Seasonality of Methylphenidate Administration among Children in Israel.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterized by inattention, impulsivity and hyperactivity. Recently, increases in ADHD prevalence and methylphenidate use have been reported. There is evidence that children and adolescents use ADHD medication only during the school year. OBJECTIVES: To investigate trends in methylphenidate dispensing over a period of 3 years (2010-2012) at the monthly level and to investigate whether there is any monthly variation, especially during the summer season. METHODS: The database of Clalit Health Services (the largest of the four health funds in Israel) was used to identify (i) patients aged 6-17 years with a diagnosis of ADHD, and (ii) methylpenidate dispensation during the period 2010-2012. RESULTS: Among children aged 6-17 years diagnosed with ADHD, 43% were treated with methylphenidate. For the period 2010 to 2012 there was an annual drop in methylphenidate dispensing, beginning in June and continuing through the 2 months of summer vacation, with a 2.5-fold reduction from July as compared to May. This decline was consistently followed by a rise in medications dispensed starting August. A similar small drop was observed during the Passover school vacation. The summer drop decreased over the years. CONCLUSIONS: Our findings showed a decrease in the number of methylphenidate prescriptions dispensed during the summer months and Passover as compared to the rest of the year. However, this phenomenon appears to be decreasing. Given that ADHD is a chronic disease state that can effectively be managed with pharmacotherapy, discontinuation of treatment may be harmful for patients and should be considered only on a patient-by-patient basis.

Disparities in assessments of asthma control between children, parents, and physicians.

OBJECTIVE: Assessment of asthma control in children by physicians, patients and their parents was compared, assuming parents may underestimate symptoms in asthmatic children and exploring whether physicians tend to agree with them. DESIGN: Asthma control perception was assessed in 4- to 11-year-old asthmatic children and their parents, using C-ACT, during 2011-2012. Pediatric pulmonologists used GINA guidelines for their assessment; pediatricians, not having spirometry, used the information given in addition to physical examination. The C-ACT scores given by the children and their parents were further analyzed separately, and compared with their physicians' assessment. Statistical methods, which also measured possible influence of different variables, included kappa, Chi-square, linear-by-linear association, McNemar test and logistic regression. PATIENT SELECTION: The study comprised 354 parents and children aged 4-11 years with moderate-severe asthma; 129 (36.4%) were treated by 23 pediatricians; 225 (63.6%) by 11 pediatric pulmonologists. RESULTS: The C-ACT was generally found valid in assessing asthma control (P < 0.001; κ 0.529; CI 0.441, 0.617) and showed that in 229/354 (53%) of children the asthma was uncontrolled. Nevertheless, of the 229 children who indicated their asthma was uncontrolled, 124 (54.1%) of their parents (κ 0.245; CI 0.15, 0.34) and 96 (41.9%) of their physicians believed it to be controlled (κ 0.331; 0.24, 0.43). Comparing the physician-child discordance vis-à-vis the parents, the significant difference was when 96/229 children (41.9%) and 34/126 parents (27.0%) indicated the asthma was uncontrolled while the physician determined it controlled (OR 1.95; 1.19, 3.24). There were no significant differences between pediatric pulmonologists and pediatricians. CONCLUSIONS: In addition to increasing awareness of parents to symptoms in their asthmatic children, physicians should question the child appropriately, as well as using the children's responses to C-ACT as an information source for properly assessing asthma control.

[Influenza vaccination of pediatric staff as a predictor for recommendations to children].

BACKGROUND: As of February 2010, the 2009 H1N1 influenza has caused more than 15,000 deaths worldwide. Seasonal influenza vaccination rates among health care workers (HCW) have been universally low; the 2009 H1N1 influenza vaccination of HCW has also been disappointing. In several studies, a correlation between HCW seasonal influenza vaccination status and vaccine recommendation to adult patients was found. OBJECTIVE: To examine the correlation between the declared influenza vaccination status of pediatric staff and vaccine recommendations to their patients. INSTRUMENT: Anonymous questionnaire concerning attitudes and practices regarding seasonal and 2009 H1N1 influenza vaccination. RESPONDENTS: 141 pediatric staff attending a conference. RESULTS: Seventy two percent of the respondents had been or intended to be vaccinated against seasonal influenza, 62% against the 2009 H1N1 influenza, and 56% against both diseases. Ambulatory setting employment was positively associated with the recommendation of seasonal influenza vaccination to all children. By multivariate Logistic regression analysis, the "vaccinated or intending to be vaccinated against seasonal influenza" was the only significant independent variable associated with recommending universal pediatric seasonal influenza vaccine (OR=15, 95% CI 6.1-41.4, p < 0.001). Similarly, "being or intending to be vaccinated against the 2009 H1N1 influenza" was the only significant independent variable associated with recommending universal pediatric vaccination against this disease (OR = 5.2, 95% CI 1.85-14.6, P = 0.002). CONCLUSION: A strong correlation between the influenza vaccination status of pediatric staff and the recommendation of the vaccines to children emphasizes that intense education of providers is a crucial step in assuring a positive recommendation to families.

RCT of montelukast as prophylaxis for upper respiratory tract infections in children.

BACKGROUND: Infections with viruses causing upper respiratory tract infection (URI) are associated with increased leukotriene levels in the upper airways. Montelukast, a selective leukotriene-receptor antagonist, is an effective treatment of asthma and allergic rhinitis. OBJECTIVE: To determine whether prophylactic treatment with montelukast reduces the incidence and severity of URI in children. METHODS: A randomized, double-blind, placebo-controlled study was performed in 3 primary care pediatric ambulatory clinics in Israel. Healthy children aged 1 to 5 years were randomly assigned in a 1:1 ratio to receive 12-week treatment with 4 mg oral montelukast or look-alike placebo. Patients were excluded if they had a previous history of reactive airway disease. A study coordinator contacted the parents by phone once a week to obtain information regarding the occurrence of acute respiratory episodes. The parents received a diary card to record any acute symptoms of URI. The primary outcome measure was the number of URI episodes. RESULTS: Three hundred children were recruited and randomly assigned into montelukast (n = 153) or placebo (n = 147) groups. One hundred thirty-one (85.6%) of the children treated with montelukast and 129 (87.7%) of the children treated with placebo completed 12 weeks of treatment. The number of weeks in which URI was reported was 30.4% in children treated with montelukast and 30.7% in children treated with placebo. There was no significant difference in any of the secondary variables between the groups. CONCLUSIONS: In preschool-aged children, 12-week treatment with montelukast, compared with placebo, did not reduce the incidence of URI.

Microbial colonization of nebulizers used by asthmatic children.

BACKGROUND: The aim of the present study was to determine the microbial colonization of nebulizers used at home by asthmatic children, and to investigate their parents' cleaning and maintenance routines. METHODS: The nebulizer equipment used at home by 39 asthmatic children was examined. Swabs taken from the inner surface of the reservoir cups, face masks and filters were cultured. Results were recorded as mean number of colony-forming units per cultured surface. Parents were interviewed regarding their cleaning and disinfection routines. RESULTS: Twenty-six reservoir cups (66.7%), 24 face masks (61.5%), and 18 filters (78.3%) were found to be contaminated. Pseudomonas aeruginosa was isolated from 17 reservoir cups (43.6%) and 12 face masks (30.8%), and Staphylococcus aureus from two face masks (5.1%). None of the parents knew that the nebulizer has a filter and that it requires periodic cleaning or changing; only eight of the parents (20.5%) received maintenance instructions from the medical staff, and only 19 (48.7%) cleaned the nebulizer equipment after use. CONCLUSION: Home nebulizers are frequently colonized with microorganisms. As recommended, nebulizers should be washed after each use and air-blown dry. Nebulizer maintenance should be emphasized in educational programs for managing asthma.

Decreased bone speed of sound in children with growing pains measured by quantitative ultrasound.

OBJECTIVE: The most common cause of recurring childhood musculoskeletal pain is termed growing pains (GP). We hypothesized that GP may represent a local overuse syndrome and therefore may be associated with decreased bone speed of sound (SOS) measured by quantitative ultrasound (US). METHODS: We studied 39 children with GP. Bone SOS was measured by US in both mid-tibial and radius bones according to a validated protocol. Unpaired Student t test was used to compare patients and norms of healthy controls. RESULTS: Tibial SOS was significantly reduced in children with GP compared to controls (Z score -0.546 for boys and -0.891 for girls; p = 0.004, p < 0.001, respectively). Radius SOS was significantly reduced only in girls with GP (Z score -0.692, p = 0.006). No correlation was found between bone SOS and various demographic and clinical factors besides the child's ethnicity and body mass index. CONCLUSION: Bone SOS was significantly reduced in children with GP, especially in painful tibial regions. GP may represent a local overuse syndrome.

Bacterial contamination of spacer devices used by asthmatic children.

OBJECTIVES: To investigate bacterial contamination in spacer devices used by asthmatic children and the device maintenance procedures practiced by parents. METHODS: Spacer devices used by 62 asthmatic children were examined. Swabs taken from the inner surface of the reservoirs and face masks were cultured. Parents were interviewed regarding their spacer cleaning and disinfection routines. RESULTS: Bacterial contamination was noted in 22 reservoirs (35.5%) and 16 masks (25.8%). Pseudomonas aeruginosa was isolated from 21.0% of the reservoirs and 14.5% of the face masks, Klebsiella pneumoniae from 6.5% and 4.8%, and Staphylococcus aureus from 9.7% and 8.1%, respectively. Only 34 parents (54.8%) reported that they received cleaning and maintenance instructions from the medical staff at initiation of spacer use by their child, and only 38 (61.8%) cleaned the device after each use. CONCLUSION: Bacterial contamination is common in spacer devices. This study demonstrates that contamination rates are significantly lower when parents clean and actually dry (preferably with an air blower) spacer devices after each use. Spacer device maintenance should be emphasized in education programs for managing asthma.

Pediatric cutaneous mastocytosis: a review of 180 patients.

BACKGROUND: Mastocytosis is a heterogeneous group of diseases characterized by the abnormal infiltration of mast cells in the skin and, sometimes, other organs. Some patients may experience symptoms related to mast cell mediator release. OBJECTIVE: To analyze the clinical features of cutaneous mastocytosis in a large series of children. METHODS: We conducted a file review of all children clinically diagnosed with cutaneous mastocytosis in our department over the last 20 years. We evaluated gender, age at onset, character and distribution of the lesions, associated symptoms, and course of the disease. RESULTS: Altogether, 180 patients with cutaneous mastocytosis were identified. The male to female ratio was 1.5:1. About one-third of patients had a mastocytoma, which was present at birth in over 40% and appeared during the first year of life in most of the remainder. Urticaria pigmentosa was noted in 65% of the patients, presenting at birth in 20% and during the first year in most of the remainder. The majority of lesions was distributed over the trunk and limbs. Different kinds of associated symptoms were noted. Prognosis in general was good. Only 11% of the cases, all urticaria pigmentosa, were familial. CONCLUSIONS: Most cases of pediatric mastocytosis are sporadic and appear during the first 2 years of life, especially on the trunk. Urticaria pigmentosa is the most frequent variant. The prognosis of pediatric mastocytosis, in general, is good.

Effectiveness of an herbal preparation containing echinacea, propolis, and vitamin C in preventing respiratory tract infections in children: a randomized, double-blind, placebo-controlled, multicenter study.

OBJECTIVE: To evaluate the effectiveness and safety of a preparation containing echinacea, propolis, and vitamin C in the prevention of respiratory tract infections in children during a 12-week winter period. DESIGN: Randomized, double-blind, placebo-controlled study. SUBJECTS: Four hundred thirty children, aged 1 to 5 years, were randomized to an herbal extract preparation (n = 215) or a placebo elixir (n = 215). INTERVENTION: Administration of an herbal preparation (Chizukit) containing 50 mg/mL of echinacea, 50 mg/mL of propolis, and 10 mg/mL of vitamin C, or placebo (5.0 mL and 7.5 mL twice daily for ages 1 to 3 years and 4 to 5 years, respectively) for 12 weeks. RESULTS: Significant mean +/- SD reductions of illnesses were seen in the Chizukit group in the number of illness episodes, 138 vs 308 (55% reduction); number of episodes per child, 0.9 +/- 1.1 vs 1.8 +/- 1.3 (50% reduction, P<.001); and number of days with fever per child, 2.1 +/- 2.9 vs 5.4 +/- 4.4) (62% reduction, P<.001). The total number of illness days and duration of individual episodes were also significantly lower in the Chizukit group. Adverse drug reactions were rare, mild, and transient. CONCLUSION: A preventive effect of a product containing echinacea, propolis, and vitamin C on the incidence of respiratory tract infections was observed.

Decreased pain threshold in children with growing pains.

OBJECTIVE: To investigate whether children with recurrent musculoskeletal pain termed growing pains (GP) have lower pain thresholds than children without GP. METHODS: We measured the pain threshold of 44 children with GP and 46 controls. Pain thresholds were measured by use of a Fisher type dolorimeter with pressure applied to areas associated with increased tenderness in fibromyalgia (FM), control points, and anterior tibia, the usual region of pain in children with GP. Unpaired Student's t test and chi-square tests were used to compare the pain threshold and number of tender points in patients and controls. RESULTS: The pain threshold in characteristic tender points of FM, control points, and anterior tibia in the children with GP was significantly lower in children with GP (3.5 +/- 0.6 kg/cm2 in GP versus 4.0 +/- 0.7 in controls, p < 0.001, 3.8 +/- 0.7 versus 4.4 +/- 0.8, p = 0.005; 5.1 +/- 1.1 versus 5.9 +/- 1.5, p = 0.004). Children with GP had a significantly greater number of tender points in response to an applied pressure of 4 kg/cm2. CONCLUSION: Children with GP have more tender points and lower pain thresholds than children without GP indicating that GP may represent a variant of a noninflammatory pain syndrome in younger children.

Nebulized 3% hypertonic saline solution treatment in ambulatory children with viral bronchiolitis decreases symptoms.

OBJECTIVE: To determine the utility of inhaled hypertonic saline solution to treat ambulatory infants with viral bronchiolitis. DESIGN: Randomized, double-blind, controlled trial. Sixty-five ambulatory infants (mean +/- SD age, 12.5 +/- 6 months) with viral bronchiolitis received either of the following: inhalation of 0.5 mL (5 mg) terbutaline added to 2 mL of 0.9% saline solution as a wet nebulized aerosol (control; group 1; n = 32) or 0.5 mL (5 mg) terbutaline added to 2 mL of 3% saline solution administered in the same manner as above (treatment; group 2; n = 33). This therapy was repeated three times every day for 5 days. RESULTS: The clinical severity (CS) scores at baseline on the first day of treatment were 6.4 +/- 1.8 in group 1 and 6.6 +/- 1.5 in group 2 (not significant). After the first day, the CS score was significantly lower (better) in group 2 as compared to group 1 on each of the treatment days (p < 0.005; Fig 1 ). On the first day, the percentage decrease in the CS score after inhalation therapy was significantly better for group 2 (33%) than for group 1 (13%) [p < 0.005; Fig 1 ]. On the second day, the percentage improvement was better in the hypertonic saline solution-treated patients (group 2) as compared to the 0.9% saline solution-treated patients (group 1) [p = 0.01; Fig 1 ]. CONCLUSIONS: We conclude that in nonasthmatic, nonseverely ill ambulatory infants with viral bronchiolitis, aerosolized 3% saline solution plus 5 mg terbutaline is effective in decreasing symptoms as compared to 0.9% saline solution plus 5 mg terbutaline.