Maternal Use of Folic Acid May Reduce Risk of Autistic Disorder in Children
A child’s risk of developing autistic disorder appears to be reduced when women take folic acid around the time of conception through early pregnancy. The findings appear in JAMA.

Supplementation with folic acid around the time of conception has been found to reduce the risk of neural tube defects in children, such as spina bifida, and emerging evidence also suggests that such supplementation is associated with reduced risk of other disorders related to impaired development of the nervous system, including autism spectrum disorders.

To test the association, researchers sampled data for 85 176 children born in 2002 to 2008 who were enrolled in the Norwegian Mother and Child Cohort Study and followed up through March 31, 2012. Mothers were asked about folic acid intake from 4 weeks before to 8 weeks after the start of pregnancy, defined as the first day of the last menstrual period before conception. By the end of the follow-up period, 270 of the children had been diagnosed with an autism spectrum disorder, which includes autistic disorder (114 children), Asperger syndrome (56 children), and pervasive developmental disorder–not otherwise specified (PDD-NOS) (100 children). Among children whose mothers took folic acid, 0.10% (64/61 042) had autistic disorder compared with 0.21% (50/24 134) of children whose mothers did not.

Watchful Waiting Best for Ear Infections
Stricter diagnostic criteria and broader use of observation to further rein in antibiotic prescribing for acute otitis media emerged in a revision of American Academy of Pediatrics (AAP) guidelines. The update, in the March issue of Pediatrics, also added a recommendation against antibiotic prophylaxis for kids with recurrent ear infections.T he 2013 guidelines are specifically for uncomplicated acute otitis media at ages 6 months to 12 years in otherwise healthy children without tympanostomy tubes, anatomic abnormalities such as cleft palate or Down syndrome, immune deficiencies, or cochlear implants.

"We've been waiting for these guidelines for some time," commented Andrew Hertz, MD, medical director of the University Hospitals Rainbow Care Network in Cleveland. "There's been a movement for a number of years for pediatricians to provide less antibiotics for ear infections and simply observe those children with mild findings on physical examination," he explained. "Hopefully, now that there is a practice guideline ... that you don't have to prescribe an antibiotic for every ear infection, this will decrease the use of antibiotics and thereby make antibiotics more successful and more useful when they are prescribed."

The pediatrics organization also cited overdiagnosis, "often without adequate visualization of the tympanic membrane," as a problem. The 2004 guidelines used a three-part definition for acute otitis media:

• Acute onset of symptoms
• Acute middle ear inflammation
• Middle ear effusion

The 2013 update also requires middle ear effusion for diagnosis, but it now has to be based on tympanometry or pneumatic otoscopy. Although early acute otitis media can occur without effusion, the guidelines committee acknowledged, "the risk of overdiagnosis supersedes that concern." They suggested that clinicians should be aware as they use these criteria that recent onset of ear pain and intense erythema of the ear drum can be the only otoscopic finding. Other diagnostic criteria are:

• Moderate to severe bulging of the tympanic membrane or new onset of discharge not due to an infected ear canal

• Mild bulging of the ear drum and onset of ear pain within 48 hours, which could be indicated by holding, tugging, rubbing of the ear for nonverbal children, or intense redness of the tympanic membrane

Antibiotics should be given for severe cases of bilateral or unilateral acute otitis media for children 6 months or older based on ear pain that is moderate or severe, lasts for at least 48 hours, or is accompanied by a temperature of 102.2°F or higher. For less severe cases, watchful waiting could be offered instead of antibiotics in joint decision-making with parents or caregivers. However, kids ages 6 to 23 months with both ears affected should be given antibiotics. "When observation is used, a mechanism must be in place to ensure follow-up and begin antibiotic therapy if the child worsens or fails to improve within 48 to 72 hours of onset of symptoms," the guidelines noted.

Another change in the 2004 guidelines addressed recurrent acute otitis media, defined as three episodes in 6 months or four in the prior year with one in the past 6 months.Prophylactic antibiotics shouldn't be prescribed to reduce recurrences, according to the AAP.  However, these children may be offered the option of tympanostomy tubes. These practice patterns should decrease use of antibiotics with the benefit of fewer adverse effects, such as diarrhea and allergic reactions, and decreased potential for bacterial resistance, the guidelines noted.When antibiotics are given, amoxicillin remains the first-line agent, with drugs with additional beta-lactamase coverage selected for kids who have already had it in the prior month or are allergic to penicillin. Physicians should recommend the pneumococcal conjugate vaccine and annual flu shot for all children, which can help reduce acute otitis media associated with those infections, the guidelines noted.

Pertussis Protection
Despite having a lower adverse event profile, acellular pertussis vaccines may not protect children as well as the whole-cell vaccine. Since the shift from using whole-cell to acellular pertussis vaccines in the 1990s, outbreaks of the illness have cropped up in the United States, Australia and other countries. In a recent study, Australian scientists compared reported pertussis infections among 58,233 children born in 1998 who received three doses of acellular vaccine, the whole-cell vaccine, or a combination of the two. The average annual infection rate between 1999 and 2008 was more than two and a half times higher among those who received three doses of acellular vaccine than among those who received three doses of whole-cell vaccine.

Pertussis Vax Loses Power Over Time
Protection from the five-dose childhood series of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine fades within 5 years of the last dose, researchers affirmed. In California children who received the vaccine, the odds of acquiring pertussis increased by a relative 42% each year after administration of the final dose (OR 1.42, 95% CI 1.21 to 1.66), according to Nicola Klein, MD, PhD, of the Kaiser Permanente Vaccine Study Center in Oakland, Calif., and colleagues. The limited duration of protection, which has been reported before, raises questions about whether the Tdap booster - usually given at age 11 - should be started earlier and given more frequently, the researchers reported in the Sept. 13 issue of the New England Journal of Medicine. That possibility, in turn, raises further questions about the effectiveness and duration of protection from that vaccine, side effects, cost and burden to families, and the risk in unprotected infants of transmission of pertussis infections that could be prevented with more frequent Tdap boosting, Klein and colleagues noted. Ultimately, though, "prevention of future outbreaks will be best achieved by developing new pertussis-containing vaccines that provide long-lasting immunity," they wrote.

In the U.S., children are recommended to complete the five-dose series of DTaP before turning 7, and vaccination has been shown to dramatically reduce the occurrence of the disease. However, some studies have shown that protection wanes.T o examine the duration of protection, Klein and colleagues examined data on children who were members of Kaiser Permanente Northern California and who received a fifth dose of DTaP at the recommended age of 4 to 6 between 2006 to 2011.That period included the large 2010 outbreak that saw the highest rates of the disease in California since 1958.The researchers compared 277 children ages 4 to 12 who had a positive polymerase-chain-reaction (PCR) test for pertussis - almost all of whom were diagnosed during the outbreak - with 3,318 children who had a negative PCR test and with 6,086 closely matched controls who were not tested for pertussis. All of the children had received DTaP, but not the whole-cell pertussis vaccine, which was phased out in the late 1990s.An increasing time since the fifth dose was associated with a rising percentage of positive PCR tests. The percentage of PCR tests that were positive was 0.8% when they were conducted 15 days to 1 year after the fifth dose and 18.5% when they were conducted 6 to 8 years after the final dose.The time since the final dose was significantly longer for the children with a positive test result than for those with a negative test result (4.7 versus 2.8 years, P<0.001). The increasing likelihood of testing positive for pertussis with each additional year after receipt of the final DTaP dose remained significant after adjustment for calendar time, age, sex, race or ethnic group, and medical service area."This in an important paper, as it adds to our understanding of the waning immunity with DTaP vaccine," said Mark Sawyer, MD, of the University of California San Diego.

These data and others "have prompted the conversation about whether changes in the immunization schedule are warranted."Sawyer, who is chair of the pertussis vaccines working group for the Advisory Committee on Immunization Practices, and other commenters raised questions about the possibility of increased side effects - mostly local reactions - and cost with more frequent Tdap boosters.He added that vaccination - even with less-than-ideal vaccines - is still important."Although the current vaccines are less than perfect, they are all we have to protect the population from pertussis," he said. "Pertussis is very contagious, and we have seen very large outbreaks in many states over the past several years. It is very important to immunize as many people as we can, including adults and especially pregnant women and others around young babies. "Klein and colleagues acknowledged some limitations of the study, including the inability to determine the initial effectiveness of DTaP because of the lack of an unvaccinated population and the possibility that PCR testing misclassified some of the children.

MMR Coverage Rates Just Miss the Mark
Vaccination coverage rates for measles, mumps, and rubella (MMR) are close to but not quite up to where they should be, CDC researchers said. Among children starting kindergarten in 2011, median coverage with two doses of measles, mumps, and rubella (MMR) vaccine was 94.8% for the District of Columbia and the 47 states that reported vaccination rates - just shy of the CDC's Healthy People 2020 goal of 95% or more. Median MMR coverage ranged from 86.8% in Colorado to 99.3% in Texas, they reported.
Of the three states that did not report vaccination rates, two -- New Hampshire and New Jersey -- do not require vaccination for school entry, and the third - Wyoming - did not conduct a vaccination survey.

"Although median MMR vaccination coverage among children entering kindergarten was close to the ≥95% target, MMR vaccination coverage and exemptions aggregated at national or state levels can mask substantial vulnerability at the local level," the researchers wrote." Since exemptions cluster geographically, there might be smaller areas and schools where low levels of immunization could sustain ongoing measles transmission after importation from other countries," they added.

Unlike MMR rates, median coverage levels for diphtheria, tetanus toxoid, and acellular pertussis (DTaP), poliovirus, and hepatitis B virus were all at or above the target range of 95%, they found. Median coverage with at least two doses of varicella vaccine, on the other hand, was 93.2%, ranging from 84% in Colorado to 99.2% in Mississippi and Texas. Exemption rates - which include medical, religious, and philosophic objections - among 49 states and the District of Columbia were up about 0.2 percentage points over the 2009-2010 school year, at a median of 1.5%. The researchers estimated that 4,124,185 kindergarten children nationwide were not vaccinated due to these objections. Exemption rates ranged, however, from <0.1% to 7%, the researchers said. Arkansas saw the largest increase in exemption levels, jumping 3.4 percentage points in 2 years, and Nebraska saw the greatest drop, falling 2.3 percentage points during that time. The investigators noted that they did not have specific information as to which vaccines children had exemptions for, and said that exemption levels "continue to be low overall." The study was limited because the data are cross-sectional and because vaccine requirements and survey methodology vary by state. Also, changes in school vaccination reporting over time limit the ability to compare national trends over time, they added.

CDC Gives Options for Kids' Flu Shots
Clinicians have two ways to decide how many doses of seasonal influenza vaccine children ages 6 months through 8 years need this year, according to CDC guidelines.One, simpler, option does not take into account whether a child received the monovalent H1N1 vaccine during the pandemic, but may result in some children receiving two doses when one would suffice. The other can be used when information about receipt of the pandemic vaccine is readily available, according to the guidance. Use of both options will ensure that children receive at least two doses of a vaccine containing the pandemic H1N1 virus, which is expected to continue circulating this season. Children who have not received at least two doses of seasonal vaccine since July 2010 require two doses for the upcoming season.That algorithm is consistent with guidance from the American Academy of Pediatrics. The guidance states that if children are known to have received at least two seasonal influenza vaccines during any previous flu season and at least one dose of a vaccine containing the pandemic H1N1 strain -- either the monovalent pandemic vaccine or the seasonal vaccine from 2010-2011 or 2011-2012 -- then they can receive just one dose this year. Other children will require two doses.Regardless of the approach, children who need to get two doses should receive them at least 4 weeks apart.

FDA OKs Preemie Respiratory Drug
The FDA has approved lucinactant (Surfaxin) for prevention of respiratory distress syndrome (RDS) in premature infants. The drug joins beractant (Survanta), poractant alpha (Curosurf), and calfactant (Infasurf) currently marketed for RDS, the FDA said in a statement. RDS is a disorder that affects the lungs of premature infants and can potentially cause difficulty breathing or lung collapse. Symptoms and precursors of RDS include signs of breathing problems and lack of oxygen at birth or in the hours after birth. Adverse events were mostly related to dosing through the patient's breathing tube and included endotracheal tube reflux or obstruction, pale skin, and a need for dose interruption.

Vitamin D Key to Girls' Bone Health
For active girls, healthy bones may require more vitamin D than the typically recommended calcium and milk intake, researchers found in a study of stress fractures. The highest vitamin D intake cut the risk of stress fractures in half, with a particularly strong effect among girls getting an hour or more of high-impact exercise a day, Kendrin R. Sonneville, ScD, RD, of Children's Hospital Boston, and colleagues reported. But dairy and calcium intake had no impact on stress fracture risk in the prospective cohort study appearing online in the Archives of Pediatrics & Adolescent Medicine. Consuming calcium and calcium-rich dairy products is routinely encouraged for optimal bone health, and does likely have long-term benefits, Sonneville noted. "Very low calcium intake is harmful to bone development," she said. "Our findings in no way suggest that calcium isn't important." Rather these results, along with most other cross-sectional, retrospective, and prospective studies, suggest that additional intake beyond some minimal threshold doesn't help early bone health, her group explained. Extra vitamin D in the diet, perhaps from supplements, may help though, particularly given that low vitamin D is common in adolescents, the group added. "Anything that will benefit your bone early is probably going to have lifelong benefits in terms of bone health, and this includes things like fracture risk later in life and osteoporosis," Sonneville said. Weight-bearing activity boosts peak bone mass during that critical window of bone building in adolescence, but can go too far and lead to overuse injury from stresses that exceed the bones' capacity to heal. In the Growing Up Today Study, an ongoing cohort study of the adolescent children of women in the Nurses' Health Study, seven years of follow-up turned up stress fractures in 4% of the 6,712 girls, ages 9 to 15, at baseline. Nearly all of those fractures (90%) occurred in the 30% who practiced sports or other high-impact activity at least an hour a day. While the mean 1,182-mg daily intake of calcium didn't meet the recommended 1,300 mg for girls this age, girls in the highest intake quintile were no less likely than those in the lowest quintile to develop a stress fracture (hazard ratio 1.57, 95% CI, 0.77 to 3.17). Likewise, there was no trend for benefit from higher intake of dairy (P=0.82). Girls who took in three or more servings a day were no less likely to develop a stress fracture than those who ate no dairy (HR 1.02, 95% CI 0.65 to 1.61). Daily vitamin D intake also fell below the recommended 600 IU, averaging just 376 IU. But the higher the vitamin D intake, the lower the girls' stress fracture tended to be in the fully adjusted model (P=0.07 for trend). The intermediate intake groups, while still averaging less than 450 IU per day, appeared to be at about one-quarter less stress fracture risk than those with the lowest vitamin D intake averaging about 100 IU per day. The only statistically significant impact on fracture risk, though, came for the group that met the 600 IU per day recommendations. That top intake quintile, averaging 663 mg per day, had a hazard ratio of 0.49 for stress fracture compared with the bottom intake group (95% CI 0.24 to 1.01). Stratifying by activity level, girls getting the most vitamin D while participating in at least an hour of high-impact exercise were at a significant 52% lower stress risk than those getting the least vitamin D (P=0.04 for trend). Dairy had no impact in that analysis, and high calcium intake in highly active girls actually tended to increase fracture risk (HR 2.14, 95% CI 0.98 to 4.69), which the researchers called an unexpected finding that warrants further study. Adjustment for soda intake had no effect on the results. The biggest limitation of the study was lack of data on serum vitamin D status, which is only partially dependent on diet, the researchers noted. The study sample also was not nationally representative, as it included more active and fewer socioeconomically disadvantaged girls. During the study period, vitamin D supplementation was uncommon, so further studies would be needed to determine whether supplements are as protective as vitamin D in the diet, the researchers added.

FDA Issues Warning On Infant Tylenol/Paracetamol
The FDA has issued a warning in regards to liquid acetaminophen marketed for children. The possibility for confusion and wrong doses has been increased due to the release of a different concentration of the product which is arriving in pharmacies this winter. Used for pain relief and to treat fever in infants, the liquid acetaminophen was originally available only in an 80mg/0.8ml or 80mg/ml concentration. The new product looks identical, but requires a larger dose of liquid at 160mg/5ml. The problem is compounded by banners on the packaging stating "NEW", which appear on both concentrations of the liquid. The FDA advises parents and caregivers to read the packaging thoroughly and insure they use the correct dose. The product is widely used especially during the cold and flu season, and it would be easy for someone whose previously used the product for their child, to just assume the dose is identical. This would lead to the infant being given a much lower dose and it being ineffective. On the other hand, someone who used the new product and then inadvertently bought a packet of the older concentration, might give a 5ml dose, where a 1ml or 2ml dose is necessary. This would result in much larger dose than necessary. The newer version with the lower concentration may come with an oral syringe, instead of a dropper as in the older packaging. Acetaminophen is marketed under brand names such as:

• Tylenol
• Little Fevers
• Triaminic
• Infant/Pain Reliever
• Pedia Care
• Triaminic Infants' Syrup Fever Reducer Pain Reliever
• Other store brands (e.g. Rite Aid, CVS, Walgreens brand, etc.)

Addition Of New Infant Acetaminophen Concentration, 160 Mg/5 ML
The FDA (Food and Drug Administration) says it has added a new concentration of acetaminophen aimed at infants, which is now available at retail outlets. The 160 mg/5 mL concentration has been added to the existing 80 mg/0.8 mL or 80 mg/mL concentrations. People who are used to the existing liquid acetaminophen concentrations should take note, the Agency emphasized. Instead of being packed with a dropper, it will include an oral syringe. Caregivers, consumers and parents need to read the Drug Facts label on the packaging carefully in order to avoid potential dosing mistakes, the FDA explained. They should not just go on what is written on the banners (that state it is a new product) when identifying various liquid acetaminophen concentrations. Several products have banners which are quite similar. The product has a dosing device, which needs to be used so that the liquid acetaminophen dosages can be measured accurately. If you find the measuring device confusing, or you are not sure how to measure the dosage for a child, you should talk to a doctor or health care professional. Doctors and other health care professionals need to ensure that proper directions are given to caregivers and patients regarding how much should be administered to a child.

Taro Receives FDA Approval For Cetirizine Hydrochloride Oral Solution, 1 Mg/mL (Sugar Free Bubble Gum Flavor)
Taro Pharmaceutical has received approval from the FDA for its Abbreviated New Drug Application for Cetirizine Hydrochloride Oral Solution, 1 mg/mL (Sugar Free Bubble Gum) ("Cetirizine Oral Solution"). Taro's Cetirizine Oral Solution is an over-the-counter antihistamine used for the relief of sneezing, runny nose, itchy, watery eyes and itchy throat or nose due to indoor and outdoor allergies and for the relief of itching due to hives and is bioequivalent to Children's Zyrtec® Syrup, 5mg/5mL of McNeil Consumer Healthcare.

No More Infant Dose of OTC Acetaminophen

Over-the-counter drug makers have announced that they will no longer produce acetaminophen in concentrated infant drops; liquid acetaminophen products for children under 12 will be sold only in a 160 mg/5 mL concentration. The Consumer Healthcare Products Association (CHPA), the chief trade group for OTC drug manufacturers, indicated the move is intended to reduce dosing errors.Currently, liquid acetaminophen formulations for children ages 2 to 11 come in the 160 mg/5 mL strength, but more concentrated products - 80 mg/0.8 mL and 80 mg/1.0 mL - are sold for infants, with droppers for administration. "CHPA member companies are voluntarily making this conversion to one concentration to help make it easier for parents and caregivers to appropriately use single-ingredient liquid acetaminophen," said CHPA president and CEO Scott Melville in a statement. Manufacturers will also be adopting syringes with dose restrictors for products intended for infants, the CHPA indicated, but cups will continue to be provided for older children. The shift will begin in the middle of the year, the group said, but it warned that there will be a "transition period" during which multiple concentrations of the infant products may be on store shelves simultaneously. "During the transition, the makers of these medicines also will work with retailers to ensure that, as the new medicines are introduced, the more concentrated infant drops will be removed from store shelves," the CHPA statement indicated. "Consumers should always read and follow the label and pay particular attention to the concentration, especially when a healthcare provider gives dosing instructions," it added.

FDA Approves NEXIUM(R) I.V. (Esomeprazole Sodium) For The Treatment Of GERD With Erosive Esophagitis In Pediatric And Adolescent Patients

The FDA has approved the use of NEXIUM® I.V. (esomeprazole sodium) for Injection for children ages greater than 1 month old for the short-term treatment of gastroesophageal reflux disease (GERD) with erosive esophagitis when oral therapy is not possible or appropriate.1 NEXIUM I.V. is the first proton pump inhibitor approved for children under one year old. "This approval of NEXIUM I.V. for the treatment of children 1 month to 17 years old who are suffering from GERD with erosive esophagitis, gives physicians an important option in the treatment of infants and children," said Marta Illueca, MD, FAAP, executive director of gastrointestinal disorders for AstraZeneca. "This approval represents an important contribution to an unmet medical need for infants in particular. While some reflux and regurgitation are normal in infants and may not require medical treatment, persistent GERD symptoms can be very uncomfortable and cause damage to the esophagus, just as they can in older patients. Close medical supervision is key in the appropriate diagnosis and choice of treatment for these infants," continued Illueca. For first-line treatment of pediatric GERD, families are encouraged to try lifestyle modifications, such as smaller, more frequent feedings or dietary changes. If these methods fail, physicians until now have very few approved pharmacological options. NEXIUM I.V. is the first proton pump inhibitor approved for use in infants younger than 1 year old. NEXIUM I.V. for Injection is an alternative to oral therapy when oral therapy is not possible or appropriate and is administered in the hospital by a health care professional. Treatment with NEXIUM I.V. for more than 10 days has not been studied.

FDA Approves The First Vaccine To Prevent Meningococcal Disease In Infants And Toddlers
The U.S. Food and Drug Administration today approved the use of Menactra in children as young as 9 months for the prevention of invasive meningococcal disease caused by Neisseria meningitidis serogroups A, C, Y and W-135. Menactra already is approved for use in people ages 2 through 55 years.

Meningococcal disease is a life-threatening illness caused by bacteria that infect the bloodstream (sepsis) and the lining that surrounds the brain and spinal cord (meningitis). Neisseria meningitidis is a leading cause of meningitis in young children. Even with appropriate antibiotics and intensive care, between 10 percent and 15 percent of people who develop meningococcal disease die from the infection. Another 10 percent to 20 percent suffer complications such as brain damage or loss of limb or hearing.

Although the rates of meningococcal disease are low in the United States, infants and toddlers are more susceptible to getting this serious illness. Meningococcal disease is particularly dangerous because it progresses rapidly and can cause death within hours. Early symptoms are often difficult to distinguish from influenza and other common illnesses.

"The highest rate of meningococcal disease occurs in children under one year of age. With today's approval, Menactra can now be used in children as young as 9 months of age to help prevent this potentially life-threatening disease," said Karen Midthun, M.D., director of FDA's Center for Biologics Evaluation and Research.

The safety of Menactra in children as young as 9 months was evaluated in four clinical studies in which over 3,700 participants received the vaccine. The most common adverse events reported in children who received Menactra at 9 months and 12 months of age were injection-site tenderness and irritability. Occurrence of fever was comparable to other vaccines routinely recommended for young children.

Menactra is given as a two-dose series beginning at 9-months, three months apart; and the study results showed the vaccine produces antibodies in the blood that are protective against the disease.

Menactra was originally approved on Jan. 14, 2005, for use in individuals ages 11 years through 55 years and was approved in October 2007 for children as young as 2 years. Menactra is manufactured by Sanofi Pasteur.

Are your children’s vaccinations up-to-date before traveling by air?
According to the Centers for Disease Control (CDC), in the past year alone there were more than 3,000 known airline passengers traveling while ill with a contagious disease.

 1. The aircraft cabin environment abets the spread of disease-causing microorganisms. Infected passengers cough up, sneeze out and exhale these organisms. Factors that favor this spread include close and prolonged contact with other passengers and, possibly, the vagaries of ventilation systems, dryness of the cabin air, and the presence of passengers originating in countries where such diseases are prevalent.

2. Likely, the number of ill passengers is far greater than the number reported. This further increases the risk of spreading disease. Some ill travelers conceal the fact that they are ill while others are in the incubation period – already contagious but not yet symptomatic and thus unaware that they are ill. The CDC recommends not traveling until 24 hours after fever subsides.  But ill persons are often reluctant to cancel scheduled trips.  One reason is that some airlines penalize for last-minute cancellations regardless of the reason are an additional disincentive.

 3. Airport personnel can refuse boarding when passengers appear ill. But, in fact, this is rarely done. (Most people denied boarding are under the influence of alcohol or drugs.)Airport personnel are poorly trained in recognizing infectious illnesses and say it is a “hassle to get involved.” They can telephone airline medical staff for advice but the staff is rarely on the premises.

 4. The CDC has guidelines for handling visibly ill passengers in flight. But the crew rarely takes action. They can ask passengers to wear surgical masks (carried on most aircraft), isolate the passengers (if room is available), contact consultants on the ground for guidance, have quarantine officers meet the aircraft on landing, and, for long flights, make unscheduled stops at a closer airport than the destination.

 5. Most diseases transmitted on aircraft are vaccine-preventable. The diseases most commonly found in the CDC survey were so-called childhood diseases: measles, mumps, chickenpox and pertussis (whooping cough). Other studies, done during flu epidemics, found passengers traveling with that disease. Optimally vaccinated children are already immune to these diseases. But an increasing number of parents refuse to vaccinate their children – though there is no known evidence that there are harmful effects.

 

6. Check with experts when traveling with infants. In infancy, immunity to vaccine-preventable diseases depends on many factors: the disease in question, immunity received from the mother during pregnancy, and vaccines administered to the infant. Generally routine vaccinations are started at about two months of age but infants are not fully protected until months later; many immunizations require multiple doses over many months to become protective. Sometimes, for travel, routine vaccination schedules may have to be altered, started earlier and repeated later, for example. Rarely, travel should be postponed. Decisions may depend on current disease activity at the destination.  Influenza vaccination is recommended for everyone who is six months of age and older. Influenza can be a serious disease for infants; hospitalization rates for infants from influenza approach those for the elderly.

 

7. Adults need vaccinations, too.  Many parents who opt not to vaccinate their children erroneously believe that the so-called “childhood” diseases affect only children. Unvaccinated children become unvaccinated adults. And infected adults spread diseases. Also, for some diseases, protection from vaccine administered in childhood wanes with age; in these cases booster doses are necessary.

 

8. Many childhood diseases are more serious in adulthood. Compared to children, adults who do become infected are more likely to have complications, the complications tend to be more severe, and the illness may last longer, prolonging the period that the adult remains contagious and is able to spread the disease. If women become infected during pregnancy, the fetus may be adversely affected.

 

9. Vaccinations are especially important for overseas travel. The lower the percentage of children vaccinated against a given disease in a country, the greater the risk of unvaccinated visitors contracting that disease. In many developing countries, many vaccines are largely unavailable. Moreover, travel to developing countries may require vaccines against diseases not seen back home (yellow fever and typhoid, for example).

 

10. Check vaccinations for cruises. Some conditions favoring the spread of disease-causing organisms in flight also occur on cruise ships: crowding (albeit less so than on aircraft), prolonged togetherness, common ventilation systems, and passengers from different parts of the world, for example. Also, check if vaccinations are necessary at scheduled ports-of call.

 

Bronchiolitis: Recent Evidence on Diagnosis and Management

Viral bronchiolitis is a leading cause of acute illness and hospitalization of young children. Research into the variation in treatment and outcomes for bronchiolitis across different settings has led to evidence–based clinical practice guidelines. Ongoing investigation continues to expand this body of evidence. Authors of recent surveillance studies have defined the presence of coinfections with multiple viruses in some cases of bronchiolitis. Underlying comorbidities and young age remain the most important predictors for severe bronchiolitis. Pulse oximetry plays an important role in driving use of health care resources. Evidence–based reviews have suggested a limited role for diagnostic laboratory or radiographic tests in typical cases of bronchiolitis. Several large, recent trials have revealed a lack of efficacy for routine use of either bronchodilators or corticosteroids for treatment of bronchiolitis. Preliminary evidence suggests a potential future role for a combination of these therapies and other novel treatments such as nebulized hypertonic saline.



Otitis Media Guidelines

Background: The American Academy of Pediatrics 2004 guidelines on diagnosis and management of acute otitis media (OM) recommends use of high-dose amoxicillin for the treatment of acute uncomplicated OM. With rising childhood obesity, recommended amoxicillin dose of 80 to 90 mg/kg per day often exceed standard adult dose of 1500 mg/d.  



Objective: To study prescribing patterns of primary care physicians for amoxicillin in the treatment of OM. To assess opinions of American Academy of Pediatrics subcommittee members who participated in guideline formulation.  



Methods: This study had 2 parts. Part 1: Retrospective review of medical records of children visiting the hospital between April and June 2008 and with a diagnosis of OM and were prescribed amoxicillin. Part 2: Web-based survey of 14 members of the OM guidelines subcommittee.  



Results: Part 1: Three hundred fifty-nine children were eligible, with a mean (SD) age of 3.2 (4.0) years and 185 (51.5%) of whom were males. Children weighing 20 kg or less received higher mean daily dose of amoxicillin (74.2 vs 40.4 mg/kg per day, P < 0.00). Part 2: Nine (64.3%) subcommittee members responded to the survey. Most (77.8%) affirmed that the impact of obesity on high-dose amoxicillin recommendation was not discussed during guideline formulation. If a patient's estimated amoxicillin dose exceeded the standard adult dose (1500 mg/d), 66.7% members would prescribe the standard adult dose whereas 33.3% would prescribe the recommended dose of 80 to 90 mg/kg per day.  



Conclusions: Primary care physicians prescribe a significantly lower-than-recommended amoxicillin dose in older children and those in the higher weight category. The opinion among subcommittee members regarding maximum dose specification of amoxicillin is varied.



Acute Bacterial Meningitis in Infants and Children

Bacterial meningitis continues to be an important cause of mortality and morbidity in neonates and children throughout the world. The introduction of the protein conjugate vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae, and Neisseria meningitidis has changed the epidemiology of bacterial meningitis. Suspected bacterial meningitis is a medical emergency and needs empirical antimicrobial treatment without delay, but recognition of pathogens with increasing resistance to antimicrobial drugs is an important factor in the selection of empirical antimicrobial regimens. At present, strategies to prevent and treat bacterial meningitis are compromised by incomplete understanding of the pathogenesis. Further research on meningitis pathogenesis is thus needed.



Child Deaths Prompt FDA Warning on Cough Drug

After reviewing reports on 31 overdoses of the prescription cough medication benzonatate (Tessalon) - including the deaths of five toddlers - the FDA said it was beefing up the drug's label warnings and urging parents to keep it out of reach of children. The product is sold in colored gelcaps with a "candy-like" appearance, the agency indicated in a press release. "Benzonatate should be kept in a child-resistant container and stored out of reach of children," said Carol Holquist, RPh, director of the agency's Division of Medication Error Prevention and Analysis. "The FDA encourages healthcare professionals to talk with their patients and those caring for children about the risk of accidental ingestion or overdose." The product will remain on the market, but new label information will be added about risks of accidental ingestion resulting in overdose and death in children younger than 10. Benzonatate was approved in 1958 for treatment of coughs in patients 10 and older. It is available in 100- and 200-mg dosage forms. An FDA review of adverse event reports disclosed 31 cases of overdose in children and adults, ranging in age from 1 to 66. The overdoses involved as many as 30 gelcaps and as few as one. Most of these appeared deliberate. However, seven were ruled accidental, all of which occurred in children younger than 10. Five of these - all involving children younger than two - ended in death. Cardiac arrest, coma, and convulsions were common in the overdose cases. In six cases where the event report included information on time course of events, the FDA said, symptoms developed within an hour of ingestion, much faster in some cases. The agency recommended that healthcare professionals prescribe the minimum number of capsules needed to treat an episode. Providers should also advise parents to keep the capsules in childproof containers out of reach of children, the FDA said.



Dosing Instructions For OTC Medicines For Children Confusing, Hard To Follow

According to a study published online Nov. 30 in the Journal of the American Medical Association, many over-the-counter, liquid medications meant for children contain dosing instructions and measuring cups or droppers that rarely match each other and could confuse even the most careful parent or caretaker. As a result, this could easily lead to under- or over-dosing, with potentially dangerous consequences, researchers said. Twenty-six percent of products had no dispensers, such as a cup or medicine dropper, forcing parents to measure out doses themselves. But even products with dispensers had problems. For example, label instructions on 99% of these products conflicted with markings on the dispensing cup or dropper.         Last year, the Food and Drug Administration issued voluntary industry guidelines for the labels on nonprescription liquid children's medicines and measuring devices after numerous overdoses were attributed to confusing labels. The results of this new study may now be used to evaluate how well companies that make over-the-counter children's medicines improve their products, the researchers said.