JOURNAL CLUB

Commentaries By Michael G. Burke, MD

Parental "fever phobia" is alive and well

A new study shows that parents and other caregivers worry excessively about fever, manifesting signs of the "fever phobia" described 20 years ago in a landmark study (Schmitt BD: Am J Dis Child 1980;134:176). Using interviews and a 19-item questionnaire that was modeled after the one used in the early study, investigators examined parents' attitudes about fever, their understanding of its effects, and use of fever reduction techniques. Subjects were 340 caregivers whose children were enrolled in two urban, hospital-based pediatric clinics in Baltimore, Md. About 56% of caregivers were very worried about how fever potentially could harm their children; 91% believed that fever could have harmful effects. Twenty-five percent gave an antipyretic for a temperature less than 37.8° C (100° F). Forty- four percent gave ibuprofen at a too-frequent dosing interval. Compared with 20 years ago, more caregivers think fever can cause a seizure but fewer consider brain damage a possibility. Today's caregivers check their child's temperature more often during a febrile illness, wake their child more often to give an antipyretic, and give an antipyretic or sponge the child more frequently for a possibly normal temperature. Caretakers who are very worried about fever are more likely than those who are not to have a child who was evaluated for a fever, to have blood work performed on their child during a febrile illness, and to believe that their doctor is very worried about fever (Crocetti M et al: Pediatrics 2001;107:1241).  

Commentary: I wonder if these families' physicians would have guessed these results. Forty-six percent of parents studied said that doctors and nurses were their primary sources for information about fever. Yet 18% of caregivers who sponge their febrile babies do so with rubbing alcohol. Who told them to do this? Are we competing with grandparents, neighbors, and others in advising parents? Or do our own words and actions mislead parents?

For further discussion of fever fact and fiction, see "Fever: Measuring and managing a sizzling symptom" in the May 2001 issue of Contemporary Pediatrics).

No mandibular frenulum and IHPS

Investigators tested the hypothesis that joint hypermobility is associated with an absent mandibular frenulum in patients with infantile hypertrophic pyloric stenosis (IHPS) and in their parents. They studied 37 children with a history of IHPS and their parents, along with 68 controls. Twelve of 37 patients with IHPS lacked a mandibular frenulum compared with none of 68 controls.

A significant relationship between joint hypermobility, absence of a glandibular frenulum, and IHPS was observed. Patients with IHPS and no mandibular frenulum were more frequently hypermobile than other study subjects, whereas patients with IHPS and an observable mandibular frenulum had no more hypermobility than controls. Mothers of the patients with IHPS and no mandibular frenulum also were more frequently hypermobile than either the mothers of controls or the mothers of patients with IHPS who had a mandibular frenulum. Likewise, fathers of the children with IHPS and no mandibular frenulum more often showed joint hypermobility than the fathers of controls, but not more than fathers of patients with IHPS and a mandibular frenulum. These findings indicate a significantly increased prevalence of joint hypermobility among children with IHPS and their parents, in particular among those who lack a mandibular frenulum (DeFelice C et al: J Pediatr 2001;138:596).

Commentary: Last year, this group described an association between pyloric stenosis and absence of the midline frenulum between lower teeth and lip (J Pediatr 2001;136:408). Now they extend their observations to include joint hypermobility. I have been looking for the absence of this frenulum in the few children I see with pyloric stenosis and have had little luck. I wonder if DeFelice and colleagues are studying a discrete gene pool with high prevalence of this new syndrome. We'll have to wait and see if their findings are generalizable.

A better way to predict UTI renal involvement?

A new study determined that the result of a procalcitonin rapid blood test is a better predictor of pyelonephritis in children with febrile urinary tract infection (UTI) than the result of a C-reactive protein rapid blood test. The study enrolled 54 children (18 boys and 36 girls) with proven UTI: 63% had renal involvement (as shown by the evidence of radionuclide imaging with ^99mTc-dimercaptosuccinic acid) and 37% had infection restricted to the lower urinary tract. For both tests, investigators determined likelihood ratios, which depend on the sensitivity and specificity of the test for specified ranges of values. The likelihood ratio of procalcitonin for predicting renal involvement in children with febrile UTI was between 3.8 and 7. For C-reactive protein, the calculated likelihood ratio was between 1.5 and 2.8. Investigators concluded that rapid determination of the procalcitonin concentration could be useful for managing children with febrile UTI in the emergency room (Gervaix A et al: Pediatr Infect Dis J 2001;20:507).

Commentary: The search for an easy and available test to differentiate upper UTI from lower UTI has gone on for years. It may be that this determination isn't as important as it once was. Hoberman and colleagues have suggested that oral therapy is as good as IV for treatment of febrile UTI, even when pyelonephritis is present (Pediatrics 1999;104:79). If you accept these findings, then knowing that a patient has an upper tract infection will not affect therapy. It may, however, still determine how aggressively you follow the patient for renal scarring and subsequent UTI.

Vaccines often stored improperly

Investigators visited private physicians' offices in Georgia to determine how often offices stored and handled vaccines in a less than ideal manner and to identify risk factors for doing so. At least two months before the 221 sites were visited (all of which were known to immunize children routinely with government-provided vaccines), about half the offices—the intervention group—were sent a draft manual prepared by the Centers for Disease Control and Prevention (CDC), "Guideline for Vaccine Storage and Handling." The other offices—the control group—did not receive the manual. Site visits revealed that storage problems were common: freezer temperatures above those recommended for storing varicella or oral polio vaccine (17% of offices); refrigerator temperatures 1° C (15%); and expired vaccines (9%). All told, investigators observed or documented at least one vaccine storage problem in 44% of intervention and control offices combined. Major risk factors associated with vaccine storage outside recommended temperature ranges were:

• lack of a thermometer in the freezer

• use of the freezer compartment in small cold-storage units

• lack of thermometer in the refrigerator

• failure to maintain the temperature log of the freezer.

Offices in the control group were no more likely to have storage inadequacies. Investigators concluded that problems with vaccine storage are common and relate mainly to inadequate monitoring of cold storage units or use of freezer units in inappropriate small refrigerators or freezers. A modest outlay to purchase equipment and train staff, they point out, could avoid these problems (Bell KN et al: Pediatrics 2001;107[6]:e100).

Commentary: Guidelines for storing vaccines are available from the CDC at www.cdc.gov/nip/publications/vac_mgt_book.pdf . This study shows that having this publication isn't enough. You'll need a smart, compulsive staff member in your office to ensure compliance.

Predicting CNS events in sickle-cell disease

Investigators tested the notion that nocturnal hypoxemia, documented by overnight pulse oximetry, can predict central nervous system (CNS) events in patients with sickle-cell disease. They screened 95 patients with sickle-cell disease (median age, 7.7 years) by transcranial doppler ultrasonography (to detect high velocities in the arteries) and overnight pulse oximetry and followed them for a median of six years. Results were compared with what was found in 52 patients who did not undergo overnight pulse oximetry. Nineteen patients had CNS events. Mean overnight oxygen saturation (SaO) and higher internal-carotid or middle-cerebral artery velocity were independently associated with time to a CNS event. High hemoglobin concentration was also associated with increased risk of a CNS event. Investigators concluded that screening for nocturnal hypoxemia, and aggressively managing it, might be a safe and effective alternative to prophylactic transfusion for primary prevention of CNS events in sickle-cell disease (Kirkham FJ et al: Lancet 2001;357:1656).

Commentary: Whoa....Transcranial ultrasonography is used as a screen to identify sickle-cell patients who are at risk for CNS events. The authors propose using nocturnal hypoxia as an alternative screen. But it seems like a big leap to say that treating with oxygen would prevent those events, especially given the unreliability of pulse oximetry in sickle-cell patients. I think that we'll need to wait for more information before acting on this observation. The authors say that a prospective treatment trial is in the works.

Fluticasone useful in obstructive sleep apnea

A six-week course of nasal fluticasone decreased the severity of obstructive sleep apnea in children, a new study shows. Twenty-five children with obstructive sleep apnea documented by polysomnography, who ranged in age from 1 to 10 years, were divided into two groups. One group of 13 received fluticasone; 12 received placebo. The study drug was given as one 50 mg spray per nostril twice daily for the first week and once daily for the subsequent five weeks of the study period. Fluticasone reduced by a modest amount the frequency of obstructive airway events (in 12 of 13 patients who received it), hemoglobin desaturation episodes, and respiratory movements and arousals. In contrast, the placebo group did not show any improvement. The size of tonsils and adenoids and the presence of symptoms did not differ significantly from one group to the other (Brouillette RT et al: J Pediatr 2001;138:838).

Commentary: This was a small study conducted at one site in a restricted group of patients. Broader follow-up studies are needed to confirm the findings and determine whether the improvements recorded are significant enough to obviate surgery in a significant percentage of children who undergo adenotonsillectomy for obstructive sleep apnea.

Also of note

Better way to diagnose GABHS? Investigators tested the performance of a predictive model for group A b-hemolytic streptococcus (GABHS) pharyngitis in children in different clinical settings (a pediatric emergency department and two pediatric outpatient clinics) and two different seasons. The model called for four independent variables to be considered predictors of a positive throat culture: moderate or severe tonsillar swelling; moderate or severe tenderness and enlargement of cervical lymph nodes; scarlatiniform rash; and absence of coryza. The study, of 587 patients with pharyngitis, looked at how well this model predicted a positive culture compared with physicians' subjective prediction. The model performed significantly better than physicians did and was comparable to a rapid antigen detection test (Attia MW et al: Arch Pediatr Adolesc Med 2001; 155: 687).

Gene therapy for hemophilia A. Implantation of genetically altered fibroblasts that produce factor VIII is safe and well tolerated in patients with severe hemophilia A, a phase 1 trial showed. Investigators isolated fibroblasts from six patients and transfected the cells with a plasmid containing sequences of the gene that encode factor VIII, a mutated form of which causes hemophilia A. They then selected and cloned cells expressing factor VIII, propagated the clone in vitro, and implanted the clonal cells into the patients. No serious adverse events resulted from use of factor VIII­producing fibroblasts or the implantation procedure. In addition, no complications developed over a 12-month period, and no inhibitors of factor VIII were detected. In four patients, the plasma level of factor VIII activity rose above the level observed before the procedure. This was accompanied by a decrease in bleeding or a reduction in the use of exogenous factor VIII, or both (Roth DA et al: N Engl J Med 2001;344:1735).

DR. BURKE, section editor for Journal Club, is chairman of the department of pediatrics at Saint Agnes Hospital, Baltimore. He is a contributing editor for Contemporary Pediatrics.

CLINICAL TIP

Ipecac: Have one for the road

Most pediatricians recommend that the parents of a young child keep syrup of ipecac in the home to treat certain kinds of toxic ingestions, although its effectiveness is debated from time to time. Unfortunately, parents may be away from home with their child when an ingestion occurs. Even if they have a cellular phone with them to call a poison control center, they can't give ipecac if instructed to do so because they have none with them. Therefore, I routinely advise parents to carry ipecac with them in the baby bag. It is also important to remind parents to contact a poison control center before giving ipecac because ipecac is not recommended for many types of ingestions.

Howard J. Bennett, MD
Bethesda, Md.

Plastic tubing beats bulbs for pneumatic otoscopy

Clinicians who have little experience with pneumatic otoscopy often find it challenging to hold the otoscope, retract the pinna, and squeeze then release the insufflator with only two hands—especially when the child does not hold still.

In our clinic, I have trainees practice pneumatic otoscopy on each other using 9-inch lengths of clear plastic 3/16-inch tubing instead of insufflator bulbs, which are awkward and sometimes in short supply. I buy about 40 feet of tubing at a time for 11 cents a foot at the local hardware store. One end just fits into the otoscope, the other goes in the examiner's mouth. I demonstrate for the trainees how to generate rapid, low-amplitude changes in pressure by blowing into the tube so that they can see the motility of their colleagues' eardrums—often the first time they have done so successfully. I point out that it takes only a tiny volume of air—less than in the length of the tubing they are using—to change the pressure in the external auditory canal. When the otoscope gets foggy, they know they are blowing too much.

Successfully visualizing tympanic membrane motility helps the trainees build on their skill with the otoscope. Many (including me) continue to prefer this method of insufflation even after learning to use the bulb.

Thomas B. Newman, MD, MPH
San Francisco, Calif.

A practical way to measure penile length in newborns

Checking for microphallus is an important part of the physical examination of male newborns. Most of the time you can do this by simple observation. Sometimes, however, it is necessary to measure stretched penile length to be sure it is 2.5 cm. Using a tape measure on a squirmy newborn is difficult. The following technique improves the ease and accuracy of penile measurement: Hold and stretch the infant's penis with one hand. Then place a tongue depressor at the base of the symphysis pubis and grip it with the same hand that holds the penis. Mark where the end of the penis falls on the tongue depressor with a pen held in your other hand. Measure the distance marked, and you are done.

Howard J. Bennett, MD
Bethesda, Md.

A polished approach to differentiating twins

A mother taught me a neat trick to avoid confusion of identity with newborn twins. The babies appeared for a well visit with one child's toenail painted with red nail polish. The mother told me she did this to relieve her very real fear that she would be unable to tell them apart. I now recommend this practice to all of my mothers of same-sex twins. Our hospital nursery has started using it, too, because infant identification tags occasionally slip off.

Joseph Moore, Jr., MD
Summerville, S.C.

Adhesive bandages—slip sliding away

To remove adhesive bandages easily, apply a pea-sized blob of petroleum jelly on top of the adhesive portion of the bandage and rub it in, using a circular motion. In about a minute, the bandage will slide off. Kids are certain to like this much better than that tried-and-true method—ripping it off.

Frances Yang, MD
Anaheim, Calif.  

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.

Journal Club.

Contemporary Pediatrics

2001;8:19.