Child Health ALERT

Volume 14 A Survey of Current Developments Affecting Child Health Care April 1996

When Is An Asthma Inhaler Empty?

One of the major advances in treating asthma in children has been the development of metered-dose inhaler, devices which deliver a specific dose of asthma medication each time the child activates the inhaler. However, inhaler canisters contain a certain number of doses; if the child uses the inhaler more than the number of times listed on the product, the canister may still "work", but the dose of medication that is dispensed may vary.

Researchers found that most adult asthmatics they surveyed did not know how many doses their inhaler contained. When they were asked how they knew it was time to replace their inhaler, about three-quarters said they would make their judgements by shaking the inhaler, or by noticing changes in the pressure of the "puff', the taste, or similar means. One approach, recommended by some manufacturers, is to float the canister in water to estimate how much medication is left. While 8% of patients used this technique, the authors found it was not a reliable way to determine whether an inhaler has run out of medication. (Ogren RA et al: Annals of Allergy, Asthma, and Immunology, Dec 1996; pp. 485-489)

DR. FRANK J. TWAROG COMMENTS: This report focuses attention on an important and very practical issue. Children who are old enough to use inhalers, like adults, are likely to have difficulty in judging when their inhaler is no longer providing them the dose of medication that is expected. The authors are correct when they say that floating the inhaler will not give a reliable estimate of how much medication is left, and approaches that rely on changes in pressure or taste are also unreliable. In fact, the only accurate method is to count the actual number of doses used and compare this with the number on the canister label.

It may sound easy enough to keep track of the doses used, but it may not be. For patients who use their medication on a regular, predictable basis, I frequently advise that they simply calculate the number of doses they use and mark on a calendar when the device is likely to become empty. For example, if the canister contains 80 doses and the child uses 3 doses per day, the canister will be empty about 26 days after it is started (parents should plan several days in advance of that date to obtain a refill, so they don't take a chance of running out of medication). If the medication is used on an intermittent basis (when the child has symptoms, for instance), then there is really no alternative but to make a note each time the inhaler is used in order to keep track of where the total number of available doses will be reached. One approach to make this simple is the authors' suggestion to keep this tally attached to the inhaler with a rubber band.

To be sure children get the full benefit of their inhaled asthma medication, they should receive careful instructions from their health care provider on how to use these devices. At the same time, just because an inhaler gives out a "puff' doesn't mean it's giving out the proper amount of medication, so it is important to help children figure out a way to know when their inhaler will be running out of the medication they require. (Dr. Taro is a member of the CHILD HEALTH ALERT Editorial Advisory Board)

RESOURCES

Let's Face It--A Useful Resource

The importance of the face can't be overemphasized-- it is the first thing you see when you are introduced to someone. For that reason, it isn't difficult to imagine the possible emotional and social consequences for a person whose face doesn't conform to what's generally considered "normal". Reasons for facial differences are almost as numerous as the differences themselves, and can include birth defects (such as cleft lip), genetic syndromes, bums, and disease.

There is a new and very good general resource about facial differences. It is published by "Let's Face It", an organization dedicated to helping people with facial differences, their loved ones, the professionals who care for them, and the communities in which they live, to understand and solve the problems of living with this disability.

The guide, called "Resources for People with Facial Differences," provides a wealth of information about facial disabilities themselves, and it also offers valuable resources that can help a person cope with the emotional challenges and adjustments that accompany these conditions. What makes this particularly useful is that the booklet isn't limited to facial differences; rather, it covers a wide variety of problems that parents and children may experience when they have chronic conditions. For example, it identifies resources that can help with financial issues, support groups for parents of children with particular problems, and information about networks on disabilities. The selections have a common theme: to help people help themselves (as Eleanor Roosevelt said, "No one can make you feel inferior without your consent.")

This resource list will obviously be of interest to parents and professionals who deal with (or know of) children with many challenging conditions; it is also ideal for a resource bulletin board or parent library, or for a health care practitioner's waiting room or library.

Through the kindness of the publisher, this resource is being made available free to CHILD HEALTH ALERT readers (send a 9x 12 inch self-addressed envelope with $3 postage); it may be ordered from Let's Face It, PO. Box 29972, Bellingham, WA 98228-1972). If you write a note describing the adult's or child's condition, "Let's Face It" will try to include additional material relevant to that condition.

Can A Child With A Mild Illness Receive A Routine Vaccination?

Without question, immunizations against the "usual childhood diseases" are one of the most useful public health actions society can offer to protect children. However, the success of immunizations depends on making sure that children receive them. A child may miss a scheduled routine shot if he or she has a cold, ear infection, or stomach flu, and all too often these children don't wind up getting the shot they missed. Experts on children's health have recommended that children with such illnesses should still get their immunizations against measles, mumps, and rubella (German measles)--the MMR vaccine--but some parents and doctors continue to worry that the vaccine won't "take" or that ill children may have more side effects from the shot.

To see whether these concerns were valid, researchers studied 386 children between the ages of 15 and 23 months who were given MMR. Among these children, 157 had acute upper respiratory infections ("colds"), otitis media (ear infections), or diarrhea, while the remainder were well. When they measured the levels of immunity against all three diseases that were produced by the vaccines, the authors found that children with these mild illnesses had the same levels of immunity as those who were well. In addition, there were no differences in rates of adverse events following the vaccine. Based on these and earlier results, the authors concluded that "vaccinating children who present with mild illnesses with MMR vaccine is a safe and efficacious practice." (King GE et al: Journal of the American Medical Association, March 6, 1996, pp. 704-707)

COMMENT- These results may sound familiar to readers, because they are very much the same as those from a study we cited last fall on the same subject (CHILD HEALTH ALERT, October, 1995). In the earlier study, none of the children had fevers, and in the current study fever was not recorded, so these results should apply primarily to children with the kinds of mild illnesses, without fever, that are so common among children.

DIET & NUTRITION

New Developments About The Benefits And Safety Of Additives In Foods: Folic Acid To Be Added

About 3% of children are born with some kind of birth defect. Among the most serious ones are neural tube defects, which involve damage to the brain and spinal cord. Research over the past few years has shown that many of these defects can be prevented if women get enough o the B vitamin folic acid in their diets around the time of conception. In an effort to reduce the risk of neural tub defects, the U.S. Food and Drug Administration (FDA) announced on February 29 that it would require all enriched foods to be fortified with folic acid. The requirement will involve most flours, com meals, pasta, and rice, and will take effect 0 January 1, 1998. This mandate is the first new fortification of foods since 1943, when vitamins and iron were added to enriched flour. It is also the first time foods are being fortified to prevent a birth defect.

Only a handful of nutrients are required to be added to foods; in 1924, salt was fortified with iodine to prevent goiter; since then vitamin D was added to milk to prevent rickets and vitamins and other substances (thiamin, niacin, riboflavin, vitamin B6 and iron) were added to enriched flour to prevent diseases due to deficiencies of these agents.

Further, FDA will permit manufacturers of food with high levels of folic acid to advertize that the foods can prevent neural tube defects--one of few health claims -the FDA has permitted.

The FDA action was hailed by experts on birth defects, medicine, and public health; though many would prefer that women obtain the target amount of folic acid by eating a diet rich in fruits and vegetables, the reality is that a large number of women just don't get enough folic acid this way. Since it is critical to have enough folic acid around the time of conception, taking prenatal vitamins after a positive pregnancy test has no benefit. Fortification was implemented only when it became clear that there was no other way to insure that the vast majority of women get enough folic acid prior to conception. (Kolata G: New York Times, Mar 11996)

... And Pesticides May Pose Less Risk Than Many Believed

According to an expert scientific committee of the National Research Council, synthetic agents in foods, which have been the focus of much concern, may pose less risk of cancer than some natural compounds in foods (such as fats and alcohols) With the exception of fats and alcohol, both natural and synthetic carcinogens are usually consumed at such low levels that they are unlikely to cause much of a problem. (Boston Globe, February 16,1996)

COMMENT: The second report offers some important reassurance to many parents who fear that our food supply is filled with synthetic pesticides that pose a major health hazard. While this report should not be viewed as an endorsement of pesticides in foods or as a reason to ignore this problem or to relax legislation, it does offer a useful perspective.

The decision of the FDA to add folic acid to the food supply is a major public health action. Research has clearly shown that certain amounts of folic acid consumption can reduce the risk of neural tube defects by about 50%. The amount needed is at least 400 micrograms ("ug") per day (equal to 0.4 mg). As it happens, most daily multivitamin tablets contain 400 ug of folic acid, and about 15-20% of U.S. women of childbearing age take a daily multivitamin; as a result, these women can be assured that they receive the desired amount. On the other hand, most diets don't provide that much folic acid.

The FDA struggled over how much folate to require. Since people's diets vary, the amount of folate taken in will also vary, depending on how much food one eats that is either naturally rich in folate or will be supplemented with folate once the new regulations go into effect. One question that was debated is how much is too much? Some experts want to avoid more than I mg/day (over 2.5 times the targeted amount) because of unproven concerns that it could make it more difficult to diagnose symptoms of pernicious anemia in the elderly. To balance benefits and risks, the FDA chose to use a supplement level that was intended to raise daily folate intakes without raising them too much.

We would add two cautions: First, women should recognize that folic acid isn't required to be added to foods for almost two years from now. Second, the average additional folate that most women will get from supplemented foods is likely to be less than 400 ug/day. If women were to rely only on dietary sources for folate, many will still fall below the target level. Taking a "one-a-day" type multivitamin is still a good way to assure getting the 400 ug/day, but at the same time it is unlikely to lead to excessive folate intake, even when the dose from the vitamin is added to doses obtained from the diet.

Neural tube defects can be devastating birth defects. It is exciting that good research has demonstrated that a substantial proportion of these defects can be prevented by something so simple and safe as folic acid. The FDA action is a major step in translating recent scientific knowledge into efforts designed to improve the health of children and their families.

PARENT/CHILD

Do Mothers' Breast Implants Pose A Risk To Their Children?

There has been a great deal of controversy over whether silicone breast implants are hazardous to women who have them, but one issue of concern to children's health was raised two years ago: researchers suggested the possibility that children who were breast fed by mothers who had silicone breast implants might have problems in the way their esophagus (foodpipe) functions. Of particular concern was that the problems in the children seemed to be similar in some ways to problems that were described in women who had breast implants.

Now, the same researchers have turned their attention to studying certain antibodies linked to these conditions. They looked for these antibodies in 80 children with various symptoms who were born to mothers who had silicone implants, and compared them to 42 children without these conditions whose mothers did not have implants.

These authors found no differences in antibody levels between the children of mothers with and without breast implants, raising the question in their minds as to whether the symptoms that had been seen in these children were unrelated to their mothers' silicone implants. (Levine JJ et al. Pediatrics, February 1996, pp. 243-245)

COMMENT: Needless to say, the authors' earlier findings were quite alarming and controversial. The media and legal attention they provoked tended to heighten the very real anxiety felt by mothers who have implants, particularly if they had breast fed their infants.

The last couple of years have seen a number of studies focused on the question of whether silicone implants cause disease in the women who have them, and the clear direction of these studies has been to find little evidence to suggest that implants cause the diseases in question. When it comes to possible effects in children of mothers with implants, we should keep in mind that the original study was flawed and the results haven't been confirmed, and much of the anxiety was based on widely-held beliefs about implant hazards in adults. The current study offers some objective scientific evidence that should be reassuring to those parents concerned about the risk of implants to their children.

PRODUCT RECALL

Bed Rail And Flashlight

Safety 1st, of Chestnut Hill, MA, is offering to replace 191,000 of its model No. 177 Bed Rail and Flashlight. The rail's support bars can separate from the rail if not firmly locked in place, allowing children to fall from the bed. The $20 item was sold nationwide from January, 1994 through June, 1995 in juvenile product and chain discount stores. For information, call the company at (800) 366-1282.

... And Various "Imperial" Toys

Imperial Toy Corp., of Los Angeles, CA is recalling about 100,000 toy vehicles, aquatic animals, bottle sets and meal sets that can break into small pieces and choke children.

The vehicles were sold in six styles: two cars, a bulldozer, a tow truck, a dump truck, and a cement truck. The wheels produce sparks, sold for $2, and were labeled "Imperial Mighty Machines--Motorized Big Wheel Sparklers."

The aquatic animal toys came in four styles, three of which are being recalled: Tammy the Turtle, Peppy the Penguin, and Sally the Seal. Sold for about $4, they were labeled "Aqua Wind Ups, Imperial, Swimming Aqua Animals, No. 8180." Their flippers, feet, and snouts break off.

The toy bottle set has two 3-inch high plastic baby bottles that sold for $2 a pair and were labeled "Imperial Cuddles Bottle Feeding Set, No. 8233." The nipple and funnel can break apart.

The plastic toy meal set includes a dish, feeding bottle, two strainers, and a funnel. It sold for about $2 and was labeled "Imperial, My Dolly Meal Time, No. 8327." The end of the bottle can break off.

The toys, imported from China, were sold by Ben Franklin, Revco. and toy stores nationwide from 1993 to April, 1995. They should be returned to the place of purchase for a refund; for more information, write Imperial Toy Corp., 2050 E. 7th St., Los Angeles, CA 9002 1, or call (800) 543-655 1.

Reports above from Consumer Product Safety Commission, Washington, D.C., some of which were cited in American Academy of Pediatric News, February, 1996.

A Warning About Granola Bars

General Mills, the manufacturer of Nature Valley Crunchy Oats n' Honey granola bars, has advised that some of these bars may contain peanut butter even though the ingredient statement on the package does not indicate the presence of peanut butter in the product. The potentially affected packages have the following product codes embossed on the top of the package: E509CI, E509C2, and E509C3.

Other codes for this product, and other Nature Valley products and flavors, are not affected. General Mills has made efforts to remove these granola bars from warehouses and grocery shelves. People who are allergic to peanut products can obtain a replacement or refund by calling General Mills Consumer Affairs department at (800) 345-2443 weekdays between 7:30 AM and 5 PM CST (News Release, Food and Allergy Network, Jan 20 1996)

COMMENT: This recall highlights the importance of peanut allergy as a health problem. ln the minds of many people, allergies to foods are often confused with other problems, such as lactose intolerance, that can cause inconvenience or discomfort but nothing more serious. However, true food allergies, and peanut allergy in particular, are quite different. Those who suffer from these allergies can have severe and even fatal reactions if they eat certain foods. Children and adults with peanut allergy have to be extremely cautious, since for many of them, even the smallest trace of peanut in their food can cause a severe reaction. Because they have to rely on what is listed on the ingredient label, it is critical that the label is accurate. The recall of the granola bars should be kept in mind by those caring for children who might have peanut allergy, and this incident should focus attention on how important this problem can be for these children.