JOURNAL CLUB

Commentaries By Michael G. Burke, MD

Mothers and respiratory symptoms

Findings in a new study highlight the physical toll of caring for young children. Asked about the presence of respiratory symptoms in the previous two weeks, most (61.6%) of 185 mothers of young children from the Midwest reported at least one such symptom, while nearly one half had two or more. The most common symptom was a runny nose, followed by a stuffy head, cough, and sinus pain. The illness was often severe enough to warrant consulting a health-care provider, taking medication, or staying in bed. About one quarter of mothers had slept six hours or less on a typical night in the previous two weeks, and a similar percentage reported that they never or rarely felt rested when they awoke. Lack of adequate sleep seemed to increase the likelihood of two or more respiratory symptoms, with those who reported they sometimes felt rested being more than two times more likely to have been ill in the previous two weeks than those who said they frequently or always felt rested.

Three quarters of mothers used some form of day care in the previous two weeks. These mothers were more than twice as likely as mothers who cared for their children at home to have suffered two or more respiratory symptoms in the past two weeks (d'Arcy H et al: Pediatrics 2000;106:1013).

Commentary: Mothers of just one child were at greatest risk for frequent infections. Those with more children likely had admirable antibody levels from exposure to the older siblings. I wonder how many dads had frequent cold symptoms or felt sleep deprived. Any guesses?

Phenylpropanolamine linked to stroke

Investigators conducted a case-control study of men and women from 18 to 49 years of age to verify a reported link between hemorrhagic stroke and products containing phenylpropanolamine, a synthetic sympathomimetic amine commonly found in appetite suppressants and cough and cold remedies. Using a structured questionnaire, researchers obtained demographic, clinical, behavioral, and pharmaceutical information from 702 patients with symptomatic subarachnoid or intracerebral hemorrhage and 1,376 matched controls.

Among women, consumption of phenylpropanolamine via an appetite suppressant was associated with an increased risk of hemorrhagic stroke. Phenylpropanolamine in cold and cough remedies may also be an independent risk factor for hemorrhagic stroke in women, according to study data. No significantly increased risk of hemorrhagic stroke was observed among men who used a cough or cold remedy that contained phenylpropanolamine. Since no male subjects reported the use of appetite suppressants containing the agent, their risk in this situation could not be determined (Kernan WN et al: N Engl J Med 2000; 343:1826).

Commentary: Last fall, you may have noticed the gaping holes in the grocery store shelves that hold cold preparations. In November 2000, the Food and Drug Administration (FDA) requested that all drug companies discontinue marketing over-the-counter products containing phenylpropanolamine. It may be worth checking your office samples for any of the many products that contain it.

Hallucinogenic drug widely available

Gamma-hydroxybutyrate (GHB) and its precursors, 1,4-butanediol (1,4-BD) and gamma-butyrolactone (GBL), remain accessible even though the FDA has issued repeated warnings about the dangers of these drugs and GHB and GBL are listed as federal Schedule I drugs under the Controlled Substances Act. Popular for their euphoric and hallucinogenic properties, the agents are available as "club drugs" on Internet Web sites, as natural dietary supplements in health food stores, and as illicit products manufactured at home in clandestine laboratories.

The clinical course of GHB overdose has been described by several large case series. Effects are worsened by coingestion of alcohol and other depressant drugs, particularly opiates, benzodiazepines, and neuroleptics. Central nervous system effects include euphoria, headache, dizziness, ataxia, confusion, amnesia, hypotonia, hallucinations, loss of peripheral vision, somnolence, unconsciousness, and coma.

Based on sleep studies, a dose-response pattern has been observed for central nervous system depression: abrupt-onset sleep, sleep paralysis, hallucinations, enuresis, and myoclonic movements at oral doses of 30 mg/kg; unconsciousness at an oral dose of 50 mg/kg; and unarousable coma at an oral dose of 60 mg/kg. Other reported effects are generalized tonic-clonic seizures; an emergence phenomenon consisting of agitation and combativeness; respiratory depression or Cheyne-Stokes respirations; cardiovascular effects such as bradycardia and hypotension; gastrointestinal effects such as excessive salivation and vomiting; and metabolic disturbances, particularly metabolic acidosis.

Patients typically make a complete recovery within seven hours without requiring intubation. Good general supportive care is required. Following ingestion, gastric emptying with syrup of ipecac is contraindicated because of the rapid onset of central nervous system depression. The authors of this review of the literature suggest that clinicians consider GHB overdose in any patient presenting with unexplained sudden coma without evidence of head trauma or elevated intracranial pressure. The diagnosis is usually made by history (Shannon M et al: Pediatr Emerg Care 2000;16:435).

Commentary: This group of drugs has caused increasing concern because the drugs are easily available and are associated with date rape. Serum and urine toxicology screens do not detect them. So clinicians need to be alert to the possibility that they have been used when evaluating comatose teens.

Scooter injuries on the rise

From January to October 2000, an estimated 27,600 people went to the emergency department for scooter-related injuries, according to the Consumer Product Safety Commission (CPSC) and the Centers for Disease Control and Prevention. The estimated number of injuries seen in emergency departments in September 2000 was nearly 18 times higher than in May 2000. This is one of several indications that the rate of injuries from these unpowered, lightweight aluminum scooters is accelerating along with their popularity. About 85% of those treated in emergency departments were children younger than 15 years, and 23% were younger than 8. Two thirds of the patients were male. The most common injury was a fracture or dislocation, generally to the arm or hand. Other injuries included lacerations, contusions and abrasions, and strains and sprains. According to the CPSC, scooter-related injuries may be prevented by wearing a helmet, elbow pads, and knee pads; riding scooters on smooth, paved surfaces without traffic; riding only in daylight; and providing close supervision for young children using scooters (Rutherford GW Jr et al: MMWR 2000;49[49]:1108).

Commentary: This MMWR article appears just in time to herald the injuries associated with all of those slick little scooters found under last year's Christmas tree. Watch for them at an emergency department near you.

Oral dexamethasone helps moderate croup

Investigators compared the use of oral (PO) and intramuscular (IM) dosing of dexamethasone in outpatient treatment of moderate croup. They divided into two groups 277 patients with moderate croup who were between the ages of 3 months and 12 years. One group received a single dose (0.6 mg/kg to a maximum of 8 mg) of IM dexamethasone and the other group the same dose PO. They contacted parents of the children 48 to 72 hours later to assess resolution of symptoms and need for further evaluation. No statistical difference in these two outcomes was seen between the two groups. Investigators also analyzed three subsets of patients who were more ill than the total study population. Here, too, they found no statistical difference between the IM and PO groups with regard to resolution of symptoms or need for further evaluation. Investigators concluded that dexamethasone given orally to outpatients with moderate croup is as effective as IM administration of the drug (Rittichier KK et al: Pediatrics 2000;106:1344).

Commentary: Here is evidence for a practice that you may have already adopted in your office. A single dose of PO dexamethasone seems to work as well as IM dexamethasone, without the sting of IM administration. The authors suggest using the tablet form of oral dexamethasone, crushed and served in flavored syrup or jelly—a recipe for painless and effective treatment of moderately severe croup.

Recognizing moms' depressive symptoms

A study conducted at a hospital-based, inner-city general pediatric clinic shows that pediatric health-care providers do not recognize most mothers with high levels of self-reported depressive symptoms. Two groups of study participants completed questionnaires; each group was unaware of the other's responses. In one group were 214 mothers who brought their children ages 6 months to 3 years for health-care maintenance or a minor acute illness and in the other 60 pediatric health-care providers, including pediatricians. The mothers' questionnaire consisted of sociodemographic items and a self-administered assessment of depressive symptoms using the Psychiatric Symptom Index (PSI). Mothers primarily were single, were black or Hispanic, and had a mean age of 26.

Pediatric health-care providers recognized only 25 of 86 mothers who had high levels (a score of >20 on the PSI) of depressive symptoms, for a sensitivity of 29%. Recognition was no better in mothers with a PSI of >30, indicating a likely diagnosis of major depressive disorder. Of the 44 mothers who scored at this higher level, providers identified only 15. Several maternal, provider, and visit characteristics did seem to be related to improved recognition of mothers with depressive symptoms, however. Mothers with symptom scores on the PSI of >20 and who were young, living alone with their children, or receiving public assistance were more likely than other high-scoring mothers to be identified accurately by pediatric health-care providers. Identification also was better when the mother had an established relationship with the child's provider or was assessed by an attending pediatrician rather than a pediatric nurse practitioner or pediatric trainee (Heneghan AM et al: Pediatrics 2000;106:1367).

Commentary: It looks like we are not very good at identifying these depressed women. Is that our job? I think so. Their mothers' mental health has a huge impact on our patients. We need to be able to recognize mental health needs of mothers in our practices, perhaps through some screening tool. And, as with any screening, we need to know what to do with the results. Be ready with information about referral for diagnosis and treatment of maternal depression.

Also of note

The whey to go for colic? An extensively hydrolyzed whey formula is effective in reducing the duration of crying in an infant with colic, a new study from the Netherlands shows. Study subjects were 43 healthy, thriving formula-fed infants younger than 6 months who cried more than three hours a day for at least three days a week during a one-week qualification period. During the following intervention week, about half of these colicky infants were fed a whey hydrolysate formula and the other half standard cow's milk formula. Those fed the whey hydrolysate formula cried about one hour less per day than the infants who had cow's milk formula, according to behavior diaries kept by the infants' caregivers (Lucassen P et al: Pediatrics 2000;106:1349).

ITP: To treat or not. What is your threshold for treatment of a child with immune thrombocytopenic purpura (ITP)? In an uncontrolled observational study in Germany of 55 patients with ITP, two researchers measured outcomes in children whose ITP was treated with watchful waiting alone. The patients ranged in age from 2 months to 16 years. None of the patients received intravenously administered immune globulin G (IVIG) or sustained prednisone treatment. Those with extensive mucosal bleeding were given prednisone 2 mg/kg/d for three days. The child was seen again after one week. If remission was not achieved, he or she was seen five weeks later, then every two months if remission was not achieved by six weeks. If mucosal bleeding was extensive, the child was admitted to the hospital for observation. Chronic ITP occurred in seven of the patients, while 29 achieved remission within six weeks and 19 patients between six weeks and six months. No life-threatening bleeding occurred and no patient died. The authors concluded that this watchful waiting approach avoided side effects, reduced cost, and was effective. They suggest this approach in contrast to a more aggressive treatment plan (George JN et al: Blood 1996;88:3) proposed by the American Society for Hematology (Dickerhoff R et al: J Pediatr 2000;137:629).

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

Keeping topical adhesives in their place

I use topical skin adhesives quite a bit—especially for forehead lacerations. No matter how far back you tilt the child's head, the adhesive can still run, and I worry that it will run into an eye.

I solved the problem by putting a line of surgical lubrication or KY Jelly above and below the cut as a sort of dam to prevent the adhesive from running into the hair or eyes. Just be sure to put the surgical lubrication far enough away from the wound so the adhesive will stick where it is needed.

Antoinette L. Laskey, MD
Columbia, Mo.

Once again, stickers to the rescue!

Before I begin examining a young child (6 months to 2 years of age), I put one sticker on the palm of each hand, making sure to include some of the volar surfaces of the fingers. The stickers keep the child's hands too busy to grab my stethoscope. They also distract the youngster's attention and minimize crying time. As you can imagine, I go through a lot of stickers. Eventually the little ones cram the stickers in their mouths and have to have them taken away, but parents are usually delighted with this trick.

Tricia Deffner, MD
La Crosse, Wis.

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;2:131.