Tuesday, November 18, 2014

Adenotonsillectomy for Sleep Apnea: A Mixed Bag

Congratulations to the investigators in the Childhood Adenotonsillectomy Trial (CHAT) group. We now have a pretty good idea of risks and benefits of early adenotonsillectomy (AT) versus watchful waiting (WW) for children with mild to moderate obstructive sleep apnea.

Source: Katz ES, Moore RH, Rosen CL, et al. Growth after adenotonsillectomy for obstructive sleep apnea: an RCT. Pediatrics. 2014;134(2):282-289; doi:10.1542/peds.2014-0591. See AAP Grand Rounds commentary by Dr. Daniel Lesser (subscription required). 

PICO Question: Among children with obstructive sleep apnea syndrome aged 5.0-9.9 years, does treatment with adenotonsillectomy compared to watchful waiting result in increased weight gain?
Question type: Intervention
Study design: Randomized controlled

Tuesday, November 11, 2014

Mothers Receiving Epilepsy Medication: Is Breastfeeding Safe?

This study addresses a very important, and difficult to answer, question about safety of breastfeeding for infants whose mothers receive anti-epileptic drugs (AEDs). The answer still isn't clear cut, but this study offers a bit of reassurance plus some instructive points about interpreting prospective observational studies.

Source: Meador KJ, Baker GA, Browning N, et al for the Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) Study Group. Breastfeeding in children of women taking antiepileptic drugs: cognitive outcomes at age 6 years. JAMA Pediatr. 2014;168(8):729-736; doi:10.1001/jamapediatrics.2014.118. See AAP Grand Rounds commentary by Dr. Lawrence Noble (subscription required).

PICO Question: Among children of women taking antiepileptic drugs, are cognitive outcomes at age 6 years different between those who were breastfed and those who were not?
Question type: Causation
Study design: Prospective observational

Tuesday, November 4, 2014

The Febrile Infant: More Data, No Closer to a Definitive Solution

Management of the febrile infant in the first few months of life strikes me as a throwback to the mid-20th century. It frustrates me to see so many infants subjected to tests and treatments when only a few ultimately need intervention. We need a breakthrough, but a retrospective study design won't get us there very fast.

Source: Biondi EA, Mischler M, Jerardi KE, et al. Blood culture time to positivity in febrile infants with bacteremia. JAMA Pediatr.2014;168(9):844-849; doi:10.1001/jamapediatrics.2014.895. See AAP Grand Rounds commentary by Dr. Matthew Garber (subscription required).

PICO Question: Among febrile bacteremic infants younger than 91 days of age on a general inpatient unit, what is the blood culture time to positivity and what proportion of positive blood cultures become positive after 24 hours?
Question type: Descriptive

Study design: Retrospective cohort

Saturday, November 1, 2014

Happy November

...and I hope everyone had a Happy Halloween, with many more treats than tricks. Speaking of treats, November's AAP Grand Rounds is full of them, with commentary on optimal timing for cleft palate repair, impact of the 2003 Pediatric Traumatic Brain Injury guidelines (spoiler alert, it's favorable), functionality following scoliosis surgery, and more.

In the coming 4 weeks, I'll be adding my thoughts on how paying attention to a blood culture analyzer might shorten length of hospital stay for febrile infants, outcomes in infants of breastfeeding moms receiving antiepileptics, growth after sleep apnea surgery, and a major brouhaha about black box warnings and antidepressants.

Tuesday, October 28, 2014

Ethics and Evidence-Based Medicine: A Natural Pairing

It's not too often (maybe never?) that I'm exploring Immanuel Kant for this blog. I learned a lot from this Back Page article in the October issue of AAP Grand Rounds.

Back Page commentary by Dr. Felipe Vizcarrondo (subscription required). Refer to Salter EK. Resisting the siren call of individualism in pediatric decision-making and the role of relational interests. J Med Philos 2014; 39:26-40. doi:10.1093/jmp/jht060.

Tuesday, October 21, 2014

Osteopathic Treatment for Ear Infection: Expanding the Evidence Base

It's extremely difficult to show conclusively that any treatment helps a condition with a very high spontaneous resolution rate, and acute otitis media is such an example. This study represents a first step towards resolving the question of whether osteopathic manipulation offers some benefit.

Source: Steele KM, Carreiro, JE, Viola JH, et al. Effect of osteopathic manipulative treatment on middle ear effusion following acute otitis media in young children: a pilot study. J Am Osteopath Assoc. 2014;114(6):436-447; doi:10.7556/jaoa.2014.094. See AAP Grand Rounds commentary by Dr. Robert Lee (subscription required). 

PICO Question: Among young children with acute otitis media and an abnormal tympanogram, does osteopathic manipulative treatment hasten resolution of middle ear effusion?
Question type: Intervention

Study design: Randomized controlled 

Tuesday, October 14, 2014

Another Failed Attempt to Legislate Healthy Fast Food?

I think I had forgotten about San Francisco's 2010 ordinance to push restaurants to set healthy nutrition standards for children's meals. Here's an interesting study with a design we don't often cover in these pages.

Source: Otten JJ, Saelens BE, Kapphahn KI, et al. Impact of San Francisco’s toy ordinance on restaurants and children’s food purchases. 2011-2012. Prev Chronic Dis. 2014; 11:E122. doi:10.5888/pcd11.140026. See AAP Grand Rounds commentary by Dr. Shelley Springer (subscription required).

PICO Question: Among children eating at fast food restaurants, do nutritional regulations positively impact their nutrition?
Question type: Intervention
Study design: Pre-post survey

Tuesday, October 7, 2014

Parasites: They're Not All Bad

Most clinicians I think would prefer to forget those agonizing parasite quizzes in medical school. In the US most primary care providers only deal with a few parasitic diseases at most, and it's hard to remember details for the others. So, I suspect receipt of a positive ova and parasite exam for Dientamoeba fragilis would send you scurrying to the books. Unfortunately, it's not always that simple.

Source: Röser D, Simonsen J, Stensvold CR, et al. Metronidazole therapy for treating dientamoebiasis in children is not associated with better clinical outcomes: a randomized, double-blinded and placebo-controlled clinical trial. Clin Infect Dis. 2014;58(12):1692-1699; doi:10.1093/cid/ciu188. See AAP Grand Rounds commentary by Dr. Rebecca Brady (subscription required).

PICO Question: Among children with Dientamoeba fragilis infection and chronic gastrointestinal symptoms, does metronidazole therapy improve clinical outcomes?
Question type: Intervention
Study design: Randomized controlled

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