PEDIATRIC

CHRONICLE
Canadas National Newspaper of Pediatric Medicine pediatric.chronicle.ca Preview Edition Autumn 2014

Super
Lice?

UTIs in children
Canadian
Paediatric Society
urges improved
management

Non-pesticide
therapies available
to treat strain
in Canada
by Halvor

R. Kinskela

for Pediatric Chronicle

Study shows
many North
American lice
infestations are
resistant to
available
pesticide-based
products

Dear Doctor:
We are pleased to introduce you to this
new publication, which we describe,
with a fair bit of pride and only a trace
measure of irony, as the Pediatric Literatures New Kid on the Block.
Metaphors aside, this is a different type of periodical, and emphatically not your fathers (or mothers)
paediatrics journal.
Pediatric chroNicLe was designed not to add to the volumes of data
regularly presented to the practitionerbut rather to aid in the orderly navigation and consideration of useful
clinical information by over-busy proplease turn to page 3

by Emily

Innes

Pediatric Chronicle Assistant Editor

n response to recent studies that have

led to changes in the management of
urinary tract infections (Utis) in children, the canadian Paediatric Society released a position statement and practice
points on Utis in June.
the cPS last released guidelines
and recommendations on the management of Utis in 2004, and the authors
note in this new statement that since then
meta-analytic reviews have investigated
the utility of diagnostic tests, radiological assessment and randomized control
treatment trials published. as well, in
2011 the american academy of Pediatrics revised its clinical practice guidelines for diagnosing and managing
febrile Uti in young children.
the cPS investigators recommend
that Utis should be ruled out in infants from two to 36 months
with a fever higher than 39c
and no other source for
fever on history or physical examination. these
patients should have
urine collected for urinalysis, and if not completely
clear then urine should be
collected by catheter or SPa
to be sent for microscopy
and culture before prescribing antibiotics.
the main challenge
[in diagnosing Utis in
children] is getting a good
urine sample . . . in children who are not yet toilet-trained, said dr. Joan
L. robinson, an albertabased pediatrician, chair
of the cPS infectious
diseases and immuniza-

tion committee, and one of the statement

authors. She said some physicians and
nurses are reluctant to use the recommended method, a catheter, so sometimes the urine is collected by other
means, most commonly by a little plastic
bag that has tape on it that is put over the
genitals. But the problem with that is that
commonly bacteria can end up in that
bag that were not actually in the bladder
. . . So then fairly often a positive result
comes back even if the child does not
have a urinary tract infection.
if a physician is uncomfortable using
catheters with infants, she suggests referring the patient to a pediatric emergency
department, if practical. having the parent
catch a urine sample in a sterile container
when the child urinates is an alternative,
although this can be time-consuming.
Antibiotic resistance
the problem with over diagnosis of
Utis, according to dr. robinson, is the growing concern
of antibiotic resistance.
there have been relatively few new classes
of antibiotics [in the
last decade] and as
time goes by we get
more and more bacteria
that are resistant to the antibiotics that we currently have.
one thing that
we know will work is
that we can markedly
decrease the use of
antibiotics, and cerplease turn to page 12

Childhood
obesity: Some
BMI metrics are
superior
fat-mass proxies
in measuring
change see page 6

More awareness
and support
needed for
pediatric patients
by Emily

Innes

Pediatric Chronicle Assistant Editor

anadian researchers have identified that availability, cost, and

product labelling are major barriers to adherence to a gluten-free (GF)
diet for pediatric patients with celiac
disease, according to their study published in the journal Paediatrics &
Child Health (June/July 2014; 19(6):
305-309).
Parents of patients between the
ages of two to 12 years with biopsy-confirmed celiac disease were surveyed
using a questionnaire to determine factors that affect adherence to a GF diet.
adolescents 13 to 18 years of age responded to the survey themselves. overall adherence was high, the authors
noted, though it was lower for adolescents. through a ranking system of one
(never) to 10 (always) based on how
often the issue
was problematic, the investigators identified the barriers listed above.
the adherence
at
home and at
school
was
quite good, but
where people
struggled was in social activities, in
restaurants [and when] eating out, at parties. certainly at sleepovers and camps
adherence was not as good, said Dr.
Mohsin Rashid (pictured above right), a
pediatric gastroenterologist, and professor in the department of Paediatrics &
Medical education at dalhousie University in halifax, and co-lead investigator
of the study. [a gluten-free diet] is a really big lifestyle change. it can be done,
and many people do really well with
this, but it has its own challenge.

A different threshold
in recent years there has been a trend
toward individuals without celiac disease following a GF diet. this, according to dr. rashid, has pros and cons for
the pediatric patients with celiac disease.
the thing that we need to be very
cautious about is that people with celiac
disease cannot take any gluten at all
their threshold for contamination is very
different, said dr. rashid, a member of
the national Professional advisory
Board of the canadian celiac association.
i think as more people get on GF
diets, for whatever reason, the food industry will respond. they are responding, restaurants are offering gluten-free
please turn to page 12

Image courtesy Walter Siegmund

Welcome to
Pediatric Chronicle

Citalliance | Dreamstime.com

ccording to some canadian specialists, North americans should

not panic about the report published in the journal Entomological Society of America (Mar. 2014; 51(2):450
457) regarding the growing frequency
of knockdown-type resistance allele in
human
head
lice, known as
super
lice.
Non-pesticide
therapies, not
discussed by
the researchers,
are now available and have
high rates of
safety and efficacy.
Dr. John
Kraft (pictured
above
left),
with the Lynde
institute
for
dermatology
in Mark ham,
ont., says that
while the news
that lice are becoming resistant to pest
icide-based treatment products in the
majority of infestations in North
america is concerning, there are
other options.
please turn to page 12

Celiac
disease

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Welcome

continued from page 1

fessionals. Please think of this title as a
type of medical search engine, utilizing the
supremely elegant and convenient delivery
technology known as ink-on-paper.
the launch of a new publication is
often taken as an occasion for the
lengthy declaration of various individuals principles. We will spare you that
pretense, in keeping with our intention
to allocate time judiciously. No declarations, then. Simply this paragraph:
This newspaper aspires to assist in
providing information and insights of
value, and to be worthy of inclusion in
a medical specialists information-gathering regimen. We promise never to
waste a moment of your time, or to undervalue or in any way fail to respect
the vital and essential work you do.
thats all. Please enjoy this Preview
issue, and by all means let us know what
you think. Mitch ShaNNoN, Publisher

Pediatrics

Pediatrics observed

In brief

St. Josephs Childrens

Hospital of tampa, Fla.
introduced mobile
telemedicine carts to connect with a specialized
remote team at childrens
hospital of Pittsburgh, to
assist in providing cardiac care to pediatric icU
patients.

Images from the world of Pediatric Medicine: We invite you to submit your photographs for publication in this regular department of Pediatric chroNicLe. Send
original high-resolution (2 megapixel and higher) JPGs to: health@chronicle.org

Pediatric mask developed using 3D camera technology

University of alberta pediatric pulmonologist has used 3d

technology to develop an inhalation mask that properly fits
pediatric patients.
Dr. Israel Amirav (left), a faculty member in the department of Pediatrics at the
University of alberta in edmonton and in
Northern israel, recognized that the inhalation masks his pediatric patients were wearing were only scaled down versions of ones
for adults and did not seal properly. this allowed medicine to dissipate in the air rather
than be properly administered to the child.
dr. amirav discovered that the only
childrens mask using childrens measurements is based on an airplane oxygen mask developed over 60
years ago. it was created using measurements from only 30 to
40 children.
i decided to measure infants faces and heard about the
3d camera technology the computer science department created
at technion israel institue of technology, said dr. amirav.
Using the camera, he took 3d images of the faces of about
300 children between the ages of zero and four. the photo-

graphs were then archived and analysed. the data was grouped
into three different sizes: small, medium, and large. Using a
mathematical process, each childs photo of each cluster size
was averaged, producing the
three average sizes. these sizes
were transferred to the design of
the mask.
dr. amirav also included a
hole in the mask so a pacifier
could fit to help soothe the
child in between taking the
medicine.
according to dr. amirav, it
used to be challenging to get a
patient to use ventilators because
of the poor fit, but his inhaler has
increased patient compliance. We can now give the mask to the
mother to use on the child. they come back to us and say, My
child takes the medication and sleeps well now, doesnt cough,
and is developing well.
the masks have Fda approval and are awaiting canadian
approval.

Pediatric

CHRONICLE
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Skin &Allergy
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canadian and irish researchers have

discovered that childrens television
programs in the U.K. and
ireland have a high level
of unhealthy food cues
such as an overrepresentation of sweet snacks and
candy being associated
with celebrations
and being hungry,
according to findings
published in the
journal Archives of
Disease in Childhood (June 30, 2014).
More at http://ow.ly/zuVIm
emergency departments in alberta are
rarely using policies and protocols to
manage pediatric pain. in
a study, published in
Paediatrics & Child
Health (apr. 2014;
19(4):190194), researchers urged canadian pediatricians to advocate for improved
analgesia to narrow the knowledge-topractice gap.
More at http://ow.ly/zuUf2
case reports of allergic contact dermatitis (adc) in pediatric patients
have risen rapidly since
2000 in many different
countries. Metal allergens
in both cheap and expensive cell phones, notably
nickel and chromium, are frequently
reported as a trigger for the acd, report authors in a study published in the
journal Pediatric Allergy, Immunology,
and Pulmonology (June 2014;
27(2):6069).
More at http://ow.ly/zuXeo

Publisher
Editorial Director
Senior Associate Editor
Assistant Editor
Assistant Editor
Advertising & Partnerships
Production & Circulation
Comptroller

Mitchell Shannon
R. Allan Ryan
Lynn Bradshaw
John Evans
Emily Innes
Sandi Leckie, RN
Cathy Dusome
Rose Arciero

n A NOTE TO OUR READERS: The Chronicle is proud to be the

first Canadian publisher to provide its national medical publications printed on 50 per cent post-consumer recycled paper,
which is the highest percentage of recycled stock currently
commercially available.
Pediatric Chronicle is committed to maintaining leadership in environmentally sustainable policies, and to encouraging the adoption of green-aware practices in healthcare.
We invite your comments via e-mail, at:health@chronicle.org

Contacting Pediatric Chronicle

QUOTED & NOTED

Anita Peppers | Morguele

For kids that are maltreated, you can think of it as

daily stress, such as being told no or peer social
interactions that they cannot regulate. they slip
more easily into emotional dysregulation, for
example a fight or flight response,

Dr. Benjamin Klein of Hamilton, Ont. (see page 10)

Autumn 2014

n READER SERVICE: to change your address, or for questions about your receipt of the journal, send an e-mail
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Please contact Mitchell Shannon for reprint information.

PEDIATRIC CHRONICLE 3

Pain under-treated in pediatric patients

Parents may be averse to
the idea of administering pain
medication to their children
by Louise

Gagnon for Pediatric Chronicle

ain is typically under-treated in pediatric patients, and healthcare professionals should educate parents about steps that they can take to
reduce their childrens experience with pain on an outpatient basis, according to a presentation at the inaugural Pediatric Wound care
Symposium in toronto, organized
through the hospital for Sick
children.
Provide them with written
and verbal advice and point them
in the direction of reputable web
sites and video clips, says Dr.
Fiona Campbell (left), an anesthesiologist and co-director of the
Pain centre at the hospital for
Sick children and associate professor at the University
of toronto.

PAIN

MANAGEMENT
in her presentation, dr. campbell stressed that parents need re-assurance about providing pain control to
their children. they need to know its okay [to intervene to reduce their childrens pain], she said.
Few analgesics administered
one study involving 132 parents of children aged two
to 12 years of age found that despite identifying pain in
their children who had undergone surgery, parents administered few doses of analgesics to them in the first
48 hours following hospital discharge.
the researchers identified attitudes to pain management that correlated with parents administration of
fewer doses of analgesia, noting more than half of parents reported they thought analgesics were addictive
(Pediatrics 2010; 125(6): e13721378).

Nutraceuticals prophylaxis of pediatric migraine?

Parents are interested in administering them to their children,
therefore side effects, efficacy should be better understood
by Emily

Innes for Pediatric Chronicle

Certain nutraceutical agents are showing promising results in the prophylaxis of migraine in pediatric patients,
though the quality of evidence for their use is still poor, according to a study published online in the journal Cephalalgia (Jan. 17, 2014).
Ottawa researchers reviewed the literature regarding six different nutraceuticals used
for treating pediatric patientsincluding butterbur, riboavin, ginkgolide B, magnesium,
coenzyme Q10 and polyunsaturated fatty acids.
The main impetus [for the study] really was the interest that I was getting from patients
and their families, said Dr. Serena L. Orr (pictured left), a neurology resident at The Childrens Hospital of Eastern Ontario (CHEO) in Ottawa and the studys lead author. Either they
have heard about it in the media or they have been doing their own reading because they
have an interest in it.
I nd that some families prefer to try to start with a nutraceutical agent, if possible,
prior to prescribing something pharmaceutical. A lot of families feel more comfortable with
that, especially if their child has never been on medication before.
Dr. Orr said there is limited research on the subject in adults and even less for pediatric patients, which she
added is a common trend across the board.
Magnesium, coenzyme q10, and butterbur have demonstrated efficacy and low side effect profile
She said that despite the lack of research, she sometimes recommends patients try magnesium, coenzyme Q10 and petadolexa formulation of butterbur root (pictured right)based
on the preliminary evidence of efcacy and the low side effect prole.
Pretty much with every new migraine patient I mention these as options and I talk
about the limitations of the literature, but I also mention that at least those three particular
agents seem to be safe based on the preliminary studies, she said.
Promising randomized control trials regarding petadolex for adult migraineurs have led
both the Canadian Society Headache and the American Academy of Neurology to strongly
recommend its use, said Dr. Orr.
The signicance of Dr. Orrs study is recognizing an area that needs to be better studied
and understood. She said she hopes her paper acts as an anchor for where researchers
might go next with this topic.
I think it is really important to do more research because the reality is that there is a
public perception that nutraceuticals are safe because they are natural, said Dr. Orr. [But]
nutraceuticals have side effects as well.
Some studies have shown that some formulations of butterbur, other than petadolex, can contain high levels of
pyrrolizidine alkaloids, which can cause liver failure. Dr. Orr said this is not the case with petadolex because it is
strictly regulated.
Other nutraceuticals have been found to have minimal side effects, according to Dr. Orr. The most frequent side
effect of coenzyme Q10, for example, is increased burping.
It is true that some are [safer] but not all [are] and I think we owe it to our patients to establish what is safe and
what is not and what works and what does not.
An area where Dr. Orr said she would like to see more research is for agents where the levels in patients can be
measured, such as magnesium or coenzyme Q10. It would be worthwhile to determine if the nutraceuticals are only
effective for those patients who are decient or if they help non-decient patients as well.
She added that more randomized controlled trials should be conducted in pediatric patients for the nutraceuticals that have shown promise in adults.
Read more information at http://ow.ly/vOidl

4 PEDIATRIC CHRONICLE

an acknowledgment by parents that their children

are having pain is not sufficient, and they should be
provided with instructions regarding measures they can
implement to provide pain relief, explained dr. campbell.
healthcare facilities should have pain assessment
policies in place, so that validated tools can be used to
assess the prevalence and degree of pain, stressed dr.
campbell.
Pain under-recognized
everyone needs to have a policy around assessing pain
and treating pain to raise the awareness [about pain],
said dr. campbell, noting pain is the fifth vital sign. if
you do not know how much pain [a patient has], how do
you treat it?
Pain is typically under-recognized and undertreated in patients in hospital and that phenomenon applies in the pediatric setting, said dr. campbell, noting
one study found that adolescents reported that pain was
the worst aspect of hospitalization (MCN: The American
Journal of Maternal/Child Nursing Sep-oct 2006;
31(5):290295).
children typically receive less medication than
what is prescribed to them, regardless of how severe
their pain is, and they also receive less analgesia than
adults, noted dr. campbell.
Several reasons may explain why pain is undertreated in children, including the lack of a diagnostic test
for pain and the lack of education that health professionals such as nurses and physicians receive with respect
to pain management, said dr. campbell.
assessing pain in children consists of three spheres
including self-reports such as the Faces scales, Numeric
rating Scale or Visual analog Scale, physiological reactions from a child, and behavioural observations such
as the Face, Legs, activity, cry, consolability (FLacc)
scale, used to measure pain in children between two
months and seven years of age or in children who are
cognitively impaired and are not able to communicate
their pain.
Pain management can include physical strategies
such as providing ice or heat and massage to patients.
it can also include psychological strategies such as
using distraction or cognitive behavioural therapy,
and pain management can also include pharmacological strategies, such as providing prescription therapies.
Tailor meds to patient
the perfect analgesic does not exist, said dr. campbell. optimal use of analgesia involves following the
World health organization recommendations and
using more than one class of analgesic or adjuvant,
with each therapy working in a different way to
achieve improved pain relief and decrease adverse
events.
initial therapies should include simple analgesia
such as acetaminophen and NSaids, said dr. campbell.
as pain increases, clinicians can add in opioids; lower
doses for moderate pain and higher doses for more severe cases of pain that prove refractory to milder treatments. accurate weight-based dosing is required for
safety, she added.
opioids rarely cause addiction when used appropriately for pain relief, she said, and can be used under
medial guidance for children of any age.
Pain management related to procedures should be
tailored to patients. For example, in infants less than 18
months of age, 24% sucrose administered on the tip of
the tongue two minutes prior to a procedure can make
the pain related to a procedure more tolerable, said dr.
campbell. topical local anesthetics should be used for
all skin breaking procedures.
it would be advisable for clinicians to keep in
mind several goals in procedural pain management
such as performing the procedure (whether it is required, and making sure it is done properly), ensuring
patient safety, preventing or minimizing discomfort,
and, if sedation is used, returning patients to a state
such that they can be discharged, added dr. campbell.

PREVIEW EDITION

Atopic dermatitis and skin barrier dysfunction

Clinical experience with the use

of skin care containing colloidal
oatmeal and ceramides

Colloidal oatmeal-containing
skin care reduces inflammation and itch in

Catherine McCuaig,
MD, FRCPC

PEDIATRIC PATIENTS
WITH ATOPIC DERMATITIS

About 90% of Atopic Dermatitis (AD) cases present before

five years of age, with an estimated prevalence of 17.2% in children
aged five to nine years.1 The cause of AD involves both genetic and
environmental factors.2 Skin barrier dysfunction in AD is evidenced
by increased transepidermal water loss, skin penetration of irritants
and allergens, leading to cytokine release, dermal inflammation and
itching. In children, itching often leads to scratching, enhancing the
risk for secondary infection.
Use of colloidal oatmeal-containing skin care to restore skin
barrier function Avena sativa extracts are well known for their
repairing and soothing properties; the compounds have the
potential to help reduce inflammation and irritation, as well as
promote skin barrier repair 6 (Table 1). In a randomized, controlled
study, Grimalt, et al. (2007) evaluated the effect of an oat-containing
moisturizer (Aveeno (Johnson & Johnson Inc.)) on the amount of
topical corticosteroids used in infants with moderate to severe AD.7
In the six-week study, 173 infants under 12 months old were
treated for inflammatory AD lesions by moderate- and/or
high-potency topical corticosteroids. Only the study group was
additionally treated with an oat-containing moisturizer.7
Corticosteroid consumption was evaluated by weighing the tubes.
Disease severity was assessed by the Scoring Atopic Dermatitis
Index (SCORAD), and quality of life (Infant's Dermatitis Quality of Life
Index and Dermatitis Family Impact scores), was scored at
baseline, week 21 and week 42.7 In the study group, the amount
of corticosteroids used in six weeks decreased by 7.5% and
42% (p<0.05), respectively.7 The SCORAD index and quality of life
scores indicated a significant improvement (p<0.0001) in both
groups.7 The colloidal oatmeal-containing moisturizer also contains
avenanthramides, which were shown to have multifaceted,
anti-inflammatory activity that includes inhibition of nuclear factor
(NF)-KB activation in keratinocytes and reduction of both the
skin immune response and the skin neurogenic inflammatory
response6 (Fig. 1).
Moisturizers that soothe pruritus, hydrate, protect and restore
the skin barrier are essential for the effective management of AD.3-5
Several pediatric atopic dermatitis consensus reports recommend
these moisturizers as first-line agents in the treatment of AD.3-5
Daily moisturizers are also used as complementary to prescription
medications for enhancement of treatment efficacy and for their
steroid-sparing effect.3-5

Table 1: Colloidal oatmeal compounds and their function [6,8]

Ingredient

Function

Protein (10%-18%)

Acts as an emulsifier, promotes hydration

and promotes antioxidant activity

Polysaccharides (60%-64%)

-glucan appears to have immunodulatory activity,

which could represent a modulating effect
on inflammation

Lipids (3%-9%)

Contribute to viscosity to reduce the rate of TEWL

Antioxidant enzymes, saponins, vitamins,

flavonoids, and prostaglandin synthesis
inhibitors (7%-9%)

All have anti-inflammatory properties

Fig 1: In Vitro Effects of an Oatmeal-Based, Avenanthramide-Containing

Moisturizer [6]
100
90
% average improvement

Case presented by

80
70
60
50
40
30

Week 1
Week 2
Week 4

20
10
0
roughness

overall
dryness

cracking

scaling

itch

Conclusions
Colloidal oatmeal is proven to be well-suited for treating
inflammatory skin conditions, including atopic dermatitis.
This natural ingredient moisturizes, helps protect the skin barrier,
and has demonstrated anti-inflammatory and anti-pruritic activity.
Additionally, colloidal oatmeal has been shown to restore skin
barrier function and has a central role in the evolution
and progression of atopic dermatitis.

References
/HUPU149LLK43(WVW\SH[PVUIHZLKZ\Y]L`VMLJaLTHWYL]HSLUJLPU[OL<UP[LK:[H[LZDermatitis1\U"! 
*VYR419VIPUZVU+(=HZPSVWV\SVZ@L[HS!5L^WLYZWLJ[P]LZVULWPKLYTHSIHYYPLYK`ZM\UJ[PVUPUH[VWPJKLYTH[P[PZ!.LULLU]PYVUTLU[PU[LYHJ[PVUZJ Allergy Clin Immunol"!
9\ILS+;OPY\TVVY[O`;:VLIHY`V9>>LUN:*.HIYPLS;4=PSSHM\LY[L33*O\*@+OHY:7HYPRO+>VUN3*3V22!*VUZLUZ\ZN\PKLSPULZMVY[OLTHUHNLTLU[VMH[VWPJKLYTH[P[PZ!HU(ZPH7HJPJWLYZWLJ[P]L
J Dermatol4HY"!
-V^SLY1-5LI\Z1>HSSV>,PJOLULSK3-!*VSSVPKHSVH[TLHSMVYT\SH[PVUZHZHKQ\UJ[[YLH[TLU[ZPUH[VWPJKLYTH[P[PZJ Drugs Dermatol"!
5LI\Z15`Z[YHUK.-V^SLY1>HSSV>!(KHPS`VH[IHZLKZRPUJHYLYLNPTLMVYH[VWPJZRPUJ Am Dermatol "!()
>HSSV>5LI\Z15`Z[YHUK.!(NLU[Z^P[OHKQ\UJ[P]LWV[LU[PHSPUH[VWPJKLYTH[P[PZJ Am Acad Dermatol "Z\WWS!()(IZ[YHJ[7-`OYX\PZ[=HUUP5(SLUP\Z/3H\LYTH(!*VU[HJ[KLYTH[P[PZDermatol Clin"!
.YPTHS[94LUNLH\K=*HTIHaHYK-!;OLZ[LYVPKZWHYPUNLMMLJ[VMHULTVSSPLU[[OLYHW`PUPUMHU[Z^P[OH[VWPJKLYTH[P[PZ!HYHUKVTPaLKJVU[YVSSLKZ[\K`Dermatology"!
*OLU*@4PSI\Y`7,*VSSPUZ->)S\TILYN1)!(]LUHU[OYHTPKLZHYLIPVH]HPSHISLHUKOH]LHU[PV_PKHU[HJ[P]P[`PUO\THUZHM[LYHJ\[LJVUZ\TW[PVUVMHULUYPJOLKTP_[\YLMYVTVH[ZJ Nutr"!
MMXIV, Chronicle Information Resources Ltd. Editorial feature supported by an unrestricted grant from Johnson & Johnson, which is not responsible for content.

BMI metrics: Some are superior fat-mas

occupational health in Montreal.
as part of a study published online in Archives of Disease in Childhood
(May 19, 2014), dr. Kakinami and her colleagues looked at data from the

Childrens physical activity: Canada

attains poor score in annual report

Walter Siegmund

by John Evans
Assistant Editor, Pediatric Chronicle

FITNESS

& Weight
MANAGEMENT
oth absolute and per cent change in Body Mass index (BMi) appear
to be good proxies for change in fat mass (FM) or fat mass index
(FMi) in eight- to 10-year old children, while BMi z-score is a good
proxy for FM z-score change in the same age group. this finding may
help support research into how childhood obesity progresses as the child grows
up.
While dual-energy X-ray absorptiometry is the gold standard for measuring adiposity, BMi is typically used as a proxy in clinical settings. Yet BMi is
age dependent, so identifying the adiposity proxy measure that best maps onto
change in actual fat mass in children would be a great benefit for tracking the
health of children at risk of obesity as adults, says dr. Lisa Kakinami, a researcher at McGill Universitys department of epidemiology, Biostatistics and

Active Healthy Kids Canada has released its 2014 report card, the 10th anniversary
edition, and Canada has received a D- for overall physical activity. Other countries
with the same score as Canada were Australia, Ireland, and the United States, while
only Scotland fell below them with an F. At the top of the chart were Mozambique and
New Zealand, each with a B.
The authors of the report noted that while Canada ranked well for sophisticated
policies, places for activities, and programs, only 4% of children between the ages of
12 and 17 years met the guidelines for physical activity of 60 minutes of moderate- to
vigorous-intensity.
The researchers commented that it is
encouraging
that 84% of children between the
ages of three and
four years met the
guidelines suggested for their
age group180
minutes of activity
at any intensity.
However, only 7%
of children between the ages of
ve and 11 years
met the 60-minute guideline.
It seems that we have built it, but they are not coming, the investigators stated.
Why are our kids sitting more and moving less? The answer requires a hard look at
our culture of convenience. For most Canadians, the socially acceptable walking distance to school is less than 1.6 km, and distance between home and school is the single most reported reason why kids do not walk or bike to get there. In Finland,
however, 74 per cent of children who live between one and three km from school use
active transport, and nearly all children living one km or less from their school commute actively. Finland is a world leader with a B in Active Transportation, in part because its social norms differ dramatically.
In the Organized Sport Participation category, Canada gets a C+, an incomplete
for Active Play, a D in Active Transportation, a grade of C in the categories of Family &
Peers and Government Strategies & Investments, and a C+ for School. Canada is in
second place with a B+ in Community & The Build Environment, and is failing in the
category of Sedentary Behaviours, with 61% of parents believing their children spend
too much time watching television.
To increase daily physical activity levels for all kids, we must encourage the accumulation of physical activity throughout a childs day, and consider a mix of opportunities(e.g., sport, active play, active transportation). In some cases, we may need to
step back and do less. Developed societies such as Canada must acknowledge
thatchildren need room to move, suggest the authors.
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ass proxies in measuring childhood adiposity change

Qubec adipose and Lifestyle investigation in Youth cohorta prospective cohort of 557 children from Qubec who were between ages eight and
10 when recruited. height and weight of the cohort children had been
recorded once in 2008, and on follow-up in 2010. the researchers compared several metrics of BMi change to fat levels measured through dualenergy X-ray absorptiometry. Metrics included raw change in BMi,
adjusted for median BMi, and age-sex-adjusted using the centers for disease control and Preventions growth curves, expressed as either centiles
or z-scores.
in children when we measure BMi, we cant just take their height and
weight like we would in an adult, says dr. Kakinami. We have to use a reference curve for children of same age and same sex, in terms of their height
and weight. as we know, children are growing. a BMi of 12 in a child might
not indicate they are underweight. it might indicate something else when you
take into account their age and their sex.
the first major finding of the study, says dr. Kakinami, is that the BMi
centile from the growth curves that doctors normally use do not map very well
to direct fat measures when looking at change over time.
even though the BMi centile is developed and is really well validated
and is a better measure than a lot of other body composition measures for
children at one point in time, our study found that it is really not necessarily the best way to measure changes is [childrens] adipose tissue, she
says.
there is some controversy in the literature over what the best way to measure fat mass in children is, says dr. Kakinami, with different researchers looking at fat mass, fat mass as a percentage of the childs total weight, or adjusting
the fat mass for the height of the child.
We found that just changes in [childrens] raw BMi, or changes in their

BMi percentage, mapped on best with changes in the raw value of fat mass,
says dr. Kakinami. and in terms of looking at changes of adiposity over
time, the FMi doesnt map very well with any of the BMi measures, she
says.
changes in BMi centile only modestly correlated with changes in raw
fat mass, percentage fat mass, and the height-adjusted fat mass index, so
dr. Kakinami and her team do not recommend it for longitudinal tracking.
dr. Kakinami says she would like to redo the study with a larger sample
over a wider age range to see whether or not this finding of the BMi centile
not mapping well onto dual-energy X-ray absorptiometry holds up.
i think that could be an important lesson for family practitioners as well
as families, in terms of knowing if their BMi percentile is changing, she
says.
We found this to be the case especially in very obese children, says dr.
Kakinami. BMi percentile only goes from zero to 100%, so for an individual
who is already very obese, their BMi percentile is not going to change as much.
in that instance it is probably better to use a BMi z-score, which is not
bounded by zero and 100, and could be a better indicator of how much of a
difference you have in your BMi over time.
it would be nice to identify the fat mass measurement that we want to be
using with [dual-energy X-ray absorptiometry]. i think that it is fairly ambiguous right now as to which measurement is best to map onto adiposity, says
dr. Kakinami.
and for that, we really need to measure adiposity in children in terms of
their [dual-energy X-ray absorptiometry] values, and then see which ones have
what types of health outcomes as adults, for example. thats really the only
way you can best assess it.

Pediatric weight management: Canadian registry in progress

As a result of a three-fold increase of overweight and
obese children in Canada over the last decade, the
CANadian Pediatric Weight management Registry (CANPWR)is in the process of being developed, according to a
study protocol published in the journal BMC Pediatrics
(July 24, 2014; 14:161).
According to the study authors the three goals of
the CANPWR are to document changes in anthropometric, lifestyle, behavioural, and obesity-related comorbidities in children enrolled in Canadian pediatric
weight management programs over a three-year period; characterize the individual-, family-, and program-level determinants of change in anthropometric
and obesity-related co-morbidities; and to examine
the individual-, family-, and program-level determinants of program attrition.
A pilot study was completed at ve centres and the
researchers stated it aided them in determining the core
data set of outcomes and measurement protocols, a
harmonized data collection method, and the case report
forms.

The 1,600 participants must be between the ages of

two and 17 years with a body mass index (BMI) of
greater than the 85th percentile. The study will be run at
eight different weight management centres afliated with
childrens hospitals across the countryincluding McMasters Children Hospital in Hamilton, Ont., BC Childrens Hospital in Vancouver, Stollery Childrens Hospital
in Edmonton, The Hospital for Sick Children in Toronto,
North York General Hospital in Toronto, Childrens Hospital
of Eastern Ontario in Ottawa, Montreals Childrens Hospital, and CHU Sainte Justine in Montreal.
The study will take place over a three-year period,
and the researchers will collect data at presentation and
at six-, 12-, 24-, and 36-month follow-up. The primary
study outcomes will be the BMI z-scores and their
changes over time. The secondary outcomes will include
anthropometric, cardiometabolic, lifestyle such as dietary
and exercise, and psychosocial variables.
The authors noted that they were inuenced by The
Canadian Clinical Practice Guidelines for the Management and Prevention of Obesity, which highlighted the

mismatch between the high prevalence and signicance of pediatric obesity and the limited knowledge
base from which to inform treatment strategies.
The investigators state that they believe the CANPWR will contribute by being the rst harmonized, evidence-based registry and platform that identies the key
determinants of weight change in eight pediatric weight
management centres across Canada.
The registry will contain detailed information regarding individual-,family-, and program-level determinants of change in health outcomes and behaviours. It
will make it possible to compare these determinants of
change in a large, diverse population of children and
their families throughout Canada. The outcomes of this
study are expected to contribute important information
on the suitability of change in weight status and obesityrelated co-morbidities.
CANPWR could also be helpful in determining subgroups of children who do not respond well to treatment
paradigms, the authors noted.
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Wound care principles of bacteria

especially important in pediatric cases
Wound swab rarely
sufficient to diagnose
serious infection
by Louise

Gagnon for Pediatric Chronicle

actors such as the host defenses,

the number of bacteria, and the
virulence of bacteria are important considerations in determining the
threat of wound infection, according to
an associate professor in the department of Pediatrics at the University of
toronto.
any time you
are dealing with a
wound, you have to
think about the vascular supply, the
host defence mechanisms, and aggressiveness of the
bacteria present,
said Dr. Elena Pope
(pictured,
left)
head, Section of dermatology, division of Pediatric Medicine, the hospital for Sick children in toronto,
discussing infection in wounds at the
inaugural Pediatric Wound Symposium
organized through the hospital for Sick
children.

Burns and injuries most common

the number of bacteria matters. a small
number contaminate each wound, but
rarely interfere with wound healing,
said dr. Pope. if the wound persists,

bacteria multiply and the wound becomes colonized. at some point the balance between host defenses and the
bacteria is tipped toward the latter, leading to true infection.
Pediatric wounds have various etiologies, with burns and injuries being the
most common.
While its probably true that children heal faster than adults, wound care
is a concern in the pediatric setting. one
study found 17% of home healthcare visits for children often involve care for
wounds (Ostomy Wound Management
2000; 46(4):3642). in addition, visits of
pediatric patients with open wounds are
not uncommon in emergency room departments.
the diagnosis of wound infection is
a clinical one, stressed dr. Pope.
When an acute wound is infected,
it appears red, swollen, and hot, she
said. if you suspect infection, you have
to treat it.

Clinical clues to watch for

For chronic wounds (lasting more than
six weeks) other clinical clues that suggest infection are used, such as deterioration of the wound, the presence of
exudate, increased size, friable tissue, increased pain, foul odor, discolouration,
and a failure to respond to therapy.
chronic wounds can become stuck,
she said.
the gold standard for diagnosing a
wound infection is a culture from a skin
biopsy; a wound swab is rarely sufficient
as it may recognize only colonization
and contamination, said dr. Pope.
When performing a swab, the

WOUND
TREATMENT

wound should be cleaned and debrided.

dr. Pope added that a wound can look
clean but colonization could be taking
place.
When taking a swab, it should be
placed on granulation tissue, pressed
lightly, and rotated 360 degrees, explained dr. Pope. avoid debris and frank
pus when performing the swab, and if the
swab is dry, its best to moisten it in
transport media first.
identification and correction of local
and systemic factors needs to precede effective wound management in pediatric
patients similarly to adult patients, said
dr. Pope.
Systemic factors such as diabetes
are typically not a challenge to face in
pediatric wound care, but pediatric patients can experience conditions such as
vasculitis or pyoderma gangrenosum, dr.
Pope said. Patients should have adequate
levels of hemoglobin and good nutritional status to ensure proper wound
healing. aspects like immunodeficiency
and immunosuppression can influence
how wounds heal in patients. these are
features that emerge in pediatric oncology in particular.
When critical colonization is present, topical antimicrobials and various
dressings should be applied. When infection is present, systemic antibiotics
should be initiated, taking into consider-

ation concerns like antibiotic resistance,

said dr. Pope.
in canada, we do not have to
worry as much about MrSa [methicillin-resistant Staphyloccus aureus],
but there is a lot of resistance to
MrSa in the U.S., said dr. Pope,
stressing clinicians have to be judicious in their selection of therapeutic
antibiotics.
Treatment recommendations
a panel of the infectious diseases Society of america (idSa) released
guidelines on treating patients with
MrSa infection in 2011. For minor infections, topical mupirocin 2% is suggested as therapy. For management of
major MrSa infections in the pediatric
setting, vancomycin is the first-line
choice followed by clindamycin and
linezolid as second-line choices. the
guidelines provide information on vancomycin dosing and monitoring (Clinical Infectious Diseases 2011; 52(3):
e811).
empirical therapy for communityassociated MrSa infection in skin and
soft tissue infections is suggested pending results of culture, according to the
idSa guidelines.
Patients can experience treatment
failure with vancomycin, with wounds
remaining infected because of strains
with decreased susceptibility to vancomycin.
dr. Pope cautioned that clinicians
should avoid using the same preparation
topically and systemically when managing infection in wounds, to prevent potential sensitizers.

Burns often the cause of pediatric wounds

Steps can be taken to reduce
incidence of potential hypertrophic scarring, skin stripping
any of the wounds in the pediatric population are
the result of burns, according to a professor of
Public Health Sciences and
Medicine at the University of Toronto.
Speaking at the inaugural Pediatric Wound Care Symposium organized by Torontos Hospital for Sick
Children, Dr. Gary Sibbald (pictured
right) noted that 70% of burn scars
occur in the pediatric population.
One of the concerns in wound
healing is insufcient oxygen and insufcient blood supply, said Dr. Sibbald.
There can be inadequate phagocytosis, and the
wound can end up being in the inammatory stage for
some time, said Dr. Sibbald. There can be poor quality
collagen which leads to skin breakdown and poor epithelialization.

Stuck in inflammatory stage

Indeed, chronic wounds can stall and fail to heal, and they
can then become classied as non-healable wounds,
noted Dr. Sibbald. He is director of the Wound Healing
Clinic at Womens College Hospital in Toronto, and a former president of the World Union of Wound Healing Societies.
Chronic wounds often get stuck in the inammatory stage, said Dr. Sibbald. That can go on for days and

8 PEDIATRIC CHRONICLE

even into months. They do not advance to the proliferative

stage, scar formation, and scar remodelling.
One of the factors that is critical to wound healing is
effective wound bed preparation, stressed Dr. Sibbald.
Even with advanced therapies, wound bed preparation
needs to be correct, he said. That is the most important
part of the equation.
Part of effective wound bed preparation is identifying
the cause of the wound and determining if systemic factors are interfering with healing or if healthcare system
factors are preventing healing, explained Dr. Sibbald
(Canadian Association of Wound Care (CAWC) Institute for
Wound Management and Prevention. Level 1 workbook:
putting knowledge into practice: knowledge learning.
Toronto: Canadian Association of Wound Care, 2010).
The choice of a dressing is signicant in inuencing
the outcome in wound healing. Wound surfaces, for example, can decrease with the use of silver dressings, noted
Dr. Sibbald.
Thermometry to ID infection
Given the prevalence of burns in the pediatric population,
it is important to avoid burn sepsis. One study that looked
at a silver dressing to treat burn wounds found burn
wound sepsis was reduced in wounds treated with a novel
silver-coated dressing. Secondary bacteremias were also
less frequent with the use of the novel dressing (Journal
of Burn Care Rehabilitation 1998; 19(6): 531537).
Identifying infection is valuable in achieving successful wound healing, and one of the avenues to detecting infection is the use of temperature, said Dr. Sibbald. An
increase in temperature can signal a wound infection, so
using thermometry may be useful for clinicians. Not
many of you use infrared thermometry in your ofce, said
Dr. Sibbald.

Referring to a study where temperature emerged as

the most important factor in determining deep infection in
wounds, Dr. Sibbald stressed that the presence of infection guides the selection of a dressing.
Antimicrobial dressings do not treat infection, Dr.
Sibbald said. They treat critical colonization.
A paper published in 2013 cited three mechanisms
that are signicant in wound healing in pediatrics: oxygen
tension-regulating angiogenesis and revascularization,
transforming growth factor-beta kinetics controlling collagen deposition, and mechanical stretch stimulating cellular mitosis and extracellular matrix remodelling (Pediatric
Research 2013; 73(4 Pt 2):553563).
Mechanical stretch is a new focus in wound healing,
and there are numerous studies examining the impact of
mechanical stretch as a means of reducing scarring in
wound healing, according to Dr. Sibbald. Some data are
indicating that the release of mechanical stress in the
wound can reduce the inammatory phase of healing and
decrease scarring.
Avoidance of scarring key
Dr. Sibbald differentiated between pre-natal skin and
post-natal skin, noting that pre-natal skin heals such that
the skin can be restored to how it was prior to an injury,
but that isnt the case with post-natal skin: the protective
barrier function can be restored but a scar is left behind,
with different characteristics than the native tissue.
One of the particular goals in pediatric wound healing
is to avoid the development of hypertrophic scarring,
noted Dr. Sibbald.
Another consideration in wound healing in children is
the use of tape and products that can strip the skin.
Where possible, these types of products should be
avoided, said Dr. Sibbald.

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ADHD: Portions of the basal ganglia shrink in affected children

Ventral striatum generally expand with age, but the opposite was found for ADHD youth

ADHD
research
by John

Evans

longitudinal brain-imaging study

of
children
with attention
deficit hyperactivity
disorder (adhd)
has found that regions of the ventral
striatal surfaces of
the basal ganglia, associated with reward
processing, shrink
progressively in surface area.
the basal ganglia, particularly in
the caudate and the ventral striatum, have
been very strongly linked with adhd,
says Dr. Philip Shaw (pictured above
right), the studys lead author and the
head of the Neurobehavioral clinical research Section of the National human
Genome research institute in Bethesda,
Md. Not only does it make sense that regions of the brain involved in control of
action and attention would be different in
brains with adhd on a theoretical level,
he says, but a past meta-analysis of
adhd imaging studies identified the
right and basal ganglia areas as the most
consistently affected.
Yet dr. Shaw says all prior studies
have been cross-sectional. While exPediatric Chronicle Assistant Editor

tremely helpful, cross-sectional data

cant tell the whole story in this condition
because adhd is inherently developmental. the best way to capture such a
moving target is to use longitudinal
data, he says.
dr. Shaw and his team enrolled 270
youths with diagnostic and Statistical
Manual of Mental health-iV-defined
adhd as well as 270 age- and sexmatched typically developing controls to
undergo neuroanatomic magnetic resonance imaging in order to define the surface morphology of their basal ganglia.
of those, 220 were scanned at least
twice. in all, the team mapped developmental changes from age four through 19
years at roughly 7,500 surface vertices in
the striatum and globus pallidus. the
method they used to define the surfaces
being studied was developed by canadian colleagues, Mallar chakravarty and
his group at the research imaging centre
at the centre for addiction and Mental
health in toronto, says dr. Shaw. his
group developed this very nice method
for mapping the surfaces of these deep
structures in the brain.

dren with adhd it contracted.

it did the direct opposite, and it was
really a very marked effect indeed, says
dr. Shaw, noting that cross-sectional data
would not have been able to reveal this
behaviour. the typically developing
group had an estimated rate of increase
of 0.54 mm2 per year, while the adhd
group showed a decrease of 1.75 mm2
per year.
the findings of
dr. Shaw and his colleagues are exciting
and interesting, and
replicate some other
findings, says Dr.
Isaac Szpindel (pictured left), consultative General Practice
in attentional disorders at the S.t.a.r.t. clinic in toronto.
We have some interesting information
and some surprising results in some respects, but i do not think these are generalizable enough to be considered
diagnostic. i think it raises some reasonable opportunities for etiological and diagnostic speculation and further study.

Ventral straitum
contracted in ADHD patients
What we did, first of all, is ask what
happens in typical kids? says dr. Shaw.
in this group they saw that the surface of
the basal ganglia generally expands with
age. that was also true for most of the
surface in adhd. it also expandedexcept for the ventral striatum. in typical
children this area expanded, but in chil-

Must keep researching

to make clinically useful
dr. Shaw agrees, adding it is important
to consider that while this observed difference is highly significant, this is a
group effect. it is something that required
a very large sample to detect.
Significant but fixed surface area reductions were also seen in dorsal striatal
regions in the adhd group at study

ADHD rates higher in child protection services in Canada

The effects of maltreatment of children in protection services can lead to behavioural problems
by Emily

Innes

Pediatric Chronicle Assistant Editor

hildren in child protection services are diagnosed with attention deficit hyperactivity disorder (ADHD) at higher rates than
the general population, although these children may have
other factors contributing to behavioural and attentional regulation
difficulties, according to a study published in the journal Child Care
Health Day (June 18, 2014).
Researchers found the effects of maltreatment in children can
lead to problems with attention that overlap or mimic ADHD-like
symptoms and co-morbid disorders. The study reports more
awareness of the challenges this group faces is needed among
caregivers, teachers, and child welfare staff to ensure the mental
well-being of these children.
[The effects of maltreatment on the emotional regulatory system] does not even have
an accepted formal diagnosis, although it has
been referred to as complex trauma or the
proposed developmental trauma disorder,
said lead author Dr. Benjamin Klein (pictured
left), medical director at Lansdowne Childrens
Centre in Brantford, Ont. When you do not
even have a name for something it is hard to
communicate it to people, and child protection
workers. Many children whose stress regulatory systems are damaged have involuntary behavioural outbursts,
which often leads to the diagnosis of oppositional defiant disorder, a
label that can be stigmatizing and ultimately not helpful.
The maltreatmentpsychological and emotional neglect
causes problems with emotional stress regulation for these children, according to Dr. Klein, an assistant clinical professor in the
Department of Pediatrics at McMaster University in Hamilton, Ont.
For kids that are maltreated, you can think of it as daily stress,
such as being told no or peer social interactions that they cannot
regulate. They slip more easily into emotional dysregulation, for example a fight or flight response, including involuntarily freezing
inattentionor flightinghyperactivity.
This can be impossible to distinguish from ADHD for clini-

10 PEDIATRIC CHRONICLE

cians, who rely heavily on accounts from parents and teachers to

make the diagnosis of ADHD.
Children with effects of maltreatment need their environmental
stress exposure carefully titrated, such as a low emotional stress
environment, he said. That allows them to stay in the calm-alert
thinking brain mode rather than fight-flight mode.
Dr. Klein explained that children in child protection services
are probably often correctly diagnosed with ADHD, but diagnostic
formulation may miss the more global effects of a suboptimal early
environment on the emotional stress regulatory system.
The ADHD is often there and ADHD medication often helps
the kids, said Dr. Klein. But what we see clinically is that it helps
somewhat, but it doesnt take away all the functional problems, of
course. [For example] if you have asthma and pneumonia and you
take medicine for asthma you are still going to have problems because there is something left untreated.
Physicians who end up seeing these kids have a much
greater access to medication and just have to write a prescription,
said Dr. Klein. But to get something like parent-child dyadic psychotherapy is problematic. First of all you might not know what that
is as a physician because there is a limited amount of training for
psychological development issues in medical training, including pediatrics.
But even if you do know about that, or know what agency to
refer someone to, it may be a long wait and local agencies may not
have the capacity.
Need grerater resources for these children
Lack of other resources, according to Dr. Klein, also exacerbates
this condition. He advocates for more access to mental health and
developmental services for children in child protection services but
also for more support for pregnant women, reducing poverty, and
improving neighbourhoods.
He would also like to see greater access to high quality full
time daycare, especially for at risk children.
Prevention of maltreatment is the most key and the most impactful step, said Dr. Klein. I would like the system to have a
greater capacity to respond to risk.
More at http://ow.ly/B5sVX

entry, which persisted into adolescence.

Further research would be needed to integrate these findings with other aspects
of the understanding of adhd to translate into something clinically useful, says
dr. Shaw.
one area where dr. Szpindel
would like to see study of this cohort
extended is by collecting additional
scans when the patients are older. the
sample size here goes from four to
about 18.9 years, which is the borderline between adolescence and adulthood, says dr. Szpindel. that means
were potentially not seeing the neurological changes fully into adulthood, really, as these brains have roughly six
more years of significant neuronal
pruning and executive development remaining. Furthermore, Pet studies
have suggested that the maturation of
the adhd brain may lag that of the
normally developing brain by an additional five years or so, he says.
this lag or delay does not account
for the involution or reduction in specific
anatomical surface areas [in dr. Shaws
research]. But it does suggest that in a
study such as this, we extend the age at
endpoint further to better consider normal and adhd neurodevelopment into
adulthood, says dr. Szpindel.
this is a structural study, and it
begs the question whats happening? in
terms of the ventral striatums functioning. So the logical next step is to look at
the functioning of the ventral striatum,
says dr. Shaw, noting that he and his
team are moving on into this further research.
it is also relevant to examine how
these shrinkages tie into other aspects of
neural structure in adhd, says dr.
Shaw, noting that his team is looking at
white matter tracks between the ventral
striatum and other brain areas.
this study compared a cohort with
severe adhd to healthy controls, notes
dr. Szpindel. expanding the study to
contrast to scans of a wider severity
range of adhd brains with other overlapping conditions that exhibit executive functioning changes, such as
anxiety and depression, would help clarify whether these shrinkages in the basal
ganglia may be specific to adhd and
therefore of potentially useful diagnostic value.
Gaining a comprehensive understanding of adhd will likely involve
looking at the condition at an array of
levels, says dr. Shaw, from the gene
level to environmental factors. Socioeconomic status is a variable that dr.
Szpindel agrees is important to examine in any follow-up studies. Looking
at predominantly affluent patients,
such as those in dr. Shaws cohort,
can be particularly problematic, because we know that the low socio-economic status patients are the ones at the
highest risk of persistence [of adhd]
into adulthood. So if were considering
adult neurodevelopment trajectories in
adhd, this is a key cohort of the sample population that should be included.
dr. Szpindel says what this study
does, very nicely, within its cohort, is
confirm that there are real, physical, biological findings in adhd patients
when compared to normal populations.

PREVIEW EDITION

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Fellowship Director, Section of Dermatology, Pediatric Medicine, at the Hospital
for Sick Children in Toronto.
Tolerability is really important, because people are using emollients every
single day, and depending on how long
they have eczema, potentially life-long,
says Dr. Weinstein. So at a bare minimum they have to be able to afford it, and
they have to be able to tolerate it. [Ninetysix per cent] is a high level of tolerance.
Also in the study, using the emollient resulted in significant improvements
in the clinical parameters of dryness, itching, scaling, and redness, on a visual assessment by dermatologists, says Dr.
Weinstein. On all these clinical parameters, at four weeks there was improvement, at eight weeks, and at 12 weeks.
The amount of improvement increased at each interval, although the improvement of scaling was not significant
at four weeks. More than 80% of patients
on subjective self-assessments of the same
four categories reported the same pattern
of improvement after each four-week period. This ongoing improvement in symptoms with sustained use is important
information when talking with patients
about the importance of adhering to a regimen, she says.
I find that moisturizing babies is not
such a big deal. I find that parents are
quite diligent and they do it. But as kids

get older, those that still have eczema

have to moisturize, and it becomes a
drag, says Dr. Weinstein. Moisturizing
twice a day for 30 seconds may not seem
like a significant burden, but to a patient
it is more the drag of having a chronic
condition and having to do something that
everybody else doesnt have to do, she
says.
If they moisturize, for sure theyre
going to get benefitbut what this [study]
shows is that if you moisturize consistently
youre going to get sustained and increasing benefits. So patients need to know that
continued use is beneficial, she says.
On the SCORAD scale (scoring for
atopic dermatitis), while there were improvements at four weeks they were not
significant overall, or when broken down
by age group in the study, says Dr. Weinstein, but by week 12 significant improvements were seen.

Reduced use of topical medication

Potentially the most important finding of

this study, says Dr. Weinstein, was that patients who regularly used the oat-based
emollient reduced their use of topical
medication.
Just at the four week mark, there was
already a reduction of 39.4 per cent in cortisone use, she says. Overall, 63% of the
participants used less medication. Now I
will say that I dont worry a whole lot about
corticosteroids, I think the side effects are
rare. But theyre not non-existent, and certainly parents are worried about them. So
we can show that with really aggressive
moisturizing with the oat derivatives helping with the inflammation, youre going to
cut down on your medication use. That is
something that is very important to parents.
And certainly while I dont worry about
[corticosteroids], if we can use less by recommending this strategy, obviously thats
the way to go.
Patient satisfaction with the emollient
was high, and significant improvements
were seen in quality of life measures.
A observational study conducted in
Greece looked at 1,800 patients with mild
to moderate eczema, of 47 pediatricians in
private practice. These patients were using
a regimen of both a wash and an oat-based
cream, as well as continuing any topical
medications they may have been on, says
Dr. Weinstein.
The study results included investigator
global assessment evaluated at visit one,
and after one and two months. This included presence or absence of signs of
eczema and a rating of severity from one to
five. As we go through the visits, there are
more patients showing an absence of features, and the amount that are showing

Supplement to Pediatric Chronicle, Forerunner Edition, Autumn 2014. Chronicle is an independent

medical news service that provides educational updates regarding medical developments around
the world. Views expressed are those of the participants and do not necessarily reflect those of
the publisher or sponsor.
Support for distribution of this report was provided by Johnson & Johnson Inc. through an
unrestricted educational grant without conditions. Information provided in this report is not intended to serve as the sole basis for individual care.
Printed in Canada for Chronicle Information Resources Ltd., 555 Burnhamthorpe Rd., Suite
306, Toronto, Ont. M9C 2Y3.Telephone 416.916.2476; facsimile 416.352.6199; e-mail: health@chronicle.org. Copyright 2014 by Chronicle Information Resources Ltd., except where noted. All rights
reserved. Reproduction in any form is expressly prohibited without written permission of the
publisher.

eczema signs is decreasing, she says.

As for efficacy, using wash and the
cream, it improves the signs of eczema, the
skin is less dry, it leaves the skin comfortable. [The data shows] after visit two, there
is an improvement, and after visit three
there is some more, in this study, says Dr.
Weinstein.
Also, 84% of patients agreed that they
had the sensation to use less medication.
This is sort of a translation because the
study was not done in an English-speaking
country, Dr. Weinstein says. But the sensation to use less medication means they
felt the need to use less medication.
The emollients used in these studies
contained a combination of three oatbased ingredients with different effects
colloidal oatmeal which is the hulled seed
rolled and ground to a fine, uniform powder, oat oil, and avenanthramides, which
are active polyphenol extracted from the
hulls of the seeds.
There are three different oat-derived
materials that can be of benefit in eczema,
and the three work in different ways, says
Michael Southall, PhD, Senior Research
Fellow of Global Skin Biology and Pharmacology, Research & Development for
Johnson & Johnson Consumer Companies, who also spoke at the meeting.
Southall and his team developed the
Aveeno Eczema Care emollient used in
the studies cited by Dr. Weinstein.
Regarding the colloidal oats, Southall

Dr. Weinstein:
With really aggressive
moisturizing with the
oat derivatives helping
with the inflammation,
youre going to cut
down on your
medication use
The oat oil included is high in lipids,
and can replenish reserves in the skin. We
also found something in the last year that
we are really excited with, Southall says.
We found that oat oil is an agonist for a
family of receptors called PPAR, which
stands for peroxisome proliferator-activated receptors. Through this pathway,
genes involved in increasing skin barrier
function are activated, he says.
We dose-dependently treat skin
equivalents with the lipids, [and] we can
show increases in ceramide production,
says Southall. What were actually doing
is by inducing activation of PPAR in the
skin, we are increasing the expression of
ceramides produced in the skin, not topically applied. So it gives another basis for
why these natural products are providing
some of the benefits in skin.
Avenanthramides,
which
are
polyphenol compounds only found in
oats, have been shown to have anti-inflammatory and anti-itch properties in animal models (Archives of Dermatological

S outhall:
By inducing activation of PPAR in the skin,
we are increasing the expression of ceramides
produced in the skin
says Oats are rich in protein. There is
about a 20 per cent protein content in the
oat grains themselves. There are high
amounts of polysacchrides, and a high degree of lipidsthe highest found in any cereal [grain]. There are also polyphenols
which are anti-oxidant-type molecules that
help relieve oxidative stress. The fine particles have a been shown clinically to attract and bind moisture, provide a pH
buffer, and have anti-pruritic activity, he
says.

Research Nov. 2008; 300(10):569-574).

One of the things theyre very good
at is reducing the pathways involved in
producing inflammatory mediators, says
Southall. They do this by blocking some
of the signalling that is involved in how
the pro-inflammatory cytokines and other
mediators are synthesized. By blocking
that signalling, it prevents them from being
produced, and therefore on skin it should
reduce the level of inflammation that occurs.

Celiac Disease

Gilles San Martin

Head lice are known to

prefer clean hairin
contrast with the stigma
associating infestation
with poor hygiene

Super Lice?

No fear of lice becoming

resistant to non-pesticide therapies
Dr. Chantelle Ung (pictured right), the director of the
dermatology
Group Skincare
and cos- metic
centre
in
toronto, says
there are no
fears of the lice
becoming resistant to nonpesticide
treatments.
NYda works in a physical method, so it physically suffocates the lice
and their eggs. You cant develop a resistance to being choked or suffocated,
she said.
dr. Ung equates the growing resistance of lice to that of the bacterial resistance to antibiotics creating the
super bug. the previous medications with many years of use [for lice],
like pyrethrin or permethrin, the lice
have learned to mutate to resist being
killed by the chemicals and then propagate, so they become the dominant
species of lice, she said. they say
that with every generation of using the
pesticides you get more of the super
lice learning to mutate and to become
resistant.
Dr. Joseph Lam, a clinical assistant

professor in the departments of Paediatrics and dermatology and Skin Sciences at the University of British
columbia in Vancouver, said that previously a lice infestation was treated with
permethrin 1%, but when that became
ineffective due to the development of
resistance, pyrethrin 5%, a therapy for
scabies, started being used for lice. if
you keep doing that you are going to
perpetuate the problem, said dr. Lam.
according to dr. Lam, the lice are
only super because they are resistant to
pesticides, but not bigger or stronger.
however, he also made the point that
using a product such as NYda will work
against regular and super lice.
another non-pesticide product on
the canadian market is called resultz
(containing isopropyl myristate) and it
acts to dissolve the lice, said dr. Lam.
dr. Ung believes there is a lack of
awareness regarding non-pesticide lice therapies and she ends up seeing the patients referred to her for difficult-to-treat lice.
Being a dermatologist, i would say
that we do not see a plethora of patients
[for lice] because most times family doctors and pediatricians are the first person
that the patient would see. But we get
cases that are resistant, said dr. Ung. i
recommend NYda all the time... because
sometimes even family doctors and pediatricians are not aware of this product.
Break unhygienic bad stigma of lice
dr. Lam said it is a common misunderstanding that having lice is associated
with poor hygiene and dirty hair. however, it seems that lice prefer cleaner hair.
he said it has not been scientifically
proven if sharing hats or combs increase
the spread of lice, but common sense dictates that one should avoid doing this as
well as avoiding head-to-head contact to
prevent against a lice infestation.
it is quite often in school-aged kids
because they are in close proximity together, said dr. Lam. Something that
has made the news, but scientifically is
not totally proven, is whether selfies put
you at more risk for lice or not because a
lot of kids are doing that these days.
dr. Kraft said he hopes the stigma of
associating lice with being unhygienic or
poor is broken. it is important to be
aware that lice can affect all children of
all socio-economic groups. it is not necessarily a sign of poor hygiene but something that needs to be recognized and
treated appropriately.
it is important to think about head
lice when you see anyone with an itchy
scalp and to offer them an appropriate
treatment for them and their family to
stop the infestation and prevent the
spread of super lice.

12 PEDIATRIC CHRONICLE

Social worker may provide benefit

the authors found that improved education is also needed to aid with early
diagnosis of celiac disease and reduce
contamination of food products. dr.
rashid said this needs be done at the
medical professional
level through lectures,
articles,
brochures,
and
awareness events,
but also at the societal level in schools,
restaurants, and daycares.
if a patient is
struggling
with
maintaining a GF
diet, dr. rashid said
the first step is to
identify the barrier.
Some patients have
difficulty
coping
with the diagnosis
and in this case letting the patient know
that they are not
alone, and that it is a
common problem is
helpful. the patient,
or their family,
should be introduced
to other families with
children with celiac
disease and to organizations, such as the
canadian celiac association, that can
help support them. if
the barrier is cost, it could be helpful to
bring a social worker to help the family
address ways to reduce the financial
strains.
if there is peer pressure then i think
someone needs to sit down with the
teenager and maybe make them aware of
short- and long-term risks of untreated
disease. it all depends on what the major
factor which prevents them from following a GF diet, said dr. rashid.
For more information visit:
http://ow.ly/zQ7qT

I think that
governments should
provide [gluten free]
foods for free to at
least the pediatric
population and hopefully to everybody

Dr. Mohsin Rashid

UTIs in children
continued from page 1
tainly the most logical way of doing that is stop treating things
that are not even bacterial infections, said dr. robinson.
Young girls can have pain when they urinate because they
have urethritis, which can occur from sitting in bubble baths too
long and because they have sensitive perineums. this is often
confused with a Uti, explains dr. robinson (pictured right).
really the lesson is that you should never make the diagnosis of a urinary tract infection in a child without having
at least sent off a proper urine sample, she said. With an
adult female it is totally acceptable that if they come in with
the right symptoms you just put them on antibiotics and only
send a urine culture if they do not get better.
the cPS also recommends that Utis for infants younger
than two years of age can be treated with antibiotics for seven
to 10 days, with oral therapy being the initial treatment if the
child has no other indication for admission to hospital. if the
child is older and does not have a fever, then a two-to fourday course of antibiotics is considered sufficient. after the
first Uti a child under the age of two should be investigated
with a renal and bladder ultrasound (rBUS). the authors state
that antibiotic prophylaxis is no longer recommended for
grades i through iii vesicoureteral reflux (VUr) or pending
result of the initial rBUS. children with grade iV or V VUr
or significantly abnormal rBUS should be referred to a pediatric urologist or nephrologist.
For more information visit http://ow.ly/zycyS

You should never

make the
diagnosis of a
urinary tract infection in a child
without having at
least sent off a
proper urine
sample

PREVIEW EDITION

Naomi | Morguele

continued from page 1

dr. Kraft said he recommends a
non-pesticide-based treatment called
NYda, which contains dimethicone, a
silicone-based polymer that has proven
in numerous studies to be safe and is
found in childrens medicine, cosmetics,
lotions and shampoos.
his patients with lice have been
thrilled to use NYda. here is a
medication that does not have any pesticides in it and it works in the vast majority of cases, he said. the lice
cannot develop resistance to it and it
means if you use it properly it is going
to kill the lice whether the lice are
super lice or not. So no matter what
type of infestation they have it will
work.
Like other lice treatments, according to dr. Kraft, NYda requires effort.
the NYda is applied to dry hair and
the scalp with the pump spray applicator. the hair and scalp should be entirely covered. then it soaks in for 30
minutes at which point the NYda
comb is used to remove the dead lice
and larvae. the NYda remains on the
hair for eight hours before being shampooed off. this procedure is repeated a
week later.

continued from page 1

foods, even fast food outlets are offering
something, and grocery stores have
more packaged products available. But
we need to be very careful that we do not
let products slowly become more contaminated.
dr. rashid said
he believes the government should provide better assistance to families that
include
children
with celiac disease.
though the industry has been responding and the
prices are coming
down, the investigators still found
that price makes a
GF diet challenging
for some families.
dr. rashid believes
the
government
should provide better assistance to
families that include children with
celiac
disease.
Some
european
countries provide
selective GF products for free, or provide stipends or tax
breaks. Some canadian provinces have
an extra stipend for
families on income
assistance with a
member who has celiac disease and at
the national level there is a tax break by
canada revenue agency, but, according to dr. rashid, the process is cumbersome to follow.
i think that governments should
provide adequate GF foods for free to
at least the pediatric population and
hopefully to everybody, said dr.
rashid. he hopes that this study will
encourage pediatricians and general
practitioners to advocate for better
support for celiac patients.



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PEDIATRIC CHRONICLE 13

Parting question
Kids with anxiety disorder: Are they wired differently?
therapeutic interventions that should be ofStructual differences found in weferedcantoimprove
this population of children, according to Tromp.
another investigation, children who did not have a
brains of children with anxiety socialInanxiety
disorder, but were categorized as having soby Louise

Gagnon for Pediatric Chronicle

rain imaging is revealing that children who are socially reticent or who have anxiety disorders have dysregulated circuitry in the brain, differentiating them
from children without social reticence or anxiety disorders.
These are children who were recently diagnosed with
an anxiety disorder and have not used any medications, and
already we see a structural difference in their brains [compared to control children], explained Do Tromp, a researcher in the Department of Psychiatry and Health
Emotion Research Institute at the University of Wisconsin
in Madison, in an interview with PEDIATRIC CHRONICLE.
We are seeing results [in the brains] of children [who
are newly diagnosed with an anxiety disorder] that we see
in adults who have had years of anxiety disorder and perhaps have used medications, said Tromp. There are structural differences that we view in the brain [early in the
course of illness].
During the annual meeting of the Anxiety and Depression Association of America (ADAA) in Chicago this past
March, Tromp described data involving research with 21
healthy control children and 23 children with an anxiety disorder where functional magnetic resonance imaging (fMRI)
scans were performed, revealing that at rest, children aged
eight to 12 years of age with an anxiety disorder, showed
decreased functional connectivity between the pre-frontal
cortex and amygdala.
Children were also asked to participate in a task where
they were given a cue before they would be exposed to either a face that had either a neutral expression or one that
had a fearful expression. The cue would let them know
whether they were to be exposed to a neutral face, or one
expressing fear. They also received an uncertain cue that
did not let them know what face to expect. There was increased amygdale activation when they were exposed to an
uncertain cue, said Tromp.
In addition, children with anxiety disorders also
showed a prolonged amygdala recovery after viewing fearful faces, said Tromp. The findings are consistent with what
Tromp and researchers have observed in non-human primates in terms of amygdala-prefrontal connectivity and
anxious temperament. Additional data from nonhuman primates also show the significance of genetics in determining
if an anxiety disorder develops in an individual, said Tromp.

Dysregulation in kids with behavioural issues

These results together can potentially inform clinicians how

cial reticence, a trait common in behaviourally-inhibited

temperament, expressed similar dysregulated brain circuitry
in an anticipation task where they were faced with ambiguity, explained Johanna M. Jarcho, PhD, a post-doctoral fellow at the National Institute of Mental Health in Bethesda,
Md.
During her presentation at the ADAA, Dr. Jarcho described the characteristics of the pediatric subjects that took
part in the study.
These are children who are at risk for developing an
anxiety disorder, said Dr. Jarcho. Whether they develop
anxiety is partially genetic and partially environmental.
One factor that can contribute to whether at-risk children develop anxiety is the nature of the parenting they are
exposed to, added Dr. Jarcho.
A total of 30 children aged 11 years with high social
reticence and 24 children also aged 11 years but with low
social reticence were tasked to interact with peers, depicted
as cartoon avatars, in a virtual classroom. They relied on
maternal reports and behavioural observations to come up
with a rating of social reticence for children.

Brain activity different in socially reticent children

Avatars had a reputation for being either friendly, mean, or
unpredictable (nice or mean), explained Dr. Jarcho. Subjects
were gender-matched, so boys interacted with a male cartoon avatar and girls interacted with a female cartoon avatar.
Investigators used fMRI to observe the brain activity of subjects.
When we looked at what is happening in their brains,
we did not see a difference in brain activity across the two
groups of children when they were anticipating predictably
positive or negative feedback, said Dr. Jarcho.
We did see a difference in brain activity in socially
reticent children when they were anticipating unpredictable
feedback, Dr. Jarcho explained. It was more evocative to
face a negative social interaction than when a child does not
know what is going to happen than when they know what
to expect. We thought we would find more robust differences [between the two groups of children] when they were
anticipating something they knew would be negative. It appears that the unpredictable is more evocative for these children than knowing when they will face a bully, for
example.
Specifically, children with high social reticence displayed heightened activity in dorsal anterior cingulate, insula, and superior temporal gyrus when they anticipated
feedback from a peer whose reputation was unpredictable.

videos of interest to
the Pediatrician on
the Internet right now

2014 PEDIATRICS BOARD REVIEW

As described by the presenter, this clip does a
lot of bouncing around
between a variety of
topics including screening for anemia, urinalysis screening, screening
for newborn metabolic
diseases, and autism screening. The presenter suggests ages
of when a child should be screened for these conditions and
examples of when a physician might want to consider screening the patient earlier than the general population. http://ow.ly/DWC56

AAP SLEEP SAFETY RECOMMENDATIONS

Dr. Rachel Moon, a sudden unexplained infant
death (SUID) researcher
for the Childrens National Health System,
presents on the American Academy of Pediatrics guidelines for safe
sleeping. Dr. Moon helps differentiate between sleep-related
deaths and SUIDs. The recommendations are to reduce the
risk of sudden infant death syndrome and sleep
related suffocation, asphyxia, and entrapment until
the age of one year old. http://ow.ly/DWDd5

PEDIATRIC CANCER: T-CELL IMMUNOTHERAPY

Researcher Dr. Michael
Jensen gives a talk
about how T-cell immunotherapy is helping
to eradicate pediatric
Ca. To treat Ca with Tcells, Dr. Jensen says
they are reprogramming
T-cells through DNA
codes to have them attach to cancerous cells and attack
them like they are the common cold.
http://ow.ly/DYa99

ENTEROVIRUS D68
Dr. David Rosenberg of
Vineland, N.J., discusses
enterovirus D68 with the
news outlet SNJ Today
about. This year there
has been the largest
confirmed outbreak of
enterovirus D68 but
there is no evidence that it is more dangerous than the other
100 other enteroviruses around. He says it is the common
cold and proper hand washing is important to
avoid contacting the virus. http://ow.ly/DWDAT

Now that youve read

PEDIATRIC

CHRONICLE ,

what do you think of

PEDIATRIC

CHRONICLE ?

Please share your opinions and impressions of this Preview Issue with the editors, by taking a brief online survey.
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14 PEDIATRIC CHRONICLE

PREVIEW EDITION

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oldo
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LYCERIDE OLEYL A
ALCOHOL
LCOHOL XANTHAN GUM
A
ACRYLATES/C
CRYLATES/C10-30 ALKYL ACRYLATE
SODIUM HYDR
HYDROXIDE
OXIDE DISODIUM EDTA
EDTA [BI 560V1].
*Moderate eczema: SCORAD between 15 and 40. Subjects had at least 3 eczema outbreaks during the 6 previous months, including the outbreak of the inclusion visit. From D0 to D10: application of topical corticosteroids on
eczema lesions, every evening. During the whole trial: application of Atoderm PP Baume.

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