HOT TOPICS IN PEDIATRICS
From Family Medicine Update 2007, sponsored by the University of Minnesota Medical School, Minneapolis
| WEIGHT MANAGEMENT IN CHILDREN AND ADOLESCENTS—Sarah Jane Schwarzenberg, MD, Associate Professor
of Pediatrics, University of Minnesota Medical School, Minneapolis
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| Obesity in pediatrics: in Minnesota, >15% of children obese; prevalence rising; higher prevalence in black and Hispanic
children, but seen in all ethnicities and ages; overweight or obese teenager has ≈75% chance of being obese in
adulthood; obesity in parents significant risk factor for obesity in children; obesity accounts for ≈10 yr of lost life in
obese individuals 20 to 30 yr of age; obesity associated with significant morbidity and increases cost of health care
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| Complications of childhood obesity: poor self-esteem; depression; 15% to 20% have sleep apnea and require continuous
positive airway pressure (CPAP) at night; 25% to 30% have nonalcoholic fatty liver disease; cirrhosis; musculoskeletal
problems; pseudotumor cerebri; dyslipidemia; ≈25% have significant hypertriglyceridemia; hypertension;
chronic inflammation and endothelial dysfunction with elevated C-reactive protein (CRP; increases risk for cardiovascular
disease); type 2 diabetes; insulin resistance; abnormal oral glucose tolerance test; polycystic ovary syndrome (PCOS)
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| Evaluation: early detection of comorbid conditions (eg, diabetes, hypertension, sleep apnea); therapy includes lifestyle
changes and behavior modification, medications, and bariatric surgery; obesity management in primary care adds time to
appointment and is poorly reimbursed; body mass index (BMI)—weight (kg)/height (m)2 ; screening tool for increased
adiposity (not diagnosis of obesity; few people [eg, elite athletes] with elevated BMI not overweight or obese; more
likely to underestimate adiposity using BMI cutoffs than overestimate); BMI for age correlates with health risks in adult
life (eg, elevated BMI for age during puberty indicates increased risk for elevated lipid levels and high blood pressure
[BP] in middle age); BMI >95th percentile in children indicates obesity, in 85th to 95th percentile indicates overweight;
between ages 3 and 5 yr, children undergo dip in BMI (children with high BMI at 3-5 yr of age at greatest risk for obesity
in puberty and adulthood); ask about—current diet and activity (24-hr diet recall helpful); after-school activities, hours
of screen time per day, sleeping, snoring, getting up at night to urinate, excessive drinking, and family history (often reveals
genetic risk factors); physical examination—use appropriate norms for BP; acanthosis nigricans suggests insulin
resistance; hirsutism in girls; check liver size; peripheral edema, especially of legs; children rarely admit to sores in folds
of skin; laboratory studies—oral glucose tolerance test (can be abnormal, even without elevated fasting glucose) with
insulin levels; fasting lipid profiles (hypercholesterolemia risk factor); elevated aspartate aminotransferase (AST) and
alanine aminotransferase (ALT); CRP; screen girls with irregular menses for PCOS
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| Goals of treatment: create expectation of weight management as lifelong commitment; reduce body weight by 5% to
10%; weight maintenance in adolescents measure of success; gradual weight loss (1-2 lb/wk for 6 mo), then weight maintenance
after 6 mo; eliminate liquid sugar (eg, soda, fruit juice, sports drinks); eat out ≤2 times per month; 2 to 3 frozen
meals per week (to teach portion control); 5 servings of fruits and vegetables daily; eliminate seconds, except for fruits
and vegetables; enroll in after-school sports
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| Morbidly obese patients: manage comorbid conditions; schedule appointments so patients can see multiple providers
in one appointment
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| Conclusion: failure rate of weight management high; counteract perception that obesity result of personal weakness; advocate
against toxic environment; demand healthy lunches in schools and encourage physical activities; increase awareness
of effective prevention and management programs
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| DEPRESSED ADOLESCENTS—Jennifer L. Welsh, MD, Director, Smiley’s Family Medicine Residency Program, University
of Minnesota Medical Center, Minneapolis
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| Introduction: depression in teenagers risk factor for suicide; good evidence that selective serotonin reuptake inhibitors
(SSRIs) helpful in adults; black box warning against use of antidepressants in children and adolescents due to increased
risk for suicide
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| Evaluation: determine whether adolescent has major depressive disorder (MDD; diagnosis influences decision to use or
not use antidepressant); global rating scales for depression in children given by psychologists; patient health questionnaire
9 (PHQ-9) and Beck Depression Inventory not validated for children <17 yr of age; obtain parental input; recognize
problems that can cause depressive symptoms or mask MDD; watch for substance abuse, bipolar illness, and other mental
health problems (eg, anxiety disorder, obsessive compulsive disorder [OCD], dysthymia)
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| Natural course of MDD: typical episode lasts 32 to 36 wk; greatest improvement after 24th to 36th wk; after ≈1 yr,
80% of children and adolescents experience remission; ≈70% have recurrence in 5 yr
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| Definition of suicidal behavior: ideation (ie, thinking about suicide); attempt with no injury; preparatory actions towards
imminent suicidal behavior, but patient stopped before completion
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| Treatment of Adolescents with Depression (TAD) study: randomized controlled trial of adolescents 12 to 17 yr
of age with MDD; compared placebo, cognitive behavioral therapy (CBT), and fluoxetine (Prozac); study did not include
sham CBT or patients with suicidal ideation or behavior; participants showed good improvement with CBT and fluoxetine
and with fluoxetine alone (statistically significant); less improvement with CBT alone; no improvement with placebo;
suicidal behavior increased from 4% to 7%; no completed suicides
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| Meta-analyses of SSRIs in childhood and adolescent depression: 1) review of published and unpublished data
found fluoxetine only SSRI with benefits that outweighed risks; 2) review of published and unpublished data found risk for
suicidal ideation or behavior in those treated with SSRI 4% (vs 2% in those not treated with SSRIs); fluoxetine only FDA-
approved medication for treatment of childhood and adolescent depression (has black box warning); 3) looked at all children
being treated with antidepressants, whether diagnosed with depression or MDD or not; included children with anxiety
disorders and OCD; efficacy of SSRIs “pretty good” for depression and “really good” for anxiety disorders and OCD; SSRIs
more effective in teenagers than in children <12 yr of age; suicidal behavior more common in children diagnosed with
depression, compared to other mental illnesses; found 1% increase in risk for suicidal behavior in children receiving SSRIs;
no completed suicides; unanswered questions—whether risk changes with duration of treatment (most studies short-
term [8-12 wk]); whether increased risk for suicidal behavior leads to increased risk for completed suicides; risks of stopping
medication; changes in risk at age 18 yr; how to balance SSRI use for individual patients; bottom line—do no harm;
involve parents and reliable family members (commitment to regular follow-up and communication required); know local
mental health professionals; children with MDD untreated for longer time (eg, 6 mo) more likely to be refractory to therapy,
compared to those untreated for short time (eg, 1 mo); better response to therapy in patients with less severe depression
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| Starting treatment: thorough documentation required; provide education to parents and teenagers; contract for safety;
review options (eg, CBT alone, medication alone, CBT and medication); obtain consent to treatment; discuss risks (eg,
increased suicidal behavior) and benefits; firearms contract (firearm in home single greatest risk for completion of suicide
by teenager; firearms should be removed from home); frequent follow-up—office visits every week for first month
after start of treatment; then every 2 wk for 1 month, and monthly for 3 mo; modify schedule as needed (eg, if patient seeing
therapist); consider more frequent follow-up when changing medications or dosages
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| Conclusion: when concerned about suicide, involve colleagues in treatment; thorough documentation important; be familiar
with local resources
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| NEONATAL SEPSIS—Theodore R. Thompson, MD, Professor of Pediatrics, University of Minnesota Medical School,
Minneapolis
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| Early-onset neonatal infection: rule out sepsis to avoid overtreatment; symptoms and signs of sepsis in newborns
subtle and vague; duration of treatment should be minimized to minimize disruption to families and anxiety
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| Incidence of neonatal sepsis: 1 to 10 per 1000 (≈50% bacterial); higher incidence in premature infants (greater incidence
with lower gestational age); data suggest ≈25% of babies with neonatal sepsis have meningitis
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| Characteristics: early-onset neonatal sepsis (EONS)—first 5 to 7 days after birth; can be fulminant multisystem illness
or may have only subtle signs and symptoms (eg, feeding intolerance, respiratory distress); ≥50% of mothers have infection
leading to preterm labor; organisms often acquired perinatally in utero; mortality rate 5% to 30%; late-onset neonatal
sepsis—after 1 wk of age
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| Maternal factors for infection: prolonged rupture of membranes; premature labor; premature rupture of membranes;
prolonged labor with excessive examinations; peripartum infections (particularly associated with fever); black ethnicity;
lower socioeconomic class; diabetes and twins (questionable); chorioamnionitis (treat baby with antibiotics); group B
Streptococcus (GBS; markedly increases risk with prolonged rupture of membranes); maternal bacteruria; baby born to
mother whose previous infant had invasive disease; if infant symptomatic (with or without risk factors), give treatment
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 | Case presentation: chorioamnionitis in full-term female infant born after membranes ruptured for 24 hr; started on ampicillin
and gentamicin and became febrile (101ºF); fetal tachycardia and late decelerations noted; no evidence of immediate
respiratory distress; management—obtain culture and complete blood cell count (CBC); x-ray if respiratory
distress present; lumbar puncture (LP); if chorioamnionitis documented, treat with antibiotics
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| Maternal fever: may be due to epidural analgesia (increases relative risk for infection 5-fold); intrapartum antibiotics decrease
risk; treatment of newborn can be discontinued in 48 hr if baby asymptomatic with normal laboratory tests and
negative cultures
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| Neonatal factors for infection: prematurity; perinatal distress; male sex; breakdown of skin; immunologic immaturity
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| Environmental factors for infection: contaminated hands of personnel in nurseries and intensive care units (ICUs);
catheters
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| Pathogenesis of infection: ascending infection into amniotic fluid; infection acquired in utero; ≥70% of babies with
bacteremia at birth have symptoms ≤6 hr after birth (90% have signs and symptoms in first 12-24 hr); postnatal acquisition
can occur; highest incidence of infections in babies caused by GBS and Escherichia coli; intrapartum treatment of
mothers to eradicate GBS and to prevent colonization in infants not shown to cause increase in other organisms
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| Clinical manifestations: baby not doing, acting, or looking well; respiratory distress; pneumonia; apneic episodes;
feeding intolerance number one sign of infection; lethargy; irritability; poor tone; seizures; acidosis; hyperglycemia or
hypoglycemia; hypothermia more common in preterm baby (hyperthermia more common in full-term baby; normothermia
most often); fever—seen in ≤50%; single elevated temperature reading as isolated finding rarely associated with infection;
if prolonged (>1 hr), fever more frequently associated with infection; more frequent in late-onset infections or
viral infections
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| Diagnosis: blood culture—definitive test; obtain 0.5 to 1.0 mL; most growth occurs within 36 to 48 hr; negative culture
does not rule out disease; assess signs, symptoms, and baby’s response over last 24 hr; reasons for negative culture when
baby has bacteremia include too little blood, intermittent bacteremia, and maternal antibiotic therapy (may suppress organisms);
urine culture—suprapubic or catheter; positive in ≈1% of babies in first 3 days after birth, 7% after 7 days;
low yield for early-onset infection; tracheal aspirate—may be positive with negative blood culture in babies with pneumonia;
cerebrospinal fluid (CSF) culture—positive culture indicative of meningitis; bacterial antigens—low sensitivity;
poor positive predictive value; may be useful for detecting GBS in CSF if mother or baby received treatment; helpful
studies—polymerase chain reaction (PCR) testing rapid (within 1 hr) and sensitive for GBS on maternal vaginal/rectal
cultures; arterial blood gas; glucose level; liver function tests; chest x-ray in babies with respiratory distress (pleural effusion
considered pneumonia until proven otherwise); white blood cell (WBC) count may be normal (15,000㪶,000/µL;
may increase with perinatal distress, fever, or stressful labor); interobserver variability; leukopenia and neutropenia key;
WBC count <7500/µL signifies infection; neutropenia <1500/µL cause for concern; many babies have infection and normal
platelet count; CRP—high negative predictive value; antibiotics may be stopped if CRP normal; follow trend; not
useful in first 24 hr after birth and probably not helpful in preterm babies; helpful for indicating when to stop antibiotics;
LP—perform in babies with infection to rule out meningitis and in babies with definite signs and symptoms of central
nervous system (CNS) infection; not routinely performed to rule out sepsis or in babies with chorioamnionitis who are
doing fine or too ill for LP; literature suggests ≤25% with early-onset sepsis have meningitis (“I just have not seen that”);
≤30% of infants with meningitis have negative blood culture
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| Treatment: ampicillin and gentamicin (or cefotaxime); for ruling out infection, use antibiotics for 36 to 48 hr; treat pneumonia
for 1 wk to 10 days; treat sepsis for 10 to 14 days; treat meningitis for 21 days (or ≥14 days with negative CSF culture)
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| C-reactive protein: if <10 mg/L (or 1 mg/dL), antibiotics may be stopped; factors that may influence CRP include mode
of delivery, granulocytopenia, gestational age, organism; may be elevated by surgery, immunizations, and severe viral infections
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| Group B streptococci: before intrapartum treatment in mothers positive for GBS, colonization rate in babies born to
such mothers 50% to 75% (invasive disease, 1%-2% [10- to 30-fold increased risk for bacterial infections]); 33% to
40% of mothers have ≥1 risk factors (eg, premature labor, prolonged ruptured membranes, fever); 66% to 75% of
mothers have no risk factors (75% of babies late preterm or full-term become infected with GBS); risk for invasive disease
increases with heavy colonization, eg, mother with bacteriuria; in 60% to 70%, onset of symptoms in first 6 hr,
90% in first 12 to 24 hr
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| Guidelines for interrupting vertical transmission: obtain culture from mothers at 35 to 36 wk (has produced 50%-70%
drop in incidence of GBS infection in babies); do not give antibiotics 4 hr before delivery; role of nonpenicillin antimicrobial
agents (except for cephalosporins) unclear; consider other bacterial causes of infection; culture may not be obtained
due to systems failure; intrapartum prophylaxis indicated in mothers who gave birth to previous infant with GBS
disease; treat if mother has history of GBS bacteriuria, history of urinary tract infection with GBS, or positive GBS
screening during current pregnancy (unless cesarean delivery in absence of labor and ruptured membranes planned);
treat if GBS status unknown and mother presents in preterm labor with prolonged (>18 hr) rupture of membranes or intrapartum
increased temperature; penicillin recommended; ampicillin acceptable; if patient allergic to penicillin, use
cephalosporin (cefoxitin, 1-2 g q8h recommended); ≈10% of GBS organisms resistant to clindamycin, 20% resistant to
erythromycin (probably does not cross placenta); GBS sensitive to vancomycin (few studies available); no resistance
to penicillin, ampicillin, cephalosporins, or vancomycin; perform full diagnostic evaluation and give therapy when
signs and symptoms of sepsis present; evaluate if gestational age <35 wk; if chorioamnionitis diagnosed, start treatment,
at least for short time
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Suggested Reading
Gohil JR: Early onset neonatal sepsis. Indian J Pediatr 73:251, 2006; Gunnell D et al: Selective serotonin reuptake
inhibitors (SSRIs) and suicide in adults: meta-analysis of drug company data from placebo controlled, randomised controlled
trials submitted to the MHRA's safety review. BMJ 330:385, 2005; Kaizar EE et al: Do antidepressants cause
suicidality in children? A Bayesian meta-analysis. Clin Trials 3:73, 2006; Merkitch KW et al: Preventing early-onset
group B streptococcal sepsis: efforts to measure and improve compliance with guidelines. WMJ 105:67, 2006; Mishra
UK et al: Newer approaches to the diagnosis of early onset neonatal sepsis. Arch Dis Child Fetal Neonatal Ed 91:F208,
2006; Savoye M et al: Effects of a weight management program on body composition and metabolic parameters in overweight
children: a randomized controlled trial. JAMA 297:2697, 2007; Torrance B et al: Overweight, physical activity
and high blood pressure in children: a review of the literature. Vasc Health Risk Manag 3:139, 2007; Whitaker RC et
al: Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 337:869, 1997; Whittington
CJ et al: Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished
data. Lancet 363:1341, 2004; Zuppa AA et al: Evaluation of C reactive protein and other immunologic
markers in the diagnosis of neonatal sepsis. Minerva Pediatr 59:267, 2007.
Educational Objectives
| The goals of this program are to reduce the incidence of overweight and obesity in children and adolescents, and to
improve the management of teen depression and neonatal sepsis. After hearing and assimilating this program, the participant
will be better able to:
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| Evaluate overweight or obese children and adolescents for comorbidities and risk factors.
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| Counsel patients and parents about weight management and lifestyle modification.
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| Discuss literature findings about risks and benefits of the use of selective serotonin reuptake inhibitors in children
and adolescents with major depressive disorders.
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| List characteristics and risk factors for early-onset neonatal sepsis.
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| Review guidelines about the use of antibiotics for group B streptococcal infection in newborns.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts
were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial
interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Drs. Schwarzenberg, Welsh, and Thompson spoke in Minneapolis, MN, at the 33rd Annual Family Medicine Update, presented
May 7-11, 2007, by the University of Minnesota Medical School. The Audio-Digest Foundation thanks the speakers
and the University of Minnesota Medical School for their cooperation in the production of this program.
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