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Copyright © 2007 Massachusetts Medical Society. All rights reserved.

Autism: What's in a name?

Failure to respond to name by age 12 months was a marker for autism in at‐risk children.

Studies of early home videos of children diagnosed with autism spectrum disorder (ASD) have shown decreased “response‐to‐name” behavior during infancy. To examine the accuracy of this behavior as a marker for autism, researchers compared infants who had older siblings with ASD (at‐risk group) and infants who did not have siblings with ASD (controls) and then followed the children prospectively for 2 years.

Responses to a standardized test of response to name (turning and making eye contact) were examined in at‐risk infants and control infants at age 6 months and age 12 months. At age 24 months, 46 at‐risk infants and 25 control infants with data from the 12‐month assessment were evaluated for ASD and other developmental delays.

At 6 months, differences between groups were not significant, but, at 12 months, more control infants than at‐risk infants responded to their names after fewer calls. Failure to respond to name at 12 months had a sensitivity of 50% and a specificity of 89% for identifying a child with ASD and a sensitivity of 39% and a specificity of 94% for identifying a child with any developmental delay, including ASD. Results of other analyses suggested that response‐to‐name behavior is a stronger measure of social interaction than of receptive language.

Comment

This study presents an interesting assessment of a simple screening test for children aged 12 months who are at risk for ASD because they have a sibling with ASD. When an at‐risk infant fails to respond to his or her name at 12 months, the clinician could follow up with other screening items. If the infant cannot point with a finger to indicate interest in something, show an object by bringing it to a person, or demonstrate babbling speech, the clinician should consider referral for comprehensive ASD assessment. However, based on these findings alone, response‐to‐name behavior should not be used for ASD screening in all children. The authors also note that a normal response to name in an at‐risk infant is not necessarily reassuring if other clinical concerns are present.

Cornelius W. Van Niel, MD

Published in Journal Watch Pediatrics and Adolescent Medicine May 2, 2007

[filled triangle] Nadig AS, et al. A prospective study of response to name in infants at risk for autism. Arch Pediatr Adolesc Med 2007;161:378–83.

More on antidepressants in children and adolescents: Analysis of benefits and risks

Treatment benefits outweigh the risk for suicide ideation.

Antidepressant use in children and adolescents has been associated with a twofold increase in risk for suicidal behavior. To further assess both efficacy and risk for suicidal thoughts and behaviors in the pediatric population, researchers conducted a meta‐analysis of data from 27 randomized, placebo‐controlled clinical trials of antidepressant treatment (mostly selective serotonin reuptake inhibitors [SSRIs]) for major depressive disorder (MDD, 15 trials), obsessive‐compulsive disorder (OCD, 6 trials), and other anxiety disorders (6 trials) in pediatric patients.

The pooled differences in response for antidepressant groups compared with placebo groups were 11% for treatment of pediatric MDD, 20% for OCD, and 37% for other anxiety disorders. The differences in risks for suicidal behavior were 1.0%, 0.5%, and 0.7%, respectively. Overall, the authors calculated that a clinician would have to treat 143 patients to see suicidal behavior in a single patient. No completed suicides were reported.

Comment

This meta‐analysis is the largest to date to examine efficacy and risk of antidepressant use in children and adolescents. Its importance for pediatricians is twofold: First, pediatricians may be surprised at the modest improvement in patients with depression and OCD. This finding serves as a reminder that cognitive behavioral therapy should be a part of treatment with or without medication and that SSRI medications are most effective in patients with non‐OCD anxiety disorders. Second, in contrast with previous meta‐analyses, this study assessed risks associated with the three disorders separately; these results point out that the risk association is with suicidal thoughts and behaviors, not completed suicides. Pediatricians can feel confident in prescribing SSRI medications for children and adolescents with specific mental health disorders as long as side effects are monitored appropriately (in particular, agitation and increasing sadness and isolation during the first month after starting or increasing the medication).

Martin T. Stein, MD

Published in Journal Watch Pediatrics and Adolescent Medicine May 2, 2007

[filled triangle] Bridge JA, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta‐analysis of randomized controlled trials. JAMA 2007;297:1683–96.

Sleep‐disordered breathing is common in obese children

Screening for sleep apnea may be indicated.

Sleep‐disordered breathing has been reported in obese children and adults. Researchers at an obesity clinic in Belgium examined the prevalence of and risk factors for sleep apnea in 27 overweight and 64 obese children and adolescents (age range, 6–17 years; 51 girls).

Among overweight patients, 44% had some form of sleep‐disordered breathing on polysomnography: mild obstructive sleep apnea (OSA) in 19%, moderate‐to‐severe OSA in 22%, and central sleep apnea in 4%. Among the obese patients, 47% had sleep‐disordered breathing: snoring only in 11%, mild OSA in 11%, moderate‐to‐severe OSA in 8%, and central sleep apnea in 17%. Overall, 17% of patients with OSA (4 patients) and 50% with central sleep apnea (6 patients) had oxygen desaturation. Moderate‐to‐severe OSA was associated with tonsillar hypertrophy but not with any anthropometric measure. Central sleep apnea was associated with higher BMI, waist circumference, waist‐to‐hip ratio, and fat mass.

Comment

Sleep‐disordered breathing is common in overweight and obese children and adolescents. Central sleep apnea is associated with abdominal obesity, fat mass, and oxygen desaturation. OSA is more common in overweight children than in obese children and may be associated with tonsillar hypertrophy. Therefore, tonsillectomy should be considered for overweight and obese children with OSA, and sleep studies should be considered for obese children to screen for sleep‐disordered breathing.

F. Bruder Stapleton, MD

Published in Journal Watch Pediatrics and Adolescent Medicine April 25, 2007

[filled triangle] Verhulst SL, et al. Sleep‐disordered breathing in overweight and obese children and adolescents: prevalence, characteristics and the role of fat distribution. Arch Dis Child 2007;92:205–8.

Treatment of gonococcal infections: No more fluoroquinolones, only cephalosporins

The CDC no longer recommends fluoroquinolones for treatment of gonococcal infections.

Neisseria gonorrhea historically has been susceptible to a number of antibiotics, including second‐ and third‐generation cephalosporins, fluoroquinolones, azithromycin, and spectinomycin. Azithromycin is not recommended for treatment of gonococcal infections because resistance can develop rapidly, and spectinomycin is not available in the U.S. Fluoroquinolones, particularly ciprofloxacin, often have been used for gonorrhea treatment because they are easily available, are efficacious, and require only one dose. However, in 2000, because of increasing resistance patterns, fluoroquinolones were no longer recommended for treatment of men in Asia, Hawaii, and California, and men who have sex with men.

The most recent data from 26 sites throughout the U.S. indicate that the prevalence of fluoroquinolone‐resistant N. gonorrhea has continued to increase from 1% in 2001 to 9% in 2005 and 13% in the first half of 2006. Further, the prevalence of resistance is now increasing in heterosexual men. In 2006, 25 of 26 reporting sites in the U.S. reported fluoroquinolone‐resistant N. gonorrhea isolates. Thus, the CDC has changed treatment guidelines and no longer recommends fluoroquinolones for treatment of gonococcal infections.

Comment

Using cephalosporins as first‐line therapy is critical for gonorrhea as well as for pelvic inflammatory disease (because it often is caused by N. gonorrhea). Acceptable cephalosporin regimens for uncomplicated gonococcal infections include one injection of ceftriaxone (125 mg) or oral cefixime (400 mg). Additional dosing guidelines for complicated or pharyngeal infections are provided in the updated guidelines. Patients diagnosed with gonococcal infections should be treated for possible Chlamydia trachomatis coinfection with one dose of azithromycin (1 g) if chlamydia infection has not been ruled out.

Peggy Sue Weintrub, MD

Published in Journal Watch Pediatrics and Adolescent Medicine May 2, 2007

[filled triangle] Centers for Disease Control and Prevention (CDC). Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep 2007;56:332–6.


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