Daily Dose of DrGreene

Allergic to Oats?

Children diagnosed with celiac disease (sensitivity to gluten in the diet) have traditionally been placed on a very strict lifelong diet free of wheat, rye, barley, and oats. The difficult diet helps protect the children from both short- and long-term damage to their intestinal linings. Recent studies in adults have suggested that oats may be okay for adults with celiac. If oats were okay for children and adolescents, it would make following the diet much easier. But I would want a careful study in children before considering this big change. Just such a study was published in the May 2004 Gut. Half of the newly diagnosed children in the study got the traditional celiac diet for a year, the others got a celiac diet plus 15 grams of oat per day. Investigators who didn’t know which group was which evaluated the children’s symptoms, their serum IgA antigliadin, antiendomysium, and antitissue transglutaminase antibodies, and their small bowel biopsies over time. All of the children in the study went into remission. No differences in improvement, in symptoms, blood tests, or biopsies were seen in those who were allowed oats. For most children with celiac, oats appear to be safe. Welcome news indeed.

Alan Greene MD FAAP

The Best Antibiotics for Ear Infections

The 2004 American Academy of Pediatrics guidelines for the treatment of ear infections includes specific recommendation for which antibiotics should be used in different situations. Most ear infections do not need antibiotics at all. If antibiotics are used, high-dose amoxicillin is the best choice for most children - along with treatment for their ear pain. If the child is allergic to amoxicillin, then Ceftin, Omnicef, or Vantin are the preferred choices. If the child is also allergic to all four of these, then Zithromax or Biaxin are the recommended alternatives. If the child with the ear infection has a fever over 102.2 F or is severely ill, then the best starting antibiotic is usually Augmentin. If the child is allergic to Augmentin, then 1 to 3 injections of Rocephin is usually the best choice. Whatever the initial antibiotic, it should be changed if there is not clear improvement within 48 to 72 hours. High-dose Augmentin is usually the best follow-up choice. If the fever is still over 102.2, the child is severely ill, or allergic to Augmentin, then three days of Rocephin injections are recommended. If the child is allergic to Rocephin, then clindamycin is the antibiotic of choice. These guidelines can help many children avoid unnecessary rounds of ineffective antibiotics.

Alan Greene MD FAAP

Strep Throat Treatment

A change may be brewing. Although strep infections are usually mild, and would often get better on their own, some untreated strep infections result in serious complications – such as rheumatic heart disease. Promptly treating strep throat with antibiotics is wise. For half a century, penicillin has been the treatment of choice. Physicians often have been tempted to use newer, broader-spectrum antibiotics, but the Centers for Disease Control, the World Health Organization, the American Academy of Pediatrics, and the American Heart Association have all urged sticking with penicillin both because of its proven effectiveness and because we don’t want to cause escalating antibiotic resistance by using ever-stronger medicines. But a major meta-analysis of 35 separate strep throat studies appeared in the April 2004 Pediatrics. They found significant resistance to penicillin has already developed. The cephalosporin family of antibiotics was more than three times more likely to be effective against strep. This was true even for older, less expensive cephalosporins such as cephalexin (Keflex). New guidelines are still a ways off, but cephalosporins should be considered as an option when treating strep throat.

Alan Greene MD FAAP

Zinc and ADHD

Children who took zinc supplements along with their ADHD medications had greater improvement and improved much more quickly than those who took medications alone, according to a small, well-designed study published April 8, 2004 in Biomed Central Psychiatry. Half of the 44 school-aged children in the study received 15 mg of elemental zinc each day, and the other half received a placebo pill. All of them also took Ritalin. Parents, teachers, and a child psychiatrist assessed the children at the beginning, and 2, 4, and 6 weeks after starting the medicine. At the time of the assessments, no one knew which children were getting the zinc and which were getting the placebo. In these kids, getting the zinc made a significant difference. We still have a lot to learn about this intriguing idea, but according to the USDA up to 62 percent of young children in the U.S. don't get enough zinc in their diets. While we are waiting for more research, making sure that kids with ADHD get 15 mg of zinc each day in their diets or in a good multivitamin seems to me like a simple, gentle, good idea.

Alan Greene MD FAAP

Treatment Strategies for ADHD

The National Institute of Mental Health has conducted a study comparing 4 different treatment options for children with a confirmed diagnosis of ADHD. Hundreds of children were involved at six different sites, in what has become known as the MTA study (Multimodal Treatment Study of Children with ADHD). The first group of children received intensive behavioral treatment. This included parent training (8 individual sessions per family, plus 27 small group sessions over 14 months), child-focused treatment (an 8-week, 5-days-per-week, 9-hours-per-day therapeutic summer camp), and a school-based program (10 to 16 sessions of bi-weekly teacher consultation about behavioral strategies, plus a dedicated, behaviorally trained teacher’s aide to work with just that child for 60 days, plus a daily behavior report card to help coordinate between home and school. The second group of children was given a tailored, intensive medication regimen, where the investigators used a placebo test to decide if medicine were needed, and at what dose. Children were given disguised capsules of 4 different doses of Ritalin and placebo, each for 5 days. After a month they were started on whichever had worked the best. If there were still symptoms, up to 6 different medicines were tested to find the best one. The third group of children received combined treatment, with both intensive medication and behavioral interventions. The fourth group received typical community physician care, where most were treated with Ritalin at one-size-fits-all doses, with perhaps a bit of behavioral support. Two-year results from this study appeared in the April 2004 Pediatrics, looking at ongoing success 10 months after stopping the trial. All four groups of children had improved significantly, but behavioral treatment worked much better than typical community care. However, tailored medication treatment worked significantly better than either, even though the same medications were used by 2/3 of the kids. Combination treatment edged out tailored medication as the best of the four treatments, though at much higher cost. One significant benefit of the combined approach was that optimal results were achieved with lower doses of medications.

Alan Greene MD FAAP

TV and ADHD

The more television that toddlers watch, the more likely they are to have ADHD when they are school age, according to a provocative study in the April 2004 Pediatrics. The study followed more than 2,600 children, initially at ages 1 to 3. The overall rate of ADHD at age 7 was about 10 percent. But for the top 10 to 20 percent of television viewers, the ADHD rate was about 3 times higher - and increased by about 9 percent for every additional hour of daily television watch. This study did not look at different kinds of programs, and certainly does not tell us what caused what. Perhaps kids who already had short attention spans were more drawn to TV. Or their parents were more likely to need the TV for relief. But it's also possible that exposure to the rapidly shifting images of television during those years of critical brain development changed the way that those brains developed. Until we know more, it is wise to be cautious about excess television viewing in the first 3 years.

Alan Greene MD FAAP

Down Syndrome Testing and Vegetarians

Pregnant women who are vegetarians may be unnecessarily worried by prenatal screening tests, according to a study from the Chang Gung Memorial Hospital in Taipei. The study followed the pregnancies of more than 200 women, half of them vegetarians. Results were published in the February 2004 American Journal of Obstetrics and Gynecology. Beta HCG, the same substance used to detect pregnancies in the first place, is also used to look for Down syndrome. In vegetarian women, levels are normally higher than in non-vegetarian women (and to a lesser extent, this is also true of alpha fetoprotein - AFP -- levels). This results in false positive screening tests about 3 times more often for vegetarian women. Until someone calculates normal test ranges for the two different groups, vegetarian women can breathe just a bit easier while waiting for confirming test results. What we eat affects us in more ways than we imagine!

Alan Greene MD FAAP

The BBC and Character Foods

At the urging of the Food Commission, the BBC has decided to become a leader in children's nutrition by changing the way they license their popular TV characters to sell kids' foods. The BBC licenses dozens of products, which are powerful at influencing children's choices. Their biggest three brands in the pre-school market are Teletubbies, Tweenies, and Fimbles. Previously, these popular characters have been used to entice children to crave tempting products that were high in fat, sugar or salt. The BBC has made a bold choice to use the brands instead to promote healthier foods such as convenience fruit, vegetable, fish, and grain products. Ravioli replaces candy. And lucrative promotions with fast food chains have ended. They've also realized that unhealthy daily snack foods and treats don't need the characters' endorsement. The BBC has decided, however, to continue licensing them for celebration snacks such as birthday treats or Easter eggs. I applaud the BBC for leading the way, and hope that other popular characters will be inspired by this courageous move, and perhaps move us even further ahead.

Alan Greene MD FAAP

Vaccine Diabetes Link?

Type 1 diabetes has increased in children over the last decade, presumably triggered by something in their diet or in their environment. Some have suggested that perhaps the disease is triggered by a child’s response to vaccines. The April 1, 2004 New England Journal of Medicine contains the results of a huge investigation into this question. Danish investigators analyzed the medical records of all children born in Denmark born between midnight January 1, 1990 and midnight December 31 2000. Over 700,000 children were included in the study. No differences were found in the diabetes rates among different groups of children related either to the number or types of vaccines the children received. No association of any kind could be found between type 1 diabetes and childhood vaccines, even among the children at the highest risk of developing diabetes, because they already had a sibling with the disease. When it’s time for children to be vaccinated, the possibility of triggering diabetes is not something that parents need to worry about.

Alan Greene MD FAAP