Category: Paediatrics

Categories : PaediatricsTags :

Evidence for Widespread Overprescription of Specialised Infant Formula

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New research published in Clinical and Experimental Allergy reveals that prescriptions of specialised infant formula have increased in recent years in England, Norway, and Australia, with rates over 10 times what would normally be expected for the number of children with milk allergies.

Increasing specialised formula use has been interpreted as evidence for milk allergy overdiagnosis, leading to the use of specialised formula for managing common infant symptoms. This is because there is little evidence in high-income countries for a change in milk allergy incidence to explain rises in specialised formula prescription. While specialised formula is reasonably well tolerated by most infants, and supports infant nutrition and growth, there are significant differences from standard cow’s milk-based infant formula or human breastmilk. In specialised formula products, the lactose found in breastmilk or cow’s milk is partially or completely replaced by alternative carbohydrate sources, often free sugars such as glucose or sucrose.

Soya milk alternatives were prevalent in the 1990s, but in the 2000s were displaced by amino-acid formulations after health concerns emerged over soya milk use in infants. Prescribed amounts of specialised formula for infants rose 2.8-fold in England from 2007–2018, with similar trends in other regions of the United Kingdom. Amounts rose 2.2-fold in Norway from 2009–2020 and 3.2-fold in Australia from 2001–2012.

In addition to added expense (specialised formula costs an average of US117 extra per birth in England), these findings are of particular concern due to their higher levels of sugar, which may promote tooth decay and obesity in young children.

“These data suggest high levels of milk allergy over-diagnosis and mark an important shift in early child nutrition,” the authors wrote.

Source: Wiley

Categories : PaediatricsTags :

A Prescription-only Video Game to Treat ADHD in Children

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Doctors in the US have been prescribing a unique new treatment for attention deficit hyperactivity disorder (ADHD) in children – a video game.

Designed in conjunction with neuroscientists, EndeavorRx, known in clinical trials as AKL-T01, is the first FDA-approved video game designed to treat ADHD in children. It is currently only available in the US by prescription but its creators are hoping to have it approved in other countries.

The game, which involves controlling a little alien racing across different environments to complete tasks, specifically trains users to concentrate on multitasking and to block out distractions – cognitive areas which often need a boost in ADHD.

In a randomised controlled trial published in The Lancet Digital Health, 348 patients, aged 8–12 years old and not receiving medication for ADHD, were randomised to receive the game intervention or a control.

For a control, the clinical trial made use of a different game specifically designed as a digital word game which did not target areas involved with ADHD.

Over four weeks, participants were instructed to play the intervention or placebo game for five minutes, five times a day, five days a week.

The trial found that compliance was high, with 83% of treatment session being played. Treatment-related adverse events were mild and included frustration (5 [3%] of 180) and headache (3 [2%] of 180).

ADHD was measured by Test of Variables of Attention (TOVA) Attention Performance Index (API). The mean change from baseline on the TOVA API was 0·93 in the AKL-T01 group and 0·03 in the control group.

An extension of the trial found that EndeavorRx also worked as an adjunct treatment in children with ADHD who were also receiving stimulant treatment for their condition. One hundred and thirty were enrolled in the On Stimulants cohort, and 76 in the No Stimulants cohort. Despite severe comorbidities being exclusionary, around 20% of the included participants still presented with at least one DSM-listed comorbidity. The trial involved a four week treatment period, a four week pause, and another four week treatment period. Improvements for both groups were found from the first treatment period, and continued into the pause and into the second treatment period, suggesting continuing and lasting gains.

Eddie Martucci, chief executive of Akili which produced the game, told the BBC that EandeavorRx offers something that pharmaceuticals currently cannot. “It is something that’s very difficult to get through molecular means, like taking a pill. But it turns out that sensory stimuli can actually directly stimulate parts of the brain controlling cognitive function.”

Categories : Paediatrics Respiratory DiseasesTags :

Hospital Readmissions for Children with Asthma on The Increase

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Hospital readmissions for asthma are increasing among children, likely stemming from COVID lockdowns reducing immunity to common respiratory viruses. These are the findings of a new study published in the Journal of Asthma. The finding highlights the gaps in health care for this most common of chronic paediatric illnesses.

The Australian study, led by the Murdoch Children’s Research Institute, found about one in three children, mostly pre-schoolers, are readmitted to hospital for asthma compared to one in five a decade ago.

Most asthma hospital presentations were preventable, Murdoch Children’s Dr Katherine Chen said, which emphasises the need for a holistic evaluation of each child’s asthma management to prevent future readmissions.

The study involved 767 children, aged three to 18 years, who were admitted to three hospitals in Victoria state between 2017-2018 with a diagnosis of asthma. It found that 34.3% were readmitted to hospital for asthma, with those aged three to five years accounting for 69.2%. Of the 767 participants, 20.6% were readmitted once, and 13.7% had two or more readmissions in 12 months. 

“Our study highlighted gaps in the children’s asthma care,” Dr Chen said. Over a third of children hadn’t had a review of their inhaler technique, and only about a quarter were prescribed a preventer or asked to continue using it.

“Almost three quarters were discharged without a preventer medication, and over 80 per cent did not have a follow-up clinic booked at the hospital, often reserved for children with difficult-to-control asthma. Most families, therefore, need to navigate their child’s asthma follow-up with their GP.”

Recently, said Dr Chen, asthma admissions had spiked due to the rise in respiratory infections and children lacking immunity to common viruses as a result of COVID lockdowns.

Professor Harriet Hiscock at MCRI said that the findings confirmed the important role of GPs in paediatric asthma management and how targeted interventions at each hospital could reduce readmissions.

“Less than 10 per cent were readmitted within 30 days suggesting the importance of ongoing community care and longer-term asthma control,” she said. The need to regularly review overall asthma management, minimise risk factors, arrange follow-up, and support optimum care in the community are key.

“Interactive digital symptom monitoring with specialist nurse support, home-based education and a culturally tailored education program could also help.”

Prof Hiscock said linked datasets were important to objectively measure the burden of asthma cases on health services.

“Our current dataset cannot verify whether the follow-up appointment was attended, whether caregivers had arranged follow-up post-discharge and if the medications were used as prescribed,” she said. “Integrating datasets such as health services and medication use into clinical care will improve the clinician’s understanding of the child’s asthma control and medication adherence and would assist in providing targeted treatments.”

Asthma is the most common chronic paediatric illness in industrialised countries, affecting 8–10% of children.

Source: Murdoch Children’s Research Institute

Categories : PaediatricsTags :

ADHD Overdiagnosis Common and Racially Skewed, US Study Finds

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A study in the Journal of Learning Disabilities examining overdiagnosis of attention-deficit/hyperactivity disorder (ADHD) found that diagnoses are common in children who are functioning well, and that there is a racial bias.

ADHD overdiagnosis and subsequent overtreatment poses needless potential harm to children. It also contributes to scepticism toward those who do have moderate or severe symptoms and significant impairments, resulting in less supportive care.

Yet which sociodemographic groups of children are overdiagnosed and overtreated for ADHD is poorly understood. As a proxy for overdiagnosis, researchers selected elementary schoolchildren who had displayed above-average levels of independently assessed behavioural, academic, or executive functioning the year prior to their initial ADHD diagnoses and who did not have prior diagnostic histories. This suggested they were unlikely to have ADHD.

The researchers conducted descriptive and logistic regression analyses of a population-based subsample of 1070 elementary schoolchildren.

Among these children, (a) 27% of White children versus 19% of non-White children were later diagnosed with ADHD and (b) 20% of White children versus 14% of non-White children were later using medication. In adjusted analyses, White children are more likely to later be diagnosed (odds ratio [OR] range = 1.70–2.62) and using medication (OR range = 1.70–2.37) among those whose prior behavioural, academic, and executive functioning suggested that they were unlikely to have ADHD.

The findings also skewed toward older children, and differences in diagnoses according to race was not linked to socioeconomic status. The authors acknowledge limitations such as a small sample size as well as not being able to account for English-speaking versus non-English speaking families, but note that their results are significant for 9 out of the 10 tests used.

The researchers suggest that greater overdiagnosis in White children may be in part explained by greater access to better-resourced schools more likely to pick up (or attempt to pick up) ADHD in children. Non-White children may also need to display behaviours more consistent with ADHD to be referred for evaluation and treatment.

Cultural misconceptions about ADHD are less likely to be prevalent in non-White families, and there is evidence to suggest that ADHD overdiagnosis is being used to gain academic achievement.

They concluded: “Preventing or reducing ADHD overdiagnosis and overtreatment should contribute to more appropriate care, limit increasing ADHD prevalence, increase the academic and behavioural functioning of elementary schoolchildren being diagnosed with ADHD but who are displaying few or mild symptoms, reduce unnecessary exposure to adverse side effects of medication use, and better allocate limited mental health resources.”

Categories : COVID PaediatricsTags :

Chinese Study Finds Children More Likely to Spread COVID

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By gaining access to a high quality COVID transmission data from a northern Chinese city which enforced stringent lockdowns, scientists concluded that young people were most responsible for an increase in direct and secondary infections, and also determined that county-wide lockdowns proved effective in limiting the virus’s spread.

The research study, led by Professor of Sociology Zai Liang at University of Albany, was given rare access to patient profiles and contact tracing data from every case accompanying the outbreak of the virus in Shijiazhuang from January to February in 2021. “Because of universal testing and digital tracing, the data are of high quality,” said Prof Liang, who was assisted by Sociology PhD student and lecturer Han Liu. Liu is from Shijiazhuang and has connections with that city’s CDC research centre, which enabled them to get the data.

The two UAlbany researchers, joined by two colleagues from China, published their findings in the Journal of Urban Health.

Prof Liang wrote that while individual-level contact tracing studies on the virus’s transmission and mitigation efforts have been growing, “because of limited testing capacities and risks of infringing on privacy, surveillance data used in individual-level research usually have limited representativeness.” His Shijiazhuang study, whose analysis included 99.52 percent (1028 of 1133) of the transmitted cases in Shijiazhuang, is designed “to fill this gap in the literature.”

The research examined sociodemographic factors including age, gender and socioeconomic status, postulating that “certain sociodemographic characteristics may facilitate the spread of germs by exposing the host to more social contacts.” This would include children interacting in the classroom, females having more contact with their relatives than do males, and less affluent workers working or living in overcrowded settings.

Among the study’s results are:

  • Children 0–17 years old had fewer close contacts than adults, but these led to more secondary infections: 32.1% infected children, 67.9% adults
  • Close contacts of children were 81% more likely to be infected than the contacts of those 18–49
  • Peasant workers, compared to non-manual workers, had 40% more secondary cases from the same neighbourhoods.

Prof Liang wrote, “While children have a low probability of having severe symptoms after being infected by COVID, they can seed the spread in the larger society by infecting their household members and other adults living in their neighbourhoods. These adults can then transmit the disease to their own social contacts. Future studies on how to control within-school infections are therefore urgently needed.”

Another major conclusion of the Shijiazhuang study is that timely non-pharmaceutical interventions, including restrictions on gatherings and school closures, effectively contained further infections via contact reduction, especially when implemented in small areas with the highest caseloads. Liang acknowledged that school closures did have negative ramifications for children’s education and socialisation.

Serendipitous data collection

How did Prof Liang and colleagues obtain comprehensive data not yet publicly available to others? “We heard of this COVID outbreak in this part of northern China early last year, when I was working on a proposal to study COVID. I asked Han Liu if we had connections in that city. It turned out that he is originally from Shijiazhuang and has connections with that city’s CDC research centre.

“The two researchers who collected the data agreed to join us in this effort. I am lucky to ask the right question at the right time.”

Source: University at Albany

Categories : Paediatrics TransplantsTags :

Paediatric Kidney Transplants without Immunosuppressive Drugs

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Anatomic model of a kidney
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Stanford Medicine physicians have developed a way to provide paediatric kidney transplants without immunosuppressive drugs. Their key innovation is a safe method to transplant the donor’s immune system to the patient before surgeons implant the kidney.

The medical team has dubbed the two-transplant combination a “dual immune/solid organ transplant,” or DISOT. The first three DISOT cases, all performed at Lucile Packard Children’s Hospital Stanford were described in the New England Journal of Medicine, accompanied by an an editorial about the research.

The Stanford innovation removes the possibility that the recipient will experience immune rejection of their transplanted organ, the most common reason for a second organ transplant The new procedure also rids recipients of the substantial side effects of a lifetime of immune-suppressing medications, including increased risks for cancer, diabetes, infections and hypertension.

“Safely freeing patients from lifelong immunosuppression after a kidney transplant is possible.”

Alice Bertaina, MD, PhD, report’s lead author, associate professor of paediatrics, Stanford University

The first three DISOT patients were children with a rare immune disease, but the team is expanding the types of patients who could benefit. The protocol received FDA approval on May 27, 2022, for treating patients with a variety of conditions that affect the kidneys. Dr Bertaina anticipates that the protocol will eventually be available to many people needing kidney transplants, starting with children and young adults, and later expanding to older adults. The researchers also plan to investigate DISOT’s utility for other types of solid-organ transplants.

The scientific innovation from Dr Bertaina’s team has another important benefit: It enables safe transplantation between a donor and recipient whose immune systems are genetically half-matched, meaning children can receive stem cell and kidney donations from a parent.

The advance is especially meaningful for Jessica and Kyle Davenport of Muscle Shoals, Alabama. Their two children, both born with a rare and potentially deadly immune disease, are among the first recipients of DISOT: 8-year-old Kruz received transplants from Jessica, while his 7-year-old sister, Paizlee, received transplants from Kyle.

“They’ve healed and recovered, and are doing things we never thought would be possible,” said Jessica Davenport. After years of helping Kruz and Paizlee cope with severe immune deficiency and its attendant infection riskk as well as kidney dialysis, she and her husband are thrilled that their children have more normal lives.

The idea of transplanting a patient with their organ donor’s immune system has been around for decades, but it has been difficult to implement. Transplants of stem cells from bone marrow provide the patient with a genetically new immune system, as some of the bone marrow stem cells mature into immune cells in the blood. First developed for people with blood cancers, stem cell transplants carry the risk of the new immune cells attacking the recipient’s body, a potentially lethal complication called graft-versus-host disease.

Source: Stanford Medicine

Categories : Diseases, Syndromes and Conditions PaediatricsTags :

Early Intervention in Spinal Muscular Atrophy is Key

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According to the results of a new study published in Developmental Medicine & Child Neurology, early identification and treatment of patients with spinal muscular atrophy (SMA) can greatly reduce the total financial costs associated with the condition. 

A genetic disorder, SMA is characterised by progressive muscle weakness, reduced tone with associated destruction of alpha motor units. There are four main subtypes of spinal muscular atrophy defined by the age of onset and severity with type 0 presenting in utero and causing death within the first months of life and type 4 in adulthood, causing mild weakness and no effect on lifespan. Understanding the underlying pathophysiology, subtypes, and emerging treatments is key to treating patients with spinal muscular atrophy effectively.

Analysing the data of 149 SMA patients, (93 untreated, 42 treated after symptoms arose, and 14 treated after early diagnosis), the total societal cost was lower in untreated patients (due to high drug costs in treated patients), but costs were lower for treated patients who were identified by newborn screening than for treated patients identified due to the development of symptoms. 

“These data are important as they are issued from a real-life prospective collection. They demonstrate clearly that as long as the decision to reimburse treatments for SMA has been made, newborn screening becomes a no-brainer—not only because it gives patients a much better future, but also because it saves a significant amount of money for the taxpayer,” said senior author Laurent Servais, PhD, of the University of Liege, in Belgium and the University of Oxford, in the UK. “Using these data issued from the real world, we are working currently on a model that estimates the lifetime cost of the different strategies.” 

Source: Wiley

Categories : PaediatricsTags :

Older Siblings Confer Healthy Development

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Children
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Being a younger sibling in a family can have more benefits than simply being spoiled by the parents. A new study, published in BMC Public Health, reveals that older siblings confer a protective effect on the behaviours of their younger brothers and sisters.

Exposure environmental stressors during critical periods of life, especially to maternal stress while in the womb, can have negative long-term consequences for children’s development.

In a new study, researchers used longitudinal data from the LINA cohort (Lifestyle and environmental factors and their Influence on the Newborn Allergy risk) to test 373 German mother-child pairs, from pregnancy until 10 years of age. 

Mothers were asked to fill in three validated questionnaires, to assess their stress levels and their child’s behavioural problems. First, the researchers assessed which social and environmental factors were linked to an increase in maternal stress levels during pregnancy, and the long-term consequences of maternal stress on the occurrence of child behavioural problems. Second, the researchers assessed whether the presence of siblings had a positive effect on the occurrence of child behavioural problems, by directly reducing stress levels and increasing children’s psychological well-being, or by indirectly buffering the negative consequences of maternal stress. 

Prenatal stress can cause behavioural problems in the child

The results of the study showed that socio-environmental stressors, like the lack of sufficient social areas in the neighbourhood, were clearly linked to an increase in maternal stress levels during pregnancy. Moreover, mothers who had experienced high stress levels, like worries, loss of joy or tension, during pregnancy were also more likely to report the occurrence of behavioural problems when their children were 7, 8 or 10 years old. “These results confirm previous findings about the negative impact that even mild forms of prenatal stress might have on child behaviour, even after several years, and highlight the importance of early intervention policies that increase maternal wellbeing and reduce the risks of maternal stress already during pregnancy,” explained Federica Amici, one of the researchers involved in the project.

On a more positive note, the study also found a lower occurrence of behavioural problems in children with older siblings. “Children who have older brothers or sisters in their households are less likely to develop problems, which suggests that siblings are crucial to promote a healthy child development,” explained Gunda Herberth, coordinator of the LINA study. 

Higher social competence thanks to older siblings?

This study further suggests that the presence of older siblings directly reduced the risk of developing behavioural problems, but did not affect negative effects of maternal stress on child behaviour. How could older siblings reduce the occurrence of behavioural problems in children? By interacting with their older siblings, children may develop better emotional, perspective taking and problem solving skills, which are linked to higher social competence and emotion understanding. Moreover, the presence of older siblings may provide learning opportunities for parents, who might thus develop different expectations and better parental skills. 

“We were especially impressed by the important role that siblings appear to play for a healthy child development,” concluded researcher Anja Widdig. “We hope that our findings will draw attention to the importance of public health policies that directly target children and their siblings, and promote a healthy environment for their well-being and the development of high-quality sibling relationships”.

Source: Helmholtz Centre for Environmental Research

Categories : Allergies PaediatricsTags :

The Process of Remission from Peanut Allergy Mapped Out

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Credit: NIH

An Australian study published in Allergy, has identified the key immunological changes that support the remission of peanut allergy in children, a discovery that could pave the way to new, more targeted treatments.

The research showed, for the first-time, that specific gene networks are rewired to drive the transition from peanut allergy to clinical remission following a combination treatment of a probiotic and peanut oral immunotherapy.

The study found that this network reprogramming essentially shuts down the allergic immune response that was responsible for causing a food allergy.

Lead researcher, Professor Mimi Tang of Murdoch Children’s Research Institute, said this was the first study to map the complex gene to gene communication and connectivity underlying clinical remission of peanut allergy.

“The immunological changes leading to remission of peanut allergy were largely unknown,” she said. Previous studies had mostly focused on examining the levels of gene expression, without also exploring how genes interact with each other. But genes don’t work in isolation; instead, biological responses are controlled by large numbers of genes communicating with each other, so it made sense to look at these interactions more closely.

“What we found was profound differences in network connectivity patterns between children who were allergic and those who were in remission. These same changes were also seen when we compared gene networks before and after immunotherapy in the children who achieved remission following immunotherapy.”

The randomised controlled trial involved 62 peanut allergic children, ages 1–10, who received a combination treatment of a probiotic and oral immunotherapy (gradual introduction of the allergen) or a placebo. Following 18 months of treatment, 74% taking the combination treatment achieved remission compared with 4% in the placebo group.

The peanut oral immunotherapy that was used in combination with the probiotic in the trial was PRT120, a lead candidate from biotech company Prota Therapeutics.

The team led by Professor Tang also recently showed in a separate trial that two treatments — the combination probiotic and peanut oral immunotherapy treatment and the peanut oral immunotherapy alone — were highly effective at inducing remission and desensitisation. About half of the treated children achieved remission, which allowed them to stop treatment and safely eat peanut freely.

Murdoch Children’s Dr Sarah Ashley said while oral immunotherapy could successfully induce desensitisation and remission, desensitisation often waned after treatment ended or even during ongoing maintenance dosing.

“Certain changes in the allergen-specific immune cells, called Th2 cells, are critical to achieving lasting remission,” she said. Th2 cells are essential for generating allergen-specific antibodies and the development of food allergy. We found that the Th2 signalling that drives allergy is ‘turned off’ in children in remission.”

Food allergy is a global public health concern, affecting 10% of infants and 5–8% of children.

Source: Murdoch Children’s Research Institute

Categories : PaediatricsTags :

New Ambulatory BP Monitoring Guidance for Children and Adolescents

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An American Heart Association scientific statement reviewing new evidence and guidance on ambulatory blood pressure monitoring (ABPM) of children and adolescents published in the journal Hypertension.

The statement provides simplified classifications for ABPM in children and adolescents. ABPM is designed to evaluate a person’s blood pressure during daily living activities, including times of physical activity, sleep and stress.

Key points of the statement:

  • The statement provides simplified classifications for ambulatory blood pressure monitoring (ABPM) in children and adolescents. ABPM is designed to evaluate a person’s blood pressure during daily living activities, including times of physical activity, sleep and stress.
  • The new classifications come with guidance on when ABPM is appropriate and how to interpret monitoring results.
  • Children who have medical diagnoses, such as kidney disease, may have normal office blood pressure but significant abnormalities noted on ABPM. Without taking ABPM into account, this can lead to a more benign prognosis.
  • Elevated childhood blood pressure is linked to heart and kidney damage during youth and adulthood, as well as brain changes associated with worse cognitive function.
  • ABPM helps ease concern of spikes in blood pressure caused by measurement anxiety, known as white coat hypertension, and helps assess daily blood pressure patterns.
  • ABPM is used to confirm whether a child or adolescent with high blood pressure during a clinic measurement truly has hypertension.

Source: American Heart Association