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Journal Watch

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Selections from Journal Watch Pediatrics and Adolescent Medicine

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Bullying hurts both victims and perpetrators

▸ Bullying has become a topic of immense interest in our increasingly violent society. These investigators studied 1985 sixth graders (mostly Latino and black) from 11 schools in communities of low socioeconomic status. Results included self-reports of psychological distress, peer reports of which students were bullies and victims, and peer and teacher reports of adjustment problems.

Consistent with previous findings, 22% of the children were involved in bullying—as perpetrators, victims, or both (bully/victims). Despite a high incidence of conduct problems, bullies were the strongest psychologically and had high social standing among their peers (although they were avoided by their peers more than other children). Victims were distressed emotionally. Bully/victims were the most troubled, with the highest levels of conduct, school, and peer problems.

Comment

▸ A strength of this study is that observations included different perspectives. Pediatricians need to learn about the prevalence of bullying and the differing psychological profiles of bullies, victims, and bully/victims. In the office and in school, bullies should be encouraged to find positive outlets; victims and bully/victims should be identified and provided appropriate interventions. The adult community needs to become aware of all aspects of bullying.

Elizabeth R. McAnarney, MD

Published in Journal Watch Pediatrics and Adolescent Medicine February 2, 2004

New guidelines for growth hormone

▸ The FDA’s recent approval of growth hormone (GH) therapy for idiopathic short stature (ISS) has led to some controversy. Recently, the Lawson Wilkins Pediatric Endocrinology Society Drug and Therapeutics Committee updated its guidelines for use of GH. No formal grading of evidence is presented to support the recommendations; nevertheless, the summary contains helpful information for pediatricians.

GH has been approved for six indications in children:

  • GH deficiency (GHD)

  • short stature with chronic renal failure

  • short stature with Turner syndrome

  • short stature with Prader-Willi syndrome

  • small size for gestational age (SGA) and sustained growth failure at age 2

  • ISS more than 2.25 SD below the mean for height

GHD should be considered for healthy children who are failing to make normal gains in height (in my experience, 5 to 7 cm each year) and in whom hypothyroidism, chronic disease, and genetic syndromes have been ruled out. Most, but not all, children with GHD fail stimulation tests.

A number of trials have shown that children who were SGA with postnatal growth restriction benefit from GH. One study found that boys and girls who received GH were 2.5 and 4.7 cm taller, respectively, than their counterparts in the control group. Treatment of children with ISS is based upon limited data that indicate such treatment will enhance adult height by 1.5 to 3 inches.

Comment

▸ Most children with these disorders will be under the care of an endocrinologist, so how do the guidelines help the primary care physician? First, it is important to monitor height accurately and recognize when the predicted adult stature is significantly less than midparental height. Second, the risk for insulin resistance in older children who were SGA suggests caution in the use of GH to promote growth in these children. Third, with the approval of GH for idiopathic short stature, pediatricians will have many opportunities to discuss this issue with parents who request hormone therapy. The stature of each child must be evaluated in the context of developmental, psychological, and educational attainments. Finally, GH therapy is costly (as high as $35,000 for every inch attained above predicted height).

Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine January 5, 2004

Immigrant adolescents: blue and stressed for success

▸ In the U.S., the population of children who are immigrants or who have immigrant parents has increased at a far faster rate than the population of children of U.S.-born parents. Some studies have shown that foreign-born youth have lower risks for health problems or risk behaviors, but others indicate that immigrant children experience more depression, feel more pressure to engage in risk behaviors, and get less parental support in coping with such pressure than native-born youth. These authors examined associations between degree of acculturation (indicated by language spoken at home) and the health and psychosocial status of 15,220 adolescents from various racial and ethnic groups.

Those whose primary language at home was not English were more likely to report being bullied, feeling alienated, having a lack of self-confidence, and feeling that parents were unable or unwilling to help with these problems. Those who spoke a combination of English and another language were also at risk and felt that they were subject to high parental expectations.

Comment

▸ This analysis demonstrates the complex relationships that come into play as adolescents seek to acculturate. Physicians pressured by time constraints may view adolescent patients as normal or abnormal based only on physical exam parameters. Beneath the physical veneer, teens experience a host of feelings that may place them at risk. Alienation, vulnerability, lack of confidence, and feelings of helplessness may lie beneath the outwardly normal physique of a teen who is attempting to fit in and achieve the nebulous American dream.

Susan Jay, MD

Published in Journal Watch Pediatrics and Adolescent Medicine February 2, 2004

Effect of radiation during infancy on cognitive development

▸ The long-term consequences of low-level ionizing radiation are of enormous concern because of increasing use of head computed tomography during childhood. These investigators assessed the relation between ionizing radiation and cognitive outcome in 2551 Swedish men who were irradiated for cutaneous hemangiomas before 18 months of age (from 1930 through 1959). Roughly 40% received radiation directly to the face or scalp; the estimated mean absorbed dose to the brain was 52 mGy (range, 0 to 2800 mGy).

At age 18 or 19 years, testing before military service showed a significant inverse relation between radiation dose to the brain and both 3 of 4 measures of cognitive development and high-school attendance. In multivariate analyses, cognitive development and high-school attendance declined at radiation doses greater than 100 mGy. (It is estimated that head CT delivers doses in excess of 100 mGy.)

Comment

▸ Measuring a dose of ionizing radiation is quite complicated, and comparing doses of ionizing radiation delivered directly through the skin with modern CT is particularly difficult. Regardless, these findings must make us reconsider use in children of head CT for problems such as headache or migraine, minor head trauma, and uncomplicated seizures. At the time of publication, the full text of the original article was available free of charge.

Howard Bauchner, MD

Published in Journal Watch February 3, 2004

Which treatment for aom in children with tympanostomy tubes?

▸ Children with tympanostomy tubes often develop acute otitis media (AOM). Treatment options include oral and topical antibiotics alone or in combination with corticosteroids. In a multicenter, observer-masked, randomized trial, 599 children (mean age, 2.5 years) with patent tympanostomy tubes and AOM with otorrhea received either topical ciprofloxacin/dexamethasone otic suspension (4 drops twice daily for 7 days) or ofloxacin otic solution (5 drops twice daily for 10 days). Drainage had been visible to parents or guardians. The study was supported by the manufacturer of ciprofloxacin/dexamethasone suspension.

On days 3, 11, and 18 after enrollment, significantly more ciprofloxacin/dexamethasone recipients than ofloxacin recipients were cured (i.e., free of otorrhea) or had experienced reductions in otorrhea volume. For example, on day 11, cure rates were 84% with ciprofloxacin/dexamethasone versus 63% with ofloxacin.

Comment

▸ Although both preparations tested in this study appear to be effective, the combination of a fluoroquinolone and a corticosteroid was superior to a fluoroquinolone alone for treating otorrhea in children with tympanostomy tubes. At the time of publication, the full text of the original article was available free of charge.

Howard Bauchner, MD

Published in Journal Watch February 6, 2004

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