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Probiotics in infectious diarrhoea in
children: are they indicated?
Infectious gastroenteritis continues to be a
leading cause of mortality and morbidity
worldwide. The cornerstone of treatment remains
replacement of water and electrolyte losses with
oral rehydration solution. Until a few years
ago, probiotics were discussed primarily in the
context of alternative medicine, but they are
now entering mainstream medical practice since a
decrease of the severity and duration of
infectious gastroenteritis in approximately 24
hours has been shown for some strains.
Therefore, probiotics are a potential add-on
therapy in acute gastro-enteritis. The
shortening of the duration of diarrhoea and the
reduction in hospital stay result in a social
and economic benefit. Evidence found in viral
gastroenteritis is more convincing than in
bacterial or parasitic infection. Mechanisms of
action are strain specific and only those
commercial products for which there is evidence
of clinical efficacy should be recommended.
Timing of administration is also of importance.
In acute gastroenteritis, there is evidence for
efficacy of some strains of lactobacilli (e.g.
Lactobacillus caseii GG and Lactobacillus
reuteri) and for Saccharomyces boulardii. Probiotics are “generally regarded as safe”, but
side effects such as septicaemia and fungaemia
have very rarely been reported in high-risk
situations. Although most studies conclude in a
statistically significant shortening of the
duration of diarrhea, the clinical relevance of
this finding is limited. In conclusion, selected
strains of probiotics result in a statistically
significant but clinically moderate benefit in
shortening the duration of diarrhoea caused by
acute infectious gastroenteritis.
(European
Journal of Pediatrics 2007;
166 (December 2007):1211-18.)
Not all probiotic preparations are equally
effective for diarrhea in children
Question
Among children with acute diarrhea, how
effective are 5 probiotic preparations in
decreasing the duration of symptoms, compared
with standard oral rehydration?
Design
Randomized controlled trial.
Setting
Primary care pediatric practices in Italy.
Participants
571 children aged 3 to 36 months visiting a
pediatrician for acute diarrhea.
Intervention
Children’s parents were randomly assigned to
receive written instructions to purchase a
specific probiotic product: oral rehydration
solution (control group); Lactobacillus
rhamnosus strain GG; Saccharomyces boulardii;
Bacillus clausii; mix of L delbrueckii var
bulgaricus, Streptococcus thermophilus, L
acidophilus, and Bifidobacterium bifidum; or
Enterococcus faecium SF68.
Outcomes
Primary outcomes were duration of diarrhea and
daily number and consistency of stools.
Secondary outcomes were duration of vomiting and
fever and rate of admission to the hospital.
Safety and tolerance were also recorded.
Results
Median duration of diarrhea was significantly
shorter (P _ .001) in children who received L
rhamnosus strain GG (78.5 hours) and the mix of
the 4 bacterial strains (70.0 hours) than in
children who received oral rehydration solution
alone (115.0 hours). 1 day after the first
probiotic administration, the daily number of
stools was significantly lower (P _ .001) in
children who received L rhamnosus strain GG and
in children who received the probiotic mix than
in the other groups. The remaining preparations
did not affect primary outcomes. Secondary
outcomes were similar in all groups.
Conclusions
Not all commercially available probiotic
preparations are effective in children with
acute diarrhea. Pediatricians should choose
bacterial preparations on the basis of
effectiveness data.
(Canani RB, Cirillo P, Terrin G, Cesarano L,
Spagnuolo MI, De Vincenzo A, et al. (Probiotics
for treatment of acute diarrhea in children:
randomised clinical trial of five different
preparations. BMJ 2007;335:340-5.)
Comment
Canani et al randomized 571 children with acute
diarrhea to receive oral rehydration alone or 1
of 5 probiotic preparations. The children were,
on average, 18 months old and 10 hours into
their illness. The study was randomized with
adequate concealment, but only the outcome
assessors were blinded to treatment group. The
pediatrician and parent knew the preparation to
which they were assigned. Furthermore,
parents were not provided with the probiotic,
but were instructed on which preparation to
purchase at the local pharmacy. Each of the 6
groups had 100 patients, and each
group lost between 1% and 10% of patients to
follow-up during the 1-week study period. 2
groups had a shorter duration of diarrhea than
oral rehydration alone (115 hours
versus 75 hours), the patients receiving the
probiotic L Rhamnosus GG and the patients
receiving a mixture of 4 different probiotics.
Daily stool output and stool consistency
were significantly better in these 2 groups
also. There were no adverse events. The main
threat to validity in this study was that it was
single blinded, and patients were instructed to
purchase their allotted preparation rather than
having it provided in a blinded fashion. All
parents did purchase their child’s allotted
preparation. Despite these concerns, this study
gives clinicians initial guidance on selection
of a probiotic for acute diarrhea and an average
expectation of its benefit that we can provide
to patients and families.
(Brett Robbins, MD, University of Rochester,
Rochester, New York, In The Journal of
Pediatrics January 2008, Volume 152, Issue 1)
Antisecretory Activity of Lactobacillus
acidophilus Strain LB Against Nonrotavirus
Diarrhea
OBJECTIVE.
Previous studies have shown that selected
strains of Lactobacillus have the capacity to
antagonize rotavirus-induced diarrhea. However,
only a few reports have documented their
efficacy against nonrotavirus diarrhea. This
study involved an experimental investigation and
a clinical trial of the antisecretory activity
of Lactobacillus acidophilus strain LB in the
context of nonrotavirus diarrhea.
METHODS.
The activity of a culture of L acidophilus LB or
of the lyophilized, heat-killed L acidophilus LB
bacteria plus their spent culture medium was
tested in inhibiting the formation of
fluid-formed domes in cultured human intestinal
Caco-2/TC7 cell monolayers infected with
diarrheagenic, diffusely adhering Afa/Dr
Escherichia coli C1845 bacteria. A randomized,
double-blind, placebo-controlled clinical trial
of male or female children who were 10 months of
age and presented with nonrotavirus,
well-established diarrhea was conducted to
evaluate the therapeutic efficacy of a
pharmaceutical preparation that contains 10
billion heat-killed L acidophilus LB plus 160 mg
of spent culture medium.
RESULTS.
Infection of the cells with C1845 bacteria that
were treated with L acidophilus LB culture or
the lyophilized, heat-killed L acidophilus LB
bacteria plus their culture medium produced a
dosage-dependent decrease in the number of
fluid-formed domes as compared with cells that
were infected with untreated C1845 bacteria. The
clinical results show that in selected and
controlled homogeneous groups of children with
well-established, nonrotavirus diarrhea, adding
lyophilized, heat-killed L acidophilus LB
bacteria plus their culture medium to a solution
of oral rehydration solution shortened by 1 day
the recovery time (ie, the time until the first
normal stool was passed) as compared with
children who received placebo oral rehydration
solution.
CONCLUSIONS.
Heat-killed L acidophilus LB plus its culture
medium antagonizes the C1845-induced increase in
paracellular permeability in intestinal
Caco-2/TC7 cells and produces a clinically
significant benefit in the management of
children with nonrotavirus, well-established
diarrhea.( Vanessa Liévin-Le Moal, Luis E.
Sarrazin-Davila, et al. Pediatrics 120:
e795-e803)
Assessment of the Long-term Safety of Inhaled
Ciclesonide on Growth in Children With Asthma
OBJECTIVE.
To assess the effects of the new inhaled
corticosteroid ciclesonide on growth in children
with asthma.
METHODS.
We performed a multicenter, randomized,
double-blind, placebo-controlled study to assess
the effects of inhaled ciclesonide on growth in
children with mild, persistent asthma. After a
6-month run-in period, 661 prepubertal children
who were aged 5.0 to 8.5 years were randomly
assigned to once-daily morning treatment for 1
year with ciclesonide 40 or 160 µg (ex-actuator)
or placebo, followed by a 2-month follow-up
period. The primary end point was the linear
growth velocity (linear regression estimate)
over the double-blind treatment period. Growth
was recorded as the median of 4 stadiometer
measurements. Adverse events and 10-hour
overnight and 24-hour urinary free cortisol
levels were also assessed.
RESULTS.
Mean linear growth velocity during run-in was
comparable between groups: 160 µg, 6.20 cm/year;
40 µg, 6.59 cm/year; placebo, 6.49 cm/year. Mean
differences from placebo (5.75 cm/year) in
growth velocity over the double-blind treatment
period were –0.02 cm/year for ciclesonide 40 µg
and –0.15 cm/year for ciclesonide 160 µg. Both
ciclesonide treatments were noninferior to
placebo with respect to growth velocity. The
overall incidence of adverse events was
comparable between groups, and no significant
changes in 10-hour overnight or 24-hour urinary
free cortisol levels were noted between groups
during the double-blind treatment period.
CONCLUSIONS.
Ciclesonide demonstrated no detectable effect on
childhood growth velocity, even at the highest
dosage, which may ease concerns about systemic
adverse events. (David P. Skoner, Jorge Maspero,
et al. Pediatrics (January 2008) 121: e1-e14.)
Comparison of Buccal Midazolam With Rectal
Diazepam in the Treatment of Prolonged Seizures
Midazolam With Rectal
Diazepam in the Treatment of Prolonged Seizures
OBJECTIVE. Our goal was to compare the efficacy
and safety of buccal midazolam with rectal
diazepam in the treatment of prolonged seizures
in Ugandan children.
METHODS.
This was a single-blind, randomized clinical
trial in which 330 patients were randomly
assigned to receive buccal midazolam or rectal
diazepam. The trial was conducted in the
pediatric emergency unit of the national
referral hospital of Uganda. Consecutive
patients who were aged 3 months to 12 years and
presented while convulsing or who experienced a
seizure that lasted >5 minutes were randomly
assigned to receive buccal midazolam plus rectal
placebo or rectal diazepam plus buccal placebo.
The primary outcome of this study was cessation
of visible seizure activity within 10 minutes
without recurrence in the subsequent hour.
RESULTS.
Treatment failures occurred in 71 (43.0%) of 165
patients who received rectal diazepam compared
with 50 (30.3%) of 165 patients who received
buccal midazolam. Malaria was the most common
underlying diagnosis (67.3%), although the risk
for failure of treatment for malaria-related
seizures was similar: 35.8% for rectal diazepam
compared with 31.8% for buccal midazolam. For
children without malaria, buccal midazolam was
superior (55.9% vs 26.5%). Respiratory
depression occurred uncommonly in both of the
treatment arms.
CONCLUSION.
Buccal midazolam was as safe as and more
effective than rectal diazepam for the treatment
of seizures in Ugandan children, although
benefits were limited to children without
malaria. (Arthur Mpimbaza, Grace Ndeezi, et al.
Pediatrics 121: e58-e64)
Topical lignocaine for pain relief in acute
otitis media: results of a double-blind
placebo-controlled randomised trial
Objective: Acute otitis media (AOM) is common in
children, yet the optimal management of ear pain
associated with AOM has not been well studied.
We set out to determine the efficacy of topical
aqueous 2% lignocaine eardrops compared with a
placebo (saline) for pain relief of AOM in
children.
Design:
Double-blind, randomised, placebo-controlled
trial.
Setting:
Tertiary children’s hospital emergency
department.
Patients and interventions:
Children aged between 3 and 17 years with
earache and AOM without evidence of perforation
were eligible. Patients were randomised to
receive either 2% lignocaine or saline eardrops
(placebo).
Main outcome measures:
Pain scores were measured before and after
ear-drop administration. Patient and
physician-interpreted pain scores were measured
by using the Bieri faces pain scale and visual
analogue scale at 10, 20 and 30 minutes. The
primary outcome measure was reduction in
patient-measured pain scores by 50% from the
baseline. Secondary outcome measures were
reduction in patient- measured pain scores by
25% or by at least two points. Telephone
follow-up occurred after 1 day and 1 week.
Analysis was by intention to treat.
Results:
63 children (31 were treated with lignocaine, 32
with placebo) aged 3 to 12 years were enrolled.
The groups were demographically and clinically
similar, with similar proportions having
received analgesia in the preceding 4 hours.
Children receiving lignocaine showed
significantly lower patient-measured pain scores
with a reduction by 50% from baseline at 10
minutes (RR 2.06, 95% CI 1.03–4.11, p = 0.03)
and 30 minutes (RR 1.44, 95% CI 1.07–1.93, p =
0.009) but not at 20 minutes (RR 1.35 95% CI
0.88–2.06). The response to lignocaine treatment
showed significantly lower patient-measured pain
scores for 25% reduction at all time points and
for two-point reduction at 10 minutes and
favoured lignocaine at 20 minutes and 30 minutes
without reaching statistical significance. There
were no serious adverse events during the 30
minute follow-up period.
Conclusion:
This study suggests that topical aqueous 2%
lignocaine eardrops provide rapid relief for
many young children presenting with ear pain
attributed to AOM. The concurrent use of simple
oral analgesia is a likely contributor to
effective management of this painful childhood
condition. (Penny Bolt, Peter Barnett, et al.
Arch Dis Child 2008 93: 40-44)
Effect of Honey, Dextromethorphan, and No Treatment on Nocturnal
Cough and Sleep Quality for Coughing Children
and Their Parents
Objectives To compare the
effects of a single nocturnal dose of buckwheat
honey or honey-flavored dextromethorphan (DM)
with no treatment on nocturnal cough and sleep
difficulty associated with childhood upper
respiratory tract infections.
Design
A survey was administered to parents on 2
consecutive days, first on the day of
presentation when no medication had been given
the prior evening and then the next day when
honey, honey-flavored DM, or no treatment had
been given prior to bedtime according to a
partially double-blinded randomization scheme.
Setting
A single, outpatient, general pediatric
practice.
Participants
One hundred five children aged 2 to 18 years
with upper respiratory tract infections,
nocturnal symptoms, and illness duration of 7
days or less.
Intervention A single dose of buckwheat honey,
honey-flavored DM, or no treatment administered
30 minutes prior to bedtime.
Main Outcome Measures Cough frequency, cough
severity, bothersome nature of cough, and child
and parent sleep quality.
Results
Significant differences in symptom improvement
were detected between treatment groups, with
honey consistently scoring the best and no
treatment scoring the worst. In paired
comparisons, honey was significantly superior to
no treatment for cough frequency and the
combined score, but DM was not better than no
treatment for any outcome. Comparison of honey
with DM revealed no significant differences.
Conclusions
In a comparison of honey, DM, and no treatment,
parents rated honey most favorably for
symptomatic relief of their child's nocturnal
cough and sleep difficulty due to upper
respiratory tract infection. Honey may be a
preferable treatment for the cough and sleep
difficulty associated with childhood upper
respiratory tract infection. (Ian M. Paul,
Jessica Beiler, et al. Arch Pediatr Adolesc Med.
2007;161(12):1140-1146.)
Maternal Waist Circumference and the Prediction
of Children's Metabolic Syndrome
Objective To determine the association between
metabolic syndrome (MS) components in 620
children and their mothers.
Design
Cross-sectional assessment. Setting Three public
elementary schools in Buenos Aires, Argentina.
Participants A total of 620 students at a mean ±
SD age of 9.00 ± 2.07 years and their mothers at
a mean ± SD age of 37.69 ± 7.19 years.
Main Outcomes Measures
The association between MS in children and
components of MS in their mothers, such as body
mass index (BMI) (calculated as weight in
kilograms divided by height in meters squared),
high-density lipoprotein cholesterol
concentration, triglycerides concentration,
glucose concentration, homeostasis model
assessment of insulin resistance, blood
pressure, and age.
Results
Ninety-five (15.3%) of the children were obese
(BMI 95th percentile), 108 (17.4%) were
overweight (BMI 85th percentile and < 95th
percentile), and 418 (67.3%) were a healthy
weight (BMI < 85th percentile). One hundred
twelve (18.1%) of the mothers were obese (BMI
30), 183 (29.5%) were overweight (BMI 25 and <
30), and 325 (52.4%) were a healthy weight (BMI
< 25). Low concentration of high-density
lipoprotein cholesterol (in 46.0% and 56.9% of
mothers and children, respectively) and central
obesity (in 36.0% and 25.0% of mothers and
children, respectively) were common, whereas
hypertension (in 10.5% and 1.9% of mothers and
children, respectively) and impaired fasting
glucose (in 2.9% and 0.3% of mothers and
children, respectively) were infrequent. The
prevalence of MS was 10.8% in children and 11.0%
in mothers. Central obesity was less frequent in
mothers of children without MS vs mothers of
those with MS (41.2% vs 78.8%, respectively; P <
.001). Mothers of children without MS had fewer
MS components than did mothers of children with
MS (BMI z score, 0.09 vs 0.69, respectively [P <
.001]; waist circumference z score, 0.15 vs
0.87, respectively [P < .001]). Mothers' waist
circumference was a significant independent
predictor of their children's MS when adjusted
for mothers' concentrations of triglycerides,
cholesterol, and glucose and age (odds ratio,
2.11; 95% confidence interval, 1.36-3.26).
Conclusion
A mother's waist circumference predicts her
child's MS, consistent with known familial
associations of obesity and type 2 diabetes.
(Valeria Hirschler, María I. Roque, et al. Arch
Pediatr Adolesc Med. 2007;161(12):1205-1210.)
Do fluoroquinolones commonly cause arthropathy in children?
Objective:
The objective of this paper was to review the
relation between fluoroquinolone (FQ) use and
arthropathy in children.
Methods:
The biomedical literature from January 1980 to
February 2007 was searched using PubMed. Key
search terms included fluoroquinolones,
arthropathy, tendinopathy and children.
Literature was included if it was a clinical
trial or meta-analysis examining the use of 1 or
more FQs in a pediatric human population and if
it had a primary outcome measure of reported
incidence of arthropathy or tendinopathy.
Articles were excluded if the primary outcome
measure was efficacy of an FQ in a particular
pediatric disease state, and evaluated safety
was a secondary end point.
Results:
Data was reviewed from 4 large retrospective
studies. Three of the 4 studies failed to find a
significant link between musculoskeletal injury
and FQ treatment. One study reported a
correlation between use of pefloxacin and
arthropathy, but the authors' conclusions
supported the use of FQs in select pediatric
cases.
Conclusion: Arthropathy that occurs as a result
of FQ use in children has not been adequately
supported by published data from safety trials
in human children. Concerns about arthropathy
with FQs should not preclude their use by
emergency physicians when appropriate and
necessary in pediatric patients. (Can J Emerg
Med 2007;9(6):459-62)
Desmopressin Nasal Spray No Longer Indicated
for Bed-Wetting
December 5, 2007 — Desmopressin acetate
intranasal formulations are no longer indicated
for the treatment of primary nocturnal enuresis
(PNE) because of the risk for severe
hyponatremia that can lead to seizures and
death, the US Food and Drug Administration (FDA)
warned healthcare professionals yesterday.
These formulations are currently marketed as
DDAVP (sanofi-aventis US, LLC), Minirin (Ferring
Pharmaceuticals, Inc), and Stimate (CSL Behring,
LLC).
The change was based on a review of data from 61
postmarketing cases of hyponatremia-related
seizures, 2 of which resulted in death. A large
percentage of these cases (41%) occurred in
pediatric patients younger than 17 years
receiving intranasal desmopressin, most commonly
for PNE.
Although desmopressin tablets may still be used
for PNE, this therapy should be interrupted
during acute illnesses that can lead to fluid
and/or electrolyte imbalance, according to an
alert sent from MedWatch, the FDA's safety
information and adverse event reporting program.
Such events can include fever, recurrent
vomiting/diarrhea, vigorous exercise, and other
conditions that increase water consumption.
The FDA also emphasized that fluid intake should
be restricted from 1 hour before to 8 hours
following dose administration and that all
desmopressin formulations should be used
cautiously in patients at risk for water
intoxication with hyponatremia. Risk factors
include habitual or psychogenic polydipsia and
use of medications such as tricyclic
antidepressants and selective serotonin reuptake
inhibitors. Of the 61 postmarketing cases, the
majority (64%) occurred in patients with at
least 1 factor (drug or disease) predisposing
them to hyponatremia or seizures.
Desmopressin nasal spray, rhinal tube,
injection, and tablets are indicated as
antidiuretic replacement therapies for central
cranial diabetes insipidus and for the
management of temporary polyuria and polydipsia
following head trauma/surgery in the pituitary
region.
Desmopressin injection also is indicated to
prevent or stop excessive bleeding in patients
with hemophilia A and for mild to moderate
classic von Willebrand's disease in patients
with factor VIII coagulant activity levels more
than 5%.
Healthcare professionals are encouraged to warn
patients and caregivers regarding the need to
monitor water intake while receiving
desmopressin therapy, particularly when taking
concurrent medications that increase dry mouth,
during hot weather or following strenuous
exercise that increases thirst, and during
periods of illness with severe vomiting/diarrhea
or fever.
Adverse events related to use of desmopressin
should be communicated to the FDA's MedWatch
reporting program by phone at 1-800-FDA-1088, by
fax at 1-800-FDA-0178, online at http://www.fda.gov/medwatch,
or by mail to 5600 Fishers Lane, Rockville, MD
20852-9787.
(Yael Waknine in MedScape Pediatrics December
2007; Available at:
http://www.medscape.com/viewarticle/566977?sssdmh=dm1.331126&src=top10#1)
Effects of
Corticosteroid on Henoch-Schönlein Purpura:
A Systematic Review
OBJECTIVE. No consensus exists among general
pediatricians or pediatric
rheumatologists regarding whether
corticosteroid therapy
ameliorates the acute manifestations of
Henoch-Schönlein purpura or
mitigates renal injury. Therefore, we sought
to synthesize the reported
experimental and observational data
regarding corticosteroid use.
METHODS. We performed a meta-analysis based
on a comprehensive review of the
literature in the Medline database (1956 to
January 2007) and the Cochrane
Controlled Trials Register. On the basis
of reported outcomes among patients
with Henoch-Schönlein purpura who
were treated at diagnosis with
corticosteroids compared with
patients treated with supportive care only,
we calculated odds ratios for the
resolution of abdominal pain, the need for
surgical intervention secondary to
severe pain or intussusception,
the likelihood of Henoch-Schönlein purpura
recurrence, and the development
of transient or persistent renal disease.
RESULTS. Of 201 articles retrieved from the
initial literature search, 15
were eligible for inclusion. Corticosteroid
treatment did not reduce the
median time to resolution of abdominal pain
but did significantly reduce the mean
resolution time and increased the
odds of resolution within 24 hours. Early
corticosteroid treatment
significantly reduced the odds of developing
persistent renal disease. In
addition, although the results were not
statistically significant, the
prospective data suggest reduced odds of
both surgical intervention and
recurrence.
CONCLUSIONS.
Corticosteroids, given early in the course
of illness, seem to produce
consistent benefits for several major
clinically relevant
Henoch-Schönlein purpura outcomes.
(Pamela
F. Weiss, James A. Feinstein, et al In
Pediatrics 120: 1079-1087.)
Small Changes in Dietary Sugar and Physical
Activity as an Approach to Preventing
Excessive Weight Gain
OBJECTIVES. The intent of this study was to
evaluate whether small changes in
diet and physical activity, as promoted by
the America on the Move initiative,
could prevent excessive weight
gain in overweight children.
METHODS. In this family-intervention study,
the America on the Move
small-changes approach for weight-gain
prevention was evaluated in
families with at least 1 child (7–14 years
old) who was overweight or at
risk for overweight. These children were
the primary target of the
intervention, and parents were the
secondary target. Families were
randomly assigned to either the
America on the Move group (n = 100)
or the self-monitor–only group (n
= 92). Families who were assigned to the
America on the Move group were
asked to make 2 small lifestyle changes:
(1) to walk an additional 2000 steps
per day above baseline as
measured by pedometers and (2) to eliminate
420 kJ/day (100 kcal/day) from
their typical diet by replacing dietary
sugar with a noncaloric
sweetener. Families who were assigned to the
self-monitor group were asked to use
pedometers to record physical
activity but were not asked to change their
diet or physical activity level.
RESULTS. During a 6-month period, both
groups of children showed
significant decreases in BMI for age.
However, the America on the Move
group compared with the self-monitor group
had a significantly higher
percentage of target children who maintained
or reduced their BMI for age and,
consistently, a significantly lower
percentage who increased their
BMI for age. There was no significant weight
gain during the 6-month intervention
in parents of either group.
CONCLUSIONS. The small-changes approach
advocated by America on the Move
could be useful for addressing childhood
obesity by preventing excess
weight gain in families.
(Susan
J. Rodearmel, Holly R. Wyatt, et al.
Pediatrics 120: e869-e879.)
Does Early
Treatment of Urinary Tract Infection Prevent
Renal Damage?
OBJECTIVE. Therapeutic delay has been
suggested as the most important
factor that is likely to have an effect on
the development of scarring after
acute pyelonephritis. However, this opinion
has not been supported by prospective
studies, so we tested it.
METHODS. In a prospective clinical study, we
evaluated whether the time
interval between the onset of the renal
infection and the start of
therapy correlates with the development of
acute inflammatory changes and
the subsequent development of renal
scars, documented by
dimercaptosuccinic acid scintigraphy. A
total of 278 infants (153 male and 125
female) aged 0.5 to 12.0 months
with their first urinary tract infection
were enrolled in the study.
RESULTS. The median time between the onset
of infection and the institution
of therapy was 2 days (range: 1–8 days).
Renal inflammatory changes were
documented in 57% of the infants.
Renal defects were recorded in 41% of the
patients treated within the first
24 hours since the onset of fever versus 75%
of those treated on day 4 and
onward. Renal scarring was developed in
51% of the infants with an abnormal
scan in the acute phase of
infection. The frequency of scarring in
infants treated early and in
those whose treatment was delayed did not
differ, suggesting that once
acute pyelonephritis has occurred, ultimate
renal scarring is independent of
the timing of therapy. Acute inflammatory
changes and subsequent scarring were
more frequent in the presence of
vesicoureteral reflux, especially that which
is high grade. However, the
difference was not significant, which
suggests that renal damage may be
independent of the presence of reflux.
CONCLUSIONS. Early and appropriate treatment
of urinary tract infection,
especially during the first 24 hours after
the onset of symptoms, diminishes
the likelihood of renal involvement
during the acute phase of the
infection but does not prevent
scar formation. (Dimitrios
Doganis, Konstantinos Siafas, et al.
Pediatrics 120: e922-e928.)
All That Forms Rings Is Not Erythema
Multiforme
Acute annular urticaria is common in
childhood, benign, and self-limiting, but
the lesions can be misleading.
Acute annular urticaria (ring-shaped hives)
is a benign cutaneous hypersensitivity
reaction that occurs frequently in
childhood. The condition is sometimes
mistaken for other ring-shaped disorders —
most often, erythema multiforme and less
commonly, serum-sickness–like reactions.
To better distinguish the clinical features
of this condition from the features of
erythema multiforme and serum-sickness–like
reaction, and to increase awareness of this
diagnosis, pediatric dermatologists at a
large children’s hospital characterized the
disease in a case series of 18 children.
Most of the patients (83%) were 2 months to
3 years of age. The most common referring
diagnosis was "rash" or "erythema multiforme."
A majority (67%) presented with antecedent
upper respiratory infection, otitis media,
or viral symptoms; fever was present in
eight patients (44%). Recent antibiotic use
was reported in 44%, and 11% had recently
been immunized. The typical features of
urticaria and angioedema were observed in
most, and pruritus was nearly universal
(94%), although visible excoriation was
rare. Edema of the hands, feet, or both was
seen in 61%. No patients had the true target
lesions of erythema multiforme, and none had
skin necrosis, blistering, mucous membrane
involvement, arthralgias, or arthritis.
Systemic antihistamines, sometimes in
combination with ranitidine, were required
for symptom relief in the majority of
patients, and the clinical signs and
symptoms remitted within 2 to 12 days.
Comment: Acute urticaria is extremely
common in childhood: Most children will
experience this transient hypersensitivity
reaction at least once. Diagnostic confusion
may arise when the urticaria is ring-shaped
or polycyclic, and being able to distinguish
this self-limited condition from other, more
serious conditions is important. The
descriptions in this report nicely
illustrate that although annular urticaria
is ring-shaped, it never forms the true
target lesions of erythema multiforme.
Furthermore, no matter the shape, urticaria
always behaves in the same way — the wheals
are evanescent rather than fixed, and they
respond to oral antihistamines. The value of
renaming acute annular urticaria "urticaria
multiforme," as the authors propose, is
debatable. Nevertheless, this paper should
be required reading for all physicians and
other health providers likely to encounter
ring-shaped rashes in children.
—
Mary Wu Chang, MD
Published in Journal Watch Dermatology
November 2, 2007
Antibiotics and Topical Nasal Steroid for
Treatment of Acute Maxillary Sinusitis
Acute sinusitis is a common clinical problem
that usually results in a
prescription for antibiotics but the role
of antibiotics is debated.
Anti-inflammatory drugs such as topical
steroids may be beneficial but are
underresearched.
Objective To determine the
effectiveness of amoxicillin and
topical budesonide in acute maxillary
sinusitis.
Design, Setting, and Patients A
double-blind, randomized,
placebo-controlled factorial trial of 240
adults (aged  16
years) with acute nonrecurrent
sinusitis (had 2
diagnostic criteria: purulent
rhinorrhea with unilateral predominance,
local pain with unilateral
predominance, purulent rhinorrhea bilateral,
presence of pus in the nasal cavity)
at 58 family practices (74 family
physicians) between November 2001 and
November 2005. Patients were
randomized to 1 of 4 treatment groups:
antibiotic and nasal steroid;
placebo antibiotic and nasal steroid;
antibiotic and placebo nasal
steroid; placebo antibiotic and placebo
nasal steroid.
Intervention A dose of 500 mg of
amoxicillin 3 times per day for 7
days and 200 µg of budesonide in each
nostril once per day for 10 days.
Main Outcome Measures Proportion
clinically cured at day 10 using
patient symptom diaries and the duration and
severity of symptoms.
Results The proportions of patients
with symptoms lasting 10 or more
days were 29 of 100 (29%) for amoxicillin vs
36 of 107 (33.6%) for no
amoxicillin (adjusted odds ratio, 0.99; 95%
confidence interval, 0.57-1.73). The
proportions of patients with
symptoms lasting 10 or more days were 32 of
102 (31.4%) for topical
budesonide vs 33 of 105 (31.4%) for no
budesonide (adjusted odds ratio,
0.93; 95% confidence interval, 0.54-1.62).
Secondary analysis suggested that
nasal steroids were significantly
more effective in patients with less severe
symptoms at baseline.
Conclusion: Neither an antibiotic nor
a topical steroid alone or in
combination was effective as a treatment for
acute sinusitis in the primary
care setting. (Ian G. Williamson,; Kate
Rumsby, BA, et al.JAMA. 2007;298(21):2487-2496.)
Childhood Body-Mass Index and the Risk of
Coronary Heart Disease in Adulthood
Background The worldwide epidemic of
childhood obesity is progressing
at an alarming rate. Risk factors for
coronary heart disease (CHD) are
already identifiable in overweight children.
The severity of the long-term
effects of excess childhood weight on CHD,
however, remains unknown.
Methods We investigated the
association between body-mass index
(BMI) in childhood (7 through 13 years
of age) and CHD in adulthood (25
years of age or older), with and without
adjustment for birth weight. The
subjects were a cohort of 276,835 Danish
schoolchildren for whom
measurements of height and weight were
available. CHD events were
ascertained by linkage to national
registers. Cox regression
analyses were performed.
Results In 5,063,622 person-years of
follow-up, 10,235 men and 4318
women for whom childhood BMI data were
available received a diagnosis of
CHD or died of CHD as adults. The risk of
any CHD event, a nonfatal event,
and a fatal event among adults
was positively associated with BMI at 7 to
13 years of age for boys and 10
to 13 years of age for girls. The
associations were linear for each
age, and the risk increased across the
entire BMI distribution.
Furthermore, the risk increased as the age
of the child increased. Adjustment for
birth weight strengthened the
results.
Conclusions Higher BMI during
childhood is associated with an
increased risk of CHD in adulthood. The
associations are stronger in boys
than in girls and increase with the age of
the child in both sexes. Our
findings suggest that as children are
becoming heavier worldwide,
greater numbers of them are at risk of
having CHD in adulthood.
(Jennifer L. Baker,
Lina W. Olsen et al In NEJM, Volume
357:2329-2337)
Delayed Diagnosis of Kawasaki Disease: What
Are the Risk Factors?
OBJECTIVE. Because late diagnosis of
Kawasaki disease increases the
risk for coronary artery abnormalities, we
explored the prevalence of and
possible risk factors for delayed diagnosis
by using the database of the Pediatric
Heart Network trial of
corticosteroid treatment for Kawasaki
disease.
METHODS. We collected sociodemographic and
clinical data at presentation for
all patients who were treated for presumed
Kawasaki disease at 8 centers (7 in
the United States, 1 in Canada).
Delayed diagnosis was evaluated by total
number of illness days to
diagnosis and by the percentage of patients
who were treated after day 10 of
illness. Independent predictors
of delayed diagnosis were identified by
using multivariate linear and
logistic regression.
RESULTS. Of the 589 patients who received
intravenous immunoglobulin, 27
were treated before screening for the trial
and excluded; 562 patients formed
the cohort for analysis. Kawasaki disease
was diagnosed at 7.9 ± 3.9 days, 92
(16%) cases after day 10. Centers
were similar with respect to patient age and
gender. Centers differed in the
patient percentage with incomplete
Kawasaki disease; clinical criteria of
cervical adenopathy, oral
changes, and conjunctivitis; and distance of
residence from the center.
Independent predictors of greater number of
illness days at diagnosis included
center, age of <6 months,
incomplete Kawasaki disease, and greater
distance from the center.
Independent predictors of diagnosis after
day 10 were age of <6 months,
incomplete Kawasaki disease, and greater
distance). Socioeconomic
variables had no association with delayed
diagnosis.
CONCLUSIONS. Even after adjustment for
patient factors, illness duration
at diagnosis varies by center. These
findings underscore the need to
maintain a high index of suspicion of
Kawasaki disease in the infant
who is younger than 6 months and has
prolonged fever even with
incomplete criteria. Outreach educational
programs may be useful in
promoting earlier recognition and treatment
of Kawasaki disease. (Pediatrics 120:
e1434-e1440.)
Controlling Feeding Practices: Cause or
Consequence of Early Child Weight?
INTRODUCTION. The exertion of control during
child feeding has been associated
with both underweight and overweight during
childhood. What is as-yet unclear is
whether controlling child feeding
practices causally affect child weight or
whether the use of control may be
a reactive response to concerns about
high or low child weight. The aims of
this study were to explore the
direction of causality in these
relationships during infancy.
METHODS. Sixty-two women gave informed
consent to take part in this
longitudinal study that spanned from birth
to 2 years of child age. Mothers
completed the Child Feeding Questionnaire
at 1 year, and their children were
weighed at 1 and 2 years of age.
Child weight scores were converted into
standardized z scores that
accounted for child age and gender.
RESULTS. Controlling for child weight at 1
year, the use of pressure to eat
and restriction at 1 year significantly
predicted lower child weight at 2
years.
CONCLUSIONS. Controlling feeding practices
in infancy have an impact on
children's weight at 2 years. The use of
restrictive child feeding
practices during infancy predicts lower
child weight at age 2 years,
which may reinforce mothers' use of this
strategy in the longer term despite
its potential association with
disinhibition and greater child weight in
later childhood. (PEDIATRICS Vol. 121 No. 1
January 2008, pp. e164-e169)
Lumbar Puncture Success Rate Is Not
Influenced by Family-Member Presence
OVERVIEW. The presence of a family member
during invasive pediatric
procedures such as lumbar puncture has been
shown to reduce patient anxiety.
However, family presence might also affect
clinicians’ stress and anxiety, with
uncertain consequences for
procedural success.
OBJECTIVE. Our goal was to evaluate the
association between family-member
presence and lumbar puncture success rates.
DESIGN/METHODS. We performed a prospective
cohort study of all children who
underwent a lumbar puncture in a single
pediatric emergency department
between July 2003 and January 2005. The
presence of a family member was
documented by the physician who
performed the lumbar puncture. Success rates
were assessed by using 2 main
outcomes: (1) the rate of traumatic
(cerebrospinal fluid red blood
cells 10000
cells per µL) or unsuccessful
lumbar puncture (no cerebrospinal fluid sent
for cell counts) and (2) the
number of lumbar puncture attempts.
Multivariate analyses were
adjusted for patient age, race, time of day,
physician experience, use of
local anesthetic, catheter stylet removal,
and patient movement during the
procedure.
RESULTS. Of the 1474 eligible lumbar
punctures, 1459 (99%) were
included in the analysis. A family member
was present for 1178 (81%) of the
procedures studied. A total of 1267 (87%)
lumbar punctures were
nontraumatic, and 192 (13%) were traumatic
or unsuccessful. Neither the rate
of traumatic or unobtainable
lumbar punctures nor the number of lumbar
puncture attempts differed based
on whether a family member was present for
the procedure.
CONCLUSIONS. The presence of a family member
was not associated with an
increased risk of traumatic or unobtainable
lumbar puncture, nor was it
associated with more attempts at the
procedure. The benefits of having
a family member present during the procedure
were not counterbalanced by adverse
effects on procedural success. (Lise
E. Nigrovic, Alisa A. McQueen, et al In
Pediatrics 120:
e777-e782.)
The New Periodicity Schedule
Recommendations for preventive pediatric
healthcare
In 2007, the American Academy of Pediatrics
revised the periodicity schedule to be more
consistent with the Bright Futures
initiative. These recommendations for
preventive pediatric healthcare represent
the core components of care from birth
through age 21 years. The major changes from
the previous schedules include:
-
All newborns should be evaluated within 2
to 3 days after discharge.
-
Three routine visits at ages 30 months, 7
years, and 9 years have been added.
-
Calculation of BMI is now recommended to
begin at age 2 years.
-
In addition to developmental surveillance,
developmental screening has been added
back to the schedule and is recommended at
ages 9, 18, and 30 months.
-
Autism screening is recommended at ages 18
and 24 months.
-
Urinalysis is no longer required.
-
Dental referral (now listed under oral
health) should start at age 12 months.
-
Cholesterol screening is now listed as
dyslipidemia screening and involves risk
assessment (based on family history and
physical examination) at ages 2, 4, 6, 8,
and 10 years, and then annually through
age 21, with dyslipidemia screening
performed sometime between ages 18 and 21
years.
-
Sexually transmitted diseases are now
referred to as sexually transmitted
infections (STIs). All sexually active
patients should be screened for STIs.
-
Every visit should be considered an
opportunity to update and complete a
child’s immunizations.
Comment: The
addition of developmental screening and
autism screening represents fundamental
changes. Unfortunately, the U.S. Preventive
Services Task Force recently concluded that
the evidence was insufficient to recommend
screening for speech and language delay.
The addition of three routine visits (at
ages 30 months and 7 and 9 years) provides
more opportunities to complete the many
assessments required by the periodicity
table, and certainly a chance to "catch up"
on any missed immunizations. The adolescent
years remain a particular concern because
adolescents average fewer than one routine
visit per year, despite the growing need for
immunizations and screening for
cardiovascular disease, mental health
problems, and STIs.
—
Howard Bauchner, MD
Published in Journal Watch Pediatrics
and Adolescent Medicine December 19, 2007 |
