Plasma 25-hydroxyvitamin D levels in young children undergoing placement of tympanostomy tubes

OBJECTIVES

We report the plasma 25-hydroxyvitamin D [25(OH)D] levels of 16 young children who were undergoing ambulatory surgery for placement of tympanostomy tubes.

METHODS

We previously obtained blood samples from young children who were undergoing ambulatory surgery and reported that they had lower blood levels than adults of eicosapentaenoic acid (an omega-3 fatty acid), vitamin A, and selenium. Plasma frozen continuously at -80 degrees C was available from 16 subjects who were undergoing placement of tympanostomy tubes.

RESULTS

The mean (+/- SD) age of the patients was 3.7 +/- 1.6 years (median, 2.9 years; range, 1.9 to 7.4 years). Sixty-two percent were male; half were white, and half were Hispanic. Sixty-two percent were private patients; the parents reported that half were taking vitamin supplements. None had a history of rickets. None had 25(OH)D levels less than 10 ng/mL; 50% had 25(OH)D levels less than 20 ng/mL (deficient in adults); another 31% had levels from 21 to 29 ng/mL (insufficient in adults).

CONCLUSIONS

Vitamin D is essential for the production of endogenous antimicrobial peptides, and has been linked to seasonal, epidemic influenza A. However, the level of 25(OH)D needed to prevent infection with various human pathogens has not been defined. In view of increasing bacterial resistance and emerging new pathogens, further research on the relationship of infection to 25(OH)D and other nutritional factors is warranted.

Effect of daily cod liver oil and a multivitamin-mineral supplement with selenium on upper respiratory tract pediatric visits by young, inner-city, Latino children: randomized pediatric sites

We studied the effect of daily supplementation with lemon-flavored cod liver oil and a children's multivitamin-mineral supplement containing selenium on the number of pediatric visits by young, inner-city, Latino children from late autumn of 2002 through early spring of 2003. Two private pediatric offices with similar demographics, located 1.1 miles apart in upper Manhattan, New York City, were randomized to a supplementation site and a medical records control site. Ninety-four children (47 at each site), 6 months to 5 years of age, were enrolled. The mean age of the supplementation group was 2.03 years (SD, +/- 1.04 years); that of the control group was 2.08 years (SD, +/- 1.10 years). Children > or = 1 year of age in the supplementation group received 1 teaspoon of lemon-flavored cod liver oil per day and one half-tablet of a children's multivitamin-mineral; the starting dose was halved for children < 1 year of age. The supplements were given from enrollment through May 1, 2003. The primary outcome measure was the number of upper respiratory tract pediatric visits during the follow-up/supplementation period. The supplementation group had a statistically significant decrease in the mean number of upper respiratory tract visits over time (p = .042; r = 0.893; y = 0.602 - 0.002x); the medical records control group had no change in this parameter (p = .999; r = 0.0006; y = 0.259 + 1.43 x 10(-6)x). The supplements were well tolerated; per parental report, 70% of children completed the 5- to 6-month course of cod liver oil. Use of these nutritional supplements was acceptable to the inner-city Latino families and their young children, and was associated with a decrease in upper respiratory tract pediatric visits over time; this approach therefore deserves further research and attention.

Nutritional supplements as adjunctive therapy for children with chronic/recurrent sinusitis: pilot research

OBJECTIVE

Inflammation and edema of the sinonasal mucosa are important in the pathophysiology of sinusitis. Based on the similarities between otitis media (OM) and sinusitis, and our previous research on OM, we hypothesized that nutritional supplements would be effective adjunctive therapy for the treatment of children with chronic/recurrent sinusitis.

METHODS

We performed a 4 month, open-label, dose-titration study; subjects were enrolled from late January to early March 2003. Each subject served as his own control. Study supplements were a lemon-flavored cod liver oil and a children's multivitamin-mineral with selenium, prescribed in escalating doses; at higher doses, fish oil was substituted for cod liver oil. Subjects were private pediatric otolaryngology outpatients with a clinical diagnosis of chronic/recurrent sinusitis, whose symptoms were refractory to treatment with antibiotics.

RESULTS

Our four subjects were Caucasian males, ranging in age from 4.2 to 9.8 years, with chronic/recurrent sinusitis for at least 3 years prior to entry in the study. Three subjects had a positive response; one subject dropped out for administrative reasons. Four, six, and eight weeks after beginning study supplements, the responders had decreased sinus symptoms, fewer episodes of acute sinusitis, and fewer doctor visits for acute illnesses. Their parents reported that they had begun to recover from upper respiratory illnesses without complications, which was unusual for these children, as was improvement in springtime; their improvement had previously been limited to the summer months or periods of home-schooling.

CONCLUSIONS

Use of flavored cod liver oil and a multivitamin-mineral with selenium as adjunctive therapy for children with chronic/recurrent sinusitis is an inexpensive, non-invasive intervention that clinicians can use for selected patients, pending the performance of definitive, large, well-controlled studies.

Lemon-flavored cod liver oil and a multivitamin-mineral supplement for the secondary prevention of otitis media in young children: pilot research

We measured blood levels of fatty acids, vitamin A, and trace metals in children undergoing ambulatory surgery for placement of tympanostomy tubes and a comparison group having other ambulatory surgical procedures. We then performed a small, outpatient, secondary prevention study using nutritional supplements chosen on the basis of those blood levels. The study subjects had lower levels of red blood cell eicosapentaenoic acid (EPA) than did adult controls. Consistent with previous reports, the levels of vitamin A were < or = 40 microg/dL for 69% of our subjects, and the plasma selenium levels for children were lower than published values for adults. We then studied one otitis media (OM) season; 8 children (0.8 to 4.4 years of age) received 1 teaspoon of lemon-flavored cod liver oil (containing both EPA and vitamin A) and 1 half-tablet of a selenium-containing children's chewable multivitamin-mineral tablet per day. During this OM season, study subjects received antibiotics for OM for 12.3% +/- 13.4% (SD; p < .05) fewer days during supplementation than before supplementation. Larger, controlled trials are warranted to assess the utility of cod liver oil (of acceptable purity and taste) and a children's multivitamin-mineral preparation containing selenium, both for the prevention of OM and for the acceptance of delayed prescription of antibiotics for this disorder.

Famotidine treatment of children with autistic spectrum disorders: pilot research using single subject research design

Using single subject research design, we performed pilot research to evaluate the safety and efficacy of famotidine for the treatment of children with autistic spectrum disorders. We studied 9 Caucasian boys, 3.8-8.1 years old, with a DSM-IV diagnosis of a pervasive developmental disorder, living with their families, receiving no chronic medications, and without significant gastrointestinal symptoms. The dose of oral famotidine was 2 mg/kg/day (given in two divided doses); the maximum total daily dose was 100 mg. Using single-subject research analysis and medication given in a randomized, double-blind, placebo-controlled, cross-over design, 4 of 9 children randomized (44%) had evidence of behavioral improvement. Primary efficacy was based on data kept by primary caregivers, including a daily diary; daily visual analogue scales of affection, reciting, or aspects of social interaction; Aberrant Behavior Checklists (ABC, Aman); and Clinical Global Improvement scales. Children with marked stereotypy (meaningless, repetitive behaviors) did not respond. Our subjects did not have prominent gastrointestinal symptoms and endoscopy was not part of our protocol; thus, we cannot exclude the possibility that our subjects improved due to the effective treatment of asymptomatic esophagitis. The use of famotidine for the treatment of children with autistic spectrum disorders warrants further investigation.

Trivalent chromium and the diabetes prevention program

The Diabetes Prevention Program is a new, 150 million dollar, NIH-sponsored study designed to determine whether non-insulin-dependent diabetes mellitus can be prevented or delayed in persons with impaired glucose tolerance. Four thousand subjects will be randomly assigned to one of four study groups and followed for 4.5 years. Study groups include intensive lifestyle intervention with diet and exercise; metformin (Glucophage) or troglitazone (an investigational drug) with standard diet and exercise; and a control group. Insulin resistance is an important pathogenic factor in impaired glucose tolerance. Trivalent chromium, a dietary supplement that potentiates the action of insulin, was not included in the program. Like metformin and troglitazone, trivalent chromium decreases insulin resistance and has an acceptable side-effect profile; furthermore, it is available at a fraction of their cost. Trivalent chromium should have been included in the Diabetes Prevention Program; it is unfortunate that it was omitted.

Oral famotidine: a potential treatment for children with autism

Famotidine (Pepcid, a histamine-2 receptor blocker, is marketed for the treatment of peptic ulcer disease, gastroesophageal reflux, and the treatment of pathological hypersecretory conditions, including the Zollinger-Ellison syndrome. Recent reports indicate that it is also effective in relieving the deficit (or withdrawal) symptoms of adults with schizophrenia. Autism, a neuropsychiatric disorder which presents within the first few years of life, is defined by deficient social interaction, communication, language, play, and a markedly restricted repertoire of activities and interests. Similarities between the deficit symptoms of schizophrenia and the social deficit symptoms of autism suggest the hypothesis that famotidine may be useful in treating children with autism. Histamine serves as a neurotransmitter and neuromodulator in the brain. H2-receptors in the brain predominantly transmit inhibitory signals; when these receptors are stimulated in animals, spontaneous activity and exploratory behavior decrease; blockade of H2-receptors would therefore be expected to reverse this inhibition.

Free radical scavenging enzyme activity and related trace metals in clozapine-induced agranulocytosis: a pilot study

We hypothesized that patients who had experienced clozapine-induced agranulocytosis would have abnormalities in their free radical scavenging enzyme activity (FRESA) and levels of related trace metals. We therefore measured FRESA profiles and related trace metals in four groups: post-clozapine agranulocytosis (POST CLOZ AGRAN) (N = 9); clozapine no agranulocytosis (CLOZ NO AGRAN) (N = 12); West Coast controls (WC CONTROLS) (N = 14); and Long Island Jewish Medical Center controls (LIJ CONTROLS) (N = 12). Glutathione peroxidase (GSH-Px, P1) levels in plasma were slowest in the POST CLOZ AGRAN group (34.3 +/- 6.9 IU/dl [standard deviation; SD]; p < 0.002); red blood cell glutathione peroxidase (GSH-Px, RBC) was highest in the WC CONTROLS (38.7 +/- 4.7 IU/g hemoglobin [Hgb]; p < 0.008); and selenium (SE) levels in plasma were lower in both the POST CLOZ AGRAN group (111.6 +/- 14.7 ng/ml) and the CLOZ NO AGRAN group(115.0 +/- 17.8) than in the WC CONTROLS (142.5 +/- 18.3; p < 0.0006). SE was also lower in the POST CLOZ AGRAN group than in the LIJ CONTROLS (129.1 +/- 21.6; p < 0.04). The presence of at least one of the following: (1) GSH-Px, P1 < 37.6 IU/dl; (2) GSH-Px, RBC < 31.0 IU/g Hgb; or (3) SE < 112.4 ng/ml, distinguished POST CLOZ AGRAN subjects from the WC CONTROLS, but not from the LIJ CONTROLS. Data from this cross-sectional pilot study suggest that abnormalities in the body's antioxidant defense system may be involved in the pathogenesis of clozapine-associated agranulocytosis. If confirmed in large-scale, prospective studies, these preliminary findings have potential clinical application in the screening and prophylaxis of clozapine agranulocytosis.

Developmental changes in renal tubular function

Use of the standard measure of renal function, glomerular filtration rate when corrected for body size, indicates fully functional renal capacity by one year of age, which remains relatively constant until the fourth decade of life, when it begins to gradually decline with advancing age. The active tubular secretion and reabsorption of cations and anions provide an occasion for drug interactions which are difficult to predict without knowledge of the exact mechanisms involved. Data support developmental changes in net tubular secretion for some substances. For digoxin, the larger ratio of digoxin clearance to creatinine clearance that is observed in children decreases during adolescence to the lower ratio observed in adults, and this decrement is better correlated with sexual maturation than with chronologic age. Thus for drugs with significant renal excretion of active drug or metabolite, the clarification of net renal tubular mechanisms would provide important clinical information.

Maternal reports of pregnancy, genital, and related fantasies in preschool and kindergarten children

OBJECTIVE

To test the hypothesis that there is no difference in the proportion of young boys with pregnancy fantasies versus young girls with penis fantasies and to explore the prevalence of pregnancy, genital, and related fantasies in 2-through 6-year-old children.

METHOD

The parents of 171 preschool and kindergarten children attending two private schools in New York City received questionnaires regarding the above fantasies. They were completed by the mothers of 31 girls and 34 boys (overall response rate of 38%).

RESULTS

There was no statistically significant difference in the proportion of girls reported to have penis/gender fantasies and the proportion of boys reported to have pregnancy fantasies. Reports of at least one fantasy were more common for girls (p < .006), as were reports of breast-feeding, other nurturing, and other reproductive fantasies (p < .03) and reports of wanting to urinate like a boy (p < .05). Reports of an "interest" in vaginas and breasts, as opposed to a fantasy about having them, were more common in boys (p < .03).

CONCLUSION

These data support the "overinclusive phase" of Fast's differentiation model of gender identity. Developmentally appropriate androgynous fantasies must be distinguished from gender identity disorder, a psychiatric condition that can emerge in the same age group.

Pubertal changes in net renal tubular secretion of digoxin

To evaluate the effect of puberty on the net renal tubular secretion of digoxin, we measured the ratio of digoxin clearance to creatinine clearance in 23 patients aged 4 to 21 yr and correlated this ratio with both sexual maturity (Tanner stage) and chronologic age. All subjects were at steady-state levels for digoxin treatment; all had normal serum creatinine values for age as well as normal serum potassium levels. Mean ratio for immature children (n = 14, Tanner 1 through 3.5) was 1.45 +/- 0.66. Mean ratio for mature adolescents (n = 9, Tanner 4 through 5) was 0.95 +/- 0.28. The difference between the two groups was significant (P less than 0.05). When patients were regrouped by age using either 13 or 15 yr as a cutoff, the difference in ratios was no longer statistically significant. Based on 45 subjects (new and from our previous study) aged 2 mo to 80 yr, there was a significant decrease in the clearance ratio with increasing age, but when the 23 subjects aged 4 to 21 yr were analyzed separately, the correlation between ratio and age was not significant. It appears that the decrease in net renal tubular secretion of digoxin from childhood to adulthood correlates better with full sexual maturation at puberty (Tanner 4 through 5) than with chronologic age. This observation may represent a developmental change in pharmacokinetics with broader significance than for digoxin disposition alone.

Noninvasive diagnosis of persistent fetal circulation versus congenital cardiovascular defects

Congenital cardiovascular anomalies associated with right-left atrial or ductal shunts must be excluded before a diagnosis of persistent fetal circulation (PFC) can be made. Despite the advent of 2-dimensional echocardiography (2-D echo), this differentiation can be difficult and may require cardiac catheterization with selective angiography. Fifteen consecutive cases were analyzed in which difficulty was encountered with this differential diagnosis, and experience with the use of cardiac auscultation, the 12-lead electrocardiogram (ECG), arterial blood gas determinations and 2-D echo, both alone and with injection of venous contrast material, is reviewed. Electrocardiographic abnormalities of ventricular axis, hypertrophy or dominance (p = 0.002) and suspicion of cardiovascular disease on 2-D echo (p = 0.011) were the most useful findings in differentiating patients with PFC from those with congenital cardiovascular abnormalities. The ECG was the most sensitive test (100% sensitivity, 90% specificity), while 2-D echo was the most specific (100% specificity, 75% sensitivity). Evidence of right-left shunting at atrial or ductal levels or both did not differentiate between the groups; both groups had evidence of such shunts. A decision tree was developed to facilitate this differential diagnosis, which uses the ECG and 2-D echo. If the ECG reveals no abnormalities of ventricular axis, dominance or hypertrophy, the 2-D echo shows no structural abnormalities, and total anomalous pulmonary venous return and coarctation/interruption of the aorta are specifically excluded, a congenital cardiovascular anomaly is effectively eliminated. We suggest that this approach can optimize the management of the cyanotic newborn with suspected PFC by eliminating the risks of cardiac catheterization and angiography without missing the diagnosis of a major structural cardiovascular anomaly.

Maturation and renal digoxin clearance

To evaluate the effect of maturation on the renal disposition of digoxin, the ratio of digoxin clearance to creatinine clearance was determined in 35 patients who were 3 days to 79 yr old. All were at steady-state levels for digoxin treatment. A mean ratio of 1.49 +/- 0.67 (SD) was obtained in the group of prepubertal children and infants greater than or equal to 2 mo of age. The mean ratio decreased to 0.82 +/- 0.25 (SD) in the adult group; adults were defined as sexually mature adolescents or older (P less than 0.005). The decrease in net renal tubular secretion of digoxin appears to occur at puberty. This observation can provide one explanation for the apparently larger doses of digoxin required by infants and children than by adults. It may also represent a developmental change in renal tubular physiology with broader significance than for digoxin disposition alone.