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Selections from Journal Watch Pediatrics and Medicine

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The metabolic syndrome: highly prevalent in overweight adolescents

▸ The metabolic syndrome is associated with the development of cardiovascular disease and type 2 diabetes. Using data from the third National Health and Nutrition Examination Survey (1988–1994), researchers evaluated the syndrome’s prevalence in 2430 adolescent respondents (age range, 12 to 19). The authors modified the National Cholesterol Education Program (Adult Treatment Panel III) definition of the metabolic syndrome, developing age-appropriate criteria for hyperinsulinemia, abdominal obesity, dyslipidemia, and hypertension.

Prevalence of the metabolic syndrome was 4.2% overall; it was higher among boys (6.1%) than girls (2.1%; P = 0.01). Among overweight adolescents (BMI, 95th percentile), 28.7% had the metabolic syndrome, compared with 0.1% of those with a BMI <85th percentile. Using these data, the authors estimate that almost 1 million U.S. adolescents have the metabolic syndrome.

Comment

▸ Early intervention is the key to preventing the metabolic syndrome in children and adolescents. Early identification of excessive weight gain, lack of activity, and other poor health habits early in childhood is critical. Thoughtful interventions – including dietary modification, increased activity, less television watching, and active participation by the child in his or her health – are keys to preventing the personal, familial, and societal consequences of this condition.

Elizabeth R. McAnarney, MD

Published in Journal Watch Pediatrics and Adolescent Medicine November 10, 2003

Adherence to asthma medication influenced by parental expectations and fears

▸ To counteract the morbidity and mortality associated with asthma, anti-inflammatory medication (AIM) is recommended for all children and adolescents with persistent asthma (defined in the NIH guideline as symptoms occurring >2 days/week or nighttime symptoms occurring >2 times/month). Because recent findings show significant underuse of inhaled steroids for treating childhood asthma, investigators sought to identify parental barriers to adherence.

Using input from asthma experts and parents of children with asthma, the investigators developed a questionnaire to assess parental perspectives on asthma causes and medications, treatment expectations, and the parent-provider relationship. The parents of 109 children with asthma completed the questionnaire; parents who reported appropriate AIM use were compared with those who reported suboptimal adherence. Important barriers to appropriate AIM use were parents’ diminished expectations of treatment benefits and their fears about AIMs. Overall, 62% of parents worried about side effects, and 21% worried about addiction. Minority parents were significantly more likely than white parents to consider asthma to be unpredictable and uncontrollable and to have negative attitudes about AIMs.

Comment

▸ Results from earlier studies of childhood asthma suggested that faulty symptom assessment and interpretation affect optimal management. These results point to another factor – low treatment expectations predict nonadherence to inhaled steroids. The authors provide the 8 questionnaire items that address parental expectations and fears and correlate with suboptimal medication. Used as a quick screening device, this evidence-based tool can help pediatricians address problems in medication adherence for children with asthma.

Martin T. Stein, MD

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

Improving asthma care in children

▸ Persistent asthma is the most common chronic condition of childhood, so improving care is crucial. Investigators in Australia randomized 174 children with persistent asthma (age range, 5–12 years) to either proactive care or routine care (controls). Proactive care comprised 3–4 scheduled visits within 1 month when the child was well; these visits involved discussing patients’ knowledge and perceptions about asthma, reviewing inhalation devices and techniques, and developing a written action plan.

During 1-year follow-up, significantly fewer children in the intervention group than in the control group used relievers (bronchodilators) more than 4 days weekly (9% vs. 30%). Significantly more children in the intervention group (62%) than in the control group (38%) used metered-dose inhalers with spacers. Although the 2 groups did not differ in number of symptom-free days, spirometric measures (FEV1 changes related to cold air challenge) were significantly better in the intervention group.

Comment

▸ This study’s message is clear: It is important for clinicians to see children with persistent asthma regularly when they are well and, at those visits, to discuss the disease, to demonstrate how to use inhalers, and to develop and reinforce a written action plan. It is very difficult to teach patients about asthma successfully during sick visits. At the time of publication, the full text of the original article was available free of charge.

Howard Bauchner, MD

Published in Journal Watch October 28, 2003

Health beliefs could explain some health disparities

▸ Reasons for racial disparities in health care are not understood well, partly because many researchers who have tried to identify racial disparities have used large administrative databases with limited clinical information. For example, lung cancer is more prevalent in blacks and is associated with a lower rate of surgery and reduced 5-year survival. To assess patient beliefs about lung cancer surgery, researchers surveyed 626 outpatients (65% white, 25% black; mean age, 60) at 5 Veterans Affairs and university clinics in Pennsylvania, California, and South Carolina. Nearly all patients had either chronic pulmonary diseases or lung cancer.

Overall, 37% of respondents believed that lung cancer spreads if it is exposed to air during surgery. Significantly more blacks than whites thought this belief was true (61% vs. 29%) and significantly more blacks opposed surgery based on this belief (19% vs. 5%). More blacks also would not believe their doctors’ assertions that the belief was false and reported knowing a patient whose cancer had spread when exposed to air. In multivariable analysis, race was the only patient characteristic that predicted this health care belief.

Comment

▸ The authors note that despite anecdotes about metastatic disease occurring soon after pulmonary surgery, this accelerated course appears to be uncommon. This report identifies a health care belief that could be important in addressing racial disparities in lung cancer care. Furthermore, it suggests that other racial health disparities could be addressed by better understanding of patients’ beliefs.

Richard Saitz, MD, MPH, FACP, FASAM

Published in Journal Watch November 4, 2003

Epinephrine better than albuterol for treating bronchiolitis

▸ About 12% of infants develop bronchiolitis in their first year. Results from several recent studies have indicated that bronchodilator treatments are not efficacious for bronchiolitis, but use of epinephrine is increasing in infants. To examine epinephrine’s efficacy for treating bronchiolitis, researchers performed a meta-analysis of data from 14 randomized controlled trials, involving children 2 years or younger, in which inhaled or systemic epinephrine was compared with other bronchodilators or placebo.

Among 5 inpatient studies in which epinephrine was compared with placebo, only 1 of 10 outcomes (change in clinical score at 60 minutes) improved significantly with epinephrine. Among 3 outpatient studies in which epinephrine was compared with placebo, 4 of 10 outcomes (oxygen saturation and respiratory rate at 30 minutes, clinical score at 60 minutes, and improvement) significantly favored epinephrine.

In 4 inpatient studies, researchers compared epinephrine with albuterol. Only 1 of 7 outcomes was statistically different: Respiratory rate improvement at 30 minutes favored epinephrine. In 4 outpatient studies of epinephrine and albuterol, 4 of 16 outcome measures favored epinephrine (oxygen saturation and respiratory rate at 60 minutes, heart rate at 90 minutes, and improvement).

Comment

▸ The evidence favors epinephrine over albuterol for outpatient treatment of infants with bronchiolitis. The authors of an accompanying journal club review note, however, that the evidence is not so compelling that epinephrine should become the standard of care.

Robert A. Dershewitz, MD, MSc

Published in Journal Watch November 7, 2003

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