How Does Pediatric Sjögren Syndrome Present?

Patient Presentation
A 14-year-old female came to clinic with fever to 101.2°F and sore throat for 36 hours. She also complained of some nausea but denied emesis, rash, cough, rhinorrhea or diarrhea. She had been around people with strep throat at school. Her past medical history was positive for Sjögren Syndrome diagnosed at age 9 after she had recurrent parotitis and multiple caries. Her disease had progressed to include some arthritis and she was treated with pulse steroids and an anti-inflammatory biological agent which did not work for her. She had been off her steroids for more than 1 year. The family history was positive for systemic lupus erythematosus. The pertinent physical exam showed a tired looking female. Her eyes were normal. Tympanic membranes were also normal. Her mouth had erythema of the posterior pharynx, and pus on her tonsils and palatal petechiae. She had some shotty anterior cervical nodes. Her lungs, abdomen and heart examinations were normal. Her skin did not show any rashes.

The laboratory evaluation of a rapid streptococcal test was positive. The diagnosis of of a patient with strep throat was made. She was prescribed penicillin. She was very knowledgeable about her disease and told the physician that “My doctor told me that as long as I am not taking the steroids then my immune system is like everyone elses.” Her mother agreed and said how they were all so glad to have her not taking the steroid medications, but they knew that her symptoms could get worse again. The girl had a followup appointment with her immunologist the following week, and so her annual influenza vaccine was deferred until that appointment.

Sjögren Syndrome (SS) is named for Swedish ophthalmologist Henrik Sjögren who published a case series in 1933 describing patients with dry eyes and arthritis. SS is a “chronic autoimmune inflammatory exocrinopathy” that is characterized by lymphocytic infiltration of the lacrimal and salivary glands and has various degrees of systematic involvement. Keratoconjunctivitis sicca and xerostomia are the main clinical symptoms.

Sicca is a Latin word meaning dry. Dryness of the eyes and mouth without evidence of autoimmune disease is called Sicca syndrome or Sicca complex. SS can be primary or secondary. Primary includes keratoconjunctivitis sicca and xerostomia which is the same as Sicca syndrome. Secondary includes keratoconjunctivitis sicca and xerostomia and evidence of connective tissue disease, usually rheumatoid arthritis. Many people with Sicca syndrome may have SS, but not all. SS is an autoimmune disease and therefore the cause of the Sicca syndrome symptoms needs to be established that it is caused by an autoimmune problem and not because of another reason. Symptoms may take time to develop and therefore patients can be diagnosed with Sicca syndrome before SS is diagnosed.

SS in adults is a clinical diagnosis with various professional organizations having diagnostic criteria for making its diagnosis. Patients usually have dry eyes, dry mouth, and abnormal salivary gland biopsies and abnormal laboratory testing. Patients are usually female and between 40-50 years old. SS can be found with other autoimmune disorders such as rheumatoid arthritis or systemic lupus erythematosus.

SS is thought to be rare or possibly underdiagnosed in children as it’s classical manifestations seen in adults are less likely to occur in children. Although dry eyes or mouth are less common, detailed history may find additional symptoms. Abnormal laboratory testing especially Anti-SS-A or Anti-SS-B or antinuclear antibodies are often positive. Recurrent parotitis is one of the first symptoms, and is the most frequent and most consistent symptom at diagnosis and followup. Causes of parotitis can be reviewed here.

Pediatric patients with SS are usually female as well (5:1 being reported) and patients can be as young as 4 years old. Average is around 10 years in some studies.

Learning Point
Pediatric patients with SS may have the following:

  • Oral symptoms and signs
    • Recurrent parotitis (64%)
    • Xerostomia – (27%) may be present with detailed history
    • Caries, multiple
    • Candidiasis, erythematous
  • Ocular symptoms and signs
    • Dry eyes – (33%)
    • Negative Schirmer or Rose Bengal testing is common
  • Salivary gland involvement
    • Histopathology changes of the parotid gland on biopsy are relatively common
    • Histopathology changes of the minor salivary glands on biopsy are less common
  • Abnormal laboratory testing
    • Anti-SS-A (Ro) positivity (67%)
    • Anti-SS-B (La) positivity (62%)
    • Antinuclear antibodies positivity (82%)
    • Rheumatoid factor positivity (53%)

Other systemic extraglandular problems include:

  • Dermatological
    • Vasculitis – can look like Henoch-Sch&oum;nlein purpura, erythema nodosum or granuloma annulare
  • Gastrointestinal
    • Hepatitis, autoimmune
    • Pancreatitis
  • Hematological
    • Anemia
    • Hypergammaglobulinemia
    • Lymphoma
  • Nervous system
    • Central nervous system
      • Cerebellar ataxia
      • Meningoencephalitis
      • Optic neuritis
      • Transverse myelitis
    • Headache
    • Peripheral neuropathy
  • Musculoskeletal
    • Arthralgia
    • Hypokalemic paralysis
    • Rheumatoid arthritis
    • Polyarthritis
    • Raynaud phenomenon
  • Pulmonary
    • Alveolitis
    • Interstitial lymphocytosis
  • Renal
    • Glomerulonephritis
    • Renal tubular acidosis

Note: percentages are from 2012 systematic review

Questions for Further Discussion
1. What treatment is available for Sjögren Syndrome?
2. What specialists should be involved in the care of patients with Sjögren Syndrome?
3. How do you perform a Schirmer test?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Sj&ouml:gren’s Syndrome

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Singer NG, Tomanova-Soltys I, Lowe R. Sjögren’s syndrome in childhood. Curr Rheumatol Rep. 2008 Apr;10(2):147-55.

de Souza TR, Silva IH, Carvalho AT, Gomes VB, Duarte AP, Leão JC, Gueiros LA. Juvenile Sjögren syndrome: distinctive age, unique findings. Pediatr Dent. 2012 Sep-Oct;34(5):427-30.

Maciel G, Crowson CS, Matteson EL, Cornec D. Incidence and Mortality of Physician-Diagnosed Primary Sj&ouml:gren Syndrome: Time Trends Over a 40-Year Period in a Population-Based US Cohort. Mayo Clin Proc. 2017 May;92(5):734-743.

Olschowka N. The History of Henrich Sjögren. Association Du Syndrome De Sjögren. Available from the Internet at: (rev. 2017, cited 10/10/17).

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

December 11, 2017

How Do You Perform the Adams Forward Bend Test?

Patient Presentation
A 12-year-old female came to clinic for her health supervision visit in June. She was doing well but her mother was concerned about her back as her aunt had noticed a “lump” on her back when she bent over at the swimming pool. The mother said that it just looks like her shoulder is a little higher on the right side. The girl denied any pain, discomfort or problems with mobility. The patient had not started her periods but had started to “develop” per her mother and was getting taller. The family history was negative for any back problems including scoliosis, but the mother said that her maternal great grandmother had lost height and became more “hunchback” when she was older. The review of systems was negative.

The pertinent physical exam showed a cooperative female with normal vital signs and growth parameters. Her height was 75% which was slightly increased from the 50-75% she had been tracking. Her weight was 50%. Her musculoskeletal examination was negative. On Adams forward bend test she had an elevation of the right rib/scapula that improved but did not go away with proper re-positioning of the patient. Her hips and shoulder levels appeared to be normal. She was Tanner 3 for breast and Tanner 2 for pubic hair. The rest of her examination was normal including skin examination.

The diagnosis of probable idiopathic scoliosis with a positive forward bend screening test was made in a skeletally immature female. The radiologic evaluation of a spine radiograph showed a right thoracic curve of 11°. The patient’s clinical course showed that after discussing the results with the family, they wanted a referral to an orthopaedist because she was undergoing her growth spurt. Repeat radiographs one year later showed an increase in the Cobb angle to 13° and another year later it was 15°. At this time she was postmenarchal and repeat examination 6 months and 1 year later showed no additional progression. She was clinically well over this entire followup time period.

Scoliosis is a lateral and rotational curvature of the spine from a plumb line hanging from C7 to the floor.
Idiopathic scoliosis is the most common form. A review of scoliosis and its differential diagnosis can be found here.

Depending on the age, 2-4% of adolescents have a positive Adams Forward Bend Test when assessed and ~2% may have idiopathic scoliosis of > 10 degrees. Curve progression relates to the magnitude of the curve and the patient’s age. Thus increased risk of progression occurs in patients with higher curvature magnitude at diagnosis, females (earlier start of puberty and therefore possibly not identified or have great curvature to start with), younger children (same reason), being skeletally immature, symptomatic (pain or other neurological problems), underlying disease (e.g. congenital, neuromuscular, connective tissue disease, or foot deformities), and patients with excessive lordosis or kyphosis.

Routine clinical screening is controversial but several professional organizations including the American Academy of Orthopaedic Surgeons and the American Academy of Pediatrics recommend screening. It is recommended to screen females in US in 5th and 7th grades (10-11 years and 12-13 years), and males in 8th grade (13-14 years).

In general, idiopathic scoliosis that has a Cobb angle 50 degrees often progress at a rate of 0.75-1.00 degree/year. Those between ~30-40 degrees may or may not progress but are at risk especially if skeletally immature.

The most common curve variation is a righted-sided thoracic curve with a compensatory left-sided lumbar curve. Some people remember this as RIGHT in the thoRax and LEFT in the Lumbar spine. If a different pattern is seen then alternative causes to idiopathic scoliosis should be considered. Treatment options depend on the magnitude of the curve and risk of progression.

Learning Point
Mr. William Adams (1820-1900) along with Dr. Thomas Hodgkin (1798-1866) described scoliosis in a post mortem examination of a contemporary physician in 1854. Mr. Adams later described his “Forward Bend Test” in lecture 10 in his series of Lectures on the Pathology and Treatment of Lateral and Other Forms of Curvature of the Spine.

The primary evaluation for scoliosis is inspection looking for asymmetric laterality and the Adams Forward Bend Test.

  • The patient is inspected standing upright with feet together and knees extended/straight with arms held at the side. The head should be in an upright neutral position. The patient is inspected from the front noticing differences in shoulder or waist alignment from side-to-side or prominence of the chest.
  • The patient is again inspected from the back noticing any differences in the shoulder or waist alignment or prominence of the scapula or ribs. The location and laterality of any potential abnormalities should be noted.
  • The patient is then instructed to put both of their palms together, head down and bend forward, similar to diving. The palms should be together but arms should hang freely.
    The examiner’s eyes should be level with the spine from behind and noticing if there are any differences in the scapula, rib cage or paraspinous muscles.

  • If a scoliometer (inclinometer) is used and there is a difference in laterality, 5-7 degrees is considered the cut-off point for positive screening.

Other areas to note on examination include dermatological examination for sign of neurofibromatosis (e.g. axillary freckling, cafe-au-lait spots, subcutaneous fibromas), joint examination for signs of connective tissue disease (e.g. joint laxity, arachnodactly), and midline spinal abnormalities such as dimpling. Leg length discrepancy may also cause a false positive Adams test.

While inspection and the Adams Forward Bend Test seems to be a simple painless test, patients will often not understand the instructions or fail to move their body into the correct position and therefore need additional instructions. The patient may need to be reminded to stand erect during the upright part of the test with weight balanced between their feet. This should correct any positional changes that are solely caused by posture or positioning. If abnormalities do not correct then there is possible scoliosis or a leg length discrepancy. Placing the examiner’s fingers on the top of the scapula (acromium) and thumb on the inferior angle of the scapula can also help the examiner to determine if there is mild shoulder height differences or scapular prominences. The examiner’s own spatial perception of where his/her hands are in space may be more sensitive than visual inspection alone. Similarly, placement of the examiner’s hands on the iliac crests bilaterally may again also allow better visual inspection for height differences between sides, especially in obese patients. The examiner’s spatial perception may also detect small alignment differences.

During the bending part of the test, patients will often try to keep their head up, place their hands on their knees or bend their knees. Again reminding the patient to move into the proper position and maintain it while the examination is carried out is important. Some patients will try to touch their feet and will not have enough flexibility to do this, thus they move during the examination. Reminding the patient they do not have to stretch, just bend forward often helps. Running the examiner’s hand over the entire spine from C7-L5 during the forward bend part of the examination may also help to assess alignment or rotation, especially in obese individuals.

Indications for further evaluation include if abnormalities are noticed on physical examination, a scoliometer reading of > 5-7 degrees, abnormal curve pattern or other abnormal physical examination findings particularly in young or skeletally immature patients.

Questions for Further Discussion
1. What other caveats do you have for performing the Adams Forward Bend Test?
2. How successful are non-surgical and surgical treatment for scoliosis?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Scoliosis and Spine Injuries and Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Hodgkin T, Adams W. Case of Distortion of the Spine, with observations on Rotation of the Vertebrae as a complication of Lateral Curvature. Med Chir Trans. 1854;37:167-180.5.

Adams W. Lectures on the Pathology and Treatment of Lateral and Other Forms of Curvature of the Spine, 2nd ed. London; J & A Churchill, 1882.

Fairbank J. Historical perspective: William Adams, the forward bending test, and the spine of Gideon Algernon Mantell. Spine (Phila Pa 1976). 2004 Sep 1;29(17):1953-5.

Rosenberg JJ. Scoliosis. Pediatr Rev. 2011 Sep;32(9):397-8; discussion 398.

Horne JP, Flannery R, Usman S. Adolescent idiopathic scoliosis: diagnosis and management. Am Fam Physician. 2014 Feb 1;89(3):193-8.

Hresko MT. Clinical practice. Idiopathic scoliosis in adolescents. N Engl J Med. 2013 Feb 28;368(9):834-41.

Hresko MT, Talwalkar V, Schwend R; AAOS, SRS, and POSNA. Early Detection of Idiopathic Scoliosis in Adolescents. J Bone Joint Surg Am. 2016 Aug 17;98(16):e67.

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

December 4, 2017

Can I Give Cholera Vaccine?

Patient Presentation
A 17-year-old male came to clinic for travel immunizations before a medical mission to Haiti for 2 weeks. His father was a health care provider and had traveled to Haiti on two previous trips, but this trip was to spend more time in more rural locations. His father had been to the travel clinic and had received cholera vaccine along with malaria prophylaxis. He was current with typhoid vaccine. The pertinent physical exam showed a healthy teenager with normal vital signs and growth parameters in the 75-95%. His examination was normal.

The diagnosis of a healthy male was made. The pediatrician reviewed the Centers for Disease Control website for current immunization recommendations for Haiti. The teenager was current with his standard vaccinations and received typhoid vaccine and malaria prophylaxis along with counseling regarding using insect repellent, safe water and hygiene practices. “Unfortunately you just turned 17, and the cholera vaccine in the United States is only for those over 18 years, so I can’t give it to you. It’s really, really important that you use safe water and wash your hands well, ALL THE TIME,” the pediatrician emphasized. The father said that he had been making his son practice at home using bottled water for drinking, toothbrushing and preparing meals. “It’s a lot of work to fill up the bottles from the faucet and practice, but I don’t want to get sick so I guess its okay,” the teen obliged.

Cholera is caused by more than 200 serogroups of Vibrio cholerae, a Gram-negative rod that is waterborne. Only two (serogroup O1 which causes about 99% of the cases, and O139) cause disease. There are biotypes of each of these serotypes. The only known hosts are humans. The organism colonizes the epithelial lining of the gut. Cholera toxin is produced by some species and if produced binds to specific receptors on host cells, activating a series of steps which cases massive loss of sodium, potassium, chloride, hydrogen carbonate, and fluids in vomitus and feces. A review of causes of diarrhea can be found here.

More than 1 billion people are at risk for cholera in endemic countries with an estimated 2.86 million cases and ~95,000 deaths annually Cholera is endemic in sub-Saharan Africa and Asia but has areas that have become epidemic such as Haiti and Yemen in the past few years. Studies in Africa have an incidence of < 0.3/10,000 which increased to 20/10,000 during epidemics. About half of the cases and deaths are in children < 5 years of age. For travelers from non-endemic countries cholera is rare with a risk of 0.01-0.001% per month of stay in a developing country. Cholera is rare in the United States with < 25 cases/year reported with most occurring among travelers to epidemic or endemic cholera.

Cholera is spread by direct fecal-oral and contaminated water or food routes thus the risk of cholera increases in areas where crowding, lack of access to clean water, sanitation and health care are issues. Incubation period is < 24 hours to 5 days. Only 1-25% of those exposed actually develop disease. Of those that are symptomatic, 10-20% experience severe disease. Symptomatic patients produce watery diarrhea sometimes referred to as "rice water stools." Emesis can also occur. Symptoms last 1 to a few days. Patients can have profuse fluid loss of up to 0.5 – 1.0 liters/hour and obviously severe dehydration is a major cause of morbidity and mortality if not promptly and aggressively treated. Healthy persons have been known to die within 24 hours of symptom onset because of the complications of dehydration.

Risk factors for cholera include number of bacteria ingested, lack of immunity from prior disease or vaccination, lack of passive immunity for newborn infants because of lack of breastfeeding, pregnancy, immunocompromised state (especially HIV), malnourishment, blood group O, and decreased ability to make gastric acid which neutralizes the bacteria. High concentrations of the bacteria is found in feces, and often vomitus also. There is some data suggesting “…that passage through a human host transiently increases the infective potential of V. cholerae by creating a hyperinfectious state that is maintained soon after shedding, and which may contribute to the epidemic spread of the disease.”

The diagnosis standard is by culture, but polymerase chain reaction testing and other rapid diagnostic testing is also available. Treatment is by rapid and aggressive administration of fluid and electrolytes. In patients with mild to moderate dehydration, oral rehydration with low osmolarity oral rehydration solution (ORS) is standard. The lower osmolarity compared to standard ORS decreases emesis. For severe dehydration, intravenous fluid administration with correction of electrolytes is imperative. Antibiotics are given to hospitalized patients during epidemics which decreases the symptom duration, stool volume, and length of time the active pathogen is excreted which reduces transmission and hospital length of stay. Doxycycline is usually the first choice, but ciprofloxacin or azithromycin are used in doxycycline-resistant areas. Unfortunately drug-resistance is common.

Although both children and adults are able to mount antibody responses to both the organism and the toxin, they are not reliably predictive of protection against cholera.

Learning Point
Cholera vaccines are available for use in endemic and epidemic areas, and for travelers.

  • Dukoral® is a whole-cell, killed, monovalent vaccine again serotype O1
    • Has a cholera toxin subunit which also has some cross-reactivity with enterotoxigenic Escherichia coli and therefore it offers some protection for this entity also
    • Given orally
      • 3 doses for children given 1-6 weeks apart for ages 2-5 years
      • 2 doses are given 1-6 weeks apart for ages 6 years and up
    • Protection is 6 months for children 2-5 years, and 2 years for those 6 years and older
    • For revaccination
      • For children 2-5 years, 1 dose can be used if given within 6 months of primary immunization, otherwise re-start primary vaccination
      • For 6 years and up, 1 dose can be used if given within 2 years of primary immunization, otherwise re-start primary vaccination
    • Licensed in countries worldwide, primarily for travelers to endemic countries but has been used for epidemics
  • Shanchol™, Euvichol®, and mORCVA™ are modified whole-cell, killed, bivalent vaccine against serotypes O1 and O139
    • These 3 vaccines are based on the same strains but are available in different areas of the world.
    • Does not have cholera toxin subunit therefore is no cross-reactivity with enterotoxigenic Escerichia coli
    • Given orally
      • 2 doses given 14 days apart for ages 1 year and older
    • Protection is up to 5 years
    • Licensed in countries worldwide, for travelers and also for epidemics
  • Vaxchora® is a live-attenuated single-dose oral vaccine.
    • It is the only cholera vaccine available in the United States and is given as a single oral dose to people ages 18-64 years for those traveling to cholera-affected areas.
    • Its protection is at least 3 months according to the Centers for Disease Control, but others studies have shown efficacy for 6 months.

The World Health Organization recommends during humanitarian emergencies where there is a risk of cholera but no current outbreak that oral cholera vaccine be considered as an additional measure for prevention. International workers and travelers should also use safe hygiene practices. Emergency/relief workers who would be likely to encounter patients with cholera or exposed to contaminated food and water should be vaccinated. “Vaccination is not generally recommended for long-term or short-term travelers to cholera-affected countries,….”

Other vaccines are currently being developed.

Questions for Further Discussion
1. What are good “hygiene” practices for places with risks for fecal-oral transmission of infections?
2. What are good malaria prevention practices?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Cholera and Traveler’s Health.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Tran NT, Taylor R, Antierens A, Staderini N. Cholera in Pregnancy: A Systematic Review and Meta-Analysis of Fetal, Neonatal, and Maternal Mortality. PLoS One. 2015 Jul 15;10(7):e0132920.

Das JK, Ali A, Salam RA, Bhutta ZA. Antibiotics for the treatment of Cholera, Shigella and Cryptosporidium in children. BMC Public Health. 2013;13 Suppl 3:S10.

Cabrera A, Lepage JE, Sullivan KM, Seed SM. Vaxchora: A Single-Dose Oral Cholera Vaccine. Ann Pharmacother. 2017 Jul;51(7):584-589.

Wong KK, Burdette E, Mahon BE, Mintz ED, Ryan ET, Reingold AL. Recommendations of the Advisory Committee on Immunization Practices for Use of Cholera Vaccine. MMWR Morb Mortal Wkly Rep. 2017 May 12;66(18):482-485.

Cholera vaccines: WHO position paper – August 2017. Wkly Epidemiol Rec. 2017 Aug 25;92(34):477-98.

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Can Fish Oil Help Reading?

Patient Presentation
A 10-year-old female came to clinic for her health maintenance examination. She was doing well physically and had many friends socially. She was having problems at school in reading where she was getting additional help and was making some progress. However she still remained behind her classmates. Her teachers and parents did not describe problems in other areas including executive function or attention. The family history revealed that her father had some reading problems as a child. The pertinent physical exam showed a smiley female with growth parameters in the 50-75%. Her examination was normal.

The diagnosis of a healthy female with a reading disability was made. The mother asked about supplementing with fish oil as her friend used it for her child who had some developmental problems. The pediatrician said that she didn’t know a lot about using it, but a quick review of the National Institutes of Health Complimentary and Alternative Medicine website showed that while there was not data to support its use for learning problems, fish oils had few side effects. “I guess that you could use them, but you could also use the money for something else too,” she said. “I do recommend that you continue to work with the teachers and follow her closely. She may need more help than she is getting now but you will only know that by working with the teachers,” she counseled.

Fats and fatty acids are essential for good human health.

Saturated fats have hydrogen pairs linked to each carbon on the carbon backbone. They are solid or semi-solid at room temperature. Common examples are butter, lard, or hardened vegetable shortening. They are linked to higher cholesterol and triglycerides and only a small amount of them are recommended to be consumed in the diet.

Unsaturated fats have one or more hydrogen atoms missing from the carbon backbone. They are liquid at room temperature.

  • Monounsaturated fatty acids have one hydrogen pair that is missing from the carbon backbone. They are liquid at room temperature but start to become solid when placed into the refrigerator. Common examples are Canola oil, olive oil, peanut oil and avocados.
    They lower total and LDL cholesterol and increase HDL cholesterol.

  • Polyunsaturated fatty acids (PUFAs) have two or more hydrogen pairs that are missing from the carbon backbone. They are liquid at room temperature and when cooled. Common examples are corn oil, soybean oil, and the seeds and oil made from safflower, sesame, and sunflower seeds.
    They lower total and LDL cholesterol but also lower HDL production.

  • Omega-3 fatty acids are a type of polyunsaturated fats derived from eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). They are commonly found in fatty fish such as mackerel, albacore tuna, sardines, salmon, herring, anchovies, sardines and lake trout. They can also be found in Canola oil, soybean oil, flaxseed oil, and walnuts. They are also a component of human breast milk.
    Omega-3 fatty acids lower total cholesterol and triglycerides.

Learning Point
Omega-3s have been shown to decrease cardiovascular disease including heart attack, arrhythmias, stroke and sudden cardiac death. Omega-3s help to regulate the immune system and they have been shown to “…decrease inflammation and be useful in the treatment of rheumatoid arthritis, [inflammatory bowel disease], and psoriasis.” Some studies support a benefit also in Alzheimer disease and depression. Omega-3s also help fetal brain development and have been added to infant formulas since 2002 to be more like breastmilk.

Current data does not support Omega-3 supplementation for improved cognition, inhibition, attention, memory, reading, reaction times, and autism spectrum disorder. Even in infant formula trials, the end-point that is measured appears to affect the outcome, and the authors concluded that “[a]vailable data are currently inadequate to conclude that [Omega-3]supplementation has a clinically meaningful beneficial effect upon neurological development.”

Fatty fish also have higher levels of mercury and toxins (especially polychorinated biphenyls and dioxin) and therefore the pros and cons of fatty fish must be balanced, and two servings of fatty fish (3-4 ounces/serving) are recommended weekly that is broiled or baked. Frying is not recommended. High levels of mercury are found in shark, swordfish, king mackerel, and tile fish (also called golden snapper or golden bass) but low levels are found in anchovies, catfish, sardines, salmon, pollock, clams, oysters and shrimp. The fish listed as having high levels of mercury are not recommended to be consumed during pregnancy, breastfeeding and for young children. Supplements of fish oil or Omega-3s have not shown to have the same benefit for cardiac disease as eating the fish itself.

Questions for Further Discussion
1. What approach to complimentary and alternative medicine to you take when discussing it with patients?
2. What sources of information for complimentary and alternative medicine do you recommend to patients?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Dietary Supplements and Learning Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

University of Illinois Extension. What are Polyunsaturated and Monounsaturated Fats?
Available from the Internet at (rev. 6/2014, cited 9/25/17).

National Center for Complimentary and Alternative Medicine. Omega-3 Supplements: In Depth.
Available from the Internet at (rev. 8/2015, cited 9/25/17).

Cooper RE, Tye C, Kuntsi J, Vassos E, Asherson P. Omega-3 polyunsaturated fatty acid supplementation and cognition: A systematic review and meta-analysis. J Psychopharmacol. 2015 Jul;29(7):753-63.

Sun H, Como PG, Downey LC, Murphy D, Ariagno RL, Rodriguez W. Infant formula and neurocognitive outcomes: impact of study end-point selection. J Perinatol. 2015 Oct;35(10):867-74.

Parian AM, Mullin GE. Fish Consumption and Health: The Yin and Yang. Nutr Clin Pract. 2016 Aug;31(4):562-5.

Gould JF, Treyvaud K, Yelland LN, Anderson PJ, Smithers LG, McPhee AJ, Makrides M. Seven-Year Follow-up of Children Born to Women in a Randomized Trial of Prenatal DHA Supplementation. JAMA. 2017 Mar 21;317(11):1173-1175.

Horvath A, Lukasik J, Szajewska H. Omega-3 Fatty Acid Supplementation Does Not Affect Autism Spectrum Disorder in Children: A Systematic Review and Meta-Analysis. J Nutr. 2017 Mar;147(3):367-376.

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa