Blaming Reflux for BRUEs -Not Changing Despite Guideline Recommendations

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Briefly noted: DR Duncan et al. J Pediatr 2019; 211: 112-9.

In this retrospective cohort study of infants with brief resolved unexplained events (BRUEs) at Boston Children’s Hospital, the authors examined guideline implementation among 359 subjects in the year before and the year after AAP guidelines.

Key findings:

  • There were no significant changes in practice after guideline publication
  • Only 13% had videofluoroscopic swallow study performed; 72% of these showed aspiration/penetration
  • No subject had reflux testing, “yet reflux was implicated as the cause” for BRUE in 40%. Children continued to be “discharged on acid suppression despite lack of efficacy”

My take: The pendulum is (slowly) starting to swing back from blaming everything (including BRUEs) on reflux but this change is not evident in this study.

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Ensuring Safe Infant Formula Use -More Complicated Than You Think

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A recent commentary (SA Abrams, SR Daniels. J Pediatr 2019; 211: 201-6) highlight some important issues regarding infant formula use/misuse.

The authors indicate that their commentary is not intended to undermine the use of breastmilk in infants.  However, they note that only about 25% of infants are exclusively breastfed until 6 months of age; thus, utilizing formula appropriately is crucial.

Annual Costs per article estimates (based on powder formula):

  • $1109 generic store-brand formula
  • $2021 name-brand routine formula
  • $222 Typical out-of-pocket for WIC clients –store brands (this assumes about 20% of formula is not covered by WIC)
  • $404 Typical out-of-pocket for WIC clients –name brands (this assumes about 20% of formula is not covered by WIC)
  • $215 Whole cow milk (not recommended)

Key points:

  • The authors discuss the role of the WIC program which is a supplemental program –does not provide 100% of an infant’s needs.
  • They describe deceptive formula marketing practices and the difficulty of ascertaining the best value of formulas.  In addition, “marketing of more expensive formula choices as having unique health benefits can easily lead families to spend more money than might be necessary” based on “meaningless” claims of being ‘closest to mother’s milk.’
  • Additives such as oligosaccharides and formulas marketed as organic or free of genetically modified organisms can be used to increase the cost of formula.
  • Use of WIC has decreased by 15% from 2010 to 2017; some may be related to fears related to immigration status of some WIC recipients.
  • Families faced with increased costs may dilute formula or use inadequate substitutes (eg. juice, cow’s milk, prepare home-made alternative)
  • Recent government shutdown placed many infants at risk.

Mistrust Concerns:

  • Many families, abetted by social media, have become distrustful of standard formulas as well as government and even pediatrician advice.
  • There has been an increase in importation of foreign formulas, especially from Europe.  THESE FORMULAS ARE NOT FDA MONITORED OR APPROVED. These illegally imported formulas have no proven advantages and their safety has not been ensured.  They do not undergo routine testing for 30 nutrients which are required by FDA monitored formulas.
  • Raw cow’s milk and raw goat milk have been promoted to ‘improve immune or gastrointestinal function.’ These products have no scientific proof of any advantage and place infants at risk as they are unpasteurized and nutrient deficient.

Author Recommendations:

  • Provide educational programs focused on formula feeding for medical providers and families
  • Increase information and regulation from government and industry about contamination issues
  • Protect the WIC program from consequences of potential government shutdown
  • Mandate improved price clarity
  • Fund research into all aspects of formula feeding, including behavioral interventions to limit inappropriate formula use
  • Monitor social media and provide correct information

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Outside Portland, OR

Psoriasis Due to Infliximab –Latest Data

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Briefly noted: O Courbette et al. JPGN 2019; 69: 189-93. In a retrospective review, among 147 children with inflammatory bowel disease treated with infliximab (IFX) (123 CD, 24 UC), 20 patients (13.6%) developed psoriaform rashes.  14 of 20 were in remission when skin rashes (especially on scalp) occurred and rash developed at median of 355 days.  In this cohort, all were controlled by local steroids; no patients required IFX discontinuation.

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Wahkeena Falls Trail, OR

Expanding Feeding Programs for Children with Autism

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A recent pilot (38 children) study (WG Sharp et al. J Pediatr 2019; 211: 185-92) examined the effectiveness of a less intensive feeding program to help children with autism and food selectivity.

Background:  Many children with autism are extremely picky eaters.

  • They may limit their diet to a ‘beige diet’ consisting of foods like chicken nuggets and fries.
  • They may insist on only pureed textures
  • They may demand only specific foods and limit to specific brands

To normalize these diets, typically intensive structured feeding programs are needed.  However, these types of programs are costly, and not available in all communities. Parental training though the MEAL (Managing Eating Aversions and Limited variety) Plan was studied by the authors.  This program consisted of 10 core and 3 booster sessions.

Key finding:

  • At week 16, positive response rates on the Clinical Global Impression Improvement scale was 47.4%for the MEAL plan compared to 5.3% in a control parent education plan.

My take: This pilot study shows that less intensive programs may be helpful in children with autism and feeding problems.  However, even with this more limited MEAL plan, a multidisciplinary team with a dietitian plan for each child along with behavior management strategies was needed.

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Artwork near Krog Street Market

What Doctors Could Do Together (Organized)

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A recent commentary (recommended by one of my sons) by Eric Topol discusses how doctors could be organized to advance the practice of medicine, address the deterioration in doctor-patient relationships, and focus on the needs of patients, whereas current medical organizations are mainly focused on the business interests of medical practice.

An excerpt from Why Doctors Should Organize:

“It’s possible to imagine a new organization of doctors that has nothing to do with the business of medicine and everything to do with promoting the health of patients and adroitly confronting the transformational challenges that lie ahead for the medical profession. Such an organization wouldn’t be a trade guild protecting the interests of doctors. It would be a doctors’ organization devoted to patients. Its top priority might be restoring the human factor—the essence of medicine—which has slipped away, taking with it the patient-doctor relationship. It might oppose anti-vaxxers; challenge drug pricing and direct-to-consumer advertisements; denounce predatory, unregulated stem-cell clinics; promote awareness of the health hazards of climate change; and call out the false health claims for products advocated by celebrities such as Gwyneth Paltrow and Mehmet Oz. This partial list provides a sense of how many momentous matters have been left unaddressed by the medical profession as a whole…

Because of the unique technological moment at which we live, we may not see an opportunity like this one for generations to come. We have a chance to affect the future of medicine; to advocate for patient interests; to restore the time doctors need to think, to listen, to establish trust, and build bonds, one encounter at a time. For these purposes, and in these times, an organization of all doctors is necessary. Rebuilding our relationships with our patients: that is our lane.”

“Pistol Butt” Pine. Tree takes on this shape due to heavy snowfall leaning on tree at early stage. Crater Lake, Oregon.

Is Cognition Affected by Obesity/Metabolic Disease?

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A recent provocative study : “Childhood Metabolic Biomarkers Are Associated with Performance on Cognitive Tasks in Young Children” ALB Shapiro et al. J Pediatr 2019; 211: 92-7

Methods: Data were obtained from children (n=137, 4.6 years old on average) participating in the Healthy Start study, a pre-birth cohort in Colorado. This included metabolic markers (HOMA-IR, glucose, insulin) and cognitive performance markers (Flanker task, Dimensional Change Card Sort test (which assesses cognitive flexibility), and Picture Vocabulary test).

Key findings:

  • HOMA-IR, glucose, and insulin were all inversely significantly-associated with cognitive flexibility testing. Thus, the authors found that “greater blood biomarkers of poor metabolic health are related to lower cognitive flexibility and inhibitory control in healthy, young children.”

Discussion:

  • The authors note that their findings “contribute to the large body of literature in children with overt type 1 and type 2 diabetes that demonstrates consistent and negative effects of poor metabolic health on cognition.”
  • The metabolic effects on cognition may be more critical in childhood due to brain maturation as well as potential for longer exposure periods.  However, studies from adults indicate that “adults without overt diabetes, the cumulative burden of metabolic conditions (eg. obesity, hyperglycemia) was significantly associated with lower cognitive scores.”

My take: While the effects of metabolic disease on cardiovascular disease is well-recognized, this study adds to the body of knowledge that indicates the potential harm of metabolic disease on the brain as well.

Near Chattahoochee River

An Insurance Company Doing the Right Thing (with Calprotectin)

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“An Insurance Company Doing the Right Thing” –not The Onion headline this time.

Recently (April 7. 2019) United Healthcare put out a policy statement explicitly stating:

“Fecal measurement of calprotectin is proven and medically necessary for establishing the diagnosis or for management of the following:

  • Crohn’s Disease
  • Ulcerative Colitis”

Thanks to Kim Conn for identifying this policy.

The policy statement provides an in-depth rationale for why calprotectin is medically-indicated along with supporting recommendations from multiple GI societies and National Institute for Health and Care Excellence (NICE).  The policy statement includes a long list of references and would provide a strong argument in supporting calprotectin testing for all insurance providers.

Here’s the link: FECAL CALPROTECTIN TESTING United Healthcare.

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Lots of lazy river floating. Deschutes River, Bend OR

Declining and Aging Rural Physician Workforce

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A recent article (L Skinner et al NEJM 2019; 381: 299-301) provided data regarding the worsening disparity in physician availability in rural areas.

Key points:

  • “While the total number of rural physicians grew only 3% (from about 61,000 in 2000 to 62,700 in 2017), the number of physicians under age 50 years living in rural areas decreased by 25%.”
  • “By 2017, more than half of rural physicians were at least 50 years old, and more than a quarter were at least 60.” In urban areas, the numbers were 39% and 18% respectively.
  • It is projected that instead of the current 12 physicians per 10,000 population in 2017 there will be a drop of 23% (9.4 per 10,000) in 2030 in rural areas; in contrast, nonrural physicians supply will be essentially the same in 2030 (29.6 per 10,000) as current supply (30.7).
  • The fact that there will be one-third fewer physicians is coupled with the fact that rural areas have populations that are older, poorer, worse health, lower life expectancy, and less insurance coverage

My take: This report highlights the current disparity in rural health care and how this is worsening as the rural physician population ages.

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Risk Factors for Progressive, Fibrotic Fatty Liver Disease

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Briefly noted: A recent study (A Mosca et al. J Pediatr 2019; 211: 72-7) examined 182 obese/overweight children with nonalcoholic fatty liver disease (NAFLD). 137 (75.3%) had liver fibrosis. 39 had fibrosis level ≥2 (21.4%)

Risk factors for liver fibrosis:

  • Not being breastfed OR 3.1
  • Parenteral obesity OR 2.9
  • PNPLA3 (palatin like phospholipase domain-containing 3) GG (1148M) variant OR 2.1
  • Fructose consumption (OR 1.6 per 1 g/day increase)
  • Vitamin D deficiency (25-OH <20 mg/dL) OR 1.24
  • A high socioeconomic status was inversely associated with fibrosis OR 0.3

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