Tuesday, April 25, 2017

Towards Lessening Neonatal Pain

Here's another study attempting to guide us towards improving newborns' comfort with medical procedures, this time looking at the type of device used to collect blood during heelstick.

Source: Britto C, Jasmine, P N Rao S. (published online ahead of print January 21, 2017). J Trop Pediatr.  doi:10.1093/tropej/fmw093. See AAP Grand Rounds commentary by Dr. Mike Dubik (subscription required).

Tuesday, April 18, 2017

The Bigger the Kid, the Bigger the Curve: Issues in Adolescent Scoliosis

The conclusions of this retrospective case series aren't terribly surprising, but raise some important considerations for front line physicians.

Source: Goodbody CM, Sankar WN, and Flynn JM. Presentation of adolescent idiopathic scoliosis: the bigger the kid, the bigger the curve. J Pediatr Orthop. 2017;37(1):41–46. doi:10.1097/BPO.0000000000000580. See AAP Grand Rounds commentary by Dr. William Hennrikus (subscription required).

Tuesday, April 11, 2017

Tonsillectomy: The Debate Goes On

I knew from the title of this article that we wouldn't have an answer to the question of tonsillectomy for recurrent throat infections. Read on.

Source: Morad A, Sathe NA, Francis DO, et al. Tonsillectomy versus watchful waiting for recurrent throat infection: a systematic review. Pediatrics.2017; 139:e20163490. doi:10.1542/peds.2016-3490. See AAP Grand Rounds commentary by Dr. Carrie Phillipi (subscription required).


The clue in the title is that this studied is labelled a systematic review, without mentioning meta-analysis. Meta-analysis is the process of applying statistical tests to studies collected in a systemic review to provide a combined summary statistic of the benefits (or lack thereof) of a particular intervention. The subject of tonsillectomy versus watchful waiting should lend itself well to a meta-analysis, but in this case the collected studies were too heterogeneous to be combined for analysis. In short, even though the studies were looking at approximately the same problems and interventions, they were too different to combine in one analysis: you can't really compare apples and oranges. 

Still, the study bears at least a glance because it highlights the problems inherent in any systematic review of the literature, plus readers can learn about the Agency for Healthcare Research and Quality's comparative effectiveness review of tonsillectomy in children

The systematic review researchers screened 9608 literature citations on the subject and ended up with only 7 studies that met the investigators' predetermined criteria for inclusion (which included randomized controlled trials as well as prospective and retrospective cohort studies) and low to moderate risk of bias. Furthermore, they felt the 7 studies were too heterogeneous in how outcomes were reported to combine in a single meta-analysis. What they could report from these studies, however, was a suggestion in the tonsillectomy group of less throat infection episodes, healthcare visits, and school episodes over a 12-month period, but lack of evidence showing persistence of any benefits over longer time periods. There were no demonstrated differences in quality of life analyses in the studies that looked at this outcome. In part, the lack of long-term benefit demonstration may be due to very high drop-out rates of study participants over time. Also, the researchers felt that all of their conclusions had relatively low degrees of strength of evidence, with only a moderate strength of evidence rating for 1 conclusion of less sore throats/throat infections in the less than 12 month follow up period. 

As the investigators point out, not all sore throats are created equal. How many of these patients had recurrent streptococcal pharyngitis, which is in itself difficult to diagnose due to high rates of asymptomatic carriage of group A streptococcus in children? How many with recurrent sore throat had the PFAPA (periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis) syndrome, for which tonsillectomy may very well be effective? These are just a few of the "apples and oranges" that complicate study interpretation. 

So, what do we do now? First, I tried to estimate a number needed to treat from 1 of the randomized controlled studies included in the review, and came up with the tonsillectomy group having 1.68 fewer episodes of sore throat in the 12 month period following the procedure. The NNT for this number is 60, meaning that 60 children with recurrent throat infections would need to undergo tonsillectomy for 1 additional child to achieve that lower sore throat rate. That's not a very good yield in my book, given that tonsillectomy is not an entirely benign procedure, but others may differ on my assessment. 

I liked the authors' wording for how to manage until better information is available, so I'll repeat it here: "...individual decision-making needs to balance the benefits of reducing illness-related outcomes (including missing school and work) with the risks associated with surgery. Caregivers and providers may wish to consider the potential benefits and drawbacks of attempting to manage children's illnesses for a period of time to see if they outgrow the propensity for infection to avoid surgery." Also, clinicians should note that at least 1 well-respected practice guideline has recommended against tonsillectomy solely to reduce the frequency of streptococcal pharyngitis. 

Tuesday, April 4, 2017

Medical Treatment of PDA in Premature Infants - Case Closed, or Just Murkier?

Treatment of patent ductus arteriosus (PDA) is pretty common in neonatal intensive care units across the world. Wending my way through this new study again reminded me that seemingly straightforward disease outcomes can be much more complicated on closer examination.

Source: El-Mashad AE, El-Mahdy H, El Amrousy D, et al. Comparative study of the efficacy and safety of paracetamol, ibuprofen, and indomethacin in closure of patent ductus arteriosus in preterm neonates. Eur J Pediatr. 2017;176(2):233-240; doi:10.1007/s00431-016-2830-7. See AAP Grand Rounds commentary by Dr. Jonathan Mintzer (subscription required).

Saturday, April 1, 2017

No Fooling, Another Month of Evidence eMended!

Welcome to April's edition of Evidence eMended. This month's issue of AAP Grand Rounds has plenty of choice articles to sample, including the frustrating (for both doctors and patients) diagnosis of irritable bowel syndrome, some thoughts on compression-only CPR, predictors of recovery after concussion, and some not-so-great news about recovery of brain function following cardiac arrest in children.

This month, I've again chosen 4 articles to expand upon: a study of the value of tonsillectomy in children with recurrent throat infections, choice of instrument to lessen pain in newborn infants undergoing blood draw by heel prick, scoliosis in obese adolescents, and perhaps safer medical management of patent ductus arteriosus in premature infants.

Join me every Tuesday for some (I hope) thoughtful consideration and fun!

Tuesday, March 28, 2017

Risks Multiply When Children Are Critically Ill

Prospective observational studies don't directly change practice, but rather help point out problems that require new approaches. This is one such study, but actually the best part about it, better than the article and the accompanying journal editorial, is Dr. Singer's AAP Grand Rounds commentary!

Source: Kaddourah A, Basu RK, Bagshaw SM, et al. Epidemiology of acute kidney injury in
critically ill children and young adults. N Engl J Med. 2017;376(1):11-20; doi:10.1056/NEJMoa1611391. See AAP Grand Rounds commentary by Dr. Pamela Singer (subscription required).

Tuesday, March 21, 2017

Preventing Migraines in Children With Placebo

It should come as no surprise to regular readers of Evidence eMended that the placebo effect is very real, and it can be dramatic particularly in disorders with prominent neuropsychiatric features. Should we now provide a sugar pill to prevent migraines in children?

Source: Powers SW, Coffey CS, Chamberlin LA, et al. Trial of amitriptyline, topiramate, and placebo for pediatric migraine. N Engl J Med. 2017;376(2):115-124; doi:10.1056/NEJMoa1610384. See AAP Grand Rounds commentary by Dr. David Urion (subscription required).

Tuesday, March 14, 2017

Oral Versus Intravenous Antibiotics: Do the Bugs Know (or Care)?

What's so magical about the route of antibiotic administration? I can understand how lay persons may perceive parenteral antibiotics as "stronger," but sometimes I think medical personnel fall victim to the same misconception. Here's a study that suggests step-down to oral therapy is a better plan for children with pneumonia complicated by pleural effusion, although I think the authors' conclusions require evidence beyond just this one study's results.

Source: Shah SS, Srivastava R, Wu S, et al. Intravenous versus oral antibiotics
for postdischarge treatment of complicated pneumonia. Pediatrics. 2016;138(6):e20161692; doi:10.1542/peds.2016-1692. See AAP Grand Rounds commentary by Dr. Daniel Lesser (subscription required).

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