Clinical Briefs



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Am Fam Physician. 2003 Aug 15;68(4):763-764.

Selecting Toys for Young Children

Play is essential for learning in children, and toys are the tools of play. Which play materials are provided and how they are used are equally important, according to a clinical report published by the American Academy of Pediatrics. “Selecting Appropriate Toys for Young Children” appears in the April 2003 issue of Pediatrics and is available online at www.aap.org.

Adults caring for children should be reminded that toys facilitate but do not substitute for the most important aspect of nurture—warm, loving, dependable relationships. Toys should be safe, affordable, and developmentally appropriate. Children do not need expensive toys. Toys should be appealing enough to engage the child over a period of time.

The clinical report includes advice for selecting and maintaining toys used in physicians' office waiting rooms, and a resource list for parents. Although there appears to be no increased rate of acute illness for children who have just visited a physician's office, toys in the office should be routinely cleaned. Among the recommendations are the following:

  • Office toys should be safe for children of all ages.

  • Always store toys safely, and avoid toy chests with lids.

  • Office toys should be engaging and encourage creativity.

  • Offices should include at least as many developmentally appropriate books and magazines as toys.

  • Parents should make a thoughtful selection of toys and remember that a good toy does not have to be trendy or expensive.

  • Parents should be skeptical of educational or developmental claims made by the manufacturer, especially product claims of intellectual enhancement.

  • Parents should provide children with safe, affordable toys that are developmentally appropriate and that help promote learning and growth in all areas of development. Parents should avoid toys that discourage children from using their imaginations. Social, emotional, and cognitive skills are developed and enhanced as children use play to work out real-life problems.

  • Parents should remember that some toys promote violence or negative social, racial, or gender stereotypes. These toys are not recommended for children.

ACOG Recommendations on Preterm Labor

The Committee on Practice Bulletins of the American College of Obstetricians and Gynecologists (ACOG) has released a new evidence-based bulletin on management of preterm labor. “ACOG Practice Bulletin Number 43—Management of Pre-term Labor” appears in the May 2003 issue of Obstetrics & Gynecology.

Preterm birth is the leading cause of neonatal mortality in the United States, and preterm labor precedes 40 to 50 percent of preterm births. Preterm birth accounts for 35 percent of all U.S. health care spending for infants and 10 percent of all such spending for children. About 467,000 live births annually occur before term in the United States, and preterm births are responsible for three fourths of neonatal mortality and one half of long-term neurologic impairment in children. Uncertainty persists about the best strategies for managing preterm labor.

Many factors influence the decision to intervene when women have symptoms of preterm labor, including the probability of progressive labor, gestational age, and the risks of treatment. There was good and consistent evidence for the following recommendations:

  • There are no clear “first-line” tocolytic drugs to manage preterm labor. Clinical circumstances and physician preferences should dictate treatment.

  • Antibiotics do not appear to prolong gestation and should be reserved for group B streptococcal prophylaxis in patients in whom delivery is imminent.

  • Neither maintenance treatment with tocolytic drugs nor repeated acute tocolysis improve perinatal outcome; neither should be used as a general practice.

  • Tocolytic drugs may prolong pregnancy for two to seven days, which may allow for administration of steroids to improve fetal lung maturity and the consideration of maternal transport to a tertiary care facility.

The guidelines also include the following, although these recommendations are based on lower quality or less consistent evidence:

  • Cervical ultrasound examination and fetal fibronectin testing have good negative predictive value; thus, either approach or both combined may be helpful in determining which patients do not need tocolysis.

  • Amniocentesis may be used in women in preterm labor to assess fetal lung maturity and intra-amniotic infection.

  • Bed rest, hydration, and pelvic rest do not appear to improve the rate of preterm births and should not routinely be recommended.

FDA Advisory

Lindane. The U.S. Food and Drug Administration (FDA) has issued a Public Health Advisory concerning the use of topical formulations of Lindane Lotion and Lindane Shampoo for the treatment of scabies and lice.

Labeling for Lindane products has been changed to include a boxed warning that highlights the most important safety issues associated with use of these products. The boxed warning contains information to better inform physicians and patients regarding the potential risks associated with the use and misuse of Lindane.

The warning emphasizes that Lindane products have been, and continue to be, indicated as a second-line therapy for the treatment of scabies and lice. While the FDA believes that the benefits of Lindane outweigh the risks when used as directed, given the potential for neurotoxicity, patients should only be treated with these medications if other treatments are not tolerable or other approved therapies have failed.

The new boxed warning also states that Lindane Lotion and Lindane Shampoo are to be used with caution in patients who weigh less than approximately 110 lb. These products are not recommended for use in infants and are contraindicated in premature infants. These warnings are based on reports to the FDA's voluntary reporting system which described approximately one half of reported adverse events occurring in pediatric patients.

It is estimated that in the United States up to 1 million prescriptions are written each year to treat new cases of head lice and scabies, which occur mostly in school-aged children. Because Lindane is absorbed through the skin, and because younger children have more skin surface area per pound of body weight than adults, the amount that is absorbed may result in higher blood levels of Lindane in children than that seen in adults. Animal studies also have shown that younger animals are more susceptible to the neurologic side effects seen with Lindane use.

Because most of the serious adverse events reported with Lindane products are caused by misuse and overuse, especially with the lotion, product package sizes will be limited to 1 and 2 oz. Patients should understand the importance of using this medication in a manner consistent with the product labeling.

The instructions for use and information about adverse events also will be provided to patients in the form of a Medication Guide. By law, the Medication Guide must be dispensed by pharmacists directly to the patient with each new prescription of Lindane Lotion or Lindane Shampoo.

Other changes in the labeling address FDA concerns about potential increased risk of adverse reactions associated with the use of Lindane products in immunocompromised patients, such as those with human immunodeficiency virus infection, or patients taking medications, such as antidepressants, that may increase the chances of having a seizure.

Permethrin 5 percent cream is recommended by the Centers for Disease Control and Prevention as primary therapy for scabies. Given the possible risks associated with the use of Lindane, physicians should consider this new safety information when deciding whether to prescribe Lindane Lotion or Lindane Shampoo for patients who may be at risk of serious adverse drug events.



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