Michael G Burke, MD

Children who are prescribed montelukast for managing their asthma are nearly twice as likely to experience a neuropsychiatric event as asthmatic children who are taking other asthma maintenance medications. Canadian investigators based this finding, which controlled for sociodemographic factors and measures of asthma severity and treatment, on analysis of data from 2004 to 2015 related to a group of asthmatic children aged from 5 to 18 years old.

Each of the 898 study children with asthma who experienced a neuropsychiatric event was matched to a maximum of 4 controls who had no neuropsychiatric events. The most common events were anxiety (48.6%) and sleep disturbance (26.1%), almost half of which arose within 90 days of the most recently dispensed asthma maintenance prescription.

In addition to being more likely to have been exposed to montelukast in the previous year, children who experienced an event also had significantly more ED visits and hospitalizations for asthma during this period and were more likely to have a dispensed prescription for systemic corticosteroids and other asthma maintenance medications (Glockler-Lauf SD, et al. 

These findings won’t stop me from using this medication in a child who needs it, but if a child with asthma who is on montelukast develops anxiety or another neuropsychiatric conditions, I’ll consider stopping it.

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Children who are prescribed montelukast for managing their asthma are nearly twice as likely to experience a neuropsychiatric event as asthmatic children who are taking other asthma maintenance medications.

Montelukast treatment for asthma raises risk of a neuropsychiatric event

Children with asthma who use a web- and mobile–web-based self-management tool show high and sustained self-monitoring and improved asthma outcomes, a study in asthmatic children showed. The 2- to 17-year-old participants, whose persistent asthma was being managed at a pediatric ambulatory clinic, were matched with controls during the 1-year study period. Investigators compared outcomes in these weekly users of an electronic-AsthmaTracker (e-AT) with their own baselines as well as with outcomes in the controls-asthmatics who were receiving usual care at the study’s participating clinics.

The e-AT is based on the asthma control test, modified for weekly assessment, and coupled with decision support for proactive care. It features automated reminders to continue self-monitoring, graphing of real-time results, alerts for patients, parents, and the physician’s office (via e-mail or text) for early signs of asthma control deterioration, and real-time recommendations. The e-AT also records and promotes adherence by generating a congratulatory message and a $10 gift certificate every time 4 assessments are completed.

Of the 327 children and parents enrolled in the trial of e-AT, 65% had maintained adherence at 12 months. Compared with baseline, participants had significantly increased quality of life, asthma control, and had fewer reduced, interrupted, and missed school and workdays at all quarterly assessments. Compared with 1 year before the intervention, they had fewer emergency department (ED) and hospital admissions and less oral corticosteroid (OCS) use.

Compared with controls, participants also had reduced ED and hospital admissions and OCS use. Parents remained satisfied with the e-AT throughout the trial (Nkoy FL, et al. 

The authors report that more than 8 million children in the United States have asthma and that 54% of them had an asthma exacerbation in 2016. Data from 2008 showed that asthma was responsible for 10 million missed school days and 14 million missed parent workdays that year. Imagine the impact if this program (with a 32% to 59% reduction in ED visits and hospitalizations and a 26% to 35% reduction in the need for oral steroid use) was implemented across the country. This innovative approach is worth a careful look. You can check out the e-AT at 

https://asthmatracker.utah.edu/public/index.php

Children with asthma who use a web- and mobile–web-based self-management tool show high and sustained self-monitoring and improved asthma outcomes, a study in asthmatic children showed.

Using an asthma self-management tool improves outcomes

Applying sunscreen as often as manufacturers recommend results in plasma concentrations of sunscreen’s 4 active ingredients that exceed the threshold for safety concerns established by the US Food and Drug Administration (FDA), according to a recent study. The clinical significance of these findings has not been established, however.

Investigators enrolled in the trial 24 healthy volunteers aged from 18 to 60 years, 14 of whom were black or African American. Participants were divided into 4 groups of 6 individuals, with each group assigned to use 1 of 4 commercially available sunscreens- 2 different sprays, a lotion, or a cream. They applied the products 4 times a day for 4 days, covering body areas generally left uncovered by swimsuits, but not exposed to direct sunlight. Investigators collected multiple blood samples on each of the 4 application days and 3 subsequent days (30 samples for each participant) and assessed them for each of the 4 active ingredients: avobenzone, oxybenzone, octocrylene, and ecamsule.

All 4 products were associated with concentrations greater than 0.5 ng/mL-the FDA’s safety cutoff-that were reached after 4 applications on the first day of the trial. For avobenzone, maximum plasma concentrations for the 2 different sprays, lotion, and cream were 4.0 ng/mL, 3.4 ng/mL, 4.3 ng/mL, and 1.8 ng/mL, respectively. For the 3 products containing oxybenzone (the cream did not include it), plasma concentrations exceeded 20 ng/mL on day 7, and all participants who received formulations containing oybenzone had plasma concentrations exceeding 0.5 ng/mL within 2 hours after a single application on day 1. All 4 products resulted in octocrylene plasma concentrations exceeding 0.5 ng/mL, starting from day 1 and lasting through day 7. Only the cream contained ecamsule, and 5 of 6 participants in the cream group had an ecamsule plasma concentration exceeding 0.5 ng/mL on day 1.

Adverse events, which resolved in all participants, included rash-most common-milia, and pruritis (Matta MK, et al. 

Thoughts from Dr. Burke                                                    

The FDA published this highly publicized report as a preliminary study to determine if sunscreens should be tested for carcinogenicity and embryofetal toxicity. All the active ingredients generated blood levels higher than the threshold the FDA considers below consideration for systemic effect (0.5 ng/mL). However, the authors are quick to note that the clinical relevance of systemic absorption of these compounds is not yet known and suggest that these findings may induce the FDA to ask the manufacturers for further studies. In the meantime, they said, “These results do not indicate that individuals should refrain from the use of sunscreen.” So, as summer continues, recommend sun protection, including liberal use of sunscreen, but keep an eye out for revised recommendations or product changes based on further study.

Applying sunscreen as often as manufacturers recommend results in plasma concentrations of sunscreen’s 4 active ingredients that exceed the threshold for safety concerns established by the US Food and Drug Administration (FDA), according to a recent study.

Sunscreen ingredients are absorbed systemically

Parents who use a web-based educational tool to boost what they know about measuring and managing fever gain significantly more knowledge than parents who follow solely written and verbal instruction, according to a trial in caregivers of children with fever. Furthermore, parents prefer the web-based instruction.

Trial participants were 233 caregivers of children aged up to 17 years who visited a Canadian emergency department (ED) because of concern about a fever or whose child had a measured temperature higher than 100.4°F (38°C). Before beginning the trial, participants provided demographic information and completed an 18-item questionnaire that tested their knowledge of the etiology, measurement, therapy, and complications of fever in children. They then were divided into 3 groups, each of which was assigned to a different educational intervention: an interactive web-based module (WBM); read-only website (ROW); or written and verbal information (standard of care [SOC]).

All 3 interventions presented identical material, including the definition, measurement, and management of fever and when to seek medical attention. Participants in the WBM group used touchpads to activate interactive components, whereas ROW had no interactive components. The SOC was a paper document that detailed appropriate dosage and frequency of antipyretics. Participants in the WBM and ROW groups could access their interventions only in the ED but took the written SOC home. In addition, a nurse provided all participants with verbal instructions.

Immediately after the intervention, participants repeated the knowledge questionnaire and, compared with their pretest questionnaire scores, both the WBM and ROW groups had significantly higher scores, even after adjusting for caregiver education level, number of children, and other potentially confounding factors. The post-intervention scores of participants in the SOC, on the other hand, changed little from pre-intervention scores. Similarly, caregiver satisfaction scores were significantly higher in the WBM and ROW groups than in the SOC group (Hart L, et al. 

Using online, interactive education modules like this one may be an effective, efficient way to expand parents’ understanding on a broad array of topics. We should investigate what’s out there and direct parents to resources that are accurate and reflect good practice.

Parents who use a web-based educational tool to boost what they know about measuring and managing fever gain significantly more knowledge than parents who follow solely written and verbal instruction, according to a trial in caregivers of children with fever.

Author | Michael G Burke, MD

Articles

Montelukast treatment for asthma raises risk of a neuropsychiatric event

Using an asthma self-management tool improves outcomes

Sunscreen ingredients are absorbed systemically

Web-based tools educate parents about fever