Journal Club

November 1, 1999

JOURNAL CLUB

JOURNAL CLUB

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COMMENTARIES BY MICHAEL G. BURKE, MD

Little time spent on anticipatory guidance

New research shows that pediatricians devote a mean of 2.4 minutes to anticipatory guidance at health supervision visits. Investigators observed a total of 166 well-child visits that lasted a mean of 17.8 minutes in 19 different pediatricians' offices—8.7 visits per pediatrician. They told the clinicians that they were interested in learning more about pediatric practice in Connecticut, where all the offices were located, but did not identify anticipatory guidance as the focus of the study. The pediatricians included 15 men and four women with a mean of 21.2 years since medical school graduation.

The amount of time spent on anticipatory guidance varied with the age of the child, with significantly more counseling provided for infants up to the age of 12 months than for 1- to 5-year olds and 6- to 12-year-olds. Pediatricians spent almost two thirds of counseling time on four topics: nutrition, safety, development, and immunizations. Nutrition got the most time in all groups except for children older than 12 years, for whom behavior was the most time-consuming topic. Safety and sleep were prominent topics in infant visits. The mean time individual pediatricians spent on anticipatory guidance ranged from 0.3 to 5.6 minutes, and varied considerably. Recently trained pediatricians spent more time counseling than those who were trained earlier. Since only four of the pediatricians were women, investigators could not make gender comparisons (Goldstein EN et al: Ambulatory Child Health 1999;5:113).

Commentary: Comparison of these results with those from a similar study conducted in Pittsburgh in 1980 shows that health maintenance visits now are longer and we spend more time on anticipatory guidance. Still, 2.4 minutes is precious little to cover a long list of topics. We need to use that time well, choose topics carefully, avail ourselves of preprinted handouts when we can, and continue to look for other ways of distributing preventive health information to families.

Firearm counseling not hitting the mark

Although they believe that all families with guns should receive firearm safety counseling, pediatricians are not good judges of which families probably own a gun, a new study shows. A total of 66 pediatricians and 169 of their patients' parents participated in a survey conducted at practices in the East, South, and Midwest. Parents and physicians completed separate surveys about safety practices and related counseling; investigators told participants that the purpose of the study was to gain an understanding of parents' and doctors' views about safety issues and parenting styles.

Pediatricians were quite accurate in estimating what proportion of families owned guns—25%, compared with the 28% of families who actually reported owning at least one gun. The clinicians were far less accurate in estimating the likelihood of gun ownership by specific families, however. Of the one third of families doctors thought were totally unlikely to own a gun, 30% reported owning at least one gun. About half of the pediatricians believed that they should discuss gun safety with all families, and 98% thought they should discuss gun safety with all families that own guns. Only 11% percent of the parents said that their pediatricians had discussed firearm safety with them, however. All parents who owned guns indicated that they would tell pediatricians about the guns if they asked (Becher EC et al: Pediatrics 1999; 104[3]:530).

Commentary: The point here is that many of our patients have guns in their homes, and we won't know which ones unless we ask. This is another item to squeeze into 2.4 minutes of anticipatory guidance. But with such high stakes, the effort may be worth the squeeze.

Breastfeeding protects against obesity

Investigators conducted a large retrospective study in rural Germany on the relationship between being breastfed in infancy and being overweight or obese at school entry. They evaluated results of a survey of parents of 5- and 6-year-old children; the 9,000 youngsters were part of a much larger group who underwent a routine health examination for entry to school, including measurements of height, weight, and body mass index. The survey questionnaire, which addressed risk factors for atopic diseases and included questions about early feeding, diet, and lifestyle, revealed that 4,022 of the children had never been breastfed and 5,184 had.

Correlation of results from the questionnaire and the school health examination showed that breastfeeding had a consistent protective effect against obesity, and that the effect was greater in those who had been breastfed longer. In children who had been exclusively breastfed for two months, prevalence of obesity was 3.8% compared with 2.3% for infants exclusively breastfed three to five months, 1.7% for six to 12 months, 0.8% for more than 12 months, and 4.5% for those who had never been breastfed. Breastfeeding had similar effects on prevalence of being overweight. Investigators concluded that exclusive breastfeeding for three to five months reduces by 35% the risk of obesity in children at school entry (von Kries R et al: BMJ 1999; 319:147).

Commentary: In 1995, 59.4% of newborns in the United States were breastfed at the time they were discharged from the hospital. That's well below the Healthy People 2000 goal of 75% but a substantial improvement from 24.9% in 1971. As these infants get older, will we see a slimming down in school-age youngsters and will these changes persist as the children reach adulthood?

New data on MRSA

A case study of methicillin-resistant Staphylococcus aureus (MRSA) in a 2-year-old boy who attended a day-care center in Canada sheds some light on transmission of both the methicillin-sensitive and methicillin-resistant forms of S aureus and the best site for culturing S aureus. After the boy failed to respond to macrolide therapy for otitis media, MRSA was isolated from persisting purulent drainage in his ear canals and he was hospitalized for intravenous therapy. Investigators gave parents of 164 of his classmates a questionnaire and obtained cultures from their children at one or more sites—nose, throat, and the perianal area. They also took nasal and perianal swabs from the 38 staff members at the center.

Non-methicillin-resistant S aureus was isolated from one or more sites from 40 (24.4%) of the children, who ranged in age from 6 weeks to 13 years, and nine (24%) of the staff members. Throat cultures were more sensitive than those of the nostrils or the perianal area. Older children were slightly more likely to carry the pathogen than younger children. Other factors associated with carriage were hospitalization in the past six months, having a family member hospitalized in the past six months, and visiting the emergency department at the local pediatric hospital in the past six months.

MRSA was recovered from only one classroom contact of the index case; although the classmate, who had chronic dermatitis, was cultured at three sites, MRSA was found only on perianal swab. Throat and nasal swabs of three household contacts of the index case were negative for MRSA. Of the three household contacts of the MRSA­positive classmate, only the 7-year-old sister was positive for MRSA on throat and nasal swabs. Investigators concluded that throat and perianal site screening are more sensitive in identifying children colonized with S aureus than nasal culturing and that clinicians should suspect MRSA infection in disease that is unresponsive to standard antibiotic therapy (Shahin R et al: Arch Pediatr Adolesc Med 1999;153:864).

Commentary: The August 20 MMWR reports four pediatric deaths in Minnesota from community-acquired MRSA. Staph identified in all four were MRSA but were susceptible to many common antibiotics other than the b-lactams. The MMWR authors suggest considering MRSA even in the absence of risk factors, for severe pediatric pneumonia or sepsis syndrome in communities where MRSA infections have been reported (MMWR 1999;48[32]:707).

More about permethrin resistance

Investigators tested the hypothesis that lice infesting the heads of children in the United States are less often susceptible to permethrin than lice on the heads of children living in an area where similar pediculicides are rarely applied. They sampled head lice from children living in Massachusetts and Idaho as well as in Borneo. A questionnaire returned for 42 of the infected Americans, who were from 5 to 8 years old, established that virtually all these children had been treated previously with pediculicides containing pyrethrins or permethrin; none of the 59 boys who were the subjects from Borneo had this exposure. Permethrin did not affect head lice sampled from the infested, previously treated US children, but it did kill the lice sampled from the children in Borneo. Further, the mortality of the lice from Borneo correlated closely with the dose of the pediculicide. Investigators noted, however, that the pyrethroid susceptibility of the general population of head lice in the US is not known. Thus, preparations containing permethrin may remain the pediculicides of choice for newly recognized louse infestations (Pollack RJ et al: Arch Pediatr Adolesc Med 1999;153:969).

Commentary: The authors made an interesting aside: They noted that infestation with head lice has absolutely no social stigma in Borneo. Compare this with the alarm that the first nit sighting causes in US schools.

Kids hospitalized for asthma sicker than in past

A study of more than 2,000 hospitalizations for asthma among children from 1 month to 19 years of age during a five-year period shows that the hospitalization rate for severe asthma episodes increased each year, tripling from 1991 through 1995. The overall asthma hospitalization rate was unchanged during the period, however, because hospitalizations for mild and moderately severe asthma episodes decreased.

Among children younger than 5 years and from 5 to 11 years old, the hospitalization rates for severe asthma episodes increased 340% and 160%, respectively. For children age 12 to 18 years, the rate remained almost unchanged. The rate of hospitalization for severe asthma episodes increased 210% for boys and 120% for girls. Meanwhile, the rate of hospitalization for mild asthma episodes decreased by half during the period (Russo MJ et al: Pediatrics 1999;104[3]:454).

Commentary: The authors look only at hospitalizations in Rochester, NY, but their work confirms the general impression of physicians in the community where I work: Children continue to be hospitalized for asthma, but those who are hospitalized are sicker than they used to be.

Flu shots reduce absenteeism

Researchers in Finland found that influenza vaccination substantially reduced absenteeism related to respiratory infection in health-care workers. For five months they followed 427 pediatric hospital employees who were vaccinated with inactivated influenza A vaccine and compared them with controls who were vaccinated with placebo. All study subjects kept a diary of their respiratory infections, absenteeism, and antibiotic use as well as details about their symptoms and general health. Absenteeism fell by 28% in subjects who were vaccinated, compared with the control group. The vaccine produced a similar decline in the days the study subjects felt unable to work, whether a work day or weekend. The total number of days individuals had respiratory infections and the number of episodes of respiratory infection they had during the five-month period were the same in the vaccinated group and the control group, however (Saxen H et al: Pediatr Infect Dis J 1999;18:779).

Commentary: Here's a reminder for you and your office staff. It's time to get your flu shot.

Also of note

Use of markers reduces unnecessary antibiotics in newborns. In working up suspected nosocomial bacterial infection (NBI) in newborns, determination of levels of interleukin 8, a new marker of infection, along with levels of C-reactive protein, appears to be a feasible strategy for restricting antibiotic therapy to truly infected infants. Researchers performed a two-part study in 1,386 newborn infants, including 223 preterm infants, admitted to the neonatal ICU at a children's hospital in Germany. During the first study period, they administered antibiotics to infants with either a C-reactive protein of more than 10 mg/L or an immature-to-total neutrophil ratio of more than 0.20. During the second study period, they tried a new protocol: administration of antibiotics only if the infant's C-reactive protein was more than 10 mg/L or if the interleukin 8 level was more than 53 pg/mL. Use of the combined interleukin-8 and C-reactive protein markers detected culture-proven NBI with 96% sensitivity, reduced unnecessary antibiotic therapy for suspected NBI by 73%, and was cost effective (Franz AR et al: Pediatrics 1999;104[3]:447).

Ultrasonography and CT together help diagnose appendicitis. Limited appendiceal computed tomography in which contrast material is administered only through the rectum (CTRC) has proved highly accurate in diagnosing appendicitis in adults. Now a study shows that a negative or indeterminate ultrasonography followed by this procedure is just as effective in diagnosing appendicitis in children. Children and adolescents with possible appendicitis who came to the emergency department of a large hospital during a five-month period were evaluated with pelvic ultrasonography. The 108 children and adolescents whose ultrasonography was negative or inconclusive also underwent CTRC, which yielded a sensitivity and specificity of 94%. This compares with a sensitivity of 44% and specificity of 93% for ultrasonography alone (Garcia Peña BM et al: JAMA 1999;282:1041).

DR. BURKE, Section Editor for Journal Club, is Chairman of the Department of Pediatrics at Saint Agnes Hospital, Baltimore.



Marian Freedman. Journal Club. Contemporary Pediatrics 1999;11:165.