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Selections from Journal Watch Pediatrics and Adolescent Medicine Copyright © 2005 Massachusetts Medical Society. All rights reserved.

Acne treatments: cheaper may be better ▸

To determine whether the increasing antibiotic resistance of propionibacteria affects the efficacy of current therapeutic agents for inflammatory facial acne, investigators compared five different regimens in 649 patients with mild-to-moderate acne. Patients were randomized to receive:

  • twice-daily oral oxytetracycline with topical placebo,

  • daily oral minocycline with topical placebo,

  • twice-daily topical 5% benzoyl peroxide (bp) with oral placebo,

  • twice-daily topical 5% bp plus 3% erythromycin with oral placebo, or

  • topical erythromycin in the AM and bp in the PM with oral placebo.

At least moderate improvement was seen with all the regimens. There was little significant difference among treatment groups, although those using erythromycin had the greatest improvement. In all groups, most improvement occurred during the first 6 weeks of treatment. Tetracycline resistance affected the efficacy of the tetracycline regimens, but erythromycin resistance did not impair the efficacy of erythromycin ointments. The most cost-effective treatments were topical bp alone and bp alternating with erythromycin, although topical bp alone caused the most skin irritation.

Comment ▸

If antibiotics are useful for acne in an era of increasing propionibacterial antibiotic resistance, topical erythromycin appears to be the best bet. Topical 5% benzoyl peroxide is the most cost-effective, if it can be tolerated. The authors note a need to study the topical retinoids in the same rigorous fashion.

F. Bruder Stapleton, MD

Published in Journal Watch Pediatrics and Adolescent Medicine January 14, 2005

Mild persistent asthma and inhaled corticosteroids: is daily therapy really necessary? ▸

Although NIH guidelines recommend daily inhaled corticosteroids as the mainstay of treatment for mild persistent asthma, patient adherence is variable. In this double-blind trial, researchers randomized 225 adults with mild persistent asthma to receive twice-daily inhaled budesonide and oral placebo tablets, twice-daily oral zafirlukast and inhaled placebo, or twice-daily oral and inhaled placebo (intermittent treatment). Patients were instructed to take budesonide twice daily for 10 days or prednisone for 5 days if their asthma symptoms worsened.

After 1 year of treatment, the mean change from baseline in morning peak expiratory flow (the primary outcome) and the proportion of patients with asthma exacerbations were similar among the three groups. Post-bronchodilator FEV1 and quality-of-life scores also were similar among groups. However, numerous outcome measures favored daily budesonide, including improvement in pre-bronchodilator FEV1, bronchial reactivity, percentage of eosinophils in sputum, exhaled nitric oxide levels, asthma-control scores, and the number of symptom-free days during a 2-week period. The greater number of symptom-free days in the budesonide group translates to 26 additional symptom-free days per year.

Comment ▸

Although this study was conducted in adults, an editorialist notes that it is relevant to children: Symptom-driven treatment would minimize lifetime exposure to corticosteroids. However, if regular treatment with inhaled corticosteroids reduces the risk for developing more severe asthma, then their use is appropriate. I find it difficult to convince parents that their children with mild asthma need daily inhaled corticosteroid treatment. Thus, this study is catching up with how a lot of children with mild asthma are actually being treated. The unanswered question is whether we must wait for data in children before officially adopting the symptom-driven treatment approach.

Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine May 6, 2005

Diagnosing celiac disease in children ▸

Celiac disease now is recognized to be more common than we once thought. To examine whether serum antibody tests can replace small-bowel biopsies for diagnosis of celiac disease, investigators at a children’s hospital in Canada retrospectively compared the results of quantitative IgA tissue transglutaminase (TTG) antibody tests (INOVA Diagnostics, San Diego, CA) and small-bowel biopsies in 103 children (mean age, 8.7 years) who had been referred for evaluation of possible celiac disease. Fifty-eight children had positive biopsy results.

Of 49 children with TTG levels higher than 100 U, 48 had positive biopsies, and only 1 child had a negative biopsy. Of 38 children with TTG levels lower than 20 U, only 3 had positive biopsies, and 35 had negative biopsies. Biopsy results varied for children with TTG levels between 20 U and 100 U.

Comment ▸

Based on these data, the authors recommend that children with TTG levels higher than 100 U first try gluten-free diets and undergo biopsies only if they do not improve with diet changes alone. Children with TTG levels lower than 100 U should undergo biopsies. The authors also suggest that clinicians search for other possible diagnoses in children with TTG levels lower than 20 U. These suggestions make sense, although patient populations in the primary care setting often are different from those in specialty clinics. In addition, appropriate cutoffs for TTG values will depend on the particular assay that is used.

Howard Bauchner, MD

Published in Journal Watch May 13, 2005

How to successfully treat childhood constipation ▸

Constipation accounts for 3% of general pediatric visits and up to 30% of pediatric gastroenterology visits, with as many as 30% of cases becoming chronic. To assess the effectiveness of constipation treatments, researchers prospectively studied 110 children (age range, 2–7 years) who presented to 26 pediatric caregivers.

Constipation was defined as fewer than seven bowel movements over a 2-week period with no medication usage as a precipitating cause. Parents completed diaries before treatment and again after 2 months of treatment; they recorded the frequency and nature of bowel movements, associated pain, and treatment used. Investigators examined medical records to track behavioral therapy; dietary changes; fiber usage; colonic evacuation by cathartics, suppositories, or enemas; and use of laxatives or stool softeners. Interventions were rated on an “aggressiveness scale”.

After 2 months, 63% of the children were no longer constipated. Children treated with some form of disimpaction (e.g., enemas or suppositories) along with a laxative were more likely to respond than children who received other treatments. Among the 87% of patients who received a laxative or stool softener, response was independent of laxative type or dosage. Behavioral interventions (e.g., establishing regular toilet times) did not improve response rate. Response was also independent of sex, age, age when toilet trained, duration of constipation, stool size, pain, or family history. Greater bowel-movement frequency at baseline predicted a positive treatment response.

Comment ▸

This evidence suggests that constipation becomes chronic in a significant number of children and that an aggressive approach, combining daily laxatives with a disimpaction procedure, gives the best results. One possible limitation of this study is the rather broad definition of constipation, which may have led to the inclusion of some children with essentially normal bowel habits.

Harlan R. Gephart, MD

Published in Journal Watch Pediatrics and Adolescent Medicine May 6, 2005

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