JOURNAL CLUB

More support for not using antibiotics in RTIs

Pediatricians in a large private practice in upstate New York performed a prospective study showing that their avoidance of antibiotic use during an initial visit for a presumed viral respiratory tract infection (RTI) was associated with good outcomes and a low rate of return for bacterial complications.

Every Tuesday for 12 months the doctors enrolled patients seen with acute RTIs. After physical examination, appropriate laboratory studies were performed and screening viral cultures were done. The 383 children had probable viral RTIs, viral RTIs associated with presumed bacterial infections such as acute otitis media, or viral RTIs with concurrent nonrespiratory illnesses such as impetigo. The pediatricians prescribed antibiotics for the children diagnosed with a viral RTI with a presumed or documented bacterial infection, about one quarter of the group. They did not prescribe an antibiotic for the three quarters of the children with an RTI and no evidence of a bacterial infection. They then followed the children for 30 days.

Of the 293 children who did not receive antibiotics, 86 (29%) were seen for a return visit within 30 days, and 49 of those 86 received an antibiotic on the return visit. Forty (44%) of the 90 children who received an antibiotic at the enrollment visit returned; 24 of those 40 were retreated with antibiotics. The authors present their practice as a model of how overuse of antibiotics can be avoided in private practice without a large number of return visits for persistent symptoms (Pichichero ME et al: Pediatrics 2000;105:753).

Commentary: It seems to me that this is where the fight to prevent overuse of antibiotics should start. Rather than fretting over antibiotic use on a sick, febrile, ill-appearing hospitalized child, who may or may not have bacterial illness, let's focus on the relatively well outpatient children with typical respiratory tract infections. These children are very likely to have viral illness, and withholding antibiotics just from them would have an enormous impact on antibiotic use. In 1998, investigators found that 44% of children seen with "colds" and 46% with "URIs" were treated with antibiotics (Nyquist A-C et al: JAMA 1998; 279:875).

Doctor is key in decision to place baby on back

The recommendation of an infant's physician, more than any other factor, determines if an infant is put to bed on his or her back, according to a telephone survey of more than 4,000 caretakers of infants younger than 7 months. The survey was conducted between 1994, before the Back to Sleep campaign began, and 1998. Other factors that increased supine placement were recommendations of the neonatal nurse, reading materials, and radio or television messages. Recommendations from all four sources increased the probability of supine placement.

Before the Back to Sleep campaign, 43% of infants slept on their stomachs and 27% on their backs. By 1998, stomach placement had fallen to 17%, with 56% of infants placed on their backs. In 1998, prone placement was more common among infants of white mothers than among infants of black mothers and was used least among Hispanics, Asians, and other ethnic groups. The percentage of caretakers who reported receiving a recommendation from at least one source to place their infant in a prone position doubled from 38% to 79% during the four-year study period. In 1997 to 1998, however, 41% of respondents said that their physician did not recommend a sleep position (Willinger M et al: JAMA 2000; 283:2135).

Commentary: This is an amazing success story, with room for an even happier ending. The rate of SIDS has dropped by 38% in the US since the American Academy of Pediatrics recommended that babies be placed supine in bed. Health-care providers and public health organizations that have worked to get the Back to Sleep message to the public should take a bow. The remaining challenge is to increase further the number of caretakers who hear and heed the advice.

Meningococcal carriage surges at start of college

A study from the United Kingdom shows that during the beginning of the college term meningococci spread rapidly in first-year students. Investigators based their findings on a study of 2,507 college freshman who completed a questionnaire about personal characteristics and lifestyle and submitted to a pharyngeal swab on one of the first four days of the semester. Second swabs were taken either one month or two months later.

Although the initial carriage rate for Neisseria meningitidis was low (8%), it rapidly increased to 23% during the first week of school. The average carriage rate of meningococci during the first week among students living in dormitories that provided meals was 14%. One month later it was 31% and in two months it had reached 34%. The carriage rate was lower in dormitories where students ate elsewhere. Although non-C strains, mainly serogroup B and nongroupable meningococci, predominated in the swabs taken the first week of school, serogroup C meningococci was the most common strain acquired during the term. Analysis showed that active and passive smoking and kissing were risk factors for carriage; in addition, students who lived off campus were less likely to be carriers than those who lived on campus. Risk factors for acquisition of meningococci were male gender, active smoking, visits to campus bars and nightclubs, kissing, and living in coed dorms. Since this study was conducted, the United Kingdom introduced meningococcal vaccination for university students (Neal KR et al: BMJ 2000;320:846).

Commentary: In the past year, how often have parents of college students asked you if they should have their child immunized against N meningitidis? The Advisory Committee on Immunization Practices has recommended that families of freshmen living in dorms be given the option of immunizing their children. For details, go to the Web site of the Centers for Disease Control and Prevention, www.cdc.gov, and search on meningococcus.

Link seen between strep infection and OCD, tics

A new study of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) indicates that this condition may develop from an autoimmune response to streptococcal infection resulting in enlargement of specific areas of the brain. Investigators recruited children with acute-onset or striking exacerbations of obsessive-compulsive symptoms or tics, making no mention of an infectious trigger. They then compared the cerebral magnetic resonance images (MRIs) of the 34 children who met the criteria for PANDAS with those of 82 healthy children. The average sizes of the caudate, putamen, and globus pallidus of the children with streptococcus-associated obsessive-compulsive symptoms or tics were significantly greater than those of the healthy children. The average size of the thalamus and total cerebrum was the same in both groups. The changes in size of basal ganglia structures are thought to result from inflammation caused by antibodies directed toward the group A b-hemolytic streptococci bacteria crossreacting with the basal ganglia of genetically susceptible hosts (Giedd JN et al: Am J Psychiatry 2000; 157:281).

Commentary: This is an interesting finding, but one that is not ready for use in diagnosing this condition. The authors specifically say that at this time MRI is not indicated for every child with a new diagnosis of obsessive-compulsive disorder or tic disorder. For information on treatment of PANDAS, see Journal Club in the December 1999 issue of Contemporary Pediatrics.

Reading to toddlers boosts vocabulary

A simple and inexpensive intervention, delivered as part of well-child care, increases how much parents read to children and enhances the language development of toddlers, according to new research conducted in a multicultural group of 205 low-income families with infants. The infants were between 5 and 11 months old when the study began, with results of the intervention evaluated about a year later. Participating families were told the study was about children's play activities, interests, language development, and sleep habits and were interviewed about these subjects when the study began. At well-child visits, pediatricians gave half the families an age-appropriate children's board book; an age-specific handout explaining how children can benefit from, enjoy, and interact with books; and literacy-promoting anticipatory guidance. The other families received no books or materials related to literacy.

After an average of 3.4 well-child visits, repeat interviews with parents and tests of the children's vocabulary showed that the intervention group had higher vocabulary scores than the control families. This result applied to toddlers 18 to 25 months old, not to those who were younger. In addition, in intervention families there was a 40% increase in parents who said they and their child usually read together at bedtime, reading aloud was one of their child's favorite activities, or that it was one of their own favorite joint activities. The comparable increase in these preferences in control families was 16%. Analyses that controlled for demographic variables showed that the effects of the intervention were strongly associated with increased emphasis on shared reading experiences and their enjoyment (High PC et al: Pediatrics 2000; 105:927).

Commentary: Here's some solid evidence to support advocates of Reach Out and Read and other office-based literacy programs. It's nice to see that these simple programs, which seem to make sense, really work.

Also of note

VCUG after UTI: Sooner better than later. The traditional policy of performing a voiding cystourethrogram (VCUG) three to six weeks after a urinary tract infection (UTI) should be reconsidered, especially for hospitalized children. So concluded investigators who conducted a retrospective study comparing the presence and severity of reflux and the proportion of scheduled VCUGs actually performed in 213 children who were admitted to the hospital with UTIs. The children were divided into two groups: those for whom a VCUG was scheduled within one week of the UTI diagnosis and those for whom the VCUG was scheduled later than one week after the diagnosis. The proportion of children with reflux, almost one-fifth, was similar in both groups. The two groups also had similar grades of reflux. Where the groups differed, however, was in the proportion that actually had the scheduled VCUG. The tests were performed in all the children scheduled within one week of diagnosis, but in fewer than half the children who were scheduled later than one week after diagnosis (McDonald A et al: Pediatrics 2000;105[4]:e50).

Another reason for pregnant women not to smoke. Mothers who smoke during pregnancy are much more likely to have toddlers who display negativity than mothers who do not smoke during pregnancy, according to a new study. Study subjects were 99 2-year-olds and their mothers, chosen from a community sample. Fifty-two of the mothers smoked throughout pregnancy, and 47 either stopped smoking while they were pregnant or started after giving birth. Investigators administered a questionnaire to the mothers to determine their smoking history, perception of their child's negativity, demographic variables, and other potential risk factors for toddler negativity. Data analyses that controlled for these factors found that maternal smoking during pregnancy was a strong independent risk factor for negativity in toddlerhood. The study also confirmed earlier findings that conflicts in the mother-child relationship, maternal use of power-assertive discipline, and low maternal socioeconomic status were associated with greater child negativity (Brook JS et al: Arch Pediatr Adolesc Med 2000;154:381).

CLINICAL TIP
Three cheers for this oral exam

When performing an oral exam—tongue, insides of the cheeks, dentition, and throat—on a verbal but reticent child, I always ask the patient to let me "count your teeth." That phrase works better than "open your mouth." Then, using the tongue blade only if I have to, I count the teeth audibly (and quickly) and perform a sweep exam. To get a look at the throat, if the child is not cooperative, I chant "One tooth, two teeth, three teeth, a dollar, all for Lower Brule Sioux (or local high school team) stand up and holler." Then I have the child repeat the cheer with me. When the child says "holler," that's the exact moment I can see the tonsils.

Peter D. Magnus, MDLower Brule Sioux, SD

Do you have a Clinical Tip to share with colleagues? Let us know; we'll pay $50 for each item accepted for publication. Tips sent by mail should be addressed to Molly Frederick, Clinical Tips Editor, Contemporary Pediatrics, 5 Paragon Drive, Montvale, NJ 07645-1742. If you submit by e-mail (Molly.Frederick@medec.com), please include your mailing address.

CLINICAL TIP
Handy handouts help get the dose right

Counseling parents on appropriate use of antipyretic medication is an important part of managing fever. With so many preparations on the market, many parents are confused about the correct dosage for their child. To help them, we provide a customized handout that describes the various preparations available—drops, suspension, chewable tablets, or suppositories—and the appropriate dose and administration interval for each.

First, using the child's current weight, we find the closest appropriate dose of acetaminophen and ibuprofen from the table on the right.

We also explain differences in concentrations, especially among liquid preparations. The handouts on the far right have been very helpful in decreasing the incidence of under- and overdosing, and in answering parents' questions.

Douglas G. Olk, MDDubuque, IA

Do you have a Clinical Tip to share with colleagues? Let us know; we'll pay $50 for each item accepted for publication. Tips sent by mail should be addressed to Molly Frederick, Clinical Tips Editor, Contemporary Pediatrics, 5 Paragon Drive, Montvale, NJ 07645-1742. If you submit by e-mail (Molly.Frederick@medec.com), please include your mailing address.

Dosages for fever control

Acetaminophen dosage

The dosage of acetaminophen for your child is: 160 mg

Any one of the following can be given every FOUR hours as needed for fever or discomfort.

Concentrated drops (80 mg in 0.8 mL) 0.8+0.8 mL

Suspension liquid (80 mg in 1/2 tsp) 1 tsp
(1/2 tsp = 2.5 mL)

Children's chewable (80 mg each) 2 tab

Junior-strength chewable (160 mg each) 1 tab

Suppository (80 mg each) 2 supp
(120 mg each)     supp
(325 mg each)     supp

Ibuprofen dosage

The dosage of ibuprofen for your child is:100 mg

Any one of the following can be given every EIGHT hours as needed for fever or discomfort.
Concentrated drops (50 mg/1.25 mL) 1.25+1.25 mL

Suspension liquid (100 mg/tsp) 1 tsp

Children's chewable (50 mg each) 2 tsp

Junior-strength chewable (100 mg each) 1 tsp

Junior-strength caplets (100 mg)       cap

Adult tablet (200 mg each)       tab

These samples use a child weighing 23 lbs as an example. You can design your own blank forms to keep on hand and fill out when parents need written instructions to take home with them.

 

Julia McMillan. Journal Club. Contemporary Pediatrics 2000;6:124.