As these authors note, infants are evil.
Well, more specifically, they note infants with non-specific complaints as benign as “crying” can be harboring serious pathologic diagnoses. Therefore, the diagnostic work-up for such complaints as “lethargy” or “poor feeding” varies widely by clinician and comfort level.
These authors retrospectively reviewed charts for 352 infants 0 – 6 months with presenting complaint of “lethargy” or “poor feeding”. They exclude the chronically ill/premature, abnormal vital signs, and those with recent trauma, and review the laboratory testing and ultimate diagnoses for each remaining patient. Of the 272 remaining, 34 patients ultimately had a diagnosis requiring intervention or monitoring. These included hematologic disorders, dehydration, intracranial bleeding and SBI. Of these 34, 26 were otherwise well-appearing. However, these authors note each of the well-appearing patients had some obvious focal finding on physical examination – mostly jaundice, leading to treatment for hyperbilirubinemia – leading to directed testing. They conclude, therefore, a well-appearing infant with a reassuring examination does not need any specific testing or monitoring.
This study is limited by its retrospective nature, as well the lack of comprehensive follow-up. That said, their algorithm for focused evaluation of “lethargy” and “poor feeding” is probably reasonable. Fishing expeditions in the otherwise well infant are certain to be costly and low-yield, with continued caregiver observation and follow-up a more prudent plan.
“Diagnostic Findings in Infants Presenting to a Pediatric Emergency Department for Lethargy or Feeding Complaints“
http://www.ncbi.nlm.nih.gov/pubmed/24583575
Category: Pediatrics
Dexamethasone. Think About It.
Many aspects of medicine are simply based on momentum and routine. One of those routines, in my anecdotal experience, is the use of 5-day courses of steroids for mild/moderate asthma exacerbations. However, why give multiple doses when one will suffice? Why not dexamethasone?
Unfortunately, this meta-analysis doesn’t really bring any new knowledge into play. These authors attempt to pool the results from all the pediatric randomized trials comparing dexamethasone vs. short-course prednisone for the outpatient management of asthma with exacerbation. No included individual trial showed a relapse rate with dexamethasone significantly worse than prednisone – and, unsurprisingly, the pooled results reflect that same finding. The only recorded adverse effect – vomiting in the ED or at home – was seen less frequently with dexamethasone, although the overall incidence in both arms was minimal.
But, there are only six trials, most of which are fewer than 100 patients. These trials are also a mix of oral and intramuscular, single and multiple dose, and dose ranges from 0.3 mg/kg to 1.7 mg/kg (“max 36 mg”!). There were also methodologic problems with blinding, allocation, and other outcomes issues with each included study.
Based on this low-quality evidence, it would be reasonable to say dexamethasone use is not adequately described in the literature. It would, likewise, be reasonable to go ahead and make use of dexamethasone in this setting, with the recognition of these limitations. Personally, I fall on the dexamethasone side of the argument – for children, as well as adults. When feasible, I use an approximately prednisone-equivalent oral dosing at 0.15 mg/kg up to a maximum dose of 12mg in both populations.
And I would love to see a high-quality trial to settle matter, once and for all.
“Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis”
http://www.ncbi.nlm.nih.gov/pubmed/24515516
Kids with Tubes and Otitis Media Get Drops not Pills
A guest post by Anand Swaminathan (@EMSwami) of EM Lyceum and Essentials of EM fame.
Over the last decade, researchers have sought to determine the usefulness, or lack there of, for systemic antibiotics in a number of infectious etiologies previously thought to require antibiotics for resolution. This includes strep throat, sinusitis, bronchitis and, more recently, diverticulitis. Acute otitis media (AOM) has long been a target for such studies and recently, the guidelines have changed. The American Academy of Pediatrics now endorses a “wait and see” approach for many children with AOM while also recommending a more stringent definition of the disease.
Over the last decade, researchers have sought to determine the usefulness, or lack there of, for systemic antibiotics in a number of infectious etiologies previously thought to require antibiotics for resolution. This includes strep throat, sinusitis, bronchitis and, more recently, diverticulitis. Acute otitis media (AOM) has long been a target for such studies and recently, the guidelines have changed. The American Academy of Pediatrics now endorses a “wait and see” approach for many children with AOM while also recommending a more stringent definition of the disease.
What about for patients with tympanostomy tubes who present with signs of AOM? These patients typically present with otorrhea (pus from the tympanostomy tube). Is the presence of drainage adequate to treat or should these patients be placed on oral or topical antibiotics? Small trials have shown good efficacy of topical antibiotics but Pediatricians and Emergency Physicians continue to prescribe oral antibiotics in the face of inadequate evidence.
The researchers here attempt to answer this question. They performed a fairly large study of 230 children who were randomized to either observation, oral antibiotics or topical antibiotic-glucocortocoid drops in an open-label fashion. The primary endpoint was resolution of otorrhea at 2 weeks. The results are surprising. Resolution was seen in 95% in the group given drops, 56% in the oral antibiotic group and 45% in the observation group. These numbers yield a miniscule NNT = 3 for resolution of otorrhea with topical antibiotics-glucocortocoids vs. oral antibiotics.
A couple of notes are important. All of the patients had otorrhea for up to 7 days prior to entering the study and the presence of a fever excluded them from the study. Additionally, tubes couldn’t be recently placed (< 2 weeks) there couldn’t be recent antibiotic use (< 2 weeks) or otorrhea (< 4 weeks).
As evidence mounts to the harms of inappropriate and unnecessary systemic antibiotic use, it’s important to tailor therapy based on the available literature. Many patients with tympanostomy tubes that develop otorrhea will resolve with simple observation. However, treatment with topical antibiotic-glucocortocoid drops should be the first line treatment as they are superior to oral antibiotics with fewer side effects.
“A trial of treatment for acute otorrhea in children with tympanostomy tubes.”
Nonsensical Opiate Overuse in Adolescent Headache
The title says it all.
This is an observational cohort analysis of linked medical and pharmacy records for commercially insured patients across 14 health plans. Patients were identified by age 13-17 with, allegedly, new-onset atraumatic headache from claims database abstraction – limited, of course, by the nature of querying such a database. 8,373 patients were identified from their two year study period as meeting these criteria.
And 46% were prescribed opiates.
52% of those received more than one prescription for opiates, including 11% who received 5 or more prescriptions for opiates during the study period.
This study came about because the insurer contacted the American Academy of Pediatrics with a query regarding the appropriate frequency of use of opiates for headache. The answer ought to be a tiny fraction, as third-line or rescue therapy.
Considering all the problems this country has with prescription opiate abuse, it is maddening to see physicians inoculating such a vulnerable population with medication whose harms almost certainly outweigh the benefits.
“Opioid Use Among Adolescent Patients Treated for Headache”
http://www.jahonline.org/article/S1054-139X(13)00834-3/abstract
Appendicitis Week Continues
As compared to the previously critiqued publication, I am rather pleased with the protocol described by these authors.
This is a clinical pathway for appendicitis from Children’s in Memphis prospectively evaluated for diagnostic accuracy. They’ve taken the idealist route – risk-stratification, followed by discharge, ultrasound, or pediatric surgery evaluation. These authors use the Pediatric Appendicitis Score, dropping patients into buckets based on scores 1-3, 4-7, and 8-10. Most interestingly, there is no role for CT scanning in this pathway unless specifically requested by the consulting surgeon.
In this study, 196 children completed the full clinical pathway – 44 were in the low-risk group, 119 in the moderate-risk, and 33 in the high-risk group. Almost all the low-risk patients were discharged from the Emergency Department with a telephone call follow-up, and only one patient had a callback – for what was eventually diagnosed as an omental infarct. In the high-risk group, all 33 patients were admitted, and all 28 patients who were taken to the OR by surgery had appendicitis. The 119 patients in the moderate-risk group are much more interesting. 33 of 119 ultimately had ultrasounds supporting a diagnosis of appendicitis, and all were confirmed in the OR. However, the remainder of these patients either were discharged without ultrasound, or had negative ultrasounds. There were, ultimately, 5 cases of appendicitis in the moderate-risk group, despite a negative ultrasound.
This is the main flaw in external validity of their protocol – what to do with a moderate-risk patient with a negative ultrasound? Per the authors, the more concerning cases were admitted – either to surgery or pediatrics, depending on level of suspicion for an alternative diagnosis – or discharged with telephone follow-up. I think many folks, when faced with this level of uncertainty, proceed to CT scan – but, amazingly, only 13 kids in this cohort were subjected to diagnostic or therapeutic radiation. This statistic alone validates the protocol – and the cultural and operations changes necessary to make it work. By having a safety net of follow-up calls in place for patients discharged from this clinical pathway, the pressure for an immediate diagnosis is eliminated.
It is a small sample size, and it requires providers to increase their comfort level with diagnostic uncertainty – but it certainly seems rational and promising.
“Prospective Evaluation of a Clinical Pathway for Suspected Appendicitis”
http://www.ncbi.nlm.nih.gov/pubmed/24379237
The Great Sugar Wars of Pediatric Critical Care
A guest post by Rory Spiegel (@CaptainBasilEM) who blogs on nihilism and the art of doing nothing at emnerd.com.
Kids are just small adults, or so says the Control of Hyperglycemia in Pediatric Intesive Care (ChiPS) trial. This impressively large RCT of 1369 pediatric ICU patients (under 16 years old) requiring at least 12 hours of vasoactive support and mechanical ventilation, examined how controlling blood glucose levels affects outcomes. Subjects were randomized to either tight glucose control (72-126mg/dL) or conventional control (less than 216 mg/dL). Patients were followed for 30 days to see if mortality and rates of ventilator dependence differed between the two groups.
Simply put the trial was negative. Though the tight glucose control group received more insulin and had lower mean daily blood glucose levels during the first 10 days after randomization, there was no statistical difference between days alive and off the ventilator between the two groups. Patients in the tight glycemic control group were less likely to receive renal replacement therapy (an odds ratio of 0.64 CI 0.45-0.89), but conversely were far more likely to suffer an episode of severe hypoglycemia (below 36mg/dL) with an absolute difference of 4.8%.
Unfortunately thanks to the authors’ spectacular display of subgroup analysis there is nothing simple about this publication. 60% of the population was admitted to the ICU after cardiac surgery. The remaining 40% were there for other reasons, though further details were not specified. A multitude of endpoints in both the cardiac and non-cardiac subgroups were examined. As with the entire cohort, there was no difference in mortality or ventilator-free days in either subgroup. The authors did observe a decrease in length of stay and mean healthcare costs in the subgroup of patients who did not undergo cardiac surgery and were treated using the tight glycemic parameters.
Though the authors conclude that these findings are at best hypothesis building and should not be used to guide therapy, this subgroup analysis will inevitably be misinterpreted, suggesting that pediatric ICU patients who have not undergone cardiac surgery will benefit from a strict glycemic regimen. This is clearly not the case. What this trial amounts to is a negative study with both negative primary and secondary endpoints that upon subgroup analysis uncovered statistical differences equally likely to be caused by chance as by the aggressive glucose management.
This trial is a reminder of our continued insistence of applying disease-oriented outcomes with questionable efficacy over the long term to an acutely ill population. The NICE-SUGAR trial established that tight glucose control was detrimental in an acutely ill adult population, the ChiP trial has demonstrated these lessons can now be applied to our smaller counterparts.
“A Randomized Trial of Hyperglycemic Control in Pediatric Intensive Care” www.ncbi.nlm.nih.gov/pubmed/24401049
Stop Using the Antibiotic Sledgehammer
There’s an interesting cultural phenomenon regarding inpatient treatment of respiratory illnesses – a sense that monitoring and close evaluation for treatment failure isn’t enough, and we must immediately deploy the nuclear option when the admission decision is made. This includes nonsense use of intravenous administration when oral is equivalent and unnecessary use of broad-spectrum agents.
This comparative-effectiveness study evaluated the necessity of broad-spectrum agents versus narrow-spectrum antibiotics for the treatment of pediatric community-acquired pneumonia. 492 CAP admissions from four children’s hospitals in 2010 were retrospectively reviewed for outcomes, stratified by antibiotic choice. Narrow-spectrum antibiotic choices were penicillin-like agents +/- macrolide, while broad-spectrum included cephalosporins or fluoroquinolones.
In their propensity-matched cohort, with the acknowledged limitations of unmeasured baseline characteristics, there were no useful differences in outcomes. Most trends favored narrow-spectrum antibiotics, but these are at best statistical noise, and at worst reflect underlying unmatched treatment-episode confounders.
Current consensus-based recommendations are for initial treatment with narrow-spectrum agents – follow them. I’d also note 51% of the population received blood cultures – 2.8% of which were positive. I’m sure these were also entirely a waste of money.
“Comparative Effectiveness of Empiric Antibiotics for Community-Acquired Pneumonia”
http://www.ncbi.nlm.nih.gov/pubmed/24324001
No, You *Still* Don’t Need Antibiotics For That URI
A guest post by Justin Mazzillo, a community doc in New Hampshire.
Perhaps you’ve seen a case or two this year – a child brought to the emergency department for a cold lasting more than a day. Little Johnny’s parents dragged him in to see you at three in the morning, in hopes of obtaining the instant cure of antibiotics.
These authors out of Washington and the United Kingdom conducted a systematic review to determine the duration of symptoms of earache, sore throat, cough and common cold in children less than 18 years of age. They included only trial arms that used no treatment, symptomatic treatment or placebo. Their findings include:
· Symptoms of earache resolved by day three in 50% of patients and day seven to eight in 90%.
· Sore throat resolved in two to seven days.
· General cough resolved by day 10 in 50% and day 25 in 90%. Symptoms of croup were gone in 80% by day two.
· Bronchiolitis symptoms were gone in 50% by day 13 and estimated to be gone in 90% of patients by day 21.
· Lastly, it took 10 days for 50% of symptoms of the common cold to resolve and 15 days for 90% to be symptom free.
The authors found this data to differ significantly from estimates by the UK National Institute for Health and Care Excellence and the US Centers for Disease Control. This information may go a long way in preventing parents from convincing doctors to put little Johnny on a myriad of antibiotics while his virus runs its course.
“Duration of symptoms of respiratory tract infections in children: systematic review”
http://www.bmj.com/content/347/bmj.f7027
God Bless Us, Everyone
So says Tiny Tim, from the Dickensian Christmas fable – or, more familiarly, from the Disney production on the same theme.
As several physician-historians have done before, this short piece explores the malady afflicting Tiny Tim in the context of industrial London. Because Dickens tended to very accurately portray phenotypic manifestations of illness – Pickwickian Joe, the epileptic Monks, the dwarf Jenny Wren – the character depictions give realistic insights into the travails of the working poor. Was it cerebral palsy? Simple malnutrition? Or something more exotic like renal tubular acidosis?
Regardless the diagnosis, the treatment of the time would have been the same: cod liver oil.
May your Christmas be merrier than that.
“Environmental Factors in Tiny Tim’s Near-Fatal Illness”
http://archpedi.jamanetwork.com/article.aspx?articleID=1107722
Uninjured Children are Uninjured, and Other Tautologies
In America’s culture wars (e.g., War on Drugs, War on Women, War on Christmas, etc.), few rise to the magnitude of the Emergency Physician vs. the consultant surgeon. The disagreement in necessity of CT radiography for minor trauma is well-documented, and even surgeons themselves admit to possibly overdoing it in their valorous quest for zero-miss.
This study has the conclusion we’d like to see – but not the evidence needed to fully support it. These authors from Denver performed a retrospective review of 174 pediatric trauma team activations, specifically evaluating the incidence of CT-identified injuries for four categories of patients. The cohort these authors focus on for their conclusions are those with no apparent injury and no abnormal vital signs, but were imaged (presumably, considering this is retrospective) based on “mechanism of injury”. Of the 66 patients who received any kind of CT imaging in the absence of objective indications, zero serious injuries were identified.
However, this MOI-indicated CT group was not exactly uninjured – over a third had a long bone fracture, and 9% had a skull fracture. In a group of children whose average age is 7, of whom half have a significant injury, it is hard to quibble retrospectively with the indications for each CT individually – even if all were ultimately negative. There is an obvious hint of truth that, yes, if MOI is the overriding justification for CT, it will result in an embarrassingly low incidence of true injury. In the end, this study only shows us we need to continue advancing our development of clinical evaluation instruments to improve yield and cost-effective care.
“Mechanism of injury alone is not justified as the sole indication for computed tomographic imaging in blunt pediatric trauma”