AAP Guidelines for Lead Screening in Children

A revised policy statement from the American Academy of Pediatrics (AAP) on screening for elevated blood lead levels in children recommends the use of targeted blood screening instead of universal screening. In the new guidelines, published in the June 1998 issue of Pediatrics, the AAP emphasizes, however, that universal screening may be necessary in some high-risk areas and population groups.

Previously, the AAP recommended universal screening for all children at one year of age and again, if possible, at two years of age. However, according to the AAP, the number of children ages one to five years with elevated blood lead levels decreased from 88.2 percent between 1976 and 1980 to 4.4 percent between 1991 and 1994. The AAP continues to stress the importance of screening for this preventable problem.

The policy statement discusses epidemiology, neurodevelopmental effects of lead, primary prevention (abatement, assessment and anticipatory guidance), secondary prevention through lead screening, management of high blood lead levels and recommendations to both physicians and government agencies.

The following are the AAP recommendations to physicians:

• Physicians should provide anticipatory guidance to parents of all infants and toddlers, including information about risk factors from exposure to lead and prevention strategies.

• Physicians should work with local government health agencies to develop risk assessment questionnaires.

• Universal screening should take place in areas defined by census tracts and zip codes where at least 27 percent of the housing was built before 1950 and in which the percentage of one- and two-year-olds with elevated blood lead levels is at least 12 percent.

• Physicians should screen high-risk children. High risk can be determined from a risk assessment questionnaire.

Statement on Hormone Replacement Therapy

The American College of Obstetricians and Gynecologists (ACOG) has issued a report reviewing hormone replacement therapy (Educational Bulletin No. 247). The educational bulletin is in the May 1998 issue of Obstetrics and Gynecology.

The report contains discussions on the indications for hormone replacement therapy, risk factors, therapeutic options and strategies to improve compliance. The section on indications discusses central nervous system symptoms, sexual function, cardiovascular symptoms, osteoporosis, genitourinary symptoms and hypogonadal conditions. Thromboembolic disease, endometrial hyperplasia and endometrial cancer, endometriosis, breast cancer, and hypertension and weight gain are the risk factors discussed.

According to ACOG, studies have shown unquestionably that estrogen replacement therapy can significantly reduce the incidence of osteoporotic fractures and vasomotor symptoms and improve genital atrophy. Other studies suggest an association with reduced cardiovascular morbidity. These benefits for women must be assessed against the potential increased risk of breast cancer.

ACOG recommends a thorough medical evaluation, including breast and pelvic examinations, before beginning any hormone replacement therapy. The medical history should focus on contraindications to estrogen and precautions against risk factors and side effects. Routine assessments such as blood pressure evaluation, Papanicolaou tests, lipid profile assessment and mammography should be performed. A baseline endometrial biopsy is not necessary unless irregular bleeding occurs. Any woman with irregular or unexpected bleeding should have an endometrial biopsy.

Therapeutic options include estrogenprogestin combinations, progestin-only regimens, estrogen-only regimens, estrogen-androgen regimens, selective estrogen modulators, growth hormone and dehydroepiandrosterone sulfate replacement.

ACOG notes that once the decision has been made to begin hormone replacement therapy, it is important for patients to continue treatment so that long-term benefits can be realized. Follow-up to identify side effects is important. Compliance may be a challenge; good rapport with ongoing communication between the patient and physician is a key to compliance.

New Prescribed Uses for Aspirin

The U.S. Food and Drug Administration (FDA) has announced a new final rule that substantially expands the recommended prescribed uses of aspirin.

The rule updates the professional labeling of over-the-counter aspirin, buffered aspirin and aspirin in combination with antacid. The following are highlights of the updated professional labeling:

• Recommended for use in men and women in the treatment of transient ischemic attack, ischemic stroke, angina, acute myocardial infarction, recurrent myocardial infarction, specific revascularization procedures and rheumatologic diseases.

• Recommended to minimize adverse events; low dosages (50 to 325 mg) are recommended for cardiac and cerebrovascular uses (75 to 325 mg are recommended for patients with angina and patients with previous heart attack).

The new expanded uses will be provided directly to physicians. They will not be printed on the labels of aspirin products.

The FDA has also required all manufacturers of over-the-counter analgesics to include organ-specific alcohol warnings on all product packaging. Acetaminophen products will carry a warning about liver damage while nonsteroidal anti-inflammatory drugs will carry a warning about stomach bleeding.

Screening Guidelines for Thyroid Disease

All women over the age of 50 should be screened for thyroid disease, according to updated guidelines issued by the American College of Physicians–American Society of Internal Medicine (ACP–ASIM). Published in the July 15, 1998, issue of the Annals of Internal Medicine, the guidelines note that one in 71 women over the age of 50 years has unsuspected but symptomatic thyroid disease that will respond to treatment.

The most common thyroid condition in adults is hypothyroidism. Hyperthyroidism is less common but affects about 2 million Americans, primarily women between the ages of 20 and 40 years.

ACP–ASIM states that the preferred screening method is a sensitive thyroid-stimulating hormone (TSH) test. A free thyroxine test should be done if the TSH level is undetectable or is 10 μU per mL (10 mU per L), or more. The guidelines recommend that physicians follow and treat patients who have overt thyroid disease.

The management of patients found by screening to have persistent subclinical hyperthyroidism is not clear, according to ACP–ASIM, and information about factors that could identify which patients may develop problems is needed to establish a strategy for the treatment of this condition. The guidelines also state that not enough evidence is available to recommend for or against treatment of subclinical hypothyroidism without symptoms.

Offices and clinics should be equipped to identify appropriate patients for screening and to perform follow-up tests without the need for a second blood sample. In particular, patients who have overt but clinically unrecognized disease must be followed because these patients will receive the most benefit from treatment.

Hospital Discharge of the High-Risk Neonate

The American Academy of Pediatrics (AAP) has issued a policy statement covering the factors to be considered in the discharge from the hospital of the high-risk neonate. The statement appears in the August 1998 issue of Pediatrics. Declaring that the traditional approach of the single criteria of a preset weight for the infant is no longer adequate, the AAP developed the statement on the basis of published, scientifically derived information. According to the AAP, the discharge decision requires balancing infant safety and well-being with family needs and capabilities, while also considering community resources and support systems.

The AAP emphasizes the importance of individualized planning and physician judgment when determining discharge. Four broad categories of high-risk situations are identified: (1) the preterm infant; (2) the infant who requires technologic support; (3) the infant who is at risk because of family issues; and (4) the infant whose irreversible condition may result in an early death.

The care of each high-risk neonate after discharge must be carefully coordinated to provide ongoing multidisciplinary support of the family. Components identified by the AAP that must be included in discharge planning include parental education; implementation of primary care; evaluation of unresolved medical problems; development of the home care plan; identification and mobilization of surveillance and support services; and determination and designation of follow-up care.

Recommendations are given for four areas of readiness for discharge to be considered: infant readiness; home care plan readiness; family and home environmental readiness; and community and health care system readiness.

Primary considerations for infant readiness include the following:

• A sustained pattern of weight gain of sufficient duration.

• Adequate maintenance of normal body temperature with the infant fully clothed in an open bed with normal ambient temperature.

• Competent suckle feeding, breast or bottle, without cardiorespiratory compromise.

• Physiologically mature and stable cardiorespiratory function of sufficient duration.

Tamoxifen for Breast Cancer Prevention

The U.S. Food and Drug Administration (FDA) has approved tamoxifen (Nolvadex) for reducing the incidence of breast cancer in women at high risk for developing the disease. This new indication for tamoxifen resulted from a recent study of the drug, conducted by the National Cancer Institute (NCI), in more than 13,000 women who were at increased risk of breast cancer. The study showed that tamoxifen reduced the chance of getting breast cancer by 44 percent. The long-term effects of tamoxifen use are not known.

The FDA notes that caution must be used in prescribing the drug because of the potential for serious side effects, such as endometrial cancer, deep venous thrombosis and pulmonary embolism. The labeling specifies that for women age 50 and older, the following risk factors would result in an increased risk of breast cancer:

• Family history of breast cancer (at least two direct-line relatives with breast cancer).

• Personal health history (presence of atypical hyperplasia on breast biopsy).

• First child born at age 30 years or older.

• Onset of menses at age 11 years or younger.

The NCI and the manufacturer of tamoxifen are making the risk assessment model used in the trial available on computer disk to health care professionals to aid in evaluating an individual woman's risk of developing breast cancer. To order the risk assessment model, call 800-4-CANCER or visit the Web site at http://cancertrials.nci.nih.gov.

The FDA also approved tamoxifen for the reduction of contralateral breast cancer. Current data from clinical trials support the recommendation for five years of adjuvant tamoxifen therapy for patients with breast cancer.