Pearls from the trenches

In my many years as a pediatrician, I have identified a number of “pearls,” or words of wisdom, that can help in the clinical setting. Some of these pearls are practical, but relatively little known, tips. Some of them are common but erroneous medical beliefs held by parents that must be addressed in order for families to follow through on a treatment plan or have faith that their pediatrician knows what he or she is doing. Lastly, some pearls are erroneous (or, at least, unsubstantiated) beliefs held by pediatricians themselves. In this first of several articles, I will review some of these unknown truths and known falsehoods.

Support for the statements that follow will be of various strengths. Although much of early medical school teaching is lost over time to the pediatrician without adverse events (I know I have never had to rely on a knowledge of the Krebs cycle to provide good care in the outpatient setting), some truths consistently remain vital, particularly in microbiology, pharmacology, genetics, and probability theory. Thus, some of the material presented here will be derived from these first principles. Other comments will be backed by evidence-based medicine; still others by common sense (which is a useful, but not infallible, justification); and some simply by practical experience. I believe them all to be true, and they arise with some regularity in the office. These “pearls” will be grouped into categories for easy retrieval.

Strep throat

1. A red throat with tonsillar exudates, fever, swollen glands, and palatal enanthem may be strep, but their predictive value is low.¹ Throw in a scarlatiniform rash and you are almost certainly dealing with strep.

2. Instructions that come with a rapid strep test may say that any red line is positive. Do not believe this. Perform a conventional culture on those weak positives and see how they really stack up. We did this in the office and no longer call them positive. We may treat presumptively if the clinical picture is suggestive, but we will send out a culture and stop treatment if it is negative.

3. Strep has an incubation period of 2 to 5 days.² If your patient’s sister had it 2 weeks ago, he did not get it from her.

4. Choose penicillin² for kids with strep who can swallow pills.

5. Amoxicillin can be given once a day for 10 days, at a dose of 50 mg/kg up to 1 gram per day.²

6. Azithromyin is not a good choice for strep. If you do use it (because of allergies), the Red Book (2012) recommends 12 mg/kg the first day, then 6 mg/kg/d the next 4 days.² However, the 2014 PREP Self-Assessment recommends 12 mg/kg/d for 5 days.³ It is not clear why there is a discrepancy, but the second seems more evidence based and would be my choice. In either case, these doses are higher than standard for other infections. If the family wants something for strep for the child who hates medicine, 1 injection of penicillin G benzathine (Bicillin L-A) is a good choice; Bicillin C-R also can be used.²

7. Conjunctivitis and a sore throat are not strep. A sore throat with lots of coughing is unlikely to be strep. Laryngitis is not from strep. Pharyngotonsillitis in children aged younger than 3 years is not likely to be strep,² and they are not as risk of rheumatic fever in any case. Do not get throat cultures on these children; you are just asking for false positives.

8. A rapid strep test can stay positive for some time because it reacts with antigen, which can be present even if the bacteria have been killed by an antibiotic. My informal observation suggests that a positive rapid strep test can remain so for up to 1 month. The child with a second recent positive rapid strep test needs this confirmed by culture.

9. Another cause of a false positive strep test is that of being a carrier. Such a child will have positive cultures but an unimpressive history or exam. Finding a positive culture when a child is well determines this. An antistreptolysin O titer also can help decide if a child is having recurrent strep; negative titers suggest not. A carrier does not need to be treated.² For the child with true recurrent strep, the bacteria can hide in the tonsils and come to the surface when antibiotics are gone. Removing the tonsils prevents this; hence, the short-term value of a tonsillectomy. However, a child can still catch strep from someone else. In that case, he or she simply has strep throat not strep tonsillitis. Another way to eradicate strep is with clindamycin.⁴ I recommend a trial of clindamycin (note the warning about possible antibiotic-associated enterocolitis) before tonsillectomy for recurrent strep.

10. Studies suggest that tonsillectomy for recurrent sore throats (including strep) can provide benefit in terms of overall illness and pain for up to 2 years.⁵

Eyes, ears, nose throat

1. Recurrent otitis media does not cause language problems.¹ Tubes are indicated for the child with recurrent ear infections who is having pain or prolonged courses of antibiotics, or whose parents are missing work. It is done for quality of life. The child who has moderate pain and responds rapidly to medicine, and whose parents do not miss work, does not necessarily require tubes.

2. Ear plugs and headbands are not routinely needed for children with pressure equalization tubes while swimming.

3. Dark circles under the eyes are not a sign of illness but of sluggish blood flow (eg, from allergies or rubbing from lack of sleep). They are not a sign of anemia.

4. Missing a tropia is bad. Missing a phoria for a little bit is not. If the eyes are usually straight, binocular vision has time to develop.

5. Green mucus does not make a sinus infection.

6. No cough implies no sinus infection.

7. Rule out a submucous cleft before removing the tonsils in a child with a bifid uvula.

8. Data do not suggest a benefit from silver nitrate cautery in the office for epistaxis.³

Conjunctivitis

1. Children hate eye drops. An easier method for applying drops, in the older and cooperative child, is to place the drops in the medial corner of the eye with the eye closed, and then have the child open the eye.

2. Sulfonamides and aminoglycosides sting more than other drops.

3. Bacterial conjunctivis (except for that associated with gonococcus) tends to be self-limited, and viral conjunctivitis does not, of course, respond to antibiotic drops. As such, I only use antibacterial drops for purulent discharge, assuming that mild crusting is viral in origin. In the latter case, I give the family a prescription for eye drops to keep in case the nature of the discharge changes. If only 1 eye is affected, I treat just the 1 eye and continue to treat it until the eye is better-usually only a few days and not for a 7- to 10-day course. Overall, I have saved children years of eye drops with this method.

4. Bacterial conjunctivitis does not automatically require exclusion from daycare, if one can convince daycare that this is so.²

5. Otitis media and conjunctivitis often are associated with Haemiohilus influenzae.² Amoxicillin is not a good choice for this combination; amoxicillin/clavulanate, cefdinir, and cefprozil are better choices. If you do this, you do not need eye drops because the oral antibiotic will also treat the conjunctivitis.

6. Vigamox, at 3 times a day, is convenient but expensive. Moxeza is even more convenient, but parents have trouble using it because of its thickness (warming the bottle in the hand before use can help). It is also quite pricey. It is important to understand how medicines work in the real world. Polymyxin B-trimethoprim drops are cheap, do not sting much, and seem to work fine when given 4 times a day-not every 4 hours as in typically written.

References:

Strep throat:

1. Steinhoff MC, Walker CF, Rimoin AW, Hamza HS. A clinical decision rule for management of streptococcal pharyngitis in low-resource settings. Acta Paediatr. 2005;94(8):1038-1042.

2. American Academy of Pediatrics. Group A streptococcal infections. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:668-680.

3. American Academy of Pediatrics. 2014 PREP Self-Assessment; 2014:C-116.

4. Tanz RR, Poncher JR, Corydon KE, Kabat K, Yogev R, Shulman ST. Clindamycin treatment of chronic pharyngeal carriage of group A streptococci. J Pediatr. 1991;119(1 pt 1):123-128.

5. Paradise JL, Bluestone CD, Bachman RZ, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials. N Eng J Med. 1984;310(11):674-683.

Eyes, ears, nose, throat:

1. Paradise JL, Campbell TF, Dollaghan CA, et al. Developmental outcomes after early or delayed insertion of tympanostomy tubes. N Engl J Med. 2005;353(6):576-586.

2. Rosenfeld RM, Schwartz SR, Pynnonen MA, et al. Clinical practice guideline: tympanostomy tubes in children. Otolaryngol Head Neck Surg. 2013;149(1 suppl):S1-S35.

3. Qureishi A, Burton MJ. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database Syst Rev. 2012;9:CD004461.

Conjunctivitis:

1. Sheikh A, Hurwitz B, van Schayck CP, McLean S, Nurmatov U. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database Syst Rev. 2012;9:CD001211.

2. Shope TR. Infectious diseases in early education and child care programs. Pediatr Rev. 2014;35(5):182-193.

3. Bingen E, Cohen R, Jourenkova N, Gehanno P. Epidemiologic study of conjunctivitis-otitis syndrome. Pediatr Infect Dis J. 2005;24(8):731-732.