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Selections from Journal Watch Pediatrics and Adolescent Medicine Copyright © 2004 Massachusetts Medical Society. All rights reserved.

Acetaminophen vs. ibuprofen: which is better for kids? ▸

A frequently asked question in pediatric practices is: “What’s better for pain relief and fever, acetaminophen or ibuprofen?” Although most believe that they are comparable, their relative safety and efficacy in children are uncertain.

In this meta-analysis, researchers identified 17 blinded, randomized controlled trials published from 1985 through 2002 that compared single-dose acetaminophen and ibuprofen for pain and fever in children. Point estimates at 2 and 4 hours after treatment slightly (but not significantly) favored ibuprofen (4–10 mg/kg) compared with acetaminophen (7–15 mg/kg) for pain relief, but at 2, 4, and 6 hours, point estimates significantly favored ibuprofen for fever reduction. The relative superiority of ibuprofen for fever reduction doubled at higher therapeutic doses (10 mg/kg of ibuprofen vs. 10–15 mg/kg of acetaminophen). For example, 38% more children experienced fever reduction from ibuprofen than from acetaminophen 4 hours after treatment. No differences in safety were noted between the two drugs or between the two drugs and placebo.

Comment ▸

Ibuprofen is the better choice for treating fever in children, especially at higher therapeutic doses. For pain relief, ibuprofen and acetaminophen are comparable. These results cannot be generalized to multidose regimens.

Robert A. Dershewitz, MD, MSc

Published in Journal Watch June 22, 2004

Cleft lip and palate: increased mortality over time ▸

The short-term morbidity associated with cleft lip and palate has been well described, but little is known about the long-term health and survival of individuals with these congenital malformations. Using a Danish registry, these researchers assessed overall mortality and causes of specific mortality in 5531 people who were born with cleft lip and cleft palate between 1943 and 1987 and followed to 1998.

Expected mortality was 259 deaths, but 402 deaths occurred, corresponding to a standardized mortality ratio of 1.4 for males and 1.8 for females. The increase in mortality risk remained constant in each interval of follow-up (first year of life, 1 to 17 years, and 18 to 55 years) and for all major causes of death. In particular, there were significant increases in risk for death related to suicide and epilepsy, in both men and women (standardized mortality ratios, 1.6 for suicide and 8.3 for epilepsy).

Comment ▸

Primary care providers need to recognize the increase in mortality among patients of all ages who have cleft lip or palate; in particular, we should screen children and adolescents for seizures and for suicidal intent. An inquiry as simple as, “It is not unusual for young people to feel down or even consider hurting themselves ... have you ever felt like hurting yourself?” could be lifesaving if the answer is affirmative and follow-up intervention is instituted. At the time of publication, the full text of the original article was available free of charge.

Elizabeth R. McAnarney, MD

Published in Journal Watch Pediatrics and Adolescent Medicine July 26, 2004

Hyperbilirubinemia: a comprehensive new guideline ▸

The increase in breast-feeding rates, the trend toward shorter hospital stays for newborns, and concern that the number of cases of kernicterus may be rising have led the AAP to release a comprehensive guideline that focuses on the detection and management of hyperbilirubinemia in newborn infants with gestational ages of ⩾35 weeks. The guideline is lengthy, with numerous appendices. Some highlights:

  • Nurseries should have standard protocols for the detection of hyperbilirubinemia. Jaundice usually begins in the face and progresses caudally, but visual estimation can be inaccurate. Measuring bilirubin levels in all infants prior to discharge is one option.

  • Bilirubin levels should be plotted on a nomogram based on the age of the infant in hours and interpreted in terms of the risk for progression to levels requiring intervention.

  • Risk factors include jaundice prior to discharge, gestational age <38 weeks, breast-feeding, and history of jaundice in a sibling.

  • All jaundiced infants should have bilirubin levels measured in the first 24 hours.

  • Follow-up should be based on time of discharge and risk for hyperbilirubinemia. Any child at risk for hyperbilirubinemia should be seen within 48 hours of discharge.

  • Indications for phototherapy and exchange transfusion depend on the age of the infant, bilirubin level, and risk factors. For example, phototherapy is indicated at 48 hours in an infant with a bilirubin level of 11 mg/dL if the infant is high-risk (e.g., 36 weeks’ gestation and breast-feeding with significant weight loss). Exchange transfusion is indicated at 48 hours in a low-risk infant with a bilirubin level of 22 mg/dL.

Some clinically useful information from the appendices:

  • Transcutaneous bilirubin is accurate, particularly at levels of <15 mg/dL.

  • Maximum weight loss in breast-feeding infants occurs by day 3 and averages about 6%.

  • The bilirubin level in infants with G6PD deficiency may increase quite quickly; thus, G6PD should be measured in infants with significant hyperbilirubinemia. G6PD-deficient infants require intervention at lower bilirubin levels.

  • Phototherapy may be discontinued when the bilirubin level falls below 13 or 14 mg/dL, except in high-risk infants.

  • It is not necessary to observe infants for bilirubin “rebound” prior to discharge.

Comment ▸

These guidelines should be mandatory reading for every pediatrician. In my experience, watch out for the 35- to 38-week infant discharged on Thursday or Friday whose mother is breast-feeding; these infants should be seen within 48 hours of discharge.

I do have some concerns about the guidelines. Very few of the recommendations are based on robust evidence; in fact, most are based on observational data and the belief that benefit exceeds harm (although cost was not considered). Although I acknowledge the importance of detecting disease and the safety of phototherapy, I remain concerned that these guidelines will increase hospitalizations for phototherapy and exchange transfusions, which, in my experience, are always complicated. In a related editorial, Ip and colleagues indicate that between 2000 and 20,000 newborns will need to undergo phototherapy to prevent one case of kernicterus. Careful monitoring of the impact of these guidelines is critical.

Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine August 9, 2004

A public health prescription: preventing aggressive behaviors in high-risk children ▸

About half of children with disruptive behavior problems in early childhood go on to display aggressive behavior in adolescence. Findings of previous studies suggest that home-visiting services can effectively prevent later sequelae in these children, including school failure, peer rejection, and delinquency.

This prospective study enrolled 41 low-income families with babies younger than 18 months who were referred for home-visiting services because of concerns about the quality of parental caregiving. These families were matched with 35 control families of similar socioeconomic status who had not sought or been referred for such services. At study entry, there were significant differences between referred and control families on three maternal factors: prior psychiatric hospitalization, prior maltreatment of a child, and depression.

The intervention families received from 0 to 18 months of weekly home visits during the study period, depending on the age of the child at entry. Visits were designed to build trust; increase parent competence in accessing community resources; model positive, developmentally appropriate interactions between mother and infant; and decrease social isolation. Teacher responses to standardized questionnaires, given when the children reached 5 years of age, revealed a significant dose-response relation between longer duration of home-visit services and decreased hostile-behavior scores. Parent reports of positive play with peers were also significantly related to longer duration of early home-visiting services.

Comment ▸

Home visits had positive long-term effects on the status of children considered to be at high risk for developing disruptive and aggressive behaviors—benefits that were evident 3.5 years after the visits ended. Home visits made by qualified providers to mothers and infants from low-income families have been shown to be cost-effective over the life of the child. These observations suggest that pediatricians should make use of and advocate for such home services for high-risk families in their communities.

Martin T. Stein, MD

Published in Journal Watch Pediatrics and Adolescent Medicine August 9, 2004

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