Laird Harrison

The new American Academy of Pediatrics guidelines for iron supplementation are drawing criticism from experts who say they go too far – and others who say they don’t go far enough.

The AAP’s Section on Breastfeeding wants to strike the recommendation that all breastfed children should get iron supplements. "No one has shown any benefit to doing that," said section chairperson, Dr. Richard J. Schanler, professor of pediatrics at Albert Einstein College of Medicine, N.Y.

By contrast, the AAP’s local nutrition committee for a New York chapter would like to see a recommendation of iron supplements for all toddlers.

The guidelines "Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age)," were published in November (Pediatrics 2010;126:1040-50), after the AAP’s Committee on Nutrition spent 5 years soliciting comments from a wide range of sources, including the Section on Breastfeeding, said Dr. Frank R. Greer, an author of the guidelines.

"It’s not without controversy," said Dr. Greer, professor of pediatrics at the University of Wisconsin, Madison. But he argued that the guidelines offer the most practical course for pediatricians advising parents of young children.

The debate over exclusively breastfed infants focuses on 2 months – the interval between 4 and 6 months of age. "Term, healthy infants have sufficient iron for at least the first 4 months of life," the guidelines state. "Human milk contains very little iron. Exclusively breastfed infants are at increasing risk of ID [iron deficiency] after 4 completed months of age." They call for 1 mg/kg per day of oral iron supplements beginning at 4 months of age until the babies begin eating iron-containing foods.

The AAP already recommends that complementary foods containing iron be introduced after 6 months. So the question is whether exclusively breastfed babies should get oral iron drops for the last 2 months before beginning to eat solid foods.

The guidelines acknowledge that the prevalence of iron deficiency among children under 12 months of age in the United States is unknown. But the document cites a double-blind controlled trial showing benefits (J. Pediatr. 2003;143:582-6). Exclusively breastfed infants supplemented with iron between 1 and 6 months of age had higher hemoglobin concentration and higher mean corpuscular volume at 6 months of age; and better visual acuity and higher Bayley Psychomotor Developmental Indices at 13 months, than did children who did not get supplements.

At the very least, supplementing with iron does no harm, argues Dr. Greer. "All the formula-fed babies get iron in their formula," he said. "Where is the harm to those babies?"

But Dr. Schanler argued that at least one study has found potential risk (J. Nutr. 2002; 132:3249-55). This controlled trial found slower growth among breastfed infants with normal hemoglobin who received iron supplements than those who did not receive supplements.

The two studies, one showing benefits and one showing detriments, are "of the same caliber," so more research needs to be done, Dr. Schanler said.

"We’re talking about millions of children, so you really have to make sure there’s enough evidence to make a change," he said.

In their letter to Pediatrics (published online Oct. 28), the Section on Breastfeeding also faulted Dr. Greer and his colleagues for not discussing the possibility of delayed umbilical cord clamping as an alternative to iron supplementation. In theory, a significant amount of blood flows from the placenta to the newborn infant in the few minutes after birth. "There are data to suggest you increase red blood cell mass that way," said Dr. Schanler. "To me, if you’re writing guidelines you should at least comment that there’s another way to increase iron stores."

Dr. Greer responded that cord-clamping doesn’t concern pediatricians. "That’s a great idea," he said. "But we can’t really recommend it if obstetricians don’t do it."

In fact, the idea has not gained traction among obstetricians, said Dr. E. Albert Reece, the John Z. and Akiko K. Bowers Distinguished Professor and dean of the School of Medicine at the University of Maryland, Baltimore.

"I’m not aware of any movement afoot in the obstetrics community to prolong the time before cord clamping," said Dr. Reece, an ob.gyn. who specializes in maternal-fetal medicine. "The data now is very sparse to show that delayed cord clamping results in any substantial benefit. And even if it did enhance the iron store of the infant initially, the iron store would still decline."

Dr. Reece said he supports the AAP Committee on Nutrition’s recommendation to supplement breastfed infants.

Dr. Alvin Eden, chairperson of the Committee on Nutrition for AAP New York Chapter 2, also supports the national AAP infant supplement guidelines. But Dr. Eden, a clinical professor of pediatrics at Weill Medical College of Cornell University in New York would like to see a recommendation that all toddlers get iron supplements.

The new guidelines recommend that children should be screened for anemia around 12 months of age by measuring hemoglobin concentrations and assessing risk factors associated with iron deficiency or iron deficiency anemia. For children whose hemoglobin level is less than 11 g/dL and in those at high risk of dietary iron deficiency, physicians should also measure serum ferritin (SF) and C-reactive protein (CRP) or reticulocyte hemoglobin (CHr), the guidelines say.

But evaluating the risk factors is difficult because it’s hard to know how much iron a child is eating, said Dr. Eden. And measuring SF and CRP or CHr is invasive because these tests require venipuncture. "It’s very expensive and a lot of labs are not doing it," he said.

As a result, Dr. Eden thinks a lot of parents won’t get the tests. "It puts the pediatrician in a difficult position. What I have been doing is putting all the toddlers on iron supplements for a year after they switch to solid foods."

Dr. Greer responded that the recommendation to do the iron deficiency testing only in those toddlers at risk – instead of all toddlers – was already a compromise intended to reduce the expense and invasiveness. And he thinks it would be even harder to get all toddlers to take iron supplements than to do the testing for iron deficiency.

So what’s next?

"I think we're going to continue having dialogue," said Dr. Schanler.

Dr. Greer, Dr. Reece, and Dr. Eden said they had no conflicts of interest to disclose.

The new American Academy of Pediatrics guidelines for iron supplementation are drawing criticism from experts who say they go too far – and others who say they don’t go far enough.

The AAP’s Section on Breastfeeding wants to strike the recommendation that all breastfed children should get iron supplements. "No one has shown any benefit to doing that," said section chairperson, Dr. Richard J. Schanler, professor of pediatrics at Albert Einstein College of Medicine, N.Y.

By contrast, the AAP’s local nutrition committee for a New York chapter would like to see a recommendation of iron supplements for all toddlers.

The guidelines "Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age)," were published in November (Pediatrics 2010;126:1040-50), after the AAP’s Committee on Nutrition spent 5 years soliciting comments from a wide range of sources, including the Section on Breastfeeding, said Dr. Frank R. Greer, an author of the guidelines.

"It’s not without controversy," said Dr. Greer, professor of pediatrics at the University of Wisconsin, Madison. But he argued that the guidelines offer the most practical course for pediatricians advising parents of young children.

The debate over exclusively breastfed infants focuses on 2 months – the interval between 4 and 6 months of age. "Term, healthy infants have sufficient iron for at least the first 4 months of life," the guidelines state. "Human milk contains very little iron. Exclusively breastfed infants are at increasing risk of ID [iron deficiency] after 4 completed months of age." They call for 1 mg/kg per day of oral iron supplements beginning at 4 months of age until the babies begin eating iron-containing foods.

The AAP already recommends that complementary foods containing iron be introduced after 6 months. So the question is whether exclusively breastfed babies should get oral iron drops for the last 2 months before beginning to eat solid foods.

The guidelines acknowledge that the prevalence of iron deficiency among children under 12 months of age in the United States is unknown. But the document cites a double-blind controlled trial showing benefits (J. Pediatr. 2003;143:582-6). Exclusively breastfed infants supplemented with iron between 1 and 6 months of age had higher hemoglobin concentration and higher mean corpuscular volume at 6 months of age; and better visual acuity and higher Bayley Psychomotor Developmental Indices at 13 months, than did children who did not get supplements.

At the very least, supplementing with iron does no harm, argues Dr. Greer. "All the formula-fed babies get iron in their formula," he said. "Where is the harm to those babies?"

But Dr. Schanler argued that at least one study has found potential risk (J. Nutr. 2002; 132:3249-55). This controlled trial found slower growth among breastfed infants with normal hemoglobin who received iron supplements than those who did not receive supplements.

The two studies, one showing benefits and one showing detriments, are "of the same caliber," so more research needs to be done, Dr. Schanler said.

"We’re talking about millions of children, so you really have to make sure there’s enough evidence to make a change," he said.

In their letter to Pediatrics (published online Oct. 28), the Section on Breastfeeding also faulted Dr. Greer and his colleagues for not discussing the possibility of delayed umbilical cord clamping as an alternative to iron supplementation. In theory, a significant amount of blood flows from the placenta to the newborn infant in the few minutes after birth. "There are data to suggest you increase red blood cell mass that way," said Dr. Schanler. "To me, if you’re writing guidelines you should at least comment that there’s another way to increase iron stores."

Dr. Greer responded that cord-clamping doesn’t concern pediatricians. "That’s a great idea," he said. "But we can’t really recommend it if obstetricians don’t do it."

In fact, the idea has not gained traction among obstetricians, said Dr. E. Albert Reece, the John Z. and Akiko K. Bowers Distinguished Professor and dean of the School of Medicine at the University of Maryland, Baltimore.

"I’m not aware of any movement afoot in the obstetrics community to prolong the time before cord clamping," said Dr. Reece, an ob.gyn. who specializes in maternal-fetal medicine. "The data now is very sparse to show that delayed cord clamping results in any substantial benefit. And even if it did enhance the iron store of the infant initially, the iron store would still decline."

Dr. Reece said he supports the AAP Committee on Nutrition’s recommendation to supplement breastfed infants.

Dr. Alvin Eden, chairperson of the Committee on Nutrition for AAP New York Chapter 2, also supports the national AAP infant supplement guidelines. But Dr. Eden, a clinical professor of pediatrics at Weill Medical College of Cornell University in New York would like to see a recommendation that all toddlers get iron supplements.

The new guidelines recommend that children should be screened for anemia around 12 months of age by measuring hemoglobin concentrations and assessing risk factors associated with iron deficiency or iron deficiency anemia. For children whose hemoglobin level is less than 11 g/dL and in those at high risk of dietary iron deficiency, physicians should also measure serum ferritin (SF) and C-reactive protein (CRP) or reticulocyte hemoglobin (CHr), the guidelines say.

But evaluating the risk factors is difficult because it’s hard to know how much iron a child is eating, said Dr. Eden. And measuring SF and CRP or CHr is invasive because these tests require venipuncture. "It’s very expensive and a lot of labs are not doing it," he said.

As a result, Dr. Eden thinks a lot of parents won’t get the tests. "It puts the pediatrician in a difficult position. What I have been doing is putting all the toddlers on iron supplements for a year after they switch to solid foods."

Dr. Greer responded that the recommendation to do the iron deficiency testing only in those toddlers at risk – instead of all toddlers – was already a compromise intended to reduce the expense and invasiveness. And he thinks it would be even harder to get all toddlers to take iron supplements than to do the testing for iron deficiency.

So what’s next?

"I think we're going to continue having dialogue," said Dr. Schanler.

Dr. Greer, Dr. Reece, and Dr. Eden said they had no conflicts of interest to disclose.

The new American Academy of Pediatrics guidelines for iron supplementation are drawing criticism from experts who say they go too far – and others who say they don’t go far enough.

The AAP’s Section on Breastfeeding wants to strike the recommendation that all breastfed children should get iron supplements. "No one has shown any benefit to doing that," said section chairperson, Dr. Richard J. Schanler, professor of pediatrics at Albert Einstein College of Medicine, N.Y.

By contrast, the AAP’s local nutrition committee for a New York chapter would like to see a recommendation of iron supplements for all toddlers.

The guidelines "Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age)," were published in November (Pediatrics 2010;126:1040-50), after the AAP’s Committee on Nutrition spent 5 years soliciting comments from a wide range of sources, including the Section on Breastfeeding, said Dr. Frank R. Greer, an author of the guidelines.

"It’s not without controversy," said Dr. Greer, professor of pediatrics at the University of Wisconsin, Madison. But he argued that the guidelines offer the most practical course for pediatricians advising parents of young children.

The debate over exclusively breastfed infants focuses on 2 months – the interval between 4 and 6 months of age. "Term, healthy infants have sufficient iron for at least the first 4 months of life," the guidelines state. "Human milk contains very little iron. Exclusively breastfed infants are at increasing risk of ID [iron deficiency] after 4 completed months of age." They call for 1 mg/kg per day of oral iron supplements beginning at 4 months of age until the babies begin eating iron-containing foods.

The AAP already recommends that complementary foods containing iron be introduced after 6 months. So the question is whether exclusively breastfed babies should get oral iron drops for the last 2 months before beginning to eat solid foods.

The guidelines acknowledge that the prevalence of iron deficiency among children under 12 months of age in the United States is unknown. But the document cites a double-blind controlled trial showing benefits (J. Pediatr. 2003;143:582-6). Exclusively breastfed infants supplemented with iron between 1 and 6 months of age had higher hemoglobin concentration and higher mean corpuscular volume at 6 months of age; and better visual acuity and higher Bayley Psychomotor Developmental Indices at 13 months, than did children who did not get supplements.

At the very least, supplementing with iron does no harm, argues Dr. Greer. "All the formula-fed babies get iron in their formula," he said. "Where is the harm to those babies?"

But Dr. Schanler argued that at least one study has found potential risk (J. Nutr. 2002; 132:3249-55). This controlled trial found slower growth among breastfed infants with normal hemoglobin who received iron supplements than those who did not receive supplements.

The two studies, one showing benefits and one showing detriments, are "of the same caliber," so more research needs to be done, Dr. Schanler said.

"We’re talking about millions of children, so you really have to make sure there’s enough evidence to make a change," he said.

In their letter to Pediatrics (published online Oct. 28), the Section on Breastfeeding also faulted Dr. Greer and his colleagues for not discussing the possibility of delayed umbilical cord clamping as an alternative to iron supplementation. In theory, a significant amount of blood flows from the placenta to the newborn infant in the few minutes after birth. "There are data to suggest you increase red blood cell mass that way," said Dr. Schanler. "To me, if you’re writing guidelines you should at least comment that there’s another way to increase iron stores."

Dr. Greer responded that cord-clamping doesn’t concern pediatricians. "That’s a great idea," he said. "But we can’t really recommend it if obstetricians don’t do it."

In fact, the idea has not gained traction among obstetricians, said Dr. E. Albert Reece, the John Z. and Akiko K. Bowers Distinguished Professor and dean of the School of Medicine at the University of Maryland, Baltimore.

"I’m not aware of any movement afoot in the obstetrics community to prolong the time before cord clamping," said Dr. Reece, an ob.gyn. who specializes in maternal-fetal medicine. "The data now is very sparse to show that delayed cord clamping results in any substantial benefit. And even if it did enhance the iron store of the infant initially, the iron store would still decline."

Dr. Reece said he supports the AAP Committee on Nutrition’s recommendation to supplement breastfed infants.

Dr. Alvin Eden, chairperson of the Committee on Nutrition for AAP New York Chapter 2, also supports the national AAP infant supplement guidelines. But Dr. Eden, a clinical professor of pediatrics at Weill Medical College of Cornell University in New York would like to see a recommendation that all toddlers get iron supplements.

The new guidelines recommend that children should be screened for anemia around 12 months of age by measuring hemoglobin concentrations and assessing risk factors associated with iron deficiency or iron deficiency anemia. For children whose hemoglobin level is less than 11 g/dL and in those at high risk of dietary iron deficiency, physicians should also measure serum ferritin (SF) and C-reactive protein (CRP) or reticulocyte hemoglobin (CHr), the guidelines say.

But evaluating the risk factors is difficult because it’s hard to know how much iron a child is eating, said Dr. Eden. And measuring SF and CRP or CHr is invasive because these tests require venipuncture. "It’s very expensive and a lot of labs are not doing it," he said.

As a result, Dr. Eden thinks a lot of parents won’t get the tests. "It puts the pediatrician in a difficult position. What I have been doing is putting all the toddlers on iron supplements for a year after they switch to solid foods."

Dr. Greer responded that the recommendation to do the iron deficiency testing only in those toddlers at risk – instead of all toddlers – was already a compromise intended to reduce the expense and invasiveness. And he thinks it would be even harder to get all toddlers to take iron supplements than to do the testing for iron deficiency.

So what’s next?

"I think we're going to continue having dialogue," said Dr. Schanler.

Dr. Greer, Dr. Reece, and Dr. Eden said they had no conflicts of interest to disclose.

SAN FRANCISCO – Cognitive function improved for most patients in the year after they underwent endarterectomy for carotid stenosis, according to the results of an ongoing prospective study.

Benefits seem to come gradually from improved blood flow, said Dr. Zoher Ghogawala, a neurosurgeon at Yale University in New Haven, Conn. “After 1 month, there was no change in any of the domains we measured,” he said. “However, if we followed these patients for a year, there was significant improvement.”

Although carotid endarterectomy is a well-established technique to treat carotid stenosis as a means of preventing stroke, its effects on cognitive function are poorly understood, Dr. Ghogawala said.

To learn more, he and his colleagues enrolled 36 patients from three sites. To estimate the extent that these patients' circulation was compromised, the researchers generated quantitative phase-contrast magnetic resonance angiography (qMRA) flow maps for their internal and middle cerebral arteries. This technology images blood flow in multiple phases of the cardiac cycle and then calculates volume, velocity, and direction.

The researchers used this technique because conventional MR techniques usually do not show changes in blood flow.

Using these data, they found that 12 patients had middle cerebral artery (MCA) flow impairment (defined as at least 15% less flow than the contralateral side) and 18 had impairment of internal carotid artery flow.

Lower blood flows were associated with a higher rate of stenosis. “It's what you might expect,” said Dr. Ghogawala.

Following surgery, new qMRA maps showed improved blood flow in these patients. Of the 12 patients who had preoperative impairment in MCA blood flow, 10 had improved flow after surgery.

After a month, there were no significant improvements in cognitive functioning. But in 29 patients who completed follow-up at 1 year, there was improvement in executive functioning (as measured by the Trail Making Test, Part B), verbal fluency (Controlled Oral Word Association FAS test), and memory (total recall score on the Hopkins Verbal Learning Test).

Scores improved on the Trail Making Test in all 9 patients with improvement in blood flow following surgery, compared with 8 of 20 patients with no improvement.

The presence of a right-sided lesion and impairment in middle cerebral artery blood flow were both significant, independent predictors of improved Trail Making Test scores.

Dr. Ghogawala said that patients with those features may have benefited the most because their cognitive function had been most impaired by their constricted blood flow.

Dr. Ghogawala disclosed that one of his coauthors received research support from VasSol Inc., the company that made the technology for producing the qMRA maps used in the study. Another coauthor owns shares in the company.

'After 1 month, there was no change, [but after] a year, there was significant improvement.'

Source DR. GHOGAWALA

View on the News

Technology May Have Future

This study that may become more important as the debate between CAS and CEA continues and further questions develop regarding intervention vs. medical management for asymptomatic patients. If these findings are reproducible on a larger scale, this might become an important testing modality for asymptomatic patients to determine who might benefit from intervention. If the technology proves successful, it would be very interesting to see if there are differences between CAS and CEA with regard to improvement in cognitive function.

LINDA HARRIS, M.D., is vice chair, faculty development, department of surgery, Millard Fillmore Gates Hospital-Kaleida, Buffalo, N.Y.

SAN FRANCISCO – Cognitive function improved for most patients in the year after they underwent endarterectomy for carotid stenosis, according to the results of an ongoing prospective study.

Benefits seem to come gradually from improved blood flow, said Dr. Zoher Ghogawala, a neurosurgeon at Yale University in New Haven, Conn. “After 1 month, there was no change in any of the domains we measured,” he said. “However, if we followed these patients for a year, there was significant improvement.”

Although carotid endarterectomy is a well-established technique to treat carotid stenosis as a means of preventing stroke, its effects on cognitive function are poorly understood, Dr. Ghogawala said.

To learn more, he and his colleagues enrolled 36 patients from three sites. To estimate the extent that these patients' circulation was compromised, the researchers generated quantitative phase-contrast magnetic resonance angiography (qMRA) flow maps for their internal and middle cerebral arteries. This technology images blood flow in multiple phases of the cardiac cycle and then calculates volume, velocity, and direction.

The researchers used this technique because conventional MR techniques usually do not show changes in blood flow.

Using these data, they found that 12 patients had middle cerebral artery (MCA) flow impairment (defined as at least 15% less flow than the contralateral side) and 18 had impairment of internal carotid artery flow.

Lower blood flows were associated with a higher rate of stenosis. “It's what you might expect,” said Dr. Ghogawala.

Following surgery, new qMRA maps showed improved blood flow in these patients. Of the 12 patients who had preoperative impairment in MCA blood flow, 10 had improved flow after surgery.

After a month, there were no significant improvements in cognitive functioning. But in 29 patients who completed follow-up at 1 year, there was improvement in executive functioning (as measured by the Trail Making Test, Part B), verbal fluency (Controlled Oral Word Association FAS test), and memory (total recall score on the Hopkins Verbal Learning Test).

Scores improved on the Trail Making Test in all 9 patients with improvement in blood flow following surgery, compared with 8 of 20 patients with no improvement.

The presence of a right-sided lesion and impairment in middle cerebral artery blood flow were both significant, independent predictors of improved Trail Making Test scores.

Dr. Ghogawala said that patients with those features may have benefited the most because their cognitive function had been most impaired by their constricted blood flow.

Dr. Ghogawala disclosed that one of his coauthors received research support from VasSol Inc., the company that made the technology for producing the qMRA maps used in the study. Another coauthor owns shares in the company.

'After 1 month, there was no change, [but after] a year, there was significant improvement.'

Source DR. GHOGAWALA

View on the News

Technology May Have Future

This study that may become more important as the debate between CAS and CEA continues and further questions develop regarding intervention vs. medical management for asymptomatic patients. If these findings are reproducible on a larger scale, this might become an important testing modality for asymptomatic patients to determine who might benefit from intervention. If the technology proves successful, it would be very interesting to see if there are differences between CAS and CEA with regard to improvement in cognitive function.

LINDA HARRIS, M.D., is vice chair, faculty development, department of surgery, Millard Fillmore Gates Hospital-Kaleida, Buffalo, N.Y.

SAN FRANCISCO – Cognitive function improved for most patients in the year after they underwent endarterectomy for carotid stenosis, according to the results of an ongoing prospective study.

Benefits seem to come gradually from improved blood flow, said Dr. Zoher Ghogawala, a neurosurgeon at Yale University in New Haven, Conn. “After 1 month, there was no change in any of the domains we measured,” he said. “However, if we followed these patients for a year, there was significant improvement.”

Although carotid endarterectomy is a well-established technique to treat carotid stenosis as a means of preventing stroke, its effects on cognitive function are poorly understood, Dr. Ghogawala said.

To learn more, he and his colleagues enrolled 36 patients from three sites. To estimate the extent that these patients' circulation was compromised, the researchers generated quantitative phase-contrast magnetic resonance angiography (qMRA) flow maps for their internal and middle cerebral arteries. This technology images blood flow in multiple phases of the cardiac cycle and then calculates volume, velocity, and direction.

The researchers used this technique because conventional MR techniques usually do not show changes in blood flow.

Using these data, they found that 12 patients had middle cerebral artery (MCA) flow impairment (defined as at least 15% less flow than the contralateral side) and 18 had impairment of internal carotid artery flow.

Lower blood flows were associated with a higher rate of stenosis. “It's what you might expect,” said Dr. Ghogawala.

Following surgery, new qMRA maps showed improved blood flow in these patients. Of the 12 patients who had preoperative impairment in MCA blood flow, 10 had improved flow after surgery.

After a month, there were no significant improvements in cognitive functioning. But in 29 patients who completed follow-up at 1 year, there was improvement in executive functioning (as measured by the Trail Making Test, Part B), verbal fluency (Controlled Oral Word Association FAS test), and memory (total recall score on the Hopkins Verbal Learning Test).

Scores improved on the Trail Making Test in all 9 patients with improvement in blood flow following surgery, compared with 8 of 20 patients with no improvement.

The presence of a right-sided lesion and impairment in middle cerebral artery blood flow were both significant, independent predictors of improved Trail Making Test scores.

Dr. Ghogawala said that patients with those features may have benefited the most because their cognitive function had been most impaired by their constricted blood flow.

Dr. Ghogawala disclosed that one of his coauthors received research support from VasSol Inc., the company that made the technology for producing the qMRA maps used in the study. Another coauthor owns shares in the company.

'After 1 month, there was no change, [but after] a year, there was significant improvement.'

Source DR. GHOGAWALA

View on the News

Technology May Have Future

This study that may become more important as the debate between CAS and CEA continues and further questions develop regarding intervention vs. medical management for asymptomatic patients. If these findings are reproducible on a larger scale, this might become an important testing modality for asymptomatic patients to determine who might benefit from intervention. If the technology proves successful, it would be very interesting to see if there are differences between CAS and CEA with regard to improvement in cognitive function.

LINDA HARRIS, M.D., is vice chair, faculty development, department of surgery, Millard Fillmore Gates Hospital-Kaleida, Buffalo, N.Y.

Major Finding: Thirty-two VLBW babies consumed an average of 523.3 ounces of formula and 74.2 ounces of donor milk over a period of 6 months. If all the babies who needed to supplement their mother's milk got donor milk, they might need 1,200 ounces a year, and at $4.50 per ounce, the researchers extrapolated an annual cost of $5,400 per year.

Data Source: Analysis of data on 32 VLBW babies at one hospital.

Disclosures: Dr. Marinelli said she had nothing to disclose.

SAN FRANCISCO — Providing donor milk to infants with very low birth weights is proving both inexpensive and practical, according to researchers from the University of Connecticut.

“You save money, and you end up with healthier babies,” said Dr. Kathleen A. Marinelli, a neonatologist in the department of pediatrics at the university.

She estimated the cost of supplementing a very-low-birth-weight (VLBW) baby's diet with donor milk at $5,400 per year per infant.

Many previous studies have established the benefits of human milk for VLBW babies, and recent research has shown that donor milk is a healthier supplement than is formula when mothers can't provide all the milk their own children need.

One study of 207 extremely premature infants weighing 500-1,250 g at birth showed a 50% reduction in necrotizing enterocolitis and an almost 90% reduction in surgical necrotizing enterocolitis in infants whose mothers' milk was supplemented with human donor milk, compared with those whose mothers' milk was supplemented with bovine formula (J. Pediatr. 2010;156:562-7.e1).

Many mothers of VLBW infants can't produce all the milk their babies need. In particular, many can't express colostrum for the first few days.

To determine the practicality of supplementing the diets of these children with donor milk, Dr. Marinelli and colleagues at the Connecticut Children's Medical Center, Hartford, studied 32 babies who were born at the hospital with weights of less than 1,500 g for a period of 6 months.

They aimed to follow the NICU protocol of initiating enteral feeds by 48 hours of life, unless there was a reason for a delay. In practice, the mean hours to first feed was 61 +/− 45 hours, even after excluding those for whom feeds were intentionally held.

“My colleagues were very wrong when they said that we were following the protocol to the T,” said Dr. Marinelli, who is director of lactation support services at the hospital.

The problem, said Dr. Marinelli, is that babies born overnight may be well into their third day of life before rounds are made, and feeds are ordered and initiated.

The hospital has a strong breastfeeding culture, and of the 32 babies, only three of their mothers refused to try expressing milk. Another six tried without success or stopped for medical reasons.

The diets of 17 of the babies (53%) were at least 99% their mother's own milk. Of the four babies who received donor milk, one got 100% donor milk, one got 51%, one got 50%, and one got 21%, with the remainder of their milk coming from their mothers. Six babies fed on at least 99% formula, and six received a mixture of formula and their mother's milk.

Overall, the mothers were able to provide an average of 85% of the milk their babies needed. The babies in this study consumed an average of 74.2 ounces of donor milk and 523.3 ounces of formula. If all the babies who needed to supplement their mother's milk got donor milk, they might need 1,200 ounces a year, which at $4.50 per ounce would cost $5,400, the researchers estimated.

Dr. Marinelli and her colleagues at Connecticut Children's Medical Center estimated that the total cost to the hospital would be about $38,448 per year. Arguing that human milk has the potential to save the hospital much greater costs because healthier babies would need less care, they were able to convince administrators to make human milk the standard of care for babies born either weighing less than 1,800 g or at 34 weeks' gestational age, starting Aug. 1, 2010.

Dr. Marinelli said that donor milk is safe because donors are screened, and the milk is tested much in the same way that blood donations are screened and tested. But in addition, the milk is pasteurized. “There's never been an untoward effect,” she said. “It's cost effective, and it's life saving.”

Major Finding: Thirty-two VLBW babies consumed an average of 523.3 ounces of formula and 74.2 ounces of donor milk over a period of 6 months. If all the babies who needed to supplement their mother's milk got donor milk, they might need 1,200 ounces a year, and at $4.50 per ounce, the researchers extrapolated an annual cost of $5,400 per year.

Data Source: Analysis of data on 32 VLBW babies at one hospital.

Disclosures: Dr. Marinelli said she had nothing to disclose.

SAN FRANCISCO — Providing donor milk to infants with very low birth weights is proving both inexpensive and practical, according to researchers from the University of Connecticut.

“You save money, and you end up with healthier babies,” said Dr. Kathleen A. Marinelli, a neonatologist in the department of pediatrics at the university.

She estimated the cost of supplementing a very-low-birth-weight (VLBW) baby's diet with donor milk at $5,400 per year per infant.

Many previous studies have established the benefits of human milk for VLBW babies, and recent research has shown that donor milk is a healthier supplement than is formula when mothers can't provide all the milk their own children need.

One study of 207 extremely premature infants weighing 500-1,250 g at birth showed a 50% reduction in necrotizing enterocolitis and an almost 90% reduction in surgical necrotizing enterocolitis in infants whose mothers' milk was supplemented with human donor milk, compared with those whose mothers' milk was supplemented with bovine formula (J. Pediatr. 2010;156:562-7.e1).

Many mothers of VLBW infants can't produce all the milk their babies need. In particular, many can't express colostrum for the first few days.

To determine the practicality of supplementing the diets of these children with donor milk, Dr. Marinelli and colleagues at the Connecticut Children's Medical Center, Hartford, studied 32 babies who were born at the hospital with weights of less than 1,500 g for a period of 6 months.

They aimed to follow the NICU protocol of initiating enteral feeds by 48 hours of life, unless there was a reason for a delay. In practice, the mean hours to first feed was 61 +/− 45 hours, even after excluding those for whom feeds were intentionally held.

“My colleagues were very wrong when they said that we were following the protocol to the T,” said Dr. Marinelli, who is director of lactation support services at the hospital.

The problem, said Dr. Marinelli, is that babies born overnight may be well into their third day of life before rounds are made, and feeds are ordered and initiated.

The hospital has a strong breastfeeding culture, and of the 32 babies, only three of their mothers refused to try expressing milk. Another six tried without success or stopped for medical reasons.

The diets of 17 of the babies (53%) were at least 99% their mother's own milk. Of the four babies who received donor milk, one got 100% donor milk, one got 51%, one got 50%, and one got 21%, with the remainder of their milk coming from their mothers. Six babies fed on at least 99% formula, and six received a mixture of formula and their mother's milk.

Overall, the mothers were able to provide an average of 85% of the milk their babies needed. The babies in this study consumed an average of 74.2 ounces of donor milk and 523.3 ounces of formula. If all the babies who needed to supplement their mother's milk got donor milk, they might need 1,200 ounces a year, which at $4.50 per ounce would cost $5,400, the researchers estimated.

Dr. Marinelli and her colleagues at Connecticut Children's Medical Center estimated that the total cost to the hospital would be about $38,448 per year. Arguing that human milk has the potential to save the hospital much greater costs because healthier babies would need less care, they were able to convince administrators to make human milk the standard of care for babies born either weighing less than 1,800 g or at 34 weeks' gestational age, starting Aug. 1, 2010.

Dr. Marinelli said that donor milk is safe because donors are screened, and the milk is tested much in the same way that blood donations are screened and tested. But in addition, the milk is pasteurized. “There's never been an untoward effect,” she said. “It's cost effective, and it's life saving.”

Major Finding: Thirty-two VLBW babies consumed an average of 523.3 ounces of formula and 74.2 ounces of donor milk over a period of 6 months. If all the babies who needed to supplement their mother's milk got donor milk, they might need 1,200 ounces a year, and at $4.50 per ounce, the researchers extrapolated an annual cost of $5,400 per year.

Data Source: Analysis of data on 32 VLBW babies at one hospital.

Disclosures: Dr. Marinelli said she had nothing to disclose.

SAN FRANCISCO — Providing donor milk to infants with very low birth weights is proving both inexpensive and practical, according to researchers from the University of Connecticut.

“You save money, and you end up with healthier babies,” said Dr. Kathleen A. Marinelli, a neonatologist in the department of pediatrics at the university.

She estimated the cost of supplementing a very-low-birth-weight (VLBW) baby's diet with donor milk at $5,400 per year per infant.

Many previous studies have established the benefits of human milk for VLBW babies, and recent research has shown that donor milk is a healthier supplement than is formula when mothers can't provide all the milk their own children need.

One study of 207 extremely premature infants weighing 500-1,250 g at birth showed a 50% reduction in necrotizing enterocolitis and an almost 90% reduction in surgical necrotizing enterocolitis in infants whose mothers' milk was supplemented with human donor milk, compared with those whose mothers' milk was supplemented with bovine formula (J. Pediatr. 2010;156:562-7.e1).

Many mothers of VLBW infants can't produce all the milk their babies need. In particular, many can't express colostrum for the first few days.

To determine the practicality of supplementing the diets of these children with donor milk, Dr. Marinelli and colleagues at the Connecticut Children's Medical Center, Hartford, studied 32 babies who were born at the hospital with weights of less than 1,500 g for a period of 6 months.

They aimed to follow the NICU protocol of initiating enteral feeds by 48 hours of life, unless there was a reason for a delay. In practice, the mean hours to first feed was 61 +/− 45 hours, even after excluding those for whom feeds were intentionally held.

“My colleagues were very wrong when they said that we were following the protocol to the T,” said Dr. Marinelli, who is director of lactation support services at the hospital.

The problem, said Dr. Marinelli, is that babies born overnight may be well into their third day of life before rounds are made, and feeds are ordered and initiated.

The hospital has a strong breastfeeding culture, and of the 32 babies, only three of their mothers refused to try expressing milk. Another six tried without success or stopped for medical reasons.

The diets of 17 of the babies (53%) were at least 99% their mother's own milk. Of the four babies who received donor milk, one got 100% donor milk, one got 51%, one got 50%, and one got 21%, with the remainder of their milk coming from their mothers. Six babies fed on at least 99% formula, and six received a mixture of formula and their mother's milk.

Overall, the mothers were able to provide an average of 85% of the milk their babies needed. The babies in this study consumed an average of 74.2 ounces of donor milk and 523.3 ounces of formula. If all the babies who needed to supplement their mother's milk got donor milk, they might need 1,200 ounces a year, which at $4.50 per ounce would cost $5,400, the researchers estimated.

Dr. Marinelli and her colleagues at Connecticut Children's Medical Center estimated that the total cost to the hospital would be about $38,448 per year. Arguing that human milk has the potential to save the hospital much greater costs because healthier babies would need less care, they were able to convince administrators to make human milk the standard of care for babies born either weighing less than 1,800 g or at 34 weeks' gestational age, starting Aug. 1, 2010.

Dr. Marinelli said that donor milk is safe because donors are screened, and the milk is tested much in the same way that blood donations are screened and tested. But in addition, the milk is pasteurized. “There's never been an untoward effect,” she said. “It's cost effective, and it's life saving.”

The new American Academy of Pediatrics guidelines for iron supplementation are drawing criticism from experts who say they go too far – and others who say they don't go far enough.

The AAP's Section on Breastfeeding wants to strike the recommendation that all breastfed children should get iron supplements. “No one has shown any benefit to doing that,” said section chairperson, Dr. Richard J. Schanler, professor of pediatrics at Albert Einstein College of Medicine, New York.

By contrast, the AAP's local nutrition committee for a New York chapter would like to see a recommendation of iron supplements for all toddlers.

The guidelines, “Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0–3 Years of Age),” were published in November (Pediatrics 2010;126:1040-50), after the AAP's Committee on Nutrition spent 5 years soliciting comments from a wide range of sources, including the Section on Breastfeeding, said Dr. Frank R. Greer, an author of the guidelines (“AAP: Assess Hemoglobin Levels In All Infants at 12 Months,”

“It's not without controversy,” said Dr. Greer, professor of pediatrics at the University of Wisconsin, Madison. But he argued that the guidelines offer the most practical course for pediatricians advising parents of young children.

The debate over exclusively breastfed infants focuses on 2 months – the interval between 4 and 6 months of age. “Term, healthy infants have sufficient iron for at least the first 4 months of life,” the guidelines state. “Human milk contains very little iron. Exclusively breastfed infants are at increasing risk of ID [iron deficiency] after 4 completed months of age.” They call for 1 mg/kg per day of oral iron supplements beginning at 4 months of age until the babies begin eating iron-containing foods.

The AAP already recommends that complementary foods containing iron be introduced after 6 months. So the question is whether exclusively breastfed babies should get oral iron drops for the last 2 months before beginning to eat solid foods.

The guidelines acknowledge that the prevalence of iron deficiency among children under 12 months of age in the United States is unknown. But the document cites a double-blind controlled trial showing benefits (J. Pediatr. 2003;143:582-6). Exclusively breastfed infants supplemented with iron between 1 and 6 months of age had higher hemoglobin concentration and higher mean corpuscular volume at 6 months of age; and better visual acuity and higher Bayley Psychomotor Developmental Indices at 13 months, than did children who did not get supplements.

At the very least, supplementing with iron does no harm, argues Dr. Greer. “All the formula-fed babies get iron in their formula,” he said. “Where is the harm to those babies?”

But Dr. Schanler argued that at least one study has found potential risk (J. Nutr. 2002; 132:3249-55). This controlled trial found slower growth among breastfed infants with normal hemoglobin who received iron supplements than those who did not receive supplements.

The two studies, one showing benefits and one showing detriments, are “of the same caliber,” so more research needs to be done, Dr. Schanler said.

“We're talking about millions of children, so you really have to make sure there's enough evidence to make a change,” he said.

In their letter to Pediatrics (published online Oct. 28), the Section on Breastfeeding also faulted Dr. Greer and his colleagues for not discussing the possibility of delayed umbilical cord clamping as an alternative to iron supplementation. In theory, a significant amount of blood flows from the placenta to the newborn infant in the few minutes after birth. “There are data to suggest you increase red blood cell mass that way,” said Dr. Schanler.

“To me, if you're writing guidelines you should at least comment that there's another way to increase iron stores.”

Dr. Greer responded that cord-clamping doesn't concern pediatricians. “That's a great idea,” he said. “But we can't really recommend it if obstetricians don't do it.”

In fact, the idea has not gained traction among obstetricians, said Dr. E. Albert Reece, the John Z. and Akiko K. Bowers Distinguished Professor and dean of the School of Medicine at the University of Maryland, Baltimore.

“I'm not aware of any movement afoot in the obstetrics community to prolong the time before cord clamping,” said Dr. Reece, an ob.gyn. who specializes in maternal-fetal medicine. “The data now is very sparse to show that delayed cord clamping results in any substantial benefit. And even if it did enhance the iron store of the infant initially, the iron store would still decline.”

Dr. Reece said he supports the AAP Committee on Nutrition's recommendation to supplement breastfed infants.

Dr. Alvin Eden, chairperson of the Committee on Nutrition for AAP New York Chapter 2, also supports the national AAP infant supplement guidelines. But Dr. Eden, a clinical professor of pediatrics at Weill Medical College of Cornell University in New York would like to see a recommendation that all toddlers get iron supplements.

The new guidelines recommend that children should be screened for anemia around 12 months of age by measuring hemoglobin concentrations and assessing risk factors associated with iron deficiency or iron deficiency anemia. For children whose hemoglobin level is less than 11 g/dL and in those at high risk of dietary iron deficiency, physicians should also measure serum ferritin (SF) and C-reactive protein (CRP) or reticulocyte hemoglobin (CHr), the guidelines say.

But evaluating the risk factors is difficult because it's hard to know how much iron a child is eating, said Dr. Eden. And measuring SF and CRP or CHr is invasive because these tests require venipuncture. “It's very expensive and a lot of labs are not doing it,” he said.

As a result, Dr. Eden thinks a lot of parents won't get the tests. “It puts the pediatrician in a difficult position. What I have been doing is putting all the toddlers on iron supplements for a year after they switch to solid foods.”

Dr. Greer responded that the recommendation to do the iron deficiency testing only in those toddlers at risk – instead of all toddlers – was already a compromise intended to reduce the expense and invasiveness. And he thinks it would be even harder to get all toddlers to take iron supplements than to do the testing for iron deficiency.

So what's next?

“I think we're going to continue having dialogue,” said Dr. Schanler.

Dr. Greer, Dr. Reece, and Dr. Eden said they had no conflicts of interest to disclose.

The new American Academy of Pediatrics guidelines for iron supplementation are drawing criticism from experts who say they go too far – and others who say they don't go far enough.

The AAP's Section on Breastfeeding wants to strike the recommendation that all breastfed children should get iron supplements. “No one has shown any benefit to doing that,” said section chairperson, Dr. Richard J. Schanler, professor of pediatrics at Albert Einstein College of Medicine, New York.

By contrast, the AAP's local nutrition committee for a New York chapter would like to see a recommendation of iron supplements for all toddlers.

The guidelines, “Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0–3 Years of Age),” were published in November (Pediatrics 2010;126:1040-50), after the AAP's Committee on Nutrition spent 5 years soliciting comments from a wide range of sources, including the Section on Breastfeeding, said Dr. Frank R. Greer, an author of the guidelines (“AAP: Assess Hemoglobin Levels In All Infants at 12 Months,”

“It's not without controversy,” said Dr. Greer, professor of pediatrics at the University of Wisconsin, Madison. But he argued that the guidelines offer the most practical course for pediatricians advising parents of young children.

The debate over exclusively breastfed infants focuses on 2 months – the interval between 4 and 6 months of age. “Term, healthy infants have sufficient iron for at least the first 4 months of life,” the guidelines state. “Human milk contains very little iron. Exclusively breastfed infants are at increasing risk of ID [iron deficiency] after 4 completed months of age.” They call for 1 mg/kg per day of oral iron supplements beginning at 4 months of age until the babies begin eating iron-containing foods.

The AAP already recommends that complementary foods containing iron be introduced after 6 months. So the question is whether exclusively breastfed babies should get oral iron drops for the last 2 months before beginning to eat solid foods.

The guidelines acknowledge that the prevalence of iron deficiency among children under 12 months of age in the United States is unknown. But the document cites a double-blind controlled trial showing benefits (J. Pediatr. 2003;143:582-6). Exclusively breastfed infants supplemented with iron between 1 and 6 months of age had higher hemoglobin concentration and higher mean corpuscular volume at 6 months of age; and better visual acuity and higher Bayley Psychomotor Developmental Indices at 13 months, than did children who did not get supplements.

At the very least, supplementing with iron does no harm, argues Dr. Greer. “All the formula-fed babies get iron in their formula,” he said. “Where is the harm to those babies?”

But Dr. Schanler argued that at least one study has found potential risk (J. Nutr. 2002; 132:3249-55). This controlled trial found slower growth among breastfed infants with normal hemoglobin who received iron supplements than those who did not receive supplements.

The two studies, one showing benefits and one showing detriments, are “of the same caliber,” so more research needs to be done, Dr. Schanler said.

“We're talking about millions of children, so you really have to make sure there's enough evidence to make a change,” he said.

In their letter to Pediatrics (published online Oct. 28), the Section on Breastfeeding also faulted Dr. Greer and his colleagues for not discussing the possibility of delayed umbilical cord clamping as an alternative to iron supplementation. In theory, a significant amount of blood flows from the placenta to the newborn infant in the few minutes after birth. “There are data to suggest you increase red blood cell mass that way,” said Dr. Schanler.

“To me, if you're writing guidelines you should at least comment that there's another way to increase iron stores.”

Dr. Greer responded that cord-clamping doesn't concern pediatricians. “That's a great idea,” he said. “But we can't really recommend it if obstetricians don't do it.”

In fact, the idea has not gained traction among obstetricians, said Dr. E. Albert Reece, the John Z. and Akiko K. Bowers Distinguished Professor and dean of the School of Medicine at the University of Maryland, Baltimore.

“I'm not aware of any movement afoot in the obstetrics community to prolong the time before cord clamping,” said Dr. Reece, an ob.gyn. who specializes in maternal-fetal medicine. “The data now is very sparse to show that delayed cord clamping results in any substantial benefit. And even if it did enhance the iron store of the infant initially, the iron store would still decline.”

Dr. Reece said he supports the AAP Committee on Nutrition's recommendation to supplement breastfed infants.

Dr. Alvin Eden, chairperson of the Committee on Nutrition for AAP New York Chapter 2, also supports the national AAP infant supplement guidelines. But Dr. Eden, a clinical professor of pediatrics at Weill Medical College of Cornell University in New York would like to see a recommendation that all toddlers get iron supplements.

The new guidelines recommend that children should be screened for anemia around 12 months of age by measuring hemoglobin concentrations and assessing risk factors associated with iron deficiency or iron deficiency anemia. For children whose hemoglobin level is less than 11 g/dL and in those at high risk of dietary iron deficiency, physicians should also measure serum ferritin (SF) and C-reactive protein (CRP) or reticulocyte hemoglobin (CHr), the guidelines say.

But evaluating the risk factors is difficult because it's hard to know how much iron a child is eating, said Dr. Eden. And measuring SF and CRP or CHr is invasive because these tests require venipuncture. “It's very expensive and a lot of labs are not doing it,” he said.

As a result, Dr. Eden thinks a lot of parents won't get the tests. “It puts the pediatrician in a difficult position. What I have been doing is putting all the toddlers on iron supplements for a year after they switch to solid foods.”

Dr. Greer responded that the recommendation to do the iron deficiency testing only in those toddlers at risk – instead of all toddlers – was already a compromise intended to reduce the expense and invasiveness. And he thinks it would be even harder to get all toddlers to take iron supplements than to do the testing for iron deficiency.

So what's next?

“I think we're going to continue having dialogue,” said Dr. Schanler.

Dr. Greer, Dr. Reece, and Dr. Eden said they had no conflicts of interest to disclose.

The new American Academy of Pediatrics guidelines for iron supplementation are drawing criticism from experts who say they go too far – and others who say they don't go far enough.

The AAP's Section on Breastfeeding wants to strike the recommendation that all breastfed children should get iron supplements. “No one has shown any benefit to doing that,” said section chairperson, Dr. Richard J. Schanler, professor of pediatrics at Albert Einstein College of Medicine, New York.

By contrast, the AAP's local nutrition committee for a New York chapter would like to see a recommendation of iron supplements for all toddlers.

The guidelines, “Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0–3 Years of Age),” were published in November (Pediatrics 2010;126:1040-50), after the AAP's Committee on Nutrition spent 5 years soliciting comments from a wide range of sources, including the Section on Breastfeeding, said Dr. Frank R. Greer, an author of the guidelines (“AAP: Assess Hemoglobin Levels In All Infants at 12 Months,”

“It's not without controversy,” said Dr. Greer, professor of pediatrics at the University of Wisconsin, Madison. But he argued that the guidelines offer the most practical course for pediatricians advising parents of young children.

The debate over exclusively breastfed infants focuses on 2 months – the interval between 4 and 6 months of age. “Term, healthy infants have sufficient iron for at least the first 4 months of life,” the guidelines state. “Human milk contains very little iron. Exclusively breastfed infants are at increasing risk of ID [iron deficiency] after 4 completed months of age.” They call for 1 mg/kg per day of oral iron supplements beginning at 4 months of age until the babies begin eating iron-containing foods.

The AAP already recommends that complementary foods containing iron be introduced after 6 months. So the question is whether exclusively breastfed babies should get oral iron drops for the last 2 months before beginning to eat solid foods.

The guidelines acknowledge that the prevalence of iron deficiency among children under 12 months of age in the United States is unknown. But the document cites a double-blind controlled trial showing benefits (J. Pediatr. 2003;143:582-6). Exclusively breastfed infants supplemented with iron between 1 and 6 months of age had higher hemoglobin concentration and higher mean corpuscular volume at 6 months of age; and better visual acuity and higher Bayley Psychomotor Developmental Indices at 13 months, than did children who did not get supplements.

At the very least, supplementing with iron does no harm, argues Dr. Greer. “All the formula-fed babies get iron in their formula,” he said. “Where is the harm to those babies?”

But Dr. Schanler argued that at least one study has found potential risk (J. Nutr. 2002; 132:3249-55). This controlled trial found slower growth among breastfed infants with normal hemoglobin who received iron supplements than those who did not receive supplements.

The two studies, one showing benefits and one showing detriments, are “of the same caliber,” so more research needs to be done, Dr. Schanler said.

“We're talking about millions of children, so you really have to make sure there's enough evidence to make a change,” he said.

In their letter to Pediatrics (published online Oct. 28), the Section on Breastfeeding also faulted Dr. Greer and his colleagues for not discussing the possibility of delayed umbilical cord clamping as an alternative to iron supplementation. In theory, a significant amount of blood flows from the placenta to the newborn infant in the few minutes after birth. “There are data to suggest you increase red blood cell mass that way,” said Dr. Schanler.

“To me, if you're writing guidelines you should at least comment that there's another way to increase iron stores.”

Dr. Greer responded that cord-clamping doesn't concern pediatricians. “That's a great idea,” he said. “But we can't really recommend it if obstetricians don't do it.”

In fact, the idea has not gained traction among obstetricians, said Dr. E. Albert Reece, the John Z. and Akiko K. Bowers Distinguished Professor and dean of the School of Medicine at the University of Maryland, Baltimore.

“I'm not aware of any movement afoot in the obstetrics community to prolong the time before cord clamping,” said Dr. Reece, an ob.gyn. who specializes in maternal-fetal medicine. “The data now is very sparse to show that delayed cord clamping results in any substantial benefit. And even if it did enhance the iron store of the infant initially, the iron store would still decline.”

Dr. Reece said he supports the AAP Committee on Nutrition's recommendation to supplement breastfed infants.

Dr. Alvin Eden, chairperson of the Committee on Nutrition for AAP New York Chapter 2, also supports the national AAP infant supplement guidelines. But Dr. Eden, a clinical professor of pediatrics at Weill Medical College of Cornell University in New York would like to see a recommendation that all toddlers get iron supplements.

The new guidelines recommend that children should be screened for anemia around 12 months of age by measuring hemoglobin concentrations and assessing risk factors associated with iron deficiency or iron deficiency anemia. For children whose hemoglobin level is less than 11 g/dL and in those at high risk of dietary iron deficiency, physicians should also measure serum ferritin (SF) and C-reactive protein (CRP) or reticulocyte hemoglobin (CHr), the guidelines say.

But evaluating the risk factors is difficult because it's hard to know how much iron a child is eating, said Dr. Eden. And measuring SF and CRP or CHr is invasive because these tests require venipuncture. “It's very expensive and a lot of labs are not doing it,” he said.

As a result, Dr. Eden thinks a lot of parents won't get the tests. “It puts the pediatrician in a difficult position. What I have been doing is putting all the toddlers on iron supplements for a year after they switch to solid foods.”

Dr. Greer responded that the recommendation to do the iron deficiency testing only in those toddlers at risk – instead of all toddlers – was already a compromise intended to reduce the expense and invasiveness. And he thinks it would be even harder to get all toddlers to take iron supplements than to do the testing for iron deficiency.

So what's next?

“I think we're going to continue having dialogue,” said Dr. Schanler.

Dr. Greer, Dr. Reece, and Dr. Eden said they had no conflicts of interest to disclose.

The new American Academy of Pediatrics guidelines for iron supplementation are drawing criticism from experts who say they go too far – and others who say they don't go far enough.

The AAP's Section on Breastfeeding wants to strike the recommendation that all breastfed children should get iron supplements. “No one has shown any benefit to doing that,” said section chairperson, Dr. Richard J. Schanler, professor of pediatrics at Albert Einstein College of Medicine, N.Y.

By contrast, the AAP's local nutrition committee for a New York chapter would like to see a recommendation of iron supplements for all toddlers.

The guidelines, “Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age),” were published in November (Pediatrics 2010;126:1040-50), after the AAP's Committee on Nutrition spent 5 years soliciting comments from a wide range of sources, including the Section on Breastfeeding, said Dr. Frank R. Greer, an author of the guidelines.

“It's not without controversy,” said Dr. Greer, professor of pediatrics at the University of Wisconsin, Madison. But he argued that the guidelines offer the most practical course for pediatricians advising parents of young children.

The debate over exclusively breastfed infants focuses on 2 months – the interval between 4 and 6 months of age. “Term, healthy infants have sufficient iron for at least the first 4 months of life,” the guidelines state. “Human milk contains very little iron. Exclusively breastfed infants are at increasing risk of ID [iron deficiency] after 4 completed months of age.” They call for 1 mg/kg per day of oral iron supplements beginning at 4 months of age until the babies begin eating iron-containing foods.

The AAP already recommends that complementary foods containing iron be introduced after 6 months. So the question is whether exclusively breastfed babies should get oral iron drops for the last 2 months before beginning to eat solid foods.

The guidelines acknowledge that the prevalence of iron deficiency among children under 12 months of age in the United States is unknown. But the document cites a double-blind controlled trial showing benefits (J. Pediatr. 2003;143:582-6). Exclusively breastfed infants supplemented with iron between 1 and 6 months of age had higher hemoglobin concentration and higher mean corpuscular volume at 6 months of age; and better visual acuity and higher Bayley Psychomotor Developmental Indices at 13 months, than did children who did not get supplements.

At the very least, supplementing with iron does no harm, argues Dr. Greer. “All the formula-fed babies get iron in their formula,” he said. “Where is the harm to those babies?”

But Dr. Schanler argued that at least one study has found potential risk (J. Nutr. 2002;132:3249-55). This controlled trial found slower growth among breastfed infants with normal hemoglobin who received iron supplements than those who did not receive supplements.

The two studies, one showing benefits and one showing detriments, are “of the same caliber,” so more research needs to be done, Dr. Schanler said. “We're talking about millions of children, so you really have to make sure there's enough evidence to make a change,” he said.

In its letter to Pediatrics (published online Oct. 28), the Section on Breastfeeding also faulted Dr. Greer and his colleagues for not discussing the possibility of delayed umbilical cord clamping as an alternative to iron supplementation. In theory, a significant amount of blood flows from the placenta to the newborn infant in the few minutes after birth. “There are data to suggest you increase red blood cell mass that way,” said Dr. Schanler. “To me, if you're writing guidelines you should at least comment that there's another way to increase iron stores.”

Dr. Greer said cord-clamping doesn't concern pediatricians. “That's a great idea,” he said. “But we can't really recommend it if obstetricians don't do it.”

In fact, the idea has not gained traction among obstetricians, said Dr. E. Albert Reece, the John Z. and Akiko K. Bowers Distinguished Professor and dean of the School of Medicine at the University of Maryland, Baltimore.

“I'm not aware of any movement afoot in the obstetrics community to prolong the time before cord clamping,” said Dr. Reece, an ob.gyn. who specializes in maternal-fetal medicine. “The data now is very sparse to show that delayed cord clamping results in any substantial benefit.” Dr. Reece said he supports the AAP Committee on Nutrition's recommendation to supplement breastfed infants.

Dr. Alvin Eden, chairperson of the Committee on Nutrition for AAP New York Chapter 2, also supports the national AAP infant supplement guidelines. But Dr. Eden, a clinical professor of pediatrics at Weill Medical College of Cornell University in New York, would like to see a recommendation that all toddlers get iron supplements.

The new guidelines recommend that children should be screened for anemia around 12 months of age by measuring hemoglobin concentrations and assessing risk factors associated with iron deficiency or iron deficiency anemia. For children whose hemoglobin level is less than 11 g/dL and in those at high risk of dietary iron deficiency, physicians should also measure serum ferritin (SF) and C-reactive protein (CRP) or reticulocyte hemoglobin (CHr), the guidelines say.

But evaluating the risk factors is difficult because it's hard to know how much iron a child is eating, said Dr. Eden. And measuring SF and CRP or CHr is invasive because these tests require venipuncture. “It's very expensive and a lot of labs are not doing it,” he said. As a result, a lot of parents won't get the tests. “It puts the pediatrician in a difficult position. What I have been doing is putting all the toddlers on iron supplements for a year after they switch to solid foods.”

Dr. Greer responded that the recommendation to do the iron deficiency testing only in those toddlers at risk – instead of all toddlers – was already a compromise intended to reduce the expense and invasiveness. And he thinks it would be even harder to get all toddlers to take iron supplements than to do the testing for iron deficiency.

Dr. Greer, Dr. Reece, and Dr. Eden said they had no relevant disclosures.

The new American Academy of Pediatrics guidelines for iron supplementation are drawing criticism from experts who say they go too far – and others who say they don't go far enough.

The AAP's Section on Breastfeeding wants to strike the recommendation that all breastfed children should get iron supplements. “No one has shown any benefit to doing that,” said section chairperson, Dr. Richard J. Schanler, professor of pediatrics at Albert Einstein College of Medicine, N.Y.

By contrast, the AAP's local nutrition committee for a New York chapter would like to see a recommendation of iron supplements for all toddlers.

The guidelines, “Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age),” were published in November (Pediatrics 2010;126:1040-50), after the AAP's Committee on Nutrition spent 5 years soliciting comments from a wide range of sources, including the Section on Breastfeeding, said Dr. Frank R. Greer, an author of the guidelines.

“It's not without controversy,” said Dr. Greer, professor of pediatrics at the University of Wisconsin, Madison. But he argued that the guidelines offer the most practical course for pediatricians advising parents of young children.

The debate over exclusively breastfed infants focuses on 2 months – the interval between 4 and 6 months of age. “Term, healthy infants have sufficient iron for at least the first 4 months of life,” the guidelines state. “Human milk contains very little iron. Exclusively breastfed infants are at increasing risk of ID [iron deficiency] after 4 completed months of age.” They call for 1 mg/kg per day of oral iron supplements beginning at 4 months of age until the babies begin eating iron-containing foods.

The AAP already recommends that complementary foods containing iron be introduced after 6 months. So the question is whether exclusively breastfed babies should get oral iron drops for the last 2 months before beginning to eat solid foods.

The guidelines acknowledge that the prevalence of iron deficiency among children under 12 months of age in the United States is unknown. But the document cites a double-blind controlled trial showing benefits (J. Pediatr. 2003;143:582-6). Exclusively breastfed infants supplemented with iron between 1 and 6 months of age had higher hemoglobin concentration and higher mean corpuscular volume at 6 months of age; and better visual acuity and higher Bayley Psychomotor Developmental Indices at 13 months, than did children who did not get supplements.

At the very least, supplementing with iron does no harm, argues Dr. Greer. “All the formula-fed babies get iron in their formula,” he said. “Where is the harm to those babies?”

But Dr. Schanler argued that at least one study has found potential risk (J. Nutr. 2002;132:3249-55). This controlled trial found slower growth among breastfed infants with normal hemoglobin who received iron supplements than those who did not receive supplements.

The two studies, one showing benefits and one showing detriments, are “of the same caliber,” so more research needs to be done, Dr. Schanler said. “We're talking about millions of children, so you really have to make sure there's enough evidence to make a change,” he said.

In its letter to Pediatrics (published online Oct. 28), the Section on Breastfeeding also faulted Dr. Greer and his colleagues for not discussing the possibility of delayed umbilical cord clamping as an alternative to iron supplementation. In theory, a significant amount of blood flows from the placenta to the newborn infant in the few minutes after birth. “There are data to suggest you increase red blood cell mass that way,” said Dr. Schanler. “To me, if you're writing guidelines you should at least comment that there's another way to increase iron stores.”

Dr. Greer said cord-clamping doesn't concern pediatricians. “That's a great idea,” he said. “But we can't really recommend it if obstetricians don't do it.”

In fact, the idea has not gained traction among obstetricians, said Dr. E. Albert Reece, the John Z. and Akiko K. Bowers Distinguished Professor and dean of the School of Medicine at the University of Maryland, Baltimore.

“I'm not aware of any movement afoot in the obstetrics community to prolong the time before cord clamping,” said Dr. Reece, an ob.gyn. who specializes in maternal-fetal medicine. “The data now is very sparse to show that delayed cord clamping results in any substantial benefit.” Dr. Reece said he supports the AAP Committee on Nutrition's recommendation to supplement breastfed infants.

Dr. Alvin Eden, chairperson of the Committee on Nutrition for AAP New York Chapter 2, also supports the national AAP infant supplement guidelines. But Dr. Eden, a clinical professor of pediatrics at Weill Medical College of Cornell University in New York, would like to see a recommendation that all toddlers get iron supplements.

The new guidelines recommend that children should be screened for anemia around 12 months of age by measuring hemoglobin concentrations and assessing risk factors associated with iron deficiency or iron deficiency anemia. For children whose hemoglobin level is less than 11 g/dL and in those at high risk of dietary iron deficiency, physicians should also measure serum ferritin (SF) and C-reactive protein (CRP) or reticulocyte hemoglobin (CHr), the guidelines say.

But evaluating the risk factors is difficult because it's hard to know how much iron a child is eating, said Dr. Eden. And measuring SF and CRP or CHr is invasive because these tests require venipuncture. “It's very expensive and a lot of labs are not doing it,” he said. As a result, a lot of parents won't get the tests. “It puts the pediatrician in a difficult position. What I have been doing is putting all the toddlers on iron supplements for a year after they switch to solid foods.”

Dr. Greer responded that the recommendation to do the iron deficiency testing only in those toddlers at risk – instead of all toddlers – was already a compromise intended to reduce the expense and invasiveness. And he thinks it would be even harder to get all toddlers to take iron supplements than to do the testing for iron deficiency.

Dr. Greer, Dr. Reece, and Dr. Eden said they had no relevant disclosures.

The new American Academy of Pediatrics guidelines for iron supplementation are drawing criticism from experts who say they go too far – and others who say they don't go far enough.

The AAP's Section on Breastfeeding wants to strike the recommendation that all breastfed children should get iron supplements. “No one has shown any benefit to doing that,” said section chairperson, Dr. Richard J. Schanler, professor of pediatrics at Albert Einstein College of Medicine, N.Y.

By contrast, the AAP's local nutrition committee for a New York chapter would like to see a recommendation of iron supplements for all toddlers.

The guidelines, “Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age),” were published in November (Pediatrics 2010;126:1040-50), after the AAP's Committee on Nutrition spent 5 years soliciting comments from a wide range of sources, including the Section on Breastfeeding, said Dr. Frank R. Greer, an author of the guidelines.

“It's not without controversy,” said Dr. Greer, professor of pediatrics at the University of Wisconsin, Madison. But he argued that the guidelines offer the most practical course for pediatricians advising parents of young children.

The debate over exclusively breastfed infants focuses on 2 months – the interval between 4 and 6 months of age. “Term, healthy infants have sufficient iron for at least the first 4 months of life,” the guidelines state. “Human milk contains very little iron. Exclusively breastfed infants are at increasing risk of ID [iron deficiency] after 4 completed months of age.” They call for 1 mg/kg per day of oral iron supplements beginning at 4 months of age until the babies begin eating iron-containing foods.

The AAP already recommends that complementary foods containing iron be introduced after 6 months. So the question is whether exclusively breastfed babies should get oral iron drops for the last 2 months before beginning to eat solid foods.

The guidelines acknowledge that the prevalence of iron deficiency among children under 12 months of age in the United States is unknown. But the document cites a double-blind controlled trial showing benefits (J. Pediatr. 2003;143:582-6). Exclusively breastfed infants supplemented with iron between 1 and 6 months of age had higher hemoglobin concentration and higher mean corpuscular volume at 6 months of age; and better visual acuity and higher Bayley Psychomotor Developmental Indices at 13 months, than did children who did not get supplements.

At the very least, supplementing with iron does no harm, argues Dr. Greer. “All the formula-fed babies get iron in their formula,” he said. “Where is the harm to those babies?”

But Dr. Schanler argued that at least one study has found potential risk (J. Nutr. 2002;132:3249-55). This controlled trial found slower growth among breastfed infants with normal hemoglobin who received iron supplements than those who did not receive supplements.

The two studies, one showing benefits and one showing detriments, are “of the same caliber,” so more research needs to be done, Dr. Schanler said. “We're talking about millions of children, so you really have to make sure there's enough evidence to make a change,” he said.

In its letter to Pediatrics (published online Oct. 28), the Section on Breastfeeding also faulted Dr. Greer and his colleagues for not discussing the possibility of delayed umbilical cord clamping as an alternative to iron supplementation. In theory, a significant amount of blood flows from the placenta to the newborn infant in the few minutes after birth. “There are data to suggest you increase red blood cell mass that way,” said Dr. Schanler. “To me, if you're writing guidelines you should at least comment that there's another way to increase iron stores.”

Dr. Greer said cord-clamping doesn't concern pediatricians. “That's a great idea,” he said. “But we can't really recommend it if obstetricians don't do it.”

In fact, the idea has not gained traction among obstetricians, said Dr. E. Albert Reece, the John Z. and Akiko K. Bowers Distinguished Professor and dean of the School of Medicine at the University of Maryland, Baltimore.

“I'm not aware of any movement afoot in the obstetrics community to prolong the time before cord clamping,” said Dr. Reece, an ob.gyn. who specializes in maternal-fetal medicine. “The data now is very sparse to show that delayed cord clamping results in any substantial benefit.” Dr. Reece said he supports the AAP Committee on Nutrition's recommendation to supplement breastfed infants.

Dr. Alvin Eden, chairperson of the Committee on Nutrition for AAP New York Chapter 2, also supports the national AAP infant supplement guidelines. But Dr. Eden, a clinical professor of pediatrics at Weill Medical College of Cornell University in New York, would like to see a recommendation that all toddlers get iron supplements.

The new guidelines recommend that children should be screened for anemia around 12 months of age by measuring hemoglobin concentrations and assessing risk factors associated with iron deficiency or iron deficiency anemia. For children whose hemoglobin level is less than 11 g/dL and in those at high risk of dietary iron deficiency, physicians should also measure serum ferritin (SF) and C-reactive protein (CRP) or reticulocyte hemoglobin (CHr), the guidelines say.

But evaluating the risk factors is difficult because it's hard to know how much iron a child is eating, said Dr. Eden. And measuring SF and CRP or CHr is invasive because these tests require venipuncture. “It's very expensive and a lot of labs are not doing it,” he said. As a result, a lot of parents won't get the tests. “It puts the pediatrician in a difficult position. What I have been doing is putting all the toddlers on iron supplements for a year after they switch to solid foods.”

Dr. Greer responded that the recommendation to do the iron deficiency testing only in those toddlers at risk – instead of all toddlers – was already a compromise intended to reduce the expense and invasiveness. And he thinks it would be even harder to get all toddlers to take iron supplements than to do the testing for iron deficiency.

Dr. Greer, Dr. Reece, and Dr. Eden said they had no relevant disclosures.

SAN FRANCISCO — It's hard to grow up in an orphanage – literally. Small stature figures prominently on a growing list of problems that children adopted from abroad are bringing to the United States, according to two adoption specialists.

“More children are being placed in-country,” said Dr. Elaine Schulte, medical director of the International Adoption Program at the Cleveland Clinic Children's Hospital, one of two speakers who outlined current trends in international adoption at the meeting. “Fewer healthy children are available for international adoption, and families are pushed to accept sicker children.”

The number of foreign adoptions to the United States has dropped roughly in half from 2004 to 2009, when it reached 12,753, according to figures from the U.S. Department of State cited by Dr. Schulte. Those children available are more likely to come with serious medical problems. Among the most common are cleft lip and palate, congenital heart disease, Down syndrome, orthopedic problems, amniotic band deformities, and infectious disease such as hepatitis B and C, and HIV.

Only 20% of internationally adopted children have no special medical or developmental issues; in 60%, these problems are mild to moderate and in the rest, severe, Dr. Schulte said.

Even before birth, most of these children suffer from their mother's substance exposures, malnutrition, or stress. After birth, some live through periods of abandonment before being taken into an orphanage.

When they arrive, they often face further malnutrition, abuse, and neglect because even well-intentioned caregivers don't have all the resources the children need, Dr. Schulte said. “These kids don't get talked to,” she said, displaying a photograph of children confined in rows of metal cribs in a barren room. “They lie in bed staring at the ceiling.”

Children coming from foster care generally fare better, but they may have changed homes frequently, leaving them with fear of abandonment.

Families who want to adopt get very little information about the children's backgrounds and health, and are getting even less time than in the past to decide whether to take these children home.

The adoption process itself can lead to health issues. The adopting families may encounter infectious diseases in the general population of the child's country, and they may be infected by the child they are adopting. “I always remind them that they have to take care of themselves,” said Dr. Schulte, the mother of two children adopted from China. “What are you going to do if you get sick, and you have to take care of the child?”

For example, 106 out of 100,000 children adopted from abroad carry hepatitis A, compared with 1 in 100,000 in the general population, she said. So the Centers for Disease Control and Prevention now recommends vaccination for anyone who will have close contact with a child arriving from a country with endemic hepatitis A. She also recommended hepatitis B immunization.

With such precautions in mind, the pediatrician should begin counseling the family before the adoption. A physician can help the family interpret whatever health records are available and formulate more questions. Dr. Schulte gave the example of a child whose photograph suggested fetal alcohol syndrome.

The physician also can prepare the family with community resources, such as a referral to an adoption specialist. (The American Academy of Pediatrics has a directory of such specialists.)

Physicians should schedule their first visits with adopted children a week or two after the children arrive home. Sooner than that, the parents will be too exhausted and will not have had time to closely observe their new children. Dr. Schulte advised allowing at least 30 minutes for the appointment, because it's so important to carefully examine the child and query the parents. The visit can be billed as a 99205 E/M.

The second speaker, Dr. Sarah H. Springer, medical director of the International Adoption Health Services of Western Pennsylvania, recommended a wide range of lab tests, including a CBC, lead level, stool test for ova and parasite (O&P) (3), rapid plasma regain (RPR) or VDRL (Venereal Disease Research Laboratory) tests for syphilis, hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HbsAb), hepatitis B core antibody (HbcAb), hepatitis C virus (HCV), HIV-1 and HIV-2, a tuberculin skin test (PPD), or an interferon gamma release assay (IGRA) test if the child is older than 5 years of age. These should be rechecked after 6 months, because some diseases take that long to seroconvert.

Whatever immunization records the child brings are unlikely to meet the AAP and CDC standards. “You can't take anything you get from another country at face value,” said Dr. Springer, also of Kids Plus Pediatrics at the University of Pittsburgh Medical Center. One increasingly common exception is immunizations supervised by the U.S. State Department. Even if records do meet standards, you should check titers.

Otherwise, you'll often have to start from scratch, using the Red Book catch-up schedule. Note, however, that there is no pertussis coverage for children aged 7-11 years. One alternative is to use Tdap off-label. “You sometimes have to fight with the insurance company,” Dr. Springer said. “They say, 'You gave it at the wrong age.' And you say, 'Would you rather pay for pertussis?'”

Among the common psychosocial issues likely to crop up in this visit are the following:

▸ Malnourished youngsters may hide food in their pockets, their beds, or even their cheeks. They also may eat ravenously. Dr. Schulte's advice: Let them have as much food as they want so that they will lose their fear of scarcity.

▸ Some children are affectionate with everyone because they are so starved for attention. They must learn to distinguish between strangers and family.

▸ Some are stubborn or angry, testing to see whether their new families really want to keep them. Parents must simply insist that they will always be there for these children.

▸ Other children may cling to one parent, crying uncontrollably if left for even a minute. Dr. Schulte advised helping these children by playing with them on the floor until they let go, then getting up to leave, promising to return and fulfilling the promise each time. Caregivers can start with separations of a couple of minutes, then gradually increase the interval.

▸ Adopted children may not sleep well. Because they often fear abandonment, Dr. Schulte advised against using “cry-it-out” technique to teach them good sleep patterns.

▸ Many children rock themselves or display other self-stimulating behavior which they embraced because they didn't get any other stimulation.

▸ Internationally adopted kids have elevated rates of schizophrenia, bipolar disease, fetal alcohol syndrome, attention-deficit/hyperactivity disorder (ADHD), and a host of other mental illnesses.

So after that first visit, see the children often. Many will grow swiftly, catching up to their normal height, overcoming emotional challenges, and recovering from illnesses. Others will need years of special education and other support.

Dr. Springer and Dr. Schulte said they had no conflicts of interest to report, but they did discuss an unapproved/investigative use of the Tdap vaccine.

SAN FRANCISCO — It's hard to grow up in an orphanage – literally. Small stature figures prominently on a growing list of problems that children adopted from abroad are bringing to the United States, according to two adoption specialists.

“More children are being placed in-country,” said Dr. Elaine Schulte, medical director of the International Adoption Program at the Cleveland Clinic Children's Hospital, one of two speakers who outlined current trends in international adoption at the meeting. “Fewer healthy children are available for international adoption, and families are pushed to accept sicker children.”

The number of foreign adoptions to the United States has dropped roughly in half from 2004 to 2009, when it reached 12,753, according to figures from the U.S. Department of State cited by Dr. Schulte. Those children available are more likely to come with serious medical problems. Among the most common are cleft lip and palate, congenital heart disease, Down syndrome, orthopedic problems, amniotic band deformities, and infectious disease such as hepatitis B and C, and HIV.

Only 20% of internationally adopted children have no special medical or developmental issues; in 60%, these problems are mild to moderate and in the rest, severe, Dr. Schulte said.

Even before birth, most of these children suffer from their mother's substance exposures, malnutrition, or stress. After birth, some live through periods of abandonment before being taken into an orphanage.

When they arrive, they often face further malnutrition, abuse, and neglect because even well-intentioned caregivers don't have all the resources the children need, Dr. Schulte said. “These kids don't get talked to,” she said, displaying a photograph of children confined in rows of metal cribs in a barren room. “They lie in bed staring at the ceiling.”

Children coming from foster care generally fare better, but they may have changed homes frequently, leaving them with fear of abandonment.

Families who want to adopt get very little information about the children's backgrounds and health, and are getting even less time than in the past to decide whether to take these children home.

The adoption process itself can lead to health issues. The adopting families may encounter infectious diseases in the general population of the child's country, and they may be infected by the child they are adopting. “I always remind them that they have to take care of themselves,” said Dr. Schulte, the mother of two children adopted from China. “What are you going to do if you get sick, and you have to take care of the child?”

For example, 106 out of 100,000 children adopted from abroad carry hepatitis A, compared with 1 in 100,000 in the general population, she said. So the Centers for Disease Control and Prevention now recommends vaccination for anyone who will have close contact with a child arriving from a country with endemic hepatitis A. She also recommended hepatitis B immunization.

With such precautions in mind, the pediatrician should begin counseling the family before the adoption. A physician can help the family interpret whatever health records are available and formulate more questions. Dr. Schulte gave the example of a child whose photograph suggested fetal alcohol syndrome.

The physician also can prepare the family with community resources, such as a referral to an adoption specialist. (The American Academy of Pediatrics has a directory of such specialists.)

Physicians should schedule their first visits with adopted children a week or two after the children arrive home. Sooner than that, the parents will be too exhausted and will not have had time to closely observe their new children. Dr. Schulte advised allowing at least 30 minutes for the appointment, because it's so important to carefully examine the child and query the parents. The visit can be billed as a 99205 E/M.

The second speaker, Dr. Sarah H. Springer, medical director of the International Adoption Health Services of Western Pennsylvania, recommended a wide range of lab tests, including a CBC, lead level, stool test for ova and parasite (O&P) (3), rapid plasma regain (RPR) or VDRL (Venereal Disease Research Laboratory) tests for syphilis, hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HbsAb), hepatitis B core antibody (HbcAb), hepatitis C virus (HCV), HIV-1 and HIV-2, a tuberculin skin test (PPD), or an interferon gamma release assay (IGRA) test if the child is older than 5 years of age. These should be rechecked after 6 months, because some diseases take that long to seroconvert.

Whatever immunization records the child brings are unlikely to meet the AAP and CDC standards. “You can't take anything you get from another country at face value,” said Dr. Springer, also of Kids Plus Pediatrics at the University of Pittsburgh Medical Center. One increasingly common exception is immunizations supervised by the U.S. State Department. Even if records do meet standards, you should check titers.

Otherwise, you'll often have to start from scratch, using the Red Book catch-up schedule. Note, however, that there is no pertussis coverage for children aged 7-11 years. One alternative is to use Tdap off-label. “You sometimes have to fight with the insurance company,” Dr. Springer said. “They say, 'You gave it at the wrong age.' And you say, 'Would you rather pay for pertussis?'”

Among the common psychosocial issues likely to crop up in this visit are the following:

▸ Malnourished youngsters may hide food in their pockets, their beds, or even their cheeks. They also may eat ravenously. Dr. Schulte's advice: Let them have as much food as they want so that they will lose their fear of scarcity.

▸ Some children are affectionate with everyone because they are so starved for attention. They must learn to distinguish between strangers and family.

▸ Some are stubborn or angry, testing to see whether their new families really want to keep them. Parents must simply insist that they will always be there for these children.

▸ Other children may cling to one parent, crying uncontrollably if left for even a minute. Dr. Schulte advised helping these children by playing with them on the floor until they let go, then getting up to leave, promising to return and fulfilling the promise each time. Caregivers can start with separations of a couple of minutes, then gradually increase the interval.

▸ Adopted children may not sleep well. Because they often fear abandonment, Dr. Schulte advised against using “cry-it-out” technique to teach them good sleep patterns.

▸ Many children rock themselves or display other self-stimulating behavior which they embraced because they didn't get any other stimulation.

▸ Internationally adopted kids have elevated rates of schizophrenia, bipolar disease, fetal alcohol syndrome, attention-deficit/hyperactivity disorder (ADHD), and a host of other mental illnesses.

So after that first visit, see the children often. Many will grow swiftly, catching up to their normal height, overcoming emotional challenges, and recovering from illnesses. Others will need years of special education and other support.

Dr. Springer and Dr. Schulte said they had no conflicts of interest to report, but they did discuss an unapproved/investigative use of the Tdap vaccine.

SAN FRANCISCO — It's hard to grow up in an orphanage – literally. Small stature figures prominently on a growing list of problems that children adopted from abroad are bringing to the United States, according to two adoption specialists.

“More children are being placed in-country,” said Dr. Elaine Schulte, medical director of the International Adoption Program at the Cleveland Clinic Children's Hospital, one of two speakers who outlined current trends in international adoption at the meeting. “Fewer healthy children are available for international adoption, and families are pushed to accept sicker children.”

The number of foreign adoptions to the United States has dropped roughly in half from 2004 to 2009, when it reached 12,753, according to figures from the U.S. Department of State cited by Dr. Schulte. Those children available are more likely to come with serious medical problems. Among the most common are cleft lip and palate, congenital heart disease, Down syndrome, orthopedic problems, amniotic band deformities, and infectious disease such as hepatitis B and C, and HIV.

Only 20% of internationally adopted children have no special medical or developmental issues; in 60%, these problems are mild to moderate and in the rest, severe, Dr. Schulte said.

Even before birth, most of these children suffer from their mother's substance exposures, malnutrition, or stress. After birth, some live through periods of abandonment before being taken into an orphanage.

When they arrive, they often face further malnutrition, abuse, and neglect because even well-intentioned caregivers don't have all the resources the children need, Dr. Schulte said. “These kids don't get talked to,” she said, displaying a photograph of children confined in rows of metal cribs in a barren room. “They lie in bed staring at the ceiling.”

Children coming from foster care generally fare better, but they may have changed homes frequently, leaving them with fear of abandonment.

Families who want to adopt get very little information about the children's backgrounds and health, and are getting even less time than in the past to decide whether to take these children home.

The adoption process itself can lead to health issues. The adopting families may encounter infectious diseases in the general population of the child's country, and they may be infected by the child they are adopting. “I always remind them that they have to take care of themselves,” said Dr. Schulte, the mother of two children adopted from China. “What are you going to do if you get sick, and you have to take care of the child?”

For example, 106 out of 100,000 children adopted from abroad carry hepatitis A, compared with 1 in 100,000 in the general population, she said. So the Centers for Disease Control and Prevention now recommends vaccination for anyone who will have close contact with a child arriving from a country with endemic hepatitis A. She also recommended hepatitis B immunization.

With such precautions in mind, the pediatrician should begin counseling the family before the adoption. A physician can help the family interpret whatever health records are available and formulate more questions. Dr. Schulte gave the example of a child whose photograph suggested fetal alcohol syndrome.

The physician also can prepare the family with community resources, such as a referral to an adoption specialist. (The American Academy of Pediatrics has a directory of such specialists.)

Physicians should schedule their first visits with adopted children a week or two after the children arrive home. Sooner than that, the parents will be too exhausted and will not have had time to closely observe their new children. Dr. Schulte advised allowing at least 30 minutes for the appointment, because it's so important to carefully examine the child and query the parents. The visit can be billed as a 99205 E/M.

The second speaker, Dr. Sarah H. Springer, medical director of the International Adoption Health Services of Western Pennsylvania, recommended a wide range of lab tests, including a CBC, lead level, stool test for ova and parasite (O&P) (3), rapid plasma regain (RPR) or VDRL (Venereal Disease Research Laboratory) tests for syphilis, hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HbsAb), hepatitis B core antibody (HbcAb), hepatitis C virus (HCV), HIV-1 and HIV-2, a tuberculin skin test (PPD), or an interferon gamma release assay (IGRA) test if the child is older than 5 years of age. These should be rechecked after 6 months, because some diseases take that long to seroconvert.

Whatever immunization records the child brings are unlikely to meet the AAP and CDC standards. “You can't take anything you get from another country at face value,” said Dr. Springer, also of Kids Plus Pediatrics at the University of Pittsburgh Medical Center. One increasingly common exception is immunizations supervised by the U.S. State Department. Even if records do meet standards, you should check titers.

Otherwise, you'll often have to start from scratch, using the Red Book catch-up schedule. Note, however, that there is no pertussis coverage for children aged 7-11 years. One alternative is to use Tdap off-label. “You sometimes have to fight with the insurance company,” Dr. Springer said. “They say, 'You gave it at the wrong age.' And you say, 'Would you rather pay for pertussis?'”

Among the common psychosocial issues likely to crop up in this visit are the following:

▸ Malnourished youngsters may hide food in their pockets, their beds, or even their cheeks. They also may eat ravenously. Dr. Schulte's advice: Let them have as much food as they want so that they will lose their fear of scarcity.

▸ Some children are affectionate with everyone because they are so starved for attention. They must learn to distinguish between strangers and family.

▸ Some are stubborn or angry, testing to see whether their new families really want to keep them. Parents must simply insist that they will always be there for these children.

▸ Other children may cling to one parent, crying uncontrollably if left for even a minute. Dr. Schulte advised helping these children by playing with them on the floor until they let go, then getting up to leave, promising to return and fulfilling the promise each time. Caregivers can start with separations of a couple of minutes, then gradually increase the interval.

▸ Adopted children may not sleep well. Because they often fear abandonment, Dr. Schulte advised against using “cry-it-out” technique to teach them good sleep patterns.

▸ Many children rock themselves or display other self-stimulating behavior which they embraced because they didn't get any other stimulation.

▸ Internationally adopted kids have elevated rates of schizophrenia, bipolar disease, fetal alcohol syndrome, attention-deficit/hyperactivity disorder (ADHD), and a host of other mental illnesses.

So after that first visit, see the children often. Many will grow swiftly, catching up to their normal height, overcoming emotional challenges, and recovering from illnesses. Others will need years of special education and other support.

Dr. Springer and Dr. Schulte said they had no conflicts of interest to report, but they did discuss an unapproved/investigative use of the Tdap vaccine.

High doses of vitamin E significantly decreased in-hospital mortality following a traumatic brain injury in the first-ever randomized, controlled clinical trial of this treatment.

High doses of the vitamin cut in-hospital mortality from traumatic brain injury (TBI) by 29% relative to the overall mortality of patients who received treatment with low or high doses of vitamin C (ascorbic acid) or placebo. The study also showed the benefits of high-dose vitamin C in stabilizing or reducing the diameter of perilesional edema and infarct, according to Dr. Ali Razmkon, a neurosurgery resident at the Shiraz (Iran) University of Medical Sciences, who presented the study at the annual meeting of the Congress of Neurological Surgeons, held in San Francisco.

The theory behind the study is that lipid peroxidation causes secondary damage in head injuries. "There are well-documented reports about vitamin C in human stress in many conditions, including common cold and stroke," Dr. Razmkon said in an interview after the meeting. "The plasma concentration is reduced. The body needs more and utilizes more."

Previous studies have suggested that vitamin C could reduce the risk of stroke and that vitamin E (alpha-tocopherol) could decrease the rate of lipid peroxidation.

To test this theory, Dr. Razmkon and his colleagues at Shiraz enrolled 100 patients (83 men) with traumatic brain injury. The patients all had Glasgow Coma Scale scores of 8 or less and radiologic diagnoses of diffuse axonal injury. The researchers excluded any patients who had significant liver or renal disease, previous head injury, or glucose-6-phosphate dehydrogenase (G6PD) deficiency.

They randomly assigned patients to low-dose intravenous vitamin C (500 mg daily) for 7 days, high-dose intravenous vitamin C (10 g on the day of admission and again on the fourth day, followed by 4 g daily for 3 more days), intramuscular vitamin E (400 IU daily) for 7 days, or placebo. The groups had no significant differences in diagnosis, age, or sex.

During the study, 26 patients died, and 67 (91%) of the remaining 74 patients attended follow-up at 2 and 6 months.

Hospital mortality was significantly lower among patients in the vitamin E group (20%) than it was in the groups receiving low- or high-dose vitamin C (30% and 29%) or placebo (33%). In-hospital mortality was 28% overall in these other three groups. At 6 months of follow-up, no differences in mortality were seen between the vitamin E (30%), low- and high-dose vitamin C (35% and 29%), and placebo groups (33%).

The vitamin E group also had significantly better Glasgow Outcome Scale scores at discharge and at 2 and 6 months of follow-up than did any of the other three groups.

The diameters of the perilesional hypodense regions in the brains of patients taking high-dose vitamin C were stabilized or reduced over the course of 7 days, dropping from a peak mean diameter of 12 mm on the third day after admission to 8 mm on the seventh day. This was significantly different from what was seen in patients in the other groups, which all had perilesional edema that continued to increase in diameter.

The researchers concluded that low-dose vitamin C didn’t affect the patients’ healing but that high doses of the vitamin slowed the progression of perilesional edema, which was likely a result of secondary oxidative insults. Neither dose of vitamin C appeared to affect neurologic outcomes.

For his work on the trial, Dr. Razmkon won the Synthes Resident Award for Research on Brain and Craniofacial Injury.

The study was funded by a grant from the Iranian National Elite Foundation. The investigators reported having no relevant conflicts of interest.

High doses of vitamin E significantly decreased in-hospital mortality following a traumatic brain injury in the first-ever randomized, controlled clinical trial of this treatment.

High doses of the vitamin cut in-hospital mortality from traumatic brain injury (TBI) by 29% relative to the overall mortality of patients who received treatment with low or high doses of vitamin C (ascorbic acid) or placebo. The study also showed the benefits of high-dose vitamin C in stabilizing or reducing the diameter of perilesional edema and infarct, according to Dr. Ali Razmkon, a neurosurgery resident at the Shiraz (Iran) University of Medical Sciences, who presented the study at the annual meeting of the Congress of Neurological Surgeons, held in San Francisco.

The theory behind the study is that lipid peroxidation causes secondary damage in head injuries. "There are well-documented reports about vitamin C in human stress in many conditions, including common cold and stroke," Dr. Razmkon said in an interview after the meeting. "The plasma concentration is reduced. The body needs more and utilizes more."

Previous studies have suggested that vitamin C could reduce the risk of stroke and that vitamin E (alpha-tocopherol) could decrease the rate of lipid peroxidation.

To test this theory, Dr. Razmkon and his colleagues at Shiraz enrolled 100 patients (83 men) with traumatic brain injury. The patients all had Glasgow Coma Scale scores of 8 or less and radiologic diagnoses of diffuse axonal injury. The researchers excluded any patients who had significant liver or renal disease, previous head injury, or glucose-6-phosphate dehydrogenase (G6PD) deficiency.

They randomly assigned patients to low-dose intravenous vitamin C (500 mg daily) for 7 days, high-dose intravenous vitamin C (10 g on the day of admission and again on the fourth day, followed by 4 g daily for 3 more days), intramuscular vitamin E (400 IU daily) for 7 days, or placebo. The groups had no significant differences in diagnosis, age, or sex.

During the study, 26 patients died, and 67 (91%) of the remaining 74 patients attended follow-up at 2 and 6 months.

Hospital mortality was significantly lower among patients in the vitamin E group (20%) than it was in the groups receiving low- or high-dose vitamin C (30% and 29%) or placebo (33%). In-hospital mortality was 28% overall in these other three groups. At 6 months of follow-up, no differences in mortality were seen between the vitamin E (30%), low- and high-dose vitamin C (35% and 29%), and placebo groups (33%).

The vitamin E group also had significantly better Glasgow Outcome Scale scores at discharge and at 2 and 6 months of follow-up than did any of the other three groups.

The diameters of the perilesional hypodense regions in the brains of patients taking high-dose vitamin C were stabilized or reduced over the course of 7 days, dropping from a peak mean diameter of 12 mm on the third day after admission to 8 mm on the seventh day. This was significantly different from what was seen in patients in the other groups, which all had perilesional edema that continued to increase in diameter.

The researchers concluded that low-dose vitamin C didn’t affect the patients’ healing but that high doses of the vitamin slowed the progression of perilesional edema, which was likely a result of secondary oxidative insults. Neither dose of vitamin C appeared to affect neurologic outcomes.

For his work on the trial, Dr. Razmkon won the Synthes Resident Award for Research on Brain and Craniofacial Injury.

The study was funded by a grant from the Iranian National Elite Foundation. The investigators reported having no relevant conflicts of interest.

High doses of vitamin E significantly decreased in-hospital mortality following a traumatic brain injury in the first-ever randomized, controlled clinical trial of this treatment.

High doses of the vitamin cut in-hospital mortality from traumatic brain injury (TBI) by 29% relative to the overall mortality of patients who received treatment with low or high doses of vitamin C (ascorbic acid) or placebo. The study also showed the benefits of high-dose vitamin C in stabilizing or reducing the diameter of perilesional edema and infarct, according to Dr. Ali Razmkon, a neurosurgery resident at the Shiraz (Iran) University of Medical Sciences, who presented the study at the annual meeting of the Congress of Neurological Surgeons, held in San Francisco.

The theory behind the study is that lipid peroxidation causes secondary damage in head injuries. "There are well-documented reports about vitamin C in human stress in many conditions, including common cold and stroke," Dr. Razmkon said in an interview after the meeting. "The plasma concentration is reduced. The body needs more and utilizes more."

Previous studies have suggested that vitamin C could reduce the risk of stroke and that vitamin E (alpha-tocopherol) could decrease the rate of lipid peroxidation.

To test this theory, Dr. Razmkon and his colleagues at Shiraz enrolled 100 patients (83 men) with traumatic brain injury. The patients all had Glasgow Coma Scale scores of 8 or less and radiologic diagnoses of diffuse axonal injury. The researchers excluded any patients who had significant liver or renal disease, previous head injury, or glucose-6-phosphate dehydrogenase (G6PD) deficiency.

They randomly assigned patients to low-dose intravenous vitamin C (500 mg daily) for 7 days, high-dose intravenous vitamin C (10 g on the day of admission and again on the fourth day, followed by 4 g daily for 3 more days), intramuscular vitamin E (400 IU daily) for 7 days, or placebo. The groups had no significant differences in diagnosis, age, or sex.

During the study, 26 patients died, and 67 (91%) of the remaining 74 patients attended follow-up at 2 and 6 months.

Hospital mortality was significantly lower among patients in the vitamin E group (20%) than it was in the groups receiving low- or high-dose vitamin C (30% and 29%) or placebo (33%). In-hospital mortality was 28% overall in these other three groups. At 6 months of follow-up, no differences in mortality were seen between the vitamin E (30%), low- and high-dose vitamin C (35% and 29%), and placebo groups (33%).

The vitamin E group also had significantly better Glasgow Outcome Scale scores at discharge and at 2 and 6 months of follow-up than did any of the other three groups.

The diameters of the perilesional hypodense regions in the brains of patients taking high-dose vitamin C were stabilized or reduced over the course of 7 days, dropping from a peak mean diameter of 12 mm on the third day after admission to 8 mm on the seventh day. This was significantly different from what was seen in patients in the other groups, which all had perilesional edema that continued to increase in diameter.

The researchers concluded that low-dose vitamin C didn’t affect the patients’ healing but that high doses of the vitamin slowed the progression of perilesional edema, which was likely a result of secondary oxidative insults. Neither dose of vitamin C appeared to affect neurologic outcomes.

For his work on the trial, Dr. Razmkon won the Synthes Resident Award for Research on Brain and Craniofacial Injury.

The study was funded by a grant from the Iranian National Elite Foundation. The investigators reported having no relevant conflicts of interest.

SAN FRANCISCO - Once abandoned because of adverse reactions, Amicar is showing new success in preventing the secondary rupture of aneurysms, a retrospective study has shown.

Most clinicians have moved away from using Amicar (epsilon aminocaproic acid) and other antifibrinolytic agents, such as tranexamic acid, in these patients since the mid- to late 1980s after studies found that they contributed to high rates of vasospasm and shunt-dependent hydrocephalus. However, Amicar has regained favor with clinicians at Emory University in Atlanta who used an intravenous drip preparation of the drug in a short-term protocol that calls for a 5-g bolus followed by a drip at 1 g/hr for 72 hours or until aneurysm treatment, whichever came first, said Dr. Albert Jesse Schuette, an interventional neuroradiologist at Emory.

Epsilon aminocaproic acid acts as an inhibitor of plasminogen activators and has some antiplasmin activity, according to its product label.

Dr. Schuette and his colleagues reviewed 454 patients with aneurysmal subarachnoid hemorrhage who received treatment with the drug under the short-term protocol during 2005-2007 and compared them with control patients who received the same overall care except for administration of Amicar.

Overall, aneurysms reruptured in 14 (7%) of 210 patients who did not get Amicar, compared with 6 (2%) of 244 patients who got Amicar. The rerupture rate was higher for patients who did not receive Amicar, regardless of their Fisher grade or Hunt and Hess grade.

Patients on Amicar did not have higher rates of ischemic events, vasospasm, or ventriculoperitoneal shunting, Dr. Schuette reported at the annual meeting of the Congress of Neurological Surgeons.

Based on these findings, he recommended that medical centers treating aneurysm patients begin a clot-stabilizing regimen with Amicar or another antifibrinolytic agent such as tranexamic acid during transfer to a high-volume tertiary care center.

None of the investigators reported relevant disclosures.

SAN FRANCISCO - Once abandoned because of adverse reactions, Amicar is showing new success in preventing the secondary rupture of aneurysms, a retrospective study has shown.

Most clinicians have moved away from using Amicar (epsilon aminocaproic acid) and other antifibrinolytic agents, such as tranexamic acid, in these patients since the mid- to late 1980s after studies found that they contributed to high rates of vasospasm and shunt-dependent hydrocephalus. However, Amicar has regained favor with clinicians at Emory University in Atlanta who used an intravenous drip preparation of the drug in a short-term protocol that calls for a 5-g bolus followed by a drip at 1 g/hr for 72 hours or until aneurysm treatment, whichever came first, said Dr. Albert Jesse Schuette, an interventional neuroradiologist at Emory.

Epsilon aminocaproic acid acts as an inhibitor of plasminogen activators and has some antiplasmin activity, according to its product label.

Dr. Schuette and his colleagues reviewed 454 patients with aneurysmal subarachnoid hemorrhage who received treatment with the drug under the short-term protocol during 2005-2007 and compared them with control patients who received the same overall care except for administration of Amicar.

Overall, aneurysms reruptured in 14 (7%) of 210 patients who did not get Amicar, compared with 6 (2%) of 244 patients who got Amicar. The rerupture rate was higher for patients who did not receive Amicar, regardless of their Fisher grade or Hunt and Hess grade.

Patients on Amicar did not have higher rates of ischemic events, vasospasm, or ventriculoperitoneal shunting, Dr. Schuette reported at the annual meeting of the Congress of Neurological Surgeons.

Based on these findings, he recommended that medical centers treating aneurysm patients begin a clot-stabilizing regimen with Amicar or another antifibrinolytic agent such as tranexamic acid during transfer to a high-volume tertiary care center.

None of the investigators reported relevant disclosures.

SAN FRANCISCO - Once abandoned because of adverse reactions, Amicar is showing new success in preventing the secondary rupture of aneurysms, a retrospective study has shown.

Most clinicians have moved away from using Amicar (epsilon aminocaproic acid) and other antifibrinolytic agents, such as tranexamic acid, in these patients since the mid- to late 1980s after studies found that they contributed to high rates of vasospasm and shunt-dependent hydrocephalus. However, Amicar has regained favor with clinicians at Emory University in Atlanta who used an intravenous drip preparation of the drug in a short-term protocol that calls for a 5-g bolus followed by a drip at 1 g/hr for 72 hours or until aneurysm treatment, whichever came first, said Dr. Albert Jesse Schuette, an interventional neuroradiologist at Emory.

Epsilon aminocaproic acid acts as an inhibitor of plasminogen activators and has some antiplasmin activity, according to its product label.

Dr. Schuette and his colleagues reviewed 454 patients with aneurysmal subarachnoid hemorrhage who received treatment with the drug under the short-term protocol during 2005-2007 and compared them with control patients who received the same overall care except for administration of Amicar.

Overall, aneurysms reruptured in 14 (7%) of 210 patients who did not get Amicar, compared with 6 (2%) of 244 patients who got Amicar. The rerupture rate was higher for patients who did not receive Amicar, regardless of their Fisher grade or Hunt and Hess grade.

Patients on Amicar did not have higher rates of ischemic events, vasospasm, or ventriculoperitoneal shunting, Dr. Schuette reported at the annual meeting of the Congress of Neurological Surgeons.

Based on these findings, he recommended that medical centers treating aneurysm patients begin a clot-stabilizing regimen with Amicar or another antifibrinolytic agent such as tranexamic acid during transfer to a high-volume tertiary care center.

None of the investigators reported relevant disclosures.

SAN FRANCISCO – The Institute of Medicine will change its recommended level of vitamin D intake for children on Nov. 30, 2010, predicted Dr. Russell Chesney, professor and chairman of pediatrics at the University of Tennessee Health Science Center in Memphis.

The change, presumably an increase, comes not a moment too soon, said Dr. Chesney, who cited a long list of potential health benefits for the substance. "Vitamin D truly is the center of the universe," he joked.

Among the conditions that vitamin D may ameliorate include infectious diseases, ovarian cancer, multiple sclerosis, rheumatoid arthritis, inflammatory bowel syndrome, wheezing, diabetes types 1 and 2, hypertension, atherosclerosis, colorectal cancer, prostate cancer, and breast cancer. "Wow, where has this stuff been all these years?" he said, drawing laughter from the plenary session audience at the annual meeting of the American Academy of Pediatrics.

Actually, vitamin D supplementation dates back to the days when mothers spooned cod-liver oil into their children's mouths. This form of the supplement proved effective in preventing and treating rickets.

Since then, evidence has mounted for other benefits. Most claims are based on epidemiological studies. For example, people who live at higher altitudes and get more sunshine exposure – which causes vitamin D synthesis – may suffer less from tuberculosis. "Our ancestors were right when they said we should go to sanatoriums in the mountains," said Dr. Chesney.

He added that prospective trials are still needed. "This is suspected. This is not proven."

But a few small studies have already reinforced such findings. In one recent study that Dr. Chesney described, a group of 167 Japanese children took supplements of 1,200 IU of vitamin D, while another group of 167 took a placebo. Those who took the vitamin D had half the influenza incidence of the placebo group, as well as fewer attacks of asthma.

How can one vitamin produce such benefits? Actually, D is not a vitamin but a hormone – strictly speaking, a secosteroid, Dr. Chesney said. It influences the promoter regions of several genes and is involved in the transcription of some 300 proteins and peptides.

Among the peptides it helps produce is LL-37 cathelicidin, which kills Mycobacterium tuberculosis and Escherichia coli.

Other research suggests that vitamin D inhibits proinflammatory and autoimmune cytokines and promotes those that are anti-inflammatory, said Dr. Chesney.

So many claims of benefits for one vitamin may sound exaggerated, he acknowledged, harkening back to the excitement over vitamin E a couple of decades ago. But it's also true that vitamin D levels are declining in the United States as Americans spend more time indoors and take precautions to avoid skin cancer. "Kids these days are on house arrest," he said, echoing Richard Louv’s keynote address on "nature deficit disorder" earlier in the meeting.

"This is not an advertisement for all of us to go out to the beach," said Dr. Chesney. "But it is a point that we are not getting as much sunshine as a society as we used to, and in that case we may need to get supplementation."

How much supplementation? That's still being debated. That teaspoon of cod-liver oil contained about 400 IU, and that's the same daily dose that the American Academy of Pediatrics has been recommending since 2008. The AAP advises supplementing with 400 IU of vitamin D for breast-fed infants and older children who are not getting at least that much through their diet.

"What led to this recommendation?" he asked. "There was growing concern that the Institute of Medicine's recommended intake of 200 IU/day [for everyone younger than 51 years of age] was not adequate. Vitamin D may be one of the only substances whose dose is lower than the RDA [recommended daily allowance]. Numerous groups have called on the institute to update their recommendation, and they are going to do so."

While there is also debate about serum levels of vitamin D (serum 25-hydroxyvitamin D), Dr. Chesney said anything below 11 ng/mL is "clearly deficient." He called 11-20 ng/mL "insufficient," and said that less than 30 ng/mL is "probably on the lower end of sufficient." (In nmol/L, those cutoffs would be 27.5, 50, and 75.)

Supplements are quite safe, he added. "The lowest observed side effects [occur at] more than 4,000 IU/day and probably more like 10,000 IU/day," he said. "The tolerable upper limit in a child is set at 1,000 IU, but you could probably go higher."

Reflecting on the country's long history of vitamin D supplementation, Dr. Chesney finished by quoting Ecclesiastes 1:9, "There is nothing new under the sun."

Dr. Chesney disclosed that he serves on the board of advisors of Cytochroma Inc.

SAN FRANCISCO – The Institute of Medicine will change its recommended level of vitamin D intake for children on Nov. 30, 2010, predicted Dr. Russell Chesney, professor and chairman of pediatrics at the University of Tennessee Health Science Center in Memphis.

The change, presumably an increase, comes not a moment too soon, said Dr. Chesney, who cited a long list of potential health benefits for the substance. "Vitamin D truly is the center of the universe," he joked.

Among the conditions that vitamin D may ameliorate include infectious diseases, ovarian cancer, multiple sclerosis, rheumatoid arthritis, inflammatory bowel syndrome, wheezing, diabetes types 1 and 2, hypertension, atherosclerosis, colorectal cancer, prostate cancer, and breast cancer. "Wow, where has this stuff been all these years?" he said, drawing laughter from the plenary session audience at the annual meeting of the American Academy of Pediatrics.

Actually, vitamin D supplementation dates back to the days when mothers spooned cod-liver oil into their children's mouths. This form of the supplement proved effective in preventing and treating rickets.

Since then, evidence has mounted for other benefits. Most claims are based on epidemiological studies. For example, people who live at higher altitudes and get more sunshine exposure – which causes vitamin D synthesis – may suffer less from tuberculosis. "Our ancestors were right when they said we should go to sanatoriums in the mountains," said Dr. Chesney.

He added that prospective trials are still needed. "This is suspected. This is not proven."

But a few small studies have already reinforced such findings. In one recent study that Dr. Chesney described, a group of 167 Japanese children took supplements of 1,200 IU of vitamin D, while another group of 167 took a placebo. Those who took the vitamin D had half the influenza incidence of the placebo group, as well as fewer attacks of asthma.

How can one vitamin produce such benefits? Actually, D is not a vitamin but a hormone – strictly speaking, a secosteroid, Dr. Chesney said. It influences the promoter regions of several genes and is involved in the transcription of some 300 proteins and peptides.

Among the peptides it helps produce is LL-37 cathelicidin, which kills Mycobacterium tuberculosis and Escherichia coli.

Other research suggests that vitamin D inhibits proinflammatory and autoimmune cytokines and promotes those that are anti-inflammatory, said Dr. Chesney.

So many claims of benefits for one vitamin may sound exaggerated, he acknowledged, harkening back to the excitement over vitamin E a couple of decades ago. But it's also true that vitamin D levels are declining in the United States as Americans spend more time indoors and take precautions to avoid skin cancer. "Kids these days are on house arrest," he said, echoing Richard Louv’s keynote address on "nature deficit disorder" earlier in the meeting.

"This is not an advertisement for all of us to go out to the beach," said Dr. Chesney. "But it is a point that we are not getting as much sunshine as a society as we used to, and in that case we may need to get supplementation."

How much supplementation? That's still being debated. That teaspoon of cod-liver oil contained about 400 IU, and that's the same daily dose that the American Academy of Pediatrics has been recommending since 2008. The AAP advises supplementing with 400 IU of vitamin D for breast-fed infants and older children who are not getting at least that much through their diet.

"What led to this recommendation?" he asked. "There was growing concern that the Institute of Medicine's recommended intake of 200 IU/day [for everyone younger than 51 years of age] was not adequate. Vitamin D may be one of the only substances whose dose is lower than the RDA [recommended daily allowance]. Numerous groups have called on the institute to update their recommendation, and they are going to do so."

While there is also debate about serum levels of vitamin D (serum 25-hydroxyvitamin D), Dr. Chesney said anything below 11 ng/mL is "clearly deficient." He called 11-20 ng/mL "insufficient," and said that less than 30 ng/mL is "probably on the lower end of sufficient." (In nmol/L, those cutoffs would be 27.5, 50, and 75.)

Supplements are quite safe, he added. "The lowest observed side effects [occur at] more than 4,000 IU/day and probably more like 10,000 IU/day," he said. "The tolerable upper limit in a child is set at 1,000 IU, but you could probably go higher."

Reflecting on the country's long history of vitamin D supplementation, Dr. Chesney finished by quoting Ecclesiastes 1:9, "There is nothing new under the sun."

Dr. Chesney disclosed that he serves on the board of advisors of Cytochroma Inc.

SAN FRANCISCO – The Institute of Medicine will change its recommended level of vitamin D intake for children on Nov. 30, 2010, predicted Dr. Russell Chesney, professor and chairman of pediatrics at the University of Tennessee Health Science Center in Memphis.

The change, presumably an increase, comes not a moment too soon, said Dr. Chesney, who cited a long list of potential health benefits for the substance. "Vitamin D truly is the center of the universe," he joked.

Among the conditions that vitamin D may ameliorate include infectious diseases, ovarian cancer, multiple sclerosis, rheumatoid arthritis, inflammatory bowel syndrome, wheezing, diabetes types 1 and 2, hypertension, atherosclerosis, colorectal cancer, prostate cancer, and breast cancer. "Wow, where has this stuff been all these years?" he said, drawing laughter from the plenary session audience at the annual meeting of the American Academy of Pediatrics.

Actually, vitamin D supplementation dates back to the days when mothers spooned cod-liver oil into their children's mouths. This form of the supplement proved effective in preventing and treating rickets.

Since then, evidence has mounted for other benefits. Most claims are based on epidemiological studies. For example, people who live at higher altitudes and get more sunshine exposure – which causes vitamin D synthesis – may suffer less from tuberculosis. "Our ancestors were right when they said we should go to sanatoriums in the mountains," said Dr. Chesney.

He added that prospective trials are still needed. "This is suspected. This is not proven."

But a few small studies have already reinforced such findings. In one recent study that Dr. Chesney described, a group of 167 Japanese children took supplements of 1,200 IU of vitamin D, while another group of 167 took a placebo. Those who took the vitamin D had half the influenza incidence of the placebo group, as well as fewer attacks of asthma.

How can one vitamin produce such benefits? Actually, D is not a vitamin but a hormone – strictly speaking, a secosteroid, Dr. Chesney said. It influences the promoter regions of several genes and is involved in the transcription of some 300 proteins and peptides.

Among the peptides it helps produce is LL-37 cathelicidin, which kills Mycobacterium tuberculosis and Escherichia coli.

Other research suggests that vitamin D inhibits proinflammatory and autoimmune cytokines and promotes those that are anti-inflammatory, said Dr. Chesney.

So many claims of benefits for one vitamin may sound exaggerated, he acknowledged, harkening back to the excitement over vitamin E a couple of decades ago. But it's also true that vitamin D levels are declining in the United States as Americans spend more time indoors and take precautions to avoid skin cancer. "Kids these days are on house arrest," he said, echoing Richard Louv’s keynote address on "nature deficit disorder" earlier in the meeting.

"This is not an advertisement for all of us to go out to the beach," said Dr. Chesney. "But it is a point that we are not getting as much sunshine as a society as we used to, and in that case we may need to get supplementation."

How much supplementation? That's still being debated. That teaspoon of cod-liver oil contained about 400 IU, and that's the same daily dose that the American Academy of Pediatrics has been recommending since 2008. The AAP advises supplementing with 400 IU of vitamin D for breast-fed infants and older children who are not getting at least that much through their diet.

"What led to this recommendation?" he asked. "There was growing concern that the Institute of Medicine's recommended intake of 200 IU/day [for everyone younger than 51 years of age] was not adequate. Vitamin D may be one of the only substances whose dose is lower than the RDA [recommended daily allowance]. Numerous groups have called on the institute to update their recommendation, and they are going to do so."

While there is also debate about serum levels of vitamin D (serum 25-hydroxyvitamin D), Dr. Chesney said anything below 11 ng/mL is "clearly deficient." He called 11-20 ng/mL "insufficient," and said that less than 30 ng/mL is "probably on the lower end of sufficient." (In nmol/L, those cutoffs would be 27.5, 50, and 75.)

Supplements are quite safe, he added. "The lowest observed side effects [occur at] more than 4,000 IU/day and probably more like 10,000 IU/day," he said. "The tolerable upper limit in a child is set at 1,000 IU, but you could probably go higher."

Reflecting on the country's long history of vitamin D supplementation, Dr. Chesney finished by quoting Ecclesiastes 1:9, "There is nothing new under the sun."

Dr. Chesney disclosed that he serves on the board of advisors of Cytochroma Inc.

SAN FRANCISCO – The Institute of Medicine will change its recommended level of vitamin D intake for children on Nov. 30, 2010, predicted Dr. Russell Chesney, professor and chairman of pediatrics at the University of Tennessee Health Science Center in Memphis.

The change, presumably an increase, comes not a moment too soon, said Dr. Chesney, who cited a long list of potential health benefits for the substance. "Vitamin D truly is the center of the universe," he joked.

Among the conditions that vitamin D may ameliorate include infectious diseases, ovarian cancer, multiple sclerosis, rheumatoid arthritis, inflammatory bowel syndrome, wheezing, diabetes types 1 and 2, hypertension, atherosclerosis, colorectal cancer, prostate cancer, and breast cancer. "Wow, where has this stuff been all these years?" he said, drawing laughter from the plenary session audience at the annual meeting of the American Academy of Pediatrics.

Actually, vitamin D supplementation dates back to the days when mothers spooned cod-liver oil into their children’s mouths. This form of the supplement proved effective in preventing and treating rickets.

Since then, evidence has mounted for other benefits. Most claims are based on epidemiological studies. For example, people who live at higher altitudes and get more sunshine exposure – which causes vitamin D synthesis – may suffer less from tuberculosis. "Our ancestors were right when they said we should go to sanatoriums in the mountains," said Dr. Chesney.

He added that prospective trials are still needed. "This is suspected. This is not proven."

But a few small studies have already reinforced such findings. In one recent study that Dr. Chesney described, a group of 167 Japanese children took supplements of 1,200 IU of vitamin D, while another group of 167 took a placebo. Those who took the vitamin D had half the influenza incidence of the placebo group, as well as fewer attacks of asthma.

How can one vitamin produce such benefits? Actually, D is not a vitamin but a hormone – strictly speaking, a secosteroid, Dr. Chesney said. It influences the promoter regions of several genes and is involved in the transcription of some 300 proteins and peptides.

Among the peptides it helps produce is LL-37 cathelicidin, which kills Mycobacterium tuberculosis and Escherichia coli.

Other research suggests that vitamin D inhibits proinflammatory and autoimmune cytokines and promotes those that are anti-inflammatory, said Dr. Chesney.

So many claims of benefits for one vitamin may sound exaggerated, he acknowledged, harkening back to the excitement over vitamin E a couple of decades ago. But it’s also true that vitamin D levels are declining in the United States as Americans spend more time indoors and take precautions to avoid skin cancer. "Kids these days are on house arrest," he said, echoing Richard Louv’s keynote address on "nature deficit disorder" earlier in the meeting.

"This is not an advertisement for all of us to go out to the beach," said Dr. Chesney. "But it is a point that we are not getting as much sunshine as a society as we used to, and in that case we may need to get supplementation."

How much supplementation? That’s still being debated. That teaspoon of cod-liver oil contained about 400 IU, and that’s the same daily dose that the American Academy of Pediatrics has been recommending since 2008. The AAP advises supplementing with 400 IU of vitamin D for breast-fed infants and older children who are not getting at least that much through their diet.

"What led to this recommendation?" he asked. "There was growing concern that the Institute of Medicine’s recommended intake of 200 IU/day [for everyone younger than 51 years of age] was not adequate. Vitamin D may be one of the only substances whose dose is lower than the RDA [recommended daily allowance]. Numerous groups have called on the institute to update their recommendation, and they are going to do so."

While there is also debate about serum levels of vitamin D (serum 25-hydroxyvitamin D), Dr. Chesney said anything below 11 ng/mL is "clearly deficient." He called 11-20 ng/mL "insufficient," and said that less than 30 ng/mL is "probably on the lower end of sufficient." (In nmol/L, those cutoffs would be 27.5, 50, and 75.)

Supplements are quite safe, he added. "The lowest observed side effects [occur at] more than 4,000 IU/day and probably more like 10,000 IU/day," he said. "The tolerable upper limit in a child is set at 1,000 IU, but you could probably go higher."

Reflecting on the country’s long history of vitamin D supplementation, Dr. Chesney finished by quoting Ecclesiastes 1:9, "There is nothing new under the sun."

Dr. Chesney disclosed that he serves on the board of advisors of Cytochroma Inc.

SAN FRANCISCO – The Institute of Medicine will change its recommended level of vitamin D intake for children on Nov. 30, 2010, predicted Dr. Russell Chesney, professor and chairman of pediatrics at the University of Tennessee Health Science Center in Memphis.

The change, presumably an increase, comes not a moment too soon, said Dr. Chesney, who cited a long list of potential health benefits for the substance. "Vitamin D truly is the center of the universe," he joked.

Among the conditions that vitamin D may ameliorate include infectious diseases, ovarian cancer, multiple sclerosis, rheumatoid arthritis, inflammatory bowel syndrome, wheezing, diabetes types 1 and 2, hypertension, atherosclerosis, colorectal cancer, prostate cancer, and breast cancer. "Wow, where has this stuff been all these years?" he said, drawing laughter from the plenary session audience at the annual meeting of the American Academy of Pediatrics.

Actually, vitamin D supplementation dates back to the days when mothers spooned cod-liver oil into their children’s mouths. This form of the supplement proved effective in preventing and treating rickets.

Since then, evidence has mounted for other benefits. Most claims are based on epidemiological studies. For example, people who live at higher altitudes and get more sunshine exposure – which causes vitamin D synthesis – may suffer less from tuberculosis. "Our ancestors were right when they said we should go to sanatoriums in the mountains," said Dr. Chesney.

He added that prospective trials are still needed. "This is suspected. This is not proven."

But a few small studies have already reinforced such findings. In one recent study that Dr. Chesney described, a group of 167 Japanese children took supplements of 1,200 IU of vitamin D, while another group of 167 took a placebo. Those who took the vitamin D had half the influenza incidence of the placebo group, as well as fewer attacks of asthma.

How can one vitamin produce such benefits? Actually, D is not a vitamin but a hormone – strictly speaking, a secosteroid, Dr. Chesney said. It influences the promoter regions of several genes and is involved in the transcription of some 300 proteins and peptides.

Among the peptides it helps produce is LL-37 cathelicidin, which kills Mycobacterium tuberculosis and Escherichia coli.

Other research suggests that vitamin D inhibits proinflammatory and autoimmune cytokines and promotes those that are anti-inflammatory, said Dr. Chesney.

So many claims of benefits for one vitamin may sound exaggerated, he acknowledged, harkening back to the excitement over vitamin E a couple of decades ago. But it’s also true that vitamin D levels are declining in the United States as Americans spend more time indoors and take precautions to avoid skin cancer. "Kids these days are on house arrest," he said, echoing Richard Louv’s keynote address on "nature deficit disorder" earlier in the meeting.

"This is not an advertisement for all of us to go out to the beach," said Dr. Chesney. "But it is a point that we are not getting as much sunshine as a society as we used to, and in that case we may need to get supplementation."

How much supplementation? That’s still being debated. That teaspoon of cod-liver oil contained about 400 IU, and that’s the same daily dose that the American Academy of Pediatrics has been recommending since 2008. The AAP advises supplementing with 400 IU of vitamin D for breast-fed infants and older children who are not getting at least that much through their diet.

"What led to this recommendation?" he asked. "There was growing concern that the Institute of Medicine’s recommended intake of 200 IU/day [for everyone younger than 51 years of age] was not adequate. Vitamin D may be one of the only substances whose dose is lower than the RDA [recommended daily allowance]. Numerous groups have called on the institute to update their recommendation, and they are going to do so."

While there is also debate about serum levels of vitamin D (serum 25-hydroxyvitamin D), Dr. Chesney said anything below 11 ng/mL is "clearly deficient." He called 11-20 ng/mL "insufficient," and said that less than 30 ng/mL is "probably on the lower end of sufficient." (In nmol/L, those cutoffs would be 27.5, 50, and 75.)

Supplements are quite safe, he added. "The lowest observed side effects [occur at] more than 4,000 IU/day and probably more like 10,000 IU/day," he said. "The tolerable upper limit in a child is set at 1,000 IU, but you could probably go higher."

Reflecting on the country’s long history of vitamin D supplementation, Dr. Chesney finished by quoting Ecclesiastes 1:9, "There is nothing new under the sun."

Dr. Chesney disclosed that he serves on the board of advisors of Cytochroma Inc.

SAN FRANCISCO – The Institute of Medicine will change its recommended level of vitamin D intake for children on Nov. 30, 2010, predicted Dr. Russell Chesney, professor and chairman of pediatrics at the University of Tennessee Health Science Center in Memphis.

The change, presumably an increase, comes not a moment too soon, said Dr. Chesney, who cited a long list of potential health benefits for the substance. "Vitamin D truly is the center of the universe," he joked.

Among the conditions that vitamin D may ameliorate include infectious diseases, ovarian cancer, multiple sclerosis, rheumatoid arthritis, inflammatory bowel syndrome, wheezing, diabetes types 1 and 2, hypertension, atherosclerosis, colorectal cancer, prostate cancer, and breast cancer. "Wow, where has this stuff been all these years?" he said, drawing laughter from the plenary session audience at the annual meeting of the American Academy of Pediatrics.

Actually, vitamin D supplementation dates back to the days when mothers spooned cod-liver oil into their children’s mouths. This form of the supplement proved effective in preventing and treating rickets.

Since then, evidence has mounted for other benefits. Most claims are based on epidemiological studies. For example, people who live at higher altitudes and get more sunshine exposure – which causes vitamin D synthesis – may suffer less from tuberculosis. "Our ancestors were right when they said we should go to sanatoriums in the mountains," said Dr. Chesney.

He added that prospective trials are still needed. "This is suspected. This is not proven."

But a few small studies have already reinforced such findings. In one recent study that Dr. Chesney described, a group of 167 Japanese children took supplements of 1,200 IU of vitamin D, while another group of 167 took a placebo. Those who took the vitamin D had half the influenza incidence of the placebo group, as well as fewer attacks of asthma.

How can one vitamin produce such benefits? Actually, D is not a vitamin but a hormone – strictly speaking, a secosteroid, Dr. Chesney said. It influences the promoter regions of several genes and is involved in the transcription of some 300 proteins and peptides.

Among the peptides it helps produce is LL-37 cathelicidin, which kills Mycobacterium tuberculosis and Escherichia coli.

Other research suggests that vitamin D inhibits proinflammatory and autoimmune cytokines and promotes those that are anti-inflammatory, said Dr. Chesney.

So many claims of benefits for one vitamin may sound exaggerated, he acknowledged, harkening back to the excitement over vitamin E a couple of decades ago. But it’s also true that vitamin D levels are declining in the United States as Americans spend more time indoors and take precautions to avoid skin cancer. "Kids these days are on house arrest," he said, echoing Richard Louv’s keynote address on "nature deficit disorder" earlier in the meeting.

"This is not an advertisement for all of us to go out to the beach," said Dr. Chesney. "But it is a point that we are not getting as much sunshine as a society as we used to, and in that case we may need to get supplementation."

How much supplementation? That’s still being debated. That teaspoon of cod-liver oil contained about 400 IU, and that’s the same daily dose that the American Academy of Pediatrics has been recommending since 2008. The AAP advises supplementing with 400 IU of vitamin D for breast-fed infants and older children who are not getting at least that much through their diet.

"What led to this recommendation?" he asked. "There was growing concern that the Institute of Medicine’s recommended intake of 200 IU/day [for everyone younger than 51 years of age] was not adequate. Vitamin D may be one of the only substances whose dose is lower than the RDA [recommended daily allowance]. Numerous groups have called on the institute to update their recommendation, and they are going to do so."

While there is also debate about serum levels of vitamin D (serum 25-hydroxyvitamin D), Dr. Chesney said anything below 11 ng/mL is "clearly deficient." He called 11-20 ng/mL "insufficient," and said that less than 30 ng/mL is "probably on the lower end of sufficient." (In nmol/L, those cutoffs would be 27.5, 50, and 75.)

Supplements are quite safe, he added. "The lowest observed side effects [occur at] more than 4,000 IU/day and probably more like 10,000 IU/day," he said. "The tolerable upper limit in a child is set at 1,000 IU, but you could probably go higher."

Reflecting on the country’s long history of vitamin D supplementation, Dr. Chesney finished by quoting Ecclesiastes 1:9, "There is nothing new under the sun."

Dr. Chesney disclosed that he serves on the board of advisors of Cytochroma Inc.