JOURNAL CLUB

Commentaries By Michael G. Burke, MD

After RSV, are steroids beneficial?

In an observational study conducted in Sweden, investigators assessed the effect of inhaled corticosteroids on subsequent respiratory symptoms and asthma in infants hospitalized for respiratory syncytial virus (RSV) infection. The 188 children, who had a median age on hospital admission of 2 to 3 months, were treated in the winter of 1994-1995 or the winter of 1995-1996. Of those treated in the earlier period, only 13% received inhaled corticosteroids at discharge. Of those treated in the later period, most (86%) received inhaled corticosteroids for six to eight weeks following discharge. An evaluation questionnaire administered 19 to 24 months after discharge showed that children in the later treatment group had postdischarge asthma and respiratory symptoms less often than children in the earlier treatment group. Diagnosis of asthma in the later treatment group was reduced from 24% to 12% and severe recurrent wheeze from 37% to 21% (Hesselmar B et al: Acta Paediatr 2001;90:260).

Commentary: This is an interesting idea but a weak study. The before-and-after observational study design and the lack of randomization, blinding, and placebo control put the study's conclusions into question. A prospective, double-blind, placebo-controlled study is needed to look at the use of long-course inhaled steroids after RSV for prevention of asthma.

KD may accelerate atherosclerosis

Investigators conducted a study to determine whether coronary artery atherosclerosis is accelerated in some patients with a history of Kawasaki disease (KD), compared with healthy controls. They studied 40 adolescents between 11 and 22 years of age, half of whom had KD and coronary artery aneurysms diagnosed six to 20 years earlier. Using ultrasonography and blood tests, they compared clinical and blood variables in the two groups.

Teens with and without past KD did not differ in levels of total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglyceride, TC/HDL-C, or the allele frequency of Apo E4. However, the carotid artery wall in patients with both KD and coronary artery lesions was less distensible and thicker than it was in controls. These changes of arterial properties were not associated with major alterations of the lipid profile. Investigators concluded that because arterial wall stiffness seems to reflect the degree of early atherosclerotic change in the arterial tree, measurements of stiffness by carotid ultrasonography may be warranted in patients with KD and coronary artery lesions (Noto N et al: Pediatrics 2001;107:1095).

Commentary: Differences in carotid artery wall thickness and stiffness were statistically significant but small. Further study will be needed to establish a role for this technique in screening patients who have had Kawasaki disease.

Guidelines for head trauma in young children

A multidisciplinary panel of nine experts in pediatric head trauma released guidelines for evaluating minor head trauma in children younger than 2 years. After reviewing evidence drawn from 404 references generated by MEDLINE, the panel formulated answers to 10 specific clinical questions about head trauma in young children and guidelines based on data and expert consensus. The panel developed a management strategy that categorizes children in four groups, based on risk of intracranial injury:

• Children at high risk of intracranial injury (those with depressed mental status, focal neurologic findings, or signs of depressed or basilar skull fracture, for example) should undergo a computed tomography (CT) scan.

• Children at intermediate risk of intracranial injury with symptoms of such injury (such as three or four episodes of vomiting, transient loss of consciousness, or history of lethargy or irritability) should undergo CT scan or observation. Children in this group with some risk of skull fracture (such as those who have undergone an accident with a high-force mechanism) should undergo CT or skull radiographs or observation.

• Children at low risk of intracranial injury do not require imaging.

The authors note that, the younger the child, the lower the threshold should be for obtaining imaging studies. Conversely, the greater the severity and number of historical symptoms and physical signs, the stronger the case for an imaging study (Schutzman SA et al: Pediatrics 2001;107:983).

Commentary: This article is difficult to synopsize and is worth reading in full. The authors don't offer new research data but do an excellent job of summarizing available evidence. They then make specific recommendations on the extent of the work up and observation required for young children who have had minor head trauma.

Early childhood program brings results

One of the first studies of long-term effects of a large-scale public early-childhood program shows that, at up to 20 years of age, low-income children who participate in such a program have better educational and social outcomes than children who haven't participated. The Chicago Child-Parent Center (CPC) Program, the subject of the study, provides comprehensive education and family and health services in the city's poorest neighborhoods. It includes half-day preschool at ages 3 and 4 years, half- or full-day kindergarten, and school-age services in elementary schools at ages 6 to 9 years.

Investigators tracked the well-being of nearly 1,600 low-income minority children (mostly African- American) born in 1980 who attended early childhood CPC programs in 25 sites in 1985 to 1986. They then collected yearly data on educational and family experiences from school records and surveys comparing outcomes in the 989 children who completed the preschool and kindergarten intervention program with 550 children in alternative early childhood programs—namely, full-day kindergarten without additional services. Investigators also compared outcomes in children who participated in the school-age intervention with those who did not participate. In addition, they compared effects of participating in an intervention beginning in preschool and continuing for four to six years through the second or third grade (extended intervention) and not participating in such a program.

Participants in the preschool program had a significantly higher rate of completing high school by 20 years of age and a lower rate of dropping out of school than children who participated in the alternative preschool program. Preschool participants also completed more years of education than the comparison group and had a lower rate of juvenile arrest and arrests for violent crime. Both preschool and school-age participation were significantly associated with a lower rate of grade retention and special education services. The effects of preschool participation on educational attainment were greater for boys than for girls, especially in reducing school dropout rates. Children with extended program participation from preschool through second or third grade also experienced a lower rate of grade retention than children who participated less extensively (Reynolds AJ et al: JAMA 2001;285:2339).

Commentary: This article provides a broad endorsement of early education programs for disadvantaged children. Clip it, and then send it to your legislators during the next budget debate. They should hear that money spent on Head Start now may reduce spending on fighting crime and administering the juvenile justice system later.

Also of note

Snacking is on the increase. A survey on snacking shows that, over a 20-year period, eating between meals has become increasingly prevalent among children, although the average size of snacks and energy per snack has remained relatively constant. Using interviewer-conducted surveys and self-administered food records, investigators collected information from more than 21,000 children 2 to 18 years of age about all the food they consumed during discrete three-day periods. Snacking represented about a fourth of the energy and a fifth of many other nutrients— similar to any meal—that the children consumed each day. The increase in the nutrients that snacks contributed to the daily diet was caused primarily by an increase in the frequency of snacking and not the size of each snack. During every period examined, 12- to 18-year-olds derived a higher proportion of calories from snacks than did any other age group (Jahns L et al: J Pediatr 2001;138:493).

Adding montelukast means better asthma control. Montelukast, 5 mg, added to budesonide significantly improves asthma control in children with inhaled glucocorticoid-dependent persistent asthma, a new study shows. Study subjects were 279 children from 6 to 14 years of age with persistent asthma who had been treated with inhaled glucocorticoid for at least six weeks before the study began. During one four-week period these children received a 5-mg chewable montelukast tablet or a placebo once daily at bedtime in addition to 200 µg of inhaled budesonide twice daily. During a subsequent four-week period, children who had been treated with montelukast received placebo and vice versa. Montelukast improved the mean percent increase from baseline in forced expiratory volume in one second (FEV₁) and morning and evening peak expiratory flows. It also decreased the number of asthma exacerbation days, decreased ß₂-adrenergic agonist use, and reduced the blood eosinophil count. Although modest, subjective and objective improvements in asthma produced by adding montelukast to inhaled budesonide were consistently and significantly greater than improvements produced by placebo. The safety of the two treatments was similar (Simons FE et al: J Pediatr 2001;138:94).

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

A bug in the ear? Flush it out

During warm weather, I occasionally encounter a child with an insect in his ear. I have had great success removing these irritating creatures by dripping hydrogen peroxide into the affected ear. Besides poisoning the insect, the hydrogen peroxide drowns it and the bubbling action lifts it to the fluid's surface and out of the ear. Then I use a curette to dispose of the insect, although sometimes it is just as easy to scoop it out with my fingers.

Judy Tapper, MD
Longmeadow, Mass.

The secret of health and wealth

All our patients come in for a checkup around 10 years of age because our state mandates a school physical for fifth graders. At the beginning of the visit I say "I have a secret to keep you healthy and wealthy throughout your life." This piques the interest of both child and parent. At the end of the exam I finally reveal the secret: Never start smoking. I go on to explain that they will always be healthier if they don't smoke than if they do. I also invite them to consider how much money they can save over a lifetime by not buying cigarettes. I say something like "I'm told that a pack of cigarettes costs $5 these days. Let's see, two packs a day for a week would be $70. How much do you think that is in a year?" They can hardly believe that would amount to $3,640, but it does. Most parents nod their heads in agreement as if to say "See, haven't I been telling you?" Some parents, however, look down sheepishly as their child says to them "See, haven't I been telling you?"

Bruce Bedingfield, DO
South Barrington, Ill.

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.

 

Michael Burke. Journal Club. Contemporary Pediatrics 2001;7:115.