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Selections from Journal Watch Pediatrics and Adolescent Medicine

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UTIs: What’s the best imaging study? ▸

Many radiographic studies are available to evaluate infants with urinary tract infections (UTIs), including ultrasound, voiding cystourethrogram (VCUG), and renal scans, but few well-designed trials have examined the effects of these techniques on management and outcome. As part of a multicenter, randomized trial of different antibiotic regimens, 309 children (age range, 1 to 24 months) who had a first febrile UTI underwent ultrasound and a renal scan within 48 hours of diagnosis, VCUG 1 month later, and a second renal scan 6 months after that.

Ultrasound results were normal in 88% of children, and the identification of abnormalities, including dilated pelvis and pelvocaliectasis, did not lead to changes in management. The initial renal scan demonstrated pyelonephritis in 61% of children. Of 302 children who underwent VCUG, 39% had vesicoureteral reflux (VCR). Of 55 children with grade III or IV VCR, 7 had an abnormal ultrasound. Renal scarring was more likely to have developed in children with VCR (16 of 109 [15%]) than in those without (10 of 166 [6%]).

Comment ▸ The goal of imaging studies in children with UTIs is to identify those at risk for renal parenchymal injury and to preserve renal function. In this study, ultrasound did not contribute to the managment or prediction of VCR. An editorialist (the editor-in-chief of Journal Watch Pediatrics and Adolescent Medicine) states that VCUG remains the most important radiographic study for infants with UTIs. Ultrasound is probably unnecessary, particularly in infants who show no evidence of obstructive lesions of the genital urinary tract on prenatal ultrasonography.

Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine February 10, 2003

Stimulants for ADHD: do they lead to substance abuse? ▸

Widespread use of stimulant medications for children with attention-deficit/hyperactivity disorder (ADHD) has led to concerns that such therapy might produce later substance abuse. Investigators in Boston conducted a meta-analysis of 6 studies, in which 674 medicated and 360 unmedicated patients with ADHD were evaluated for substance use during adolescence or adulthood.

The pooled analysis indicated an almost 2-fold reduction in risk for substance-use disorders (drug or alcohol abuse or dependence) among children treated with stimulants. For example, in one study, 42% of children with untreated ADHD developed substance-use disorders as adolescents, compared with 16% who received stimulants. The findings were more robust when analysis was restricted to the 4 studies in which both groups had similar baseline disease severity: A 3.5-fold reduction in risk was noted for the treated group. The protective effect was more modest in studies that followed children into adulthood (1.4-fold reduction) compared with those that followed patients only through adolescence (5.8-fold reduction).

Comment ▸ These findings are very encouraging and suggest that stimulant medications protect against substance-use disorders in children with ADHD. The authors speculate that diminution of this effect in children who were followed into adulthood might reflect the fact that many patients with ADHD stop taking medications when they get older.

Howard Bauchner, MD

Published in Journal Watch Dermatology March 26, 2003

Originally published in Journal Watch February 4, 2003

When to stop patching for amblyopia—three strikes and you’re out ▸

The traditional treatment for amblyopia is to patch (occlude) the good eye for at least 75% of the child’s waking hours. However, a question remains regarding the sufficiency of the traditional trial of this therapy—3 intervals of full-time occlusion (FTO), with each interval equaling 1 week per year of the child’s age. To address this question, Keech and colleagues conducted a retrospective, noncomparative, interventional case study.

Sixty-four patients (31 girls and 33 boys; mean age, 2.8 years) underwent 81 occlusion trials consisting of 1 FTO interval without improvement followed by at least 1 more FTO interval. Visual acuity improved after the second interval in 25 cases (31%). Of the 44 trials consisting of 2 FTO intervals without improvement, visual acuity improved after the third interval in 12 cases (27%). Of the 11 trials consisting of 3 FTO intervals without improvement followed by at least 1 additional interval, acuity did not improve.

Comment ▸ Pediatricians are often queried by frazzled parents about the need to keep patches on recalcitrant toddlers. This study indicates that the persistence of doctors, parents, and kids is not in vain. If a first attempt at reversing amblyopia is not a success, don’t give up: In this study, 31% of amblyopic children improved after the second try, and 27% improved after the third try. After 3 attempts, however, there appears to be little chance for improvement.

Walter M. Jay, MD, and Susan Jay, MD

Dr. Walter M. Jay is the John M. Krasa Professor of Ophthalmology at Loyola University Medical School, Maywood, Illinois.

Published in Journal Watch Pediatrics and Adolescent Medicine February 24, 2003

Value of ultrasound in hip dysplasia diagnosis ▸

All pediatricians perform physical examinations of infants’ hips to detect developmental dysplasia of the hip (DDH). Researchers in the U.K. investigated whether ultrasonography (US) added benefit and cost efficiency in the diagnosis and management of 629 infants with hip instability during the first 6 weeks of life. Infants with instability on clinical examination were randomized to future ultrasonographic examination plus clinical examination or to the traditional clinical examination alone.

At 8 weeks of age, hips found to be unstable by either examination modality were splinted. Plain radiographs were taken at 12 to 14 months and at 24 months of age. One percent of the US group and 2% of the traditional examination group were found to have hip abnormalities on final plain radiographs.

Inclusion of US in the diagnosis and management of unstable hips reduced the rate of any type of hip treatment by one third, compared with the rate with clinical examination alone. Use of US also reduced the number of children placed in abduction splints (P=0.01) without increasing the need for surgical procedures. Five children were not walking at 2 years of age, including 1 in the US group. Despite the increased cost of multiple ultrasonographic examinations, the total cost of the diagnosis and management of DDH was slightly less in the US group, but the difference was not statistically significant.

Comment ▸ Hip US is a valuable aid in the management of children with abnormal findings on clinical hip examination. This study was carefully designed, and important variables were considered. The reduced use of abduction splints may prevent some of the adverse consequences associated with splinting.

F. Bruder Stapleton, MD

Published in Journal Watch Pediatrics and Adolescent Medicine February 24, 2003

Improving health outcomes of children with appendicitis ▸

Children with equivocal signs of appendicitis can be diagnosed accurately with a combination of ultrasound and computerized tomography with rectal contrast (

). In 1998, investigators in Boston implemented an imaging protocol: Children with unequivocal presentations of appendicitis went directly to surgery without imaging, but children with equivocal presentations underwent ultrasound followed by CT if ultrasound was inconclusive. Prior to 1998, children who did not proceed directly to surgery were observed, and imaging studies were not performed routinely. Rates of perforation and negative appendectomy were compared before and after the protocol was in place.

Before the protocol was implemented, 44% of children (404 of 920) went directly to surgery without imaging. After it was implemented, 30% (124 of 418) went directly to surgery without imaging. Among all patients (with and without equivocal signs), rates of perforation and negative appendectomies declined significantly after implementation (from 35% to 16% and from 15% to 4%, respectively). The declines were similar when analysis was restricted to patients with equivocal signs of appendicitis. Declines occurred only among children older than 5 years.

Comment ▸ The implementation of this imaging protocol had 2 effects: First, fewer children went directly to surgery, and more children underwent imaging. Second, specific health outcomes improved. Of note, before introduction of the protocol, perforation and negative appendectomy rates were somewhat higher at this center compared with rates reported at other centers.

Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine March 10, 2003

Originally published in Journal Watch January 17, 2003

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