Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

The ear exam is one of the components of every visit to the pediatrician. It can determine ear infections and help lead to a hearing loss diagnosis.



 sat down with Andrew Schuman, MD, FAAP, to discuss the ear exam, hearing loss, and when to refer to audiology.

Podcasts

Contemporary Pediatrics sat down with Andrew Schuman, MD, FAAP, to discuss the ear exam, hearing loss, and when to refer to audiology. 

Tackling the ear exam and hearing loss

When it comes to a child’s diet, there are many factors that can determine what it consists of and whether it’s healthful, such as what their peers are eating, diets in the household, and even pop culture. Advertising of foods deemed unhealthy have been restricted, particularly for children, in a number of countries, but depiction of food in movies is not regulated. An 

 looked at the nutrition shown in films and whether those food choices meet federal nutrition recommendations.

Researchers looked at the foods and beverages that were found in the 250 top-grossing movies in the United States from 1994 to 2018. The United Kingdom’s traffic light guidelines were used to determine nutrition ratings of food and beverages. In the guidelines, foods that are high in fats, sugars, and salt are given a red label; foods with medium levels are given an amber label; and foods with low levels are given a green label. They then compared the nutrition content of a film to the US Food and Drug Administration’s recommended daily levels of nutritional intake as well as the actual consumption reported through the National Health and Nutrition Examination Survey 2015-2016. They also looked at the number of branded versus nonbranded items and whether this changed over time.

In the 250 movies studied, there were 9198 foods and 5748 beverages. Snacks and sweets, 2173 items, and alcoholic beverages, 2303 items, were the most commonly seen food and beverages in the movies. Alcohol alone made up 18.1% of beverages seen in G-rated movies, 27.0% of beverages seen in PG-rated movies, 41.8% of drinks seen in PG-13 movies, and 49.1% of drinks seen in R-rated movies. They found that a majority of the films would fail the legal limits of advertising to children and adolescents in the United Kingdom, with 178 movies earning less healthy food ratings and 222 earning less healthy beverage ratings. When looking at foods, many movies showed medium to high levels of saturated fat (208 of 245 [84.9%]), total fat (228 of 245 [93.1%]), sugar (229 of 245 [93.5%]), and sodium (123 of 245 [50.2%]). Visible branding of foods and drinks were relatively rare with just 11.5% showing commercial logos, but those with visible branding scored lower on nutrition ratings than items with no branding. Unfortunately, the food and drink nutrition scores did not improve over time, nor did they improve in movies that were advertised to appeal to children.

Movies are a frequent source of entertainment, especially for children. However, this study indicates that many movies are illustrating unhealthy food consumption that doesn’t meet dietary recommendations. It also indicates that the regulation that restricts food advertising may need to be extended to depictions of nutritional consumption in entertainment.

1. Turnwald B, Handley-Miner I, Samuels N, Markus H, Crum A. Nutritional analysis of foods and beverages depicted in top-grossing US movies, 1994-2018. 

. November 23, 2020. Epub ahead of print. doi:10.1001/jamainternmed.2020.5421

Articles

Diet is impacted by more than just what a child sees in the home. An investigation examines the dietary quality seen in popular movies.

 Nutritional quality seen in movies gets 2 thumbs down

Looking for something to listen to when you make your Thanksgiving meal this Thursday? It’s the perfect time to check out the 

. Each episode is a quick bite of pediatric information. Episodes come out every 3 weeks and you can subscribe to the podcast on Apple Podcasts or Spotify to ensure you never miss any episode.

Why not check out the following episodes:

The COVID-19 pandemic has to changes on many levels from the personal to the societal. There are many simple ways to combat the spread: handwashing, social distancing, and wearing masks, but there's also a place for using more high-tech tools.

When the country started shutting down, many were optimistic and thought that people would only have so stay home for a few weeks. During these early days many parents relaxed the screen time and media use rules. However, many children are still at home and remain under those relaxed rules. Cori Cross, MD, offers some guidance to help parents get back to normal.

Meet the Board: Andrew J Schuman, MD, FAAP

 editorial advisory board is key to ensuring that the magazine is providing the practical clinical guidance the pediatric provider needs to offer the best care possible. The series "Meet the Board" offers a chance to get to know the people who help shape the magazine. For our first episode in the series, we sat down with Andrew J. Schuman, MD, FAAP.

Looking for something to listen to while making the turkey? Check out Small Talk, the bite size podcast packed with pediatric information.

Check out Small Talk

As the United States prepares for a much different Thanksgiving holiday than usual, the question of what families are planning to do remains up in the air for many. The University of Michigan’s latest C.S. Mott National Poll on Children’s Health tackles 

The researchers used a nationally representative sample of 1443 parents of children aged 0 to 12 years and asked them what their plans were for holiday gatherings with their extended family. Nearly every parent, 94%, said that their child gets together with extended family on a number of different occasions under normal circumstances. However, 51% of the parents said that the pandemic had led to a significant reduction in time spent with extended family and 23% said that it had led to only a slight reduction.

When asked about usual Thanksgiving plans, 76% of the parents said that their child usually sees extended family. Most of these Thanksgiving dinners are attended by grandparents or other older extended family members and 40% of the gatherings involve family members traveling from other states. Among families who usually have extended family for Thanksgiving, 61% plan to have extended family over for Thanksgiving later this week and 18% said that some of that family will be coming from out of state.

Many of the parents said that they had different priorities for Thanksgiving 2020. Many of the parents (78%), said that it was important to not spread COVID-19 at family gatherings. A little over half of the parents also said that it was imperative that children spend time with extended family, 53%, as well as sharing family traditions, 58%. When asked if the benefits of connecting with family for Thanksgiving outweighed the potential risk of spreading COVID-19, only 35% said that it did.

When asked how they were planning on preventing the spread of COVID-19 at their Thanksgiving celebration, they said they’d take the following precautions:

88% of parents will ask people to not come to Thanksgiving if they have COVID-19 symptoms or exposure;

76% of parents will limit the contact between their child and those who are high-risk, such as seniors and certain medical conditions;

68% of parents will make sure guests social distance during the celebration; and

64% of parents won’t invite people who haven’t been following precautions such as masking and handwashing.

C.S. Mott Children’s Hospital. National Poll on Children's Health: Considering Children in COVID-19 Thanksgiving Plans. 2020;37(3). Published November 23, 2020. Accessed November 23, 2020. Available at: Available at: 

https://mottpoll.org/reports/considering-children-covid-19-thanksgiving-plans

Despite public health agencies warning against gathering for Thanksgiving, many families are still planning to do so. A new poll offers some insight on why parents still plan to gather and what they are doing to try to keep everyone safe.

Families still planning to gather for Thanksgiving

The complete toll of COVID-19 will not be known for quite some time. However, a 

 offers some insight into the epidemiology of the disease in pediatric patients across the United States.

Investigators ran a retrospective cohort study that used data from electronic health records. They looked for patients aged younger than 25 years who had been tested for SARS-CoV-2, the virus that causes COVID-19, from January 1, 2020 through September 8, 2020. They used data from PEDSnet, which is a network of 7 US pediatric hospital systems, which covers 6.5 patients from 11 states.

A total of 135,795 patients were tested for SARS-CoV-2; 5374 of those tested were found to be infected with COVID-19 (12 per 10 000 population [range, 7-16 per 10 000 population]). When compared to white patients, Black, hispanic, and Asian children and young adults were found to have lower rates of testing (Black: odds ratio [OR], 0.70 [95% CI, 0.68-0.72]; hispanic: OR, 0.65 [95% CI, 0.63-0.67]; Asian: OR, 0.60 [95% CI, 0.57-0.63]). Unfortunately, these race/ethnicity groups are also significantly more likely to have positive test results (Black: OR, 2.66 [95% CI, 2.43-2.90]; Hispanic: OR, 3.75 [95% CI, 3.39-4.15]; Asian: OR, 2.04 [95% CI, 1.69-2.48]). Increased risk of infection was linked to public payer (OR, 1.43 [95% CI, 1.31-1.57]), emergency department testing (OR, 3.16 [95% CI, 2.72-3.67]), older age 5-11 years: OR, 1.25 [95% CI, 1.13-1.38]; 12-17 years: OR, 1.92 [95% CI, 1.73-2.12]; 18-24 years: OR, 3.51 [95% CI, 3.11-3.97]), and outpatient testing (OR, 2.13 [1.86-2.44]). Following univariate analysis, the researchers found that nonmalignant chronic disease was linked to lower likelihood of testing and preexisiting respiratory conditions were linked to a lower risk of positive test results (standardized ratio [SR], 0.78 [95% CI, 0.73-0.84]). A higher risk of positive test results were linked to a number of diagnosis groups, including:

cardiac disorders (SR, 1.18 [95% CI, 1.05-1.32]),

endocrinologic disorders (SR, 1.52 [95% CI, 1.31-1.75]),

gastrointestinal disorders (SR, 2.00 [95% CI, 1.04-1.38]),

genetic disorders (SR, 1.19 [95% CI, 1.00-1.40]),

hematologic disorders (SR, 1.26 [95% CI, 1.06-1.47]),

malignant disorders (SR, 1.54 [95% CI, 1.19-1.93]),

mental health disorders (SR, 1.20 [95% CI, 1.10-1.30]),

metabolic disorders (SR, 1.42 [95% CI, 1.24-1.61]), and

musculoskeletal disorders (SR, 1.18 [95% CI, 1.07-1.30])

Among the patients who were found to be positive for COVID-19, 359 patients were hospitalization for hypotensive, respiratory, or COVID-19 specific illness. Intensive care unit services were needed for 99 of those who were hospitalized and 33 needed mechanical ventilation. The overall case fatality rate in this cohort was 0.2%.

The researchers concluded that COVID-19 infection rates were low and often mild in pediatric cases. Additionally, a number of factors were linked to identified infection such as nonrespiratory chronic medical conditions as well as adolescence and young adulthood.

1. Bailey L, Razzaghi H, Burrows E, et al. Assessment of 135,794 pediatric patients tested for severe acute respiratory syndrome coronavirus 2 across the United States. 

. November 23, 2020. Epub ahead of print. doi:10.1001/jamapediatrics.2020.5052

A new study examines the epidemiology of pediatric COVID-19 cases in a large cohort.

 Looking at the epidemiology of COVID-19 in pediatrics

The US Food and Drug Administration (FDA) has 

 Zokinvy (lonafarnib) capsules from Eiger BioPharmaceuticals, Inc.

 The drug, which is a farnesyltransferase inhibitor, was approved to reduce the risk of death because of Hutchinson-Gilford progeria syndrome as well as treating certain processing-deficient progeroid laminopathies. It has been approved for use in children aged 1 year and older, but not approved for other progeroid syndromes or laminopathies.

The efficacy of Zokinvy was assessed in 62 patients who had been enrolled in 2 single-arm trials. In the studies, when compared to patients who were not treated, patients who had been administered Zokinvy had a lifespan that increased an average of 3 months during the first 3 years of treatment and, through the maximum follow-up period of 11 years, the average increase in lifespan was 2.5 years. Common side effects seen in the participants included nausea, vomiting, infection, diarrhea, fatigue, and decreased appetite.

The drug is contraindicated for co-administration with moderate of strong CYP3A inhibitors, certain cholesterol-lowering drugs, and midazolam. Additionally, some patients who were administered Zokinvy developed laboratory test abnormalities, like lowered white blood cell counts, increased liver blood tests, changes in blood sodium levels, and changes in blood potassium levels. Due to this possibility, it is recommended that routine blood laboratory testing occur on a periodic basis. Additionally, because of eye toxicity seen in animals, eye exams should be performed periodically or when visual changes are noted by patients.

In the press release for the drug’s approval, Hylton V. Joffe, MD, MMSc, director of the Office of Rare Diseases, Pediatrics, Urologic and Reproductive Medicine in the FDA’s Center for Drug Evaluation and Research said “Hutchinson-Gilford progeria syndrome and progeroid laminopathies are rare genetic diseases that cause premature aging and death and have a debilitating effect on people’s lives. With today’s approval, Zokinvy is the first FDA-approved medication for these devastating diseases. The FDA will continue to work with stakeholders to advance the development of additional new, effective and safe therapies for these patients.”

1. US Food and Drug Administration. FDA approves first treatment for Hutchinson-Gilford progeria syndrome and some progeroid laminopathies. Published November 20, 2020. Accessed November 23, 2020. 

https://www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-hutchinson-gilford-progeria-syndrome-and-some-progeroid-laminopathies

The US Food and Drug Administation (FDA) has approved Zokinvy to reduce risk of death due to Hutchinson-Gilford progeria syndrome and to treat some progeroid laminopathies.

 FDA approves Zokinvy to reduce death from Hutchinson-Gilford progeria syndrome

No safe level of exposure to lead exists, which is the reason for the intensive removal of the substance from older buildings where it’s in the paint, the pipes that bring water from water sources, and even attempts to remove the lead that sits on roadsides as a result of leaded gasoline. One of the worst effects of lead exposure in a child is the impact that it has on the child’s brain. A 

 provides further evidence of this danger by looking at magnetic resonance imaging (MRI) in adults.

The researchers used the Dunedin Study, which included a population-representative 1972-1973 birth cohort in New Zealand, and followed those participants until age 45 tears. They used MRIs to look at the structural brain integrity of each participant at age 45 years, which included gray matter (cortical thickness, surface area, hippocampal volume); white matter (white matter hyperintensities; fractional anisotropy [theoretical range, 0 {diffusion is perfectly isotropic} to 100 {diffusion is perfectly anisotropic}]); and the Brain Age Gap Estimation (BrainAGE), which is a composite index of the gap between a matching learning algorithm-estimated brain age and the participant’s chronological age with an 0 representing a brain age equivalent to the chronological age and positive and negative values representing older and younger brain ages. The Wechsler Adult Intelligence Scale IV was used to assess each participant’s cognitive function.

There were 997 participants in the cohort who reached their 45th birthday and 564 of those participants underwent lead testing when they were aged 11 years. The average blood lead level at 11 years of age was 10.99 μg/dL. When the researchers adjusted for all covariates, they found that each increase of 5-μg/dL in the childhood blood level was significantly linked to 1.19-cm

 smaller cortical surface area (95% CI, −2.35 to −0.02 cm

 smaller hippocampal volume (95% CI, −0.17 to −0.03 cm

 = .006), lower global fractional anisotropy (

 = −0.12; 95% CI, −0.24 to −0.01; 

 = .04), and a BrainAGE index 0.77 years older (95% CI, 0.02-1.51 years; 

 = .05) at age 45 years. Additionally, each 5-μg/dL increase in the childhood blood lead level had a significant tie with a a 2.07-point lower IQ score at age 45 years (95% CI, −3.39 to −0.74; 

 = .002) and a 0.12-point higher score on informant-rated cognitive problems (95% CI, 0.01-0.23; 

 = .03). However, the researchers found no statistically significant link between childhood blood lead levels and self-reported cognitive problems (

 = −0.02 points; 95% CI, −0.10 to 0.07; 

 = .68) or blood lead levels and log-transformed white matter hyperintensity volume (

 = −0.004 mm; 95% CI, −0.012 to 0.004 mm; 

The investigators concluded that having a higher blood lead level in childhood was linked to certain differences in some MRI measures of brain structures that would indicate lower structural brain integrity in midlife. They did note that some of the findings could indicate a type I error due to the large number of statistical comparisons.

1. Reuben A, Elliott M, Abraham W. Association of childhood lead exposure with mri measurements of structural brain integrity in midlife. 

. 2020;324(19):1970-1979. doi:10.1001/jama.2020.19998

A new investigation reports on the long-term effect of lead exposure found in brain imaging of midlife adults.

Effects of childhood lead exposure on the brain seen in midlife

Parental eating behaviors, both their personal habits and the way parents choose to feed their infants, children, and influence the eating habits of their older school-age children and adolescents leads to either healthy infant, childhood, and adolescent eating behaviors or a life-long struggle with eating and weight management. The Centers for Disease Control and Prevention identifies obesity as a serious problem in the United States with a prevalence of 18.5% of children and adolescents, aged 2 to 19 years, meeting the body mass index (BMI) criteria for obesity.

A major component of pediatric practice is guiding parents’ understanding of best feeding practices for infants, children, and adolescents. Obtaining relevant history related to eating practices and providing guidance on the weight and BMI status of the child and adolescent are significant aspects of every well pediatric health care visit. For years, much of pediatric nurse practitioners’ (PNPs) and other practitioners’ guidance for feeding infants was ‘passed down from training’ rather than based on scientific studies that investigated best nutritional practices. In the article entitled, 

Helping parents – and their kids – eat better

 Zimlich reports on a research study that investigated parental influences on their child’s diet and ways parents can change the dietary habits of their children and adolescents. Results revealed that parents should be encouraged to model healthful eating behaviors and select foods for home meals that reduce total sugar content and the consumption of junk food in the diets of their children and adolescents.

Parental weight and the influence on child/adolescent weight

The study, reported by Ms. Zimlich, does not report on the nutritional status of the parents who participated in the study. Previous studies have shown that the children of parents who are overweight or obese have a higher prevalence of obesity than children of parents whose BMI is within the normal range for their age and height. A child with one obese parent has a 50% change of being obese and when both parents are obese, their children have an 80% change of obesity.

 These data support the nutritional study reported by Ms. Zimlich that parental eating practices are a direct influence on their children’s eating behaviors. Parental obesity is a complex problem that is out of the scope of practice of pediatric providers, even though there is a direct correlation between child and parental obesity. As noted by Dr. Thomson, a lead author on the report, obesity is an ‘uncomfortable conversation’ with parents. As PNPs we understand the sensitivity of a discussion on healthy eating and role modeling healthy nutritional habits when 1 or both parents are obese. These discussions have the potential to hinder the trusting relationships we work hard to build with parents. Often, we circle the problem by referring the parents to websites that support healthy eating practices, such as Choose My Plate.

 We also refer the parents to a nutritionist for counseling for better eating practices for their children.

Pediatric providers who support exclusive breastfeeding for the first 6 months of life set the groundwork for healthy eating. Likewise, providers who strive to engage parents in developing healthy eating behaviors when introducing foods to infants aged 6 months and to continue healthy behaviors throughout toddlerhood, review growth charts with parents during routine office visits, and provide evidence-based feeding practices for infants and toddlers may be more successful in achieving healthy weight gains. However, studies need to be designed and conducted to analyze the outcomes of these strategies. Additionally, studies on methods to influence changing parental behaviors and ways to communicate with parents that their poor eating practices negatively influence the overall health of their children and adolescents are also needed.

1. Center for Disease Control and Prevention. Childhood Obesity Facts | Overweight & Obesity | CDC. Cdc.gov. Update June 24, 2019. Accessed November 17, 2020. 

https://www.cdc.gov/obesity/data/childhood.html

2. UCSF Benioff Children's Hospital . Obesity | Conditions & Treatments. Ucsfbenioffchildrens.org. Published 2020. Accessed November 17, 2020. 

https://www.ucsfbenioffchildrens.org/conditions/obesity/#:~:text=A%20child%20with%20one%20obese,gain%20varies%20for%20different%20people

3. United States of Agriculture. MyPlate | ChooseMyPlate. Choosemyplate.gov. Published 2020. Accessed November 17, 2020. 

Encourage parents to model healthful eating behaviors and positive relationships with good eating habits.

The relationship of parental eating behaviors and their children and adolescents’ weight   

During the week of Thanksgiving, as many Americans travel or host dinners for both small and large groups, the Infectious Disease Society of America issued priority guidance, italicizing the safety measures that have helped people remain safe since the pandemic’s start in the United States: social distance, wash hands, use a mask, and reduce exposure to others.

The webcast, which aired Monday morning, November 23, included discussion of monoclonal antibodies, which have become a hot topic in COVID-19 treatment following the emergency use authorization from the US Food and Drug Administration for casirivimab and imdevimab over the weekend. Adarsh Bhimraj, MD, FIDSA, associate staff physician in the Department of Infectious Diseases at the Cleveland Clinic, in Ohio, and Rajesh T. Gandhi, MD, FIDSA, professor of medicine at Harvard Medical School in Boston, Massachusetts, both highlighted that the data for the efficacy of monoclonal antibodies are still in the early days of study, but the information coming in from the early studies appears to be positive. Gandhi also stressed that as of right now, only dexamethasone has been shown to improve survival.

During the question session of the webcast, Gandhi also spoke about the COVID-19 vaccine news. Earlier that morning, AstraZeneca had announced that their COVID-19 vaccine candidate AZD1222 was 70% effective on average. Unlike the Pfizer/BioNTech and Moderna vaccines, which are mRNA vaccines, AZD1222 uses a virus vector. Gandhi highlighted the fact that the vaccine appeared to reduce asymptomatic infections, which would be a key way to stop the spread of COVID-19, as asymptomatic cases have helped spur the spread.

Both Bhirmaj and Gandhi said that they felt more optimistic now than they did in the early days of the pandemic, thanks to greater understanding of the virus as well as the vaccine news. However, flattening the curve should still be the goal, especially as hospitals deal with the current surge and the country closes in on multiple effective vaccines.

Infectious Disease Society of America offered a look at the current treatment options for COVID-19 and stressed the need to maintain precautions to keep people safe.

“Stay home” to improve COVID-19 numbers

Golimumab, a human monoclonal antibody, has been approved to treat a number of autoimmune conditions in both the adult and pediatric populations. This success has led to curiosity over whether the drug could help patients with type 1 diabetes. A 

 looked into the efficacy of golimumab in preserving beta-cell function in pediatric patients who had a new diagnosis of overt (stage 3) type 1 diabetes.

The investigators ran a phase 2, multicenter, placebo-controlled, double-blind, parallel-group trial. They randomly assigned children and young adults who were aged 6 to 21 years and had a new diagnosis of stage 3 type 1 diabetes in a 2:1 ratio to be given either subcutaneous golimumab or placebo for a period of 52 weeks. The researcher’s primary end point at week 52 was endogenous insulin production, which was assessed as the area under the concentration–time curve for C-peptide level following a 4-hour mixed-meal tolerance test. Other end points for the researchers included the glycated hemoglobin level, the number of hypoglycemic events, the ratio of fasting proinsulin to C-peptide over time, response profile, and insulin use.

There were a total of 84 children and young adults who went through randomization, with 56 being put into the golimumab treatment group and 28 being put into the placebo group. Investigators found that the average area under the concentration–time curve for C-peptide level following a 4-hour mixed-meal tolerance test at week 52 was significantly different between the golimumab group and the placebo group group (0.64±0.42 pmol per milliliter vs. 0.43±0.39 pmol per milliliter, 

<0.001). Using a treat-to-target approach resulted in good glycemic control in both of the group and no significant difference was seen in the glycated hemoglobin level in both arms. The use of insulin was lower in the golimumab treatment group than in the placebo group. Additionally, a partial remission response, which was defined as an insulin dose–adjusted glycated hemoglobin level score (calculated as the glycated hemoglobin level plus 4 times the insulin dose) of ≤9, occurred in 43% of the participants in the treatment group and 7% in the placebo group (difference, 36 percentage points; 95% CI, 22 to 55). The average number of hypoglycemic events showed no difference between the groups. Hypoglycemic events that were severe enough to be recorded as adverse events at the discretion of the researchers occurred in 13 participants in the golimumab group and 2 in the placebo group.

The researchers concluded that in pediatric patients who had a new diagnosis of type 1 diabetes, golimumab led to better endogenous insulin production as well as less insulin use than those who were given a placebo.

1. Quattrin T, Haller M, Steck A, et al. Golimumab and beta-cell function in youth with new-onset type 1 diabetes. 

. 2020;383(21):2007-2017. doi:10.1056/NEJMoa2006136

Golimumab has shown great promise in treating autoimmune conditions. An investigation looks into whether patients with type 1 diabetes may also benefit from the drug.

FDA approves Zokinvy to reduce death from Hutchinson-Gilford progeria syndrome

Effects of childhood lead exposure on the brain seen in midlife

The relationship of parental eating behaviors and their children and adolescents’ weight

“Stay home” to improve COVID-19 numbers

Golimumab could improve type 1 diabetes outcomes