After-School Programs Can Ease Kids’ ADHD

By Sonya Collins

Kids with ADHD often struggle just to stay on task or behave in school. So the idea of taking on more activities after school might feel like you’re asking for trouble. But new research shows that after-school programs could relieve some troubles for kids with this condition.

“These activities have potential benefits for kids with ADHD and should be part of the holistic strategies that we offer,” says Nicole Brown, MD, a pediatrician at Children’s Hospital at Montefiore in New York City. Brown co-led a study on this subject with Yonit Lax, MD, a pediatrician at Maimonides Medical Center in New York City.

Brown and Lax pulled data from the 2016 National Survey on Children’s Health, a questionnaire for parents of children ages 5 to 17. Parents of 4,185 children reported that their child had ADHD and answered questions about how severe it was. Kids who did after-school activities were more likely to have only mild — versus moderate to severe — ADHD symptoms. These children were less likely than others who have ADHD to have missed more than 7 days of school in the last 12 months.

The researchers can’t say for sure whether after-school programs ease symptoms or whether kids with already mild symptoms are more likely to enroll in such programs. But they see clear benefits to enrollment. “When children are in after-school activities,” says Lax, “they’re less likely to be sitting and watching TV for several hours a day and more likely to be engaging both their mind and their body.” That results in better mental and physical health for everyone.

After-school programs can also build friendships and confidence. These perks could ease the school-related anxiety and stress that often come with ADHD, “which is very strongly linked with refusal to go to school,” says Brown.

Treating ADHD isn’t just about prescription medications and behavioral therapy. “We need to think about multimodal strategies that can also help with symptoms, and after-school programs are pretty low-cost and associated with great outcomes,” she says.
Four Tips

After-school activities are just one lifestyle change that could help improve symptoms for a child with ADHD. Brown and Lax offer more tips:

  • Limit screen time: Keep the use of tablets, computers, phones, and TVs to less than 2 hours per day.
  • Go outside: Don’t let your child spend all their downtime in the same indoor space. “Get them out into different settings, such as parks or the backyard, to avoid stagnant time in the same environment for extended periods,” says Lax.
  • Get fit: Help your child get as close to national physical activity guidelines as possible. The CDC recommends 60 minutes of mostly aerobic activity per day.
  • Stick to a schedule: “Structure is very important, no matter what the activity, so try to have your child do the same things at the same time every day,” says Brown.

More Sleepless Nights for Toddlers With Autism

by Elizabeth Hlavinka, Staff Writer, MedPage Today

Children with autism spectrum disorder (ASD) were more than twice as likely to have problems sleeping than those without neurodevelopmental disorders, according to a community-based case-control study.

In a sample of nearly 2,000 children ages 2 to 5 years, those with ASD had significantly higher odds of sleep troubles — such as night waking and bedtime resistance — than kids in the general population (adjusted OR 2.37, 95% CI 1.75-3.22), reported Ann Reynolds, MD, of the University of Colorado School of Medicine, and colleagues.

Children with ASD were also more than twice as likely as children with other developmental delays and disorders to have problems sleeping (adjusted OR 2.12, 95% CI 1.57-2.87), they wrote in Pediatrics.

“For all children, lack of sleep can cause increased hyperactivity, inattention, and irritability, but for kids with ASD, poor sleep has been associated with more repetitive behaviors and self injury and so that has an impact on the quality of life for the child,” Reynolds told MedPage Today in an interview in which a media relations representative was present.

Although this study did not examine the cause of this increased risk for sleep disturbances, it’s possible that multiple contributing factors could predispose children with ASD to sleep problems, including obstructive sleep apnea, attention-deficit hyperactivity disorder (ADHD), or behavioral disturbances that interfere with sleep, Reynolds and colleagues noted.

Catherine Lord, PhD, of the David Geffen School of Medicine at UCLA, who wrote an accompanying commentary, said that although the same strategies and medications that improve childhood sleep are typically helpful in children with ASD, certain treatments like sleep training can take longer to change autistic children’s sleep patterns.

“Although medication used for sleep have been shown to be safe and have similar effects in kids with autism, there’s always variation and there will be more variation in kids with autism than in other populations,” Lord told MedPage Today.

Lord stressed the importance of pediatricians and healthcare providers working with parents of children with ASD to develop plans for improving sleep disturbances, particularly because a lack of sleep could further exacerbate their condition.

Reynolds and her team examined data from the Study to Explore Early Development (SEED) study, noting that all children included in this analysis were born from September 2003 to August 2006, completed a developmental evaluation, and had a caregiver interview and a completed Children’s Sleep Habits Questionnaire. Three groups of children were included in the study — those with a research classification of ASD, children with other developmental delays and disorders, and children from the general population.

Notably, a higher score on the 33-item Children’s Sleep Habits Questionnaire indicates more sleep issues, but researchers used two cut-offs for this study. While a total score of 41 differentiates a clinical sample of children with sleep problems, the authors said, they also used a total score cutoff of 48 for a more conservative estimate.

Data was adjusted for mothers’ education, race or ethnicity, and family income, as well as children’s sex, enrollment age, cognitive scores, and prior genetic or neurological diagnoses.

Of the 1,987 children included, those with ASD were more likely to be boys and have lower cognitive scores, and were less likely to have high-income families and non-Hispanic white mothers with a college degree.

Using the standard total score cutoff of 41, the results were “attenuated, but similar” as the more conservative total score cutoff. There were higher odds of sleep problems among children with ASD versus the children in the general population (adjusted OR 1.75, 95% CI 1.27-2.42) and versus children with other developmental delays and disorders (adjusted OR 1.45, 95% CI 1.05-2.00).

There was no difference in sleep patterns observed between children with ASD and children with other developmental delays and disorders in addition to ASD at either cutoff, Reynolds and colleagues noted.

Using the more conservative sleep score cut-off, 47% of parents reported sleep problems in their children with ASD compared to 29% of children with other developmental delays and disorders, and 25% of children in the general population, the authors noted.

Limitations to the data mainly involve limits to the Children’s Sleep Habits Questionnaire. Because it is a parent-completed questionnaire, there is no objective measure of sleep and no clinical assessment of sleep problems, the authors said, meaning “determining the exact prevalence of sleep problems” on the basis of the questionnaire “may be problematic.” In addition, the questionnaire was not designed to make a sleep order diagnosis or address the severity of sleep problems, nor has it been validated for use in young children (ages <4 ) or children with ASD as well, they noted.

Pediatric leukemia ‘super drug’ could be developed in the coming years

Northwestern Medicine scientists have discovered two successful therapies that slowed the progression of pediatric leukemia in mice, according to three studies published over the last two years in the journal Cell, and the final paper published Dec. 20 in Genes & Development.

When a key protein responsible for leukemia, MLL, is stabilized, it slows the progression of the leukemia, the most recent study found. The next step will be to combine the treatments from the past two years of research into a pediatric leukemia “super drug” to test on humans in a clinical trial.

The survival rate is only 30 percent for children diagnosed with MLL-translocation leukemia, a cancer that affects the blood and bone marrow. Patients with leukemia have a very low percentage of red blood cells, making them anemic, and have approximately 80 times more white blood cells than people without cancer.

“These white blood cells infiltrate many of the tissues and organs of the affected individuals and is a major cause of death in leukemia patients,” said senior author Ali Shilatifard, the Robert Francis Furchgott Professor of Biochemistry and Molecular Genetics and Pediatrics, the chairman of biochemistry and molecular genetics and the director of Northwestern’s Simpson Querrey Center for Epigenetics. “This is a monster cancer that we’ve been dealing with for many years in children.”

There are several types of leukemia. This research focused on the two most common found in infants through teenagers: acute myeloid leukemia (AML) and acute lymphocytic leukemia (ALL).

For the past 25 years, Shilatifard’s laboratory has been studying the molecular function of MLL within its complex known as COMPASS (Complex Proteins Associated with Set1). Most recently, it was demonstrated that COMPASS components are one of the most frequently identified mutations in cancer. The next step of this work will be to bring the drug to a clinical trial setting, which Shilatifard said he hopes will happen in the next three to five years.

“I’ve been working on this translocation for more than two decades, and we’re finally at the point where in five to 10 years, we can get a drug in kids that can be effective,” Shilatifard said. “If we can bring that survival rate up to 85 percent, that’s a major accomplishment.”

Earlier work from Shilatifard’s laboratory published in Cell in 2018 identified compounds that could slow cancer growth by interrupting a gene transcription process known as “Super Elongation Complex” (SEC). It was the first compound in its class to do this.

This MLL stabilization process discovered in the most recent paper could potentially work in cancers with solid tumors, such as breast or prostate cancer, said first author Zibo Zhao, a postdoctoral research fellow in Shilatifard’s lab.

“This opens up a new therapeutic approach not only for leukemia, which is so important for the many children who are diagnosed with this terrible cancer, but also for other types of cancers that plague the population,” Zhao said.

“The publication of these four papers and the possibility of a future human clinical trial could not have happened if it weren’t for the cross-disciplinary collaboration at Northwestern,” Shilatifard said.

Longer breastfeeding tied to lower risk of liver disease

(Reuters Health) – – Mothers who breastfeed for six months or more may have less fat in their livers and a lower risk of liver disease, a U.S. study suggests.

Breastfeeding has long been tied to health benefits for women, including lower risks for heart disease, diabetes and certain cancers. The current study focused on whether nursing might also be tied to a reduced risk of non-alcoholic fatty liver disease (NAFDL), which is usually linked with obesity and certain eating habits.

Researchers followed 844 women for 25 years after they gave birth. Overall, 32 percent reported nursing for up to a month, 25 percent said they breastfed for one to six months and 43 percent reported nursing for longer.

By the end of the study, the women were 49 years old on average. Fifty-four, or about 6 percent, had developed NAFLD. Women who breastfed babies for at least six months were 52 percent less likely to develop liver disease than mothers who nursed for less than one month, researchers report in the Journal of Hepatology.

“This new analysis contributes to the growing body of evidence showing that breastfeeding a child also offers significant health benefits to the mother,” said study leader Dr. Veeral Ajmera of the University of California, San Diego.

“Future studies will be needed to assess if breastfeeding can decrease the severity in NAFLD in women at high risk,” Ajmera said by email.

The women in the analysis were part of the larger Coronary Artery Risk Development in Young Adults study. They were assessed when they joined the study in 1985 and 1986, surveyed about breastfeeding with any subsequent births, and then examined for fat in their liver at the end of the study using computed tomography.

The study can’t prove whether or how breastfeeding might stave off NAFLD. It’s possible that women who breastfed for longer periods had healthier lifestyles that contributed to their lower risk of liver disease, the study authors note.

In particular, women who got more exercise appeared to nurse for longer periods, said Yukiko Washio of RTI International and the University of Delaware, College of Health Sciences.

“Recent evidence shows that physical activity helps improve fatty liver disease,” Washio, who wasn’t involved in the study, said by email.

Women are advised to breastfeed babies exclusively for at least six months, and it’s also unclear how much protection women might get if they achieved a total of six months of nursing after breastfeeding multiple children for shorter periods, said Dr. Lori Feldman-Winter of the Cooper Medical School of Rowan University in Camden, New Jersey.

“Maintaining lactation through at least the first six months is physiologically how the mother’s body reprograms metabolism and prevents chronic diseases,” Feldman-Winter, who wasn’t involved in the study, said by email. “While obesity and diet also modify this risk, the effect of lactation seems to be greatest and offers the best potential to decrease the prevalence of fatty liver disease.”

More research is needed to confirm the potential for breastfeeding to help prevent liver disease, said Jennifer Yourkavitch of the University of North Carolina, Greensboro.

“But there is a mountain of evidence supporting breastfeeding as beneficial to women’s and children’s health and it should be promoted and supported,” Yourkavitch, who wasn’t involved in the study, said by email. “These findings give us another reason to do that.”

Adolescent brain development impacts mental health, substance use

Advances in understanding adolescent brain development may aid future treatments of mental illness and alcohol and substance use disorders. The findings were presented at Neuroscience 2018, the annual meeting of the Society for Neuroscience and the world’s largest source of emerging news about brain science and health.

Adolescence is a developmental period characterized by outsized risk-taking and reward-seeking behavior, including first alcohol and drug exposures, as well as the first emergence of symptoms such as depression and anxiety. And yet, much of the research on brain functions related to these conditions is performed on adults. As we gain a better understanding of adolescence-specific neurological causes of these conditions and behaviors, we increase the potential for early treatments and for interventions even before serious symptoms emerge.

Today’s new findings show that:

A variant in an opioid receptor gene in the brain reduces the natural reward response in young adolescents before they have started using alcohol or other substances, indicating carriers of this genetic variant may be more susceptible to addiction (John W. VanMeter, abstract 281.06).
Childhood trauma impacts the development of critical brain networks during adolescence, elevating the risk for alcohol abuse (Sarita Silveira, PhD, abstract 645.04).
The strength of connections between the brain’s reward and anti-reward systems corresponds to the severity of several important psychiatric symptoms in adolescents, including anxiety and depression (Benjamin Ely, abstract 320.11).
“The neuroscience advances presented today help expand our understanding of the connections between adolescent brain development and mental health issues, including alcohol and substance use,” said press conference moderator Jay Giedd, MD, of the University of California, San Diego, who conducts research on the biological basis of cognition, emotion, and behavior with an emphasis on the teen years. “These advances provide potential new methods to identify young people who have biological susceptibility to addiction and mental illnesses, so we can implement intervention strategies even before problems emerge.”

This research was supported by national funding agencies including the National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcoholism, and several U.S. universities. Find out more about adolescent brain development on BrainFacts.org.

Type 1 Diabetes in Children and Adolescents: A Position Statement by the American Diabetes Association

Introduction

Since the American Diabetes Association (ADA) published the Position Statement “Care of Children and Adolescents With Type 1 Diabetes” (1) in 2005, innovations have transformed the landscape and management of type 1 diabetes: novel autoantibodies, sophisticated devices for delivering insulin and measuring glucose, and diabetes registries. However, strategies to prevent or delay type 1 diabetes in youth remain elusive, and meanwhile the number of affected children continues to grow. The SEARCH for Diabetes in Youth (SEARCH) study found a 21.1% rise in the prevalence of type 1 diabetes from 2001 to 2009 in youth aged 0 through 19 years, with increases observed in all sex, age, and race/ethnic subgroups except those with the lowest prevalence (0–4 years old and American Indians) (2). Incidence has also increased; the adjusted risk for developing type 1 diabetes increased 1.4% annually between 2002 and 2012, with significant increases in all age-groups except those 0–4 years old (3).

One theme of this Position Statement is that “children are not little adults”—pediatric-onset diabetes is different from adult diabetes because of its distinct epidemiology, pathophysiology, developmental considerations, and response to therapy (4,5). Diabetes management for children must not be extrapolated from adult diabetes care. In caring for children and adolescents, clinicians need to be mindful of the child’s evolving developmental stages and must adapt care to the child’s needs and circumstances. Timely anticipatory guidance and care coordination will enable a seamless child/adolescent/young adult transition for both the developing patient and his or her family.

Although the ADA stopped developing new position statements in 2018 (6), this Position Statement was developed under the 2017 criteria (7) and provides recommendations for current standards of care for youth (children and adolescents) with type 1 diabetes. It is not intended to be an exhaustive compendium on all aspects of disease management, nor does it discuss type 2 diabetes in youth, which is the subject of an ADA Position Statement currently under review. While adult clinical trials produce robust evidence that has advanced care and improved outcomes (8), pediatric clinical trials remain scarce. Therefore, the majority of pediatric recommendations are not based on large, randomized clinical trials (evidence level A) but rely on supportive evidence from cohort/registry studies (B or C) or expert consensus/clinical experience (E) (Table 1). Please refer to the ADA’s “Standards of Medical Care in Diabetes” for updates to these recommendations (professional.diabetes.org/SOC).

Read More…

The Alleged Dangers of Vaping — Are They Real?

By Dr. Sudip Bose, MD, FACEP, FAAEM

It is well known that cigarette smoking is dangerous to one’s health and to the health of others. For some, using e-cigarettes or “vapes” has allowed them to reduce or quit the use of tobacco. I applaud those who have been able to quit smoking by using these devices. It is a step in the right direction. However, as a practicing emergency room physician, I still have some concerns about the safety of these devices. As a friend who vapes once directly, albeit somewhat inelegantly, put it, “Only a moron would believe that inhaling [stuff] into your lungs is totally harmless.”

For the sake of this article, I will use the general term ENDS (electronic nicotine delivery systems), though I acknowledge that not all e-liquids contain nicotine. This is not an attack on people who use the devices or even sell them, but simply an attempt to educate Americans on the possible risks associated with their use. For the record: I absolutely am not incentivized by any pharmaceutical companies, government agency, political organizations or anyone else.

The Royal College of Physicians published research in the Annals of Internal Medicine and actually encouraged the use of ENDS. That may be misleading, however, because the study didn’t show that vaporizers and e-cigarettes are safe, but rather that their use is safer than smoking tobacco cigarettes. It is encouraging to note, however, that they do not think vaping is a gateway to cigarette smoking. This is especially important because of the popularity of ENDS use among younger people.

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The Medical Emergency Of Otto Warmbier

By Dr. Sudip Bose, MD, FACEP, FAAEM

All that the doctors who treated Cincinnati, Ohio resident Otto Warmbier knew is what they had seen or maybe read in the news. They knew he had just been released on June 13 from imprisonment in North Korea where he had been held by for more than 17 months. He had been sentenced in March 2016 to 15 years of hard labor for allegedly removing a propaganda poster from a wall at a Pyongyang hotel where he had been staying. The University of Virginia honors student had been visiting the authoritarian state during a five-day trip with a group called Young Pioneer Tours, which is a group out of China – an important note.

Otto Warmbier (Facebook)
Otto Warmbier’s ordeal began on Jan. 2, 2016 when he was removed from a flight that was about to leave Pyongyang, the capital of North Korea, by two North Korean officials who explained that he was very sick and needed to go to a hospital. He was not sick and did not need to go to a hospital. He had just been arrested for allegedly trying to steal that poster.

Most of us have seen the video by now of Otto Warmbier in captivity from March 2016 – just a couple months after he was removed from the flight – he was alert and made a confessional statement in front of media cameras, where he pleaded for leniency and then broke down crying. In another video clip, we see him paraded before cameras being roughly escorted by two North Korean soldiers who had tight grips on each of his arms, his head bowed, his feet shuffling.

Then came the news well over a year later that through various means of diplomacy, he was being released to go back home to Cincinnati, but that he was in a coma and had been for most of his time in captivity. The explanation from the North Koreans? He had contracted botulism and had taken a sleeping pill.

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The Surgeon General’s Report on E-Cigarettes: Quitters & Starters


By Dr. Sudip Bose, MD, FACEP, FAAEM

A report on e-cigarettes released at the end of last year by the US Surgeon General’s office shows a number of risks related to the popular product — particularly regarding young people — that should make them a lot less popular, but likely won’t. The act of “vaping” is often thought of as a safer alternative to smoking, but that’s not necessarily the case. Here are the dangers and potential dangers people should be paying attention to related to e-cigarettes:

The Debate

E-cigs are at the center of one of the most contentious debates in public health. The availability and appeal of using e-cigs as an alternative to smoking cigarettes has been growing quickly over the years for both those who are new to smoking, as an introductory product, and to those who are trying to quit smoking, who see it as a more “healthful” way of trying to kick the smoking habit.

However, e-cigs don’t solve the nicotine problem at all. Yes, e-cigs eliminate tar, and yes, e-cigs eliminate the tobacco — both dangerous elements to one’s health. And that’s definitely good. But what they do not eliminate is the critical element of nicotine. Nicotine is one of the most highly addictive substances on earth. It’s presented in a liquid and then vaporized form in an e-cig; you inhale through the e-cig, and as you inhale, the nicotine and other substances in the liquid are atomized and absorbed into your lungs. The nicotine in an e-cig is a lot more concentrated and potent.

New Users

For those who have never smoked and who are interested in the experience, e-cigs are an entry-level product that have been promoted and marketed as being safe. They’re not. They may be “safer” than cigarettes, but that’s only by degree.

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