Tag Archives: Pediatric

I usually don’t trash talk, but….

 You should be concerned about the effects of asthma medication on the developing fetus; fortunately, birth defects are rare and often overstated, but you always have to maintain vigilance for new developments.
 
Why the concern about atresia? 
 

Maternal Asthma Medication Use May Cause Certain Birth Defects

Approximately 4% to 12% of pregnant women have asthma. Current clinical guidelines recommend that women with asthma maintain asthma therapy use during pregnancy. These medications act in 2 ways: as bronchodilators or anti-inflammatories. Few studies have examined the effects of maternal asthma medication use on birth defects.

The aim of this study by Lin and colleagues was to examine whether maternal asthma medication use during early pregnancy increases the risk for selected birth defects.  (Pediatrics. Published online January 16, 2012)

Study Synopsis and Perspective

A recent study found a statistically significant increase in the risk for isolated esophageal atresia, isolated anorectal atresia, and omphalocele in infants whose mothers used asthma medications within the month before conception or during the first 3 months of pregnancy.

Shao Lin, PhD, from the Center for Environmental Health, New York State Department of Health, Troy, and colleagues reported their study results in an article published online January 16 in Pediatrics.

The researchers used data collected for the National Birth Defects Prevention Study, an ongoing, multicenter, population-based, case-control study of the causes of birth defects that has been collecting data from 10 states in the United States since 1997 by conducting interviews with mothers and analyzing DNA obtained from cheek swabs from family members. That study includes both infants with 1 or more specified birth defects (diaphragmatic hernia, esophageal atresia, small intestinal atresia, anorectal atresia, neural tube defects, omphalocele, or limb deficiencies) and control infants without those birth defects.

For this study, the researchers analyzed data from a case group consisting of 2853 live births, stillbirths, or elective terminations with estimated dates of delivery from October 1, 1997, through December 31, 2005, and with 1 or more of the identified birth defects. The control group comprised 6726 infants born alive and without birth defects during the same period, randomly selected from birth hospital information or birth certificates.

Dr. Lin’s team concentrated on periconceptional use of anti-inflammatory medications, bronchodilators, or both. They defined exposure as use of asthma medication once or more from 1 month before conception through the third month of gestation. Mothers who described their medication use as only “as needed” and who could not provide an exact time frame for use were excluded from the study.  (This is a good study design to exclude these patients…doesn’t give you biased results for minimal exposure)

The study found a statistically significant association between isolated esophageal atresia and bronchodilator use only (adjusted odds ratio [aOR], 2.39; 95% confidence interval [CI], 1.23 – 4.66). The aORs for esophageal atresia and anti-inflammatory use only (aOR, 1.61; 95% CI, 0.69 – 3.76) and for use of both bronchodilators and anti-inflammatory medications (aOR, 2.93; 95% CI, 0.88 – 9.75) were elevated, but were not statistically significant.

There was a statistically significant increase in the risk for isolated anorectal atresia associated with anti-inflammatory use only (aOR, 2.12; 95% CI, 1.09 – 4.12).

Use of both bronchodilators and anti-inflammatory medications was associated with a statistically significant increase in the risk for isolated omphalocele (aOR, 4.13; 95% CI, 1.43 – 11.95).

The results are not all bad however.  The medications studied were not significantly associated with 6 other birth defects studied (neural tube defects, anencephaly, spina bifida, small intestinal atresia, limb deficiency, and diaphragmatic hernia).

The researchers performed a stratified analysis by time of medication use, using the periconceptional period and the period from the fourth through ninth month of gestation. The positive associations were found only in infants of women who took the medications during the periconceptional period, and not in infants whose mothers took the medications only in the fourth through ninth months of pregnancy. 

My comment—>by the time you know you’re pregnant, you’ve had the exposure!

The authors write that from 60% to 67% of mothers of infants with esophageal atresia, anorectal atresia, and omphalocele used bronchodilators during their entire pregnancy, although these data were not shown.

This is a key point–“With the interview information available for analysis, we were unable to distinguish between the effects of asthma and those of asthma medications; however, we did observe that mothers with possible indicators of uncontrolled asthma or severe asthma episodes (eg, use of multiple bronchodilators) were at higher risk for delivering a child with 1 of the defects studied than those who used 1 bronchodilator,” the authors write.

“When regular use of bronchodilators is required, an activated inflammatory process is implied; thus, use of bronchodilators throughout pregnancy might indicate that these mothers had frequent or ongoing inflammatory exacerbations during pregnancy,” they add.

Noting the importance of controlling asthma during pregnancy, the authors write, “The current clinical guidelines and specific recommendations for aggressive asthma management during pregnancy should remain unchanged.”

“Given the low baseline prevalence of these defects, if the observed association proved to be causal, the absolute risks of asthma medications on these rare defects would be small,” they conclude.

The study was supported by the Centers for Disease Control and Prevention. The authors have disclosed no relevant financial relationships.

Clinical Implications

  • Clinical guidelines recommend that women with asthma maintain asthma medication use during pregnancy.
  • In the current study, positive associations were observed for anorectal atresia, esophageal atresia, and omphalocele and maternal periconceptional use of asthma medications, but not for other birth defects studied.

You must want to know how to treat esophageal atresia?

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Complementary medicine to treat Asthma?

I have a story for you….but first, “traditional” medicine is trying very hard to work with other methods for treating asthma.  The web page below reviews treatment of asthma using something other than “inhalers“.  Now on to the story….

I am a member of the Complementary Medicine Committee of the American Academy of Allergy, Asthma, & Immunology (that’s a mouthful).  We met last month to discuss better ways to “integrate” traditional health care with Chinese medicine for instance.  Another member of the group had studied accupressure in China before coming to the United States 20 years ago.  When she first arrived, while on rounds she intervened using accupressure with a parent experiencing asthma.  The “attack” stopped immediately.  Later on that day, her attending physician who happened to be the chairman of Pediatrics, called her in his office and let her know that further intervention using accupressure would not be tolerated and she would be dismissed from the training program if this ever happened again. 

I’m glad times have changed and this type of intimidation is rare; what are your thoughts about integration of traditional and other forms of complementary medicine?  The government is putting together a great effort to see this happen.  See below.

Complementary treatment & asthma

New Year’s Resolution–Who Should start Controller Meds?

New Year’s resolution!

I don’t like New Year’s Resolutions–if I don’t do something everyday, how is a resolution going to change my priority?  Behold…I bring you good tidings of great joy…taking regular PREVENTATIVE medication works the same way! 

So what’s the issue at hand?  Patients with asthma often want to stop preventive medication for the cough & wheeze.  I often hear…I don’t need it, only to suffer from an asthma attack with their next cold.  What are some useful strategies to improve asthma care in this regard?

 From the American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition: Abstract 14793. Presented October 14, 2011: 

American Academy of Pediatrics
  • Pediatricians strongly support the recommendation that emergency department (ED) physicians start asthma controller medications during an acute visit to the ED, according to research presented here at the American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition.
  • Why in the emergency room?  It’s the best time to have that one-on-one discussion with asthma patients.  You have their attention.

National asthma guidelines recommend that ED physicians consider initiating long-term controller medications when children present with an acute asthma attack. We all (I mean physicians) follow the guidelines, right?  Think again!

  • Many ED doctors are reluctant to do so, lead author Esther Maria Sampayo, MD, MPH, from the University of Pennsylvania School of Medicine, Philadelphia, said in an oral abstract session.
  • “One AAP study noted that less than 20% of ED doctors actually do this,” Dr. Sampayo told Medscape Medical News. “When you ask them why, they say it’s not their role to be the pediatrician and they shouldn’t be providing long-term management.”

If you don’t know the answer….then let’s find out.  The researchers did a cross-sectional mail survey of a randomly selected national sample of pediatricians involved in providing primary care from the AAP.

  • Of the 527 pediatricians who responded to the survey, 83% reported that they feel it is appropriate for the ED physician to initiate controller medications.
  • Just 23% of pediatricians reported that their patients “almost always” follow-up within 1 month after an ED visit. Makes you wonder what else gets “missed!”
  • Half (51%) of those surveyed believe that having ED physicians prescribe controller meds in the ED will encourage patients to follow-up. 
  • The survey also asked the pediatricians what they consider to be the benefits of having ED physicians initiate asthma controller medications. Most (85%) feel that it is a “teachable moment” and represents an important opportunity to capture patients who are poorly controlled.  Strike it while the iron is hot!

    Strike When the Iron is Hot!

Noah Kondamudi, MD, an asthma specialist in the Pediatric Emergency Department of the University of Medicine & Dentistry of New Jersey in Newark, said that in his experience, more and more ED doctors are prescribing asthma controller medications when children present with acute asthma.

Here in Oklahoma, no data is available on prescribing habits of emergency room physicians for asthma controller meds or the opinion of local pediatricians.  Do I hear a study that needs to be done?

“In general, emergency room doctors would not want to add to or change the primary care doctor’s chronic disease plan. However, more and more data are showing that many asthmatic children are not on controller medication, so initiating controller therapy should make a big difference,” he said.

My thanks to Fran Lowry who is a freelance writer for Medscape.  She has disclosed no relevant financial relationships.

The More Ya Know, the Less Ya Know!

I have just returned from the Annual Meeting of the American College of Allergy, Asthma, and Immunology held in Boston from Nov 3-8.  Sure the meeting was good, but the food was even better.  Consider the oldest “active” restaurant in America, Union Oyster House–the stew was delightful and if you’re bored with allergies, peruse the menu on-line and dream of dining with JFK (he has a booth in his name there). 

On to what’s new in allergy & asthma….

My, how things have changed!

Environmental Tobacco Smoke

Smoking bans in Tulsa have stirred some vigorous debate this year (see link).  Most importantly, do they work? Information presented last week would suggest a resounding YES!  In the U.S. more than 200,000 asthma admissions per year are attributed to Environmental Tobacco Smoke (ETS). Smoking bans can prevent this complication!  The Scottish health system has the database to measure the effects of a community-wide smoking ban and their intervention was associated with an 18% reduction in hospital admissions for asthma (NEJM 2010). Wow

If you have to smoke inside, HEPA filters reduced asthma visits in 6-12-year-old children by 18%.

VCD–Vocal Cord Dysfunction

I have a post on this blog describing VCD or paradoxical vocal cord motion.  Our terminology is now changing and instead of VCD, I like the term” irritable larnyx syndrome (WILS).”  The vocal cords are “housed” in the larynx and many structures and muscles have to work correctly in order for the vocal cords to allow air in and out of the lungs. This implies that multiple triggers will cause an attack and patients with difficult asthma may have a laryngeal dysfunction not just VCD. If you don’t believe me, look at this study.  World-wide recognition (AJRCCM, a study from Australia).

Tiotropium–alias Spiriva

Way too many choices in the treatment of asthma!  Why would you consider Tiotropium or Spiriva for asthma?

Picture says 1,000 words!

1.  Tiotropium works as step-up therapy in adult asthma.  Some patients just can’t tolerate albuterol or Xopenex™ because of tremor and other side effects.  Now you have an alternative: There were similar improvements in lung function and symptom-free days with Spiriva as adding long acting bronchodilator (NEJM 2011).

2.  Tiotropium does fit into the Asthma Guidelines (2007) and works better than increasing the dose of inhaled steroids (yea, less steroids) and is equal to salmeterol (Serevent).

3.  This report is from England, so BEWARE!  The Respimat inhaler isn’t used in the United States and should you read about this study, it doesn’t apply to patients in the US.  (Recent BMJ meta-analysis showed increased cardiovascular mortality with that formulation in COPD) (BMJ, 2011).Anti IL-13 (lebrikuzumab)–Did you say leprechaun?

There is one take home message with the use of lebrikuzumab:

1.  Personalized medicine is here!  In this study, patients that improved with anti IL-13 also had elevated levels of periostin in blood tests. Periostin is a marker of airway remodelling and gives us a clue as to why and how IL-13 contributes to asthma.  Lebrikizumab improved FEV1, but there was no improvement in symptoms or medication use (NEJM 2011).

Antibiotics

This comes from the literature review at the College meeting—1 of every 6 children with asthma seen the ED are prescribed antibiotics. Don’t you think this is high for a “practice” that is supposed to be very selective in who gets antibiotics?  Generally, antibiotics are not helpful in asthma anyway. More than 2 courses of antibiotics for cough in a 6-month time frame should warrant consideration of asthma as a cause (Pediatrics, 2011).

Mold allergy

In a study in Arizona, Fernandez et al. showed skin testing to Alternaria to be surprisingly accurate.  Ninety-six percent of patients with a positive skin test to this mold had a positive bronchial provocation test with Alternaria. In Arizona, Alternaria has surpassed dust mite as number one allergen in asthma (due to dry climate).  I wonder what results would be in Oklahoma?  Here’s what alternaria looks like: 

Alternaria under a microscope
Alternaria in real life

Immunotherapy

Come on now, do allergy shots REALLY work? Shots with dust mite allowed for inhaled steroid reduction by 50% in children with asthma vs. 30% in controls. Not bad! Do I have to take my medication with shots? Adding dust mite shots to pharmacologic treatment was an effective and safe strategy to reduce corticosteroid doses while maintaining disease control in children with mite-induced allergic asthma (JACI 2011).

Asthma

Which inhaled steroid to use?  Does it matter?  QVAR™ & Alvesco™ have said for quite some time that small particles penetrate the airways of an asthmatic better than the competition.  They may be right– small particle size inhaled steroids may allow for equal efficacy (benefit) with 1/2 to 1/3 the dose of a larger size of same steroid. Marketing isn’t bad, sometimes it’s just delayed results.

SABA update: Levalbuterol (Xopenex™) may not have any real-life advantages over albuterol. Even in the Xopenex™ package insert, there is  mention that there was no difference in heart rate or tremor.  In patients who swear by Xopenex™, there’s no reason to change, just start out with cheaper albuterol. 

Antihistamines for asthma?

Many patients take antihistamines every day like vitamins.  They feel better if an antihistamine is “on-board.”  Once again, learn from your patient….they will often give you clues to what medications work.  Symptom scores in asthma patients show comparable improvement when given desloratadine (antihistamine) compared to montelukast. Use of antihistamine may prevent the development of asthma in some predisposed children.  Well I’ll be….

Grandpa can’t breathe!

Asthma in the elderly

The majority of asthma deaths are in patients older than 65.

Asthma in adults/elderly is still predominantly an atopic disease. This means, it’s still due to allergy.  Don’t forget to test your older population.  In a University of Michigan study, 77% of adult asthma patients were skin test positive.

Depression is definitely underdiagnosed in our loved ones who have retired (ie, grandma & grandpa).  Why? They should have a carefree life during retirement, but they don’t. Depression is a significant factor for poor asthma quality of life in the elderly. You are 10x more likely to suffer from psychological dysfunction if you have more than 3 exacerbation of asthma in a single year. 

Just goes to show you that allergic respiratory disease is a very complicated condition and every year I’m challenged with new treatments!  I can’t ask for anything more.