Journal Club

A two-drug combo for bronchiolitis

The infants were divided into four groups: nebulized epinephrine plus oral dexamethasone, nebulized epinephrine plus oral placebo, nebulized placebo plus oral dexamethasone, and nebulized placebo plus oral placebo. The nebulized treatments, administered 30 minutes apart, consisted of 3 mL of epinephrine in a 1:1,000 solution or an equivalent volume of saline. The oral treatments, given after the first nebulized treatment, consisted of 1.0 mg of dexamethasone per kilogram of body weight (maximum dose, 10 mg) or placebo, followed by five once-daily doses of dexamethasone (0.6 mg per kilogram to a 10 mg maximum daily dose).

Combining epinephrine and dexamethasone was most apparently beneficial in the first three days after enrollment. Combined therapy also was associated with earlier discharge from medical care and more rapid resumption of quiet breathing and normal feeding (Plint AC et al: N Engl J Med 2009;360:2079).

Commentary

Let the debates begin...again. In the words of the authors, bronchodilators and steroids are "widely used but not routinely recommended" for treatment of bronchiolitis. Here's a good description of a situation where we have little evidence for use but few alternatives for treatment of a common and sometimes severe condition. Many, when faced with a wheezing infant in the office or ED, will order one, or both: this offers some tentative support for both. For every 11 children treated with both epinephrine nebs and dexamethasone, one hospitalization was avoided. Certainly not a silver bullet, but an interesting finding that will generate more debate on this topic, and more study of combination therapies.

Can 'social marketing' improve vaccination rates?

Social marketing, a behavior change strategy that uses commercial marketing technologies to influence voluntary behavior, has the potential to improve immunization rates, according to authors of a recent article. To show how such a program would work, the authors described a social marketing campaign currently being developed in Washington State to increase timely immunization in children.

The program focuses on parents (expecting or currently have a child up to the age of 24 months) who might be described as "hesitant" about immunizations. Compared with parents who refuse vaccination, such parents are more numerous and more likely to be open to considering vaccination. Research will determine what barriers and benefits to immunization hesitant parents perceive. A positioning and marketing mix strategy then will be designed to decrease the barriers, dispel vaccine myths, and highlight the benefits.

Enlisting spokespersons to convey the campaign's message will be an important component of the program. These individuals must provide a warm and sympathetic face for vaccine advocacy, and tell an emotional story that resonates with parents. Two types of individuals might meet these criteria: a formerly hesitant parent whose unvaccinated child caught a vaccine-preventable disease, or a recognizable public figure who has personal life experience with such a disease.

In addition, trusted local health care providers will deliver fact-oriented vaccination messages and stories about real people who were affected by vaccine-preventable disease. Local media channels and presentations at mothers' groups and birthing classes are other possible venues for advocacy. Sponsors who are funding the development phase of the campaign have been assembled, keeping in mind that parents perceive nonprofit organizations as more trustworthy than those with a stake in a vaccine-related product (Opel DJ et al: Arch Pediatr Adolesc Med 2009;163:432).

Commentary

It is about time that sophisticated methods of marketing be used to effectively promote the health of our patients. Misinformation spreads quickly, often unchecked, through the Internet and the media. We shouldn't abandon one-on-one counseling and education of parents in our practices, but we could complement it with carefully planned marketing campaigns. And, like smart marketers everywhere, these investigators will be measuring results of their program.