Clinical Briefs

Am Fam Physician. 2003 Dec 1;68(11):2277-2280.

AHRQ Criteria on Disability in Infants and Children

The Agency for Healthcare Research and Quality (AHRQ) has issued three guidelines to assist the Social Security Administration in determining disability in infants and children with low birth weights, failure to thrive, and short stature. The full evidence reports are available online at http://www.ahrq.gov.

Low Birth Weight. The AHRQ investigated the presence of developmental disability in former premature infants and risk for long-term developmental disabilities. Among the 4 million infants born in the United States in 2000, about 58,000 (1.5 percent) weighed less than 1,500 g (3.3 lb). This category of infants has the highest neonatal mortality and morbidity. The AHRQ found evidence that infants who weigh less than 1,500 g at birth are at increased risk for cerebral palsy, major neurologic disability, cognitive abnormality in early childhood, mental retardation, blindness, hearing loss, and growth impairment. Infants with very low birth weights and bronchopulmonary dysplasia also are at increased risk for long-term pulmonary disability.

Failure to Thrive. The underlying cause of failure to thrive is insufficient nutrition. This may occur when sufficient nutrients are not available to the child as a result of social or environmental causes that prevent parents from obtaining, preparing, or offering age-appropriate food. This growth failure often includes concurrent and potentially persistent disability.

Almost any serious childhood illness also can result in failure to thrive through the following mechanisms:

  • Insufficient nutrition because of the child's inability to feed properly (e.g., severe neurologic dysfunction, gastroesophageal reflux, cleft palate).

  • Nutrition is adequate but inadequately absorbed (e.g., malabsorption syndromes).

  • The disease process creates added metabolic requirements (e.g., asthma, cardiac failure, thyroiditis).

Failure to thrive may be the first clue to an active disease process that has not yet manifested with specific symptoms.

Severe malnutrition has been shown to cause permanent damage to various parts of the brain and central nervous system, leading to a range of disabilities manifested by aberrant behavior, cognitive, language, and motor development. Failure to thrive also is closely linked with infectious disease.

Children who are undernourished consistently have been found to have significant and profound changes in cell-mediated immunity, complement levels, and opsonization that lead to susceptibility to various infections. Failure to thrive also is associated with disabilities in cardiac function, gastrointestinal conditions, persistently small stature, and other physiologic problems.

The AHRQ found evidence that in developed countries, failure to thrive is associated with growth retardation that persists despite adequate correction of malnutrition.

Short Stature. Medically determinable causes of short stature include abnormalities in the growth hormone axis (e.g., decreased growth hormone production, diminished response to growth hormone). Other endocrine abnormalities such as hypothyroidism and Cushing's disease may lead to short stature, as can a variety of genetic disorders, including chromosomal, metabolic, and single gene disorders.

Skeletal dysplasias are genetic disorders that result in abnormal formation of part or all of the skeleton. The skeletal dysplasias most likely to lead to short stature are those that involve formation and growth of the long bones or the spine. The AHRQ found that children with skeletal dysplasias are not at increased risk for severe impairments in intelligence, academic achievement, or psychologic outcomes. There was an increased risk for delay in achievement of motor skills in children with achondroplasia and osteogenesis imperfecta, and decreased ambulation, range of motion, and mobility in children with more severe forms of osteogenesis imperfecta.

The presence of a chronic disease in a child is known to be a risk factor for decreased growth to a varying degree. However, the underlying cause of the decreased growth has not been determined in all chronic diseases.

The AHRQ found that children with short stature do not have enough difficulties with academic achievement to qualify as a disability.

CDC Guidelines for Infection Control

The Centers for Disease Control and Prevention (CDC) has issued guidelines for controlling environmental infection in health care facilities. The full report is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm.

Although health care facilities rarely are implicated in disease transmission, inadvertent exposures to environmental or airborne pathogens can result in adverse patient outcomes and cause illness among health care workers. Environmental infection-control strategies and engineering controls can effectively prevent these infections.

Included in the recommendations are standards for the following:

  • Design and maintenance of air-handling systems.

  • Demolition, construction, repair, and renovation projects.

  • Ventilation requirements for protective environment, airborne infection isolation, and operating rooms.

  • Control of waterborne microorganisms in distribution systems, ice machines, and hydrotherapy tanks.

  • Cleaning and disinfecting surfaces in patient-care areas.

  • Cleaning blood and body substance spills.

  • Allowing flowers and plants in patient-care areas.

  • Pest control.

  • Handling of laundry and bedding.

  • Sampling of air, water, and environmental surfaces.

  • Handling of animals in health care facilities.

  • Handling, transporting, storing, and disposal of medical waste.

The CDC concludes that the incidence of infections and pseudo-outbreaks can be minimized by appropriate use of cleaners and disinfectants, appropriate maintenance of medical equipment, adherence to water-quality standards for hemodialysis and ventilation standards for specialized care environments, and prompt management of water intrusion into the health care facility.

New Web Site on Hormone Therapy

The U.S. Food and Drug Administration (FDA) has launched a Web site containing information about hormone therapy for women. Recent clinical trial data regarding the usage of hormone therapy through menopause and beyond has created confusion and concern for many women. The Web site is available at http://www.fda.gov/womens/menopause.

The Web site contains information for women about hormones, hormone therapy, and a pocket guide that women can carry to their physician's office when discussing therapy options. The guide explains how to weigh the risks and benefits of both estrogen-progestin combination and estrogen alone.

Print versions of the resources can be ordered online or by calling 800-994-9662.

FDA Approval

The U.S. Food and Drug Administration has approved lamotrigine (Lamictal) for the long-term maintenance treatment of adults with bipolar I disorder to delay the time to occurrence of mood episodes (depression, mania, hypomania, mixed episodes) in patients treated for acute mood episodes with standard therapy.

The FDA has noted that the findings for lamotrigine maintenance treatment were more robust in bipolar depression. The effectiveness of lamotrigine in the acute treatment of mood episodes has not been established.

According to the manufacturer, the most common side effects are nausea, insomnia, somnolence, back pain, fatigue, rhinitis, nonserious rash, abdominal pain, dry mouth, constipation, vomiting, exacerbation of cough, and pharyngitis. Serious rashes requiring hospitalization and discontinuation of therapy, such as Stevens-Johnson syndrome, have been reported in association with the use of lamotrigine. The safety and effectiveness of lamotrigine have not been established as initial monotherapy, for conversion to monotherapy from nonenzyme-inducing antiepileptic drugs, or for simultaneous conversion to monotherapy from two or more concomitant antiepileptic drugs.

Lamotrigine has been available since 1994 and is indicated as adjunctive therapy for partial seizures in adults and children.


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