Journal Club: baby crying, HPV prevention in boys, and when to teach swimming

Is testing required to explain a baby's crying?

Overall, the most serious underlying disease was urinary tract infection, found in three (25%) of the 12 children. Two infants had a clavicle fracture. Children at least 4 months old were slightly more likely to have a serious illness than younger children. Fourteen children were diagnosed with colic, and 11 infants with atypical colic.

Investigations performed in the absence of a suggestive clinical picture were crucial in determining a diagnosis in only two of the 237 children. The most common tests were urinalysis and culture, both of which contributed to the final diagnosis in fewer than 3% of the cases for which they were performed. Other investigations included anterior eye fluorescein staining, fecal occult blood testing, blood and cerebrospinal fluid analyses, and radiologic investigations. Of 574 tests performed on the 237 children, 81 were positive, but only eight (1.4%) diagnoses were assigned on that basis (Freedman SB, et al: Pediatrics 2009;123:841).

Commentary

I like the "back to basics" recommendations of these authors: When faced with an afebrile, crying infant, rely on your history and physical exam. Then, in the youngest children, add a urinalysis and urine culture. I suggest adding a quick review of the differential diagnosis before performing

the history and physical exam. A glance at a reference such as Tunnessen's Signs and Symptoms in Pediatrics will remind you of some unusual possibilities, and help to focus your efforts in interviewing the family and examining the child.

Circumcision prevents HSV-2 & HPV infections, too

Investigators enrolled 5,534 HIV-negative males from 15 to 49 years old in two trials. The 61.3% of these subjects who were HSV-2 seronegative at enrollment were assigned to one of two groups: the intervention group, which underwent immediate circumcision, or the control group, which underwent circumcision after 24 months. At baseline and at six, 12, and 24 months, investigators tested for HSV-2 and HIV infection and syphilis. They also evaluated a subgroup of subjects for HPV infection at baseline and at 24 months. All subjects were offered free HIV counseling and testing, health education, and condoms.

At 24 months, the cumulative probability of HSV-2 seroconversion was 7.8% in the intervention group and 10.3% in the control group. In the intervention group, the prevalence of high-risk HPV genotypes was 18.0% compared with 29.9% in the control group. Circumcision also reduced the incidence of HIV infection, but the incidence of syphilis was similar in the two groups (Tobian AAR, et al: N Engl J Med 2009;360:1298).