JOURNAL CLUB

Commentaries By Michael G. Burke, MD

Steroids for bronchiolitis: The debate goes on

Until now, corticosteroids have demonstrated their effectiveness in asthma and croup but not in acute bronchiolitis, a closely related childhood respiratory disease. A new study, however, shows significant clinical benefit when oral dexamethasone is administered to outpatients younger than 2 years during emergent evaluation of a first-time wheezing episode diagnosed as bronchiolitis.

The investigation was conducted in 70 children between 8 weeks and 23 months of age with acute bronchiolitis who were seen in the emergency department of an urban hospital. Half were given dexamethasone (1 mg/kg of body weight); the rest, placebo. Children in both groups received nebulized albuterol. Clinical benefits were assessed hourly for four hours after the initiation of treatment and one week later after five days of continued therapy.

Children in the dexamethasone group showed significantly greater overall improvement in respiratory distress, measured by changes in retractions, wheezing, and respiratory rate on the Respiratory Assessment Change Score. In addition, the rate of hospitalization was much higher in the placebo group (44%) than in the dexamethasone group (19%). Last, seven of 32 infants (22%) in the placebo group were treated with a corticosteroid at follow-up with their primary care physician; none of the children in the dexamethasone group were given additional corticosteroids (Schuh S et al: J Pediatr 2002;140:27).

Commentary: After a long winter and on the cusp of spring, you may not want to think about RSV. But it may be worth it to put aside this study for now and consider it again before the next RSV season. For me, improvement in the clinical score for respiratory distress isn't as impressive as the fall in the hospitalization rate in the group treated with dexamethasone. This therapy may be worthwhile. You can bet that the debate over the use of steroids and b-agonists in bronchiolitis will continue until we have a clearly helpful, harmless treatment for children with this disease.

Does immersion in day care boost immunity?

Many observers suspected it for a long time, and now it appears confirmed in a recently published investigation: Attendance at day care is associated with the common cold during the preschool years but in fact protects against the common cold during the early school years, probably because of acquired immunity. This protective effect was not associated with all day-care facilities—only those considered "large" (six or more unrelated children). Protection was greatest in children who attended a large day-care facility for two years or longer. But the study also concluded that, by the time a child who attended a large day care center reaches 13 years, the protective effect appears to wane and he (or she) is no less likely than children who attended a small day-care facility (as many as five unrelated children) or who were cared for at home to get a cold frequently (i.e., at least four a year).

These results came from a prospective investigation in more than 1,000 children. In response to a questionnaire, parents reported on the frequency of colds and possible confounding variables, such as education, ethnicity, household pets, siblings, breastfeeding status, and exposure to smoke at home (Ball TM et al: Arch Pediatr Adolesc Med 2002;156:121).

Commentary: Here's a source of consolation for parents of toddlers who attend day care. Those winter-long battles with colds may pay off in the long run when Junior starts school well armed with an experienced immune system.

Lyme disease is over—overdiagnosed and overtreated

Despite publication in 1995 of standard criteria for diagnosing Lyme disease, overdiagnosis and overtreatment of this condition appears to be common—at least in areas where Lyme disease is endemic. Investigators evaluated 216 children as old as 18 years who were referred to a pediatric infectious disease clinic on Long Island, N.Y., during a 30-month period because they were believed to have Lyme disease or an acute recurrence. For study purposes, children were divided in three groups: those who met criteria for an initial diagnosis of active disease; those previously diagnosed with Lyme disease and believed to be having a recurrence; and children who did not meet criteria for an initial diagnosis of active disease.

Fewer than one third of referred patients met criteria for active Lyme disease: either (1) erythema migrans or (2) characteristic articular, neurologic, or cardiac symptoms of active disease plus serologic confirmation. A two-test confirmation strategy was used: a sensitive enzyme immunoassay (EIA) or immunofluorescent assay (IFA) and a Western immunoblot for IgG and IgM antibodies. Of 68 children who met criteria for active disease, 36 had arthritis, 17 had central nervous system disease, and 15 had erythema migrans—in fact, the least common presentation in this referred population.

Thirty-nine of the 216 children had previously "diagnosed" Lyme disease; at referral, none met criteria for the diagnosis of active Lyme disease. Seventeen of the 39 had symptoms of another illness, but the family or referring provider thought the child had an acute recurrence of Lyme disease. Depression and poor school performance were among the presenting complaints, and some asymptomatic children were referred because of confusion in the interpretation of IgG immunoblot test results. Thirty (77%) of the 39 received an antibiotic before referral.

Another 109 children—almost half the total group—likewise did not meet diagnostic criteria for Lyme disease. More than two thirds had a history of tick bite but never had symptoms. All had received an antibiotic on the basis of a borderline IFA or EIA or a positive IgG immunoblot for any one band—even though only an immunoblot test that is positive for multiple bands is diagnostic for Lyme disease (Qureshi MZ et al: Pediatr Infect Dis J 2002; 21:12).

Commentary: The authors speculate that Lyme disease is overdiagnosed because the public is panicky and because physicians aren't certain about diagnostic criteria. You'll find detailed information on the diagnosis of Lyme disease in the AAP's Red Book 2000: Report of the Committee on Infectious Diseases (p. 373FF).

Also of note

Dramatic decline in varicella disease five years after vaccine is introduced. Surveillance for varicella in three communities where vaccine coverage is considered moderate shows that varicella disease has declined substantially during the four years since implementation of a vaccination program in 1995. The decline in cases of varicella in the three communities, each in a different region of the country, ranged from 71% to 84%. Reduction in disease was greatest among preschoolers but was seen in every age group, including infants and adults (Seward JF et al: JAMA 2002;287:606).

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

Simon says: Make examinations a game

If you have trouble performing joint and musculoskeletal exams on toddlers and preschoolers with rheumatologic disease, try a game of Simon Says. Kids as young as 2 years of age enjoy imitating the leader, and older children (up to 7 or 8 years) like to try to outsmart "Simon."

In as few as five minutes you can put a patient through all the necessary range-of-motion maneuvers. The game relieves the anxiety associated with the subsequent hands-on exam. It can be made even more fun by giving small rewards like stickers or pencils for completing the exam. For frequent visitors to your office, start a star chart and keep score, offering a larger prize at the end several exams.

Vickie Vandergrift, RN
Pittsburgh, Pa.

A real eye opener

In a large newborn with puffy eyelids, it is sometimes difficult to open the eyes by forcing the lids apart. The eyes often open spontaneously, however, if the examiner holds the infant upright—while supporting the neck and head—and gently tips her back and forth. This maneuver takes advantage of the oculocephalic reflex, which is typically used to inspect the eyes. It also prevents injury to the newborn's eyes from the examiner's fingernails.

Rajender Gattu, MD
Monroe, Mich.

A palatable mineral oil mixture

When mineral oil is needed to treat short-term constipation in a child, I advise parents to mix the age-appropriate dose with about 4 ounces of milk, shake it well, and serve it in a sippy cup. The amount of milk in the mixture should be just enough to make the mineral oil palatable since large amounts of milk could worsen the constipation.

For a child who doesn't mind taking medicine, a vanilla-flavored product called Kondremul that contains emulsified mineral oil is available over the counter at any drug store. Doses are the same as for regular mineral oil. There are other products that may perform just as effectively as Kondremul—such as Liqui-Doss, Petrogalar Plain, Milkinol, and Zymenol. I have only had experience, however, with Kondremul.

Sretenka Dokich, MD
Imperial Beach, Calif.

Lacrimal duct stenosis— observation is enough

The standard approach to managing infants with lacrimal duct stenosis is to massage the tear duct a few times a day and treat infections with topical antibiotics as needed. If symptoms continue beyond 12 months of age, referral to an ophthalmologist is recommended. When I started practicing pediatrics 20 years ago, I followed that advice, diligently teaching parents how to massage their baby's eyes and reviewing the procedure at well-child visits.

After 10 years in practice, I started asking parents whether they followed my advice. To my surprise, only half did what I told them. The ones who didn't gave two reasons: They forgot, or they were afraid that they might hurt the baby if they accidentally poked his eye. During this time, only two of my patients needed to have their tear ducts probed.

As a result of this experience, I have stopped recommending massage and merely encourage parents to wipe away any debris that accumulates in the baby's eye (I continue to treat conjunctivitis when it occurs).

Over the past 10 years, only one of my patients has needed to have a tear duct probed. While this is not a double-blind study, it seems clear to me that most infants with lacrimal duct stenosis get better on their own and that massage has little impact on the natural history of the disorder.

Howard J. Bennett, MD
Bethesda, Md.

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 2002;4:164.