Vascular anomalies in childhood: When to treat and when to refer.

Vascular anomalies are heterogeneous conditions that affect blood and/or lymphatic vessels. Affected children may experience pain, functional loss, infection, coagulopathies, and psychological challenges. Diagnosis and management often warrant an interdisciplinary approach. There are seven vascular anomalies clinics in Canada that offer interdisciplinary care. This practice point outlines a treatment approach for the most common paediatric vascular anomaly (hemangioma). It reviews indications for referral to a specialized clinic, with focus on complex vascular anomalies, specifically infantile hemangioma, which can pose complications.

Les anomalies vasculaires pendant l'enfance : quand traiter les patients et quand les diriger vers une ressource spécialisée.

Les anomalies vasculaires sont des affections hétérogènes qui touchent les vaisseaux sanguins ou lymphatiques. Les enfants atteints peuvent éprouver de la douleur ou une perte fonctionnelle, présenter une infection ou une coagulopathie ou être confrontés à des difficultés psychologiques. Le diagnostic et la prise en charge exigent souvent une approche interdisciplinaire. Sept cliniques d'anomalies vasculaires au Canada offrent des soins interdisciplinaires. Le présent point de pratique propose une approche thérapeutique des anomalies vasculaires pédiatriques les plus fréquentes (hémangiomes). On y passe en revue les indications de diriger les patients vers une clinique spécialisée, en s'attardant sur les anomalies vasculaires complexes, et notamment les hémangiomes infantiles, qui peuvent provoquer des complications.

Dietary exposures and allergy prevention in high-risk infants.

Infants at high risk for developing a food allergy have either an atopic condition (such as eczema) themselves or an immediate family member with such a condition. Breastfeeding should be promoted and supported regardless of issues pertaining to food allergy prevention, but for infants whose mothers cannot or choose not to breastfeed, using a specific formula (i.e., hydrolyzed formula) is not recommended to prevent food allergies. When cow's milk protein formula has been introduced in an infant's diet, make sure that regular ingestion (as little as 10 mL daily) is maintained to prevent loss of tolerance. For high-risk infants, there is compelling evidence that introducing allergenic foods early-at around 6 months, but not before 4 months of age-can prevent common food allergies, and allergies to peanut and egg in particular. Once an allergenic food has been introduced, regular ingestion (e.g., a few times a week) is important to maintain tolerance. Common allergenic foods can be introduced without pausing for days between new foods, and the risk for a severe reaction at first exposure in infancy is extremely low. Pre-emptive in-office screening before introducing allergenic foods is not recommended. No recommendations can be made at this time about the role of maternal dietary modification during pregnancy or lactation, or about supplementing with vitamin D, omega 3, or pre- or probiotics as means to prevent food allergy.

Dietary exposures and allergy prevention in high-risk infants.

Infants at high risk for developing a food allergy have either an atopic condition (such as eczema) themselves or an immediate family member with such a condition. Breastfeeding should be promoted and supported regardless of issues pertaining to food allergy prevention, but for infants whose mothers cannot or choose not to breastfeed, using a specific formula (i.e., hydrolyzed formula) is not recommended to prevent food allergies. When cow's milk protein formula has been introduced in an infant's diet, make sure that regular ingestion (as little as 10 mL daily) is maintained to prevent loss of tolerance. For high-risk infants, there is compelling evidence that introducing allergenic foods early-at around 6 months, but not before 4 months of age-can prevent common food allergies, and allergies to peanut and egg in particular. Once an allergenic food has been introduced, regular ingestion (e.g., a few times a week) is important to maintain tolerance. Common allergenic foods can be introduced without pausing for days between new foods, and the risk for a severe reaction at first exposure in infancy is extremely low. Pre-emptive in-office screening before introducing allergenic foods is not recommended. No recommendations can be made at this time about the role of maternal dietary modification during pregnancy or lactation, or about supplementing with vitamin D, omega 3, or pre- or probiotics as means to prevent food allergy.

L'exposition aux aliments et la prévention des allergies chez les nourrissons à haut risque.

Un nourrisson est à haut risque d'allergie alimentaire si lui ou un membre de sa famille immédiate présente une affection atopique (comme l'eczéma). Il faut promouvoir et soutenir l'allaitement, quels que soient les enjeux reliés à la prévention des allergies alimentaires, mais chez les nourrissons dont la mère ne peut pas allaiter ou choisit de ne pas le faire, il n'est pas recommandé d'utiliser une préparation en particulier (p. ex., les préparations hydrolysées) pour prévenir les allergies alimentaires. Lorsque les préparations à base de lait de vache sont introduites dans l'alimentation d'un nourrisson, il faut s'assurer de maintenir une ingestion régulière (pas nécessairement plus de 10 mL par jour) pour éviter la perte de tolérance. Chez les nourrissons à haut risque, des données concluantes indiquent que l'introduction précoce d'aliments allergènes (vers l'âge de six mois, mais pas avant l'âge de quatre mois) peut prévenir les allergies alimentaires courantes, notamment les allergies aux arachides et aux œufs. Lorsqu'un aliment allergène a été introduit, il est important d'en maintenir une ingestion régulière (p. ex., quelques fois par semaine) pour maintenir la tolérance. Il est possible d'introduire les aliments allergènes courants sans faire de pause de quelques jours entre chaque nouvel aliment. Par ailleurs, le risque d'une grave réaction lors de la première exposition est très faible chez le nourrisson. Il n'est pas recommandé de procéder au dépistage préventif en cabinet avant d'introduire des aliments allergènes. Aucune recommandation ne peut être formulée pour l'instant sur le rôle des modifications à l'alimentation de la mère pendant la grossesse ou l'allaitement, ou sur les suppléments de vitamine D, d'oméga 3, de prébiotiques ou de probiotiques pour prévenir les allergies alimentaires.

Head lice infestations: A clinical update.

Head lice (Pediculus humanus capitis) infestations are not a primary health hazard or a vector for disease, but they are a societal problem with substantial costs. Diagnosis of head lice infestation requires the detection of a living louse. Although pyrethrins and permethrin remain first-line treatments in Canada, isopropyl myristate/ST-cyclomethicone solution and dimeticone can be considered as second-line therapies when there is evidence of treatment failure.

An update to the Greig Health Record: Executive summary.

The Greig Health Record is an evidence-based health promotion guide for clinicians caring for children and adolescents 6 to 17 years of age. It provides a template for periodic health visits that is easy to use and adaptable for electronic medical records. On the record, the strength of recommendations is indicated in boldface for good, in italics for fair, and in regular typeface for recommendations based on consensus or inconclusive evidence. Checklist templates include sections for Weight, Height and BMI, Psychosocial history and Development, Nutrition, Education and Advice, Specific Concerns, Examination, Assessment, Immunization, and Medications. Included with the checklist tables are five pages of selected guidelines and resources. This update includes information from recent guidelines and research in preventive care for children and adolescents 6 to 17 years of age. Regular updates are planned. The complete Greig Health Record can be found online at the Canadian Paediatric Society's website: www.cps.ca.

Le relevé médical Greig est un guide de promotion de la santé fondé sur des données probantes destiné aux cliniciens qui s'occupent d'enfants et d'adolescents de six à 17 ans. Ce modèle pour les bilans de santé périodiques est facile à utiliser et adaptable aux dossiers médicaux électroniques. Sur le relevé, les recommandations sont indiquées en caractères gras lorsqu'elles sont de bonne qualité, en caractères italiques lorsqu'elles sont de qualité acceptable, et en caractères normaux lorsqu'elles sont consensuelles ou peu concluantes. Les listes de vérification comprennent des rubriques sur le poids, la taille et l'indice de masse corporelle, l'histoire psychosociale et le développement, la nutrition, l'éducation et les conseils, les problèmes particuliers, les examens, les évaluations, la vaccination et les médicaments. Elles s'accompagnent de cinq pages de lignes directrices et de ressources sélectionnées. La présente mise à jour contient de l'information tirée des lignes directrices et des recherches récentes sur les soins préventifs pour les enfants et les adolescents de six à 17 ans. Des mises à jour régulières sont prévues. Il est possible de consulter l'intégralité du relevé médical Greig, en anglais, dans le site Web de la Société canadienne de pédiatrie, à l'adresse www.cps.ca.

Dietary exposures and allergy prevention in high-risk infants: a joint position statement of the Canadian Society of Allergy and Clinical Immunology and the Canadian Paediatric Society.

Allergic conditions in children are a prevalent health concern in Canada. The burden of disease and the societal costs of proper diagnosis and management are considerable, making the primary prevention of allergic conditions a desirable health care objective. This position statement reviews current evidence on dietary exposures and allergy prevention in infants at high risk of developing allergic conditions. It revisits previous dietary recommendations for pregnancy, breastfeeding and formula-feeding, and provides an approach for introducing solid foods to high-risk infants. While there is no evidence that delaying the introduction of any specific food beyond six months of age helps to prevent allergy, the protective effect of early introduction of potentially allergenic foods (at four to six months) remains under investigation. Recent research appears to suggest that regularly ingesting a new, potentially allergenic food may be as important as when that food is first introduced. This article has already been published (Paediatr Child Health. 2013 Dec;18(10):545-54), and is being re-published with permission from the original publisher, the Canadian Paediatric Society.

Dietary exposures and allergy prevention in high-risk infants: A joint statement with the Canadian Society of Allergy and Clinical Immunology.

Allergic conditions in children are a prevalent health concern in Canada. The burden of disease and the societal costs of proper diagnosis and management are considerable, making the primary prevention of allergic conditions a desirable health care objective. This position statement reviews current evidence on dietary exposures and allergy prevention in infants at high risk for developing allergic conditions. It revisits previous dietary recommendations for pregnancy, breastfeeding and formula feeding, and provides an approach for introducing solid foods to high-risk infants. While there is no evidence that delaying the introduction of any specific food beyond six months of age helps to prevent allergy, the protective effect of early introduction of potentially allergenic foods (at four to six months of age) remains under investigation. Recent research appears to suggest that regularly ingesting a new, potentially allergenic food may be as important as when that food is first introduced.

Au Canada, les troubles allergiques sont un problème de santé prévalent chez les enfants. Le fardeau de la maladie et les coûts sociétaux d'un diagnostic et d'une prise en charge convenables sont considérables. C'est pourquoi la prévention primaire constitue un objectif souhaitable en matière de soins. Dans le présent document de principes, les auteurs analysent les données probantes à jour sur l'exposition alimentaire et la prévention des allergies chez les nourrissons à haut risque de troubles allergiques. Ils revoient les recommandations antérieures en matière d'alimentation pendant la grossesse, l'allaitement et l'alimentation au moyen de préparations lactées et proposent une approche pour introduire les aliments solides chez les nourrissons à haut risque. Aucune donnée probante n'indique que le fait de reporter l'introduction de certains aliments après six mois contribue à prévenir les allergies, mais l'effet protecteur de l'introduction précoce d'aliments au potentiel allergène (entre quatre et six mois) fait l'objet d'études. Les recherches récentes laissent supposer que la consommation régulière d'un nouvel aliment au potentiel allergène peut être tout aussi importante que le moment de son introduction.

Melatonin for the management of sleep disorders in children and adolescents.

Problems of sleep initiation and maintenance occur in 15% to 25% of children and adolescents. Studies of the benefits of melatonin for sleep disorders have been published for healthy populations, for children and adolescents with attention-deficit hyperactivity disorder, for children and youth with autism, and for several other special populations. These studies demonstrate benefit with minimal side effects. However, all studies have involved small numbers of subjects and address only short-term use of melatonin. There are no good data concerning the safety and efficacy of long-term melatonin use. Further studies are needed to confirm the usefulness and safety of melatonin for sleep disorders in children and adolescents.

On constate un problème d'initiation et de maintien du sommeil chez 15 % à 25 % des enfants et des adolescents. Il existe des études sur les bienfaits de la mélatonine dans le traitement des troubles du sommeil auprès des populations en santé, des enfants et des adolescents ayant un trouble de déficit de l'attention avec hyperactivité, des enfants et des adolescents autistiques et de plusieurs autres populations ayant des problèmes particuliers. Ces études en démontrent les bienfaits, sans compter qu'ils ont des effets secondaires minimes. Cependant, toutes les études portaient sur des petits groupes de sujets et ne traitaient que de l'utilisation à court terme de la mélatonine. Il n'y a pas de données solides sur l'efficacité et l'innocuité de l'utilisation prolongée de la mélatonine. D'autres études s'imposent pour en confirmer l'utilité et l'innocuité dans le traitement des troubles du sommeil chez les enfants et les adolescents.

Positional plagiocephaly.

Cranial asymmetry occurring as a result of forces that deform skull shape in the supine position is known as deformational plagiocephaly. The risk of plagiocephaly may be modified by positioning the baby on alternate days with the head to the right or the left side, and by increasing time spent in the prone position during awake periods. When deformational plagiocephaly is already present, physiotherapy (including positioning equivalent to the preventive positioning, and exercises as needed for torticollis and positional preference) has been shown to be superior to counselling about preventive positioning only. Helmet therapy (moulding therapy) to reduce skull asymmetry has some drawbacks: it is expensive, significantly inconvenient due to the long hours of use per day and associated with skin complications. There is evidence that helmet therapy may increase the initial rate of improvement of asymmetry, but there is no evidence that it improves the final outcome for patients with moderate or severe plagiocephaly.

Effects of age on cerebrospinal fluid oxytocin levels in free-ranging adult female and infant rhesus macaques.

There is growing interest in examining oxytocin and social functioning in human and non-human primates. Studies of human oxytocin biology are typically restricted to peripheral assessments because opportunities to collect cerebrospinal fluid (CSF) are rare. Several studies have examined CSF oxytocin levels in captive adult primates, but none to our knowledge have been conducted under free-ranging conditions and inclusive of infants. The main goal of this study was to establish feasibility of quantifying CSF oxytocin levels in free-ranging adult female and infant rhesus monkeys living on Cayo Santiago, PR. CSF oxytocin levels were examined in relation to individuals' demographic and reproductive characteristics as well as plasma cortisol levels. CSF oxytocin concentrations ranged from 36.02 to 134.41 pg/ml in adult females (ages 7-26 years; N = 31) and 35.94 to 77.3 pg/ml in infants (ages 38-134 days; N = 17). CSF oxytocin levels were positively correlated with adult female age and negatively correlated with infant age. The former correlation was driven by reproductive status. CSF oxytocin levels were unrelated to dominance rank or plasma cortisol levels. In contrast to a previous study of plasma oxytocin concentrations in this population, CSF oxytocin levels did not differ significantly between lactating and non-lactating females. These findings: 1) provide feasibility data for examining CSF oxytocin levels in free-ranging non-human primates and 2) indicate that CSF oxytocin levels may be a biomarker of age-related central nervous system changes across lifespan development. Research is now required to examine CSF oxytocin levels in the context of social functioning in free-ranging rhesus monkeys.