Nachsorge im Erwachsenenalter

Cancer and its treatment can lead to chronic or late occurring problems many years after therapy. The most important known late effects include second primary malignancies, caused by radiotherapy or alkylating agents, cardiomyopathy, endocrine late effects, and cardiovascular problems which are often exacerbated by obesity and subsequent metabolic syndrome. Knowledge about late effects in adulthood brings new problems, which can only be addressed in cooperation between pediatric oncologists and adult specialists in various disciplines. While scientifically gathered information is required to form a basis, we also need to develop new treatment models, which in principal have the same goals, but which are wholly location-specific. Ensuring that both patients and their treating physicians are well informed has been proven to form a strong basis for good treatment in adulthood.     

ADHS und Psychotherapie

Psychotherapy and psychosocial interventions can be focused on the patient, the parents or other persons (teacher). Generally these interventions have been proven to be effective in numerous empirical studies; however, their overall effects are somewhat less than those of pharmacotherapy. Parent-education and school-based interventions yielded significant results. The combination of pharmaco- and psychotherapy is often indicated. The Treatment Program for Children with Hyperkinetic and Oppositional Problem Behavior (THOP) and the Treatment Program for Adolescents with Disturbances of Self-Esteem, Performance and Relationship (SELBST) are outlined as examples of psychotherapeutic interventions. The main problem in clinical practice is the lack of resources available for these interventions.     

Angeborene Herzfehler im Erwachsenenalter

The advances in pediatric cardiology, pediatric cardiac surgery and postoperative intensive care have led to a long-term survival of children of over 90% even with complex congenital heart diseases. Hence, a new challenging patient population emerges for follow-up in adult life. Residual as well as subsequently developed lesions have to be recognized and treated correctly. These include acute complications, such as arrhythmias, endocarditis, cerebral events due to embolisms as well as chronic problems, such as central cyanosis or arterial hypertension. Optimal timing of cardiac surgery or catheter interventions is crucial. Management of pregnancy and delivery requires a specific, interdisciplinary guidance of the patients. The optimal care of adults with congenital heart disease should be multidisciplinary with a close cooperation of pediatric cardiologists and cardiologists with extensive experience in the care of this patient group. Last but not least psychosocial issues should be taken into consideration and dealt with.     

Pharmakotherapie bei Kindern und Jugendlichen mit ADHS

The clinical guidelines for hyperkinetic disorder in children and adolescents include, besides medication, nonpharmaceutical therapies such as psychological interventions and educational changes. The diagnosis should be made in accordance with DSM-IV criteria or the guidelines in ICD-10 and should be based on a full history and evaluation of the patient. Pharmacotherapy is not indicated for all children with this syndrome, and the decision to use any of the drugs must be based on a thorough assessment of the severity, impact, and developmental appropriateness of the child’s symptoms. To date, stimulants and atomoxetine remain the preferred means of treating attention deficit hyperactivity disorder (ADHD) pharmacologically. Meanwhile, new drugs and drug preparations have been approved, the effects of which last through a substantial part of the day. In addition, atomoxetine as a nonstimulant has been licensed and is used often. However, all of these new drugs are associated with higher costs, and choosing among them can be difficult. This article provides an overview of the different pharmacological treatment options.     

Atomoxetinbehandlung von Kindern und Jugendlichen mit ADHS

This paper reviews the pharmacology, efficacy, duration, tolerance, and side effects of atomoxetine for children, adolescents, and adults. A systematic review of the clinical studies and poster abstracts which have been published in the literature was conducted. Atomoxetine is a highly selective inhibitor of the noradrenaline transporter, and the first non-stimulant compound that was FDA-approved in the US for the treatment of ADHD in children, adolescents and adults. In clinical studies, its efficacy was examined in more than 4,000 patients. Compared with placebo, atomoxetine was shown to be superior in reducing impulsivity, hyperactivity, and inattention. There are indications of comparable efficacy to methylphenidate. In general, atomoxetine was well tolerated. The most frequently reported adverse events were a decrease in appetite, abdominal problems, somnolence, fatigue and dizziness. These were classified as mild and were mostly found at the beginning of treatment. The existing research results indicate that atomoxetine is a promising substance for the treatment of ADHD in children, adolescents, and adults.     

Diagnostik des ADHS

Attention deficit hyperactivity disorder (ADHD) is a very common disorder in childhood and adolescence. The diagnosis is challenging and requires deep insight regarding the developmental psychopathology of children and adults. Different assessments of the child’s behaviour from parents and teachers, self-assessment, and a medical history and exploration are essential parts of the clinical investigation. Conduct disorder, affective and anxiety disorder, and developmental disorder are commonly associated with ADHD; therefore, different dimensions of feeling, behaviour, and scholastic skills should also be investigated.     

Komorbidität bei ADHS

Attention-deficit hyperactivity disorder (ADHD) is frequently associated with other neuropsychiatric childhood disorders. Thus, the clarification and routine assessment of these comorbidities should be a major focus in clinical practice (i.e., in diagnosing and treating children suffering from ADHD). Over the past decade scientific endeavors targeted at better characterizing the background and dynamics of ADHD-associated comorbidities increased considerably. The main aims of this article are: (a) to present an overview of current conceptualizations of comorbidities, and (b) to provide the reader with the prevalence rates as well as the genetic and cognitive aspects of ADHD-associated disorders (e.g., dyslexia, dyscalculia, oppositional defiant disorders, depression, anxiety). Based on the presented findings, the currently most plausible explanations for the respective comorbidities as well as their implications for clinical practice will be discussed. Overall, greater attention should be devoted to the complex interplay between ADHD and associated disorders.     

Aufmerksamkeitsdefizit-Hyperaktivitäts-Syndrom (ADHS)

Zusammenfassung 12 Jungen mit gesichertem, schwerem ADHS, die zum Zeitpunkt der Studie keine Medikation erhielten, wurden erfasst. Bezüglich des DSM-IV-Systems waren alle für alle Teilaspekte der Klassifikation positiv. Sie wurden mit einer eigens programmierten Software PC-gestützt untersucht: Die Knaben wurden aufgefordert, eine Taste insgesamt 128-mal in der ihnen angenehmen Taktfrequenz zu drücken. Hinsichtlich Median und Mittelwert der Tastintervalle fand sich kein statistisch signifikanter Unterschied. Streuung und Spannweite der Intervalle waren bei Patienten mit ADHS gegenüber dem Vergleichskollektiv signifikant erhöht. Bei diesen Kindern liegt somit trotz frei wählbarer Frequenz eine erhöhte Arrhythmizität vor, was durch Umwelteinflüsse oder genetische Polymorphismen erklärt werden könnte. Eine mögliche Ursache könnte im genetischen Uhrensystem liegen. Beim Menschen sind derzeit 3 zirkadiane Uhrengene, die als Kandidatengene in Frage kommen, bekannt (clock, per2, bmal1). Sowohl bei diesen als auch bei an der Signalkaskade beteiligten Proteinen sind Polymorphismen und Mutationen beschrieben, die mit einer vermehrten Arrhythmizität gekoppelt sind.Prof. D. Harms zum 65. Geburtstag gewidmet.     

Behandlung von ADHS mit Atomoxetin

Most children presenting with attention deficit–hyperactivity syndrome (ADHS) do not receive any medication, even though pharmacological treatment of ADHS is one of the most efficient elements in a multimodal approach to treatment. As a rule, in children who are treated for ADHS with medication the drug administered is the stimulant methylphenidate. A stimulant therapy does have disadvantages, however: lack of efficacy or inadequate effect in some cases, and potential side effects and abuse. One alternative for use in ADHS is the noradrenaline receptor inhibitor atomoxetine. Its pharmacology, efficacy and tolerability in children and adolescents are presented, as are tips for making the switch from stimulants to atomoxetine. Early experience in children and adolescents in whom the switch has been made is definitely positive. The particular advantages of atomoxetine lie in its continuous effect, which lasts throughout the day to the next morning, and its favourable side effect profile. A combination of atomoxetine and psychostimulants is also possible, and it seems this would always be helpful when it has not proved possible to attenuate the symptoms by means of monotherapy.     

Sport- und Wettkampftauglichkeitsuntersuchungen im Kindes- und Jugendalter

Background

Children over 8 years old and at the latest 10 years old who participate in club competitions must be medically examined to ensure that they are fit enough to participate in competitive sports.

Objective

It is the duty of the examining physician to carry out examinations to test the capability to participate in competitive sports in such a way that the children, parents and trainers can be sure that there are no tangible risks which prohibit participation in the type of sport or competitive sports

Material and methods

The medical examination must include the medical and family history, the general and training history as well as a clinical and pediatric examination including postural behavior and the musculoskeletal system. In order to exclude congenital risk factors it must be obligatory to carry out a resting electrocardiogram (ECG). The medical examination must be carried out at least once. In order to detect intercurrent pediatric problems, e.g. growth surges, infections, injuries and overexertion injuries and pathological compensation problems of the cardiovascular system, the examination should be optimally carried out annually.

Results and discussion

Using a standardized investigation form the frequency of cardiovascular events can be reduced and damage due to congenital or acquired pathologies of the musculoskeletal system can be prevented. This results in the greatest possible safety for parents, trainers and athletes that only children who are suitable for the sports selected for them can participate in competitions. By regularly carrying out adequate medical physical examinations stress-related damage and injury due to the sport can be kept to a minimum.     

Passionsblume in der Behandlung des ADHS

Hintergrund:

Psychostimulantien, sowie – als zweite Wahl – Clonidin und Noradrenalin- Wiederaufnahmehemmer sowie SSRI haben sich als effizient in der Behandlung der ADHD erwiesen. Aber auch Phytotherapeutika wie Kamille, Hopfen, Baldrian oder gar Ginkgo scheinen in der Behandlung dieser Störung wirksam zu sein. Es gibt aber wenig diesbezügliche systematische Beobachtungen. Aus diesem Grund wurde der Effekt von Passiflora incarnata für die ADHD untersucht.

Methode:

Unser 14jähriger männlicher Patient mit der nachgewiesenen Diagnose ADHD, diagnostiziert nach ICD-10 Kriterien, wurde vor und nach der 4wöchigen Verabreichung von Passiflora incarnata anhand der Conner-Skalen bewertet.

Resultate:

Insgesamt wurde der Durchschnittsscore deutlich besser, wie auch die Faktoren Überaktivität und Unaufmerksamkeit sowie Impulsivität.

Schlussfolgerungen:

Trotz der Einschränkung, dass die Generalisierung einer Einzelfallbeobachtung sehr schwer ist, legen die Ergebnisse unserer Beobachtung doch eine zumindest supportive Wirkung von Passiflora incarnata nahe.

     

Übergewicht und Adipositas im Kindes- und Jugendalter

Zusammenfassung Übergewicht ist eines der größten Gesundheitsprobleme in der westlichen Welt. Aktuelle Studien zeigen einen alarmierenden Anstieg in der Prävalenz von Übergewicht und Adipositas im Kindes- und Jugendalter. Seit 1976 stieg die Häufigkeit in Deutschland um mindestens 50% an. Eine kürzlich vorgestellte deutsche Studie des Robert Koch-Instituts an 17.000 Kindern und Jugendlichen zeigte, dass insgesamt 15% aller deutschen Kinder und Jugendlichen übergewichtig sind, 6,3% leiden unter Adipositas. Aus übergewichtigen Kindern entwickeln sich in den meisten Fällen übergewichtige Erwachsene mit hohen Risiken für akute und chronische Folgeerkrankungen wie Bluthochdruck, Fettstoffwechselstörungen, koronare Herzkrankheit, Krebs, Gicht, psychosoziale Störungen und orthopädische Erkrankungen. Die Prävention von Übergewicht muss bereits ab der frühen Kindheit erfolgen. Bisher werden nur etwa 20% der übergewichtigen Kinder diagnostiziert und behandelt.Korrespondenzadresse:Prof. Dr. B. KoletzkoAbteilung Stoffwechselkrankheiten und Ernährungsmedizin, Dr. von Haunersches KinderspitalKlinikum der Ludwigs-Maximillians-UniversitätLindwurmstraße 480337 München     

Asthmamanagement im Kindes- und Jugendalter

Background

Despite widespread use of anti-inflammatory drugs the morbidity of asthma in the paediatric age group is still increasing. Los acceptance of therapy may be a reason for this.

Methods

A validated questionnaire was administered in to 101 children and 109 of their parents in personal interviews and to 102 paediatriicians in telephone interviews.

Results

The majority of the children and their parents expressed dissatisfaction with the current asthma management. Children and their parents expressed very similar judgments, but the answers given by the paediatricians differed notably from those of both other groups. The physicians underestimated the time taken up by the therapy, and overestimated the patients’ anxiety aboutasthma drugs. New types of inhalers (dry powder inhalers; DPIs) were not rated at all highly, “classic” MDIs (metered dose inhalers) being preferred by children and their parents, followed by tablets or capsules. Physicians imagined patients would prefer DPIs,as they themselves thought these were superior for inhalation therapy. In addition, children and their parents reported more frequently than the paediatricians imagined that they would like more information on the disease and the medication available, Especially if this were presented in a group situation or through the new media.

Conclusion

It will not be possible to improve compliance in asthma management unless the frequency of drug administration isreduced and better communication between doctor and patient is achieved.     

Akne im Kindes- und Jugendalter

Acne vulgaris is one of the most common diseases of the skin. With a prevalence of over 80% it is perceived as a physiological condition in adolescence and typically resolves by the age of 20 years. At other points in life acne is less common but still has to be considered clinically. In this context acne in young children (acne neonatorum, infantile acne) as well as persisting acne until the fourth or fifth decade (acne tarda) or acneiform diseases should be mentioned. Those diseases can present at any time of life and basically include rosacea, perioral dermatitis (rosacea-like dermatitis), pityrosporum folliculitis and acneiform reactions due to medication. The etiopathogenetic factors concerning the sebaceous gland-follicular unit have to be considered for therapeutic approaches. Retinoids, antibiotics, benzoyl peroxide and azelaic acid are the main therapeutic medications.     

Knochenschmerzen im Kindes- und Jugendalter

Pain of the musculoskeletal system is a frequent symptom in childhood. Malignancies like primary bone tumors, metastases, and diseases of the bone marrow or inflammation as in bacterial osteomyelitis and nonbacterial osteitis may be the underlying disease. Chronic pain syndromes and growth pain are further differential diagnoses. Rarely endocrinologic disorders are the cause of bone pain. This broad spectrum of possible disorders complicates the choice of diagnostic procedures. In malignancy and osteomyelitis, early diagnosis and therapy are essential for outcome and prognosis. Chronic pain syndromes are seen mainly in female adolescents.