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

Reflux in infants: new data, old treatments ▸

Most infants outgrow gastroesophageal reflux (GER). However, some infants (and their families) need an active approach to this normal developmental phenomenon. A recent Cochrane Collaboration review focused on randomized clinical trials that evaluated thickened feeds, positional changes, and metoclopramide for GER treatment in infants aged 1 month to 2 years. The authors identified 20 trials involving 771 infants (8 evaluating thickened feeds; 5, positioning; 7, metoclopramide), but differences in trial design made comparison difficult. Most of the reported findings are based on a few studies.

Thickened feeds significantly reduced GER severity scores (2 studies) and frequency of emesis (3 studies), but had no effect on the reflux index (RI; percent of time that pH is <4.0; 2 studies). Elevating the head of the bed (5 studies) had no effect on esophageal pH, the primary outcome measure. Metoclopramide significantly improved daily symptoms (2 studies) and the RI score (2 studies), but had no effect on the number of reflux episodes lasting more than 5 minutes or the number of low-pH episodes (2 studies).

Comment ▸

These results are not consistent with the conclusions of the North American Society for Pediatric Gastroenterology and Nutrition, which found no proven benefit from metoclopramide (see JW Pediatr Adolesc Med Nov 10, 2003). Most of my GI colleagues are not big fans of metoclopramide, although I find it to work well about half the time, and its use is supported by this Cochrane review. Most primary care physicians start with reassurance that reflux resolves with time, particularly if the infant is growing well. If a more active approach is necessary, thickened feeds, metoclopramide, and proton-pump inhibitors are all reasonable treatments.

Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine December 13, 2004

Repetitive movements are not seen only in children with autism ▸

Repetitive movements of arms, hands, and other parts of the body (complex motor stereotypies) are often seen in children with autism spectrum disorders, mental retardation, or sensory deprivation. These movements can take the form of hand flapping, arm or body shaking, hand clenching, and body stiffening. When found in healthy infants and children, they may cause concern. To describe the clinical course of this condition, researchers analyzed data on 40 typically developing children (age range, 9 months to 17 years; 63% male) with persistent repetitive movements – defined as involuntary, patterned, coordinated, and repetitive rhythmic movements associated with a trigger and usually performed for a few seconds to minutes many times each day.

The onset of repetitive movements was before age 3 (mean age, 1.1 years) in 90% of the children. Episodes occurred at least once daily in 90%; excitement was the trigger in 70%. Movements stopped in 98% of the children in response to a cue (e.g., calling his or her name). A family history of stereotypies was identified in 25% of the children, ADHD in 10%, and a mood or anxiety disorder in 38%. Over 50% had had symptoms for more than 5 years. Treatment was limited to the associated conditions. Movements resolved in 5% of the children, improved in 33%, were unchanged in 50%, and worsened in 13%.

Comment ▸

This study reminds us that repetitive arm, hand, and body movements occasionally occur in typically developing children and that not all repetitive movements are associated with autism. The authors provide a table to help clinicians differentiate motor tics from stereotypies.

Martin T. Stein, MD

Published in Journal Watch Pediatrics and Adolescent Medicine December 13, 2004

Can ultrasound aid the diagnosis of appendicitis? ▸

Appendicitis can be a difficult clinical diagnosis, and physicians turn to technology to reduce the number of unnecessary appendectomies. In this prospective study, two Japanese surgeons report 21 months’ experience using ultrasound (US) to diagnose acute appendicitis in children aged 15 years and younger.

Overall, 165 children were evaluated for abdominal pain (86 girls; median age, 10.6 years; 4 obese). Disease severity was graded; patients with grade I (early) or II (suppurative) appendicitis received conservative treatment (antibiotic therapy). Patients with grade III (severe suppurative/gangrenous) or IV (gangrenous) appendicitis had surgery.

US findings were positive in 93 patients (7, grade I; 17, grade II; 41, grade III; and 28, grade IV). Of the 24 patients in grades I and II, 22 were treated conservatively as planned; 2 underwent appendectomy because their parents refused conservative treatment. In the 22 treated conservatively, symptoms resolved in a mean of 4.2 days, but 6 patients had recurrence and surgery 1 to 13 months later. All 69 patients with grade III or IV disease had surgery, and no normal appendices were removed. On pathologic exam, 15 appendices were seen to be perforated.

Thirty-four patients had clinical diagnoses of appendicitis (presence of both rebound tenderness and muscle guarding). Three of these patients avoided surgery as a result of correct negative US findings, and eight patients without a clinical diagnosis underwent appendectomies after correct positive findings. The authors conclude that US identified patients who required surgery and permitted conservative treatment for mild appendicitis.

Comment ▸

I discussed this paper with a pediatric surgeon who observed that the success of ultrasound diagnosis of appendicitis is highly operator dependent. The authors acknowledge this point, and they performed their own US examinations in this study. They note that US is difficult in obese patients, which may limit its use in this country. It is not yet time to make US the gold standard for diagnosing appendicitis. I was intrigued by the conservative treatment of mild appendicitis but would like to see more data before adopting this nonoperative approach.

William P. Kanto, Jr., MD

Published in Journal Watch Pediatrics and Adolescent Medicine December 13, 2004

Appendicitis: problems inside and outside the hospital ▸

To investigate factors related to negative appendectomy and appendiceal rupture, the most frequent complications in suspected appendicitis, researchers retrospectively reviewed 24,411 appendectomies performed in children (age range, 5 to 17 years) at 36 children’s hospitals.

The median negative appendectomy rate was 3% (range, 1%–12%); it was lower in the 5- to 12-year age group than in the 13- to 17-year age group, and it was unrelated to health insurance or race. Girls had a 58% greater risk for a negative appendectomy than boys, and older girls had a greater risk than younger girls. For every 1000 appendectomies performed at any hospital, the rate of negative appendectomies decreased by 50%. The median appendiceal rupture rate was 35% (range, 22%-62%). A greater risk for appendiceal rupture was found in Asian children and in children with public health insurance. Hospital volume of appendectomy was not related to rupture. There was no relation between the rate of negative appendectomy and the rate of appendiceal rupture.

Comment ▸

This fascinating analysis points out the need to improve early diagnosis and access to medical care before presentation at the hospital. The rate of appendiceal rupture is unacceptable and cannot be addressed by improved hospital performance. The rate of negative appendectomy is affected by gynecologic symptoms in adolescent girls, but this rate can and should be reduced by referring children who may need appendectomy to hospitals with high volumes of this procedure.

F. Bruder Stapleton, MD

Published in Journal Watch Pediatrics and Adolescent Medicine December 13, 2004

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