Nail Shedding Following Hand, Foot and Mouth Disease

Zhen Han Tan, Mark Jean-Aan Koh

Arch Dis Child. 2013;98(9):665 

A previously well 5-year-old Chinese girl presented to the children's emergency with nail discolouration of 5 days duration. There was no associated pain or history of trauma. She had otherwise just recovered from hand, foot and mouth disease (HFMD) 3 weeks ago. On examination, there was separation of the nail plate from the nail bed, beginning at the proximal nail fold, affecting both thumbs and big toes (figure 1). No other cutaneous lesions were noted, and general examination was unremarkable. The diagnosis of onychomadesis was made, and her parent was reassured that no treatment was required.

Figure 1.

 

Patient's right thumb showing onychomadesis.

Onychomadesis is defined as a painless spontaneous separation of the nail plate from the bed, beginning at the proximal end with subsequent shedding of the nail as the new nail grows. It can occur idiopathically, after trauma, or in association with serious systemic illnesses, infections and drugs reactions.^[1,2] The association between onychomadesis and HFMD was first proposed by Clementz et al,^[3] with recent studies of HFMD outbreaks in Spain and Finland providing further supporting evidence.^[4]

Onychomadesis occurs as a result of temporary arrest of nail growth at the nail matrix. Other possible mechanisms of onychomadesis in HFMD include inflammation of the nail matrix and intensive hygienic measures resulting in maceration, Candida infection and allergic contact dermatitis.^[5] No treatment is required for onychomadesis, and onward referral to specialist is unnecessary. Patients should be reassured that spontaneous regrowth of a new normal nail is usually seen within a few months.

Should We Just Say Yes to Pacifiers?

William T. Basco, Jr., MD, MS

Jun 28, 2013

Pacifier Restriction and Exclusive Breastfeeding

Kair LR, Kenron D, Etheredge K, Jaffe AC, Phillipi CA

Pediatrics. 2013;131:e1101-1107

Study Summary

Kair and colleagues conducted a quasi-experimental study in which they evaluated changes in exclusive breastfeeding rates in a hospital before and after an initiative that involved reducing pacifier access in the newborn nursery. Conflicting evidence has raised the concern that pacifier use interferes with initiation of breastfeeding. Observational studies suggest a potential negative effect of pacifier use on breastfeeding outcomes, whereas randomized trials do not show a difference in breastfeeding outcomes with different times and types of pacifier use. The World Health Organization and the United Nations Children's Fund urge hospitals to implement 10 steps designed to increase the frequency of successful breastfeeding. Among the 10 precepts are:

• Increase maternal education about the benefits of breast-feeding;

• Limit exposure to any food or drink other than breast milk; and

• Avoid pacifiers or other artificial nipples in the newborn nursery.

The large, university teaching hospital where this study was conducted began a program that included 5 of the 10 precepts: initiation of breastfeeding immediately after birth, feeding only breast milk in the hospital, rooming-in of the mother and child, no use of pacifiers, and provision of postdischarge breastfeeding support. The analysis of breastfeeding outcomes covered the latter months of 2010 and the early months of 2011. A changeover month between the 2 periods was not analyzed because staff were in the process of implementing the 5 precepts.

Access to pacifiers was made difficult but not impossible, with employees required to sign for any pacifiers taken from supply and given to an infant. Parents could bring pacifiers to the hospital, and the frequency of this practice was not monitored. The 5 desired breastfeeding behaviors were communicated to parents, including specific discussions about limiting pacifier use. The bulk of the data for this report was obtained from the electronic medical records of the hospital.

The study involved 2249 infants (812 in the "preintervention" group and 1278 in the "postintervention" group). The 2 groups were generally similar except that the postintervention group was more likely to be privately insured than the preintervention group. The medical histories and physical examinations of the infants in both groups were similar. When looking at the primary outcome, the proportion of infants who were exclusively breastfed in the preintervention period was 79% compared with 68% in the postintervention group. This was associated with a 10 percentage-point increase in the proportion of children who were receiving some degree of formula supplementation. Kair and colleagues concluded that restricting access to pacifiers without also restricting access to formula was associated with reduced rates of exclusive breastfeeding.

Viewpoint

This study points out the limitations of quasi-experimental and observational study designs. Certainly, it is important for hospitals to track the outcomes associated with process of care changes. However, implementation of a program such as the Baby-Friendly Hospital Initiative, whether complete or partial, does not occur in a vacuum. System-wide changes are often necessitated by the implementation, along with a great deal of provider and staff education. If an intervention is successful, it can be very difficult to determine which component of the intervention was responsible for success. On the reverse side, when an intervention does not work but was not tightly controlled, it can be difficult to identify the reasons why it failed.

Kair and colleagues seem to think that the failure to entirely limit access to pacifiers and to limit access to formula were associated with the lower percentage of exclusive breastfeeding, but the true reasons for this unexpected change are unknown. A shift towards more privately insured mothers in the postintervention group was identified, but this should have biased the results towards a higher frequency of breastfeeding based on historical epidemiologic data. It makes the change in frequency of exclusive breastfeeding observed at this hospital even more intriguing.

Commentary: Antibiotic Recommendations for Acute Otitis Media and Acute Bacterial Sinusitis in 2013

The Conundrum

Ellen R. Wald, MD, Gregory P. DeMuri, MD

Pediatr Infect Dis J. 2013;32(5):641-643. 

Introduction

The pathogens that cause acute otitis media (AOM) and acute bacterial sinusitis are well known to primary care practitioners.^[1,2] The source of microbiologic data are cultures of middle ear fluid that are obtained by the performance of tympanocentesis, a procedure that can be safely undertaken in the office setting after specific training of clinicians, and with appropriate measures to manage pain for the child.^[3,4] Unfortunately, in contrast to AOM, there has been very little study of the microbiology of acute bacterial sinusitis as this requires a more invasive procedure usually performed by pediatric otolaryngologists under local or general anesthesia.^[4]Two publications in the early 1980s described the microbiology of acute bacterial sinusitis in children in the United States, based on the results of maxillary sinus aspiration.^[5,6] Subsequently, discussions of the microbiology and recommendations for antibiotic management of acute bacterial sinusitis have leaned heavily on recommendations and data developed for AOM.^[1]

Pathogenesis and Physiology of Acute Otitis Media and Acute Bacterial Sinusitis

The willingness to rely on data derived from tympanocentesis as a guide to the microbiology of acute bacterial sinusitis relates to the similarity of AOM and acute bacterial sinusitis with regard to anatomy, physiology and pathogenesis. Parsons noted, more than 15 years ago, that the middle ear is a paranasal sinus^[7] as the Eustachian tube acts in a similar fashion to the ostia of the paranasal sinuses. In both cases, the common preceding event is a viral upper respiratory infection.^[8] The mucosal swelling of the Eustachian tube and sinus ostia lead to (1) impairment of drainage of the secretions, which are produced by the lining of the middle ear and the paranasal sinuses, respectively; (2) a disorder of the pressure relationships between the cavities of the middle ear, paranasal sinuses and the nose and (3) the development of negative pressure within the middle ear or paranasal sinuses, which favors aspiration of mucus and bacteria from the nasopharynx into the middle ear space or paranasal sinuses. Ordinarily this material would drain out again, but, when there is Eustachian tube dysfunction, impaired ciliary activity and a functional or mechanical obstruction of the sinus ostia, bacteria multiply and AOM or acute bacterial sinusitis develops.

Tympanocentesis—Infrequently Performed

Antimicrobial recommendations for the treatment of AOM and acute bacterial sinusitis depend on the age of the child, recent antibiotic use, regional variations in antibiotic susceptibility and resistance patterns and knowledge of the current microbiology. Therefore, the alarming news with regard to antibiotic recommendations for both AOM and acute bacterial sinusitis is that there are very few remaining medical centers where tympanocentesis is performed routinely. Locations in the United States that historically generated the bulk of data regarding the microbiology of AOM were in Pittsburgh, Pennsylvania,^[9,10] Boston, Massachusetts,^[11–13] Bardstown, Kentucky^[14,15] and Rochester, New York.^[16–18] The decrease in centers at which tympanocentesis is performed most probably reflects few recent introductions of antibiotics that might be useful in the management of AOM—and therefore no requirement to demonstrate their ability to eradicate pathogens or compare them to standard therapies. This state of affairs leaves us in a very precarious situation with regard to selection of antimicrobial agents for treatment of 2 of the most common clinical infections in childhood because we have no up-to-date microbiology on which to base treatment decisions.

History of Microbiology and Treatment of Aom

Historically, the relative proportion of bacterial agents in AOM was Streptococcus pneumoniae at 40%, Haemophilus influenzae at 25% and Moraxella catarrhalis at 12%.^[19] The original distribution of bacterial pathogens in acute bacterial sinusitis was S. pneumoniae at 30% and H. influenzae and M. catarrhalis at 20% each.^[5,6]Streptococcus pyogenes was a minor cause of both entities, accounting for 2% to 4% of cases.

For many years, amoxicillin 45 mg/kg/day in 3 divided doses was the drug of choice for AOM. The preference for amoxicillin relates to its excellent safety profile, relatively narrow spectrum, low cost and general effectiveness.^[2] The first challenge to the effectiveness of amoxicillin arose in the mid-1970s when the issue of β-lactamase production among H. influenzae emerged. The decision to continue to recommend amoxicillin for children with AOM was based on a calculation which involved multiplying the proportion of cases of AOM caused by H. influenzae, by the proportion of isolates that were β-lactamase positive; the rate of probable spontaneous cure was also taken into consideration. In the past, when H. influenzae caused 25% of cases of AOM and β-lactamase production occurred in 20%–30% of isolates, it could be calculated that a middle ear isolate would be resistant to amoxicillin in 6% of cases. Although M. catarrhalis produces β-lactamase nearly 100% of the time, it was isolated less frequently and was thought to have a very high rate of spontaneous resolution. Accordingly, amoxicillin remained a good choice.

Emergence of Penicillin-resistant S. Pneumoniae

The emergence of penicillin-resistant S. pneumoniae in the 1990s became a challenge to the dose of amoxicillin that was prescribed. The mechanism of resistance, alteration of penicillin binding proteins, may be overcome, largely, by raising the dose of amoxicillin to increase concentrations of antibiotic in middle ear or sinus fluid. This became the stimulus to increase the dose of amoxicillin from 45 mg/kg/day to 90 mg/kg/day in situations in which it was anticipated that penicillin-nonsusceptibleS. pneumoniae might be present (eg, in children <2 years of age, those subjected to recent antibiotic exposure [<30 days] or attendance at day care).^[2]

Soon after licensure of the pneumococcal conjugate vaccine (PCV7) in 2000, there were some changes in the relative prevalence of the microbes that cause AOM, that is, a decrease in the prevalence of S. pneumoniae (including penicillin-nonsusceptible S. pneumoniae)^[20] and a relative increase in the prevalence of H. influenzae. Data from 3 major surveillance programs in the United States showed slight variations in the frequency of β-lactamase-positive H. influenzae from 27% to 43%.^[21–23]Although these data may not be directly comparable to isolates obtained exclusively by tympanocentesis or sinus aspiration, they describe a trend. Likewise, studies by Casey and Pichichero^[24] and Block et al^[25] demonstrated an increase in the proportion of AOM due to nontypeable H. influenzae and an absolute increase in the proportion of isolates that were β-lactamase positive.^[26] This trend was altered briefly between 2005 and 2010, with the emergence of penicillin-resistant infections caused by S. pneumoniae of serotype 19A.^[27] However, the inclusion of serotype 19A in PCV13 has reversed the escalation of this serotype as a cause of invasive and local diseases.^[28] Now we can anticipate, and several pieces of information support the notion, that there will be a further decrease in the prevalence of S. pneumoniae (including penicillin-nonsusceptible S. pneumoniae) and a further increase in H. influenzae secondary to the use of PCV13, which was licensed in 2010 and has enjoyed a rapid increase in use.^[29–31] If the decrease in prevalence of S. pneumoniae (and highly penicillin-resistant S. pneumoniae) persists, the recommended dose of amoxicillin could then be reduced to 45 mg/kg/day in 2 divided doses once again.^[32] It is essential to recognize that this is a very dynamic situation and that there is a possibility that the few nonvaccine strains of S. pneumoniae, which are resistant to penicillin, may, similar to serotype 19A, become more prevalent. This possibility underscores the importance of the continuous availability of current data that reflects local and national microbiologic trends.

Current Data

Unfortunately, there are very few data by which to judge the prevalence of penicillin-nonsusceptible S. pneumoniae or β-lactamase production among the H. influenzaein 2013. The single center in the United States where tympanocentesis continues to be performed is in Rochester, NY. In that center, there is evidence that as predicted, recovery of S. pneumoniae from middle ear fluid has dramatically decreased, and H. influenzae and M. catarrhalis have increased to account for 90% of isolates. The surprising data are that the prevalence of β-lactamase producing organisms is quite high, in the range of 70–80%.^[29] In addition, cumulative microbiologic data published annually by Dr. Mary Glode from Denver Children's Hospital shows 68% of H. influenzae isolates are β-lactamase producing (personal communication August 22, 2012). Furthermore, in 2011, a small sample of nasopharyngeal isolates obtained between 2008 and 2010 from children meeting clinical criteria for acute bacterial sinusitis in Pittsburgh, PA, showed (16 of 33) 48% of children harboring β-lactamase-positive H. influenzae (personal communication, N. Shaikh, September 26, 2012). Finally, a recent study reported from Boston, MA, showed nasopharyngeal carriage of pneumococcal serotypes contained in PCV13 has decreased as use of the vaccine has become more widespread.^[33] It is noteworthy that the latter 2 studies reflect respiratory tract mucosal colonization, which may be slightly different than middle ear or sinus isolates.

The Conundrum

Two clinical trials of amoxicillin/clavulanate, 1 standard dose and 1 high dose in children with AOM showed similar rates of superiority of antibiotic over placebo.^[34,35]In addition, a trial of high-dose amoxicillin/clavulanate in children with clinically diagnosed sinusitis demonstrated the efficacy of this antibiotic over placebo.^[36] If the sparse current microbiologic data that are available truly reflect general trends, H. influenzae now accounts for 60–70% of cases of AOM and 60–70% of these may be β-lactamase producing.

The questions are: Should we use amoxicillin or amoxicillin/clavulanate? Should we recommend high dose or standard dose amoxicillin? In the absence of data derived from tympanocentesis, these are difficult questions to answer. Although neither nasopharyngeal nor throat cultures have been a useful guide to recommendations for the treatment of specific patients with AOM or acute bacterial sinusitis, they may be useful on a population basis in formulating recommendations in different regions of the United States. Accordingly, we urge that medical centers within various geographic areas begin to generate these data to provide guidance regarding antimicrobial choices. In the meanwhile, on the basis of the limited data that are available, it seems reasonable to recommend standard dose of amoxicillin–clavulanate (45 mg/kg/day in 2 divided doses) as preferred initial therapy for children with AOM and acute bacterial sinusitis.

Hand, Foot, and Mouth Disease: CVA6 Diagnostic Clues Found

Jenni Laidman

Jun 17, 2013

The unusual characteristics of hand, foot, and mouth disease (HFMD) caused by coxsackievirus A6 (CVA6) are easily confused with several other diseases, but the authors of an analysis of the 2011 to 2012 outbreak have characterized distinctive morphologies of this more severe enterovirus in a study published online June 17 inPediatrics.

Erin F. Mathes, MD, assistant clinical professor, Department of Dermatology and Department of Pediatrics, University of California, San Francisco, and colleagues examined the medical records of 80 children who tested positive for CVA6 (n = 17), using nucleotide sequencing, or who met clinical criteria for atypical HFMD between July 2011 and June 2012 at 7 academic pediatric dermatology centers around North America.

The authors found 4 morphologies that distinguished this coxsackievirus-associated outbreak from classic HFMD, including widespread vesiculobullous and erosive lesions extending beyond the palms and soles; eczema herpeticum-like eruptions in areas previously or currently affected by atopic dermatitis; eruptions similar to those in Gianotti-Crosti and focused in areas of previous skin injury, such as in areas of sunburn; and petechial or purpuric eruptions, frequently on acral sites, as in acral purpura.

"The phenotypic variability and unusual skin eruptions can be confused with other infectious disease and inflammatory skin diseases," the authors write.

The current analysis could help sort out this confusion, Dean Morrell, MD, professor, director of pediatric and adolescent dermatology, University of North Carolina Department of Dermatology, Chapel Hill, told Medscape Medical News in an email. Dr. Morrell was not involved in the current study.

"This paper is an excellent and timely review of a new clinical entity," Dr. Morrell noted. "Eczema coxsackium was seen across the country and initially fooled many of us. The first case seen at [the University of North Carolina] was initially diagnosed as eczema herpeticum, but that diagnosis didn't really fit the clinical constellation of findings. This manuscript will further educate medical caregivers, who will certainly have the condition come through their practices."

The authors found that the most common symptoms of CVA6 were widespread vesicles, bullae, and/or erosions. Ninety-nine percent of patients had vesiculobullous and erosive eruptions. Infants younger than 1 year were more likely to have bullae than older children (38% of patients younger than 1 year compared with 7% aged 1 to 5 years and 18% of those older than 5 years; P = .039).

Although classical HFMD generally involves hands, feet, and occasionally the buttocks, with enanthem of small vesicles and eruptions of the oral mucosa, the exanthem differed in the CVA6 HFMD by frequently including the perioral area, extremities, and torso. Intraoral outbreaks also occur less frequently in the classic condition.

In most patients (61%), the vesicles, erosions, and bullae of various sizes covered more than 10% of body surface area, which has not been reported in previous HFMD outbreaks.

CVA6 often appeared in areas of previous trauma or inflammation, including diaper rash or healing lacerations, the authors report. Forty-four (55%) of the 80 patients had eruptions in areas of eczematous dermatitis, and 14 patients (18%) had eruptions in other areas of skin injury.

"Enteroviral infections, particularly CVA6, should now be considered in the differential diagnosis of patients presenting with new-onset vesicles and extensive erosions in preexisting areas of eczema," the authors write.

More than one third of the patients with CVA6 had Gianotti-Crosti-like distribution, with lesions on cheeks, extensor surfaces of extremities, and buttocks, but not on the trunk (28/76, 37%).

One coauthor is a consultant and has received payment for lectures and has a grant/pending grant from bioMérieux, which makes the enterovirus assay used in diagnosis at North Shore-Long Island Jewish Health Systems Laboratories. The other authors and Dr. Morrell have disclosed no relevant financial relationships.

Pediatrics. Published online June 17, 2013. Abstract

Pediatric Ear Infection: Updated AAP Treatment Guidelines

Laurie Barclay, MD

Feb 25, 2013

Updated American Academy of Pediatrics (AAP) clinical practice guidelines address the diagnosis and management of uncomplicated acute otitis media (AOM) in children aged 6 months to 12 years. The new recommendations, which offer more rigorous diagnostic criteria to reduce unnecessary antibiotic use, were published online February 25 and in the March issue of Pediatrics.

"Although OM remains the most common condition for which antibacterial agents are prescribed for children in the United States, clinician visits for OM decreased from 950 per 1000 children in 1995–1996 to 634 per 1000 children in 2005–2006," write Allan S. Lieberthal, MD, and colleagues. "There has been a proportional decrease in antibiotic prescriptions for OM from 760 per 1000 in 1995–1996 to 484 per 1000 in 2005–2006."

The guideline updates the 2004 AOM guideline from the AAP and American Academy of Family Physicians, based on a comprehensive literature review in 2009 by an expert panel from the AAP, the Agency for Healthcare Research and Quality, and the Southern California Evidence-Based Practice Center. The panel used systematic grading of evidence quality and benefit-harm analysis to develop the guideline, which underwent comprehensive peer review.

Taking into account patient age and symptom severity, AOM may be managed with antibiotics and analgesics or with observation alone. The guidelines cover pain management, antibiotic options, prevention, and recurrent AOM (an addition to the 2004 guideline).

Specific action statements include the following:

• AOM should be diagnosed when there is moderate to severe tympanic membrane (TM) bulging or new-onset otorrhea not caused by acute otitis externa.
• AOM may be diagnosed for mild TM bulging and ear pain for less than 48 hours or for intense TM erythema. In a nonverbal child, ear holding, tugging, or rubbing suggests ear pain.
• AOM should not be diagnosed when pneumatic otoscopy and/or tympanometry do not show middle ear effusion.
• AOM management should include pain evaluation and treatment.
• Antibiotics should be prescribed for bilateral or unilateral AOM in children aged at least 6 months with severe signs or symptoms (moderate or severe otalgia or otalgia for 48 hours or longer or temperature 39°C or higher) and for nonsevere, bilateral AOM in children aged 6 to 23 months.
• On the basis of joint decision-making with the parents, unilateral, nonsevere AOM in children aged 6 to 23 months or nonsevere AOM in older children may be managed either with antibiotics or with close follow-up and withholding antibiotics unless the child worsens or does not improve within 48 to 72 hours of symptom onset.
• Amoxicillin is the antibiotic of choice unless the child received it within 30 days, has concurrent purulent conjunctivitis, or is allergic to penicillin. In these cases, clinicians should prescribe an antibiotic with additional β-lactamase coverage.
• Clinicians should reevaluate a child whose symptoms have worsened or not responded to the initial antibiotic treatment within 48 to 72 hours and change treatment if indicated.
• In children with recurrent AOM, tympanostomy tubes, but not prophylactic antibiotics, may be indicated to reduce the frequency of AOM episodes.
• Clinicians should recommend pneumococcal conjugate vaccine and annual influenza vaccine to all children according to updated schedules.
• Clinicians should encourage exclusive breastfeeding for 6 months or longer.

The AAP supported development of these guidelines and addressed disclosures of the guidelines authors.

Pediatrics. 2013;131:e964-e999.

Influenza: Vaccinate Kids as Soon as Possible, AAP Says

Laurie Barclay, MD

Sep 02, 2013

All children at least 6 months of age should be vaccinated against influenza as soon as trivalent or new quadrivalent vaccine is available, according to an updated statement from the American Academy of Pediatrics (AAP).

The statement, published online September 2 and in the October issue of Pediatrics, updates recommendations for routine use of seasonal influenza vaccine and antiviral medications to prevent and treat influenza in children.

"Parents should not delay vaccinating their children to obtain a specific vaccine," lead author Henry Bernstein, DO, said in a news release. Dr. Bernstein is the Red Book Online associate editor. "Influenza virus is unpredictable, and what's most important is that people receive the vaccine soon, so that they will be protected when the virus begins circulating."

For the 2013 to 2014 season, the trivalent influenza vaccine contains an A/California/7/2009 (H1N1) pdm09-like virus (same as 2012-2013), an A/Texas/50/2012 (H3N2) virus (antigenically similar to the 2012-2013 strain), and a B/Massachusetts/2/2012-like virus (a B/Yamagata lineage, similar to 2012 - 2013, but a different virus).

The US Food and Drug Administration has licensed new quadrivalent influenza vaccines containing an additional B virus (B/Brisbane/60/2008-like virus [B/Victoria lineage]).

The updated statement calls for annual universal influenza immunization, with no preference regarding the trivalent vs the quadrivalent vaccine.

Recent evidence suggests that inactivated influenza vaccine may be safely given to most persons allergic to eggs. A single, age-appropriate dose of inactivated influenza vaccine is well tolerated by those with egg allergy, but the AAP recommends consultation with an allergist for any child with a history of a severe reaction.

For children aged 6 months through 8 years, the dosing algorithm for administration of influenza vaccine is the same as in 2012-2013. If a child has received a seasonal vaccine previously, he or she needs only 1 dose of the current vaccine. If there is no prior vaccination or no clear record of prior vaccination, then the child should receive 2 doses, 4 weeks apart. Similarly, children who have not received 2 or more doses of the seasonal vaccine since July 1, 2010, should also receive 2 doses of the 2013-2014 vaccine.

Clinical Implications

The AAP recommends that clinicians make a special effort to vaccinate persons in vulnerable groups. These include children with chronic health conditions, children of American Indian or Alaskan Native heritage, healthcare workers, pregnant or breast-feeding women or those who may become pregnant, and household contacts and caregivers of children in high-risk populations.

The statement also recommends that pediatric offices consider offering vaccination to parents or other adults who care for children.

"As always, pediatricians, nurses, and all health care personnel should promote influenza vaccine use and infection control measures," the statement authors write. "In addition, pediatricians should promptly identify influenza infections to enable rapid antiviral treatment, when indicated, to reduce morbidity and mortality."

For children with influenza and severe symptoms or underlying chronic conditions, or for those who are hospitalized, the AAP still recommends treatment with oseltamivir or zanamivir. The safety profile of oseltamivir allows its use in both term and preterm infants from birth. However, chemoprophylaxis should be considered only in term infants, and chemoprophylaxis should not be considered a substitute for immunization.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online September 2, 2013.

Reserve Tympanostomy Tubes for Chronic Otitis Media With Effusion: Guideline

CLINICAL CONTEXT

Tympanostomy tube placement is the most common ambulatory surgery performed among children in the United States, according to the authors of the current study. By age 6 years, 40% of children have experienced 3 or more episodes of otitis media. Although tympanostomy tubes have helped many thousands of children with persistent middle ear effusions and hearing loss, precise guidelines for the application of tympanostomy tube placement are lacking. The current practice guideline from the American Academy of Otolaryngology—Head and Neck Surgery addresses this issue.

STUDY SYNOPSIS AND PERSPECTIVE

Kids with uncomplicated, short-term otitis media with effusion (OME) generally don't need tympanostomy tubes, which should be reserved for children with chronic OME, according to new guidelines from the American Academy of Otolaryngology—Head and Neck Surgery Foundation.

Dr. Richard M. Rosenfeld, who headed the guideline panel, told Reuters Health that although tympanostomy tube insertion is the most common pediatric ambulatory surgery in the United States, there have been no recent clinical practice guidelines that address specific indications for surgery.

The new guidelines, he and his colleagues write, are "intended for any clinician involved in managing children, aged six months to 12 years, with tympanostomy tubes or being considered for tympanostomy tubes in any care setting, as an intervention for otitis media of any type."

Dr. Rosenfeld, from the State University of New York Downstate Medical Center, Brooklyn, New York, and colleagues published the guidelines in the July Supplement of Otolaryngology—Head and Neck Surgery.

The document includes a dozen action statements, starting with an assertion that echoes the 1994 OME guideline from the American Academy of Pediatrics, American Academy of Family Medicine, and American Academy of Otolaryngology—Head and Neck Surgery.

Namely, clinicians should not routinely perform tympanostomy tube insertion in children with a single episode of OME of less than three months' duration.

Instead, tympanostomy tube insertion should be reserved for children with chronic OME (i.e., longer than three months) and documented hearing difficulties or structural abnormalities of the tympanic membrane or middle ear.

Other candidates for tympanostomy tube insertion include children with recurrent acute otitis media (AOM) with middle ear effusion at the time of assessment for tube candidacy and those with recurrent AOM or OME of any duration with increased risk for speech, language, or learning problems from otitis media.

Dr. Rosenfeld pointed out that including effusion as an indication for tube placement represents a significant difference from what happens today in clinical practice. Even 10 infections a year aren't an indication for tube placement, if the child's ear is pristine, Dr. Rosenfeld said. Doctors shouldn't be putting these tubes in based just on the child's history, he added.

Once the decision has been made to insert tympanostomy tubes, parents or other caregivers should be educated regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications. The guidelines include sample education sheets for this purpose.

For children who have tympanostomy tubes, topical antibiotic eardrops only (not oral antibiotics) are indicated for uncomplicated acute tympanostomy tube otorrhea, Dr. Rosenfeld emphasized.

However, to avoid yeast infections in the ear canal, antibiotic eardrops shouldn't be used frequently or for more than 10 days in a row.

Also, he pointed out, for kids who do have the tubes in place, the guidelines recommend against routine prophylactic water precautions (including use of earplugs or headbands and avoidance of swimming or water sports), unless kids are symptomatic or are consistently swimming at depths greater than six feet. (The guidelines also note that water precautions may be necessary for kids who submerge in bathwater, because soapy water has a lower surface tension than plain water.)

The group placed additional emphasis on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes, and identified knowledge gaps they hope will guide future research.

Otolaryngol Head Neck Surg. 2013;149:S1-S35.

STUDY HIGHLIGHTS

• The panel members, who wrote the current guidelines, included otolaryngologists as well as primary care physicians and nonphysician healthcare providers.
• Systematic reviews and randomized trials were used to develop the guidelines.
• The guidelines were focused on the treatment of children between 6 months and 12 years old.
• Tympanostomy tubes should not be provided for children with a single episode of OME of less than 3 months' duration.
• Children should undergo an age-appropriate hearing test before tympanostomy tube placement. Most children 4 years and older can be tested with conventional audiometry. A more comprehensive evaluation with an audiologist is usually necessary for younger children.
• Once OME has persisted for more than 3 months, the rate of spontaneous resolution is only 30% at 1 year. Children with OME for at least 3 months and with documented hearing problems may be considered for tympanostomy tubes.
• The principal benefits of tympanostomy tube placement are improved hearing along with patient and caregiver quality of life.
• The most common adverse event related to tympanostomy tube placement is tympanostomy tube otorrhea, which affects up to 26% of patients.
• Tympanostomy tubes may also be considered for children with other symptoms potentially related to chronic OME, including vestibular complaints, poor school performance, behavioral problems, ear pain, or reduced quality of life.
• Children with chronic OME who do not receive tympanostomy tubes should be monitored at 3- to 6-month intervals for complications of OME.
• The prognosis for children with recurrent AOM without effusion is generally good, and tympanostomy tubes provide questionable clinical benefit for these children. Recurrent AOM alone is insufficient as an indication for tympanostomy tubes.
• However, children with recurrent AOM who have evidence of middle ear effusion should be considered for tympanostomy tubes.
• Children who are at particularly high risk for complications of middle ear effusion or recurrent AOM, such as those with hearing aids, Down's syndrome, or cleft palate, should receive special consideration for tympanostomy tubes.
• Uncomplicated cases of tympanostomy tube otorrhea should be treated with topical, but not oral, antibiotics. Rates of clinical cure appear higher with topical vs oral antibiotics.
• Children with tympanostomy tubes do not require routine protection against water such as ear plugs or headbands. The mild benefit of ear protection against tympanostomy tube otorrhea is probably outweighed by the effort in consistently protecting the ears against water.

Diagnosis and management of acute bacterial sinusitis

CLINICAL CONTEXT

The American Academy of Pediatrics (AAP) has issued a new clinical practice guideline regarding diagnosis and management of acute bacterial sinusitis in children. Medscape Medical News interviewed lead author Ellen Wald, MD, about changes in the updated guidelines from the 2001 AAP guideline.

Review of the medical literature since 2001 suggests that evidence regarding diagnosis and management of acute bacterial sinusitis in children is still limited. Because of differences in inclusion and exclusion criteria, 4 placebo-controlled studies of antibiotic treatment in children differed in their findings. Nonetheless, these data suggested that antibiotic treatment was more likely to benefit children presenting with more severe illness.

STUDY SYNOPSIS AND PERSPECTIVE

Acute bacterial sinusitis may now be diagnosed in a child with upper respiratory infection (URI) and worsening symptoms after initial improvement, according to updated guidelines from the AAP, published online June 24 in Pediatrics. The new clinical practice guideline addresses diagnosis and judicious antibiotic use, updating the 2001 AAP guideline based on a review of the medical literature since publication of the previous recommendations.

"Acute bacterial sinusitis is a common complication of viral [URI] or allergic inflammation," write Ellen R. Wald, MD, and colleagues from the AAP. "Using stringent criteria to define acute sinusitis, it has been observed that between 6% and 7% of children seeking care for respiratory symptoms [have] an illness consistent with this definition."

Previous criteria for acute bacterial sinusitis in children were acute URI with either nasal discharge and/or daytime cough for longer than 10 days or severe onset of fever (≥39°C/102.2°F), purulent nasal discharge, and other respiratory symptoms for 3 or more consecutive days. A third criterion added to the 2013 guideline is URI with worsening symptoms such as nasal discharge, cough, and fever after initial improvement.

Another change in the updated guideline is that clinicians may now observe children with persistent infection lasting longer than 10 days for an additional 3 days before prescribing antibiotics, whereas the 2001 guideline recommended antibiotics for all children diagnosed with acute bacterial sinusitis. However, antibiotics should still be given to children with severe onset or worsening symptoms.

Management Recommendations

First-line therapy for acute bacterial sinusitis is amoxicillin with or without clavulanate. If symptoms worsen or do not improve after 72 hours, another antibiotic may be substituted.

If the caregiver reports progression of initial signs and symptoms or appearance of new signs and symptoms, or if the child's condition fails to improve within 72 hours of initial management, clinicians should reevaluate initial management and change or start antibiotics if indicated.

The AAP does not recommend imaging tests for children with uncomplicated acute bacterial sinusitis, based on its evidence review, because these tests do not distinguish acute bacterial sinusitis from viral URI. However, children with suspected orbital or central nervous system complications should undergo contrast-enhanced computed tomography (CT) scanning of the paranasal sinuses.

"Changes in this revision include the addition of a clinical presentation designated as 'worsening course,' an option to treat immediately or observe children with persistent symptoms for 3 days before treating, and a review of evidence indicating that imaging is not necessary in children with uncomplicated acute bacterial sinusitis," the guidelines authors conclude.

Underlying Evidence

In an accompanying technical report, coauthor Michael J. Smith, MD, MSCE, assistant professor of pediatrics, Division of Pediatric Infectious Diseases, University of Louisville School of Medicine, Kentucky, notes that data are limited regarding the diagnosis and management of acute bacterial sinusitis in children. Four placebo-controlled studies of antibiotic treatment in children with acute sinusitis yielded varying results, likely because of varying inclusion and exclusion criteria. Although heterogeneity precluded formal meta-analyses, qualitative analysis suggested that children presenting with greater severity of illness were more likely to benefit from antimicrobial therapy.

"It is clear that some children with sinusitis benefit from antibiotic use and some do not," Dr. Smith writes. "Diagnostic and treatment guidelines focusing on severity of illness at the time of presentation have the potential to identify children who will benefit from therapy and at the same time minimize unnecessary use of antibiotics."

The AAP supported development of these guidelines. Dr. Smith has reported receiving financial support from Sanofi Pasteur and Novartis, and one coauthor is employed by McKesson Health Solutions. The remaining authors have disclosed no relevant financial relationships.

Pediatrics. Published online June 24, 2013. Guidelines full text, Technical report full text

STUDY HIGHLIGHTS

• In the 2001 guidelines, criteria for acute bacterial sinusitis in children were acute URI with nasal discharge and/or daytime cough for more than 10 days, or severe onset of fever (≥ 39°C/102.2°F), purulent nasal discharge, and other respiratory tract symptoms for 3 or more consecutive days.
• The 2013 guidelines maintain the above criteria but add a third criterion: URI with initial improvement followed by worsening symptoms such as nasal discharge, cough, and fever.
• This presentation can be distinguished from the common cold because the fever lasts longer (at least 3 - 4 days), and the purulent nasal discharge appears early along with the fever.
• Using severity of illness at presentation may help identify children who will benefit from antibiotics while minimizing unnecessary use of antibiotics.
• The 2001 guideline recommended antibiotics for all children diagnosed with acute bacterial sinusitis, but the updated guideline notes that clinicians may now observe children with infection lasting more than 10 days for an additional 3 days before prescribing antibiotics.
• However, children with severe onset or worsening symptoms should still receive antibiotics.
• For acute bacterial sinusitis, first-line treatment is amoxicillin with or without clavulanate.
• Some children may be treated with standard-dose amoxicillin (45 mg/kg/day in 2 divided doses), or high-dose amoxicillin (80 - 90 mg/kg/day in 2 divided doses) for patients thought to have resistant Streptococcus pneumoniae.
• Amoxicillin/potassium clavulanate is more effective against beta lactamase–producingHaemophilus influenzae.
• When data are unavailable concerning the relative prevalence of S pneumoniae, H influenzae, and beta lactamase–producing strains, amoxicillin/potassium clavulanate is the most comprehensive option, and it is probably safe to use in regular, rather than high, doses.
• Another antibiotic may be substituted if symptoms do not improve or worsen after 72 hours.
• Regardless of initial management, children whose condition fails to improve or in whom new or progressing signs and symptoms develop within 72 hours should undergo reevaluation and change or initiation of antibiotic therapy if indicated.
• Potentially useful adjunctive therapy includes ibuprofen or acetaminophen for discomfort or fever, saline nasal spray, and humidifiers or vaporizers.
• The evidence review suggests that imaging tests do not distinguish acute bacterial sinusitis from viral URI.
• Therefore, the AAP does not recommend imaging tests to confirm or refute the diagnosis of uncomplicated acute bacterial sinusitis in children.
• Results on radiography, CT, or magnetic resonance imaging scans performed during an uncomplicated cold are frequently abnormal, and these abnormalities are very similar to those seen in children with acute sinusitis.
• However, contrast-enhanced CT of the paranasal sinuses is recommended for children with suspected orbital or central nervous system complications to confirm the presence of the complication, define its extent, and help determine the need for surgical intervention.

CLINICAL IMPLICATIONS

• A change from 2001 in the updated guideline is that clinicians may now observe children with infection lasting more than 10 days for an additional 3 days before prescribing antibiotics. However, children with severe onset or worsening symptoms should still receive antibiotics.
• The AAP does not recommend imaging tests to confirm or refute the diagnosis of uncomplicated acute bacterial sinusitis in children. However, children with suspected orbital or central nervous system complications should undergo contrast-enhanced CT of the paranasal sinuses.

CME TEST

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Algorithm Efficiently Guides Pediatric Chest Pain Evaluation

Diedtra Henderson

Sep 09, 2013

Heart disease rarely is to blame for chest pain suffered by children, and the ailment can be evaluated cost-effectively in the ambulatory setting, according to a regional study testing an algorithmic tool to guide the care of symptomatic patients.

Gerald H. Angoff, MD, from the Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, Lebanon, New Hampshire, and colleagues report their findings in an article published online September 9 in Pediatrics.

Chest pain is a common complaint among children and adolescents. Clinicians often spend significant time and resources evaluating such complaints to rule out heart disease.

Therefore, Dr. Angoff and colleagues tested a methodology developed at Boston Children's Hospital called Standardized Clinical Assessment and Management Plans (SCAMPs) to see whether it would streamline diagnosis. Unlike typical clinical guidelines, SCAMPs mandate data acquisition, regular analysis of the data, and refinement of the guidance to reflect the evolving data.

In this case, the SCAMP algorithm fed in patient history, physical examination, and electrocardiogram data to glean when further diagnostic testing would be indicated. Echocardiograms were used only when the initial evaluation identified 1 or more prespecified abnormalities.

Dr. Angoff and colleagues enrolled 1016 pediatric patients aged 7 to 21 years who were being seen by a cardiologist for the first time for chest pain. The 109 providers who participated in the study practiced at New England Congenital Cardiology Association sites or Boston Children's Hospital. The researchers measured their adherence to the algorithm by tracking tests that were performed or not performed in accordance with the protocol.

"Echocardiography was performed as recommended in 423 patients (41.6%), when not recommended in 81 (8.0%), and was abnormal in 48 (9.5%) of all studies. In 2 instances, the echocardiogram findings explained the chest pain (0.5% of the recommended tests, 0.4% overall)," Dr. Angoff and coauthors write. None of the nonrecommended echocardiograms uncovered the cause of the chest pain.

In addition to affirming that cardiac disease is rarely the cause of children's chest pain, the authors report that "[t]he great majority of patients can be seen, evaluated, and discharged with a single visit."

A number of high-profile sudden cardiac deaths among young athletes has heightened anxiety on the part of families, referring pediatricians, and pediatric cardiologists, knowing that very rare cases of pediatric cardiac disease exist and can be catastrophic if undiagnosed, Robert M. Campbell, MD, chief of the Children's Healthcare of Atlanta Sibley Heart Center and professor of pediatrics at Emory University School of Medicine in Georgia, told Medscape Medical News.

SCAMPs serve as a "system of red flags" to uncover the warning signs for children more likely to have heart disease combined with a "very disciplined approach, so it doesn't vary doctor to doctor, day to day, site to site," Dr. Campbell said. "It's a move in the right direction, in terms of how much testing needs to be done, how specific can we be," he told Medscape Medical News.

"Using SCAMPs methodology, we have demonstrated that chest pain in children is rarely caused by heart disease and can be evaluated in the ambulatory setting efficiently and effectively using minimal resources," the study authors conclude. "The methodology can be implemented regionally across a wide range of clinical practice settings and its approach can overcome a number of barriers often limiting clinical practice guideline implementation."

Dr. Campbell was less convinced that such implementation would occur at this time in pediatrics, given the current fee-for-service world in which clinicians' incomes and business viability are linked to payments for conducting tests. In the future, if they were "managing a population of patients, then, it would not only be possible but it would be necessary to use these strategies."

Support for this study was provided by the Boston Children's Heart Foundation, Provider-Payor Quality Initiative at Boston Children's Hospital, the Program for Patient Safety and Quality of Boston Children's Hospital, and the Hinden Family Fund. The study authors and Dr. Campbell have disclosed no relevant financial relationships.

Pediatrics. Published online September 9, 2013.

Antibiotic Exposure in Infancy Linked to Food Allergies

Kate Johnson

Feb 28, 2013

SAN ANTONIO, Texas — Exposure to more than 2 courses of antibiotics in the first year of life is associated with a significantly increased rate of food allergy, according to research presented here at the American Academy of Allergy, Asthma & Immunology 2013 Annual Meeting.

"We believe it may be related to a disruption of normal gut flora," lead investigator Bryan Love, PharmD, from the South Carolina College of Pharmacy in Columbia, toldMedscape Medical News.

"Systemic antibiotics not only kill bacteria causing an infection...[they] are also distributed to other parts of our body where they can kill susceptible bacteria that are part of our normal flora — especially in the gastrointestinal tract," Dr. Love explained.

In their retrospective case–control study, presented as a late-breaking abstract at the meeting, Dr. Love and colleagues found an almost 2-fold increase in food allergy in children exposed to 3 or more courses of antibiotics between the ages of 7 and 12 months.

 

We believe it may be related to a disruption of normal gut flora.

 

Dr. Love explained that younger children (from birth to 6 months) also faced an increased risk with exposure (odds ratio, 1.43), although he did not present those data.

In both age groups, rates of food allergy were significantly higher (P < .0001), he told Medscape Medical News.

The investigators used South Carolina Medicaid billing data to identify more than 1100 children diagnosed with food allergy before the age of 3 and 6433 control subjects. They matched cases and controls by birth year, sex, and race.

Subjects in the 2 groups received a total 8046 courses of antibiotics, including penicillin (54%), cephalosporins (21%), macrolides (18%), and sulfonamides (7%).

The investigators controlled for asthma, atopic dermatitis, and eczema. "We know these patients tend to be more prone to food allergy," Dr. Love said. "They're also more likely to receive antibiotics, so we wanted to control for that."

Logistic regression analysis showed that subjects with food allergy were more likely than control subjects to have received a course of antibiotics.

Table. Antibiotic Exposure Before 12 Months

Outcome	Food Allergy Group	Control Group	P Value
At least 1 course of antibiotic	77%	66%	<.001
Mean number of antibiotic courses	2.65	1.84	<.001
Time to first antibiotic	181.5 days	190.1 days	.009

One or 2 rounds of antibiotics did not significantly increase the rate of food allergy, the investigators report, but 3 or 4 did.

Table. Risk for Food Allergy With Antibiotic Exposure

Antibiotic Exposure	Odds Ratio
Before 12 months	1.71
Between 0 and 6 months	1.43
Between 7 and 12 months	1.98
3 courses	1.45
4 courses	1.60
5 courses	2.15

"Whilewe understand that this type of study can't assign causality, it does appear that this needs to be looked at further. This could be a reason for increasing rates of food allergy," Dr. Love said.

Katie Allen, MD, from the Murdoch Children's Research Institute at the University of Melbourne in Australia, noted that it is not clear how the investigators controlled for eczema in this study.

"In our HealthNuts cohort of 5300 kids [Clin Exp Allergy.2010;40:1516-1522], we found a high rate of antibiotic use in kids with allergy. Unfortunately, almost all of it was due to the fact that they had infected eczema," she said.

"We think antibiotics being associated with food allergy is a spurious association, but it's really only associated with the treatment of infected eczema." Dr. Allen toldMedscape Medical News.

She added that "we know there's a lot of eczema in the first year of life. It may well be that antibiotic use is associated with eczema, and we know that eczema is associated with food allergy."

She thinks there is evidence that the widespread use of antibiotics has changed the microbiome at the population level. "But we need to do due diligence at the individual level to ensure that we're not making a spurious association," she noted.

"It's a wonderful hypothesis and we're all hotly looking at it, but...we need to be very careful to make sure that the work is of the highest quality and we don't jump on the bandwagon before we've looked at it properly," Dr. Allen noted.

This study was funded by the US Department of Health and Human Services Health Resources and Services Administration. The investigators and Dr. Allen have disclosed no relevant financial relationships..

American Academy of Allergy, Asthma & Immunology (AAAAI) 2013 Annual Meeting: Abstract L14. Presented February 26, 2013.