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Selections from Journal Watch Pediatrics and Adolescent Medicine

Irregular menses in perimenarcheal girls—evaluate or wait? ▸

Irregular menses may warrant more detailed evaluation than is commonly performed. These authors retrospectively reviewed the charts of all girls aged 13 to 21 who presented to an inner-city clinic over a 3-year period; the 47 girls who reported irregular menses during the perimenarcheal period (i.e., within 3 years of menarche) were the focus of the study.

On physical examination, there were no significant findings in 39 girls; 3 had signs of functional ovarian hyperandrogenism (FOH), including obesity, hirsutism, acne, and ratios of luteinizing hormone to follicle-stimulating hormone (LH:FSH) >3, although pelvic ultrasound exams were normal. LH:FSH testing was performed in 4 of the 39 patients with normal physicals, 1 of whom had an abnormal ratio that suggested possible FOH. Other abnormal findings included microcytic, hypochromic anemia in three patients, and an elevated erythrocyte sedimentation rate in one patient. The authors suggest that menstrual irregularities in perimenarcheal girls who also have obesity, acne, or pallor are likely to have a treatable cause.

Comment ▸

Limitations of this study include its retrospective design, lack of a standardized protocol to systematically collect data, and possible selection bias (85% of subjects were Hispanic). However, the authors correctly remind us that thorough history taking and physical examination, coupled with laboratory assessment of select young women, can exclude other treatable underlying conditions. Although gynecologic immaturity is the leading cause of dysfunctional uterine bleeding in adolescents, even when ovulation does not occur gonadotropin levels decrease in response to increasing estrogen levels; as a result, most anovulatory cycles tend to be fairly regular, with limited bleeding. This fact of nature allows pediatricians to sagely counsel that a tincture of time is often the best approach.

Susan Jay, MD

Published in Journal Watch Pediatrics and Adolescent Medicine February 17, 2004

Human metapneumovirus: a new respiratory pathogen ▸

Human metapneumovirus (HMP), which was isolated in 2001, is an RNA virus related to respiratory syncytial virus (RSV). Investigators from a university-based clinic tested nasal washings, obtained between 1976 and 2001 from children with respiratory illnesses (mean age, 11.6 months), for HMP and other common viruses, such as RSV and adenovirus.

Specimens were available from 248 children with lower respiratory infections in whom no cause of illness was identified; of these children, 49 (20%) were positive for HMP. Seasonal patterns of infection were similar to those for RSV infection, peaking in the winter months. Common symptoms included cough (90%) and coryza (88%), along with rhinitis (77%) and wheezing (52%). Common diagnoses included bronchiolitis (59%), croup (18%), and pneumonia (8%). In addition, of among a random sample of 261 children with upper respiratory infections and negative viral cultures, 15% were positive for HMP.

Comment ▸

Human metapneumovirus appears to be a common cause of respiratory illness in the first few years of life. In a related article, key facts about HMP are highlighted: It is common, it causes diseases such as bronchiolitis and pneumonia, and it has similarities to RSV (type and prevalence of infection, seasonality of disease). How contagious HMP is and how it is spread remain uncertain. The continuing identification of such new infectious agents enhances our understanding of disease, may lead to new diagnostic tests and therapeutic interventions, and must be considered in updating recommendations for isolation of hospitalized children.

Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine March 1, 2004

Childhood migraine: when are neuroimaging and prophylaxis needed? ▸

Migraine is one of the most prevalent neurologic conditions in any age group, with a childhood incidence of 7% and a lifetime incidence of 15%. It is primarily a clinical diagnosis, and most patients have normal neuroimaging results. Prophylactic medication is efficacious in adults and probably in children as well.

This study was designed to determine the frequency of prior neuroimaging by primary care physicians and the use of prophylactic medication in 106 consecutive patients (age range, 26 months to 21 years) presenting to a headache clinic at an urban children’s hospital. General and headache-focused histories were taken, and each patient had physical and neurologic examinations. A six-item validated questionnaire was used to define migraine symptoms and response to treatment.

About half of the patients had already had neuroimaging before their initial appointments at the headache clinic. According to published criteria from the International Headache Society, adapted for children, neuroimaging should be used when: (1) Headache does not meet clinical criteria for childhood migraine; (2) there is no family history of migraine, migraine variant, motion sickness, or sleepwalking; and (3) there has been no abnormal neurologic examination or history of focal neurologic dysfunction. When these criteria were applied, only 10% of patients qualified for neuroimaging. Only about 30% of patients received prophylactic treatment, although about 60% met the criteria for treatment.

Comment ▸

Children who do not meet the criteria for neuroimaging (noted earlier) but whose migraine episodes are debilitating, are protracted, or occur more than six times per month should receive prophylactic treatment. Children with an abnormal neurologic history or examination (e.g., focal findings or symptoms, altered state of consciousness, increased intracranial pressure, severe or changing headache) should receive neuroimaging, as should those who fail to improve on prophylactic treatment.

Harlan R. Gephart, MD

Published in Journal Watch Pediatrics and Adolescent Medicine March 15, 2004

Constraint-induced movement therapy benefits children with hemiparesis ▸

Hemiparesis, or a substantial deficit in one upper extremity compared with the other, is a common finding in children with cerebral palsy (CP), and for decades, occupational and physical therapies have been the interventions of choice. These authors assessed whether constraint-induced (CI) movement therapy, an approach used successfully in adults with stroke-induced hemiparesis, would benefit young children with CP. In CI movement therapy, the less-impaired upper extremity is encased in a lightweight fiberglass cast from upper arm to fingertips to limit its use, and the children receive intensive occupational and physical therapy to encourage them to reach, grasp, and otherwise use the more-impaired arm.

Eighteen children diagnosed with CP and hemiparesis (age range, 7 months to 8 years; mean age, 42 months) were randomized to CI therapy or conventional treatment. The CI group received 21 days of therapy for 6 hours per day; the conventional-treatment group underwent an average of 2.2 hours of therapy per week. Functional upper arm skills were measured at baseline, at the end of treatment, and at 3 weeks after treatment ended. Children receiving CI therapy acquired significantly more new motor skills than the children receiving conventional therapy (9.3 vs. 2.2 skills), and they showed more improvement in home use of the affected arm. Benefits were maintained 6 months after treatment.

Comment ▸

The sample in this study is small, but the results suggest that a revolutionary new concept in treatment may offer great hope for improved functional outcome and quality of life in children with CP.

Harlan P. Gephart, MD

Published in Journal Watch Pediatrics and Adolescent Medicine March 15, 2004

Are we aware of school fallout from epilepsy? ▸

Despite a favorable medical prognosis, children with “simple,” uncomplicated epilepsy may later demonstrate psychosocial difficulties, such as inability to complete their education or keep a job. In this case-control study, Dutch researchers sought to determine at what point after diagnosis and treatment of epilepsy, educational and psychosocial deterioration start to manifest.

From January 1997 through November 1998, 51 patients (age range, 7–16 years) who had had at least two unprovoked, afebrile seizures were enrolled immediately after diagnosis and before the start of treatment. Each of 48 patients was matched with a classmate by age, sex, and education level. All children received neuropsychological assessment three times in the first year after diagnosis; parents and teachers completed behavioral questionnaires; and parents were interviewed.

Significantly more patients than controls (51% vs. 27%) required special education despite similar intelligence and backgrounds. Also, patients scored significantly worse than controls on teacher and parent measurements of behavior. These differences, which appeared early in the course of the disorder, persisted. The authors speculate that some of the outcomes might be attributed to changing psychodynamics within the family structure rather than to the patient’s epilepsy per se.

Comment ▸

We know from other research that conditions like epilepsy and ADHD can profoundly affect family dynamics. These results show that a diagnosis of uncomplicated epilepsy can cause significant fallout in terms of education and behavior. As primary care physicians, we need to be aware of this vulnerability and provide vigilant monitoring, as well as preventive educational and psychosocial services, to these high-risk patients.

Harlan R. Gephart, MD

Published in Journal Watch Pediatrics and Adolescent Medicine March 1, 2004

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