Kids' Sinusitis Might Not Need Antibiotics, New Guidelines Say

Doctors can 'watch and wait' for an additional 3 days

By Dennis Thompson

HealthDay Reporter

MONDAY, June 24 (HealthDay News) -- Doctors don't have to automatically prescribe an antibiotic to treat children who appear to have acute sinus infections, according to new guidelines issued by a leading group of pediatricians.

Instead, they can take a "watch and wait" approach if it appears the infection might clear on its own, according to the new American Academy of Pediatrics guidelines.

"The practitioner can either treat immediately or consider waiting for a couple of days," said Dr. Ellen Wald, chairwoman of the academy's subcommittee on acute sinusitis. "If the kid doesn't look dramatically ill, you can wait an extra couple of days to see if they improve on their own."

The previous guidelines, passed in 2001, recommended antibiotic therapy for all children diagnosed with acute bacterial sinusitis, which is defined as persistent signs of sinus infection lasting more than 10 days.

Doctors now can observe kids for up to an additional three days past that 10-day period to see if their symptoms will ease without antibiotic treatment.

"There's nothing absolutely sacred about 10 days. It could be 11 days. It could be 12 days," said Wald, chairwoman of pediatrics at the University of Wisconsin School of Medicine and Public Health, in Madison. "In the child who looks sicker, we wouldn't do that. We would start on antibiotics immediately."

The new guidelines, published online June 24 in the journal Pediatrics, are driven primarily by concern over antibiotic resistance, she said. There is a lot of overlap between the common cold and acute sinusitis, and some children who are not suffering from a bacterial infection may be receiving antibiotics.

"If we prescribe fewer antibiotics, then the problem of antibiotic resistance is controlled," Wald said. "If you can avoid the use of antibiotics, then that is reasonable."

Between 6 percent and 7 percent of children who visit doctors seeking care for a respiratory condition have acute sinusitis, according to the report.

Most cases of acute sinusitis develop from a common cold. Colds usually last five to seven days and peak within two or three days, Wald said.

Acute sinusitis does not often develop into a life-threatening illness, but it can be very uncomfortable and even painful. Symptoms of sinusitis include a runny nose, a persistent daytime cough, headache and fever.

"I think cases of acute sinusitis resolve on their own, by and by," Wald said. "There are not children who are dying left and right from sinusitis. But there is a quality-of-life issue too. You get better more quickly with treatment."

The revised guidelines further underline the need for parents to seek out pediatricians who are adept at diagnosing and monitoring sinusitis, said Dr. Jordan Josephson, a sinus and allergy specialist at Lenox Hill Hospital in New York City and author of the book Sinus Relief Now.

This is especially true for children with ongoing sinus problems, he said.

"Treatment of chronic sinusitis is not simple, and I think it's important that patients get to a doctor who really understands the disease," Josephson said. "Guidelines are guidelines. The ultimate thing is to get to a physician who is a really good diagnostician who can determine whether antibiotics are needed."

The new guidelines for acute sinusitis also discourage the use of imaging tests to help diagnose the condition in uncomplicated cases.

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Most Docs Don't Follow ADHD Treatment Guidelines for Preschoolers: Study

Some specialists turn to medications too soon while others avoid them completely

By Robert Preidt

HealthDay Reporter

SATURDAY, May 4 (HealthDay News) -- About 90 percent of pediatric specialists who diagnose and manage attention-deficit/hyperactivity disorder (ADHD) in preschool children do not follow treatment guidelines published recently by the American Academy of Pediatrics, according to a new study.

Some prescribe medications too soon, while others do not give the young patients drugs even as a second-line treatment, according to study author Dr. Andrew Adesman, chief of developmental and behavioral pediatrics at Cohen Children's Medical Center in New Hyde Park, N.Y., and colleagues.

The American Academy of Pediatrics (AAP) guidelines recommend that behavior therapy be the first treatment approach for preschoolers with ADHD, and that treatment with medication should be used only when behavior-management counseling is unsuccessful.

The researchers also found that more than one in five specialists who diagnose and manage ADHD in preschoolers recommend medications as a first-line treatment alone or in conjunction with behavior therapy.

The study is scheduled for Saturday presentation at the Pediatric Academic Societies' annual meeting in Washington, D.C. Data and conclusions should be viewed as preliminary until published in a peer-reviewed journal.

"It is unclear why so many physicians who specialize in the management of ADHD -- child neurologists, psychiatrists and developmental pediatricians -- fail to comply with recently published treatment guidelines," Adesman said in a medical center news release.

Some physicians also deviate from guidelines with their choice of medication. Although methylphenidate (Ritalin) is recommended as the first drug to try when medications are warranted, many doctors prescribed other types of drugs.

"With the AAP now extending its diagnosis and treatment guidelines down to preschoolers, it is likely that more young children will be diagnosed with ADHD even before entering kindergarten," Adesman said. "Primary care physicians and pediatric specialists should recommend behavior therapy as the first-line treatment."

Awareness is lacking across specialties, another study author said.

"Although the AAP's new ADHD guidelines were developed for primary care pediatricians, it is clear that many medical subspecialists who care for young children with ADHD fail to follow recently published guidelines," study principal investigator Dr. Jaeah Chung said in the news release.

"At a time when there are public and professional concerns about overmedication of young children with ADHD, it seems that many medical specialists are recommending medication as part of their initial treatment plan for these children," Chung added.

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Pediatricians Endorse New Acne Treatment Guidelines

Experts note many medications now available for range of cases

By Amy Norton

HealthDay Reporter

MONDAY, May 6 (HealthDay News) -- Pimples have long been the bane of teenage existence, but pediatricians say there is now enough evidence on effective treatments to put out the first guidelines on battling acne in children.

There is a range of medications that can clear up even severe cases of acne, according to the American Academy of Pediatrics (AAP). Writing in the May issue of its journal Pediatrics, the group throws its support behind new guidelines from the American Acne and Rosacea Society that detail how to treat acne in children and teens of all ages.

That "all ages" part is important because acne is becoming more and more common in pre-teens, too, said Dr. Lawrence Eichenfield, the lead author of the AAP report. One study of 9- and 10-year-old girls found that more than three-quarters had pimples.

It's thought that it may be because boys and girls are, on average, starting puberty earlier compared with past generations, said Eichenfield, a pediatric dermatologist at Rady Children's Hospital in San Diego.

According to the AAP, mild acne often can be tackled with over-the-counter fixes. Washes, lotions and other products containing benzoyl peroxide are the best studied, and the best place to start, the group said.

"It's a pretty effective agent, especially for mild acne," Eichenfield said. Benzoyl peroxide is also the most common ingredient in over-the-counter acne fighters. Another common one is salicylic acid, but there has not been much research on it. When it has been tested head-to-head against benzoyl peroxide, Eichenfield said, the latter has won out.

If over-the-counter products do not do the job, the next step could be topical retinoids -- prescription medications like Retin-A, Avita and Differin. They are vitamin A derivatives and work by speeding up skin cell turnover, which helps unclog pores.

The main side effects of all the topical treatments are skin irritation and dryness, the AAP said.

If the acne is moderate to severe, oral antibiotics could be added to the mix because bacteria that live on the skin play a role in acne. When pores become clogged with oil and skin cells, bacteria can grow in the pore and cause inflammation. Antibiotics help by killing bacteria and soothing inflammation.

But, Eichenfield said, "it's important to use antibiotics appropriately." One reason is because acne-causing bacteria have become less sensitive to common antibiotics in the past couple decades, due to widespread use of the drugs.

Another is that antibiotics can have side effects, such as stomach upset, dizziness and, in girls, yeast infections.

When acne is severe and other treatments have failed, the AAP said, doctors and parents might consider the prescription drug isotretinoin -- brand-names including Roaccutane (formerly known as Accutane) and Claravis.

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Urologists' Group Issues Updated Guidelines on PSA Test

FRIDAY, May 3 (HealthDay News) -- New guidelines from the nation's leading group of urologists on the controversial PSA test for prostate cancer highlight the importance of discussions between a man and his doctor.

Especially for men in their late 50s and 60s, the usefulness of the blood test may have to be decided on a case-by-case basis, according to new recommendations from the American Urological Association (AUA).

One expert called the new guidelines "a paradigm shift" in prostate cancer detection.

Dr. Louis Potter, chairman of radiation medicine at North Shore-LIJ Health System in New Hyde Park, N.Y., said the recommendations mark a move to more "personalized health management, where risk and age are balanced against the value of screening."

Prostate-specific antigen (PSA) screening is a test that measures the level of a key marker for prostate cancer in the blood. In general, the higher the level of this protein, the more likely it is that a man has prostate cancer, according to the U.S. National Cancer Institute.

The value of the PSA test has recently come into question, however, with several studies suggesting it causes men more harm than good -- spotting too many slow-growing tumors that, especially in older patients, may never lead to serious illness or death. In 2012, the U.S. Preventive Services Task Force, an influential government-appointed panel, advised against the routine use of the PSA test for prostate cancer.

The new AUA guidelines are more nuanced. The group does recommend against the PSA test for men under age 40 or for those aged 40 to 54 at average risk for prostate cancer.

The AUA says, however, that men aged 55 to 69 should talk to their doctors about the risks and benefits of PSA screening and make a decision based on their personal values and preferences.

Routine PSA screening is not recommended for men over age 70 or any man with less than a 10- to 15-year life expectancy.

The best evidence of benefit from PSA screening was among men aged 55 to 69 screened every two to four years. In this group, PSA testing was found to prevent one death a decade for every 1,000 men screened. But this benefit could be much greater over a lifetime, the guidelines noted.

The guidelines also said PSA screening could benefit men in other age groups who are at higher risk of prostate cancer due to factors such as race and family history. These men should discuss their risk with a doctor and assess the benefits and potential harms of PSA testing.

The new guideline updates the AUA's 2009 Best Practice Statement on Prostate-Specific Antigen and was announced at the association's annual meeting in San Diego on Friday.

"There is general agreement that early detection, including prostate-specific antigen screening, has played a part in decreasing mortality from prostate cancer," Dr. H. Ballentine Carter, who chaired the panel that developed the guidelines, said in an AUA news release.

There is more and better data about PSA screening available today than there was in 2009, so it is "time to reflect on how we screen men for prostate cancer and take a more selective approach in order to maximize benefit and minimize harms," Carter said.

One expert said the revised guidelines made sense.

"I think these guidelines are quite appropriate given the [slow-growing] nature of many prostate cancers," said Dr. Erik Goluboff, an attending urologist in the department of urologic oncology at Beth Israel Medical Center in New York City.

He agreed that discussions between a patient and his doctor on the PSA test are "extremely important."

"It has become increasingly evident that many, if not most, men diagnosed with early prostate cancer will never need treatment and can be spared the potentially devastating side effects of treatment such as urinary incontinence and erectile dysfunction," Goluboff said.

Some men, including black patients and patients with a family history of prostate cancer, may still decide to undergo PSA testing, he added. "This is in contrast to the U.S. Preventive Services Task Force, where a blanket statement that PSA screening is bad, regardless of individual patient risk, was made," Goluboff said.

A better test that pinpoints aggressive, life-threatening prostate tumors might be developed in the future, to better guide patients. "Hopefully, with discovery of better tumor markers, aggressive prostate cancers can be distinguished from [slow-growing] ones and only patients who need to will receive treatment," Goluboff said.

-- Robert Preidt
Copyright © 2013 HealthDay. All rights reserved. SOURCES: Louis Potters, M.D, chair, radiation medicine, North Shore - LIJ Health System, New Hyde Park, NY; Erik Goluboff, M.D., attending urologist, department of urologic oncology, Beth Israel Medical Center, New York City; American Urological Association, news release, May 3, 2013

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Mammo Rates Unchanged Despite Controversial Guidelines

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New Guidelines Raise Safety Bar on Concussions

If head trauma is suspected, health care professional should determine it is safe to return to play, recommendations say

By Alan Mozes

HealthDay Reporter

MONDAY, March 18 (HealthDay News) -- Any athlete who suffers a suspected concussion should be withdrawn from play and stay on the sidelines until a qualified health care professional determines that all symptoms have subsided and it is safe to return to the field, new guidelines state.

Issued by the American Academy of Neurology, the latest recommendations aim to keep young athletes as safe as possible.

"With the older guidelines, we were trying to rate concussions at the time of the injury and predict recovery times, but now we know, 'When in doubt, sit 'em out,'" said guideline co-author Dr. Christopher Giza, an associate professor of pediatric neurology and neurosurgery with the David Geffen School of Medicine at the University of California, Los Angeles, and Mattel Children's Hospital.

"The point is that no single quick test is really a litmus test for a concussion," he said. "We know now that we need to make sure a player has had a thorough and proper evaluation, involving a symptoms checklist, a standardized assessment and balance and cognitive testing, before being returned to play. This evaluation has to be done on a case-by-case basis, so each person goes through an individualized recovery process."

Giza and his colleagues reported the new guidelines in the March 18 online issue of the journal Neurology.

According to the academy, upwards of 1 million professional and amateur U.S. athletes suffer a concussion every year.

The new guidelines were issued following a thorough look at all the available concussion research through June 2012.

Among the conclusions: experiencing a concussion raises the risk for experiencing a second, and perhaps more debilitating, one. That risk was found to be highest in the 10 days following the initial injury.

One expert said the new guidelines are needed.

"One of the big problems is that we have a culture within many sports that still encourages young people to play through the pain, including head pain," said Dr. Gail Rosseau, a clinical assistant professor in the department of neurosurgery at the Northshore University Health System in Chicago.

"But one of the most important things we now know is that until those who have had one concussion are fully recovered they are more likely to have a second concussion," Rosseau said. "The stories we hear that are horrific to every parent and every coach is the child who gets a concussion and goes back to play too soon, and gets a second one with devastating consequences."

Just how devastating it can be was outlined earlier this year in the Journal of Neurosurgery: Pediatrics, which detailed the harrowing double-concussion experience of Indiana high school student Cody Lehe. Resuming football too soon after an initial concussion, Lehe suffered a second concussion. Severe brain injury ensued, leaving Lehe mentally impaired and largely wheelchair-bound.

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What do the new concussion guidelines mean for my high-school football player?

Posted May 24, 2013, 2:00 am

I have a teenage son who plays high school football, so I’m interested in the new concussion guidelines. Can you tell me what they say?

In March of this year, the American Academy of Neurology released new guidelines for recognizing and managing sport-related concussions. These guidelines could help protect the brains of athletes at all levels of play, from professional football to youth soccer. In a phrase, the new concussion guidelines recommend “when in doubt, sit it out.”

Concussions occur when something makes the head and brain move quickly back and forth. This can be a jolt to the head, a fall or a blow to the body. They cause a short-term disturbance in brain function. Contact sports such as football and ice hockey are most likely to increase the risk of concussions, but concussions can happen in any sport.

Many athletes don’t get medical attention for concussion. That’s often because they or their coaches don’t recognize the warning signs or take them seriously. Concussions can cause temporary loss of consciousness. They also typically cause confusion and problems with recent memory. The confusion may occur immediately, or a few minutes after the injury.

Other symptoms of a concussion often include dizziness, nausea (with or without vomiting) and headache. After a concussion, a person may seem to have trouble paying attention to you, or may seem to be lost in his thoughts. His speech may be slow or even slurred. A few days later, the person who has suffered a concussion may seem moody or depressed, may be bothered by amounts of light or noise that never used to bother him, and may have poor quality sleep.

All these symptoms can be pretty subtle, and if they occur during an exciting sporting event, the people who are evaluating the person may be distracted. In other words, it can be hard to determine if a person has really suffered a concussion.

The new guidelines take the guesswork out of the equation. They step away from having coaches or trainers try to diagnose concussions on the field or sidelines. Instead, they recommend that athletes who are suspected of having a concussion should be immediately removed from play and evaluated. What’s more, the guidelines state that athletes who have sustained concussions should not return to play until a licensed health care provider gives the green light.

Not all concussions are serious. Many young people and athletes recover from a head injury in minutes or hours. The danger is that athletes who have had one concussion are at greater risk of having another. The first 10 days after a concussion is a period of special danger. Repeated minor head injuries over a short period greatly increase the risk of serious or permanent brain damage.

The next step is to educate coaches and trainers about the new guidelines. They are the people who have ringside seats when concussions happen, and they’re making the decisions about whether to let the athletes continue to play.

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New Pap Guidelines May Miss Aggressive Cancer in Young Women: Study

Title: New Pap Guidelines May Miss Aggressive Cancer in Young Women: Study
Category: Health News
Created: 3/7/2013 6:36:00 PM
Last Editorial Review: 3/8/2013 12:00:00 AM

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Pediatrics Group Issues New Ear Infection Guidelines

By Serena Gordon

HealthDay Reporter

MONDAY, Feb. 25 (HealthDay News) -- The American Academy of Pediatrics has issued new guidelines for identifying and treating a common childhood ailment that can cause a lot of misery -- the ear infection.

In the guidelines released Monday, the pediatrics group more clearly defines the signs and symptoms that indicate an infection that might need treatment. They also encourage observation with close follow-up instead of antibiotic treatment for many children, including some under the age of 2 years. And, for parents of children with recurrent infections, the new guidelines advise physicians and parents when it's time to see a specialist.

"Between a more accurate diagnosis and the use of observation, we think we can greatly decrease the use of antibiotics," said the lead author of the new guidelines, Dr. Allan Lieberthal, a pediatrician at Kaiser Permanente Panorama City, in Los Angeles, and a clinical professor of pediatrics at the Keck School of Medicine at the University of Southern California.

The last set of guidelines was issued in 2004. Lieberthal said those stimulated a lot of new research, which provided additional evidence for the current American Academy of Pediatrics (AAP) guidelines appearing in the March issue of Pediatrics.

Lieberthal said the biggest change in the new document is the definition of the diagnosis itself.

Pediatrician Dr. Roya Samuels, who has reviewed the new guidelines, agreed. "The definition is more clear-cut, more precise," she said. But, she added, "There's still no gold standard for diagnosis. There are different stages of [ear infections], and making the diagnosis can be tricky."

Because the diagnosis isn't always easy to make, the AAP offers detailed treatment suggestions, encouraging observation with close follow-up, but also leaves it up to the discretion of the doctor whether or not to prescribe antibiotics. If children who are being observed don't improve within 48 to 72 hours from when symptoms first began, the guidelines recommend beginning antibiotic therapy.

Previous guidelines recommended giving antibiotics for ear infections in children age 2 and under. The new guidelines suggest that children aged between 6 months and 23 months can be observed with close follow-up as long as they don't have severe symptoms.

Another key component of the new guidelines is pain management. "Antibiotics take 24 to 48 hours before they start to improve signs and symptoms, so if a child has fever or pain, it's important to place them on [pain-relieving or fever-reducing medications]," Samuels said.

The guidelines also confirm that amoxicillin should be the antibiotic of choice unless the child is allergic to penicillin, or if the child has been treated with amoxicillin during the past month.

The new guidance from the AAP also states that children, even those with recurrent infections, shouldn't be on long-term daily antibiotics to try to prevent infections from occurring.

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New Guidelines Issued for Genetic Screening in Newborns, Children

Title: New Guidelines Issued for Genetic Screening in Newborns, Children
Category: Health News
Created: 2/21/2013 12:35:00 PM
Last Editorial Review: 2/22/2013 12:00:00 AM

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Re-Analysis Refutes Diet Guidelines Favoring Vegetable Fats

By Alan Mozes

HealthDay Reporter

WEDNESDAY, Feb. 6 (HealthDay News) -- Enduring dietary wisdom -- that polyunsaturated vegetable fats are better for your heart than saturated animal fats -- may be turned on its head by a fresh analysis of a nearly 50-year-old study.

The reasoning has been that a diet rich in omega-6 polyunsaturated fats lowers cholesterol, and is therefore good for heart health. But an updated look at the study indicates that heart disease patients who follow this advice may actually increase their risk for death.

The original "Sydney Diet Heart Study," was initially conducted between 1966 and 1973, at a time when the cholesterol-lowering benefits of all polyunsaturated vegetable acids (PUFAs) were touted with a broad brush.

But in the ensuing years, researchers have come to understand that not all PUFAs are alike, with key biochemical differences -- and perhaps varying cardiovascular impacts -- observed among multiple types of omega-3s (found in fish oils) and omega-6 linoleic acids.

"There is more than one type of polyunsaturated fatty acid," explained Dr. Christopher Ramsden, who headed the re-analysis and is a clinical investigator with the laboratory of membrane biophysics and biochemistry at the National Institute on Alcohol Abuse and Alcoholism, part of the U.S. National Institutes of Health.

"And so, we were interested in trying to evaluate just one of these compounds, linoleic acid, by looking at this old trial using modern statistical methods, and also by re-including some original data that had gone missing from the first analysis," Ramsden explained.

The findings appeared online Feb. 5 in the BMJ.

The 458 male participants in the original study had been between the ages of 30 and 59 at enrollment, and all had a history of heart disease, with most having survived a heart attack.

The men were placed into two groups. The first group was told to consume linoleic acid, in the form of safflower oil and safflower oil polyunsaturated margarine, at levels equal to 15 percent of total calorie intake. This, said Ramsden, is equivalent to roughly twice the amount that Americans currently consume.

While omega-3 consumption was not affected, the men were also asked to lower their saturated fat intake so that it made up less than 10 percent of their diets. They did so by substituting safflower oil for animal fats, common margarines and shortening oils, salad dressings, baked goods and other products, according to the study.

The second group continued their routine nutritional habits, and both groups kept food diaries and underwent regular assessments during the three-year-plus study period.

By newly crunching all the original data the NIH team found that, compared to the no-dietary-change group, the linoleic acid group faced a higher risk of death, from both heart disease specifically as well as from all causes overall.

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