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NIÑOS AGRESORES “BULLIES”

 

 

Su hijo(a) siempre ha disfrutado aprendiendo pero últimamente prefiere evitar ir a la escuela. Dolores de estómago y misteriosas enfermedades aparecen durante la tarde y parecen empeorar a medida que el autobús escolar se acerca a su calle en las mañanas. Es posible que el problema no tenga nada que ver con la digestión o la forma en la que su hijo(a) digirió la cena la noche anterior. Su hijo(a) puede que esté enfermo de preocupación ante un posible enfrentamiento en la escuela con otros niños agresores. Este tipo de comportamiento agresivo de un grupo de niños se conoce en Inglés como bullying.

Los enfrentamientos en la escuela pueden restar diversión al hecho de ir al colegio- donde suelen ocurrir la mayoría de los enfrentamientos con estos niños (comportamiento agresivo) – y convertir algo tan simple como ir en el autobús escolar, buscar algo en el vestuario o ir al baño, en un episodio temido que se anticipa con preocupación durante todo el día.

Los niños que sufren los enfrentamientos agresivos de otros niños en la escuela generalmente experimentan baja autoestima y depresión, mientras que los niños que propician los enfrentamientos puede que continúen involucrándose en conductas anti-insociables incluso más destructivas cuando llegan a ser adolescentes y adultos. Los niños que se enfrentan a otros (bullies en Inglés), quienes generalmente también han sido víctimas de enfrentamientos por parte de otros niños, puede que ataquen a otros niños para sentirse poderosos, populares o en control de las situaciones. Generalmente, estos niños(as) antagonizan a los mismos niños(as) repetidas veces.

Lamentablemente, el enfrentamiento agresivo en la escuela es un hecho que ocurre en muchos lugares. Según un estudio realizado en 2004 por KidsHealth, el 86% de más de 1,200 niños y niñas en edades comprendidas entre los 9 y 13 años admitieron haber visto a niños(as) enfrentados por otros niños, 48% dijeron haber sido víctimas de estos enfrentamientos, y el 42% admitieron haber enfrentado a otros niños(as) al menos de vez en cuando.

Si su hijo(a) es una víctima de este comportamiento agresivo, usted puede ayudarle a reducir su intimidación y miedo escuchando a su hijo y ofreciéndole ayuda. Si su hijo(a) es el agresor, usted debe enfatizar que este tipo de comportamiento es inaceptable, así como hablar sobre las razones que le motivan a enfrentarse a otros niños para terminar con este comportamiento.

Las diferentes formas de enfrentamientos entre los niños

Comportamiento agresivo no son fáciles de definir. ¿Dónde debe trazarse el límite entre un intercambio típico entre niños comportamiento agresivo? A pesar de que cuando un niño(a) se mete con otro puede propiciar sentimientos de enfado o vergüenza, este tipo de intercambio entre niños puede ser menos hostil e incluso hecho con humor en lugar de daño. Cuando los niños bromean de esta forma entre ellos, hay un intercambio de comunicación entre personas en lugar de un acto de intimidación dirigido hacia una persona solamente.

A pesar de que tener un ojo morado es un signo concreto de que su hijo(a) puede ser la victima de enfrentamientos por parte de un grupo de niños(as), existen diferentes maneras mediante las cuales los niños(as) agresores son difíciles de identificar:

  • Comportamiento agresivo en el cberespacio (en Ingles: “Cyber Bullying “) – un fenómeno relativamente nuevo – comenzó a surgir a medida que las tecnologías de comunicación moderna avanzaron. A través de correos electrónicos, mensajes instantáneos, salas de charla por Internet, y objetos electrónicos como teléfonos móviles con cámara, los agresores en el ciberespacio envían y distribuyen imágenes y mensajes ofensivos. Los agresores utilizan esta tecnología para molestar a sus víctimas a toda hora, en círculos amplios muy rápidamente.
  • Comportamiento agresivo emocional puede ser más sutil y puede comprender el aislar o excluir a un niño(a) de ciertas actividades (i.e., evitando a la víctima en el comedor o en las excursiones de la escuela) o circular rumores. Este tipo de agresión es muy frecuente entre las niñas.
  • Comportamiento agresivo físico puede acompañar al comportamiento agresivo verbal y comprende comportamientos como dar patadas, golpear, morder, pellizcar, halar el cabello o amenazas de daño físico. 
  • Comportamiento agresivo basado en racismo agrede a los niños a base de comentarios racistas, gestos ofensivos o mediante chistes con burlas a las tradiciones culturales de otros niños(as).
  • Comportamiento agresivo sexual involucra contacto físico involuntario o comentarios sexuales abusivos o inapropiados.
  • Comportamiento agresivo verbal generalmente comprende sobrenombres ofensivos, burlas constantes y reírse a costa de otros niños(as).

A pesar de la noción común de que los comportamientos enfrentamientos agresivos son un problema que ocurre generalmente en los niños, este problema ocurre tanto en los niños como las niñas. Ambos, tanto los niños como las niñas lo manifiestan en diferentes grados. Las niñas tienden a herir a un nivel emocional. Por ejemplo, pueden aislar a sus victimas excluyéndolas de los arreglos para sentarse en el comedor escolar, ignorándolas en el patio de juego, o rehuyéndolas a la hora de repartir invitaciones para reuniones en casa de las amigas que incluyen quedarse a dormir.

Los niños no son tan sutiles y pueden agredir mediante acciones físicas. Por ejemplo, los niños son más adeptos a insultar a sus victimas en el patio de juegos en lugar de ignorarlas. En lugar de aislar a un compañero que no sea atlético  durante un juego de esquivar la pelota en el gimnasio, los niños agresores puede que no dejen tranquila a su víctima tomándola como objetivo para lanzarle bola tras bola.

¿Por qué los niños(as) se enfrentan de este modo?

Existen muchas razones por las que los niños(as) pueden convertirse en niños(as) agresores. Frecuentemente, seleccionan a las personas que son diferentes a ellos(as) para después explotar al máximo estas diferencias. Ellos(as) eligen a victimas que a su parecer serán incapaces de tomar represalias. Este tipo de victimas seleccionadas como objetivos de ridículo, incluye a niños con sobrepeso, quienes usan gafas o espejuelos, o aquellos con diferencias físicas como orejas grandes o problemas de acné. Pero estas diferencias puede que no sean solamente físicas. Los niños que aprenden a una velocidad diferente o tienen inseguridad o ansiedad también pueden ser objeto de enfrentamientos.

Los niños(as) agresores también adoptan este tipo de comportamiento como una forma de lidiar con situaciones difíciles en su hogar, como por ejemplo un divorcio. Los niños(as) agresores puede que no se den cuenta de la medida en que sus actos pueden herir a otros niños(as), mientras que otros ninos sí son conscientes de ello ya que lo han experimentado en carne propia tras haber sido agredidos por otros niños. Algunos agresores piensan que su conducta es normal porque ellos vienen de familias en las que sus miembros generalmente se enfadan entre sí mediante insultos y gritos. De esta forma, repiten lo que ya conocen. Y al igual que sus victimas, los niños(as) agresores también son víctimas de baja autoestima.

Independientemente de la causa, los niños agresores generalmente agreden verbalmente a otros niños(as) como un modo de lidiar con sus propios problemas. Algunas veces, estos niños (as) se meten con otros niños porque necesitan una victima – alguien que parezca emocionalmente o físicamente más debil que ellos(as)- para intentar ganar aceptación y sentirse más importantes, populares o en control. Aunque algunos niños(as) agresores son mayores o más fuertes que sus víctimas, este tipo de niños(as) no se limita a este tipo de rasgos.

¿Cuáles son los síntomas de que un niño(a) está siendo agredido por otros niños(as)?

Obviamente, las marcas y los moretones, son signos de que su hijo(a) está siendo agredido físicamente, pero usted también puede estar pendiente de otros síntomas que no son tan obvios, como por ejemplo:

  • Inventar enfermedades misteriosas para evitar ir a la escuela (dolores de estómago, dolores de cabeza, etc.)
  • Perdida de útiles personales o dinero
  • Trastornos del sueño
  • Mojar la cama
  • Irritabilidad
  • Poca concentración
  • Cambios inesperados en la rutina
  • Problemas con los deberes escolares

Ser agredido por otros niños(as) también puede tener consecuencias a largo plazo, afectando a los niños(as) en el desarrollo de sus relaciones como adolescentes y adultos e incluso influenciando la aparición de problemas más serios como abuso de sustancias tóxicas y depresión. Además, las victimas de este tipo de agresiones por parte de otros niños, son más proclives a manifestar conductas de aislamiento como la ansiedad y la depresión.

Cómo ayudar a su niño(a) si está siendo agredido por otros niños

Ser un buen oyente es una de las mejores formas de calmar a su hijo(a). Tan solo hablar del problema y hacerle saber que a usted le importa lo que le ocurre puede ayudar. Puede que su hijo(a) se sienta vulnerable mientas conversan sobre cómo ha sido agredido y cómo se siente al respecto, así que es importante que usted le demuestre su amor y su apoyo.

Si usted está al tanto de que su hijo(a) ha sido agredido, no añada al problema disgustándose al respecto. Aunque es entendible que usted se sienta disgustado(a), tenga cuidado de que su hijo(a) no sea testigo de su actitud. Su tristeza puede interpretarse como una desilusión. Asegúrese de legitimar los sentimientos de su hijo(a) – en lugar de minimizarlos.

Usted también debe reafirmar a su hijo que él o ella no tienen la culpa de este tipo de agresiones. Explíquele que los niños agresores generalmente están confundidos o infelices porque no se sienten bien consigo mismos.

También considere preguntarle a su hijo(a) lo siguiente:

  • ¿Qué ocurre cuando camina desde la parada de autobús hasta la casa al volver de la escuela?
  • ¿Qué ocurre mientras viaja en autobús de la casa a la escuela y viceversa?
  • ¿Qué ocurre en el patio de juegos durante el recreo o antes o después de asistir a clases?
  • ¿Qué ocurre en los pasillos de la escuela durante la hora de almuerzo?
  • ¿Le han amenazado algún grupo de niños(as) o alguien que conozca en el vecindario o en la escuela?
  • ¿Conoce a niños(as) que reciban correo electrónico, mensajes instantáneos o mensajes de texto que causen distubios, amenacen o insulten?

Este enfoque puede que facilite el que su hijo(a) hable sobre los grupos de niños(as) que lo enfrentan ya que no es un demasiado personalizado y enfatiza que otros niños(as) también enfrentan situaciones similares.

Los trabajos de arte y dibujos o muñecos tipo marionetas pueden provocar que las víctimas mas jóvenes hablen sobre los niños(as) que se meten con ellos. Otros niños, puede que hablen con mayor facilidad con preguntas directas, como por ejemplo preguntándoles sobre sus amigos y enemigos.

Sin embargo decirle a su hijo(a) que debe de hacer cuando otros niños(as) se enfrentan a él puede ser otra historia. La encuesta nacional en los Estados Unidos KidsHealth KidsPoll demostró que un 46% de los niños(as) que participaron en el estudio dijeron haber sido enfrentados y haber respondido peleando físicamente con los niños(as) que los enfrentan, una solución que puede empeorar las cosas. Los niños(as) en el estudio fueron más propensos a decir que estaban dispuestos a defenderse peleando (53% de los niños vs. 38% de las niñas), mientras que las niñas fueron más propensas a decir que hablarían con un adulto sobre el tema (32% de las niñas vs. 19% de los niños).

La clave para ayudar a su niño a lidiar con los niño(as) que se enfrentan a ellos es ayudarles a recuperar su dignidad y su autoestima lesionada. Para ayudarle a mantener a los niños(as) agresores lejos de su hijo(a), usted puede darle a su niño(a) los siguientes consejos:

  • Controlar el enfado. Es natural querer reaccionar con gran disgusto cuando un niño(a) quiera agredir, pero eso es exactamente la reacción que este tipo de niños(as) agresores está buscando. Una reacción agresiva no solucionará el problema, más bien lo empeorará. Los niños(as) agresores quieren tener el control sobre las emociones de otros niños(as). Cada vez que obtienen una reacción del niño(a) al que agreden, añade leña al fuego a su capacidad de agredir – reaccionar disgustado solamente hace sentir al agresor más poderoso.
  • Evitar reaccionar con violencia física. Haga énfasis en que su hijo(a) nunca debe utilizar la fuerza física (como patalear, golpear o empujar) para lidiar con un niño(a) agresor. Esta reacción demuestra enfado y nunca se sabe cómo responderá el agresor. Dígale a su hijo(a) que es mejor estar al lado de otros niños, permanecer seguros y buscar ayuda de una persona adulta.
  • Actuar con valentía, alejarse de la situación e ignorar al Agresor. Dígale a su hijo(a) que mire a su agresor a los ojos diciendo palabras como “Quiero que dejes de molestarme ahora mismo”. Aconséjele a su hijo(a) a que se aleje de la situación ignorando futuras provocaciones. Motive a su hijo a que “camine erguido” con la frente en alto (este tipo de lenguaje corporal comunica el mensaje de que su hijo(a) no es vulnerable). Los correos electrónicos y los mensajes de los niños (as) agresores se fortalecen con las reacciones que desencadenan, y el alejarse de sus provocaciones o el ignorar mensajes hirientes y ofensivos, su hijo(a) le estará comunicando a su agresor que a él o a ella no les importan sus provocaciones. Tarde o temprano, el niño(a) agresor se cansará o se aburrirá de tratar de molestar a su hijo(a).
  • Utilize el humor. Si su hijo(a) está en una situación en la que tiene que lidiar con un agresor y no puede alejarse manteniendo la compostura, dígale que haga uso del sentido del humor o que halague a su agresor con un cumplido para sorprenderlo repentinamente. Sin embargo, aconseje a su hijo(a) a que nunca utilice el sentido del humor para burlarse de su agresor.
  • Hablar con un adulto. Si su hijo(a) está siendo enfrentado por niños(as) agresores, hágale saber que es importante contarle a un adulto lo que está pasando. Los profesores, principales de las escuelas y el personal que trabaja en el comedor de la escuela pueden ayudar a detenerlo. Los estudios demuestran que las escuelas que se ocupan de este tipo de problemas tienen menos incidentes de este tipo.
  • Hablar sobre el tema. Puede que ayude si su hijo habla con un consejero en la escuela, con un maestro o un amigo – la persona que pueda proveer a su hijo(a) el apoyo que necesite. Hablar puede ser una buena solución para los miedos y las frustraciones que pueden surgir cuando su hijo(a) está siendo enfrentado por otros niños.
  • Utilice un sistema de apoyo entre compañeros. Reunir ayuda de amigos o de un grupo puede ayudar tanto a su hijo(a) como a otros niños(as) a enfrentarse a los agresores. Este tipo de niños busca el reconocimiento y el poder, después de todo, gran parte de los enfrentamientos tienen lugar alrededor de otros niños. Si el niño(a) agresor se mete con otro niño(a), dígale a su niño(a) que le diga al agresor que su conducta es una forma inaceptable de tratar a otra persona. Esto puede dar resultado especialmente en cierto tipo de situaciones (i.e. cuando un miembro del círculo de amigos de su hijo(a) comienza a meterse con uno de los niños(as) a su alrededor). Dígale a su hijo(a) que haga planes de formar equipo con uno o dos amigos(as) de camino a la escuela, en el autobús, en los pasillos o en los recreos para almorzar -donde quiera que su hijo(a) piense que podrá encontrar al agresor. Dígale a su hijo(a) que se ofrezca para hacer lo mismo por un amigo que esté siendo agredido por otro niño(a). Cuando una persona se expresa abiertamente en contra de un niño(a) agresor, ayuda a que otros se unan para apoyarlo y expresar también su opinión.
  • Desarrolle amistades uniéndose a organizaciones sociales, clubs o programas de deportes. Motive la visita de otros niños(as) a su casa para que jueguen con los suyos. Estar en un grupo con otros niños puede ayudar a que su hijo(a) fortalezca su autoestima poniendo a su alcance un grupo más grande de amistades positivas con las que podrá pasar su tiempo y contar con su apoyo.

Obviamente, usted puede que tenga que intervenir en los casos donde las agresiones de niños(as) hacia su hijo(a) sean persistentes. Este tipo de intervenciones puede incluir caminar a la escuela con su hijo(a) y hablar con los maestros, consejeros en la escuela, o directores. La seguridad de los niños(as) debe ser una preocupación para todos. Si usted ha intentado todos los métodos detallados anteriormente y todavía siente la necesidad de hablar con los padres del niño(a) agresor, es mejor que lo haga dentro del contexto de la escuela, donde un oficial como un consejero pueda ejercer como mediador.

Si su hijo es el agresor

Enterarse de que su hijo es el agresor puede sorprenderle. Pero es importante permanecer en calma y evitar actuar a la defensiva, ya que esto puede empeorar la situación. Usted puede tener un mayor impacto si usted expresa a su hijo(a) su desilusión -en lugar de su disgusto.

Debido a que agredir a otros niños(as) generalmente surge de la infelicidad y la inseguridad, intente descubrir si algo está molestando a su hijo(a). Los niños(as) agresores no son muy propensos a confesar su conducta, pero usted debe de intentar que su hijo hable haciendo preguntas específicas directas, como por ejemplo:

  • ¿Cómo te sientes contigo mismo?
  • ¿Cómo crees que van las cosas en la escuela y en la casa?
  • ¿Hay niños(as) que te agraden?
  • ¿Te llevas bien con otros niños en la escuela?
  • ¿Cómo tratas a otros niños(as)?
  • ¿Cómo te sientes cuando te consideran un niño(a) agresor?
  • ¿Por que crees que eres un niño(a) agresor?
  • ¿Qué podría ayudarte a dejar de agredir a otros niños?

Para llegar al fondo de lo que motiva a que su hijo(a) ataque a otros niños(as) puede que usted quiera hacer una cita con el consejero de su hijo(a) o un experto en salud mental en la escuela (el doctor de su hijo(a) debería poder recomendarle a la persona indicada).

Si usted sospecha que su hijo(a) es un agresor, es importante que se ocupe del problema y trate de solucionar este tipo de conducta hiriente en su hijo(a). Después de todo, este tipo de agresiones se consideran conductas violentas y antisociales en la medida en que el niño(a) agresor crece. De hecho, uno de cada cuatro niños(as) agresores en la escuela elemental terminan con un record criminal cuando llegan a los treinta años. Algunos niños(as) agresores también terminan siendo rechazados por sus compañeros y pierden amistades a medida que crecen. Los niños(as) agresores también pueden ser propensos a fallar en la escuela y no llegar a obtener el éxito personal en relaciones o en el ámbito profesional que otras personas disfrutan.

Ayudando a que su hijo deje de agredir a otros niños(as)

Aunque no todos los problemas de agresión nacen a partir de problemas familiares, es una buena idea examinar el comportamiento y las interacciones personales que su hijo(a) ve en el hogar. Si su hijo(a) es constantemente provocado por sus hermanos(as) o uno de sus padres o si se dirigen a él o ella con sobrenombres, esto podría provocar conductas agresivas o hirientes fuera del hogar. Lo que pueden parecer bromas en casa generalmente sirven como modelo de conducta para agredir a otros niños(as). Los niños(as) víctimas de estos enfrentamientos aprenden que esto se traduce en control sobre los niños(as) que estos perciben como debiles.

Las bromas personales constantes – independientemente de que ocurran en la casa o en la escuela- también pueden afectar su autoestima. Los niños(as) con baja autoestima pueden crecer emocionalmente inseguros. También pueden terminar culpando a otros por sus errores. Hacer que otras personas se sientan mal por medio de agresiones comportamiento agresivo puede dar a ciertos niños(as) un sentido de poder.

Por supuesto, habrá momentos donde habrá que enfatizar críticas constructivas, como por ejemplo, “Contaba contigo para que sacaras la basura y debido a que te olvidaste, tenemos que aguantar el mal olor en el garaje durante una semana”. Pero tenga cuidado en no dejar que sus palabras terminen criticando a la persona en lugar del comportamiento: “Tú eres flojo. Apuesto que finges olvidar tus quehaceres para no ensuciarte las manos.” Concéntrese en la conducta que considera inaceptable en lugar de la persona.

El hogar debe ser un refugio seguro donde los niños(as) no estén expuestos a críticas fuertes e incomodas por parte de la familia y sus seres queridos.

Además de mantener una atmósfera positiva en el hogar, existen otro tipo de formas de motivar a que su hijo(a) deje de agredir verbalmente a otros niños(as):

  • Enfatice que agredir verbalmente a otros niños(as) es un problema serio. Asegúrese de que su hijo(a) entiende que usted no tolerará este tipo de conducta agresiva hacia otros niños(as)  y que hacerlo tendrá consecuencias en casa. Por ejemplo, si su hijo está agrediendo a otros a través de la Internet, suprima el acceso a la tecnología que emplea para que sus agresiones lleguen a otros (i.e., computadoras, teléfono celular, mensajes de texto o envío de fotos). O de instrucciones a su hijo para que utilice la Internet para investigar sobre este tipo de agresiones  y tomar nota de estrategias para reducir este tipo de comportamiento. Otros ejemplos de disciplina incluyen restricciones en los horarios de salida de su hijo(a) si este tipo de agresiones ocurre fuera del hogar, restitución de privilegios permitiendo la oportunidad de ganarlos de nuevo según su conducta, requerir que su hijo(a) participe como voluntario para ayudar a los más necesitados.
  • Enseñe a su hijo(a) a tratar a las personas que sean diferentes con respeto y consideración. Enseñe a su hijo(a) aceptar, en lugar de ridiculizar las diferencias (i.e., raza, religión, apariencia, necesidades especiales, género, estatus económico). Explíquele que todo el mundo tiene derechos y sentimientos.
  • Descubra si lo amigos de su hijo(a) también están agrediendo verbalmente a otros niños(as). Si éste es el caso, busque a un grupo de intervención a través del director de la escuela de su hijo, consejero de la escuela y/o sus maestros.
  • Establezca límites. Detenga cualquier tipo de agresión inmediatamente y ayude a que su hijo(a) aprenda formas no violentas de reaccionar.
  • Observe cómo su hijo(a) interactúa con otros niños(as) y halague comportamientos apropiados. Las críticas positivas son más eficaces que la disciplina.
  • Hable con el personal de la escuela para ayudar a que su hijo(a) cambie su comportamiento. Asegúrese de mantener contacto con el personal de la escuela para lograr este objetivo.
  • Fije metas realistas y no espere cambios inmediatos. A medida que su hijo aprende a modificar su conducta, asegúrese de repetirle que usted lo quiere como persona -enfatizando que lo que no le gusta es su comportamiento.

Obteniendo ayuda para ambos, los niños(as) que agreden y los niños(as) que reciben las agresiones

Una buena parte de ayudar a su hijo(a) es no tener miedo de pedir ayuda y consejo a otras personas. Independientemente de que su hijo(a) esté siendo agredido o sea el agresor, puede que usted necesite ayuda adicional. Además de hablar con los maestros de su hijo(a), puede que usted quiera aprovechar el tener servicios de consejeros en la escuela y hablar con el medico de su hijo, quien puede referirle a un profesional en salud mental.

Puede que usted también quiera hablar con el director de la escuela sobre las reglas en cuanto a este tipo de agresión verbal entre niños(as). Por ejemplo, pregunte cómo son castigados los agresores y si las áreas donde ellos pueden meterse con otros niños(as) como las escaleras o los campos de juego son supervisadas por el personal de la escuela. De a conocer su opinión a los maestros, padres de niños(as) en la escuela, la junta de la escuela y la asociación de padres y maestros. Si la escuela de su hijo(a) aun no tiene este tipo de asociación, comience un programa en contra de la violencia. Si el ambiente en la escuela de su hijo(a) apoya el tipo de conducta de agresión hacia otros niños(as), intentar cambiarla puede ayudar.

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AMA Recommends 4-Stage Approach to Treatment of Childhood Obesity

 

July 17, 2008 — A 4-stage approach to treatment of childhood obesity is recommended by the American Medical Association (AMA), according to a review for primary care clinicians in the July 1 issue of the American Family Physician. The study authors note that many of these recommendations for treatment and prevention can be carried out by family clinicians.

“Childhood obesity has become so severe that diseases that once affected only adults are now appearing in children,” writes Goutham Rao, MD, from Children’s Hospital of Pittsburgh in Pittsburgh, Pennsylvania. “The long-term implications of this epidemic are extremely serious. Obese children are much more likely than children of healthy weight to become obese adults.”

The statistics are alarming, with “overweight” youth (those with age-adjusted and sex-adjusted body mass index [BMI] above the 95th percentile, which is equivalent to the “obese” classification for adults) consisting of 13.9% of children 2 to 5 years old, 18.8% of children 6 to 11 years old, and 17.4% of adolescents and teenagers 12 to 19 years old.

Although type 2 diabetes in children was rare 2 decades ago, it now accounts for nearly one half of all new cases of diabetes among children in some settings. In adults, correlates of obesity include not only type 2 diabetes but also hypertension, osteoarthritis, gout, dyslipidemia, cardiovascular disease, and biliary tract disease as well as cancers of the colon, breast (in postmenopausal women), endometrium, and esophagus.

Recognizing the scarcity of practical strategies available to primary care clinicians to combat the problem of childhood obesity, the AMA recently convened an expert panel to review evidence about how best to manage and prevent obesity and to write a series of reports.

Specific recommendations of The Expert Committee on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity, and their accompanying level of evidence, are as follows:

  • At least once a year, measure height and weight and calculate BMI plus BMI percentile for all children (level of evidence, C).
  • To achieve or maintain a healthy weight, encourage all children to participate in at least 60 minutes of moderate to vigorous physical activity on most, and preferably all, days of the week (level of evidence, A).
  • Advise children not to drink more than 1 serving per day of sweetened beverages, such as fruit juice, fruit drinks, regular-calorie soft drinks, sports drinks, energy drinks, sweetened or flavored milk, or sweetened iced tea (level of evidence, B).
  • Advise families to limit their children’s television viewing and other screen time to 2 hours per day or less (level of evidence, B).
  • Recommend that children’s fast-food consumption be limited to no more than once per week (level of evidence, C).
  • Advise families with children to eat meals together as often as possible, on most, and preferably all, days of the week (level of evidence, C).

 

During the annual visit, family clinicians should evaluate key dietary and lifestyle habits, including consumption of sweetened beverages and physical activity; willingness to improve dietary and lifestyle habits; and family history of obesity and related illnesses.

Dietary habits that contribute to obesity include frequent consumption of fast food and large volumes of sweetened beverages, eating large portions, skipping breakfast, eating high-fat snacks or other foods high in energy density, low intake of fruits and vegetables, and irregular meal frequency and snacking patterns.

Physical examination should include measurement of pulse, blood pressure, and evaluation for signs often associated with obesity, such as hepatomegaly from fatty liver disease and acanthosis nigricans, which is associated with insulin resistance. The examination may detect signs of possible reversible causes of obesity, such as deep purple striae and the “buffalo hump” of Cushing’s syndrome.

The degree of obesity and presence of comorbid conditions should determine laboratory testing. A fasting lipid profile is recommended for children with BMI between the 85th and 94th percentiles but with no obesity-related illnesses, Children with BMI between the 85th and 94th percentiles and with obesity-related illnesses should also be tested for alanine transaminase, aspartate transaminase, and fasting blood glucose levels, and children with BMI higher than the 95th percentile should also undergo measurement of serum urea nitrogen and creatinine levels.

Depending on progress, the committee recommends a staged approach of increasing intensity to manage overweight and obese children and adolescents 2 to 19 years old:

  • Stage I (Prevention-Plus Protocol): Make specific dietary and physical activity recommendations, with monthly follow-up. If BMI does not improve in 3 to 6 months, consider stage II.
  • Stage II (Structured Weight Management Protocol). This more structured plan includes a low–energy-dense, balanced diet; structured meals; supervised physical activity of at least 60 minutes daily; limiting television-watching and other screen time to 1 hour per day or less; and use of logs to self-monitor these behaviors. Family clinicians may require assistance from allied care professionals to implement this step, and children should be followed up as often as needed. If BMI does not improve in 3 to 6 months, stage III is appropriate.
  • Stage III (Comprehensive, Multidisciplinary Intervention) and Stage IV (Tertiary-Care Intervention) are more intensive interventions administered by highly trained teams expert in obesity management. Specialized centers can provide effective, intensive counseling programs that promote behavior modification for obese children. Referral is especially indicated for severely obese children and for those with obesity-related comorbidities.
  • “A four-stage approach to treatment of childhood obesity is recommended,” Dr. Rao writes. “Many of these recommendations can be carried out by family physicians for treatment and prevention. These include advising families to limit consumption of sweetened beverages and fast food, limit screen time, engage in physical activity for at least 60 minutes per day, and encourage family meals on most, and preferably all, days of the week.

 

Dr. Rao has disclosed no relevant financial relationships.

Am Fam Physician. 2008;78:56-63.

Clinical Context

According to the Centers for Disease Control and Prevention, children with age-adjusted and sex-adjusted BMI from the 85th to 94th percentiles are considered “at risk for overweight” and those with BMI at the 95th percentile or greater are considered “overweight.” The prevalence of overweight children is 13.9% for ages 2 to 5 years, 18.8% for ages 6 to 11 years, and 17.4% for ages 12 to 19 years. In the May-June 2005 issue of Ambulatory Pediatrics, Perrin and colleagues found that only 12% of pediatricians self-reported high efficacy in the management of obesity.

This study summarizes the recommendations for the assessment and management of childhood overweight and obesity from the AMA Expert Committee on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity.

Study Highlights

  • Recommendations were based on literature review and expert opinion.
  • The AMA recommends consistent terminology for children and adults: “overweight” (BMI from 85th to 94th percentile), “obese” (BMI at or above 95th percentile), and “severely obese” (BMI above 99th percentile).
  • Assessment includes dietary and lifestyle habits, family history, physical examination, readiness to change, and laboratory tests.
  • Dietary habits linked to obesity are frequent fast-food intake, large volumes of sweetened drinks, large portions, skipping breakfast, high-energy dense foods, few fruits and vegetables, and irregular meals and snacking.
  • Lifestyle habits include environment, social support, barriers to activity, sedentary behavior, and physical activity.
  • Pertinent family history includes obesity, type 2 diabetes, and cardiovascular disease.
  • Physical examination should include height, weight, BMI, pulse, and blood pressure.
  • Physical examination findings associated with obesity are hepatomegaly from fatty liver disease, acanthosis nigricans linked to insulin resistance, and striae and buffalo hump from Cushing’s syndrome.
  • Stages of readiness to change are precontemplation, contemplation, preparation, action, and maintenance.
  • Laboratory testing is guided by BMI and personal or family history of risk factors:
    • BMI from 85th to 94th percentiles and no risk factors: fasting lipid profile
    • BMI from 85th to 94th percentiles and risk factors: add alanine transaminase and aspartate transaminase and fasting blood glucose
    • BMI above 95th percentile: add serum urea nitrogen and creatinine levels
  • Address weight and lifestyle habits once a year with all patients.
  • Treatment for overweight and obese children aged 2 to 19 years includes 4 stages.
  • Stage I consists of specific recommendations, monthly follow-up, and advancement to stage II if BMI does not improve in 3 to 6 months: 5 or more daily servings of fruits and vegetables, television and computer use of no more than 2 hours daily, no television in child’s room, at least 60 minutes of daily moderate to vigorous physical activity, no sugar-sweetened drinks, breakfast daily, meals outside the home limited, family meals at least 5 times a week, and self-regulation of food.
  • Stage II consists of more structured and supervised stage I recommendations, limiting television and computer use to less than 1 hour daily, follow-up as often as needed, help from allied health professionals, and advancement to stage III if BMI does not improve in 3 to 6 months.
  • Stage III involves multidisciplinary intervention.
  • Stage IV involves tertiary care intervention.
  • Referrals are important for children with severe obesity or obesity-related morbidities.
  • Goal is to maintain lifetime healthy behaviors, but guidelines depend on age and obesity level:
    • BMI 85th to 94th percentiles: maintain weight until BMI below 85th percentile or BMI curve decreases
    • BMI at 95th percentile or greater: maintain weight until BMI below 85th percentile or weight loss up to 1 pound per month until BMI below 85th percentile
    • BMI more than 21 or 22 kg/m2 in children aged 2 to 5 years or at 99th percentile or greater: weight loss of 1 to 2 pounds per month until BMI below 85th percentile
  • Obesity prevention for children with BMI between 5th and 84th percentiles should address dietary habits, sedentary behaviors, physical activity, authoritative parenting, family involvement, and school and community support.
  • The National Initiative for Children’s Healthcare Quality published a guide to facilitate implementation.

Pearls for Practice

  • The recommended assessment of childhood obesity includes evaluation of dietary and activity habits, family history of obesity-related illnesses, readiness to change habits, and related physical examination findings. Depending on the severity of obesity and related conditions, laboratory testing might include fasting lipid profile, alanine transaminase, aspartate transaminase, fasting blood glucose, serum urea nitrogen, and creatinine.
  • The recommended 4-stage approach to treatment of childhood obesity includes limiting intake of sweetened drinks and fast food; limiting television and computer use; physical activity for at least 60 minutes daily; family meals; close follow-up; and, if needed, assistance from allied health professionals or weight management center.

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Neonates in Intensive Care Endure Painful Procedures, Mostly Without Analgesia

 

July 11, 2008 — Over a 2-week period, neonates in intensive care underwent a median of 10 painful procedures per day, 79.2% without analgesia, in a study from Paris.

“The number of painful procedures is so high that the first step to improve procedural pain management must significantly reduce these numbers,” the authors, led by Ricardo Carbajal, MD, from the Hôpital d’enfants Armand Trousseau, in Paris, France, write.

“The knowledge that some vulnerable neonates underwent 153 tracheal aspirations or 95 heel sticks in a 2-week period should elicit a thoughtful and relevant analysis on the necessity and the risk/benefit ratio for our clinical practices,” they observe.

The study is published in the July 2 issue of the Journal of the American Medical Association.

Vulnerable Neonates, Long-Term Consequences From Pain

Compared with older children and adults, neonates are more sensitive to pain, and multiple lines of evidence suggest that repeated and prolonged exposure to pain alters a neonate’s subsequent pain processing, long-term development, and behavior. “It is essential, therefore, to prevent or treat pain in neonates,” the group writes, and there are numerous pharmacological and nonpharmacological treatments that can alleviate procedural pain in these infants.

Effective strategies to improve pain management in neonates require a clear understanding of the epidemiology and management of procedural pain, they add.

They aimed to report the findings from epidemiologic data on neonatal pain collected from direct bedside observations of neonates in Paris as part of the Epidemiology of Procedural Pain in Neonates study.

This prospective observational study collected around-the-clock bedside data on all painful or stressful procedures performed in 430 neonates admitted to 13 of 14 intensive care units in tertiary care centers in Paris. Data were collected from the first 14 days of admission during a 6-week period.

Painful procedures were considered as those that invaded a neonate’s bodily integrity, and stressful procedures were defined as those that mainly caused physical uneasiness or annoyance.

Nonpharmacologic analgesia included administering sweet solutions or allowing nonnutritive sucking. Pharmacologic analgesia included intravenous opioids and topical drugs.

The average gestational age was 33 weeks, and the average intensive care unit stay was 8.4 days.

The investigators identified 44 painful procedures, of which the 6 most common were nasal aspiration (28.9% of the procedures), tracheal aspiration (23.3%), heel stick (19.8%), adhesive removal (12.7%), gastric tube insertion (2.4%), and venipuncture (1.8%).

Of the 16 identified stressful procedures, the 6 most frequent were nursing care (39.2%), oral aspiration (26.9%), washing the neonate (8.5%), blood pressure measurement (8.5%), radiographs (6.0%), and infant weighing (5.8%).

Average of 16 Painful or Stressful Procedures Each Day

During the study period, neonates experienced 42,413 painful and 18,556 stressful first-attempt procedures and 10,366 painful and 1180 stressful supplemental-attempt procedures.

Each neonate experienced a mean of 16 painful plus stressful procedures each day, and some experienced as many as 62 procedures each day.

Table. Number of Painful and Stressful Procedures in Neonates in ICU*

Procedure In 2 Weeks Per Day
Painful or stressful procedures, n, mean (SD) 141 (107) 16 (9)
Painful procedures, n, mean (SD) 98 (78) 12 (8)
Painful or stressful procedures, n, median (range) 115 (4 – 613) 16 ( 0 – 62)
Painful procedures, n, median (range) 75 (3 – 364) 10 (0 – 51)

*ICU indicates intensive care unit.

Of the 42,413 painful procedures, only 20.8% were carried out with specific analgesia before the procedure: 2.1% were performed with pharmacologic-only therapy, 18.2% with nonpharmacologic therapy, and 0.4% with both.

“Advances in neonatal care in recent decades, with increased survival of immature and sick neonates, have led to an increased number of invasive procedures that may cause pain in these vulnerable neonates,” the group writes. “The prevention of pain in critically ill neonates is not only an ethical obligation, it also averts immediate and long-term consequences,” they add.

Clinical Pain Assessment Correlates With Brain Activity

In another study, changes in brain activity in response to a painful stimulus (a heel prick) were well correlated to facial expression changes in 33 test occasions in 12 infants. In 10 of the 33 test cases, however, the infants showed a cortical response without a change in facial expression, suggesting that pain assessment based on behavioral tools alone may underestimate pain.

These findings, by Rebeccah Slater, PhD, from University College London, in the United Kingdom, and colleagues, are published online June 24 in PLoS Medicine.

Pain in infancy is poorly understood, the group writes. Current assessment tools such as the premature infant pain profile (PIPP) are based on behavioral measures (changes in facial expression) and physiologic measures (changes in heart rate and oxygen saturation).

The ability to use near-infrared spectroscopy to measure changes in oxygenated and deoxygenated hemoglobin concentration in the cortex in response to a noxious stimulus has provided investigators with the first opportunity to evaluate whether pain-assessment tools reflect pain processing in the brain, they add.

The team hypothesized that in infants who received a heel prick, clinical pain scores calculated using the PIPP would correlate with cortical hemodynamic activity.

They studied 12 clinically stable infants in a neonatal unit in a London hospital. The postmenstrual age (gestational age plus postnatal age) of the infants was 25 to 43 weeks, and their postnatal age was 5 to 134 days.

Clinical pain scores — facial expression (eye squeeze, brow bulge, and nasolabial furrow), heart rate, and oxygen saturation — and cortical hemodynamic activity were assessed during 33 clinically required heel pricks.

Behavioral Tools May Underestimate Pain Response

Clinical pain scores, especially facial expression, correlated well with cortical hemodynamic activity, but in some cases, infants did not show changes in facial expression but did show cortical responses to pain.

“While painful stimulation generally evokes parallel cortical and behavioral responses in infants . . . pain assessment based on behavioral tools alone should be interpreted with caution, as they could underestimate the total pain response,” the researchers write.

In an accompanying Editors’ Summary, A. David Edwards, MD, also from Imperial College London, writes that attention-deficit disorders, learning disorders, and behavioral problems in later childhood may be linked to repetitive pain in the preterm infant.

Concurring with the study authors’ conclusions, he notes: “The results of this study raise further awareness of the ability of infants to experience pain and highlight the possibility that pain based on behavioral tools alone may underestimate the pain response in infants.”

The Journal of the American Medical Association article was supported by funds from the Fondation CNP and the Fondation de France, in France. Lead author Dr. Carbajal is affiliated with the Centre National de Ressources de lutte contre la Douleur. A complete list of disclosures is available in the original article. The PLoS Medicine article was funded by the Wellcome Trust, the Medical Research Council, and SPARKS. The study authors have disclosed no relevant financial relationships.

JAMA. 2008;300:60-70.

PLoS Med. 2008;5:e129.

Clinical Context

In the November 2006 issue of Pediatrics, Batton and colleagues reported the recommendation from the American Academy of Pediatrics to minimize painful interventions in neonates. In the 1998 issue of Biology of the Neonate, Amand noted that neonates have greater pain sensitivity than other individuals. In the December 1997 issue of the Clinical Journal of Pain, a multicenter chart review by Johnston and colleagues found that each neonate underwent an average of 2 procedures per day during a 1-week period.

This prospective study uses direct bedside observation to report data on painful or stressful procedures and analgesic therapy in neonates admitted to the intensive care unit.

Study Highlights

  • 430 neonates, including preterm neonates younger than 45 postconceptional weeks and term neonates younger than 28 days, admitted to 8 neonatal intensive care units and 5 pediatric intensive care units in 1 region in France were enrolled.
  • There were no exclusion criteria.
  • Subjects included 309 neonates (71.9%) in neonatal intensive care units and 121 (28.1%) in pediatric intensive care units.
  • Mean gestational age at birth was 33 weeks (range, 24 – 42 weeks).
  • Mean birth weight was 1962 g (range, 490 – 4760 g).
  • 237 (55.1%) were boys.
  • 303 (70.5%) required mechanical tracheal ventilation.
  • Data collection on pain, stress, discomfort, and analgesic therapy occurred for the first 14 days of admission.
  • Mean duration of stay was 8.4 days.
  • 24 (5.6%) died during the study period.
  • No modifications were made in each institution’s pain management protocol.
  • Pharmacologic therapy included intravenous opioids, topical eutectic mixture of lidocaine and prilocaine, or other drugs.
  • Nonpharmacologic therapy included sweet solution, nonnutritive sucking, and skin-to-skin maternal contact.
  • Nursing and medical staff recorded bedside procedures, defined as medical, nursing, surgical, diagnostic, or therapeutic activity performed in the unit.
  • Procedures did not include continuous therapy.
  • Painful procedures were defined either by invasion of the bodily integrity, causing skin or mucosal injury from introducing or removing foreign material into the airway, digestive, or urinary tract, or by clinician assessment.
  • A group of 15 nurses and physicians in the neonatal intensive care unit assigned final classification of painful procedures, defined by a mean score of more than 40 on a 100-point scale.
  • Stressful procedures were defined by physical uneasiness or annoyance or by disturbance of equilibrium between the neonate and the environment.
  • A research assistant verified documentation of procedures up to 3 times per week in each site.
  • 60,969 first-attempt procedures included 42,413 (69.6%) painful and 18,556 (30.4%) stressful procedures.
  • 11,546 supplemental attempts at procedures included 10,366 (89.8%) attempts at painful procedures and 1,180 (10.2%) attempts at stressful procedures.
  • Each neonate underwent an average of 141 procedures (range, 4 – 613 procedures) and 16 procedures per day (range, 0 – 62 procedures).
  • Each neonate underwent an average of 98 painful procedures (range, 3 – 364 procedures) and 10 painful procedures per day (range, 0 – 51 procedures).
  • The most common painful procedures were nasal aspiration (28.9%) and tracheal aspiration (23.3%).
  • The most common stressful procedures were nursing care (39.2%) and oral aspiration (26.9%).
  • Analgesic therapy specifically for painful procedures included pharmacologic-only in 907 (2.1%), nonpharmacologic-only in 7734 (18.2%), both pharmacologic and nonpharmacologic in 164 (0.4%), and none in 33,608 (79.2%).
  • Nonspecific analgesia was received during 14,495 (34.2%) painful procedures.
  • Analgesic therapy specifically for stressful procedures included pharmacologic-only in 136 (0.7%), nonpharmacologic-only in 1077 (5.8%), both pharmacologic and nonpharmacologic in 6 (< 0.1%), and no treatment in 17,337 (93.4%).
  • Nonspecific analgesia was received during 3144 (16.9%) stressful procedures.
  • Factors associated with greater use of specific analgesia included prematurity, parental presence, surgery, daytime (7 AM to 6 PM), category of procedure, and hospitalization days 2 to 14.
  • Factors associated with less use of specific analgesia included mechanical ventilation, noninvasive ventilation, nonspecific analgesia, and higher Clinical Risk Index for Babies score.

Pearls for Practice

  • In the first 14 days of admission to the intensive care unit, each neonate undergoes an average of 16 painful or stressful procedures per day and an average of 12 painful procedures per day.
  • Neonates who undergo painful procedures in the intensive care unit receive specific pharmacologic or nonpharmacologic analgesia in 20% of cases.

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CONFERENCIAS DEL CONGRESO DE PEDIATRIA

DESAFIOS DE LA NUTRICION PEDIATRICA EN AMERICA DEL SIGLO XXI

desafios-de-la-nutricion-pediatrica-xxi-dr-uauy1

EL PEDIATRA Y LAS VITAMINAS

el-pediatra-y-las-vitaminas-congreso

AMIGOS Y AMIGAS

HE COLOCADO EN ESTE POST ALGUNAS DE LAS PRESENTACIONES DE LOS CONFERENCISTAS DEL PASADO CONGRESO NACIONAL DE PEDIATRIA GUATEMALA MAYO 2008

 

ESPERO SEA DE SU UTILIDAD

 

 

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TRATAMIENTO PREVIO CON ALBUTEROL VS MONTELUKAST EN NIÑOS CON ASMA INDUCIDA POR EJERCICIO

Pretreatment with Albuterol versus Montelukast for Exercise-Induced Bronchospasm in Children

Hengameh H. Raissy, PharmD; Michelle Harkins, MD; Franceska Kelly, BS; H. William Kelly, PharmD
Author Information

Abstract

Study Objectives: To compare pretreatment with albuterol versus montelukast added to the current asthma regimen for protection against exercise-induced bronchospasm in children with mild-to-moderate asthma, and to determine whether cysteinyl leukotriene (Cys-LT) concentrations measured in the exhaled breath condensate correlated with response to montelukast.
Design: Prospective, randomized, double-blind, double-dummy, crossover study.
Setting: Asthma clinic at a university-affiliated medical center.
Patients: Eleven children aged 7–17 years with physician-diagnosed mild-to-moderate asthma for at least 6 months and with self-reported exercise-induced bronchospasm (defined as ≥ 15% decrease in forced expiratory volume in 1 sec [FEV1] at screening and baseline visit).
Intervention: Patients were randomly assigned to receive 3–7 days of oral montelukast 5–10 mg/day or 2 puffs of an albuterol metered-dose inhaler just before an exercise challenge and then were crossed over to the alternate therapy for the last visit.
Measurements and Main Results: Serial spirometry was performed before and at 0, 5, 10, 15, 30, 45, and 60 minutes after the exercise challenge at each visit. Measurement of exhaled breath condensate was performed at the screening visit and study visits 1 and 2. The primary outcome was the maximum change in FEV1 after exercise. Secondary outcomes were the area under the curve for FEV1 (expressed as percentage decrease from baseline) during the first 60 minutes (AUC0–60) after exercise and the proportion of patients in whom exercise-induced bronchospasm was prevented (defined as < 15% decrease in FEV1 after exercise challenge). The mean ± SD maximum decrease in FEV1 was 27.5 ± 7.9% at baseline. Patients receiving montelukast had an 18.3 ± 13.7% decrease in FEV1 compared with 0.7 ± 1.6% in patients receiving albuterol (p=0.002, paired t test). Exercise-induced bronchospasm was prevented in 100% of the patients receiving albuterol compared with 55% receiving montelukast (p<0.05, McNemar’s test). The AUC0–60 was significantly smaller with albuterol compared with montelukast (p<0.001, Wilcoxon signed rank test). No correlations were found between Cys-LT concentration and the severity of exercise-induced bronchospasm or the response to montelukast.
Conclusion: Pretreatment with albuterol is more effective than montelukast for prevention of exercise-induced bronchospasm in children with asthma.

Introduction

Exercise-induced bronchospasm is common in children with asthma,[1,2] and exercise limitation is a primary complaint in children with mild-tomoderate asthma. Although exercise-induced bronchospasm may be the only asthma symptom or some patients, it may result from an overall lack of asthma control.

Exercise-induced bronchospasm has a discrete pathophysiology that remains poorly understood. The cysteinyl leukotrienes (Cys-LTs) LTC4, LTD4, and LTE4 have been detected in exhaled breath condensate in children with asthma[3-5]and have been reported to be higher in those with exercise-induced bronchospasm.[6]

Long-term controller drugs may have a role in the management of exercise-induced bronchospasm. Inhalation of corticosteroids has been shown to attenuate the exercise-induced bronchospasm response, although not completely abate it.[7,8] The long-acting β2-agonist salmeterol inhibits exercise-induced bronchospasm for 12 hours after a single dose; however, after long-term monotherapy the duration of protection is only about 4 hours.[9,10] Results of comparative studies of long-term montelukast and salmeterol monotherapy for exercise-induced bronchospasm, where the exercise-induced bronchospasm challenge is performed 12 hours after the last dose of montelukast or salmeterol, show that montelukast provides superior attenuation of the bronchospasm.[11] Long-term treatment with montelukast reduces exercise-induced bronchospasm by 20-50%[11-13] but does not appear to prevent the bronchospasm to the same extent as pretreatment with an inhaled short-acting β2-agonist administered just before exercise, although no direct comparisons have been performed. In addition, up to 50% of patients may not respond to montelukast.[14] Recently, it has been suggested that a reduction in the Cys-LTs correlates with initial Cys-LT concentrations before treatment with montelukast.[15,16]

In April 2007, montelukast gained United States Food and Drug Administration (FDA)-approved labeling as a single dose for prevention of exercise-induced bronchospasm in patients aged 15 years or older. Currently, to our knowledge, no data exist that compare standard of care (i.e., pretreatment with albuterol) with montelukast for prevention of exercise-induced bronchospasm in children. Therefore, our primary hypothesis in this study was that pretreatment with albuterol would provide superior protection against exercise-induced bronchospasm compared with montelukast in children with asthma. A secondary objective was to determine whether Cys-LT concentrations measured in the exhaled breath condensate correlated with response to montelukast.

Methods

This prospective, randomized, double-blind, double-dummy, crossover clinical trial was conducted from November 1, 2005-April 30, 2007. Patients aged 7-17 years with physiciandiagnosed asthma for at least 6 months in addition to self-reported exercise-induced bronchospasm were screened. Long-term controller drugs were allowed if patients were receiving a stable dosage for at least 4 weeks. Patients were excluded if they had a history of cardiac dysfunction, were unable to perform exercise challenge or spirometry, used montelukast for asthma management, had upper respiratory infection in the previous 4 weeks, or used oral corticosteroids in the previous 3 months. Informed consent and authorization for the use and disclosure of Protected Health Information were obtained according to institutional review board-approved processes of the University of New Mexico.

The study consisted of four visits: screening visit, baseline visit, study visit 1, and study visit 2 (Figure 1). Exercise-induced bronchospasm was assessed at the screening visit followed by a baseline visit in 1-14 days, when a second exercise challenge was performed. Patients were required to have a positive exercise challenge, defined as a 15% or greater decrease in forced expiratory volume in 1 second (FEV1), at both the screening and baseline visits to qualify. At the end of the baseline visit, eligible patients were randomly assigned to receive either montelukast capsules 5-10 mg (depending on age) or matching placebo capsules to be taken every night. Study visit 1 was scheduled 3-7 days later (Figure 1). At this visit, exhaled breath condensate was measured, and baseline spirometry was performed. Patients who had received montelukast were then instructed to use 2 puffs of a placebo metered-dose inhaler (MDI) without a spacer 15 minutes before the exercise challenge; patients who had received placebo used 2 puffs (90 µg/puff) of an albuterol MDI 15 minutes before the exercise challenge. At the end of study visit 1, patients were crossed over to the alternative therapy and scheduled for study visit 2.

 

Click to zoom
Figure 1.  (click image to zoom)Schematic of the study procedures.

     

 

To allow double blinding of the study drug, placebo and montelukast capsules were prepared from chewable tablets by the investigational pharmacist, based on experience from another study.[17] The study drugs were dispensed for each subject according to a random code. Patients were instructed to take placebo or montelukast capsules at 9:00 P.M. every night and to bring all their unused study drugs to the clinic at study visits 1 and 2 in order to monitor adherence. All visits were scheduled for 7:30 A.M. (± 30 min), so the exercise challenge could be performed approximately 12 hours (± 30 min) after the last dose of montelukast.

Exercise Challenge

Preexercise spirometry was performed 5 minutes before the challenge. The preexercise FEV1 was required to be at least 70% of the predicted value and within 20% of the baseline visit value at study visits 1 and 2. A standardized exercise challenge was performed on a treadmill. Workload was increased until 80-90% of the maximum heart rate (220 minus age) was achieved in the first 2 minutes, and exercise was sustained for 6 minutes. The individual workload established at enrollment for each patient was used as a starting point at each visit and was adjusted as needed to achieve 80-90% of the maximum heart rate.

Spirometry was performed immediately after exercise (time 0) and at 5, 10, 15, 20, 30, and 60 minutes. Patients performed two or three maneuvers at each testing time. A positive exercise challenge was defined as a decrease in FEV1 from the preexercise value by at least 15%. A standard spirometer (Sensormedics, Yorba Linda, CA) was used to perform spirometric maneuvers that achieved American Thoracic Society acceptability and reproducibility criteria,[18] and the best FEV1 from each set of measurements was used for the analysis. Patients were discharged from the clinic when their FEV1 was at least within 5% of their baseline. After 60 minutes of exercise, if patients were still symptomatic or their FEV1 was not within 5% of baseline, 2-4 puffs of albuterol MDI were administered, and their FEV1 was measured in 15 minutes. Patients were instructed to withhold their short-acting β2-agonist and cromolyn for 6 hours and long-acting β2-agonist for 12 hours before the exercise challenge.

At the investigators’ discretion, the challenge could be stopped and albuterol could be administered. Patients were discontinued from the study if they were not compliant with their drug therapies, had an upper respiratory infection with worsening of asthma symptoms, required treatment with oral corticosteroids, or had a change in regular asthma drug therapy.

Collection of Exhaled Breath Condensate

Samples of exhaled breath condensate were collected at the beginning of study visits 1 and 2 with use of a disposable collection kit (RTube; Respiratory Research, Inc., Charlottesville, VA). Patients were asked to breathe tidally for 10 minutes with no nose clip. The samples were stored at -70°C until analyzed at the end of the study.

The Cys-LT concentrations were measured by Cayman Chemical (Ann Arbor, MI) using a specific enzyme immunoassay with a lower limit of detection of 7 pg/ml. Samples below the lower limit of detection were concentrated by a factor of 3-4 to determine their concentration. The exhaled breath condensate was collected and analyzed in all of the qualified patients and the last 11 patients with a negative exercise challenge.

End Points

The primary outcome was the maximum change in FEV1 after exercise. Secondary outcomes were the area under the curve for FEV1 (expressed as percentage decrease from baseline FEV1 before challenge on each day) in the first 60 minutes (AUC0-60) after exercise and the proportion of patients in whom exercise-induced bronchospasm was prevented. Only the area below the preexercise baseline FEV1 was used in calculating the AUC.

Statistical Analysis

This study was designed to have a 90% power to detect at least 13.7% difference in the mean change for the maximum percentage decrease in FEV1 between albuterol and montelukast based on an estimated standard deviation of 25.0 and with a significance level (α) of 0.05 by using a two-sided one-sample t test and a correlation of 0.25.[13]

Data are presented as mean ± SD. The clinical outcomes and Cys-LT levels were compared by using the paired t test and Wilcoxon signed rank test as appropriate. Correlations were evaluated by Spearman rank test between Cys-LT levels and severity of exercise-induced bronchospasm or the response to montelukast compared with baseline visit.

McNemar’s test was used to compare the percentage of patients in whom exercise-induced bronchospasm was prevented (defined as < 15% decrease in FEV1 after exercise) in each treatment group. Leer el resto de esta entrada »

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Antiflea Pet Shampoos with Pyrethrin May Play a Role in Autism

 

May 20, 2008 (London, United Kingdom) — Compared with mothers of typically developing children, mothers of children with autism spectrum disorders were twice as likely to report that they had shampooed their pets with pyrethrin-containing antiflea/antitick shampoos around the time of their pregnancy, in a Californian case-control study that looked at household pesticide use.

 

The findings were presented by lead study author Irva Hertz-Picciotto, PhD, from the University of California, Davis, at the 7th Annual International Meeting for Autism Research.

When participants in the study, the Childhood Autism Risks and the Environment (CHARGE) trial, were questioned about their prenatal, gestational, and postnatal use of pesticides, the researchers found that products containing pyrethrin — pet shampoos and certain sprays for controlling flies, ants, and cockroaches — were associated with an increased risk for autism spectrum disorders.

These are initial findings and need to be confirmed in other population studies, Dr. Hertz-Picciotto told Medscape Psychiatry, adding: “The bottom line here is [that pyrethrin] is something that really deserves further study.”

It is important to remember that autism is multifactorial, she stressed, explaining that “generally speaking, probably most cases of autism arise from multiple genetic as well as multiple environmental factors.”

Outdoors, pyrethrin has a very short half-life, but indoors it lingers for a long time — for example, in pet hairs — so that people continue to be exposed, she noted. Concerned consumers can seek out more natural, nontoxic alternatives (such as boric acid for cockroaches).

Potent Chemicals

Pesticides are designed to attack the central nervous system of lower species such as insects and rodents, Dr. Hertz-Picciotto explained.

A recent study suggests that there is a link between maternal exposure to commercially applied organochlorine pesticides and subsequent risk of autism in the child, she said. Eric M. Roberts, MD, from the California Department of Public Health, in Richmond, and colleagues reported that pregnant mothers who lived in the California Central Valley close to fields where organochlorine pesticides were being applied had an increased risk of giving birth to a child with autistic spectrum disorder (Roberts EM et al. Environ Health Perspect. 2007;115:1482-1489).

The current study aimed to examine the relationship between use of household pesticides during pregnancy and subsequent autism in the child.

The researchers looked at data from the CHARGE study of 2- to 5-year-olds living in California — 333 children with autism spectrum disorder and 198 typically developing children. The children’s diagnosis of autism was confirmed using the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview (ADI).

 

In a 90- to 100-minute telephone interview, the children’s mothers were asked about their use of household pest-control products (such as insecticide sprays, ant poisons, pet shampoos, and weed-control products) during the exposure period (which was defined as 3 months prior to conception until the child was 1 year old).

After adjustment for socioeconomic variables, compared with mothers of typically developing children, mothers of children with autistic spectrum disorders were twice as likely to report having shampooed their pets with antiflea/antitick shampoos during the exposure period (odds ratio [OR], 2.0; 95% CI, 1.2 – 3.6). The adjusted odds ratio for this association was strongest for the second trimester (OR, 2.6; 95% CI, 1.3 – 6.0).

The researchers determined that the active ingredient in these pet shampoos was pyrethrin, which came into use about 20 years ago to replace organophosphates, said Dr. Hertz-Picciotto.

When the researchers went back and analyzed the data according to products containing pyrethrin (which included some sprays for controlling flies, ants, and cockroaches, as well as pet shampoos) instead of by product type, the association between pyrethrin and autism spectrum disorder remained.

Was Recall Bias a Factor?

Because these data were collected retrospectively, it is possible that the mothers of typically developing children tended to forget about their use of pesticides around the house, unlike the mothers of the children with autistic spectrum disorders, who may have been more attuned to thinking about this. However, since the researchers did not find an association between autism and products not containing pyrethrin, recall bias was not likely to be a strong factor.

What Does This Mean?

Pyrethrins have largely replaced organophosphates for flea control, the group writes. In insects, pyrethrins affect the nervous system and sodium channels, which results in repeated firing of neurons and death. In rodent studies, pyrethrin exposure when the fetal brain is developing was found to compromise the blood-brain barrier.

Although pyrethrin-containing pesticides have been tested for safety, animal findings and the current study findings raise concerns about the long-term neurodevelopmental effects from prenatal, gestational, and early postnatal exposure to pyrethrin-based products.

The group is planning to submit this work for publication in the near future.

Toxic Organophosphates

In another presentation at the meeting, Brenda Eskenazi, PhD, from the University of California, Berkeley, reported that in a study of low-income Mexican farmworker families in California, organophosphates were associated with pervasive developmental disorder (or autism spectrum disorder) in children.

The study participants, from the Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS) birth cohort study, included over 400 children as well as their mothers. Urine samples from pregnant mothers and from their offspring were analyzed to detect organophosphate metabolites. The presence of these agents was linked with increased odds of the mothers reporting that their children had pervasive developmental disorder at age 2 years.

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MUERTE FETAL EN MADRE DE 30 AÑOS

Presentation of Case

A 30-year-old primigravida was admitted to the hospital in active spontaneous labor at 39.7 weeks’ gestation.

The patient had received prenatal care at this hospital since 11.1 weeks’ gestation. She had been well. She had had varicella and had received bacille Calmette–Guérin (BCG) vaccine as a child. Four years earlier, a tuberculin skin test had been positive, and a chest radiograph had been negative; she had received antituberculosis medication for 6 months. There was no history of sexually transmitted diseases, and she did not smoke cigarettes, drink alcohol, or use intravenous drugs. She was born and raised in West Africa and had immigrated to the United States 7 years earlier. She had returned to Africa twice in the previous 3 years, most recently 2 months before the first prenatal visit, and had not received pretravel vaccinations or malaria prophylaxis. Her father had type 2 diabetes mellitus.

Physical examination at the first prenatal visit revealed a blood pressure of 116/70 mm Hg. Ultrasonographic examination of the pelvis showed a single intrauterine gestational sac containing a normal-appearing fetus with a normal heart rate. The placenta was posterior, and the nuchal translucency was normal (<3 mm). Urinalysis showed 3 to 5 white cells per high-power field, with few squamous cells, and urine culture grew moderate mixed bacteria and rare (100 to <1000) group B streptococci.

At 14.6 weeks’ gestation, the pelvic examination was normal, and a Papanicolaou smear revealed yeast. Screening tests for Neisseria gonorrhoeae and chlamydia were negative. Terconazole was prescribed. The white-cell count was 15,200 per cubic millimeter; the remainder of the complete blood count was normal. The blood type was B Rh-positive, and an antibody screen was negative; antibodies against rubella were present. Tests for antibodies against human immunodeficiency virus, rapid plasma reagin, and hepatitis B surface antigen were negative. Ultrasonographic examination at 18.1 weeks’ gestation showed an active fetus with normal fetal and placental anatomy; biometric assessment was consistent with a gestation of 19.0 weeks.

At 23.6 weeks’ gestation, the patient reported pelvic cramping and pain with ambulation. Routine culture of the urine showed rare mixed bacteria (100 to <1000 colony-forming units per milliliter) that included one potential pathogen. The internal laboratory record described the potential pathogen as forming gray, nonhemolytic colonies on sheep-blood agar but did not further identify it because the quantity was less than 1000 colony-forming units per milliliter and it was mixed with several types of regional flora. According to the current laboratory procedure at this hospital, potential group B streptococcus would be fully identified and reported if present in any quantity in a patient known to be pregnant. Her symptoms resolved without treatment.

At 25.9 weeks’ gestation, pain developed over the right rib cage; it was worse with coughing, laughing, and moving. A diagnosis of costochondritis was made, and acetaminophen was prescribed. Fetal activity was noted at 27.1 weeks’ gestation. At that time, the results of a glucose-tolerance test were normal. The white-cell count was 12,800 per cubic millimeter, platelet count 370,000 per cubic millimeter, hematocrit 34.8%, hemoglobin 11.7 g per deciliter, hemoglobin A 97.2%, and hemoglobin A2 2.7%.

Between 30.1 and 36.1 weeks’ gestation, fetal growth and activity were appropriate for gestational dates. Approximately 6 weeks before admission, a red, oval-shaped rash with central clearing developed on the left inner thigh. It resolved within 10 days; a second, similar lesion that developed on her right arm shortly thereafter also resolved spontaneously. She had no fever or arthralgias.

At weekly visits between 36.1 and 39.1 weeks’ gestation, fetal movement was present. There was no vaginal bleeding, rupture of membranes, or cervical tenderness. On the last visit, the blood pressure was 130/80 mm Hg. She had gained 8.62 kg in weight during the pregnancy, and the fundal height was normal at 37 weeks’ gestation, with a cephalad presentation. The estimated fetal weight was 3400 g (45th percentile). Ultrasonographic examination of the uterus revealed a single active fetus in vertex presentation, with a posterior placenta. The fetal heart rate and amniotic-fluid volume appeared to be normal, and no structural abnormalities of the fetus were detected.

On the day of admission, the fetal movements ceased in midmorning. Spontaneous, regular contractions began approximately 4 hours later, and the patient was admitted to the labor and delivery department of this hospital 2.5 hours after the onset of contractions.

There was no recent abdominal trauma, and the patient had no symptoms of bleeding, fever, chills, diarrhea, cough, shortness of breath, or headache. She had no recent exposure to cats or other animals. She had traveled to Cape Cod, Massachusetts, during the late spring (5 months before admission).

Physical examination showed normal vital signs and a fully dilated cervix. Sterile vaginal examination showed an intact and bulging amniotic sac. The remainder of the examination was normal. An external fetal monitor did not detect a fetal heartbeat. Fetal death was confirmed by means of ultrasonographic examination.

Thirty minutes after arrival in the labor and delivery department of this hospital, the membranes were ruptured, and 4 minutes later, spontaneous vertex vaginal delivery of a stillborn male infant occurred. The weight was 3093 g, the head was soft, and the skin was macerated. The amniotic fluid was clear and did not have a foul odor. There was no nuchal cord.

An autopsy was performed.

PARA LEER EL ARTICULO ORIGINAL ACCESE A ESTA DIRECCION

http://content.nejm.org/cgi/content/full/357/9/918

 

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