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Preventing rickets: sunlight exposure may not be sufficient

▸ Several factors have prompted the American Academy of Pediatrics (AAP) to reconsider its recommendations regarding vitamin D intake. The number of breast-fed infants is increasing, new evidence suggests that early sun exposure is a risk factor for the development of skin cancer, and the National Academy of Sciences recently reduced the amount of daily vitamin D considered necessary for prevention of rickets (from 400 IU/day to 200 IU/day). Highlights of the new recommendations include:

All breast-fed infants who take less than 500 mL/day of vitamin D-fortified formula should receive 200 IU/day of vitamin D within the first 2 months of life. (All formulas in the U.S. contain at least 400 IU/L, and multivitamins usually contain 400 IU/mL.) All non-breast-fed infants who take less than 500 mL/day of vitamin D-fortified formula should receive multivitamins with vitamin D. This recommendation should affect very few healthy formula-fed infants, as most consume more than 500 mL/day of formula.

Comment

▸ Although the AAP calls these recommendations “guidelines”, it does not present the strength of evidence that should underlie such statements. It also acknowledges that there are limited data to support its recommendations. However, given the low cost and ease of providing multivitamins to infants, the suggestions represent a reasonable approach to the problem of rickets and low vitamin D intake. It is likely that some parents of breast-fed infants will object to giving their children multivitamins; in such cases, ensuring adequate, safe exposure to sunlight is important.

Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine April 14, 2003.

The evolving science of peanut allergy

▸ The apparent increase in cases of peanut allergy has led to renewed study of the allergy’s etiology and treatment. Two groups of researchers investigated these topics.

Researchers in the UK identified 49 preschool children with histories of peanut allergy among 13 971 children who were enrolled in a longitudinal, prospective study; the allergy was confirmed by challenge in 23 of 36 tested children. Maternal consumption of peanuts during pregnancy or breast-feeding was unrelated to the development of peanut allergy in children. Intake of soy milk or soy-based formula by children was independently associated with peanut allergy. Use of creams containing peanut oil was also significantly related to allergy (91% of children with positive peanut allergy had been exposed to such creams, vs. 53% of atopic controls and 59% of healthy controls).

In a double-blind, randomized treatment trial, 82 patients (age range, 13–59 years) with histories of immediate peanut hypersensitivity received weekly treatment with subcutaneous doses of 150, 300, or 450 mg of TNX-901 (a humanized IgG1 monoclonal antibody) or placebo for 4 weeks. Two to 4 weeks after treatment ended, recipients of the higher doses of TNX-901 had significantly greater tolerance of ingested peanut flour than did recipients of the lower doses.

Comment

▸ The search continues for easy modifications that can avoid the induction of peanut allergy. These findings suggest that parents should not give their children soy milk, soy formula, or creams containing peanut oil. The ultimate test of a therapeutic approach to peanut allergy will be how well treated patients react to inadvertent exposures; in this study, monoclonal antibody appeared promising.

Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine March 24, 2003

Natural history of pediatric hepatitis C

▸ The progression of hepatitis C virus (HCV) infection to such serious outcomes as cirrhosis and hepatocellular cancer is well studied in adults, but little is known about the long-term risks of infection in children. Early studies suggested that childhood infection is relatively benign, but the duration of follow-up in these studies was limited. In this multicenter, European study, researchers retrospectively reviewed the characteristics and outcomes of HCV infection in 200 untreated children (age range, 9 months to 17 years) who were followed for 1 to 17 years (mean, 6.2 years).

Vertical transmission and blood transfusion (prior to 1991) were the most common routes of infection; few children were infected through family contact, surgery, or other routes. At the time of initial evaluation, 87% of children (including all those with vertical transmission) were asymptomatic. Only 6% of patients cleared their viremia; 86% continued to have persistently or intermittently elevated alanine aminotransferase (ALT) levels during a mean follow-up of 4 years, and 8% were viremic but had normal ALT levels. One patient developed liver failure. Among the 4 children who were followed for 15 to 17 years, biopsies showed mild hepatitis in 1 and moderate hepatitis in 3.

Comment

▸ This study broadens the scope of our understanding of HCV infection in children and shows that serious outcomes may be more common than we previously appreciated. Pediatricians need to remain vigilant about long-term follow-up of these children because some children who appear to be asymptomatic may have progressive liver disease. Early referral to a gastroenterologist should be considered so that treatments can be offered as they become available.

Peggy Sue Weintrub, MD

Published in Journal Watch Pediatrics and Adolescent Medicine March 24, 2003

Errors in medical care affect hospitalized children

▸ The annual US cost of medical errors is estimated to be between $17 and $29 billion. The Institute of Medicine’s widely read year-2000 report on patient safety indicated that medical error contributed to as many as 44 000 adult deaths annually in the U.S. Similar information on pediatric morbidity and mortality is not available. Using data from the Healthcare Cost and Utilization Project, these authors examined patient discharge information in 4 separate years (1998, 1991, 1994, and 1997) from more than 900 community hospitals in a 20-state region. During these years, there were roughly 6 million discharges of patients 18 years old and younger, excluding newborns. The primary outcome measure was the ICD-9 code indicating a hospital-reported medical error.

The incidence of hospital-reported errors ranged from 1.81 per 100 pediatric admissions in 1988 to 2.96 in 1994. The 3 later years had significantly higher error rates than the first year. There were no consistent differences in error rates associated with race, payer status, or median household income in the patient’s zip code area, but there was a significant trend toward higher rates in families with higher incomes. Boys had significantly higher rates of medical errors than girls did. Also, children aged 6 to 12 years and children with special needs tended to have higher error rates.

Comment

▸ Limitations of the study included potential underreporting and the difficulty of assessing cause and effect. Nevertheless, medical errors in pediatric hospital practice are as troubling as they are in adult hospital practice. This large study provides some baseline information on which we may build interventional strategies.

Harlan P Gephart, MD

Published in Journal Watch Pediatrics and Adolescent Medicine April 14, 2003

Make no bones about it—midpuberty is when calcium counts

▸ Much attention has been paid to adolescent eating habits, particularly calcium intake. Bone mineral density increases rapidly throughout puberty. These investigators evaluated whether calcium intake is more important to skeletal development at particular periods. This retrospective cohort study evaluated relations between bone mass and diet in black and white women, aged 21 to 24, who were 9 to 10 years old when enrolled in the 10-year National Heart, Lung, and Blood Institute Growth and Health Study. The authors hypothesized that dietary calcium is more important to peak bone mass in midpuberty (defined by Tanner staging) than after puberty; that calcium intake greater than 1000 mg/day is associated with higher bone mass; and that race has on effect on the relation between dietary calcium and bone mass.

The outcome variable was young adult bone mass (YABM), which was measured by dual-energy x ray absorptiometry. Complete data were available for 161 black and 180 white subjects. The authors found that the developmental stage at which dietary calcium intake and YABM were most closely associated was midpuberty; that calcium intake greater than 1000 mg/day was associated with higher YABM, although this association was not significant at all skeletal sites; and that race did not affect the relation between calcium intake and YABM.

Comment

▸ Although complete data were available for only 341 young women, the associations are impressive. Ideally, these results should be replicated. It would be wise, meanwhile, to tell adolescents and their parents that adequate calcium intake (1300 mg/day for children and adolescents aged 9 to 18 years), particularly in midpuberty, is critically important for bone development. Midpuberty is the ideal time for optimal development of bone mass.

Elizabeth R. McAnarney, MD

Published in Journal Watch Pediatrics and Adolescent Medicine April 14, 2003

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