Elective caesarean delivery appears to be associated with a 10% increase in the risk for hospitalisation for bronchiolitis.
Hannah C. Moore, Grad. Dip. Clin. Epi., from the Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, and colleagues reported their findings in an article published online October 28 in the Archives of Disease in Childhood.
"There have been numerous reports associating elective caesarean delivery with poor outcomes, including birth trauma in infants, respiratory morbidity of the newborn, respiratory distress syndrome, admissions to advanced care nursery and transient tachypnoea of the newborn," the authors note.
The authors previously reported an increased risk for hospitalization for acute lower respiratory infection up to age 2 years in children delivered by elective caesarean. In the current retrospective, population-based cohort study, Dr. Moore and colleagues sought to examine the association between the number of hospital admissions for bronchiolitis or pneumonia and elective caesarean delivery in 212,068 singleton births of 37 to 42 weeks' gestation between 1996 and 2005. The researchers assessed the link between mode of delivery and hospitalizations for both bronchiolitis and pneumonia in children younger than 12 months and aged from 12 to 23 months using birth records and hospitalization data from administrative healthcare databases that cover the Western Australia population. Sixteen percent of the infants were delivered by elective caesarean delivery. Compared with spontaneous vaginal delivery, infants delivered by a caesarean delivery had approximately a 10% increased risk for admissions for bronchiolitis at age younger than 12 months (incidence rate ratio [IRR], 1.11; 95% confidence interval, 1.01 - 1.23), after adjustment for other maternal and fetal factors. The study also found a 20% increased risk at age 12 to 23 months, but that increase did not reach statistical significance (IRR, 1.20; 95% confidence interval, 0.94 - 1.53). No association was reported between elective caesarean delivery and number of pneumonia admissions for either age group.
The authors speculate that the act of labour promotes the production of various cytokines and stimulates the immune system in both the mother and the child. "Therefore the cytokine environment differs in a newborn delivered by elective caesarean delivery, as shown by the lower levels of interleukin (IL) 6 and IL-10 in their cord blood than in those who had a normal vaginal delivery," they write. "Differing cytokine environment with elective caesarean delivery may lead to increased susceptibility to respiratory infections in infancy," they hypothesize.
The authors conclude that physicians and expectant parents should be made aware of the additional risks associated with elective cesarean delivery, including increased infant morbidity, to aid in deciding the most appropriate mode of delivery.
Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents
Cochrane Database Syst Rev. 2011 Sep 7;9:CD005506.
Fedorowicz Z, Jagannath VA, Carter B.
Should children presenting to emergency departments with vomiting related to acute gastroenteritis be given anti-emetics? Many EDs are now doing this. This Cochrane review examined 7 studies with a total of >1000 children. Oral ondansetron is confirmed to have benefits in reducing vomiting, reduced hospitalization and reduced need for IV therapy. The number needed to treat is quite high however (17) and the drug is expensive (but not as expensive as a stay in hospital for rehydration). The cost-benefit ratio is probably less favourable for its use in primary care settings. The article is available here.
Vomiting is a common manifestation of acute gastroenteritis in children and adolescents. When untreated it can be a hindrance to oral rehydration therapy, which is the cornerstone in the management of acute gastroenteritis. Evidence is needed concerning the safety and efficacy of antiemetic use for vomiting in acute gastroenteritis in children.
To assess the safety and effectiveness of antiemetics on gastroenteritis induced vomiting in children and adolescents.
We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conferences.The search was re-run and is up to date as on 20 July 2010.
Randomized controlled trials comparing antiemetics with placebo or no treatment, in children and adolescents under the age of 18, for vomiting due to gastroenteritis.
DATA COLLECTION AND ANALYSIS:
Two review authors independently assessed trial quality and extracted data.
We included seven trials involving 1,020 participants. Mean time to cessation of vomiting in one study was 0.34 days less with dimenhydrinate suppository compared to placebo (P value = 0.036). Pooled data from three studies comparing oral ondansetron with placebo showed: a reduction in the immediate hospital admission rate (RR 0.40, NNT 17, 95% CI 10 to 100) but no difference between the hospitalization rates at 72 hours after discharge from the Emergency Department (ED); a reduction in IV rehydration rates both during the ED stay (RR 0.41, NNT 5, 95% CI 4 to 8), and in follow-up to 72 hours after discharge from the ED stay (worst-best scenario for ondansetron RR 0.57, NNT 6, 95% CI 4 to 13) and an increase in the proportion of patients with cessation of vomiting (RR 1.34, NNT 5, 95% CI 3 to 7)). No significant difference was noted in the revisit rates or adverse events, although diarrhea was reported as a side effect in four of the five ondansetron studies. In one study the proportion of patients with cessation of vomiting in 24 hours was (58%) with IV ondansetron, (17%) placebo and (33%) in the metoclopramide group (P value = 0.039).
Oral ondansetron increased the proportion of patients who had ceased vomiting and reduced the number needing intravenous rehydration and immediate hospital admission. Intravenous ondansetron and metoclopramide reduced the number of episodes of vomiting and hospital admission, and dimenhydrinate as a suppository reduced the duration of vomiting.
Salicylate Intoxication from Teething Gel in Infancy:
2011; 194 (3): 146-148
Gary D Williams, Edwin P Kirk, Callum J Wilson, Caroline A Meadows and Betty S Chan.
Bonjela Teething Gel contains the aspirin like compound choline salicylate. Excessive use can lead to Salicylate Poisoning as detailed in these case reports. Below is a commentary on this by Noel Cranswick, Paediatric Clinical Pharmacologist.
It is clearly important to know this when advising families about the use of therapies for teething symptoms. In the UK, Bonjela Teething Gel does not contain salicylates (it has lignocaine) and the government actively advises that the adult form of Bonjela (which does contain salicylates) should not be given to children under 16 years of age – partly because of toxicity and partly because of the theoretical risk of Reye Syndrome.
A recent article in the MJA has highlighted the issue of toxicity of OTC medications. This small case series involved the inadvertent poisoning of two infants with a commonly recommended teething gel containing choline salicylate (Bonjela teething gel). In the first case a 7 month old child presented with a short 24 hour history of being acutely unwell. After detecting salicylates in the urine, and treating appropriately, a thorough investigation of the family’s medicine cabinet resulted in the family admitted to using large amounts of Bonjela over the preceding 2 months; going through two to three tubes per week. In the second case, a 13 month old infant presented with failure to thrive. An arterial blood gas alerted the clinician to an unexplained metabolic acidosis and respiratory alkalosis. On further questioning, the parents admitted the frequent use of Bonjela, sometimes going through an entire tube in one night to settle the infant to sleep. There have been some short-term follow-up studies which show a tendency to spontaneous resolution of the abnormal head shape. Helmet moulding therapy has become quite commonly used in some centres to promote more rapid resolution towards the normal head shape. It has become quite an “industry” in some parts of the world.
This case series highlights several issues to the practicing clinician and parallels some of the concerns raised about complementary and alternative medicines (CAMs) in the recent paper from Lim et al. The specific problem of toxicity of teething gels containing choline salicylate is not new but most parents are probably unaware of the risks. Clinicians should warn parents about the risks associated with using teething gels – especially if used excessively.
The paper also reminds us that OTC medications are not without risk and that we should be mindful of this in our discussions with parents and in any recommendations that we make. An old review of OTC medicines in children from the Australian prescriber and the associated consumer summary may be helpful in this regard. More recently concerns about the potential toxicity of OTC cough medicines has moved the TGA to limit their availability by making them prescription only for younger children and S3 (through a pharmacist) for older children. In regards to OTC medicines, the following points need to be considered:
- Many parents and health professionals assume that OTC medicines are safe because they can be accessed directly by consumers.
- OTC Medicines can have the same range and severity of adverse effects as prescription medications.
- Parents may not recognise the potential relationship of the OTC medication and not mention their use to health professionals (as in these cases).
- Health professional may need to repeatedly question parents about the use of OTC medicines and use examples to clarify the question.
- Do not recommend OTC medications unless you are familiar with them and believe that the benefits outweigh the potential risks. Should you choose to recommend an OTC preparation, always mention potential side effects and the risk of overdose.
Deformational plagiocephaly: a follow-up of head shape, parental concern and neurodevelopment at ages 3 and 4 years
Arch Dis Child 2011;96:85-90 doi:10.1136/adc.2010.190934
Dr B L Hutchison and others, Department of Paediatrics: Child and Youth Health, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand;
“Positional” or “deformational” plagiocephaly or brachycephaly are the result of head moulding when a foetus or infant lies in a persisting head posture. It has become much very more prevalent since the recommendation that babies should not be placed in the prone position for sleeping to help avoid SIDS. Such positional moulding of the head can produce quite dramatic flattening in the occipital region associated with misalignment of the ears and other compensatory skull changes. Parents are commonly very concerned about these perceived abnormalities.
There have been some short-term follow-up studies which show a tendency to spontaneous resolution of the abnormal head shape. Helmet moulding therapy has become quite commonly used in some centres to promote more rapid resolution towards the normal head shape. It has become quite an “industry” in some parts of the world.
This nice New Zealand study provides information on longer term outcomes. They followed their 129 patients to a mean age of four years. None of the infants in this study received helmet therapy.
The results are very reassuring - 61% of children had a normal head shape at age 4, most of the remainder had only a mild-to-moderate abnormality of head shape, with only 4% having a persistent severe abnormality. The small number of infants were the ones who had the most severe abnormality is of head shape in early infancy.
Facial and frontal region asymmetry completely resolved. Parental concern over the child's head shape also improved markedly by the age of four with only 13% having any residual anxieties.
It has been known for some time that babies with deformational plagiocephaly have a higher rate of developmental delay. This is particularly true for gross motor delay. It is thought the infants with some motor delay tend to lie more in one position and produce some deformational changes to their skull, rather than that plagiocephaly causes developmental delay. In this study babies with pleasure carefully did have a higher rate of developmental delay, but by four years of age rated developmental problems had fallen to that seen in the normal community at this age.
One limitation of this study is that it involves two dimensional measurements for what is essentially a three-dimensional problem. A current study under way at our hospital is using 3-D photography to try and document evolution of head shape changes more precisely.
Toddler diarrhoea: is it a useful diagnostic label?
Review Toddler diarrhoea: is it a useful diagnostic label?
Arch Dis Child doi:10.1136/adc.2010.191825
C V E Powell1, H R Jenkins2
1Department of General Paediatrics, The Children's Hospital for Wales, Cardiff, UK
2Department of Child Health, The Children's Hospital for Wales, Cardiff, UK
This is a nice simple review of this common problem with suggested approaches to coming to a more specific diagnosis, plus ongoing advice / management. There is an interesting discussion of the value of the term "Toddler diarrhea"
The article is available HERE
Toddler diarrhoea is a term coined many years ago to describe a young child who passes several loose stools a day but who is otherwise healthy with excellent growth and normal examination. It could be argued that it is not an appropriate diagnostic term as it potentially stops the clinician from thinking about the possible causes of loose stools in this clinical situation. This article, which follows a debate between the authors on the topic at the 2010 Royal College of Paediatrics and Child Health Annual meeting, discusses the differential diagnoses of a young child presenting with the so-called toddler diarrhoea.
Suggested Initial Investigations:
- Full blood count
- C reactive protein
- Erythrocyte sedimentation rate
- Coeliac disease screen-anti-tissue transglutaminase antibody and total serum IgA
- Stool culture (including Clostridium difficile and giardia)
- A 6-week trial of a cow's milk- and egg-free diet with dietetic help
- Reduce fructose/juice intake
- Trial of metronidazole
- Loperamide for symptomatic relief once other diagnoses are excluded
Efficacy of Proton-Pump Inhibitors in Children With Gastroesophageal Reflux Disease
This systematic review suggests that there is little evidence for efficacy of PPIs in infants and limited evidence of efficacy in older children. I'm not sure that fits uniformly with clinical observation but it should give us pause for thought when reaching for the script pad, particularly given the potential for adverse effects.
Thickening has been shown to be a moderately effective intervention for reflux in babies and should probably be the first intervention (if any is needed)
Fourteen randomized, controlled trials with a parallel or crossover design, some with methodologic limitations, were included. Use of thickened formulas compared with standard formula significantly increased the percentage of infants with no regurgitation, slightly reduced the number of episodes of regurgitation and vomiting per day (assessed jointly or separately), and increased weight gain per day; it had no effect on the reflux index, number of acid gastroesophageal reflux episodes per hour, or number of reflux episodes lasting >5 minutes but significantly reduced the duration of the longest reflux episode of pH < 4. No definitive data showed that one particular thickening agent is more effective than another. No serious adverse effects were noted
Use of proton-pump inhibitors (PPIs) for the treatment of gastroesophageal reflux disease (GERD) in children has increased enormously. However, effectiveness and safety of PPIs for pediatric GERD are under debate.
We performed a systematic review to determine effectiveness and safety of PPIs in children with GERD.
We searched PubMed, Embase, and the Cochrane Database of Systematic Reviews for randomized controlled trials and crossover studies investigating efficacy and safety of PPIs in children aged 0 to 18 years with GERD for reduction in GERD symptoms, gastric pH, histologic aberrations, and reported adverse events.
Twelve studies were included with data from children aged 0-17 years. For infants, PPIs were more effective in 1 study (compared with hydrolyzed formula), not effective in 2 studies, and equally effective in 2 studies (compared with placebo) for the reduction of GERD symptoms. For children and adolescents, PPIs were equally effective (compared with alginates, ranitidine, or a different PPI dosage). For gastric acidity, in infants and children PPIs were more effective (compared with placebo, alginates, or ranitidine) in 4 studies. For reducing histologic aberrations, PPIs showed no difference (compared with ranitidine or alginates) in 3 studies. Six studies reported no differences in treatment-related adverse events (compared with placebo or a different PPI dosage).
PPIs are not effective in reducing GERD symptoms in infants. Placebo-controlled trials in older children are lacking. Although PPIs seem to be well tolerated during short-term use, evidence supporting the safety of PPIs is lacking.
Complications of Sinusitis in Children
The majority of children with sinusitis don't develop complications. However the condition is often under-recognised and can spread into surrounding orbit and brain tissue. In this study all the children had complications therefore a very selected group.
Intracranial complications were more severe than intraorbital complications. Serious complications of sinusitis occur more often in children than in adults. Prompt diagnosis and treatment is necessary to minimize morbidity and the risk for permanent sequelae or death. In a recent study, investigators reviewed records from a large children's hospital to examine the presentation, course, and severity of two such complications: intraorbital extension (IOE) and intracranial extension (ICE).
The researchers identified 118 children aged 3 months through 18 years who had radiographic evidence of sinusitis and imaging findings of IOE or ICE between 1997 and 2006. Eighty-five children had IOE; among these children, 41 had subperiosteal abscess, 24 had subperiosteal phlegmon, and 20 had orbital cellulitis or orbital abscess. Of the 33 children with ICE, 20 had dural enhancement, 15 had epidural abscess, 16 had subdural empyema, 9 had frontal bone osteomyelitis/Pott puffy tumor, 4 had brain abscess, and 1 had sinus thrombosis. Some had more than one finding. Contrast-enhanced computed tomography of the orbit and sinuses was sufficient for medical decision making in IOE, whereas magnetic resonance imaging offered increased sensitivity to identify the location and extent of ICE.
Compared to children with IOE, those with ICE had a longer duration of headache before diagnosis and were more likely to have vomiting; they also had a longer hospital stay and a longer course of intravenous antibiotics. Most of those with ICE were initially treated with cefotaxime, vancomycin, and metronidazole. Until 2002 (when methicillin-resistant Staphylococcus aureus became a potential threat), most children with IOE were initially treated with cefuroxime alone or nafcillin plus cefotaxime; since then, the most common regimen has been clindamycin or vancomycin, plus cefotaxime.
Extension of sinus infection can occur hematogenously, by contaguous spread or by retrograde extension along the valveless diploic veins. Early diagnosis using the findings in this study can improve prognosis.
Infants with Bronchiolitis
Predictors of Admission in Infants with Bronchiolitis
The authors used five clinical predictors of admission to develop a clinical risk score.
Bronchiolitis accounts for a significant number of hospital admissions during infancy. Its main clinical features are difficulty breathing, wheezing, coryza, poor feeding, cough, and crepitations with auscultation. Investigators in the U.K. retrospectively reviewed clinical records of 449 infants (age, <12 months; mean age, 23 weeks; 66% male) who presented with symptoms of acute bronchiolitis to an emergency department during a 12-month period in 2009-2010. A total of 163 infants (36%) were admitted to the hospital, and 29 potential predictors of admission were examined.
The best predictors of admission were age at presentation, respiratory
rate, heart rate, oxygen saturation, and duration of symptoms. The
investigators developed a clinical risk scoring system using the area
under the receiver operating characteristic curve to determine the
weight given for each predictor. The following predictors of admission
were assigned 1 point each: symptom duration <5 days, respiratory rate
50 breaths/minute, heart rate 155 beats/minute, oxygen saturation <97%,
and age <18 weeks. A clinical risk score of greater than 3 predicted need for admission
(sensitivity, 74%; specificity, 77%; positive and negative predictive
values, 67% and 83%, respectively).
If this scoring system is validated in a prospective study, it could prove to be a valuable addition to both office-based and emergency department evaluation of infants who present with bronchiolitis. In the primary care office setting, paediatricians might carefully watch infants with scores below the cut-off. As the authors candidly admit, the patient's clinical condition, social support system, and co morbid medical conditions also play an important role in determining whether to admit a child with bronchiolitis.
Neurodiagnostic evaluation of the child with a Simple Febrile Seizure
American Academy of Pediatrics 2011,Feb;(2):389-94. Sub Committee on Febrile Seizures: American Academy of Pediatric.
Duffner PK, Berman PH, Baumann RJ, Fisher PG, Green JL, Schneider S, Davidson C.
This article reminding us that a Simple Febrile Seizure occurs in children aged 6 to 60 months, it is generalised in nature, and lasts less than 15 minutes. It does not recur within 24 hours. A lumbar puncture should be performed in those with meningeal signs (neck stiffness, Kernig and/or Brudzinski signs) or in any child whose history or examination suggests the presence of meningitis or intracranial infection. Likewise any child 6-12 months of age who has not received scheduled vaccinations is potentially at higher risk of meningitis. Hib Meningitis and Strep Pneumonia are two of commonest causes of bacterial meningitis in this age group.
No evidence that EEG in the acute setting predicts further seizures. MRI or CT brain are not usually indicated. Routine blood tests not warranted. Children following a febrile seizure may have relatively low sodium concentrations and thus reminding us not to over hydrate children with hypotonic fluids.
To formulate evidence-based recommendations for health care professionals about the diagnosis and evaluation of a simple febrile seizure in infants and young children 6 through 60 months of age and to revise the practice guideline published by the American Academy of Pediatrics (AAP) in 1996.
This review included search and analysis of the medical literature published since the last version of the guideline. Physicians with expertise and experience in the fields of neurology and epilepsy, paediatrics, epidemiology, and research methodologies constituted a subcommittee of the AAP Steering Committee on Quality Improvement and Management. The steering committee and other groups within the AAP and organizations outside the AAP reviewed the guideline. The subcommittee member who reviewed the literature for the 1996 AAP practice guidelines searched for articles published since the last guideline through 2009, supplemented by articles submitted by other committee members. Results from the literature search were provided to the subcommittee members for review. Interventions of direct interest included lumbar puncture, electro-encephalography, blood studies, and neuroimaging. Multiple issues were raised and discussed iteratively until consensus was reached about recommendations. The strength of evidence supporting each recommendation and the strength of the recommendation were assessed by the committee member most experienced in informatics and epidemiology and graded according to AAP policy.
Clinicians evaluating infants or young children after a simple febrile seizure should direct their attention toward identifying the cause of the child's fever. Meningitis should be considered in the differential diagnosis for any febrile child, and a lumbar puncture should be performed if there are clinical signs or symptoms of concern. For any infant between 6 and 12 months of age who presents with a seizure and fever, a lumbar puncture is an option when the child is considered deficient in Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae immunizations (ie, has not received scheduled immunizations as recommended), or when immunization status cannot be determined, because of an increased risk of bacterial meningitis. A lumbar puncture is an option for children who are pretreated with antibiotics. In general, a simple febrile seizure does not usually require further evaluation, specifically electroencephalography, blood studies, or neuroimaging
Antibiotics for the Prevention of Acute and Chronic Suppurative Otitis Media in Children.
Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004401. DOI: 10.1002/14651858.CD004401.pub2.
Amanda J Leach1, Peter S Morris2 1Ear and Oral Health Program, Child Health Division, Menzies School of Health Research, Tiwi, Australia. 2Ear Health and Education Unit, Menzies School of Health Research, Royal Darwin Hospital, Block 4, Darwin, Australia.
Contact address: Amanda J Leach, Ear and Oral Health Program, Child Health Division, Menzies School of Health Research, John Mathews Building (bldg 58), Royal Darwin Hospital, Tiwi, Northern Territory, 0811, Australia.
This recently updated Cochrane review suggests that long-term use of antibiotics does not prevent otitis media(ear infections) in children who have this recurrent problem but that it does reduce the frequency(occurs less often) of AOM from an average of 3 to 1.5 episodes per year. Five children need to be treated to prevent one child from getting AOM. May be useful in selected high risk children.
It seems like a useful potential strategy in children who have more frequent or more severe AOM but in most the costs, inconvenience, potential adverse effects(penicillin allergy), and selection pressure for more resistant organisms(bugs) in the childhood community would seem to favour not using this approach.
The full article is available here: (Opens in a new window).
Acute otitis media (AOM) is a common childhood illness. These middle ear infections may be frequent and painful. AOM may be associated with perforation of the tympanic membrane and can progress to chronic suppurative otitis media (CSOM).
To determine the effectiveness of long-term antibiotics (for longer than six weeks) in preventing any AOM, AOM with perforation and CSOM.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 1), MEDLINE (January 1966 to March Week 3 2006), OLD MEDLINE (1950 to 1965), EMBASE (1990 to December 2005) and the references of relevant studies.
All randomised controlled trials of long-term (longer than six weeks) antibiotics versus placebo or no treatment for the prevention of AOM, AOM with perforation, or CSOM were eligible.
Data Collection and Analysis:
Two authors independently extracted the data for: any AOM; episodes of AOM; any recurrent AOM; episodes of illness; any side effects; any antibiotic resistance, as well as outcomes at end of intervention (any AOM); and following cessation of intervention (any AOM). For dichotomous outcomes, the summary risk ratio (fixed and random-effects models) was calculated. For rate outcomes, the summary incidence rate ratio was calculated.
Sixteen studies involving 1483 children met our inclusion criteria. All studies enrolled children at increased risk of AOM, and in seven studies the children were prone to otitis media. The majority of studies were high quality and most (15 studies) reported data for our primary outcomes. None reported AOM with perforation or CSOM. Long-term antibiotics reduced any episode of AOM (13 studies, 1358 children, risk ratio (RR) 0.62, 95% CI 0.52 to 0.75; random-effects model) and number of episodes of AOM (12 studies, 1112 children, incidence rate ratio (IRR) 0.48, 95% CI 0.37 to 0.62; random-effects model). Approximately five children would need to be treated long term to prevent one child experiencing AOM whilst on treatment. Antibiotics prevented 1.5 episodes of AOM for every 12 months of treatment per child. Statistical heterogeneity was explored. Long-term antibiotics were not associated with a significant increase in adverse events (11 studies, 714 children, RR 1.99, 95% CI 0.25 to 15.89; random-effects model).
For children at risk, antibiotics given once or twice daily will reduce the probability of AOM while the child is on treatment. Antibiotics will reduce the number of episodes of AOM per year from around three to around 1.5. We believe that larger absolute benefits are likely in high-risk children. These conclusions were not affected by sensitivity analyses.
Glucocorticoids for acute viral bronchiolitis in infants and young children.
Cochrane Database Systematic Reviews 2010 Oct 6.
Fernandes RM, Bialy LM, Vandermeer B, et al.
My current practice is not to use ‘steroids’ in acute bronchiolitis. This practice is evidence based as you’ll see from the article below (Cochrane Review). This updated Cochrane Review does not support a clinically relevant benefit of systemic or inhaled steroids in babies with acute viral bronchiolitis.
Previous systematic reviews have not shown clear benefit of glucocorticoids for acute viral bronchiolitis, but their use remains considerable. Recent large trials add substantially to current evidence and suggest novel glucocorticoid-including treatment approaches.
To review the efficacy and safety of systemic and inhaled glucocorticoids in children with acute viral bronchiolitis.
We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, issue 4); MEDLINE (1950 to November 2009); EMBASE (1980 to Week 47 2009); LILACS (1982 to November 2009); Scopus(R) (1823 to November 2009); and IRAN MedEx (1998 to November 2009).
Randomised controlled trials (RCTs) comparing short-term systemic or inhaled glucocorticoids versus placebo or another intervention in children < 24 months with acute bronchiolitis (first episode with wheezing). Our primary outcomes were: admissions by days 1 and 7 for outpatient studies; and length of stay (LOS) for inpatient studies. Secondary outcomes included clinical severity parameters, healthcare use, pulmonary function, symptoms, quality of life and harms.
Data Collection and Analysis:
Two authors independently extracted data on study and participant characteristics, interventions and outcomes. We assessed risk of bias and graded strength of evidence. Inpatient and outpatient results were meta-analysed separately using random-effects models. We pre-specified subgroup analyses, including the combined use of protocolised bronchodilators.
Main Results: We included 17 trials (2596 participants); only two had low overall risk of bias. Baseline severity, glucocorticoid schemes, comparators and outcomes were heterogeneous. Glucocorticoids did not significantly reduce outpatient admissions by days 1 and 7 when compared to placebo (pooled risk ratios (RRs) 0.92; 95% CI 0.78 to 1.08; and 0.86; 95% CI 0.7 to 1.06, respectively). There was no benefit in LOS for inpatients (mean difference -0.18 days; 95% CI -0.39 to 0.04). Unadjusted results from a large factorial low risk of bias RCT found combined high-dose systemic dexamethasone and inhaled epinephrine reduced admissions by day 7 (baseline risk of admission 26%; RR 0.65, 95% CI 0.44 to 0.95; number needed to treat 11, 95% CI 7 to 76), with no differences in short-term adverse effects. No other comparisons showed relevant differences in primary outcomes.
Authors' Conclusions: Current evidence does not support a clinically relevant effect of systemic or inhaled glucocorticoids on admissions or length of hospitalization. Combined dexamethasone and epinephrine may reduce outpatient admissions, but results are exploratory and safety data limited. Future research should further assess the efficacy, harms and applicability of combined therapy.
The full article is available here: (Opens in a new window).
Food Allergy in Children.
Food allergy (FA) affects approximately 5% of young children and 4% of teens and adults in the U.S. NIAID has released a guideline with 43 recommendations for diagnosis and management of FA derived from 348 articles reviewed by an expert panel. Highlights of the guideline include the following
Definition, Prevalence, Epidemiology
- FA is defined as "an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food."
- Mechanisms of FA reactions can be IgE mediated (acute urticaria, oral allergy syndrome), non–IgE mediated (food protein–induced enteropathy), mixed IgE and non–IgE mediated, or cell mediated.
- Prevalence is uncertain; FA is over reported by patients on the basis of symptoms alone (e.g., 3% of patients report symptoms of milk allergy, but only 0.9% are confirmed by food challenge).
- Most infants with egg or milk allergy develop tolerance at a young age. Lower levels of allergen-specific IgE (sIgE) at diagnosis are associated with more-rapid development of tolerance. Decreases in sIgE level often are associated with tolerance.
- About one third of children <5 years with moderate-to-severe atopic dermatitis also have FA.
- FA should be suspected in any individual who presents with anaphylaxis or any combination of 37 listed symptoms that occur within minutes to hours after ingesting food.
- All reports of presumed FA should be confirmed (50%–90% of cases are not allergies).
- The double-blind placebo-controlled food challenge is the gold standard for diagnosing FA; a negative test rules out FA.
- Skin-prick test (SPT) and sIgE measurement should be used to assist in the diagnosis of FA, but neither test alone can be considered diagnostic.
- Intradermal tests, total serum IgE measurement, and atopy patch tests are not recommended.
- The type of diagnostic testing should be selected based on medical history and not comprise large general panels of food allergens.
- The guideline includes lengthy discussion of many non–IgE-mediated FAs.
Management and Prevention
- Individuals with documented FA should avoid the offending food.
- The frequency of follow-up testing (e.g., SPT or sIgE) depends on the offending food, age of the child, and intervening medical history.
- No medications prevent the development of FA.
- MMR and MMRV vaccines are safe for children with egg allergy, even for those with a history of severe reaction. The guideline includes extensive information regarding the administration of influenza vaccine in children with egg allergy.
- Routine testing for FA before introduction of highly allergic foods is not recommended, even in high-risk children.
- Children with atopic dermatitis that is unresponsive to therapy and those with atopic dermatitis and a reliable history of an immediate reaction after ingestion of a specific food should be tested for FA.
- Maternal diet during pregnancy should not be restricted to prevent FA.
- Soy milk should not be substituted for cow's milk as a strategy for preventing or modifying the development of FA.
- Use of hydrolyzed infant formulas in infants at risk for the development of FA who are not exclusively breast-fed might help delay or prevent FA (consistent with recent American Academy of Pediatrics recommendations [JW Pediatrics and Adolescent Medicine Feb 20 2008]).
- Introduction of solids, including allergenic foods, should not be delayed beyond age 4 to 6 months.
Diagnosis and Management of Food-Induced Anaphylaxis
- Anaphylaxis is "a serious allergic reaction that is rapid in onset and may cause death." The guideline includes detailed diagnostic criteria and pharmacologic management.
- Up to 20% of individuals with anaphylaxis have biphasic reactions.
- Lab tests, including plasma histamine and serum or plasma total tryptase, are rarely diagnostic.
- Epinephrine is the mainstay of treatment and should be administered as soon as anaphylaxis is recognized.
Prior to discharge, all patients with anaphylaxis
- an emergency action plan
- two prescriptions for epinephrine autoinjectors
- a plan for monitoring expiration dates
- follow-up appointments
- printed information about anaphylaxis and treatment.
I like to use sIgE testing to guide diagnosis and treatment, although the ease of interpretation depends on the presence of symptoms and level of sIgE; the predictive value improves as levels rise above >3K IU. My practice is to test children with hard-to-control atopic dermatitis and those with histories consistent with FA before we institute an elimination diet, because the diet is so difficult to maintain in young children. The recommendation to provide two epinephrine autoinjectors for all children with anaphylaxis is better practice than the recent recommendation to provide two autoinjectors for all children with food allergy (JW Pediatrics and Adolescent Medicine Apr 7 2010). I am disappointed that the expert panel did not include a primary care pediatrician (PCP) because recommendations from specialists often do not translate well to the primary care setting. See JW Pediatrics and Adolescent Medicine Jan 19 2011 for additional commentary on the NIAID guidelines.
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