Journal Club: Sleep apnea, sexual abuse testing, and colic

Novel sleep apnea treatment shows promise

Subjects in this study of treatment with nasal insufflation (TNI) were mostly obese boys ranging in age from 5 to 15 years. The children, some of whom had undergone adenotonsillectomy, were recruited from a sleep disorders center where they were recommended treatment with CPAP. Adherence was poor: half of the children reported using CPAP for fewer than four hours each night and for fewer than five days a week.

TNI also improved oxygen stores and decreased arousals, which reduced occurrence of obstructive apnea from 11 to five events per hour. In most children, reduction in the apnea-hypopnea index on TNI was similar to that on CPAP, and comparable in children with and without adenotonsillectomy (McGinley B et al: Pediatrics 2009;124:179).

Commentary
In 2008, Kheirandish-Gozal and colleagues published a study of nightly nasal steroid spray for treatment of children with mild OSA (Pediatrics 2008;122:e149). The current study looks at a different alternative treatment for a small group of children with more severe OSA (eight of 12 required this intervention despite prior adenotonsillectomy). Both interventions offer a "kinder, gentler" therapeutic approach for children along the spectrum of this condition.Consider nasal steroids before turning to surgery. If, after surgery, OSA doesn't improve, try TNI. Still no improvement? It's time for CPAP. -MB

A BETTER WAY FOR DETECTING STIS IN SUSPECTED SEXUAL ABUSE?

Culture, which requires collection of urogenital, oral, and/or anal swabs, is the current forensic standard. Based on results of the current study, investigators suggest that NAATs on urine, with confirmation, are adequate for use as a new forensic standard for diagnosis of these organisms in cases of suspected sexual abuse.

Investigators found that the sensitivity of vaginal culture for C trachomatis was 39% in all children studied and 20% in prepubertal female children (age range of subjects was 0 to 13). In contrast, the sensitivities of urine and vaginal swab NAATs were 100% and 85%, respectively, in all female children for detection of C trachomatis. For N gonorrhoeae detection, culture sensitivity was 75% in all female children and 100% in prepubertal female children, whereas urine and vaginal swab NAAT sensitivities were 88% in all children and 100% in prepubertal female children. None of the male children tested positive for either organism by any test.

Because investigators observed no false positives in their test results, they concluded that positive predictive values for all tests were 100% (Black CM et al: Pediatric Infect Dis J 2009;28:608).

Commentary
If you are the physician evaluating a child for possible sexual abuse, you need to know both the science and the law of this topic. It may be that NAAT is a more sensitive test for sexually transmitted infections (STIs) in sexually abused children. But until the legal system in your community views these tests as valid, you may need both culture and a polymerase chain reaction assay. The authors point out that nucleic acid screening of urine eliminates the need for more traumatic urogenital swabs. NAATs have not been validated for use on rectal or pharyngeal specimens, however. In cases of possible sexual abuse, the authors (and the 2009 AAP Red Book Committee) also recommend confirmation of positive urine NAATs with a second study that assays other nucleic acids chains from the same organism. -MB