Recent Articles That May Affect Pediatric Practices

Educational Objectives

The goal of this program is to improve the management of hypomastia and protruding ears in pediatric patients. After hearing and assimilating this program, the clinician will be better able to:

1. Counsel patients about breast reconstruction or augmentation.

2. Determine age-appropriate interventions for patients with protruding ears.

Summary

Silicone Breast Implants

Case study: 17-yr-old girl exploring possibility of implant surgery; 1 in 20 breast implant procedures performed in teenagers; patient has mitral valve prolapse (MVP) and hypomastia; according to US Food and Drug Administration (FDA) criteria, indications for implant in this patient not cosmetic but reconstructive; patient fully mature; patient and mother prefer silicone implants over saline; have questions about safety and earliest age for medical indication

Balk et al: performed meta-analysis and systematic review of literature on silicone implants from first reports of use to present; found that evidence to support association between breast implants and health outcomes insufficient (eg, cancer, connective tissue disorders [scleroderma], rheumatologic and other autoimmune diseases, disorders of reproduction and offspring, mental health conditions); findings underscore idea that with indication for use, risks associated with silicone implants (cosmetic or reconstructive) potentially acceptable

FDA approval: silicone implants approved, with age restrictions; of all breast implantation procedures, ≈5% performed in teenagers; silicone implants previously removed from market based on studies that found rheumatologic complications (eg, scleroderma) in patients with ruptured implants; subsequent data do not suggest risk; silicone implants returned to market in 2006; preferred implant at all ages for majority of individuals

Age restrictions: FDA approved silicone implants for breast augmentation (cosmetic indications) in women aged ≥22 yr and for reconstruction at any age; approved saline implants for augmentation at ≥18 yr of age and reconstruction at any age; age 18 yr chosen because younger patients may not realize associated risks, have achieved full sexual development, or be psychologically prepared for change in body; indications for implantation at <18 yr of age — majority reconstructive surgical indications; speaker recommends waiting until age 22 yr, even in patient with indications; FDA recommends age 22 yr for best cosmetic lifetime outcome

Indications for reconstruction: Poland syndrome — unilateral absence of pectoralis major muscle with hypomastia; tuberous breast development — indication in 5% of augmentation procedures; breasts do not develop at puberty because of congenital deformity of ductal formation; skin forms pendulous breasts without breast tissue; others — severe hypomastia; asymmetry; condition causing deformity; consequence of surgical procedure (eg, cancer treatment)

Case study (continued): MVP may occur in complex with hypomastia, pectus excavatum, scoliosis, and high degree of laxity of joints (incidence high in ballet dancers); hypomastia defined as breast volume <200 mL, measured by displacement of water; of patients with hypomastia, MVP present in 48%; of patients with MVP, hypomastia present in >50%; incidence of MVP in children and adults 5%; thus, incidence of hypomastia in teenaged girls 2% to 3%

Prominent Ears

Case study: 2-yr-old boy recently adopted from China (minimal history available); noticeably protruding ears only physical abnormality; parents told ears protruding since infancy; angle of ear to temporal bone 50° (prominent); parents concerned that ears source of ridicule and bullying by peers; interested in learning about nonsurgical and surgical treatment; surgical treatment optimal at age 5 to 6 yr if not performed during first year of life

Bullying: incidence of noticeably protruding ears in children ≈5%; characters in comics who have prominent ears depicted as less intelligent; literature describes perception that children with outstanding ears not intelligent and immature; media portray individuals with large ears as less intelligent, less trustworthy, and undesirable as friends or associates; Litschel et al study — used marketing technology to determine whether prominent ears draw attention (pilot groups and eye tracking); teens and adults shown pictures of children with and without protruding ears, and fixation time noted; found attention focused on protruding ears; first documentation of amount of attention individuals pay to prominent ears

Evaluation and treatment: age critical in determining treatment; ideal time for intervention very early in life (clips worn on ears [Auri clips]); ears pliable because of effect of maternal estrogen from birth to 1 yr of age; reported efficacy of clips 70% to 100%; if correction not performed in infancy, surgical procedure required (optimal age 5 to 6 yr); teenagers with prominent ears may use double-adhesive tape (Auri strips) to pin ears back

Readings

Balk EM et al: Long-term health outcomes in women with silicone gel breast implants. Ann Intern Med 2016 Oct 4;165(7):527-8; Gabriel A et al: The evolution of breast implants. Clin Plast Surg 2015 Oct;42(4):399-404; Hajdu SD et al: Silicone and autoimmunity. Eur J Clin Invest 2011 Feb;41(2):203-11; Litschel R et al: Effect of protruding ears on visual fixation time and perception of personality. JAMA Facial Plast Surg 2015 May-Jun;17(3):183-9; Pawar SS et al: Treatment of prominent ears and otoplasty: a contemporary review. JAMA Facial Plast Surg 2015 Nov-Dec;17(6):449-54; van Wijk MP et al: Non-surgical correction of congenital deformities of the auricle: a systematic review of the literature. J Plast Reconstr Aesthet Surg 2009 Jun;62(6):727-36.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Stockman was recorded at Hot Topics in Pediatrics, presented by Nemours Children’s Health System and held July 27-30, 2016, in Lake Buena Vista, FL. For information about upcoming CME conferences from Nemours Children’s Health System, please visit www.pedsuniversity.org. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PD631102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.