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You might like also to look at the many other free paediatric resources we have at: www.rch.org.au/genmed/clinical.cfm?doc_id=10999

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Are you familiar with all the various asthma inhalers and spacer devices?

Do your patients sometimes forget to bring them to an appointment and you try to guess which one they are talking about?

We have updated our

http://sn.im/asthma_devices

There are also links to this from the asthma Clinical Practice Guideline and I have also put a link on the Gen Med Clinical Resources page.

·        http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5251

·        http://www.rch.org.au/genmed

I’m grateful to Jeffrey Ong (Clinical Pharmacist), and Noel Cranswick (Clinical Pharmacologist) for their help

I hope you find it useful

Cheers Mike Prof Mike South, Royal Children's Hospital, Parkville, Victoria 3052, Australia

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The Gilles De La Tourette syndrome: the current status

Arch Dis Child Educ Pract Ed doi:10.1136/archdischild-2011-300585
Mary May Robertson, ¹Department of Mental Health Sciences, University College, London

I really know very little about Tourette syndrome as these children rarely come my way, but I’m aware some paediatricians do see cases – this article may be of interest.

Cheers

Mike

The article is available at: http://ep.bmj.com/content/early/2012/03/21/archdischild-2011-300585.abstract?papetoc

Abstract

Gilles de la Tourette syndrome (GTS) is characterised by multiple motor and one or more vocal/phonic tics. GTS was once thought to be rare, but many relatively recent studies suggest that the prevalence is about 1% of the worldwide community, apart from in Sub-Saharan Black Africa. Comorbidity and coexistent psychopathology are common, occurring in about 90% of clinical cohorts and individuals in the community. The most common comorbidities are attention deficit hyperactivity disorder, obsessive-compulsive behaviours, and disorder, and autistic spectrum disorders, while the most common coexisting psychopathologies are depression, anxiety and behavioural disorders such as oppositional defiant and conduct disorder. There has been an increasing amount of evidence to show that the quality of life in young people is reduced when compared with normative data or healthy control populations. It is widely accepted that most cases of GTS are inherited, but the genetic mechanisms appear much more complex than previously understood, as evidenced by many recent studies; indeed, there have been suggestions of ‘general neurodevelopmental genes’ which affect the brain development after which the ‘specific GTS gene(s)’ may further affect the phenotype. Other aetiopathogenetic suggestions have included environmental factors such as neuro-immunological factors, infections, prenatal and peri-natal difficulties and androgen influences. Few studies have addressed aetiology and phenotype, but initial results are exciting. The search for endophenotypes has followed subsequently. Intriguing neuroanatomical and brain circuitry abnormalities have now been suggested in GTS; the most evidence is for cortical thinning and a reduction in the size of the caudate nucleus. Thorough assessment is imperative and multidisciplinary management is the ideal. Treatment should be ‘symptom targeted’, and in mild cases, psycho-education and reassurance for the patient and the family may be sufficient. Behavioural treatments such as Comprehensive Behavioural Intervention for Tics including Habit Reversal Training have been shown to be significantly better than other behavioural/psychological treatments and ‘placebo’. Medication is often necessary for moderately affected individuals. In more severe cases, medical treatment is not simple and referral to an expert may be advisable. In general, neuroleptics and clonidine or guanfacine are the medications of choice for the tics. Other treatments which may be needed for loud and severe phonic tics include botulinum toxin. In severe adult GTS patients who are refractory to medication and other therapies, deep brain stimulation looks promising.

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old

The Cochrane Library 10.1002/14651858.CD004873.pub4

This Cochrane review of 9 studies confirms what we know from experience – physiotherapy (all modalities) does not improve outcomes in babies with bronchiolitis

Mike

The article is available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004873.pub4/abstract

BACKGROUND: This is an update of the original Cochrane review published in 2005 and updated in 2007. Acute bronchiolitis is the leading cause of medical emergencies during winter in children younger than two years of age. Chest physiotherapy is thought to assist infants in the clearance of secretions and to decrease ventilatory effort.

OBJECTIVES: The main objective was to determine the efficacy of chest physiotherapy in infants aged less than 24 months old with acute bronchiolitis. A secondary objective was to determine the efficacy of different techniques of chest physiotherapy (for example, vibration and percussion and passive forced exhalation). SEARCH

METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4) which contains the Cochrane Acute Respiratory Infections Group`s Specialised Register, MEDLINE (1966 to November week 3, 2011),

MEDLINE in-process and other non-indexed citations (8 December 2011), EMBASE.com (1990 to December 2011), CINAHL (1982 to December 2011), LILACS (1985 to December 2011) and Web of Science (1985 to December 2011).

SELECTION CRITERIA: Randomised controlled trials (RCTs) in which chest physiotherapy was compared against no intervention or against another type of physiotherapy in bronchiolitis patients younger than 24 months of age.

DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data. Primary outcomes were respiratory parameters and improvement in severity of disease. Secondary outcomes were length of hospital stay, duration of oxygen supplementation and the use of bronchodilators and steroids. No pooling of data was possible.

MAIN RESULTS: Nine clinical trials including 891 participants were included comparing physiotherapy with no intervention. Five trials (246 participants) evaluated vibration and percussion techniques and four trials (645 participants) evaluated passive expiratory techniques. We observed no significant differences in the severity of disease (eight trials, 867 participants). Results were negative for both types of physiotherapy. We observed no differences between groups in respiratory parameters (two trials, 118 participants), oxygen requirements (one trial, 50 participants), length of stay (five trials, 222 participants) or severe side effects (two trials, 595 participants). Differences in mild transient adverse effects (vomiting and respiratory instability) have been observed (one trial, 496 participants).

AUTHORS' CONCLUSIONS: Since the last publication of this review new good-quality evidence has appeared, strengthening the conclusions of the review. Chest physiotherapy does not improve the severity of the disease, respiratory parameters, or reduce length of hospital stay or oxygen requirements in hospitalised infants with acute bronchiolitis not on mechanical ventilation. Chest physiotherapy modalities (vibration and percussion or forced expiratory techniques) have shown equally negative results.

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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Diagnosis and management of the epilepsies in adults and children: summary of updated NICE guidance

BMJ2012;344:e281

There is an excellent recent update to the UK NICE Guideline on the diagnosis and management of epilepsy.

This BMJ article provides a good summary. It is free on the BMJ website at the moment.

Mike

The BMJ article is available at: http://www.bmj.com/content/344/bmj.e281?etoc

The full NICE Guideline is here

1. National Institute for Health and Clinical Excellence. The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care (update). (Clinical guideline 137.) 2012. http://guidance.nice.org.uk/CG137.

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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Changing trends in the UK management of childhood ITP

Arch Dis Child 2012;97:8-11 doi:10.1136/adc.2010.184234

John D Grainger1, Joanne L Rees1, Marie Reeves1, Paula H B Bolton-Maggs2

The University of Manchester, Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, Manchester, UK

Manchester Academic Health Science Centre, Manchester Royal Infirmary, The University of Manchester, Manchester, UK

Which patients with ITP need treatment?

This study from the UK shows a progressive reduction in the proportion of children with ITP being treated (61% in 1995, 38% in 2000, 16% in 2009), so if you are using a watch and wait approach in children without significant bleeding symptoms you are in keeping with contemporary practice.

The authors reference a very comprehensive consensus guideline about many aspects of ITP (a valuable reference document):

International consensus report on the investigation and management of primary immune thrombocytopenia

http://bloodjournal.hematologylibrary.org/content/115/2/168.abstract

It has many useful components including the recommendation that Children with acute ITP and mild clinical disease may be managed expectantly irrespective of platelet count.

Minor bleeding, few petechiae (≤100 total) and/or ≤5 small bruises (≤3 cm diameter); no mucosal bleeding � watch and wait

Mild bleeding, many petechiae (>100 total) and/or >5 large bruises (>3 cm diameter); no mucosal bleeding � consider treatment according to age/activity

Moderate bleeding, overt mucosal bleeding, troublesome lifestyle � treatment recommended

Suspected internal hemorrhage � urgent treatment recommended

In general, a short course of 1�2 mg/kg/day of prednisone may be given, with treatment titrated against the platelet count and with rapid tapering.
Alternatively, a higher dose of corticosteroids 4 mg/kg/day for 4 days may be used.

The RCH CPG on ITP is at http://www.wch.org.au/clinicalguide/cpg.cfm?doc_id=5214

Mike

Abstract

Objective To compare the treatment of childhood immune thrombocytopenia (ITP) with historical practice in the UK.

Design Data collection through a national UK Childhood ITP registry (http://www.uk-itp.org) started in January 2007.

Settings UK hospitals.

Participants Children admitted with a new diagnosis of acute ITP and their treating physicians.

Main outcome measures Bleeding severity, platelet count, disease management and outcome from the time of presentation to 6 months.

Results Data from 225 children were analysed. 54% of children had clinically mild, 42% had moderate and 4% had severe disease as defined previously.¹ The mean platelet counts at diagnosis for these groups were 14, 8 and 6×10⁹/l respectively. Children with mild disease had fewer bleeding sites (1.9), compared with moderate (2.5) or severe disease (3.6). There was one intracranial haemorrhage reported. At 6 months' follow-up, 32% had a persistent platelet count <150×10⁹/l, but only 4.8% had a count <20. The proportion of UK children receiving platelet-raising treatment was noted to decrease from 61% in 1995 to 38% in 2000. The current UK 2009 registry data show a continued decrease in treatment to 16% of all the children. In contrast, historical international data report 69% of children receiving interventional therapy.

Conclusion The current UK practice has shown a continued reduction in the number of children receiving treatment in comparison with historical data and international practice.

The article is available at: http://adc.bmj.com/content/97/1/8.abstract?etoc

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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Suicidal Thoughts and Behavior With Antidepressant Treatment

Reanalysis of the Randomized Placebo-Controlled Studies of Fluoxetine and Venlafaxine

Arch Gen Psychiatry. Published online February 6, 2012. doi:10.1001/archgenpsychiatry.2011.2048

Robert D. Gibbons, PhD; C. Hendricks Brown, PhD; Kwan Hur, PhD; John M. Davis, MD; J. John Mann, MD

Do antidepressants work in adolescent depression?

Do they increase the risk of suicide?

See this paper and this commentary by Daryl Efron. The results seem reassuring.

Mike

Important paper.

we know SSRI antidepressants are not fantastic for depression in adolescents, and probably have little if any effect on depression in pre-pubertal kds  - although excellent anti-anxiety agents of course. So are they worth using for depression at all? and is the risk of suicidal thinking/ behaviour real, beyond paroxetine. I do use them to treat adolescent depression, and sometimes see apparent good benefit.

These authors looked at all longitudinal RCT data on fluoxetine from Lily (incl non-published), as well as data from the NIMH TADS study (Treatment for Adolescents With Depression Study - fluoxetine again). The findings are encouraging (my bold in abstract below).

Intrerestingly there was no relationship between reduction in depressive symptoms and reduction in suidicality, suggesting perhaps an alternate mediating factor / behaviour / mood state - although the numbers with suicidality are small so v hard to study. From the results:

"we could find no difference between treated and control patients in terms of suicide risk. The marginal ORs indicated a 61.3% decrease in the probability of suicidal thoughts or behavior for control patients after 8 weeks of study participation and a 50.3% decrease for treated patients."

My take - Fluoxetine may reduce depressive symptoms in adolescents, and is unlikely to incr risk of suicidaility

Daryl

The article is available at: http://archpsyc.ama-assn.org/cgi/content/abstract/archgenpsychiatry.2011.2048

ABSTRACT

Context The US Food and Drug Administration issued a black box warning for antidepressants and suicidal thoughts and behavior in children and young adults.

Objective To determine the short-term safety of antidepressants by standard assessments of suicidal thoughts and behavior in youth, adult, and geriatric populations and the mediating effect of changes in depressive symptoms.

Data Sources All intent-to-treat person-level longitudinal data of major depressive disorder from 12 adult, 4 geriatric, and 4 youth randomized controlled trials of fluoxetine hydrochloride and 21 adult trials of venlafaxine hydrochloride.

Study Selection All sponsor-conducted randomized controlled trials of fluoxetine and venlafaxine.

Data Extraction The suicide items from the Children's Depression Rating Scale–Revised and the Hamilton Depression Rating Scale as well as adverse event reports of suicide attempts and suicide during active treatment were analyzed in 9185 patients (fluoxetine: 2635 adults, 960 geriatric patients, 708 youths; venlafaxine: 2421 adults with immediate-release venlafaxine and 2461 adults with extended-release venlafaxine) for a total of 53 260 person-week observations.

Data Synthesis Suicidal thoughts and behavior decreased over time for adult and geriatric patients randomized to fluoxetine or venlafaxine compared with placebo, but no differences were found for youths. In adults, reduction in suicide ideation and attempts occurred through a reduction in depressive symptoms. In all age groups, severity of depression improved with medication and was significantly related to suicide ideation or behavior.

Conclusions Fluoxetine and venlafaxine decreased suicidal thoughts and behavior for adult and geriatric patients. This protective effect is mediated by decreases in depressive symptoms with treatment. For youths, no significant effects of treatment on suicidal thoughts and behavior were found, although depression responded to treatment. No evidence of increased suicide risk was observed in youths receiving active medication. To our knowledge, this is the first research synthesis of suicidal thoughts and behavior in depressed patients treated with antidepressants that examined the mediating role of depressive symptoms using complete longitudinal person-level data from a large set of published and unpublished studies.

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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Delayed Puberty

N Engl J Med 2012; 366:443-453February 2, 2012

Mark R. Palmert, M.D., Ph.D., and Leo Dunkel, M.D., Ph.D.

Nice clinical practice article in NEJM today.

Has a clear and evidence-based approach to sequential evaluation of a child with Delayed Puberty.

The flow chart is very helpful.

A 14-year-old boy with an unremarkable medical history presents because of lack

of pubertal development. He has always been relatively short, but his growth velocity

is slowing as compared with that of his peers. His height is 146 cm (57.5 in., <3rd

percentile for age), and his weight is 37 kg (82 lb, 3rd percentile). His father, who is

168 cm (66.1 in.) tall, continued to grow until his second year in college; his mother is

153 cm (60.2 in.) tall and began menstruating at the age of 14.0 years. The patient’s

target height on the basis of the parental heights is 167 cm (65.8 in.). The physical

examination reveals Tanner stage 1 pubic hair and prepubertal-sized testes. How

should the boy be evaluated and treated?

Key Clinical Points

•       Delayed puberty is diagnosed when there is no testicular enlargement in boys or breast development in girls at an age that is 2 to 2.5 SD later than the mean age at which these events occur in the population (traditionally, 14 years in boys and 13 years in girls).

•       Constitutional delay of growth and puberty (CDGP) is the single most common cause of delayed puberty in both sexes, but it can be diagnosed only after underlying conditions have been ruled out.

•       The cause of CDGP is unknown, but most patients with CDGP have a family history of delayed puberty.

•       Management of CDGP may involve expectant observation or therapy with low-dose sex steroids.

•       When treatment is given, the goals are to induce the appearance of secondary sexual characteristics or the acceleration of growth and to mitigate psychosocial difficulties associated with pubertal delay and short stature.

•       The routine use of growth hormone, anabolic steroids, or aromatase inhibitors is not currently recommended.

The article is available at: http://www.nejm.org/doi/abstract/10.1056/NEJMcp1109290?query=TOC

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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How to use serum-specific IgE measurements in diagnosing and monitoring food allergy

Arch Dis Child Educ Pract Ed 2012;97:29-36

Gary Stiefel1, Graham Roberts Southampton University Hospital NHS Trust,

This is a very well laid out article on the value of RAST (serum-specific IgE measurements) testing in childhood allergy. The main learning points are listed below, but the full article is worth a read..It contains some very practical case scenarios and a self-assessment quiz

The article is available at: http://ep.bmj.com/content/97/1/29.extract?etoc

Clinical summary

·         Serum-specific immunoglobulin E (sIgE) is a widely available test used to support a diagnosis of IgE-mediated food allergy and a method for monitoring resolution of allergy.

·         The interpretation of sIgE must be taken within the context of the history.

·         A positive sIgE indicates sensitisation to a specific food. This does not necessarily equate with clinical allergy.

·         If there is clinical doubt after the history and sIgE, a supervised open food challenge (OFC) should be performed to make a definitive diagnosis.

·         The result of the sIgE does not correlate with the severity of the clinical reaction. However, the higher the sIgE, the greater the likelihood of clinical allergy.

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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Impact of a More Restrictive Approach to Urinary Tract Imaging After Febrile Urinary Tract Infection

Arch Pediatr Adolesc Med. 2011;165(11):1027-1032. doi:10.1001/archpediatrics.2011.178

Alan R. Schroeder, MD; Jennifer M. Abidari, MD; Rashmi Kirpekar, MD; John R. Hamilton, PhD; Young S. Kang, MD; VyThao Tran, MD; Stephen J. Harris, MD. Santa Clara Valley Medical Center, San Jose, California

As evidence has emerged to support a less aggressive approach to imaging and intervention in children following UTI, most paediatricians have greatly reduced their reliance on imaging and prophylactic antibiotics. For the former you can see some data I published at http://adc.bmj.com/content/94/12/927 - figure shown below for MCU.

In this study, the authors compared their use of imaging investigations and prophylactic antibiotics during 2 one year periods (2 years apart) – either side of a change in their adoption of new guidelines. They also studied some outcomes – the rates of recurrent UTI and diagnosis of higher grades of VUR.

There was a dramatic change in practice:

·         MCU rate period A = 99% vs 13% in period B

·         prophylactic antibiotics 97% in period A vs 5% in period B

There was no change in rates of detection of high grade VUR, nor of recurrent UTI in this period.

This was not an RCT, nor a study properly powered for equivalence (it had 201 subjects) but the results are reassuring in the light of change in Australian practice.

The article is available at: http://archpedi.ama-assn.org/cgi/content/short/165/11/1027 and I have copied the useful guideline of who to investigate and when below.

Abstract

Objectives  To determine the impact of using an algorithm requiring selective rather than routine urinary tract imaging following a first febrile urinary tract infection (UTI) on imaging use, detection of vesicoureteral reflux (VUR), prophylactic antibiotic use, and UTI recurrence within 6 months.

Design  Retrospective review comparing outcomes during periods before algorithm use (September 1, 2006, to August 31, 2007) and after algorithm use (September 1, 2008, to August 31, 2009). The new algorithm, which adapted recommendations from the United Kingdom's National Institute for Health and Clinical Excellence 2007 guidelines, was implemented in 2008. The algorithm calls for renal ultrasonography in most cases and restricts voiding cystourethrography for use in patients with certain risk factors.

Setting  County health system.

Participants  Children younger than 2 years with a first febrile UTI.

Intervention  Selective algorithm for urinary tract imaging.

Main Outcome Measures  Urinary tract imaging use, detection of VUR, prophylactic antibiotic use, and UTI recurrence within 6 months.

Results  After introduction of the new algorithm, voiding cystourethrography and prophylactic antibiotic use decreased markedly. Rates of UTI recurrence within 6 months and detection of grades 4 and 5 VUR did not change, but detection of grades 1 to 3 VUR decreased substantially. Patients in the prealgorithm group with grades 1 to 3 VUR who would have been missed with selective screening underwent no interventions other than successive urinary tract imaging and prophylactic antibiotic use.

Conclusions  By restricting urinary tract imaging after an initial febrile UTI, rates of voiding cystourethrography and prophylactic antibiotic use decreased substantially without increasing the risk of UTI recurrence within 6 months and without an apparent decrease in detection of high-grade VUR. Clinicians can be more judicious in their use of urinary tract imaging.

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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Melatonin in autism spectrum disorders: a systematic review and meta-analysis

Developmental Medicine & Child Neurology Volume 53, Issue 9, pages 783–792, September 2011

DANIEL A ROSSIGNOL1, RICHARD E FRYE2 1International Child Development Resource Center, Melbourne, FL, USA 2Division of Child and Adolescent Neurology and Children’s Learning Institute, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, TX, USA.

This systematic review and meta-analysis is a good summary of existing knowledge about the role of abnormalities of melatonin secretion in children with autism, the possible genetic mechanisms underlying this, and the benefits of treatment with melatonin on sleep behavior and possibly some daytime autistic behaviours (including improvements in behavioural rigidity, ease of management for parents and teachers, social interaction, temper tantrums, irritability, playfulness, academic performance and alertness).

The article is available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2011.03980.x/full

A reminder that our list of Victorian sources of Melatonin from compounding pharmacies is available at

http://www.wch.org.au/genmed/clinical.cfm?tab=m&type=title&doc_id=2399 under “melatonin”.

MIKE

Aim The aim of this study was to investigate melatonin-related findings in autism spectrum disorders (ASD), including autistic disorder, Asperger syndrome, Rett syndrome, and pervasive developmental disorders, not otherwise specified.

Method Comprehensive searches were conducted in the PubMed, Google Scholar, CINAHL, EMBASE, Scopus, and ERIC databases from their inception to October 2010. Two reviewers independently assessed 35 studies that met the inclusion criteria. Of these, meta-analysis was performed on five randomized double-blind, placebo-controlled studies, and the quality of these trials was assessed using the Downs and Black checklist.

Results Nine studies measured melatonin or melatonin metabolites in ASD and all reported at least one abnormality, including an abnormal melatonin circadian rhythm in four studies, below average physiological levels of melatonin and/or melatonin derivates in seven studies, and a positive correlation between these levels and autistic behaviors in four studies. Five studies reported gene abnormalities that could contribute to decreased melatonin production or adversely affect melatonin receptor function in a small percentage of children with ASD. Six studies reported improved daytime behavior with melatonin use. Eighteen studies on melatonin treatment in ASD were identified; these studies reported improvements in sleep duration, sleep onset latency, and night-time awakenings. Five of these studies were randomized double-blind, placebo-controlled crossover studies; two of the studies contained blended samples of children with ASD and other developmental disorders, but only data for children with ASD were used in the meta-analysis. The meta-analysis found significant improvements with large effect sizes in sleep duration (73min compared with baseline, Hedge’s g 1.97 [95% confidence interval {CI} CI 1.10–2.84], Glass’s Δ 1.54 [95% CI 0.64–2.44]; 44min compared with placebo, Hedge’s g 1.07 [95% CI 0.49–1.65], Glass’s Δ 0.93 [95% CI 0.33–1.53]) and sleep onset latency (66min compared with baseline, Hedge’s g−2.42 [95% CI −1.67 to −3.17], Glass’s Δ−2.18 [95% CI −1.58 to −2.76]; 39min compared with placebo, Hedge’s g−2.46 [95% CI −1.96 to −2.98], Glass’s Δ−1.28 [95% CI −0.67 to −1.89]) but not in night-time awakenings. The effect size varied significantly across studies but funnel plots did not indicate publication bias. The reported side effects of melatonin were minimal to none. Some studies were affected by limitations, including small sample sizes and variability in the protocols that measured changes in sleep parameters.

Interpretation Melatonin administration in ASD is associated with improved sleep parameters, better daytime behavior, and minimal side effects. Additional studies of melatonin would be helpful to confirm and expand on these findings.

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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Randomized Clinical Trial of Rapid Versus 24-Hour Rehydration for Children With Acute Gastroenteritis

Colin V. E. Powell, MD, FRACP, FRCPCH, Stephen J. Priestley, FACEM 3. Simon Young, ACEM,  4. Ralf G. Heine, MD, FRACP

Departments of aEmergency Medicine and Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Australia;

Department of Emergency Medicine, Sunshine Hospital, Melbourne, Australia;

Department of Pediatrics, School of Medicine, University of Cardiff, Cardiff, United Kingdom;

Department of Emergency Medicine, Nambour Hospital, Queensland, Australia;

Department of Paediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Australia; and

Murdoch Childrens Research Institute, Melbourne, Australia

This local study adds to the body of literature showing that rapid nasogastric rehydration RNR  (over 4 hours) is as effective as more standard rehydration over 24 hours. The sample size wasn’t large enough to state this with a high degree of confidence for non-inferiority but the findings are still useful.

The article is available at:

http://pediatrics.aappublications.org/content/early/2011/09/21/peds.2010-2483.abstract

Our (RCH) regimen for RNR is at:

http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=12364#5

Mike

Objective: To compare the efficacy of 2 nasogastric rehydration regimens for children with acute viral gastroenteritis.

Methods: Children 6 to 72 months of age with acute viral gastroenteritis and moderate dehydration were recruited from emergency departments (EDs) at 2 metropolitan, pediatric, teaching hospitals. After clinical assessment of the degree of dehydration, patients were assigned randomly to receive either standard nasogastric rehydration (SNR) over 24 hours in the hospital ward or rapid nasogastric rehydration (RNR) over 4 hours in the ED. Primary (>2% weight loss, compared with the admission weight) and secondary treatment failures were assessed.

Results: Of 9331 children with acute gastroenteritis who were screened, 254 children were assigned randomly to receive either RNR (n = 132 [52.0%]) or SNR (n = 122 [48.0%]). Baseline characteristics for the 2 groups were similar. All patients made a full recovery without severe adverse events. The primary failure rates were similar for RNR (11.8% [95% confidence interval [CI]: 6.0%–17.6%]) and SNR (9.2% [95% CI: 3.7%–14.7%]; P = .52). Secondary treatment failure was more common in the SNR group (44% [95% CI: 34.6%–53.4%]) than in the RNR group (30.3% [95% CI: 22.5%–38.8%]; P = .03). Discharge from the ED after RNR failed for 27 patients (22.7%), and another 9 (7.6%) were readmitted to the hospital within 24 hours.

Conclusions: Primary treatment failure and clinical outcomes were similar for RNR and SNR. Although RNR generally reduced the need for hospitalization, discharge home from the ED failed for approximately one-fourth of the patients.

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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Abdominal Migraine: An Under-Diagnosed Cause of Recurrent Abdominal Pain in Children

Headache 2011;51:707-712

Division of Pediatric Neurology, Children’s Hospitalof The King’s Daughters, Norfolk, VA, USA.

This article is a useful reminder that Abdominal Migraine is a distinct entity in the known spectrum of functional abdominal pain.

Diagnostic criteria for abdominal migraine include all of the following, with 2 or more episodes in the preceding 12

months:

A. Paroxysmal episode of intense, acute periumbilical pain that lasts 1 hours or more.

B. Intervening periods of usual health lasting weeks to months.

C. The pain interferes with normal activities.

D. The pain is associated with 2 or more of the following:

a. Anorexia.

b. Nausea.

c. Vomiting.

d. Headache.

e. Photophobia.

f. Pallor.

E. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process.

A key feature of AM is the complete resolution of symptoms between attacks

It joins functional dyspepsia, irritable bowel syndrome, and functional abdominal pain syndrome in this spectrum.

It is a useful diagnosis to recognize because it may respond well to dietary, lifestyle, and pharmacological interventions as used in migraine headache. Preventive medications that have demonstrated efficacy in clinical trials include pizotifen, propranolol, and cyproheptadine.

The article is available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4610.2011.01855.x/abstract

Cheers

Mike

Objective.—Our objective was to demonstrate that, despite recognition by both the gastroenterology and headache communities, abdominal migraine (AM) is an under-diagnosed cause of chronic, recurrent, abdominal pain in childhood in the

USA.

Background.—Chronic, recurrent abdominal pain occurs in 9-15% of all children and adolescents. After exclusion of

anatomic, infectious, inflammatory, or other metabolic causes, “functional abdominal pain” is the most common diagnosis

of chronic, idiopathic, abdominal pain in childhood. Functional abdominal pain is typically categorized into one,or a combination

of, the following 4 groups: functional dyspepsia, irritable bowel syndrome, AM, or functional abdominal pain syndrome.

International Classification of Headache Disorders—(ICHD-2) defines AM as an idiopathic disorder characterized by

attacks of midline, moderate to severe abdominal pain lasting 1-72 hours with vasomotor symptoms, nausea and vomiting, and

included AM among the “periodic syndromes of childhood that are precursors for migraine.” Rome III Gastroenterology

criteria (2006) separately established diagnostic criteria and confirmedAMas a well-defined cause of recurrent abdominal pain.

Methods.—Following institutional review board approval, a retrospective chart review was conducted on patients referred

to an academic pediatric gastroenterology practice with the clinical complaint of recurrent abdominal pain. ICHD-2 criteria

were applied to identify the subset of children fulfilling criteria for AM. Demographics, diagnostic evaluation, treatment

regimen and outcomes were collected.

Results.—From an initial cohort of 600 children (ages 1-21 years; 59% females) with recurrent abdominal pain, 142 (24%)

were excluded on the basis of their ultimate diagnosis. Of the 458 patients meeting inclusion criteria, 1824 total patient office

visits were reviewed. Three hundred eighty-eight (84.6%) did not meet criteria for AM, 20 (4.4%) met ICHD-2 formal criteria

forAM and another 50 (11%) had documentation lacking at least 1 criterion, but were otherwise consistent withAM (probable

AM). During the observation period, no children seen in this gastroenterology practice had received a diagnosis of AM.

Conclusion.—Among children with chronic, idiopathic, recurrent abdominal pain,AM represents about 4-15%. Given the

spectrum of treatment modalities now available for pediatric migraine, increased awareness of cardinal features of AM by

pediatricians and pediatric gastroenterologists may result in improved diagnostic accuracy and early institution of both acute

and preventative migraine-specific treatments.

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents

Cochrane Database Syst Rev. 2011 Sep 7;9:CD005506.

Fedorowicz Z, Jagannath VA, Carter B.

Should children presenting to emergency departments with vomiting related to acute gastroenteritis be given anti-emetics?

Many EDs are now doing this.

This Cochrane review examined 7 studies with a total of >1000 children.

Oral ondansetron is confirmed to have benefits in reducing vomiting, reduced hospitalization and reduced need for IV therapy.

The number needed to treat is quite high however (17) and the drug is expensive (but not as expensive as a stay in hospital for rehydration). The cost-benefit ratio is probably less favourable for its use in primary care settings.

The article is available at:

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005506.pub5/abstract

MIKE

BACKGROUND: Vomiting is a common manifestation of acute gastroenteritis in children and adolescents. When untreated it can be a hindrance to oral rehydration therapy, which is the cornerstone in the management of acute gastroenteritis. Evidence is needed concerning the safety and efficacy of antiemetic use for vomiting in acute gastroenteritis in children.

OBJECTIVES: To assess the safety and effectiveness of antiemetics on gastroenteritis induced vomiting in children and adolescents.

SEARCH STRATEGY: We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conferences.The search was re-run and is up to date as on 20 July 2010.

SELECTION CRITERIA: Randomized controlled trials comparing antiemetics with placebo or no treatment, in children and adolescents under the age of 18, for vomiting due to gastroenteritis.

DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS: We included seven trials involving 1,020 participants. Mean time to cessation of vomiting in one study was 0.34 days less with dimenhydrinate suppository compared to placebo (P value = 0.036). Pooled data from three studies comparing oral ondansetron with placebo showed: a reduction in the immediate hospital admission rate (RR 0.40, NNT 17, 95% CI 10 to 100) but no difference between the hospitalization rates at 72 hours after discharge from the Emergency Department (ED); a reduction in IV rehydration rates both during the ED stay (RR 0.41, NNT 5, 95% CI 4 to 8), and in follow-up to 72 hours after discharge from the ED stay (worst-best scenario for ondansetron RR 0.57, NNT 6, 95% CI 4 to 13) and an increase in the proportion of patients with cessation of vomiting (RR 1.34, NNT 5, 95% CI 3 to 7)). No significant difference was noted in the revisit rates or adverse events, although diarrhea was reported as a side effect in four of the five ondansetron studies. In one study the proportion of patients with cessation of vomiting in 24 hours was (58%) with IV ondansetron, (17%) placebo and (33%) in the metoclopramide group (P value = 0.039).

AUTHORS' CONCLUSIONS: Oral ondansetron increased the proportion of patients who had ceased vomiting and reduced the number needing intravenous rehydration and immediate hospital admission. Intravenous ondansetron and metoclopramide reduced the number of episodes of vomiting and hospital admission, and dimenhydrinate as a suppository reduced the duration of vomiting.

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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Premature adrenarche

Arch Dis Child doi:10.1136/archdischild-2011-300011

Rachel M Williams, Caleb E Ward, Ieuan A Hughes Department of Paediatrics, University of Cambridge, Box 116 Addenbrooke's Hospital, Hills Road, Cambridge

Early development of secondary sexual hair in children is a concern for their parents and often leads to a paediatric referral.

This article gives a good explanation of the generally benign condition of premature adrenarche, and how to differentiate the rare other conditions that need to be considered. There is a useful algorithm in the article.

While premature adrenarche  is generally considered a benign condition, there may be associated morbidities to consider/monitor.

The article is available at: http://adc.bmj.com/content/early/2011/08/11/archdischild-2011-300011.abstract?papetoc

MIKE

Abstract

Premature adrenarche refers to the presence of secondary sexual hair in girls younger than 8 years old and boys younger than 9 years old. It is a relatively common presentation to paediatricians and is more frequent in girls than boys. It is a benign diagnosis, but other causes of androgen excess such as congenital adrenal hyperplasia or adrenal tumours should be excluded first. In conjunction with history and clinical examination, first line investigations should include determination of serum androgen concentrations, along with bone age, proceeding to synacthen stimulation test (for 17OHP levels) and adrenal ultrasound if indicated. The phenotype of premature adrenarche varies considerably between populations but may be associated with low birth weight, insulin resistance, adverse cardio-metabolic risk and progression to polycystic ovarian syndrome in some populations. In the majority of cases, no specific treatment is recommended, but where there is a history of low birth weight, with associated insulin resistance, intervention with the insulin sensitising agent metformin may be considered on a case by case basis.

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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Review  Toddler diarrhoea: is it a useful diagnostic label?

Arch Dis Child doi:10.1136/adc.2010.191825

C V E Powell1, H R Jenkins2

1Department of General Paediatrics, The Children's Hospital for Wales, Cardiff, UK

2Department of Child Health, The Children's Hospital for Wales, Cardiff, UK

This is a nice simple review of this common problem with suggested approaches to coming to a more specific diagnosis, plus ongoing advice / management. There is an interesting discussion of the value of the term “Toddler diarrhea”

The article is available at: http://adc.bmj.com/content/early/2011/08/09/adc.2010.191825.abstract

Mike

Abstract

Toddler diarrhoea is a term coined many years ago to describe a young child who passes several loose stools a day but who is otherwise healthy with excellent growth and normal examination. It could be argued that it is not an appropriate diagnostic term as it potentially stops the clinician from thinking about the possible causes of loose stools in this clinical situation. This article, which follows a debate between the authors on the topic at the 2010 Royal College of Paediatrics and Child Health Annual meeting, discusses the differential diagnoses of a young child presenting with the so-called toddler diarrhoea.

Suggested initial investigations

      ▶ Full blood count

      ▶ C reactive protein

      ▶ Erythrocyte sedimentation rate

      ▶ Coeliac disease screen—anti-tissue transglutaminase antibody and total serum IgA

      ▶ Stool culture (including Clostridium difficile and giardia)

Management strategies

      ▶ A 6-week trial of a cow's milk- and egg-free diet with dietetic help

      ▶ Reduce fructose/juice intake

      ▶ Trial of metronidazole

      ▶ Loperamide for symptomatic relief once other diagnoses are excluded

      ▶ Reassurance

      ▶ Follow-up

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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Should children with cerebral palsy and normal imaging undergo testing for inherited metabolic disorders?

Developmental Medicine & Child Neurology Volume 53, Issue 3, March 2011, Pages: 226–232

JANE M LEONARD1 | ALISON L COZENS2 | SUSAN M REID3 | MICHAEL C FAHEY4 | MICHAEL R DITCHFIELD5 |

DINAH S REDDIHOUGH61 Department of Developmental Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia. 2 Department of Metabolic Medicine, Genetic Health Services, Melbourne,Victoria, Australia. 3 Developmental Disability Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia. 4 Department of Clinical Genetics, Genetic Health

Services, Melbourne, Victoria, Australia. 5 Department of Medical Imaging, Royal Children's Hospital, Melbourne, Victoria, Australia. 6 Department of Developmental Medicine,

Royal Children's Hospital, Melbourne, Victoria, Australia.

The aetiology of CP is usually fairly well understood when there is a structural brain problem demonstrated, but what about those with normal imaging.

This local research shows that the yield of routine metabolic testing in children with CP and normal MRI is very low.

While the yield was low even amongst those with atypical features, the sample size for this group was small and I imagine there may be a place for testing in those with unusual progressive features, regression, or non-CNS organ problems, or who present with any acute metabolic derangements.

Should children with cerebral palsy and normal imaging undergo testing for inherited metabolic disorders? – generally “No”

The article is available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2010.03810.x/abstract

Mike

AIM For the 9% to 16% of children with cerebral palsy (CP) who have normal brain imaging,

further testing formetabolic and ⁄ or genetic conditions has been recommended. This study aimed

to identify a cohort of children with CP with normal magnetic resonance imaging (MRI), clinically

review and describe the cases, and assess the value of testing for inheritedmetabolic disorders in

these children.

METHOD Children with congenital CP born from 1999 to 2005 were selected from a population

register. NormalMRI reports were identified and the scans reassessed. Children whose scans were

performed before 18 months were excluded, as were children with spastic CP (Gross Motor Function

Classification System[GMFCS] level I). The remainder were reviewed clinically and offered

investigations.

RESULTS Of 730 children identified, 515 had available imaging and 54 were confirmed as normal.

Cases with non-spastic CP and those withmilder clinical severity were more likely to have normal

imaging. Twenty-three children (17 males, six females; mean age 6y 11mo, SD 1y 10mo, range 3y

0mo to 10y 0mo) were reviewed clinically and offered investigations. Twelve children had spasticity

(11 with diplegia, one quadriplegia), three had dyskinesia, five ataxia, and three hypotonia.

Two children functioned inGMFCS level I, 11 in level II, seven in level III and three in level IV. Four

children with spasticity had unusual features. No alternative diagnoses were made.

INTERPRETATION Although important to consider in individual cases, comprehensive metabolic

testing failed to clarify the aetiology of CP further in this large cohort of children with normal MRIs,

even those with atypical features.

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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Osgood-Schlatter disease -  10-Minute Consultation

BMJ 2011; 343:d4534

1.            Richard Weiler, specialist registrar in sport and exercise medicine; locum general practitioner 1,

2.            Michael Ingram, general practitioner2,

3.            Roger Wolman, consultant in rheumatology and sport and exercise medicine3

1.            1Homerton University Hospital NHS Foundation Trust, Homerton Row, London E9 6SR, UK

2.            2The Red House Group, Radlett, Hertfordshire

3.            3The Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK

An active 14 year old boy, accompanied by his father, presents because of persisting knee pain, which is worse during and after sports.

There is no abstract but this brief article is worth a read if you see kids with knee pain

The article is available at: http://www.bmj.com/content/343/bmj.d4534.extract?etoc

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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Efficacy of Proton-Pump Inhibitors in Children With Gastroesophageal Reflux Disease: A Systematic Review

Pediatrics 2011;127:925–935

Rachel J. van der Pol, MD,a Marije J. Smits, MSc,a Michiel P. van Wijk, MD, PhD,a Taher I. Omari, PhD,b,c Merit M. Tabbers, MD,a and Marc A. Benninga, MD, PhDaDepartment of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital AMC, Amsterdam, Netherlands; bCenter for Pediatric and Adolescent Gastroenterology, Women’s and Children’s Hospital, Children, Youth and Women’s Health Service, North Adelaide, Australia; and cSchool of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia

The article is available at: http://pediatrics.aappublications.org/content/early/2011/04/04/peds.2010-2719.abstract

This systematic review suggests that there is little evidence for efficacy of PPIs in infants and limited evidence of efficacy in older children. I’m not sure that fits uniformly with clinical observation but it should give us pause for thought when reaching for the script pad, particularly given the potential for adverse effects.

Thickening has been shown to be a moderately effective intervention for reflux in babies and should probably be the first intervention (if any is needed)

http://pediatrics.aappublications.org/content/122/6/e1268.abstract

(Fourteen randomized, controlled trials with a parallel or crossover design, some with methodologic limitations, were included. Use of thickened formulas compared with standard formula significantly increased the percentage of infants with no regurgitation, slightly reduced the number of episodes of regurgitation and vomiting per day (assessed jointly or separately), and increased weight gain per day; it had no effect on the reflux index, number of acid gastroesophageal reflux episodes per hour, or number of reflux episodes lasting >5 minutes but significantly reduced the duration of the longest reflux episode of pH < 4. No definitive data showed that one particular thickening agent is more effective than another. No serious adverse effects were noted).

Efficacy of Proton-Pump Inhibitors in Children With Gastroesophageal Reflux Disease: A Systematic Review

INTRODUCTION: Use of proton-pump inhibitors (PPIs) for the treatment of gastroesophageal reflux disease (GERD) in children has increased enormously. However, effectiveness and safety of PPIs for pediatric GERD are under debate.

OBJECTIVES: We performed a systematic review to determine effectiveness and safety of PPIs in children with GERD.

METHODS: We searched PubMed, Embase, and the Cochrane Database of Systematic Reviews for randomized controlled trials and crossover studies investigating efficacy and safety of PPIs in children aged 0 to 18 years with GERD for reduction in GERD symptoms, gastric pH, histologic aberrations, and reported adverse events.

RESULTS: Twelve studies were included with data from children aged 0-17 years. For infants, PPIs were more effective in 1 study (compared with hydrolyzed formula), not effective in 2 studies, and equally effective in 2 studies (compared with placebo) for the reduction of GERD symptoms. For children and adolescents, PPIs were equally effective (compared with alginates, ranitidine, or a different PPI dosage). For gastric acidity, in infants and children PPIs were more effective (compared with placebo, alginates, or ranitidine) in 4 studies. For reducing histologic aberrations, PPIs showed no difference (compared with ranitidine or alginates) in 3 studies. Six studies reported no differences in treatment-related adverse events (compared with placebo or a different PPI dosage).

CONCLUSIONS: PPIs are not effective in reducing GERD symptoms in infants. Placebo-controlled trials in older children are lacking. Although PPIs seem to be well tolerated during short-term use, evidence supporting the safety of PPIs is lacking.

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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A systematic review of medical treatments for children with autism spectrum disorders. 

Pediatrics. 2011 May;127(5):e1312-21. Epub 2011 Apr 4

McPheeters ML, Warren Z, Sathe N, et al. 

This SR examines the evidence for the most commonly used medications in children with autism, in particular

The atypical antipsychotics:

·        risperidone (Risperdal and others) – licensed for use in children in Australia and is on PBS authority
(http://www.pbs.gov.au/medicine/item/8787L-8869T)

·        aripiprazole (Abilify) – not licensed for use in children in Australia and not on PBS for autism
(http://www.pbs.gov.au/medicine/item/8717T) but being used a lot in the USA

The serotonin reuptake inhibitors:

·        Citalopram, Fluoxetine, sertraline, paroxetine, fluvoxamine

Psychostimulants

·        Methyphenidate

Only the first class (atypical antipsychotics) has a reasonable evidence base suggesting benefit for challenging and repetitive behaviors. For the other two classes there are insufficient data to assist in assessing their efficacy.

Both risperidone and aripiprazole  are limited in use by high rates of side effects: especially weight gain, sedation, and extrapyramidal effects

The article is available at:

http://pediatrics.aappublications.org/content/127/5/e1312.abstract

MIKE

CONTEXT: As many as 1 in every 110 children in the United States has an autism spectrum disorder (ASD). Many medical treatments for ASDs have been proposed and studied, but there is currently no consensus regarding which interventions are most effective.

OBJECTIVE: To systematically review evidence regarding medical treatments for children aged 12 years and younger with ASDs.

METHODS: We searched the Medline, PsycInfo, and ERIC (Education Resources Information Center) databases from 2000 to May 2010, regulatory data for approved medications, and reference lists of included articles. Two reviewers independently assessed each study against predetermined inclusion/exclusion criteria. Studies of secretin were not included in this review. Two reviewers independently extracted data regarding participant and intervention characteristics, assessment techniques, and outcomes and assigned overall quality and strength-of-evidence ratings on the basis of predetermined criteria.

RESULTS: Evidence supports the benefit of risperidone and aripiprazole for challenging and repetitive behaviors in children with ASDs. Evidence also supports significant adverse effects of these medications. Insufficient strength of evidence is present to evaluate the benefits or adverse effects for any other medical treatments for ASDs, including serotonin-reuptake inhibitors and stimulant medications.

CONCLUSIONS: Although many children with ASDs are currently treated with medical interventions, strikingly little evidence exists to support benefit for most treatments. Risperidone and aripiprazole have shown benefit for challenging and repetitive behaviors, but associated adverse effects limit their use to patients with severe impairment or risk of injury.

Mike
Prof Mike South,
Royal Children's Hospital, Parkville, Victoria 3052, Australia

www.mikesouth.org.au

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