Tuesday, January 31, 2017

Low back pain in school-aged children a common occurrence


Low back pain in school-aged children is a common occurrence, and the prevalence of low back pain increases once children reach school age - one percent at age seven years; six percent at age 10 years; and 18 percent at ages 14-16 years. Yet only seven percent of adolescents with lower back pain will seek medical care. Diagnosis, pathophysiological findings, evaluation, treatment and prevention are outlined in a recent review of the literature published online today by the Journal of the American Medical Association Pediatrics (JAMA Pediatrics)
According to the literature review led by Nationwide Children's Hospital Sports Medicine, most causes of low back pain in this population are benign; however the effect of low back pain can be significant, affecting daily activities such as school attendance and participation in gym class or other athletic activities. Development of low back pain in adolescents is a substantial risk factor for the possibility of low back pain as an adult. 
The literature review demonstrates that there is no single risk factor or factors for lower back pain as previously thought. For school-aged children, most cases are because of musculoskeletal overuse or trauma. One possible cause for the prevalence in adolescents is participation in athletic activities. Studies have shown there is a correlation between the level of competition and low back pain, as well as there being an increased risk of low back pain with both high and low levels of physical activity. Other possible risk factors include a quickening of growth, adverse psychosocial factors, increase in age, a previous back injury and family history of low back pain. Females are also at a greater risk for low back pain.
"Historically, pediatric training has emphasized that a specific factor or factors cause low back pain in children and adolescents, but recent studies have informed us that is not necessarily the case," said James P. MacDonald, MD, MPH, lead author of the review and sports medicine physician at Nationwide Children's. "It is important for physicians to have a firm understanding of the relevant spinal anatomy and the etiological factors of low back pain in children and adolescents." 
While some lower back pain needs to be treated by a specialist, most pediatricians who have a good understanding of the principles outlined in our article can help children and adolescents prevent and manage lower back pain," said Dr. MacDonald, who is also an associate professor in the Department of Pediatrics and Family Medicine at The Ohio State University College of Medicine. "Most pain with no specific cause responds to rest, rehabilitation and identification of predisposing risk factors."
Although the causes of lower back pain in school-aged children are most often benign, according to the literature, a thorough evaluation performed by the primary care physician can help rule out a more serious condition. For example, obtaining a full clinical history, asking certain questions associated with an inflammatory cause of lower back pain, examining the back for signs of deformities, performing neurologic workups and potentially ordering imaging tests if deemed necessary as a result of the overall evaluation. 
Based on the review, because children and adolescents' musculoskeletal systems are still developing they are at an increased risk to trauma and explosive muscle contractions, especially during periods of rapid growth. For this reason, evidence suggests the importance of pre-season sports conditioning programs and neuromuscular training that will allow the athlete to gradually increase his or her training intensity and help reduce injuries. Additionally, rest should be incorporated into the training regimen, especially for athletes who perform repetitive motions, such as tumbling in gymnastics. Young athletes should not participate in more hours of sports in a week than their number of age in years.

Thursday, January 26, 2017

Tonsillectomies offer only modest benefits, studies find



Removing tonsils modestly reduced throat infections in the short term in children with moderate obstructive sleep-disordered breathing or recurrent throat infections, according to a systematic review conducted by the Vanderbilt Evidence-based Practice Center for the Agency for Healthcare Research and Quality.

Four papers derived from the larger review include two that were published online on Jan. 17 and appear in the February issues of Pediatrics. These papers report results regarding the effectiveness of tonsillectomy for treating children with obstructive sleep-disordered breathing or recurrent throat infections. The papers concluded that more research is necessary to determine the long-term impacts of tonsillectomies in those groups.

In the full systematic review, Vanderbilt researchers considered almost 10,000 studies of tonsillectomy efficacy, primarily randomized control trials.

"It's probably the most comprehensive study in tonsillectomy literature ever done," said investigator David Francis, M.D., M.S., assistant professor of Otolaryngology. "We determined the lay of the land of what's known and what's not known about this extremely common procedure."

For the paper, "Tonsillectomy vs. Watchful Waiting for Recurrent Throat Infection: A Systematic Review," researchers examined illness rates and quality of life for children who have undergone tonsillectomies versus watchful waiting for throat infections. Though there is more robust evidence to support tonsillectomy in children with high infection rates, most of the literature identified for the review concentrated on children with a moderate number of infections.

The researchers found that throat infections and school absences declined in the first year after children received tonsil surgery, as well as health care visits for sore throats. However, the benefits of reduced infection did not persist over time.

A companion paper, "Tonsillectomy for Obstructive Sleep-Disordered Breathing: A Meta-Analysis," examined whether children with obstructive sleep-disordered breathing showed improvement after tonsillectomy. The same authors found that children who had surgery had better sleep outcomes than those who engaged in watchful waiting.

Another companion study, published in Otolaryngology -- Head & Neck Surgery, also considered the risks of tonsil surgery, which is primarily bleeding. Regardless of tonsillectomy technique used, fewer than 4 percent of patients experienced bleeding and fewer than 1 percent needed readmission or reoperation as a result, Francis said.

The investigators involved in the report also acknowledged its limitations and opportunities for further study. Siva Chinnadurai, M.D., MPH, associate professor of Otolaryngology, another author of the report, said the type of study, known as a meta-analysis, is only as strong as the studies available in the literature.

"Our greatest impediment to draw really wide, sweeping conclusions is the lack of consistency in the way we as a specialty define the problems that we're treating," he said.

The benefits of surgery waned over time and long-term outcome information is limited because most studies don't follow children over the long term, Francis said. Also, the definition of infection was not consistent in the studies, and, in the case of obstructive sleep-disordered breathing, other factors that could cause the condition weren't consistently taken into account in the studies. These areas are opportunities for further research.

Francis said that the precision of the findings and the identified limitations in the current literature will help inform policymakers as they refine current tonsillectomy guidelines.

The authors conclude that doctors and patient families need to make shared decisions on about whether an individual child should undergo tonsillectomies, weighing the benefits and the risks illuminated in this report.

"I think that for any individual child who is considered a candidate for surgery, the family really has to have a personalized discussion with their health care provider about all of the factors that may be in play and how tonsils fit in as one factor in the overall picture of that child's health," Chinnadurai said.

The full AHRQ report is available at https://www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=2423

"This enormous effort can happen only in an ecosystem like Vanderbilt where surgeons can work and attract funding with colleagues from other disciplines to create a unified picture of the tonsil galactic world from thousands of smaller studies," said Ron Eavey, M.D., Guy M. Maness Professor and chair of Otolaryngology and director of the Vanderbilt Bill Wilkerson Center. "Many patients and parents and physicians will benefit from this achievement."

Saturday, January 7, 2017

New guidelines show how to introduce peanut-containing foods to reduce allergy risk


The wait is over for parents who've been wanting to know how and when to introduce peanut-containing foods to their infants to prevent peanut allergy. New, updated guidelines from the National Institute of Allergy and Infectious Diseases (NIAID), published today, define high, moderate and low-risk infants for developing peanut allergy, and how to proceed with introduction based on risk.
"This update to the peanut guidelines offers a lot of promise," says allergist Stephen Tilles, MD, president of the American College of Allergy, Asthma and Immunology (ACAAI). "Peanut allergy has literally become an epidemic in recent years, and now we have a clear roadmap to prevent many new cases moving forward. The Learning Early About Peanut allergy (LEAP) study, the study that paved the way for the updated guidelines, has had a dramatic impact on day-to-day patient care. In fact, during my career as an allergist I cannot think of a single publication with more of an impact."

According to the new guidelines, an infant at high risk of developing peanut allergy is one with severe eczema and/or egg allergy. The guidelines recommend introduction of peanut-containing foods as early as 4-6 months for high-risk infants who have already started solid foods, after determining that it is safe to do so.

"If your child is determined to be high risk, the new guidelines recommend evaluation by an allergy specialist, which may involve peanut allergy testing, followed by trying peanut for the first time in the specialist's office," says allergist Matthew Greenhawt, MD, MBA, MSc, ACAAI Food Allergy Committee chair, and a co-author of the guidelines. "If a child is tested and found to have peanut sensitization, meaning they have a positive allergy test to peanut, from that positive test alone we still don't know if they're truly allergic. Peanut allergy is only diagnosed if there is both a positive test and a history of developing symptoms after eating peanut-containing foods."

A positive test alone is a poor indicator of allergy, and studies have shown infants who have a peanut sensitivity aren't necessarily allergic. "In fact in the LEAP study, infants sensitized to peanuts showed the most benefit from early introduction of peanut-containing foods," says Dr. Greenhawt. The updated guidelines recommend that Infants with a positive peanut skin test have peanut fed to them the first time in the specialist's office. Some infants may have a large reaction to the skin test (8 mm or larger) which could indicate they are already peanut allergic. "An allergist may decide not to have the child try peanut at all if they have a very large reaction to the skin test. Instead, they might advise that the child avoid peanuts completely due to the strong chance of a pre-existing peanut allergy. Other allergists may still proceed with a peanut challenge after explaining the risks and benefits to the parents."

Moderate risk children - those with mild to moderate eczema who have already started solid foods - do not need an evaluation. These infants can have peanut-containing foods introduced at home by their parents starting around six months of age. Parents can always consult with their primary health care provider if they have questions on how to proceed. Low risk children with no eczema or egg allergy can be introduced to peanut-containing foods according to the family's preference, also around 6 months.

The new guidelines offer several peanut-containing food suggestions as well as methods to introduce age-appropriate peanut-containing foods to infants who have already eaten solid foods. It is extremely important parents understand the choking hazard posed by whole peanuts and to not give whole peanuts to infants. Peanut-containing foods should not be the first solid food your infant tries, and an introduction should be made only when your child is healthy. Do not do the first feeding if he or she has a cold, vomiting, diarrhea or other illness.

"The guidelines are an important step toward changing how people view food allergy prevention, particularly for peanut allergy," says Dr. Tilles. "They offer a way for parents to introduce peanut-containing foods to reduce the risk of developing peanut allergy."

The guidelines are simultaneously being published in Annals of Allergy, Asthma and Immunology, the ACAAI's scientific publication, and several other scientific journals.

Identifying children at risk of eating disorders is key to saving lives


Spotting eating disorder symptoms in children as young as nine years old will allow medics to intervene early and save lives, experts say.

A team from Newcastle University has identified that girls and boys with more eating disorder symptoms at age nine also had a higher number of symptoms at age 12.

A new study published in the academic journal, Appetite, reveals the need to treat eating disorder problems as early as possible to help prevent children developing the life-threatening illness.

The six-year study identified three areas that parents, teachers and doctors should be alert to when looking to detect and help youngsters at risk of the mental health problem.

These factors are: boys and girls with body dissatisfaction, girls with depressive symptoms, and boys and girls who have had symptoms at an earlier stage.

It is believed that this research will help pave the way for early interventions to help young patients deal with their eating disorder.

Dr Elizabeth Evans, Research Associate at Newcastle University's Institute of Health and Society, led the study.

She said: "This research was not about investigating eating disorders themselves, rather we investigated risk factors for developing early eating disorder symptoms.

"Most previous work on children and young adolescents has only looked at the symptoms at one point in time so cannot tell which factors precede others.

"Our research has been different in that we have specifically focused on the factors linked with the development of eating disorder symptoms to identify children at the greatest risk.

"Results suggest the need to detect eating disorder symptoms early, since a higher level of symptoms at nine years old was the strongest risk factor for a higher level of symptoms at 12 years old."
Eating disorders are rare at age nine (1.64 per 100,000) but more prevalent at age 12 (9.51 per 100,000). The most common age for hospitalisation is 15 years old for both boys and girls.

Many more children have symptoms but do not develop a full eating disorder. Symptoms can include rigid dieting, binge-eating, making oneself sick after eating, and high levels of anxiety about being fat or gaining weight. Eating disorders are serious and can be fatal.

For the research, children from a birth cohort, the Gateshead Millennium Study, completed questionnaires about eating disorder symptoms, depressive feelings and body dissatisfaction when they were seven, nine and 12.

The North East has the highest rate of eating disorder hospital admissions in the UK, at approximately six per 100,000. Many more sufferers are treated as outpatients.

The research highlights that some risk factors precede the symptoms of the condition and others occur at the same time.

At age 12, boys and girls who are more dissatisfied with their bodies have greater numbers of eating disorder symptoms. Body dissatisfaction is an important indicator of increased risk of the condition.
Girls with depressive symptoms at 12 years old also have greater numbers of eating disorder symptoms. This relationship was not seen in boys.

The study is being followed up by repeating the questionnaires with the same cohort of children at 15 years old. This will allow researchers to assess what happened next for the youngsters with greater numbers of eating disorders at age 12.

Dr Evans said: "Future studies we do will investigate if our findings with young adolescents hold true for older adolescents, or whether we detect new risk factors.

"Both possibilities will further inform our efforts to promote and target early prevention for eating disorders."