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Selections from Journal Watch Pediatrics and Adolescent Medicine

Ipecac—going, going, gone!

▸ Ipecac has long been the cornerstone of treatment for childhood poisoning. When administered at home, it was thought to reduce emergency department (ED) use and to improve health outcomes. Using data from 64 poison control centers that serve most of the U.S. population, researchers assessed how home ipecac use correlated with rate of referral to EDs and with outcomes in more than 700,000 young children (age, <6 years) who unintentionally ingested pharmacologic agents.

Only 1.8% of children were given ipecac at home. Overall, 9% were referred to EDs. No relation was observed between home use of ipecac and ED referral. The researchers classified the centers as belonging to one of two groups: those with high rates of recommending home use of ipecac and those with low rates. Both groups had similar rates of ED referral and adverse outcomes.

Comment

▸ Although ipecac use has declined during the past decade, these findings suggest that the clinical care of poisoned children has not been compromised. In a statement published simultaneously with this report, the American Academy of Pediatrics reiterates that prevention strategies are critical. These include posting the universal poison control center number (800-222-1222) in homes and keeping poisons out of children’s sight and reach. The AAP recommends that syrup of ipecac no longer be used routinely as poison treatment in the home and that clinicians advise parents to discard any ipecac they have in the house -- fundamental changes in our approach to the treatment of poisoning in children.

Howard Bauchner, MD

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

A new therapy for whooping cough

▸ The American Academy of Pediatrics recommends a 14-day course of erythromycin for treatment of clinical or laboratory pertussis, but this therapy can cause gastrointestinal disturbances, which may limit adherence. In vitro data have shown that azithromycin has excellent activity against Bordetella pertussis. The high tissue concentrations achieved with this antibiotic make it a reasonable alternative, but without clinical data, many clinicians have been reluctant to prescribe it for whooping cough. In this manufacturer-sponsored, open-label, 5-day, noncomparative trial, researchers tested the efficacy of azithromycin in treating pertussis and pertussis syndrome.

Of 34 cases (5 adults; 29 children and adolescents aged 6 months to 20 years), 29 had culture-proven pertussis syndrome, and 5 had polymerase-chain-reaction-proven infection. All patients received 10 mg/kg of azithromycin on day 1, followed by 5 mg/kg on days 2 through 5. After 2 or 3 days of therapy, 97% were culture- or PCR-negative; by day 21, 100% were negative. All patients recovered fully after a mean of 28 days; 10% complained of gastrointestinal disturbances.

Comment

▸ Although this study had no comparison group, the results are similar to (or better than) those seen in other research, and the outcome supports the use of azithromycin for pertussis. Azithromycin should decrease transmission by eradicating the organism and can be used as prophylaxis by close contacts of the index patient. However, erythromycin remains a less expensive option for those who can tolerate it. For patients and contacts of patients intolerant to this therapy, azithromycin provides an excellent alternative.

Peggy S. Weintrub, MD

Published in Journal Watch Pediatrics and Adolescent Medicine December 15, 2003

Is surgery the answer for morbid obesity in adolescence

▸ Having had little success in treating obesity in the pediatric population, clinicians are seeking new approaches to this problem. Although various surgical techniques are effective in adults with morbid obesity, the possibility of complications has led to the avoidance of such interventions in patients younger than 18 years. These authors describe their experiences with 8 female and 3 male adolescents (age range, 11 to 17) who underwent laparoscopic adjustable gastric banding. The patients, who met National Institutes of Health criteria for morbid obesity, had failed to lose weight despite a low-calorie diet.

No patient experienced perioperative complications. During an average follow-up period of 23 months (range, 6 to 36 months), the mean BMI fell from 46.6 kg/m2 to 32.1 kg/m2. After surgery, cholesterol levels did not drop in 1 patient with abnormal preoperative levels, but triglyceride levels decreased to normal in 2 patients with elevated preoperative levels. A patient with pulmonary hypertension and heart failure was able to return to school after the operation. The authors believe that bariatric surgery is a safe and effective therapy for adolescent morbid obesity.

Comment

▸ Although these 11 cases are insufficient to make me accept a surgical technique as a routine treatment, they do make me take notice, particularly because the complications of morbid obesity are so severe and the current treatments are so unsuccessful. We need to pay attention to future results from bariatric surgery and discuss with our surgical colleagues the use of this treatment for our patients.

William P. Kanto, Jr., MD

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

Teaching parents behavior management

▸ Educational programs that focus on changing parental behavior have a considerable impact on child behavior. The challenge has been to find an efficient and cost-effective program that can be adapted to pediatric practice. These authors report a community-based study from Canada involving 198 parents of 3- and 4-year-old children with behavior problems.

Parents were randomized to receive the study intervention (weekly 2-hour meetings in small groups for 3 weeks, followed by a booster session 4 weeks later) or to serve as waiting-list controls (scheduled for future intervention). Seven or 8 parents and a facilitator attended each meeting. The facilitators encouraged parents to explore strategies and to support each other in problem solving. A video (1-2-3 Magic) was used in the first 3 sessions as a guide to managing difficult behaviors, and handouts on specific behavior problems were distributed.

Four standardized questionnaires were administered to both groups at baseline and at 3 months after the intervention. At 3 months, parents in the intervention group reported more positive parenting behaviors (i.e., less parental overactivity, laxness, or verbosity) and improved child behavior (e.g., less hyperactivity and distractibility), and they perceived their children to be more compliant, happier, and less difficult than at baseline. Comparisons between the 2 groups were statistically significant. Gains in positive parenting behaviors were maintained at 1-year follow-up in a subset of intervention parents.

Comment

▸ Supporting effective discipline and management of child behavior is a major goal of pediatric health supervision, but doing this work effectively in a busy traditional practice presents an enormous challenge. This brief psychoeducational program provides an evidence-based intervention that can be adapted to pediatric practice at minimal cost.

Martin T. Stein, MD

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

Pneumococcal vaccine not effective in children with recurrent otitis media

▸ In 2 clinical trials involving almost 40,000 healthy infants, 7-valent conjugate pneumococcal vaccine (PCV7) was found to be highly effective in reducing severe pneumococcal infections. To determine whether the vaccine is effective in older children with a history of recurrent acute otitis media (AOM), investigators in the Netherlands (where PCV7 is not used routinely) randomized 383 children (age range, 1 to 7 years) double-blind to receive either PCV7 followed in 6 months by 23-valent polysaccharide vaccine (PPV23) or hepatitis A or B vaccine. Children aged 12 to 24 months received 2 doses of PCV7 (at entry and 1 month); those aged 25 to 84 months received 1 dose. The primary endpoint was the number of episodes of AOM during 18 months of follow-up. Cultures were obtained from the nasopharynx at study entry and follow-up visits.

No significant differences were noted between the groups in the number or severity of AOM episodes or in the percentage of children carrying pneumococci in the nasopharynx. Carriage of conjugate vaccine serotypes declined in the vaccine group compared with the control group, while nonvaccine serotypes increased. Based on limited culture data (middle-ear fluid from myringotomies for first-episode AOM and spontaneously drained fluid in a few children), AOM caused by conjugate vaccine serotypes decreased 51% in the vaccine group, and Staphylococcus aureus was isolated more often from the vaccine than the control group.

Comment

▸ These results show that vaccination with PCV7 followed by PPV23 does not reduce episodes of AOM in previously unvaccinated (with PCV7) children aged 1 year and older and suggest that other approaches to prevention are needed.

Mary E. Wilson, MD

Published in Journal Watch Pediatrics and Adolescent Medicine December 15, 2003

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