TBD Meeting (3911-11)

BOSTON – Because asymptomatic Clostridium difficile colonization is so common among infants, routine testing in cases of diarrhea isn’t warranted, according to Dr. L. Clifford McDonald.

Up to 70% of newborns may be colonized with C. difficile, but that percentage drops rapidly over the first 2 years of life as babies develop a healthy intestinal microbiome.

"In children younger than 2 years, consider other diagnoses first, especially if there hasn’t been any exposure to antibiotics," said Dr. McDonald, senior adviser for science and integrity in the division of health care quality promotion at the Centers for Disease Control and Prevention. "Colonization in this age group doesn’t carry as much weight as it does in other age groups."

The clinical picture begins to change after age 2 when the intestinal flora is well established. "Certainly over 2 years old, C. difficile is not part of the normal microbiota. In this case, you should test and treat as you would in an adult," Dr. McDonald said at the annual meeting of the American Academy of Pediatrics.

Hospital discharge data show about 500,000 health care–acquired C. difficile infections occur each year. This results in about 20,000 excess deaths annually – mostly in older people – and several billion dollars in excess health care costs. Most of the patients are older than 65, but the number of infections is rising in younger people as well.

Antibiotic exposure plays a large part in the changing frequency and toxicity of the infections, Dr. McDonald said. "The bacteria first developed a resistance to fluoroquinolones, and now we are seeing clindamycin-resistant strains," he noted.

One study has examined C. difficile infection outcomes in a national database of children’s hospital discharge records. Children with the infections were 20% more likely to die, 36% more likely to have a colectomy, and four times more likely to have an increased length of stay. They were 11 times more likely to have inflammatory bowel disease and significantly more likely to be on immunosupressant or antibiotic regimens (Arch. Ped. Adolesc. Med. 2011;165:451-7).

"So although these infections are not as common in children as they are in older individuals, you can see there are still some very serious sequelae," he said.

Researchers have identified some risk factors for toxigenic C. difficile strains in young children and infants, including formula feeding and cesarean section. Diseases that require immunosuppression and antibiotics also predispose to the infection, probably because they perturb the normal gut flora. Most transmission occurs in a day care or health care setting, including the hospital.

"We are also seeing new data that infants colonized with C. difficile in the first year of life seem to have higher rates of allergy at up to 5 years old," Dr. McDonald said. "The presence of C. difficile is probably a marker of a perturbation of the child’s intestinal flora and delayed establishment of the normal microbiome," which predisposes to atopy.

Until recently, the treatments of choice have been metronidazole and vancomycin. Although effective for quelling the infection, both have a recurrence rate of 20%-30%. Most recurrences occur soon after treatment, while the microbiota are still off balance, Dr. McDonald said.

A new drug, fidaxomicin, may offer a better solution. Approved by the Food and Drug Administration last May, the drug is not systemically absorbed – a benefit in C. difficile infections. Patients treated with fidaxomicin appear to have a lower recurrence rate – 15% vs. 25% with vancomycin in a phase III trial published earlier this year (N. Engl. J. Med. 2011;364:422-31).

However, Dr. McDonald noted, the drug was not studied in young children.

Dr. McDonald said he had no relevant financial disclosures.

BOSTON – Because asymptomatic Clostridium difficile colonization is so common among infants, routine testing in cases of diarrhea isn’t warranted, according to Dr. L. Clifford McDonald.

Up to 70% of newborns may be colonized with C. difficile, but that percentage drops rapidly over the first 2 years of life as babies develop a healthy intestinal microbiome.

"In children younger than 2 years, consider other diagnoses first, especially if there hasn’t been any exposure to antibiotics," said Dr. McDonald, senior adviser for science and integrity in the division of health care quality promotion at the Centers for Disease Control and Prevention. "Colonization in this age group doesn’t carry as much weight as it does in other age groups."

The clinical picture begins to change after age 2 when the intestinal flora is well established. "Certainly over 2 years old, C. difficile is not part of the normal microbiota. In this case, you should test and treat as you would in an adult," Dr. McDonald said at the annual meeting of the American Academy of Pediatrics.

Hospital discharge data show about 500,000 health care–acquired C. difficile infections occur each year. This results in about 20,000 excess deaths annually – mostly in older people – and several billion dollars in excess health care costs. Most of the patients are older than 65, but the number of infections is rising in younger people as well.

Antibiotic exposure plays a large part in the changing frequency and toxicity of the infections, Dr. McDonald said. "The bacteria first developed a resistance to fluoroquinolones, and now we are seeing clindamycin-resistant strains," he noted.

One study has examined C. difficile infection outcomes in a national database of children’s hospital discharge records. Children with the infections were 20% more likely to die, 36% more likely to have a colectomy, and four times more likely to have an increased length of stay. They were 11 times more likely to have inflammatory bowel disease and significantly more likely to be on immunosupressant or antibiotic regimens (Arch. Ped. Adolesc. Med. 2011;165:451-7).

"So although these infections are not as common in children as they are in older individuals, you can see there are still some very serious sequelae," he said.

Researchers have identified some risk factors for toxigenic C. difficile strains in young children and infants, including formula feeding and cesarean section. Diseases that require immunosuppression and antibiotics also predispose to the infection, probably because they perturb the normal gut flora. Most transmission occurs in a day care or health care setting, including the hospital.

"We are also seeing new data that infants colonized with C. difficile in the first year of life seem to have higher rates of allergy at up to 5 years old," Dr. McDonald said. "The presence of C. difficile is probably a marker of a perturbation of the child’s intestinal flora and delayed establishment of the normal microbiome," which predisposes to atopy.

Until recently, the treatments of choice have been metronidazole and vancomycin. Although effective for quelling the infection, both have a recurrence rate of 20%-30%. Most recurrences occur soon after treatment, while the microbiota are still off balance, Dr. McDonald said.

A new drug, fidaxomicin, may offer a better solution. Approved by the Food and Drug Administration last May, the drug is not systemically absorbed – a benefit in C. difficile infections. Patients treated with fidaxomicin appear to have a lower recurrence rate – 15% vs. 25% with vancomycin in a phase III trial published earlier this year (N. Engl. J. Med. 2011;364:422-31).

However, Dr. McDonald noted, the drug was not studied in young children.

Dr. McDonald said he had no relevant financial disclosures.

BOSTON – Because asymptomatic Clostridium difficile colonization is so common among infants, routine testing in cases of diarrhea isn’t warranted, according to Dr. L. Clifford McDonald.

Up to 70% of newborns may be colonized with C. difficile, but that percentage drops rapidly over the first 2 years of life as babies develop a healthy intestinal microbiome.

"In children younger than 2 years, consider other diagnoses first, especially if there hasn’t been any exposure to antibiotics," said Dr. McDonald, senior adviser for science and integrity in the division of health care quality promotion at the Centers for Disease Control and Prevention. "Colonization in this age group doesn’t carry as much weight as it does in other age groups."

The clinical picture begins to change after age 2 when the intestinal flora is well established. "Certainly over 2 years old, C. difficile is not part of the normal microbiota. In this case, you should test and treat as you would in an adult," Dr. McDonald said at the annual meeting of the American Academy of Pediatrics.

Hospital discharge data show about 500,000 health care–acquired C. difficile infections occur each year. This results in about 20,000 excess deaths annually – mostly in older people – and several billion dollars in excess health care costs. Most of the patients are older than 65, but the number of infections is rising in younger people as well.

Antibiotic exposure plays a large part in the changing frequency and toxicity of the infections, Dr. McDonald said. "The bacteria first developed a resistance to fluoroquinolones, and now we are seeing clindamycin-resistant strains," he noted.

One study has examined C. difficile infection outcomes in a national database of children’s hospital discharge records. Children with the infections were 20% more likely to die, 36% more likely to have a colectomy, and four times more likely to have an increased length of stay. They were 11 times more likely to have inflammatory bowel disease and significantly more likely to be on immunosupressant or antibiotic regimens (Arch. Ped. Adolesc. Med. 2011;165:451-7).

"So although these infections are not as common in children as they are in older individuals, you can see there are still some very serious sequelae," he said.

Researchers have identified some risk factors for toxigenic C. difficile strains in young children and infants, including formula feeding and cesarean section. Diseases that require immunosuppression and antibiotics also predispose to the infection, probably because they perturb the normal gut flora. Most transmission occurs in a day care or health care setting, including the hospital.

"We are also seeing new data that infants colonized with C. difficile in the first year of life seem to have higher rates of allergy at up to 5 years old," Dr. McDonald said. "The presence of C. difficile is probably a marker of a perturbation of the child’s intestinal flora and delayed establishment of the normal microbiome," which predisposes to atopy.

Until recently, the treatments of choice have been metronidazole and vancomycin. Although effective for quelling the infection, both have a recurrence rate of 20%-30%. Most recurrences occur soon after treatment, while the microbiota are still off balance, Dr. McDonald said.

A new drug, fidaxomicin, may offer a better solution. Approved by the Food and Drug Administration last May, the drug is not systemically absorbed – a benefit in C. difficile infections. Patients treated with fidaxomicin appear to have a lower recurrence rate – 15% vs. 25% with vancomycin in a phase III trial published earlier this year (N. Engl. J. Med. 2011;364:422-31).

However, Dr. McDonald noted, the drug was not studied in young children.

Dr. McDonald said he had no relevant financial disclosures.

BOSTON – Writing an exercise prescription for obese children may not be child’s play – but it’s not brain surgery, either.

With a basic physical, some creative thinking, and a few caveats, obese children can safely tolerate 60 minutes of moderate to vigorous exercise every day. The rewards can be not only physical, but also psychosocial, as children build self-confidence and friendships.

But it’s not quite as easy as turning kids loose on the playground, Dr. Blaise A. Nemeth said at theannual meeting of the American Academy of Pediatrics.

Obese children have an increased risk of fractures and knee injuries, so pain complaints should be taken seriously, said Dr. Nemeth of the departments of pediatrics and of orthopedics and rehabilitation at the University of Wisconsin, Madison.

An obese child who presents with knee or hip pain may very well have a slipped capital femoral epiphysis. "Have a low threshold for ordering radiographs for the hips to assess this," he said. "It should be the first consideration in an overweight child," who presents with a limp or hip or knee pain.

Fractures also can be an issue with increased exercise. Since obese children aren’t as agile as nonobese kids, they are more prone to falling while exercising. Poor bone quality caused by diet or sedentary lifestyle means that fractures are more likely in a fall. The overlying adipose tissue also can make fracture diagnosis a bit tougher.

Ironically though, increased exercise is one of the best ways to reduce the fracture risk associated with obesity, he said. Exercise improves bone quality; increases muscle strength and coordination; and promotes weight loss – all of which positively affect fracture risk.

Writing an exercise prescription for these children is a three-step process:

• Obtain a baseline health status. A complete physical will identify any reasons to restrict or modify activity. It also provides a jumping-off point for tracking improvement. When children can see their progress on a chart, it helps motivate them to do more.

• Obtain a baseline fitness status. Exercise testing in a lab or under the eye of a trainer gets everyone on the same page with goal setting. It’s important to set reasonable goals, to maximize motivation by achievement, and to minimize discouragement through failure.

• Maintain follow-up visits. Don’t let go of your patient. Regular visits let you monitor health improvements and identify potential problems, like musculoskeletal issues.

Since most pediatricians’ offices don’t come equipped with a gym, it’s crucial to know your community resources. Help children pair up with a coach or trainer who can focus on strength and conditioning, or sport programs. Community centers will probably offer low-cost activity programs and often have a certified trainer on board. Obesity clinics usually offer exercise programs under medical supervision.

But remember, Dr. Nemeth said, that some community or private fitness facilities have age restrictions. "Usually a doctor’s prescription will provide an exception to this," he said. Some facilities and programs require parental involvement or adult supervision, especially for younger children.

It’s also important to fit the program to the child. "Group activities might be motivating, or they might be intimidating," for an obese child.

When looking for results, he advised, don’t get too hung up on the body mass index. BMI reconciles total body weight with height, but it doesn’t differentiate muscle mass from fat mass. "The body composition may change, but this might not be reflected in the BMI," he said. Other measures, including balance, coordination, stamina, and overall health measures, also can be used to assess progress.

Finally, food will continue to factor into the exercise and weight equation. When children get more active, the time available for food consumption (like sitting in front of the television) decreases. But they may be even hungrier as their metabolism revs up through exercise.

"You need to ensure that they get an adequate caloric intake to cover their energy output during exercise," and prevent a post workout binge. And it almost goes without saying, he added, that "food should never be used as a reward."

Dr. Nemeth said he had no relevant financial disclosures.

BOSTON – Writing an exercise prescription for obese children may not be child’s play – but it’s not brain surgery, either.

With a basic physical, some creative thinking, and a few caveats, obese children can safely tolerate 60 minutes of moderate to vigorous exercise every day. The rewards can be not only physical, but also psychosocial, as children build self-confidence and friendships.

But it’s not quite as easy as turning kids loose on the playground, Dr. Blaise A. Nemeth said at theannual meeting of the American Academy of Pediatrics.

Obese children have an increased risk of fractures and knee injuries, so pain complaints should be taken seriously, said Dr. Nemeth of the departments of pediatrics and of orthopedics and rehabilitation at the University of Wisconsin, Madison.

An obese child who presents with knee or hip pain may very well have a slipped capital femoral epiphysis. "Have a low threshold for ordering radiographs for the hips to assess this," he said. "It should be the first consideration in an overweight child," who presents with a limp or hip or knee pain.

Fractures also can be an issue with increased exercise. Since obese children aren’t as agile as nonobese kids, they are more prone to falling while exercising. Poor bone quality caused by diet or sedentary lifestyle means that fractures are more likely in a fall. The overlying adipose tissue also can make fracture diagnosis a bit tougher.

Ironically though, increased exercise is one of the best ways to reduce the fracture risk associated with obesity, he said. Exercise improves bone quality; increases muscle strength and coordination; and promotes weight loss – all of which positively affect fracture risk.

Writing an exercise prescription for these children is a three-step process:

• Obtain a baseline health status. A complete physical will identify any reasons to restrict or modify activity. It also provides a jumping-off point for tracking improvement. When children can see their progress on a chart, it helps motivate them to do more.

• Obtain a baseline fitness status. Exercise testing in a lab or under the eye of a trainer gets everyone on the same page with goal setting. It’s important to set reasonable goals, to maximize motivation by achievement, and to minimize discouragement through failure.

• Maintain follow-up visits. Don’t let go of your patient. Regular visits let you monitor health improvements and identify potential problems, like musculoskeletal issues.

Since most pediatricians’ offices don’t come equipped with a gym, it’s crucial to know your community resources. Help children pair up with a coach or trainer who can focus on strength and conditioning, or sport programs. Community centers will probably offer low-cost activity programs and often have a certified trainer on board. Obesity clinics usually offer exercise programs under medical supervision.

But remember, Dr. Nemeth said, that some community or private fitness facilities have age restrictions. "Usually a doctor’s prescription will provide an exception to this," he said. Some facilities and programs require parental involvement or adult supervision, especially for younger children.

It’s also important to fit the program to the child. "Group activities might be motivating, or they might be intimidating," for an obese child.

When looking for results, he advised, don’t get too hung up on the body mass index. BMI reconciles total body weight with height, but it doesn’t differentiate muscle mass from fat mass. "The body composition may change, but this might not be reflected in the BMI," he said. Other measures, including balance, coordination, stamina, and overall health measures, also can be used to assess progress.

Finally, food will continue to factor into the exercise and weight equation. When children get more active, the time available for food consumption (like sitting in front of the television) decreases. But they may be even hungrier as their metabolism revs up through exercise.

"You need to ensure that they get an adequate caloric intake to cover their energy output during exercise," and prevent a post workout binge. And it almost goes without saying, he added, that "food should never be used as a reward."

Dr. Nemeth said he had no relevant financial disclosures.

BOSTON – Writing an exercise prescription for obese children may not be child’s play – but it’s not brain surgery, either.

With a basic physical, some creative thinking, and a few caveats, obese children can safely tolerate 60 minutes of moderate to vigorous exercise every day. The rewards can be not only physical, but also psychosocial, as children build self-confidence and friendships.

But it’s not quite as easy as turning kids loose on the playground, Dr. Blaise A. Nemeth said at theannual meeting of the American Academy of Pediatrics.

Obese children have an increased risk of fractures and knee injuries, so pain complaints should be taken seriously, said Dr. Nemeth of the departments of pediatrics and of orthopedics and rehabilitation at the University of Wisconsin, Madison.

An obese child who presents with knee or hip pain may very well have a slipped capital femoral epiphysis. "Have a low threshold for ordering radiographs for the hips to assess this," he said. "It should be the first consideration in an overweight child," who presents with a limp or hip or knee pain.

Fractures also can be an issue with increased exercise. Since obese children aren’t as agile as nonobese kids, they are more prone to falling while exercising. Poor bone quality caused by diet or sedentary lifestyle means that fractures are more likely in a fall. The overlying adipose tissue also can make fracture diagnosis a bit tougher.

Ironically though, increased exercise is one of the best ways to reduce the fracture risk associated with obesity, he said. Exercise improves bone quality; increases muscle strength and coordination; and promotes weight loss – all of which positively affect fracture risk.

Writing an exercise prescription for these children is a three-step process:

• Obtain a baseline health status. A complete physical will identify any reasons to restrict or modify activity. It also provides a jumping-off point for tracking improvement. When children can see their progress on a chart, it helps motivate them to do more.

• Obtain a baseline fitness status. Exercise testing in a lab or under the eye of a trainer gets everyone on the same page with goal setting. It’s important to set reasonable goals, to maximize motivation by achievement, and to minimize discouragement through failure.

• Maintain follow-up visits. Don’t let go of your patient. Regular visits let you monitor health improvements and identify potential problems, like musculoskeletal issues.

Since most pediatricians’ offices don’t come equipped with a gym, it’s crucial to know your community resources. Help children pair up with a coach or trainer who can focus on strength and conditioning, or sport programs. Community centers will probably offer low-cost activity programs and often have a certified trainer on board. Obesity clinics usually offer exercise programs under medical supervision.

But remember, Dr. Nemeth said, that some community or private fitness facilities have age restrictions. "Usually a doctor’s prescription will provide an exception to this," he said. Some facilities and programs require parental involvement or adult supervision, especially for younger children.

It’s also important to fit the program to the child. "Group activities might be motivating, or they might be intimidating," for an obese child.

When looking for results, he advised, don’t get too hung up on the body mass index. BMI reconciles total body weight with height, but it doesn’t differentiate muscle mass from fat mass. "The body composition may change, but this might not be reflected in the BMI," he said. Other measures, including balance, coordination, stamina, and overall health measures, also can be used to assess progress.

Finally, food will continue to factor into the exercise and weight equation. When children get more active, the time available for food consumption (like sitting in front of the television) decreases. But they may be even hungrier as their metabolism revs up through exercise.

"You need to ensure that they get an adequate caloric intake to cover their energy output during exercise," and prevent a post workout binge. And it almost goes without saying, he added, that "food should never be used as a reward."

Dr. Nemeth said he had no relevant financial disclosures.