BEST RECENT ARTICLES
From Current Clinical Pediatrics, presented April 18-20, 2005, by Boston University School of Medicine, and the Department of Pediatrics at Boston Medical Center
Howard Bauchner, MD, Professor of Pediatrics and Public Health, and Director, Division of General Pediatrics, Boston University School of Medicine, Boston Medical Center
| Landmark study: large cohort study conducted in Finland; serum from ≈3500 children (7 to 16 yr of age) drawn and banked in 1994; serum tested in 2001 (diagnostic test for celiac disease developed during intervening years); no child diagnosed with celiac disease in 1994; by 2001, 10 children diagnosed with celiac disease (children tested positive for enzymes; biopsies confirmed diagnosis); in 2001, 56 samples tested positive for celiac-associated antibodies (including 10 children previously diagnosed); diagnosis of celiac disease confirmed with biopsy in 27 asymptomatic children; prevalence of disease—1 in 100 (symptomatic and asymptomatic children with confirmed disease); conclusion—celiac disease meets criteria required for implementation of national screening program |
| Other studies: Colorado—22,000 newborns screened for HLA type associated with celiac disease; 1000 children identified and followed; by 5 yr of age, 19 children met case definition for celiac disease (persistent positive antibodies against transglutaminase or changes on biopsy); United Kingdom—screening among college students found prevalence of 1 in 166; another study showed differences in height and weight for children positive for IgA antiendomysial antibodies (EMA; prevalence in study ≈1 in 100) |
| Study: case-control study compared 42 children with recurrent abdominal pain with 38 controls (all children drawn from primary care settings); children with recurrent abdominal pain slightly younger (mean 11.5 yr of age) and more likely to live with 1 parent; psychologic evaluation—80% of children with recurrent abdominal pain fulfilled Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for anxiety disorder (separation anxiety, obsessive-compulsive disorder, or phobia); 43% had depressive disorder; 25% had disruptive disorder (attention-deficit/hyperactivity disorder or oppositional-defiant disorder); conclusions—among adolescents, recurrent abdominal pain may indicate risk for psychologic disorder; rates of morbidity within control group reflected prevalence in community (ie, ≈10%); clinical implications—consider psychologic referral for adolescents with repeated presentations for recurrent abdominal pain |
| Background: prevalence has increased; radioallergosorbent test (RAST) has improved; laboratories can quantify likelihood of true allergy based on response to RAST (ie, no longer simply “positive” or “negative”); question persists about whether children outgrow allergy |
| Study: double-blind placebo-controlled food challenge (gold standard, rarely used in clinical settings) confirmed allergy to cow’s milk in young children; children rechallenged each year until 4 yr of age; delayed response—onset of symptoms within hours to ≈1 day, with variety of dermal, pulmonary, and gastrointestinal (GI) presentations; 90% of these children outgrow allergies by 4 yr of age; immediate response—children have much lower rate of resolution of allergy; RAST—82% of children with milk-specific IgE levels <2 kU/L developed tolerance to milk by 4 yr of age; 71% of children with greater RAST responses had persistent allergy; conclusions—decision to rechallenge child dependent on onset of symptoms and degree of allergic response |
| Background: many serotypes of Streptococcus pneumoniae; current vaccine immunizes against 7 serotypes; concern about potential effect of vaccine on prevalence of other serotypes |
| Study: vaccinations completed in 74% of children 1 yr of age and 31% of children 2 yr of age within managed health care system; no cases of invasive pneumococcal disease caused by vaccine serotypes in children <2 yr of age; rates of invasive pneumococcal disease also fell from 11 to 9 cases per 100,000 patients \>5 yr of age and from 35 to 30 cases per 100,000 elderly patients (ie, reducing reservoir of disease in children benefits entire community); pneumococcal serotypes not covered by vaccine caused 6.2 cases of invasive disease in children <5 yr of age (rate doubled, compared to previous years); concern that other serotypes may replace those covered by vaccine |
| Penicillin-resistant pneumococcus: rates of resistance, which peaked in 2000 at 15%, declined to 5% in 2003; reasons for decline include successful campaign to reduce use of antibiotics and use of pneumococcal vaccine |
| SNORING, OSA, AND SURGERY |
| Study: concern about impaired cognitive development in children who snore, even without obstructive sleep apnea (OSA); 20 children, 2 to 14 yr of age, with primary snoring (diagnosed using validated measure) but without OSA (verified by sleep study) randomized to observation or treatment (tonsillectomy and adenoidectomy); clinical signs and symptoms associated with primary snoring—mouth-breathing; chronic rhinorrhea; recurrent tonsillitis; body mass index (BMI) indicative of obesity; high blood pressure; adenoid facies, and enlarged tonsils; nighttime symptoms include snoring, pauses in breathing, gasping, choking, restless sleep, frequent awakening, and sleeping with neck extended or in fetal position; daytime symptoms include daytime somnolence, headaches in morning, irritability, hyperactivity, and delays in development; points calculated based on presence and frequency of symptoms; effect of surgery—all measures improved in children who received surgery; scores declined by 49 points in treatment group, compared to 8 points in observation group; 82% of treatment group and 22% of observation group asymptomatic by end of study; conclusions—tonsillectomy and adenoidectomy may be appropriate treatment for children with primary snoring |
| Sleep studies: overnight sleep studies (performed in hospital, monitoring O2 saturation, flow of air through nose, and movements of chest) often not feasible; results from 6- or 8-hr study using transcutaneous O2 -saturation monitor predictive of primary snoring when positive; overnight sleep study recommended for patients with high index of suspicion, if findings from transcutaneous O2 study negative (ie, test specific but not sufficiently sensitive) |
| Study: 512 children with reactions to bee stings followed for 20 yr; 44 children who originally had large local reaction to bee sting had subsequent challenge; 3 developed mild to moderate systemic reaction; venom therapy—children with initial systemic reaction to bee sting randomized to venom therapy or control; venom therapy significantly reduced likelihood of developing systemic reaction on subsequent challenge (from 13% to 0% among children with mild initial response and from 32% to 5% among children with moderate to severe response); conclusions— children with large local reactions unlikely to develop systemic response on subsequent challenge; children with moderate to severe systemic reactions should receive venom therapy |
| Study: 708 children with mild croup (score ≤2 of 17 on validated measure) and average age of 35 mo received 0.6 mg/kg dexamethasone or placebo; children in treatment group half as likely to return for care in 7 days (7.3% vs 15.3%), had lower clinical scores on days 1 and 2, and cried less (2.9 hr vs 4.2 hr within 24-hr period); conclusions—steroids appear to hasten recovery for children with mild croup |
| O 2 OR AIR FOR NEONATAL RESUSCITATION |
| Study: meta-analysis of 5 prospective trials (2 randomized and 3 quasi-randomized) compared O2 and air for neonatal resuscitation; pooled data from 1302 asphyxiated newborns, all weighing ≥2400 g; newborns presented with low heart rate and apnea; results—although no single study showed significant differences in mortality, meta-analysis of pooled data showed 1 additional death for every 20 children who received O2 ; no differences noted in rates of encephalopathy, cerebral palsy, or developmental outcomes; impact—guidelines for resuscitation of neonates, which all currently call for O2 , may change if additional data confirm findings |
| TINEA CAPITIS: GRISEOFULVIN OR TERBINAFINE |
| Background: diagnosis and treatment often difficult; treatment involves 6 to 8 wk daily oral therapy; diagnosis accurate in ≈90% of patients who present with loss of hair, pruritus, and lymphadenopathy of scalp |
| Study: meta-analysis of randomized trials comparing treatment outcomes of griseofulvin for 6 to 8 wk or terbinafine for 2 to 4 wk; initial analysis found no differences in cure rates at 12 wk; second analysis removed data from 1 study because of high prevalence of unusual organism responsible for tinea capitis; results of restricted analysis favored terbinafine; length and cost of treatment lower for terbinafine; griseofulvin available in 3 formulations, each with different dosing regimens (specify formulation when prescribing) |
| Background: 70% of adolescents and adults with chlamydial disease asymptomatic; seroprevalence studies show rate of infection 3% to 14% for late adolescents and young adult women; Centers for Disease Control and Prevention (CDC) and United States Preventive Services Task Force recommend routine screening |
| Study: CDC analyzed data from Health Plan Employer Data and Information Set (HEDIS); in 2001, only 26% of women covered by commercial plans and 38% of women covered by Medicaid screened for Chlamydia; screening rates should approach 100% for adult women; lower rates acceptable for adolescents if history (ie, absence of sexual activity) credible |
| HELICOBACTER PYLORI TESTING |
| Background: discovery of bacterial etiology of ulcers fueled interest in relationship between infectious diseases and other problems (eg, cardiac disease and premature labor); tests for Helicobacter pylori—urea breath test; stool antigen; serum antibody; urine antibody |
| Study: comparison of different tests for H pylori in 316 children, 2 to 17 yr of age; 42% of children positive for H pylori (confirmed on biopsy); breath test 96% sensitive, 97% specific, and 97% accurate (percent of patients scored correctly); other tests less sensitive; clinical implications—breath test recommended if test for stool antigens, serum antibodies, or urine antibodies negative in child with high index of suspicion for infection with H pylori |
| Candidates for testing: no evidence for increased rate of infection in children with recurrent abdominal pain; presence of duodenal ulcers warrants testing for H pylori; beginning at ≈7 yr of age, seropositivity increases by ≈5% per year, but many individuals do not have active disease; signs and symptoms associated with active disease in children and adolescents not yet identified |
| ULTRASONOGRAPHY OF THE HEAD |
| Study: multisite study followed 1400 infants with low birth weights (average 792 g) and gestational ages (average 26 wk); ultrasonography of head revealed no abnormal findings at birth and 36 wk, corrected age; children assessed annually until 4 yr of age; findings—9% of children diagnosed with cerebral palsy (62% of cases considered mild, 24% moderate, and 14% severe); 25% of children had IQ scores <70; clinical implications—follow-up required for children with low birth weights to ensure appropriate interventions provided as needed |
| STEROIDS FOR MILD PERSISTENT ASTHMA |
| Treatment guidelines: National Institutes of Health (NIH) recommends daily treatment with inhaled corticosteroids for children with mild persistent asthma, but problems with adherence |
| Study: randomized, double-blind clinical trial followed 225 adults with mild persistent asthma for 1 yr; treatment groups— budesonide bid plus oral placebo; leukotriene inhibitor bid plus placebo inhaler; placebo tablets plus placebo inhaler; all patients given budesonide bid for 10 days and oral prednisone for 5 days for treatment of exacerbations; primary outcomes—changes in peak expiratory flow (measured in morning and averaged over 2 wk) and number of exacerbations; results—no differences in primary outcomes among patients taking active drugs or placebo; patients taking budesonide showed improvements in forced expiratory volume in 1 sec (FEV1 ; measured before taking bronchodilator), less bronchoreactivity, fewer eosinophils in sputum, and lower levels of exhaled nitrous oxide (ie, budesonide possibly associated with modifications of lung architecture); patients taking budesonide also had 1 additional day without symptoms every 2 wk |
| Clinical implications for children with asthma: concern about long-term effects of treatment with inhaled corticosteroids (eg, potential for increased rates of osteoporosis later in life); symptom-driven therapy may replace daily therapy with corticosteroids in children with mild persistent asthma; more research required to determine whether inhaled corticosteroids prevent progression to moderate persistent disease; options for treatment of patients with mild persistent disease include intermittent treatment with inhaled corticosteroids or short-acting β-agonists |
Educational Objectives
| The goal of this activity is to review recent research with important clinical implications for pediatric medicine. After hearing and assimilating this program, the clinician will be better able to: |
 | 1. Appropriately refer children with recurrent abdominal pain for psychiatric evaluation. |
| 2. Educate parents about allergy to cow’s milk and its potential to spontaneously resolve. |
| 3. Educate parents about allergy to bee stings and recommend venom therapy when appropriate. |
| 4. Discuss issues in screening children for celiac disease, chlamydial disease, and Helicobacter pylori. |
| 5. Discuss use of steroids for the treatment of children with mild croup or mild persistent asthma. |
Discussed on This Program
Budesonide [Entocort EC, Pulmicort Respules, Pulmicort Turbuhaler, Rhinocort, Rhinocort Aqua] Dexamethasone (several formulations and trade names) Griseofulvin microsize [Fulvicin U/F, Grifulvin V, Grisactin] Griseofulvin ultramicrosize [Fulvicin P/G, Grisactin Ultra, Gris-PEG, Ultramicrosize Griseofulvin] Prednisone [Deltasone, Liquid Pred, Meticorten, Orasone, Panasol-S, Prednicen-M, Prednisone Intensol Concentrate, Strerapred DS] Terbinafine HCl [DesenesMax, Lamisil]
Suggested Reading
Blunden S, et al: Neuropsychological and psychosocial function in children with history of snoring or behavioral sleep problems. J Pediatr 146:780, 2005; Custer JR: A randomized trial of a single dose of oral dexamethasone for mild croup. J Pediatr 146:434, 2005; Fasano A, Catassi C: Coeliac disease in children. Best Pract Res Clin Gastroenterol 19:467, 2005; Gruchalla RS: Immunotherapy in allergy to insect stings in children. N Engl J Med 351:707, 2004; Haddy RI, et al: Comparison of incidence of invasive Streptococcus pneumoniae disease among children before and after introduction of conjugated pneumococcal vaccine. Pediatr Infect Dis J 24:320, 2005; Haiden N, et al: 3-D ultrasonographic imaging of the cerebral ventricular system in very low birth weight infants. Ultrasound Med Biol 31:7, 2005; Kaestle CE, et al: Young age at first sexual intercourse and sexually transmitted infections in adolescents and young adults. Am J Epidemiol 161:774, 2005; Kato S, Sherman PM: What is new related to Helicobacter pylori infection in children and teenagers? Arch Pediatr Adolesc Med 159:415, 2005; Keskin O, et al: Evaluation of the utility of atopy patch testing, skin prick testing, and total specific IgE assays in the diagnosis of cow’s milk allergy. Ann Allergy Asthma Immunol 94:553, 2005; Malaty HM, et al: Development of a multidimensional measure for recurrent abdominal pain in children: population-based studies in 3 settings. Pediatrics 115:e210, 2005; Roberts BJ, Friedlander SF: Tinea capitis: a treatment update. Pediatr Ann 34:191, 2005; Saugstad OD: Oxygen for newborns: how much is too much? J Perinatal 25(Suppl 2):S45, 2005; Sullivan SD, et al: A multisite randomized trial of the effects of physician education and organizational change in chronic asthma care. Arch Pediatr Adolesc Med 159:428, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported nothing to disclose.
Dr. Bauchner was recorded in Boston at Current Clinical Pediatrics, sponsored by Boston University School of Medicine and the Department of Pediatrics at Boston Medical Center, and held April 18-20, 2005. The Audio-Digest Foundation thanks the speaker and the sponsors for their cooperation in the production of this program.
|
