Child Health Alert Newsletter May 96

Child Health ALERT

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

Smoking News?

Does Smoking In Pregnancy Cause Mental Retardation?

Smoking has been linked to many health problems in children, and a recent report now claims that smoking in pregnancy may cause mental retardation in the offspring. Re-searchers from Atlanta, Georgia, interviewed mothers of 221 children with mental retardation (defined as an IQ of 70 or less and no identify-able cause) and 400 control children drawn from public schools; the children were at least 10 years old when their mothers were interviewed.

After taking certain factors into account, the authors found that smoking during pregnancy was associated with slightly more than a 50% increase in the risk of mental retardation; they conclude that “these results indicate that smoking prevention pro-grams could provide a way to pre-vent mental retardation for a substantial number of children.” (Drews CD et al: Pediatrics, April, 1996; pp. 547-553)

...And Estimating Hazards From Passive Smoking

The hazards of cigarette smoking for adults are well known, and some adults may choose to assume such risks. Children exposed to passive cigarette smoke may also suffer health hazards. However, unlike adults who choose to smoke, children exposed to passive smoke have little choice. To estimate the number of children who are harmed by involuntary exposure to cigarette smoke, researchers analyzed previous reports in the medical literature, focusing their attention on conditions like ear infections, other infections, and ton-sillectomies and/or adenoideetomies (“T&As”).

The authors estimate that each year in the U.S., tobacco is associated with hundreds of thousands of these conditions. For example, they estimate 14,000 to 21,000 T&As, 529,000 physician visits for asthma, up to 2 million visits for cough, and (for children under 5 years of age) as many as 436,000 visits for bronchitis and 190,000 for pneumonia.

The authors conclude that “the use of tobacco products by adults has an enormous adverse impact on the health of children” and argue that ‘‘smoking should be banned wherever children are present. Children should be excluded from designated smoking areas. Organizations that cater to children should guarantee them smoke-free environments at all facili-ties and events.” (DiFranza JR & Lew RA: Pediatrics, April, 1996; pp. 560-568)

COMMENT: Both these studies attracted a great deal of publicity, so it is particularly important to put them into perspective. Though the first study claims to have found a link between smoking in pregnancy and mental retardation in the off-spring, there are other studies that have not found a similar link, so the jury is still out on this important question.

The study on passive smoking did not provide any new findings; rather, it summarized research that has been conducted in the past. For a number of reasons, the estimates provided in this review article are too speculative to be considered reliable.

Though these two studies may have their limitations, they do serve to remind us that there is strong and consistent evidence that smoking in pregnancy is bad for the fetus (it’s a major cause of low birth weight, for example) and that children who are exposed to passive smoking have more health problems (such as respiratory infections). There is already enough evidence to justify strong efforts to protect the fetus and child from exposure to cigarette smoke.

INFECTIONS/ILLNESS

Lyme Disease: Prevention Is The Best Treatment

Lyme disease is becoming an increasingly important concern since it was first identified over 20 years ago near the Connecticut town of the same name. Because children spend so much time outdoors, they are particularly susceptible to this illness. The risk of Lyme disease is greatest in the spring and summer, so we felt it was timely to describe what it is and how it can be prevented.

Lyme disease is caused by a kind of bacteria that are spread through the bite of certain ticks that are common in the northeastern, upper mid-western, and western United States. However, there are more and more states where Lyme disease is being identified. These ticks live off deer and white-footed mice, and for that reason Lyme disease is most often found in areas where these animals are found--beach grass and grassy meadows that are next to woodlands. In fact, one reason given for the recent spread of Lyme disease is that deer are coming into closer contact with people as housing developments push into woodlands and as the deer population increases.

The ticks attach themselves to humans during the late spring and summer months. Lyme disease often begins with a red circular rash at the site of the tick bite. It may last a few weeks, and be accompanied by flu-like symptoms such as headache, fever, and muscle aches. If caught early, Lyme disease generally responds well to treatment with antibiotics. However, making a diagnosis can sometimes be difficult. For this and many other reasons, public health experts believe that the best way to handle Lyme disease is to pre-vent it from occurring in the first place.

The first line of defense is to try to avoid areas where the ticks are common. Second, make sure that any ticks that might have become attached are removed. There’s no emergency to doing this, since it takes a couple days for the disease to be transmitted by a tick. The best approach is to conduct a thorough “tick check” at the end of each day. Dog ticks and other relatively large ticks should not be confused with the small ticks that carry this disease. In May and June, deer ticks are about the size and color of a poppy seed, making them difficult to find, but a good place to look is the waist and thigh areas, where they commonly attach themselves. A shower can remove those that aren’t attached, and those that are attached can be removed with a tweezers by grasping the tick as close to the child’s skin as possible and gently but firmly pulling it off.

POINTS TO REMEMBER:
   *Don’t confuse large dog ticks with smaller deer ticks
   *Ticks are most likely to attach in May or June
   *If a circular rash or flu follows a tick bite, seek medical attention
   *Conduct a tick check at the end of each day
   *When in tick infested areas:
        • Wear a hat
        • Wear white or light colors to make tick detection easier
        • Wear long trousers tucked into long socks according to directions
        • Use insect repellents according to directions

It’s important to realize that not all tick bites will lead to Lyme disease. On the other hand, preventive measures are reasonably simple and highly effective, so children can enjoy being outside without being at great risk for Lyme disease.

POISON SAFETY

Warning On Inhalant Abuse

Since 1975, surveys of high school seniors in the U.S. have shown that 15-20% of children abuse inhalants at some time in their school years. These findings prompted a current warning from two committees of the American Academy of Pediatrics (the Committees on Substance Abuse and Native American Child Health). Inhalant abuse can begin at a very early age and is, according to the statement, a little recognized form of substance abuse that can cause serious medical problems and even death.

The inhalants in question are chemicals called hydrocarbons, and almost any hydrocarbon can have mind-altering effects when inhaled in large doses. What makes this form of abuse particularly difficult to control is that these chemicals are found in thousands of commonly used and readily available consumer products; it should also be recognized that almost all pressurized aerosol products can be abused because their propellants are hydrocarbons.

There are two important factors that may put children at high risk: peer pressure and dysfunctional family situations; the problem also crosses all socioeconomic boundaries. It is especially prevalent among Hispanic and Native American children and adolescents.

Health professionals notice that children who abuse inhalants will first become stimulated, uninhibited, and prone to impulsive behavior. Their speech becomes slurred, and their gait becomes staggered. They can become euphoric and have hallucinations, which are followed by drowsiness and sleep, particularly if they inhale the chemicals repeatedly.

Longer-term effects include school failure, delinquency, and other forms of substance abuse. Abusers can also suffer loss of cognitive and other higher mental functions and they can lose coordination. Children can die from inhalant abuse; one problem that is unique to this kind of abuse is something called the “sud-den sniffing death syndrome’, which can occur if the user is startled during inhalation of a solvent.

The American Academy of Pediatrics hopes to increase public awareness of this problem by bring-ing it to the attention of children, adolescents, parents, teachers, the media, and even those who sell volatile substances. Inhalant abuse should be included in all substance abuse prevention curricula in the primary grades, especially where the problem has been identified.

(AAP Committees on Substance Abuse and Native American Child Health, Pediatrics Mar 1996; 9 7:420-423)

Dr. Michael Shannon Comments: This statement on inhalant abuse is an overdue effort to alert doctors and parents to a growing, under recognized form of substance abuse. Having a host of aliases including “glue sniffing”, “gas sniffing”, ‘huffing”, “bagging” and “whip-ping”, inhalant abuse is considered the most prevalent drug problem among preadolescents, surpassing marijuana and, by some estimates, alcohol.

Beginning at ages as young as 6 years old, children--who have ready access to these chemicals because they are so widely available, inexpensive, and quite legal--begin to sniff them for their narcotic effect. In preadolescent and adolescent years, peer pressure, school failure and family dysfunction can act together to produce “glueheads”. As a testimony to the many patterns of solvent abuse, the Massachusetts Poison Control System has received calls from parents, pharmacists, teachers and school nurses who report an unusual number of children carrying PAM cooking spray, Binaca mouthwash spray, and cigarette lighter fluid, all of which contain solvents as their propellant. It also seems to be common knowledge among children through adolescence that typewriter correction fluid, which has strong effects when inhaled, offers the added benefit of being permitted in the school without arousing suspicion.

The most important step in the prevention of inhalant abuse regulation is unlikely to occur. Because these agents are an essential part of our society, there is no way to eliminate them. How ever, there are a number of other prevention strategies that may stem the growing tide of solvent sniffing. The first step is, of course, education. Parents and teachers need to understand how widespread the problem is among young children and need to recognize its early signs. Because inhalant abuse starts at such a very young age, there is a clear need for starting prevention efforts in elementary schools. (Dr. Shannon is Associate Chief of Emergency Services, Children’s Hospital, and Associate Professor of Pediatrics, Harvard Medical School, Boston, MA)

ASTHMA/ALLERGY

Thunderstorms May Provoke Asthma Attacks

After a severe thunderstorm one Friday in June, 1994, emergency departments in London, England, were flooded with children and adults who had attacks of asthma. This unusual situation led researchers to survey 12 accident/emergency departments in London for the month before and following the thunderstorm. The authors found that nearly 10 times the expected number of patients came to emergency departments beginning on the evening of the storm. For almost half the patients, this visit was their first known attack of asthma. Most had hay fever, and about 15% of the patients were under the age of 16.

The daily pollen count had been exceptionally high during the two days before the epidemic, and the count came down with the rain associated with the thunderstorm. Some other allergens also increased in relation to the storm, as did certain kinds of air pollution.

In trying to explain why there was an epidemic of asthma following the thunderstorm, the authors speculate that the large amount of pollen before the storm may have been deposited in London, only to be stirred up by the very gusty winds accompanying the thunderstorm. They also speculate that the effects of the pollen may have been made worse by the high levels of air pollution that were present at the same time. (Thames Regions Accident and Emergency Trainees Association et al: British Medical Journal, March 9, 1996, pp. 60 1-604)

In another report, other researchers in London studied environmental factors associated with the same thunderstorm and the asthma admissions it seemed to provoke. They found that the epidemic cases occurred in relation to a drop in air temperature and a rise in grass pollen concentration. The authors also describe a curious finding--cases of asthma seen at times well before or after the thunderstorm seemed to be related to different environmental conditions, such as lightning strikes, increased humidity, or increased sulfur dioxide concentrations. “This may indicate that the patients with thunderstorm-associated asthma were a separate population, sensitive to different environmental stimuli.” (Celenza A et al: British Medical Journal, March 9, 1996, pp. 604-607)

COMMENT: There have now been a number of reports that have described epidemics of asthma following thunderstorms, but no one has yet checked to see whether every thunderstorm produces the same problem.

It also seems clear that there are situations where air pollution can make asthma worse--for example, a study at a children’s summer camp showed that increases in the amount of ozone in the air led to changes in the children’s lung functions. While the growing evidence certainly suggests that thunderstorms may make asthma worse, it’s not yet clear what other conditions must be present at the same time (such as high pollen counts), nor does it seem that all children with asthma would be bothered by the storm’s effects.

Parents whose children have asthma--especially asthma that is triggered by high grass pollen levels--might want to observe whether their children get worse following a summer storm. If they do, it may be helpful to present that information to the child’s health care provider, who may advise the parents on ways that the problem could be anticipated and the asthma attack prevented.

PRODUCT SAFETY

What Kind Of Helmet For Mountain Bikers?

Despite the enormous growth of mountain biking, and the heavy involvement in the sport by children, little is known about risks of injury. A California study found that 15% of all those injured while riding bikes off-road had injuries to the head and neck (ranging from abrasions to fractures), despite the fact that 88% of these riders were wearing helmets at the time of their crash. Though several studies have demonstrated the effectiveness of helmets in preventing serious head injuries in standard bicycling accidents, the safety provided by conventional bike helmets may be inadequate for those who take part in off-road biking.

Emergency medicine physicians from Loma Linda, CA, describe two cases involving young men who were injured while riding off-road at fast speeds downhill. Both were wearing approved standard bike helmets which were properly positioned on their heads, but in both cases the helmets had cracked or broken.

The authors point out that standard bike helmets don’t offer protection to the face, and they may not provide enough protection to the head in off-road riding. They warn that “cyclists, both road riders and mountain bikers, should be cautioned that conventional helmets are limited in their capacity to protect the head in a high-velocity direct impact.” Instead, they recommend that helmets for these cyclists resemble those used by motorcyclists, which provide greater crash protection both to the face and skull. (Chow TX et al: Wilderness And Environmental Medicine, 1995, pp. 385-390)

COMMENT: We are becoming more and more accepting of the fact that protective equipment not only can reduce the risk of injury associated with all sorts of sports, but the same equipment needn’t get in the way of the enjoyment the sport has to offer.

While bike helmets are becoming widely used, parents, children, and adolescents may not recognize that mountain biking poses greater hazards than conventional biking. Newer studies are identifying injuries that result from specific sports, and helmets are becoming more sport-specific. Until helmets made specifically for mountain biking become available, it may be helpful to use the kind that are made for competitive mountain biking (they look like motorcycle helmets, with protection around the face and jaw). However, it is far better to wear a standard bike helmet when mountain biking than no helmet at all. As with any intervention, the best way to encourage use of motorcycle-type helmets for mountain biking is to make them attractive to the rider (using bright colors and styles) and have them promoted by role models who wear them in competitions and movies.

PRODUCT RECALLS

Alupent Recall

During routine quality control procedures, the manufacturer of the asthma drug Alupent Inhalation Aerosol (metaproterenol sulfate) found a single canister of a different asthma drug, Atrovent Inhalation Aerosol (iprat-ropium bromide), among the Alupent canisters. Though no further Atrovent canisters were found among this lot of Alupent refills, the manufacturer, Boehringer Ingelheim Corp., is recalling all 8,400 inhalers distributed since March 11, 1996. The lot number affected by the recall is 951051A, with an expiration date of 9/97. Patients treated with this drug should examine the lot number printed on the label of any recently purchased Alupent Inhalation Aerosol refill canisters and promptly exchange them at their pharmacy if they come from the affected lot. (Recall Notice, Boehringer Ingelheim Corp., Ridgefield, CT; Apr 12 1996)

Children’s Furniture Warning

Ridgewood, Inc., of Ontario, Canada, and Charleswood Inc., of Wright City, MO, have warned that some of their children’s bedroom furniture could tip over, seriously injuring children. The two companies sold almost 600,000 chifferobes (combination dresser/wardrobes), models 80813 and 88813, and over 300,000 four-drawer dressers, models 80413 and 88413, under the brand name “Cosco Youth Options.” Since 1991, the chif-ferobe has sold nationwide for $89-109, and the dresser for $79-89 in depart-ment stores, juvenile furniture stores, Wal-Marts, and Kmarts. Consumers are urged to remove the feet/glides to reduce the risk of tipping. For more information, call the companies’ hot-line: (800) 314-9317.

Mini-Hammock Recall

Consolidated Stores Corp., of Columbus, OH, is recalling 26,000 mini-hammocks because they have been implicated in 17 strangulations. The product does not have a spread bar to hold the hammock open, so children can become entangled while getting in or out of the hammock. They sold for $3.99 nationwide in 1990 and 1991 at Consolidated Big Lots and Odd Lots stores. Consumers should return the hammocks to the place of purchase for full refund. For more information, call Consolidated Stores at (800) 877-1253, ext 6807. (AAP News, April, 1996)