Journal Club

JOURNAL CLUB

COMMENTARIES BY MICHAEL G. BURKE, MD

Doctors influence decision to breastfeed

The opinion of a woman's doctor as to whether she should breastfeed orformula feed her infant strongly influences her feeding intentions, accordingto interviews with 441 African-American women receiving care at prenatalclinics associated with WIC (Special Supplemental Nutrition Program forWomen, Infants, and Children). Other strong influences on feeding decisionsare the woman's previous breastfeeding experience and the opinion of femalerelatives and the baby's father. Friends and other relatives are not influential,and while expectant mothers are swayed by their mothers, their opinionscan be overridden by those of the baby's father. Women who intend to breastfeedwere more likely than those who expected to use formula to be older, tohave higher levels of education, to be married, to have breastfed previously,and to be living alone.

Women who said that their doctor thought they should breastfeed weremuch more likely to intend to breastfeed than other women. Of those whointended to breastfeed, 41.9% indicated that their doctors thought theyshould, compared with only 19.2% of women who intended to formula feed.In addition, about 74% of women who intended to use formula said that theyeither did not know their doctor's opinion on feeding practices or thatthe doctor did not care how the infant was fed; in contrast, only 58% ofwomen who intended to breastfeed said this about their doctors (BentleyME et al: J Hum Lact 1999;15[1]:27).

Commentary: It's nice to hear that patients sometimes considertheir doctors' opinions when they make health-care decisions. This shouldencourage us, as well as our colleagues in obstetrics, to make our opinionsabout breastfeeding known.

Outpatient therapy for infants with UTIs

Do young, febrile children with urinary tract infections need to be treatedwith intravenous antimicrobials? Not according to a new study, which showsthat outpatient therapy with a third-generation cephalosporin may be aseffective as the standard hospital treatment.

Investigators compared the efficacy of oral and intravenous therapy in306 children 1 to 24 months old who had fever and urinary tract infection.Children assigned to intravenous treatment were hospitalized and receivedcefotaxime (200 mg/kg/d in four divided doses) for three days or until theyhad no fever for 24 hours, whichever was longer. Later these children weregiven oral cefixime (8 mg/kg once daily) to complete a 14-day course, followedby prophylaxis with cefixime (4 mg/kg once daily) for two weeks. Childrenassigned to oral treatment received cefixime (8 mg/kg once daily) for 14days; they had a double dose the first day. After treatment these childrenwere placed on the same cefixime prophylaxis as children who had intravenoustreatment.

Results were similar in both groups. Within 24 hours of starting antimicrobialtherapy, all 291 children whose urine was cultured had sterile cultures.The two groups also became afebrile at almost identical times. As to long-termoutcomes, symptomatic reinfections developed in 4.6% of children treatedorally compared with 7.2% of those who were treated intravenously. No significantdifference was seen between treatment groups in the incidence of new renalscarring or in the extent of scarring. Renal scarring was much more likelyin children with vesicoureteral reflux than in those without it. Finally,the mean costs of treatment were at least twice as high for children treatedintravenously as for those treated orally (Hoberman A et al: Pediatrics1999;104[1]:79).

Commentary: This study is well designed and carefully done. Ihave only two concerns about it. First, treatment was started when urinarytract infection was suspected based on an "enhanced urinalysis,"a technique that the Pittsburgh group (which several of the authors represent)has used with great success, but which may be difficult to institute inevery office and emergency room lab. Patients were later excluded if theirurine culture was negative; in the office, decisions must be based onlyon the information available at the time. Second, while the study was of306 children between 1 and 24 months old, only 13 of the subjects were between4 and 7 weeks of age. I am hesitant to back away from conservative treatmentof these smallest children based on such a small sample. Despite these concerns,this study may change how we handle most children with fever and urinarytract infection--another step away from inpatient practice of pediatrics.

Also of note

Information calms parents' fears about febrile seizures. Investigatorsin the Netherlands surveyed parents whose children had experienced febrileseizures about their perceptions and beliefs about fever and febrile seizures.Respondents to the questionnaire received oral information about fever andfebrile seizures as well as a leaflet that addressed the prevalence of febrileseizures, the risk of recurrence, the benign nature of febrile seizuresin general, and a description of the typical attack. At the time of theirchild's first febrile seizure, 47% of respondents thought that their childwas dying. After education efforts, 45% of the 181 respondents continuedto be "afraid" or "very afraid" of fever. Of the 79(44%) parents who thought that febrile seizures were not harmful, abouthalf said their belief was based on the reassuring information they hadreceived (van Stuijvenberg M et al: Acta Paediatr 1999;88:618).

Hyperthyroidism may be associated with hyperkinetic behavior. Developmentallearning disabilities (DLDs) often are associated with hyperkinetic behavior.Now a report on three children documents an association between subclinicalhyperthyroidism and DLDs in children with hyperkinetic behavior . The threechildren, who had different types of DLD, responded to treatment with antithyroiddrugs, and their hyperactivity improved significantly--facilitating thespeech therapy they required. In a 7-year-old whose learning disabilitywas largely confined to reading and writing, a serum hormone assay usingradioimmunoassay revealed abnormal levels of thyroid hormones. Treatmentwith neomercazole resulted in good control of the child's hyperkinetic behaviorwithin one month. The child's attention span improved, and he cooperatedwith the speech therapist. When the neomercazole was tapered and stoppedwithin three months, the hyperkinetic behavior returned and the hormonelevels rose. When neomercazole was reinstated, the hyperkinetic behaviordecreased. A hyperactive 2-year-old with a history of poor language developmentalso was found to have hyperthyroidism. Therapy with neomercazole significantlyreduced the hyperkinetic behavior, and his language development improved.Finally, a hyperactive 5-year-old with delayed speech and language milestonesand abnormal thyroid function tests also responded well to neomercazole.None of these children showed any classic signs of thyrotoxicosis (SureshPA et al: Pediatr Neurol 1999;20:192).

Marian Freedman. Pediatric Journal Club. Contemporary Pediatrics 1999;9:167.