Journal Club

JOURNAL CLUB
COMMENTARIES BY MICHAEL G. BURKE, MD

Cisapride: Hard facts about hard stools

Cisapride, a prokinetic agent that has an effect on colonic propulsion, is effective in the treatment of children with constipation, according to a recent study. Investigators assigned 36 children from 2 to 16 years old with chronic constipation to 12 weeks of treatment with cisapride or placebo. The treatments were supplemented by Senokot in children who did not have a bowel movement for 48 hours. If the child did not have a bowel movement after taking Senokot along with cisapride or placebo for two days, a daily enema was added to the therapy. Once the child had a bowel movement, the Senokot and enemas were stopped.

At 12 weeks, the cisapride group had significantly increased numbers of spontaneous bowel movements compared with baseline. In addition, they experienced decreases in episodes of fecal soiling and doses of laxatives, and a smaller percentage of them used laxatives or had encopresis. In the placebo group, the number of spontaneous bowel movements did not change significantly, nor did the percentage of subjects using laxatives or having encopresis decline. The number of fecal soiling episodes and number of laxative doses did decrease significantly in the placebo group, however. Overall by the end of the study period, 13 of 17 (76%) patients in the cisapride group had more than three spontaneous bowel movements a week, with no fecal soiling and no use of other laxatives, compared with eight of 19 (42%) in the placebo group. The mean time to response with cisapride treatment was nine weeks (Nurko S et al: J Pediatr 2000;136:35).

Commentary: The authors are not suggesting that cisapride replace diet modification or more benign medications as first-line therapy for chronic constipation. They say that for the most severe cases, however, cisapride may be an option. Before starting this agent, you should be familiar with reports of an association between prolonged QT syndrome and high doses of cisapride.

Editor's note: At press time, the manufacturer of cisapride announced that it will stop marketing the agent because of 341 reports of heart rhythm abnormalities, resulting in 80 deaths.

Kids and homeopathy and naturopathy

Investigators surveyed 42 homeopathic and 23 naturopathic practitioners in Massachusetts to determine practice characteristics and how these practitioners deliver care to pediatric patients. Both groups of practitioners conducted about 25 to 40 patient visits a week, approximately one third of them with children and adolescents. Fewer than half those surveyed had any formal pediatric training, though more than half the homeopaths were licensed medical doctors. Initial patient visits typically lasted more than one hour and cost $140 to $150. Follow-up visits were every four to six weeks and lasted an average of more than 30 minutes. Insurance covered fewer than one third of patient visits, and fewer than half of respondents offered sliding scale payments.

When asked about the number of treatments necessary to determine that naturopathy or homeopathy was not helping a patient, respondents in both groups reported an average of three sessions.

Eight homeopathic practitioners and three naturopathic doctors said they opposed childhood immunizations. The rest reported that they did not make any recommendations on immunization or did not answer this question on the four-page survey.

Faced with a neonate who has a fever, five of 19 nonphysician homeopathic practitioners would immediately refer the patient to a physician, three would treat the child, one would take more history, and one omitted the question. Among naturopathic practitioners, eight of 15 would take additional history, six would refer the patient directly to a physician, and one would treat the child (Lee ACC et al: Arch Pediatr Adolesc Med 2000;154:75).

Commentary: This article and others like it from Harvard's Center for Holistic Pediatric Education and Research are helping to educate all of us about what is "out there" in the world of complementary and alternative medicine. I wonder why these alternative treatments have become so popular with our patients and their parents in the past 10 years. The authors suggest that more contact with the practitioner—initial visits were 75 minutes and follow-up appointments 32 minutes—may be one key. Perhaps these extended visits are replacing the long-gone, leisurely house calls of traditional Western medicine.

Are colicky babies "emotional" toddlers?

Using subjects from an earlier study of colic, Swedish investigators followed 50 formerly colicky infants and 102 controls to determine whether colic has physical or psychosocial complications at 4 years of age. Mothers of toddlers in the study responded to a questionnaire that addressed six areas: eating habits, sleeping habits, behavior, temperament, psychosomatic complaints, and "family climate." Investigators also obtained data on the children's growth and number of hospital stays.

The two groups did not differ significantly in most aspects of everyday behavior, in family climate, or in growth, weight, height, or number of hospital stays. Formerly colicky children were seen as more "emotional" than those in the control group, however. Mothers of formerly colicky children were far more likely than the other mothers to agree that their child "cries easily," "tends to be somewhat emotional," "often fusses and cries," "gets upset easily," and "reacts intensely." Ex-colics, according to their mothers, were much less likely than controls to enjoy meals and to like eating; they refused certain foods more often as well. Formerly colicky children were more likely to have temper tantrums than control children. Finally, formerly colicky children were more likely than controls to complain about stomachaches. No other statistically significant differences were seen between the two groups (Canivet C et al: Acta Paediatr 2000;89:13).  

Commentary: What this study really measured was parents' perceptions of their child's temperament and behavior. I've got to believe that even by the time the child is 4 years old those perceptions are colored by night after night of colicky crying in infancy.

How rare is celiac disease in US?

Authors of a new study suggest that, contrary to common belief, celiac disease is not rare in the United States. Screening for IgA and IgG antigliadin antibodies (AGA­IgG and AGA­IgA) and antiendomysium antibodies (EMA) is useful for identifying patients who should undergo a small intestinal biopsy to make a definitive diagnosis, they say.

Investigators studied 1,200 children between 6 months and 20 years of age who visited a pediatric gastroenterology or pediatric endocrinology clinic. Initial signs and symptoms in study subjects were diarrhea, abdominal pain, insulin-dependent diabetes mellitus, short stature, and failure to thrive. Also included were those with conditions known to be associated with celiac disease, such as Down syndrome, and those who had relatives with biopsy-proven celiac disease. Subjects were screened for AGA­IgG, AGA­IgA, and EMA. Those who tested positive for EMA and those with selective IgA deficiency were advised to undergo an intestinal biopsy. Investigators also recommended intestinal biopsy in individuals in whom celiac disease was strongly suspected on the basis of clinical presentation.

In 21 of the 26 patients who had a small intestinal biopsy (19 of whom were EMA positive), findings were compatible with a diagnosis of celiac disease, a prevalence of one in 57 in this high-risk referral population. Adding the 15 EMA­positive patients who refused a biopsy to this number would yield a prevalence of CD as high as one in 33 (Hill I et al: J Pediatr 2000;136:86).

Commentary: I now keep celiac disease on my list of conditions to consider when I can't figure out what is wrong with a child. The disease may have many presentations, and they may be subtle. If we keep thinking of this diagnosis, we may find that, as these authors suggest, the US prevalence is not as low as once thought.

Predicting severe sickle cell disease

Three easily identifiable manifestations of sickle cell disease that may appear in the first two years of life can help to predict later development of severe disease, according to new findings. Study subjects were 392 infants who were diagnosed with homozygous sickle cell anemia (380 subjects) or sickle cell­b-thalassemia (12 subjects) before the age of 6 months. Investigators recorded comprehensive clinical and laboratory data for these children for a mean of 10 years.

During this period, 70 (18%) of the children had "an adverse outcome": 18 died, 26 had strokes, 17 had frequent pain, and 10 had recurrent acute chest syndrome. Analysis linked these outcomes to the following manifestations of disease during the first 2 years of life: dactylitis (pain and tenderness, with or without swelling, in the hands or feet), severe anemia (hemoglobin level of less than 7g/dL), or leukocytosis in the absence of infection.

Children at lowest risk of severe sickle cell disease by the age of 10 years did not have early dactylitis and had steady-state hemoglobin levels of at least 7g/dL, and below-average leukocyte counts. Such children accounted for 44% of the group. Patients who were most likely to develop severe disease represented only 3% of the group; these children had both early dactylitis and severe anemia or one of these risk factors along with a high leukocyte count. More than half the patients were at medium risk of severe disease (Miller ST et al: N Engl J Med 2000;342:83).

Commentary: This information probably won't help primary care physicians during individual encounters with children with sickle cell. But it may help hematologists as they grapple with selection of patients for new, sometimes high-risk, preventive treatments.

BID dosing of strep tonsillopharyngitis

Investigators conducted a meta-analysis of clinical trials that compare once-a-day (qd) or twice-a-day (bid) dosing of penicillin or amoxicillin with three or four-times-a-day (tid or qid) dosing in the treatment of Group A ß-hemolytic streptococcus tonsillopharyngitis. Of the six studies included in the analysis, four enrolled chiefly pediatric subjects. Results of the analysis suggest that bid dosing of penicillin for 10 days is as effective as more frequent doses. This finding holds true when only pediatric cases are considered and does not vary with total daily dosage. Qd dosing of penicillin, but not of amoxicillin, is associated with a significantly lower cure rate than more frequent dosing. Investigators concluded that the meta-analysis supports current recommendations for bid dosing of penicillin in treating streptococcal tonsillopharyngitis (Lan AJ et al: Pediatrics 2000;105[2]:e19).

Commentary: Think of all the busy parents who no longer have to fret over how to fit a midday dose into their child's schedule. Now that is a medical advance.

Do patients know how to use their EpiPens?

Patients prescribed self-injectable epinephrine and their parents often don't know how to use the delivery devices correctly and don't have the medication readily available, according to a study. Pediatricians, too, frequently are not familiar with the EpiPen, EpiPen Jr., and Ana-Kit, and may fail to review their use with patients.

Investigators surveyed families of food-allergic children with a mean age of 6.4 years, who were prescribed self-injectable epinephrine by a pediatrician or an allergist. Although 86% of the families said they had the device with them "at all times," only 71% had the epinephrine at the study visit. And since 10% of that group had devices beyond the labeled expiration date, only 55% of the 101 families had unexpired epinephrine on hand when the survey was conducted. Of children attending school, 77% had the medication available in their school, but only 81% of this group had ensured that the school knew how and when to give the medication.

In addition to administering the questionnaire, investigators asked participants to demonstrate correct use of the devices with which they were familiar, using a trainer. Only 32% could do so, though 49% of parents recalled that a physician demonstrated use of the device and 80% said they received a verbal explanation. Of the 29 pediatricians enrolled in the study, 18% were familiar with at least one device and were able to demonstrate its use; 24% gave patients written material about use indications (Sicherer SH et al: Pediatrics 2000;105:359).  

Commentary: We attending physicians had a pretty weak performance here: 21% were able to demonstrate use of an EpiPen. For a quick refresher, contact the Food Allergy Network at 800-929-4040 or on the Web at www.foodallergy.org. For $2 plus shipping and handling, this group sells a practice EpiPen (trainer) without needle or medication.

Also of note

Teen tobacco use high and varied. Results of the National Youth Tobacco Survey, conducted in the fall of 1999, shows that more than 10% of middle school students and more than one third of high school students use some type of tobacco. In both middle school and high school, cigarettes were the most popular form of tobacco, followed by cigars. Percentages of high school students who currently use bidis (clove cigarettes) and kreteks (flavored cigarettes), two new forms of imported tobacco now available in the US, are almost as high (5.0% and 5.8%, respectively) as the proportion who use smokeless tobacco (6.6%). Data were collected from 15,058 sixth to 12^th graders, who completed anonymous, self-administered questionnaires about smoking habits (MMWR 2000;49[3]:49).  

Differentiating aseptic and bacterial meningitis. Predominance of polymorphonuclear (PMN) cells in the cerebrospinal fluid (CSF) of children with meningitis contracted during the peak season for enteroviral disease does not by itself suggest that the disease is bacterial rather than aseptic (viral), a new study shows. Investigators reviewed 158 cases of meningitis, 138 of which were aseptic and 20 bacterial. The children were hospitalized from April to October. PMN cells predominated in the CSF of 78 (56.5%) of patients with aseptic disease and the predominance was not limited to the first 24 hours of onset of symptoms, as in some earlier studies. PMN cells predominated in 18 (90%) of those with bacterial disease (Negrini B et al: Pediatrics 2000;105:316).

CLINICAL TIP
It comes right out, by gum!

Here is an effective home remedy you can recommend to remove chewing gum from a child's hair. Just have parents spray Suave Hair Detangler on dry hair in the affected area. The oil base of this product loosens gum so that it can be separated easily from the hair. Detangler also loosens gum stuck to color-fast carpet. The product is available at any drug store.

Frances Yang, DOLos Alamitos, CA

A better use for Q-Tips

As I see it, there is only one use for cotton-tipped applicators (Q-Tips): cleaning toddler training cups. Q-Tips can clean all the nooks in the lids and spouts. They can also fit into the suction-spring mechanism without damaging it and can get rid of juice stains even the dishwasher doesn't remove.

When patients insist on using Q-Tips to dry the ear canal after a shower or swimming, I try to discourage them. Instead, I recommend using a blow-dryer, set on the coolest setting, and held one foot away from the ear.

Sheryl A. Pearl, MDNorth Woodmere, NY

Do you have a Clinical Tip to share with colleagues? Let us know; we'll pay $50 for each item accepted for publication. Tips sent by mail should be addressed to Molly Frederick, Clinical Tips Editor, Contemporary Pediatrics, 5 Paragon Drive, Montvale, NJ 07645-1742. If you submit by E-mail (Molly.Frederick@medec.com), please include your mailing address.

DR. BURKE, Section Editor for Journal Club, is Chairman of the Department of Pediatrics at Saint Agnes Hospital, Baltimore. He is a Contributing Editor for Contemporary Pediatrics.

Marian Freedman. Journal Club.

Contemporary Pediatrics

2000;4:183.