real, physical, biological findings in adhd patients when compared to normal populations.”

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Special Report

Oatmeal-based emollients offer many benefits to children with eczema

Improves symptoms and skin barrier function

mollients containing colloidal oatmeal and other oatmeal-derived molecules can improve symptoms of atopic dermatitis and eczema and improve skin barrier function, potentially reducing usage of topical corticosteroids, according to research presented during a recent symposium in Toronto.

A multi-national study of avenanthramides (Aveeno Eczema Care™, Johnson & Johnson), a proprietary topical emollient containing colloidal oatmeal, oatmeal oil, and oat-extracted compounds, was carried out with 71 patients with mild to moderate eczema, some of whom were using medicated treatments. The emollient was well tolerated by 96% of patients through three months, according to Dr. Miriam Weinstein who presented during the event. Dr. Weinstein is the Dermatology Fellowship Director, Section of Dermatology, Pediatric Medicine, at the Hospital for Sick Children in Toronto. “Tolerability is really important, because people are using emollients every single day, and depending on how long they have eczema, potentially life-long,” says Dr. Weinstein. “So at a bare minimum they have to be able to afford it, and they have to be able to tolerate it. [Ninetysix per cent] is a high level of tolerance.” Also in the study, “using the emollient resulted in significant improvements in the clinical parameters of dryness, itching, scaling, and redness,” on a visual assessment by dermatologists, says Dr. Weinstein. “On all these clinical parameters, at four weeks there was improvement, at eight weeks, and at 12 weeks.” The amount of improvement increased at each interval, although the improvement of scaling was not significant at four weeks. More than 80% of patients on subjective self-assessments of the same four categories reported the same pattern of improvement after each four-week period. This ongoing improvement in symptoms with sustained use is important information when talking with patients about the importance of adhering to a regimen, she says. “I find that moisturizing babies is not such a big deal. I find that parents are quite diligent and they do it. But as kids

get older, those that still have eczema have to moisturize, and it becomes a drag,” says Dr. Weinstein. Moisturizing twice a day for 30 seconds may not seem like a significant burden, but to a patient “it is more the drag of having a chronic condition and having to do something that everybody else doesn’t have to do,” she says. “If they moisturize, for sure they’re going to get benefit—but what this [study] shows is that if you moisturize consistently you’re going to get sustained and increasing benefits. So patients need to know that continued use is beneficial,” she says. On the SCORAD scale (scoring for atopic dermatitis), while there were improvements at four weeks they were not significant overall, or when broken down by age group in the study, says Dr. Weinstein, but by week 12 significant improvements were seen.

Reduced use of topical medication

Potentially the most important finding of this study, says Dr. Weinstein, was that patients who regularly used the oat-based emollient reduced their use of topical medication. “Just at the four week mark, there was already a reduction of 39.4 per cent in cortisone use,” she says. Overall, 63% of the participants used less medication. “Now I will say that I don’t worry a whole lot about corticosteroids, I think the side effects are rare. But they’re not non-existent, and certainly parents are worried about them. So we can show that with really aggressive moisturizing with the oat derivatives helping with the inflammation, you’re going to cut down on your medication use. That is something that is very important to parents. And certainly while I don’t worry about [corticosteroids], if we can use less by recommending this strategy, obviously that’s the way to go.” Patient satisfaction with the emollient was high, and significant improvements were seen in quality of life measures. A observational study conducted in Greece looked at 1,800 patients with mild to moderate eczema, of 47 pediatricians in private practice. These patients were using a regimen of both a wash and an oat-based cream, as well as continuing any topical medications they may have been on, says Dr. Weinstein. The study results included investigator global assessment evaluated at visit one, and after one and two months. This included presence or absence of signs of eczema and a rating of severity from one to five. “As we go through the visits, there are more patients showing an absence of features, and the amount that are showing

Supplement to Pediatric Chronicle, Forerunner Edition, Autumn 2014. Chronicle is an independent medical news service that provides educational updates regarding medical developments around the world. Views expressed are those of the participants and do not necessarily reflect those of the publisher or sponsor. Support for distribution of this report was provided by Johnson & Johnson Inc. through an unrestricted educational grant without conditions. Information provided in this report is not intended to serve as the sole basis for individual care. Printed in Canada for Chronicle Information Resources Ltd., 555 Burnhamthorpe Rd., Suite 306, Toronto, Ont. M9C 2Y3.Telephone 416.916.2476; facsimile 416.352.6199; e-mail: health@chronicle.org. Copyright 2014 by Chronicle Information Resources Ltd., except where noted. All rights reserved. Reproduction in any form is expressly prohibited without written permission of the publisher.

eczema signs is decreasing,” she says. As for efficacy, “using wash and the cream, it improves the signs of eczema, the skin is less dry, it leaves the skin comfortable. [The data shows] after visit two, there is an improvement, and after visit three there is some more,” in this study, says Dr. Weinstein. Also, 84% of patients agreed that they had ‘the sensation to use less medication’. “This is sort of a translation because the study was not done in an English-speaking country,” Dr. Weinstein says. “But the sensation to use less medication means they felt the need to use less medication.” The emollients used in these studies contained a combination of three oatbased ingredients with different effects– colloidal oatmeal which is the hulled seed rolled and ground to a fine, uniform powder, oat oil, and avenanthramides, which are active polyphenol extracted from the hulls of the seeds. There are three different oat-derived materials that can be of benefit in eczema, and the three work in different ways, says Michael Southall, PhD, Senior Research Fellow of Global Skin Biology and Pharmacology, Research & Development for Johnson & Johnson Consumer Companies, who also spoke at the meeting. Southall and his team developed the Aveeno Eczema Care™ emollient used in the studies cited by Dr. Weinstein. Regarding the colloidal oats, Southall

Dr. Weinstein: “With really aggressive moisturizing with the oat derivatives helping with the inflammation, you’re going to cut down on your medication use” The oat oil included is high in lipids, and can replenish reserves in the skin. “We also found something in the last year that we are really excited with,” Southall says. “We found that oat oil is an agonist for a family of receptors called PPAR, which stands for peroxisome proliferator-activated receptors.” Through this pathway, genes involved in increasing skin barrier function are activated, he says. “We dose-dependently treat skin equivalents with the lipids, [and] we can show increases in ceramide production,” says Southall. “What we’re actually doing is by inducing activation of PPAR in the skin, we are increasing the expression of ceramides produced in the skin, not topically applied. So it gives another basis for why these natural products are providing some of the benefits in skin.” Avenanthramides, which are polyphenol compounds only found in oats, have been shown to have anti-inflammatory and anti-itch properties in animal models (Archives of Dermatological

S outhall: “By inducing activation of PPAR in the skin, we are increasing the expression of ceramides produced in the skin” says “Oats are rich in protein. There is about a 20 per cent protein content in the oat grains themselves. There are high amounts of polysacchrides, and a high degree of lipids–the highest found in any cereal [grain]. There are also polyphenols which are anti-oxidant-type molecules that help relieve oxidative stress.” The fine particles have a been shown clinically to attract and bind moisture, provide a pH buffer, and have anti-pruritic activity, he says.

Research Nov. 2008; 300(10):569-574). “One of the things they’re very good at is reducing the pathways involved in producing inflammatory mediators,” says Southall. “They do this by blocking some of the signalling that is involved in how the pro-inflammatory cytokines and other mediators are synthesized. By blocking that signalling, it prevents them from being produced, and therefore on skin it should reduce the level of inflammation that occurs.”

Ped_Autumn_2014)_final_11-11-2014_Layout 1 11/11/2014 5:03 PM Page 12

Celiac Disease

Gilles San Martin

Head lice are known to prefer clean hair—in contrast with the stigma associating infestation with poor hygiene

‘Super Lice’?

No fear of lice becoming resistant to non-pesticide therapies Dr. Chantelle Ung (pictured right), the director of the dermatology Group Skincare and cosmetic centre in toronto, says there are no fears of the lice becoming resistant to nonpesticide treatments. “NYda works in a physical method, so it physically suffocates the lice and their eggs. You can’t develop a resistance to being choked or suffocated,” she said. dr. Ung equates the growing resistance of lice to that of the bacterial resistance to antibiotics creating the “super bug.” “the previous medications with many years of use [for lice], like pyrethrin or permethrin, the lice have learned to mutate to resist being killed by the chemicals and then propagate, so they become the dominant species of lice,” she said. “they say that with every generation of using the pesticides you get more of the ‘super lice’ learning to mutate and to become resistant.” Dr. Joseph Lam, a clinical assistant

professor in the departments of Paediatrics and dermatology and Skin Sciences at the University of British columbia in Vancouver, said that previously a lice infestation was treated with permethrin 1%, but when that became ineffective due to the development of resistance, pyrethrin 5%, a therapy for scabies, started being used for lice. “if you keep doing that you are going to perpetuate the problem,” said dr. Lam. according to dr. Lam, the lice are only “super” because they are resistant to pesticides, but not bigger or stronger. however, he also made the point that using a product such as NYda will work against regular and “super” lice. another non-pesticide product on the canadian market is called resultz (containing isopropyl myristate) and it acts to dissolve the lice, said dr. Lam. dr. Ung believes there is a lack of awareness regarding non-pesticide lice therapies and she ends up seeing the patients referred to her for difficult-to-treat lice. “Being a dermatologist, i would say that we do not see a plethora of patients [for lice] because most times family doctors and pediatricians are the first person that the patient would see. But we get cases that are resistant,” said dr. Ung. “i recommend NYda all the time... because sometimes even family doctors and pediatricians are not aware of this product.” Break unhygienic bad stigma of lice dr. Lam said it is a common misunderstanding that having lice is associated with poor hygiene and dirty hair. however, it seems that lice prefer cleaner hair. he said it has not been scientifically proven if sharing hats or combs increase the spread of lice, but common sense dictates that one should avoid doing this as well as avoiding head-to-head contact to prevent against a lice infestation. “it is quite often in school-aged kids because they are in close proximity together,” said dr. Lam. “Something that has made the news, but scientifically is not totally proven, is whether ‘selfies’ put you at more risk for lice or not because a lot of kids are doing that these days.” dr. Kraft said he hopes the stigma of associating lice with being unhygienic or poor is broken. “it is important to be aware that lice can affect all children of all socio-economic groups. it is not necessarily a sign of poor hygiene but something that needs to be recognized and treated appropriately. “it is important to think about head lice when you see anyone with an itchy scalp and to offer them an appropriate treatment for them and their family to stop the infestation and prevent the spread of ‘super lice’.”

12 • PEDIATRIC CHRONICLE

Social worker may provide benefit the authors found that improved education is also needed to aid with early diagnosis of celiac disease and reduce contamination of food products. dr. rashid said this needs be done at the medical professional level through lectures, articles, brochures, and awareness events, but also at the societal level in schools, restaurants, and daycares. if a patient is struggling with maintaining a GF diet, dr. rashid said the first step is to identify the barrier. Some patients have difficulty coping with the diagnosis and in this case letting the patient know that they are not alone, and that it is a common problem is helpful. the patient, or their family, should be introduced to other families with children with celiac disease and to organizations, such as the canadian celiac association, that can help support them. if the barrier is cost, it could be helpful to bring a social worker to help the family address ways to reduce the financial strains. “if there is peer pressure then i think someone needs to sit down with the teenager and maybe make them aware of short- and long-term risks of untreated disease. it all depends on what the major factor which prevents them from following a GF diet,” said dr. rashid. For more information visit: http://ow.ly/zQ7qT

‘I think that governments should provide [gluten free] foods for free to at least the pediatric population and hopefully to everybody’

—Dr. Mohsin Rashid

UTIs in children continued from page 1— tainly the most logical way of doing that is stop treating things that are not even bacterial infections,” said dr. robinson. Young girls can have pain when they urinate because they have urethritis, which can occur from sitting in bubble baths too long and because they have sensitive perineums. this is often confused with a Uti, explains dr. robinson (pictured right). “really the lesson is that you should never make the diagnosis of a urinary tract infection in a child without having at least sent off a proper urine sample,” she said. “With an adult female it is totally acceptable that if they come in with the right symptoms you just put them on antibiotics and only send a urine culture if they do not get better.” the cPS also recommends that Utis for infants younger than two years of age can be treated with antibiotics for seven to 10 days, with oral therapy being the initial treatment if the child has no other indication for admission to hospital. if the child is older and does not have a fever, then a two-to fourday course of antibiotics is considered sufficient. after the first Uti a child under the age of two should be investigated with a renal and bladder ultrasound (rBUS). the authors state that antibiotic prophylaxis is no longer recommended for grades i through iii vesicoureteral reflux (VUr) or pending result of the initial rBUS. children with grade iV or V VUr or significantly abnormal rBUS should be referred to a pediatric urologist or nephrologist. For more information visit http://ow.ly/zycyS

‘You should never make the diagnosis of a urinary tract infection in a child without having at least sent off a proper urine sample’

PREVIEW EDITION

Naomi | Morgueﬁle

continued from page 1— dr. Kraft said he recommends a non-pesticide-based treatment called NYda, which contains dimethicone, a silicone-based polymer that has proven in numerous studies to be safe and is found in children’s medicine, cosmetics, lotions and shampoos. his patients with lice have been “thrilled” to use NYda. “here is a medication that does not have any pesticides in it and it works in the vast majority of cases,” he said. “the lice cannot develop resistance to it and it means if you use it properly it is going to kill the lice whether the lice are ‘super lice’ or not. So no matter what type of infestation they have it will work.” Like other lice treatments, according to dr. Kraft, NYda requires effort. the NYda is applied to dry hair and the scalp with the pump spray applicator. the hair and scalp should be entirely covered. then it soaks in for 30 minutes at which point the NYda comb is used to remove the dead lice and larvae. the NYda remains on the hair for eight hours before being shampooed off. this procedure is repeated a week later.

continued from page 1— foods, even fast food outlets are offering something, and grocery stores have more packaged products available. But we need to be very careful that we do not let products slowly become more contaminated.” dr. rashid said he believes the government should provide better assistance to families that include children with celiac disease. though the industry has been responding and the prices are coming down, the investigators still found that price makes a GF diet challenging for some families. dr. rashid believes the government should provide better assistance to families that include children with celiac disease. Some european countries provide selective GF products for free, or provide stipends or tax breaks. Some canadian provinces have an extra stipend for families on income assistance with a member who has celiac disease and at the national level there is a tax break by canada revenue agency, but, according to dr. rashid, the process is “cumbersome” to follow. “i think that governments should provide adequate GF foods for free to at least the pediatric population and hopefully to everybody,” said dr. rashid. he hopes that this study will encourage pediatricians and general practitioners to advocate for better support for celiac patients.

Ped_Autumn_2014)_final_11-11-2014_Layout 1 11/11/2014 5:05 PM Page 13

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Parting question Kids with anxiety disorder: Are they wired differently? therapeutic interventions that should be ofStructual differences found in weferedcantoimprove this population of children, according to Tromp. another investigation, children who did not have a brains of children with anxiety socialInanxiety disorder, but were categorized as having soby Louise

Gagnon for Pediatric Chronicle

rain imaging is revealing that children who are socially reticent or who have anxiety disorders have dysregulated circuitry in the brain, differentiating them from children without social reticence or anxiety disorders. “These are children who were recently diagnosed with an anxiety disorder and have not used any medications, and already we see a structural difference in their brains [compared to control children],” explained Do Tromp, a researcher in the Department of Psychiatry and Health Emotion Research Institute at the University of Wisconsin in Madison, in an interview with PEDIATRIC CHRONICLE. “We are seeing results [in the brains] of children [who are newly diagnosed with an anxiety disorder] that we see in adults who have had years of anxiety disorder and perhaps have used medications,” said Tromp. “There are structural differences that we view in the brain [early in the course of illness].” During the annual meeting of the Anxiety and Depression Association of America (ADAA) in Chicago this past March, Tromp described data involving research with 21 healthy control children and 23 children with an anxiety disorder where functional magnetic resonance imaging (fMRI) scans were performed, revealing that at rest, children aged eight to 12 years of age with an anxiety disorder, showed decreased functional connectivity between the pre-frontal cortex and amygdala. Children were also asked to participate in a task where they were given a cue before they would be exposed to either a face that had either a neutral expression or one that had a fearful expression. The cue would let them know whether they were to be exposed to a neutral face, or one expressing fear. They also received an uncertain cue that did not let them know what face to expect. “There was increased amygdale activation when they were exposed to an uncertain cue,” said Tromp. In addition, children with anxiety disorders also showed a prolonged amygdala recovery after viewing fearful faces, said Tromp. The findings are consistent with what Tromp and researchers have observed in non-human primates in terms of amygdala-prefrontal connectivity and anxious temperament. Additional data from nonhuman primates also show the significance of genetics in determining if an anxiety disorder develops in an individual, said Tromp.

Dysregulation in kids with behavioural issues These results together can potentially inform clinicians how

cial reticence, a trait common in behaviourally-inhibited temperament, expressed similar dysregulated brain circuitry in an anticipation task where they were faced with ambiguity, explained Johanna M. Jarcho, PhD, a post-doctoral fellow at the National Institute of Mental Health in Bethesda, Md. During her presentation at the ADAA, Dr. Jarcho described the characteristics of the pediatric subjects that took part in the study. “These are children who are at risk for developing an anxiety disorder,” said Dr. Jarcho. “Whether they develop anxiety is partially genetic and partially environmental.” One factor that can contribute to whether at-risk children develop anxiety is the nature of the parenting they are exposed to, added Dr. Jarcho. A total of 30 children aged 11 years with high social reticence and 24 children also aged 11 years but with low social reticence were tasked to interact with peers, depicted as cartoon avatars, in a virtual classroom. They relied on maternal reports and behavioural observations to come up with a rating of social reticence for children.

Brain activity different in socially reticent children Avatars had a reputation for being either friendly, mean, or unpredictable (nice or mean), explained Dr. Jarcho. Subjects were gender-matched, so boys interacted with a male cartoon avatar and girls interacted with a female cartoon avatar. Investigators used fMRI to observe the brain activity of subjects. “When we looked at what is happening in their brains, we did not see a difference in brain activity across the two groups of children when they were anticipating predictably positive or negative feedback,” said Dr. Jarcho. “We did see a difference in brain activity in socially reticent children when they were anticipating unpredictable feedback,” Dr. Jarcho explained. “It was more evocative to face a negative social interaction than when a child does not know what is going to happen than when they know what to expect. We thought we would find more robust differences [between the two groups of children] when they were anticipating something they knew would be negative. It appears that the unpredictable is more evocative for these children than knowing when they will face a bully, for example.” Specifically, children with high social reticence displayed heightened activity in dorsal anterior cingulate, insula, and superior temporal gyrus when they anticipated feedback from a peer whose reputation was unpredictable.

videos of interest to the Pediatrician on the Internet right now

2014 PEDIATRICS BOARD REVIEW As described by the presenter, this clip does “a lot of bouncing around” between a variety of topics including screening for anemia, urinalysis screening, screening for newborn metabolic diseases, and autism screening. The presenter suggests ages of when a child should be screened for these conditions and examples of when a physician might want to consider screening the patient earlier than the general population. http://ow.ly/DWC56

AAP SLEEP SAFETY RECOMMENDATIONS Dr. Rachel Moon, a sudden unexplained infant death (SUID) researcher for the Children’s National Health System, presents on the American Academy of Pediatrics guidelines for safe sleeping. Dr. Moon helps differentiate between sleep-related deaths and SUIDs. The recommendations are to reduce the risk of sudden infant death syndrome and sleep related suffocation, asphyxia, and entrapment until the age of one year old. http://ow.ly/DWDd5

PEDIATRIC CANCER: T-CELL IMMUNOTHERAPY Researcher Dr. Michael Jensen gives a talk about how T-cell immunotherapy is helping to eradicate pediatric Ca. To treat Ca with Tcells, Dr. Jensen says they are reprogramming T-cells through DNA codes to have them attach to cancerous cells and attack them like they are the common cold. http://ow.ly/DYa99

ENTEROVIRUS D68 Dr. David Rosenberg of Vineland, N.J., discusses enterovirus D68 with the news outlet SNJ Today about. This year there has been the largest confirmed outbreak of enterovirus D68 but there is no evidence that it is more dangerous than the other 100 other enteroviruses around. He says “it is the common cold” and proper hand washing is important to avoid contacting the virus. http://ow.ly/DWDAT

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CHRONICLE ,

what do you think of PEDIATRIC

CHRONICLE ?

Please share your opinions and impressions of this Preview Issue with the editors, by taking a brief online survey. Your feedback is invaluable in helping us plan our 2015 publishing schedule. Ten randomly selected survey respondents will receive a gift card, with our thanks. Visit pediatric.chronicle.ca and click on ‘Survey’

14 • PEDIATRIC CHRONICLE

PREVIEW EDITION

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A proven efficacy Clinical study carried out by 6 dermatologists among 60 patients (average age 4.8 years old) with moderate atopic dermatitis*

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