Melissa Young

Pediatric migraine and the International Headache Society (IHS) criteria

BACKGROUND The optimal criteria for the diagnosis of migraine without aura in children are controversial. One strategy for assessing the validity of diagnostic criteria is to compare them with expert clinical diagnoses. OBJECTIVE To study the agreement between clinical headache diagnoses assigned by pediatric neurologists and symptom-based diagnoses using the International Headache Society (IHS) criteria as well as alternative case definitions. METHODS We reviewed the records of 253 children and adolescents consecutively evaluated by pediatric neurologists at the Montefiore Headache Unit. Clinical diagnoses assigned by the physicians were used as the gold standard in evaluating the validity of the IHS criteria for the diagnosis of migraine without aura. Alternative symptom-based diagnoses were compared with the clinical gold standard. RESULTS Detailed headache histories were abstracted from charts of 253 children; 167 children had complete data on all features required for IHS diagnosis. Eighty-eight (52.7%) children received a diagnosis of migraine without aura. Using the clinical diagnosis as the gold standard, the IHS criteria had a sensitivity of 27.3% and a specificity of 92.4%. The poor sensitivity of the IHS definition is a consequence of the rarity of certain features in children clinically diagnosed with migraine: duration of 2 hours or longer (55.7%), unilateral pain (34.1%), vomiting (47.7%), and phonophobia (27.3%). Based on these findings we suggested a definition for pediatric migraine headache without aura that is less complex, more sensitive (71.6%), and almost as specific as the IHS criteria. CONCLUSIONS The IHS criteria for migraine without aura have poor sensitivity but high specificity using a clinical diagnosis as the gold standard. The IHS criteria should be modified to better reflect current pediatric clinical practice.

Estimation of fish and ω-3 fatty acid intake in pediatric nonalcoholic fatty liver disease.

Aims: Fish and &ohgr;-3 fatty acids are reported to be beneficial in pediatric nonalcoholic fatty liver disease (NAFLD), but no studies have assessed their relation to histological severity. The objectives of this study were to evaluate the dietary intake of fish and &ohgr;-3 fatty acids in children with biopsy-proven NAFLD, and examine their association with serological and histological indicators of disease. Methods: This was a cross-sectional analysis of 223 children (6–18 years) who participated in the Treatment of Nonalcoholic Fatty Liver Disease in Children trial or the NAFLD Database study conducted by the Nonalcoholic Steatohepatitis Clinical Research Network. The distribution of fish and &ohgr;-3 fatty acid intake was determined from responses to the Block Brief 2000 Food Frequency Questionnaire, and analyzed for associations with serum alanine aminotransferase, histological features of fatty liver disease, and diagnosis of steatohepatitis after adjusting for demographic, anthropometric, and dietary variables. Results: The minority of subjects consumed the recommended 8 ounces of fish per week (22/223 [10%]) and 200 mg of long-chain &ohgr;-3 fatty acids per day (12/223 [5%]). Lack of fish and long-chain &ohgr;-3 fatty acid intake was associated with greater portal (P = 0.03 and P = 0.10, respectively) and lobular inflammation (P = 0.09 and P = 0.004, respectively) after controlling for potential confounders. Conclusions: Fish and &ohgr;-3 fatty acid intake was insufficient in children with NAFLD, which may increase susceptibility to hepatic inflammation. Patients with pediatric NAFLD should be encouraged to consume the recommended amount of fish per week.

Detection of Polyethylene Glycol-based Laxatives in Stool

The ability to test stool for laxatives is an important part of patient care in some clinical circumstances. Some patients take or are given laxatives surreptitiously. Additionally, failure to take prescribed laxatives may result in treatment failure in children with constipation or encopresis. Although laboratory methods have been available to identify many laxatives in the stool, tests are not available for detecting polyethylene glycol (PEG)–based laxatives. PEG-based laxatives are frequently used in the treatment of children with constipation. We developed a mass spectrometry (MS)–based analysis for detecting PEG in stool and verified the technique in an adult volunteer. We then piloted the assay on stools from children taking PEG for constipation versus children with diarrhea who were not taking PEG. Eleven subjects with diarrhea and 8 receiving PEG were enrolled. Nine of the children with diarrhea and 7 receiving PEG were evaluated by MS. All 3 subjects with PEG who had a stool osmolal gap determined had elevated gaps. Stools of all 7 subjects with PEG were positive for PEG by MS, whereas none of the 9 subjects with diarrhea had stool positive for PEG. This new MS methodology to test stool for PEG is described. It is likely to prove useful in the documentation of surreptitious PEG administration and in evaluation of PEG treatment failure.