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Selections from Journal Watch Pediatrics and Adolescent medicine

Cephalosporins vs. penicillin for group A strep pharyngitis ▸

Penicillin is the most commonly recommended therapy for group A streptococcal (GAS) pharyngitis. Although group A streptococcus has not developed resistance, antibiotic therapy fails to eradicate the infection in some patients. Many authors have suggested using a cephalosporin as an alternative to penicillin. Casey and Pichichero performed a meta-analysis of 35 randomized, controlled trials comparing penicillin with cephalosporins in children.

Bacteriologic cure and clinical cure were both significantly more likely with the cephalosporins than with penicillin (odds ratios, 3.02 and 2.33, respectively). When the authors limited the analysis to trials with high quality scores, the difference in clinical cure rates was smaller; when only double-blind trials were considered, the treatments had equal clinical effect. The three generations of cephalosporins did not show different bacteriologic cure rates, though some agents performed better than others.

Comment ▸

This article demonstrates that cephalosporins have a higher cure rate than penicillin for the treatment of GAS pharyngitis. Other factors, however, must be considered in choosing the best therapy for a patient. Penicillin continues to have some advantages: It is the treatment with the narrowest antimicrobial spectrum, it is inexpensive, and it is well studied for the prevention of rheumatic fever. Of all the cephalosporins, only first-generation drugs should be considered for the treatment of GAS pharyngitis. The clearest advantage of cephalosporins is for patients in whom eradication of the organism is critical: those with frequent, recurrent, or complicated GAS infections.

Peggy Sue Weintrub, MD

Published in Journal Watch Pediatrics and Adolescent Medicine May 10, 2004

Planning ahead: advance emergency contraception for adolescents ▸

Advance provision of emergency contraception (EC) may improve its effectiveness, but the effect on adolescent sexual and contraceptive behaviors is unknown. In this randomized trial conducted in an urban hospital-based clinic, investigators evaluated 301 predominantly minority-group, low-income women aged 15 to 20 who were sexually active and not using long-acting contraception. Participants received advance EC or instruction in how to get EC. Self-reports of sexual behavior were obtained by monthly telephone interviews over 6 months.

At 1 month and 6 months, the advance-EC and control groups did not differ in rates of unprotected intercourse within the past month or of unprotected last intercourse. At 6 months, significantly more advance-EC participants than controls reported condom use in the past month (77% vs. 62%) but not at last intercourse. The advance-EC group reported significantly more EC use than the control group at 1 month (15% vs. 8%) but not at 6 months (8% vs. 6%); the advance group began EC significantly sooner after unprotected intercourse (11.4 hours vs. 21.8 hours). The authors conclude that providing advance EC to adolescents is not associated with more unprotected intercourse or less condom or hormonal contraception use.

Comment ▸

This study adds to the existing literature about advance provision of emergency contraception, with a focus on patients in middle and late adolescence. A high attrition rate and reliance on patient self-reports may limit the value of these findings. Whether the data can be generalized to other groups of young women, including those not yet sexually active, is unknown. The study design allowed for provision of only one course of EC at enrollment, so additional EC had to be procured through an office visit, which may explain why both groups had similar patterns of use by 6 months. How well adolescents will use EC when they need to obtain it from a pharmacy and without associated counseling is a question that remains to be answered.

Susan Jay, MD

Published in Journal Watch Pediatrics and Adolescent Medicine May 10, 2004

Diagnosis and management of AOM ▸

Acute otitis media (AOM) continues to occupy the pages of pediatric journals, and JW Pediatrics and Adolescent Medicine has published many summaries on this topic. Why? An obvious answer is that AOM is the most common illness for which children receive antibiotics. More to the point may be the uncertainty, complexity, and variability that accompany the diagnosis and management of this condition. After many years of struggle, the American Academy of Pediatrics and the American Academy of Family Physicians have released a joint clinical practice guideline for AOM. Interestingly, their recommendations echo those promulgated by “ear experts” in a recent review (see JW Pediatr Adolesc Med Mar 29 2004).

Two important themes emerge:

  • Accurate diagnosis is imperative, and middle-ear effusion (MEE) must be present to make the diagnosis. MEE can be confirmed by pneumatic otoscopy. The clear intent is to improve diagnostic accuracy by regular use of insufflation bulbs or other tests of middle-ear mobility.

  • In practice, certain diagnosis (rapid onset, signs of MEE, signs and symptoms of middle-ear inflammation) is not always possible, and, depending upon the child’s age and the clinician’s confidence in the diagnosis, therapeutic options vary. Observation is a reasonable alternative to antibiotics in children who are older and relatively well.

Specific recommendations include:

  • Children younger than 6 months should receive antibiotics.

  • Children aged 6 months to 2 years should receive antibiotics if diagnosis is certain or disease is severe (moderate-to-severe ear pain or temperature ≥39°C); observation is appropriate if the diagnosis is uncertain and the illness is mild or moderate.

  • Children older than 2 years should receive antibiotics if the diagnosis is certain and the illness is severe; others can be observed with follow-up. Whenever observation is the chosen approach, follow-up must be assured and antibiotics started if necessary.

Pain relief, including acetaminophen, ibuprofen, and topical agents, is an important part of management. Few data are available about the effectiveness of such home remedies as application of heat or cold oil or homeopathic agents. Codeine is effective for moderate or severe pain. I vividly recall a parent calling the day after I had diagnosed AOM in her 4-year-old child and given her a prescription for three doses of codeine. She was profusely thankful that both she and her child had slept through the night. Antibiotics may help to clear the infection, but they do little for pain.

When an antibiotic is prescribed, most children should receive amoxicillin (80 mg to 90 mg/kg/day). Amoxicillin is recommended for its safety, low cost, acceptable taste, and general effectiveness against susceptible and intermediate resistant pneumococci. In children with severe illness and when effectiveness against Haemophilus influenzae and Moraxella catarrhalis is desired, therapy should start with high-dose amoxicillin plus clavulanate (90 mg/kg/day of amoxicillin + 6.4 mg/kg/day of clavulanate).

In children with a history of amoxicillin allergy but no type 1 reaction, cefdinir, cefpodoxime, or cefuroxime can be used. If there is a history of type 1 reaction, azithromycin or clarithromycin are acceptable alternatives.

Regardless of whether the initial decision is for antibiotics or observation, a system for appropriate follow-up must be in place. Symptoms should resolve in most children in 48–72 hours.

Comment ▸

I applaud these guidelines. Withholding antibiotics but providing pain relief is an option, depending on the age and condition of the patient. I would find it difficult to withhold antibiotics from a febrile infant with AOM or consider such a patient to have mild-to-moderate disease. Data consistently show that infants with AOM get better more quickly if they are given antibiotics.

Howard Bauchner, MD

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

Detecting obesity? Use the BMI ▸

Before body-mass index (BMI) tables were available, pediatricians attempting to detect obesity used standardized growth charts for height, weight, and the ratio of height to weight. To determine the efficacy of BMI versus standardized charts and the frequency of use of the two methods, researchers asked members of the North Carolina Pediatrics Society to complete a self-administered, mailed, quasi-experimental survey. All 356 respondents received a clinical vignette describing the same 10-year-old girl. For approximately half of the pediatricians, information about the hypothetical child consisted of height and weight (expressed as raw numbers and percentiles) and standard height and weight charts; the other half received BMI (raw and percentile) and BMI scales. Using a Likert scale, the pediatricians evaluated the child’s degree of obesity and indicated their level of concern about the results of their weight assessment.

Compared with pediatricians who used the height and weight data, those who used the BMI data perceived the girl to be closer to the “too-fat” classification; they also indicated a higher level of concern about present and future medical and psychological consequences. Despite existing recommendations to use BMI measurement to determine overweight, the combined height and weight charts were the screening method most often used by these physicians; visual impression was the next most common method. No specific characteristics identified pediatricians who routinely used BMI measurements.

Comment ▸

Use of body-mass index is not routine practice, even though it is unequivocally the gold standard. We don’t serve our obese or overweight patients well if we rely on visual or weight-percentile screening. Annual plotting of BMI should be standard practice.

F. Bruder Stapleton, MD

Published in Journal Watch Pediatrics and Adolescent Medicine May 10, 2004

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