JOURNAL CLUB

Commentaries by Michael G. Burke, MD

Antibiotics may lack benefit in acute sinusitis

A randomized, placebo-controlled trial in three community pediatric practices showed that neither amoxicillin nor amoxicillin-clavulanate offered any clinical benefit compared with placebo for children with clinically diagnosed acute sinusitis. Study subjects were 161 children between the ages of 1 and 18 years who had 10 to 28 days of persistent sinus symptoms. The children were treated for 14 days, either with amoxicillin (40 mg/kg/d), amoxicillin-clavulanate (amoxicillin 45 mg/kg/d), or placebo. Investigators assessed outcomes by telephone interview with the caregiver or patient during a two-month period, relying on a quantitative symptom score and subjective impressions.

Symptoms improved over time and at a similar rate in all three groups. Antimicrobial treatment also offered no benefit in recovery to usual functional status, days missed from school or child care, or relapse and recurrence of sinus symptoms. The overall rate of reported side effects did not differ among treatment groups, although patients who were treated with amoxicillin had abdominal pain more frequently than those in the other groups (Garbutt JM et al: Pediatrics 2001;107:619).

Commentary: This article is sure to generate plenty of discussion, and its findings eventually might change how you treat children with prolonged upper respiratory tract symptoms and possible sinusitis. Be aware, however, that the authors were looking at what I would call "soft-call" sinusitis. They excluded from their study those with fever >39° C, facial swelling, or facial pain. I would not change treatment of these sicker children based on this study. And, even for the milder illness considered here, I might wait for a follow-up study, perhaps one using a higher dose of amoxicillin in the treatment group and one that looked at changes in symptoms on days 1 and 2 of treatment. I think we'll hear more on this topic.

Looking for a SIDS-P carinii infection link

Correlation between sudden infant death syndrome (SIDS) and infection with Pneumocystis carinii merits further attention, results of a new study suggest. Investigators examined lung sections of 79 infants who died from SIDS in Rochester, N.Y., and Connecticut for the presence of P carinii. Of the 52 cases in Rochester, P carinii was found in the specimens of six (11.5%) infants. Of 27 cases in Connecticut, five lung specimens (18.5%) contained the organism. P carinii infection results in overt disease in immunocompromised individuals, but the infants in whom P carinii was identified had a normal thymus and no other findings suggestive of immunocompromise (Morgan DJ et al: Pediatr Infect Dis J 2001;20:306).

Commentary: This is an interesting finding but is a long way from establishing a cause-and-effect relationship between P carinii and SIDS. About 75% of children have antibodies to P Carinii by 4 years of age, presumably after asymptomatic infection. The Pneumocystis that investigators noted in 12% to 19% of babies with SIDS may well be an incidental finding. The authors say as much and suggest a future case-control study to sort out this information.

"Yes" to flu vaccination for asthmatics?

Investigators studied the effectiveness of influenza vaccine in protecting children against influenza-related exacerbations of asthma. They reviewed the records of asthmatic children 1 to 6 years of age in four large health maintenance organizations on the West Coast for three consecutive influenza seasons. Between 22,000 and 71,000 children with asthma were studied in each season. Investigators found that the apparent effectiveness of influenza vaccination against asthma exacerbations is highly confounded by asthma severity. When vaccinated children were compared with unvaccinated children, vaccination was associated with an increased risk of exacerbation. However, when incidence of exacerbation after vaccination was compared with incidence before vaccination in the same child (thereby controlling for asthma severity on an individual level), influenza vaccination decreased the risk of exacerbation by as much as 22% to 41%. The authors note that these findings support current recommendations to vaccinate asthmatic children (Kramarz P et al: J Pediatr 2001;138:306).

Commentary: The findings here aren't as clear as we would hope. Immunization data for individual asthmatics before and after immunization might have prevented subsequent attacks. But other effects of the contact with the pediatrician might have come into play.

Housing factors affect asthma incidence

A survey conducted between 1988 and 1994 of the parents of 8,257 children younger than 6 years shows that several housing-related exposures are associated with asthma diagnosed by a doctor. Other factors related to doctor-diagnosed asthma were a parental history of atopy, black race, and a history of allergic rhinitis. Six percent of the children surveyed had doctor-diagnosed asthma.

Children who had a history of allergies to a pet—defined as having ever given away or avoided pets due to allergies—were 24 times more likely than other children to have doctor-diagnosed asthma. Presence of a dog in the house, exposure to second-hand smoke, and use of a gas stove or oven for heat also were independently associated with the disease. These data indicate that about 532,000, or 39%, of the 1.36 million cases of doctor-diagnosed asthma in US children younger than 6 years could be prevented by eliminating exposures to indoor pollutants and allergens in housing. Investigators estimated that this would represent a $402 million reduction in costs related to asthma (Lanphear BP et al: Pediatrics 2001; 107:505).

Commentary: These findings suggest that pursuing environmental triggers in the home would save big money and avoid significant morbidity. Maybe it is time to bring back the house call or, at least, to send asthma educators to where the culprits lie.

New look at tympanostomy tubes

Does prompt insertion of tympanostomy tubes in young children with persistent otitis media with effusion improve developmental outcomes? Not according to a new study, which shows that early tube insertion makes no measurable difference in speech, language, cognition, and psychosocial development in children at the age of 3 years.

Investigators randomly assigned 429 children younger than 3 years with persistent effusion to have tympanostomy tubes inserted either as soon as possible (early-treatment group) or up to nine months later if effusion persisted (late-treatment group). Of 216 patients assigned to the early referral group, 169 (82%) eventually had tubes placed. Among the late treatment group, 66 (34%) of 213 underwent tube placement. Developmental outcomes were assessed in 402 of these children at about the age of 3 years by using formal, norm-referenced tests, assessing a sample of 15 minutes of spontaneous conversation, and obtaining parental reports. No significant differences in various developmental areas were seen between the children who were referred early and those in whom referral was delayed. These areas included word diversity, speech- sound production, receptive language, sentence length, grammatical complexity, parent-child stress, and behavior (Paradise JL et al: N Engl J Med 2001;344:1179).

Commentary: These authors note that an estimated 280,000 American children underwent myringotomy and tympanostomy tube placement in 1996. If these developmental findings hold when children are retested at school age, we may be leaving a lot more eardrums intact.

Genetic counseling and CF screening

Investigators surveyed families who had undergone genetic counseling to assess the effectiveness of communication between health-care providers and parents of children identified as heterozygote carriers for cystic fibrosis (CF) in the Wisconsin Newborn Screening Program. This statewide system recommended but did not mandate a follow-up sweat test at one of the state's two certified CF centers, where parents were offered counseling immediately after the sweat test. Investigators administered a questionnaire to 183 parents whose infants had a sweat test. The instrument assessed the parents' knowledge of CF genetics and their CF newborn screening experiences. Of 138 responders, 123 (89%) also were interviewed by telephone. On average, the questionnaires were returned about 2¹/₂ years after the sweat test.

About two thirds of parents recalled having received genetic counseling at the time of their child's sweat test. About 88% of respondents understood that their child was a carrier for CF, but 15.4% were unsure whether being a carrier could cause illness. In addition, 12.4% of parents were unsure whether at least one of them was a carrier of the CF gene. Only 57% of parents knew that their child had a one in four chance of having a child with CF if he or she reproduced with another carrier of the CF gene. Parents who received genetic counseling were significantly more likely to be knowledgeable about these matters than parents who did not recall receiving counseling. Accuracy of responses was not related to educational background or whether the parent was counseled by a genetic counselor, nurse practitioner, or physician. In addition, parents whose child had a sweat test at a certified CF center had a higher rate of correct responses to questions about CF carriage than parents seen at other hospitals and clinics (Ciske DJ et al: Pediatrics 2001;107:699).

Commentary: To me, providing adequate counseling is the biggest challenge the human genome project and broader newborn screening presents to the general pediatrician. Someone needs to teach parents what results of screening mean—and that necessitates teaching probability to lay people. Genetic counselors are pros at this, but the volume of information coming at us will overwhelm them. Primary care physicians may need to translate genetic screening results for families.

Also of note

Probiotics appear to prevent atopic disease. Results of a new study suggest that consumption of probiotics prenatally and postnatally reduces occurrence of atopic disease in infants. Probiotics are cultures of potentially beneficial bacteria of the healthy gut microflora. The 159 pregnant women in the trial, recruited in antenatal clinics in Finland, had at least one first-degree relative with atopic eczema, allergic rhinitis, or asthma. The women were divided into two groups; one received two capsules of 1 x 10¹⁰ colony-forming units of Lactobacillus GG daily for two to four weeks before expected delivery and the other received placebo. Infants (or breastfeeding mothers) continued consuming the probiotic for six months after birth. At 2 years of age, 46 of 132 children had a diagnosis of atopic eczema. The infants given probiotics were half as likely to have atopic eczema as those given placebo (Kalliomäki M et al: Lancet 2001;357:1076).

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

Stop, listen, look

When screening for visual acuity using the Welch Allyn SureSight Vision Screener, I find it helps to play the harmonica. The unusual sound of the harmonica, totally different from singing or whistling sounds, captures the patient's attention and keeps him looking at the screening device. The built-in beeps and lights do the rest. There are probably other tests I could use my harmonica with, but so far this is what I can report from personal experience.

Carl E. Smith, MD
Harlan, Ky.

Irrigating ears: No raincoat needed

When irrigating a child's ear to remove cerumen, place a large disposable diaper, absorbent side up, on the patient's shoulder. The diaper absorbs splashes that would otherwise soak your patient. Other pads are available, but the children I have worked with seem to find the diaper comfortingly familiar.

Jerome T. Combs, MD
Wallingford, Conn.

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;6:16.