Probiotics Likely Do Little to Soothe Colicky Babies

Norra MacReady

October 09, 2013

Sad news for sleep-deprived parents: probiotics may not quiet their colicky babies, a new meta-analysis suggests.

Evidence is still insufficient "to support probiotic use to manage colic, especially in formula-fed infants, or to prevent infant crying," lead author Valerie Sung, MPH, and colleagues report in an article published online October 7 in JAMA Pediatrics.

Colic, defined as excessive crying or fussing for no apparent reason, affects up to 20% of infants younger than 3 months, but its etiology remains unclear, write Sung, from the Murdoch Children's Research Institute and Royal Children's Hospital, Parkville, Australia, and coauthors. Some evidence points to an association with food allergies, but other data show differences in gut microflora between babies with and without colic. "The logical next step is to determine whether intervening to alter gut microbiota can effectively prevent or reduce infant crying," the authors write.

Use of probiotics, products that use live microorganisms to confer health benefits, can change the infant gut environment and has been shown to suppress intestinal inflammation, strengthen mucosal barriers, and modulate gut contractility, any of which could produce uncomfortable symptoms and contribute to an infant's irritability. In a meta-analysis, the authors sought to determine whether probiotics were better than no or standard treatment at reducing the duration of infant crying or distress, number of episodes of crying or distress, and proportion of infants with colic (crying or fussing for at least 3 hours a day, at least 3 days a week, for at least 1 week).

The authors identified 12 randomized, clinical trials including 1825 infants: 271 term babies with colic, 1534 term infants without colic, and 20 preterm newborns without colic. Five studies focused on probiotics specifically to manage colic, and 7 examined the use of probiotics to reduce infant crying. Some of the studies examined use of a single product, whereas others looked at the use of multiple products administered together. The products were administered as drops, capsules, or formula in a range of doses. All of the studies were placebo-controlled. Daily infant crying time was the most common reported outcome. The analysis was conducted according to guidelines from the Cochrane Handbook for Systematic Reviews of Interventions.

Mean daily crying time was significantly less in 2 of 7 trials in which probiotics were used to prevent colic; there were no differences between probiotics and placebo in the other 5 trials. Of the 5 trials examining probiotics in the management of colicky episodes, probiotics were significantly more effective than placebo in 3 trials in whichLactobacillus reuteri was administered in drops to breast-fed, full-term infants. Compared with placebo, probiotics were associated in those trials with a median reduction in daily crying time of 62.10 minutes (95% confidence interval [CI], −85.82 to −44.38 minutes; P < .001), but there was substantial heterogeneity among the trials. The authors conclude that the effect of probiotics in treating colic remains unclear because of the difficulty in comparing studies that examined vastly different products on different populations.

At least one outside expert agrees with this conclusion, despite some reservations about the authors' methods. "The definition of colic was not rigorously controlled; there is likely to be no single cause of colic and no single treatment that is effective," said Frank R. Greer, MD, professor of pediatrics, Wisconsin Perinatal Center, Meriter Hospital, Madison, Wisconsin. "The dosages and specific probiotic preparations were too variable[, and] whether they were given prenatally or not to both mother and infant after delivery also was extremely variable." In addition, Dr. Greer told Medscape Medical News, "the authors did not use a validated methodology for recording the primary outcome, which was length of crying time."

In Dr. Greer's opinion, there is currently no place for probiotics in the management of infant colic. In contrast, he said, it has no serious adverse effects, "other than it adds unnecessarily to the cost of infant formula."

One author is a member of the Nestle Nutrition Institute Medical Advisory Board Oceania and the Nutricia Medical Advisory Board Australasia and received honoraria for speaking at symposia sponsored by the Nestle Nutrition Institute and Nutricia (Danone). She also received probiotic and placebo research products from Nestle Research Centre Switzerland and Dicofarm Italy for studies unrelated to this systematic review. No other conflicts of interest were reported. Dr. Greer has disclosed no relevant financial relationships.

JAMA Pediatrics. Abstract

AAP Guidance Tied to Less Intensive Bronchiolitis Management

Diedtra Henderson

December 02, 2013

The use of chest radiography, steroids, and bronchodilators for infants and toddlers with bronchiolitis decreased significantly after the American Academy of Pediatrics (AAP) published evidence-based clinical practice guidelines in 2006, according to a retrospective, observational cohort study.

Kavita Parikh, MD, a pediatric hospitalist in the Division of Hospitalist Medicine at Children's National Medical Center in Washington, DC, and colleagues published their results online December 2 in Pediatrics.

According to the National Institutes of Health, infants are often hospitalized during the winter and early spring with bronchiolitis, a respiratory ailment. Bronchiolitis accounts for $543 million in annual hospitalization charges, the authors note.

The AAP guidelines endorsed supportive care with oxygen and, when needed, hydration, and they counseled against diagnostic testing and medications unsupported by scientific evidence. To gauge the guidelines' impact, the researchers analyzed administrative billing data from 130,262 patients aged 1 to 24 months who were first admitted for bronchiolitis from November 1, 2004, to March 31, 2012, at 41 pediatric hospitals that contribute data to the Pediatric Health Information System.

The use of diagnostic chest radiography, corticosteroids, and bronchodilators (P < .0001) decreased significantly. Antibiotic use also trended downward, but the magnitude of the change did not achieve statistical significance.

"For hospitalized patients with bronchiolitis aged 1 to 24 months, we show a temporal association between publication of the 2006 AAP bronchiolitis guidelines and a decrease in resource use, including both diagnostic tests (CBC [complete blood cell] count and CXR [chest radiography]) and therapies (corticosteroids and bronchodilators)," the authors write. "Although we cannot demonstrate a causal relationship, this reduction of diagnostic testing and treatment resources for bronchiolitis after guideline publication is striking and may be reducing costs associated with this common respiratory illness."

Among the limitations of the study, the administrative and billing database used by the researchers did not include detailed clinical information, and the team relied on diagnosis and procedure codes to select patients. In addition, the database does not include community hospitals, which treat more than 70% of infants and toddlers with bronchiolitis.

"The AAP's publication of its 2006 evidence-based guidelines for bronchiolitis was associated with a reduction of non–evidence-based diagnostic testing and medication use for inpatients in a representative sample of children's hospitals. These trends may demonstrate a benefit of nationally developed guidelines to reduce variations in care and unnecessary costs," Dr. Parikh and coauthors conclude.

One study author disclosed receiving funding from the Academic Pediatric Association. The remaining authors have disclosed no relevant financial relationships.

Pediatrics. Published online December 2, 2013. Abstract

Nondrug Treatment for Chronic Tension Headache in Teens

Fran Lowry

October 01, 2013

ORLANDO, Florida — Chronic tension-type headache (CTTH), which may affect up to 20% of teens, can be successfully treated without pharmacologic agents, a new study shows.

A retrospective review of 83 adolescents diagnosed with CTTH found that osteopathic manipulation and instruction in daily mindfulness and the traditional Chinese practice of qi gong was more effective than pharmacologic therapy in relieving their headaches.

"There is nothing in the literature for these kids, who often end up on chronic opioids," lead author Peter Przekop, DO, PhD, from the Betty Ford Center, Rancho Mirage, and Loma Linda University School of Medicine, Loma Linda, California, told Medscape Medical News.

The results were presented here at the American Academy of Pain Management (AAPM) 24th Annual Clinical Meeting.

"I wanted to figure out some way to help them because I see about 60 to 80 teens with this condition a year, and they are miserable. They are not doing well in school, they are not doing well in life. I don't want them on medications, which is always a problem in kids because the brain is changing and developing until 22 to 24 years in females and age 26 in males. Centrally acting medications can affect this development," Dr. Przekop said.

To compare the efficacy of pharmacologic vs nonpharmacologic treatment in teens with CTTH, Dr. Przekop and his team reviewed the charts of 83 adolescents (67 girls and 16 boys) who presented to their outpatient clinic for headache management between 2009 and 2013. Their average age was 15.7 years (range, 13 to 18 years).

There were 2 treatment groups. Group 1 (n = 44 patients) received amitriptyline or gabapentin as daily preventive medication. Group 2 (n = 39 patients) received bimonthly osteopathic manipulation and instruction in daily mindfulness and internal qi gong.

"Qi gong is a traditional Chinese practice that aligns breathing, slow, repeated movements and awareness to promote healing," Dr. Przekop explained. "The instruction on how to do mindfulness involves telling the patients to close their eyes, get in touch with what they were feeling inside, breathe, and stop the story going on in their head, to stop the story."

The teens in the experimental group were taught an internal qi gong routine that consisted of 6 simple moves that they practiced each day.

Both groups were assessed at study entry, 3 months, and 6 months to see whether the number and intensity of their headaches changed and whether the intervention affected their general health and quality of life.

Both groups improved, but the improvement was much more dramatic in the group that did qi gong and practiced mindfulness, Dr. Przekop said.

The nonpharmacologic intervention produced better results in headache frequency, headache pain intensity, general health, social activity, and number of tender points in the trapezius, cervical spine, and superior occipital notch than did pharmacologic treatment (P = .001 for all 5 measures).

Over the 6-month period, headache frequency decreased from 23.9 to 16.4 in the pharmacologic treatment group and from 22.3 to 4.9 in the nonpharmacologic group.

"Their perception of their general health improved, and most of these kids actually did quite well," Dr. Przekop said.

"If you meet these kids, they're not doing well in school, they don't have friends, they're staying home, they don't feel good about themselves. That's the thing I wanted to change, and that actually improved," he pointed out. "I think they were able to cope with their overall pain and overall stress and change the way they perceived the world and how they perceived themselves.

"Most pain has a cognitive component, which is how you perceive the world, how you perceive yourself, how you perceive life, and it has an emotional component where these children can't handle negative emotions. That's the thing that really changes with this treatment," he said.

One potential problem is that insurance often will not pay for nonpharmacologic treatment, Dr. Przekop noted.

"These groups were divided pretty much by what insurance would pay. All insurance plans will pay for amitriptyline and gabapentin; few insurances will pay for the other. Some of the kids actually heard that the kids on the nonpharmacologic treatment were improving, and the parents then came and paid cash. It's sad, but that's the state of affairs that we're in now."

Teens Want Control of Their Lives

Gerard J. Hevern, MD, from New Hampshire's Hospital for Children in Allenstown, New Hampshire, commented on this study for Medscape Medical News.

I've never seen anything quite like this before, and I think it makes some sense, because when pediatric patients come in they are looking for ways to maintain control of their lives without the use of medications, and if you create the opportunity, many of them will grab on to it," Dr. Hevern, who is also a practitioner at Elliot Pain Management Center in Manchester, New Hampshire, said.

"Also, the parents are very concerned about beginning their children on these medications, especially over the long run, so this is a great opportunity to begin to say that these nonpharmacological things actually do work as good, if not better than medications," he said.

Dr. Przekop and Dr. Hevern have disclosed no relevant financial relationships.

American Academy of Pain Management (AAPM) 24th Annual Clinical Meeting. Abstract #25. Presented September 27, 2013.

Early Worries Predict Breast-feeding Discontinuation

Jenni Laidman

September 24, 2013

First-time mothers who expressed concerns about breast-feeding their new baby 3 days postpartum were 9 times more likely to stop breast-feeding by 60 days postpartum than mothers who reported no concerns in a new study.

The study was published online September 23 in Pediatrics.

Erin A. Wagner, MS, clinical research coordinator, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Ohio, and colleagues, assessed prenatal intent to breast-feed, postnatal support for breast-feeding, and concerns about breast-feeding among 532 expectant primiparas who took part in a prospective cohort study at the University of California Davis Medical Center. The researchers interviewed the women between 32 and 40 weeks' gestation and then postpartum on days 0, 3, 7, 14, 30, and 60 postpartum or until the mother reported she was no longer breast-feeding. Overall, they conducted 2946 interviews and tallied 4179 breast-feeding concerns.

They found that any expression of breast-feeding concern postpartum was associated significantly with an increased likelihood of discontinuation of breast-feeding within 60 days postpartum, with the peak adjusted relative risk at day 3 of 9.2 (95% confidence interval [CI], 3.0 - infinity). The authors adjusted for maternal education and prenatal breast-feeding intention.

Maternal concerns that associated with the largest adjusted population attributable risk (PAR) for discontinuation of breast feeding were "infant feeding difficulty" on day 7 (PAR, 32%) and "milk quantity" on day 14 (PAR, 23%). PAR stands for the excess proportion of mothers no longer breast-feeding who, theoretically, could have kept breast-feeding with the right intervention at the right time.

Concerns expressed on day 3 represented the highest relative risk not only for discontinuation of breast-feeding but also for the use of formula between days 30 and 60 (adjusted relative risk, 3.3; 95% CI, 1.7 - 15.0).

Almost all study participants (92%) reported at least 1 concern on day 3 postpartum, the peak day for expression of concern. The most frequent concerns were difficulty with the infant feeding at the breast (54%), breast-feeding pain (44%), and milk quantity (41%). Day 3 was the peak day for reporting of infant feeding difficulties, and day 7 was the peak for reports of pain at breast-feeding (47%). Breast-feeding pain remained the most prevalent concern at later interviews. Milk quantity concerns peaked at day 3 (41%).

The concerns that most significantly associated with discontinuation of breast feeding by day 60 or use of formula between days 30 and 60 were a mention in at least 1 postpartum interview of concerns about milk quantity, infant feeding difficulty, uncertainty about breast-feeding ability, and "sign of insufficient intake."

Thirty-four women expressed no breast-feeding concerns on day 3, and only 1 of those had stopped breast-feeding by day 60. In a post hoc analysis, the authors found that these 34 women were more likely to be younger than 30 years, Hispanic, and report strong breast-feeding support. They were also more likely to have expressed a strong prenatal breast-feeding self-efficacy and have had an unmedicated vaginal delivery.

Prenatal expression of a desire to breast-feed exclusively for at least 60 days was no guarantee mothers would do so. Among the 354 women who planned to use breast milk alone for more than 2 months, 47% (166) used at least some formula between days 30 and 60. Of 406 women who planned prenatally to breast-feed for more than 2 months, 21% (86) had stopped breast-feeding by day 60.

One coauthor received a stipend for presenting a lecture at the National WIC Association meeting in 2012. The other authors have disclosed no relevant financial relationships.

Pediatrics. Published online September 23, 2013. Abstract

The Healthy Short Child: How Much Testing?

William T. Basco, Jr., MD, MS

November 26, 2013

Low Incidence of Pathology Detection and High Cost of Screening in the Evaluation of Asymptomatic Short Children

Sisley S, Trujillo MV, Khoury J, Backeljauw P
J Pediatr. 2013;163:1045-1051

Study Summary

Guidelines published in 2008^[1] suggest a standard panel of screening laboratory and radiologic tests for all patients with short stature (< 2 SD below the mean) if the patient's history and physical examination do not identify a specific diagnosis. The recommended tests include the following:

• Complete blood count;
• Basic metabolic panel;
• Erythrocyte sedimentation rate;
• Calcium and phosphorus levels;
• Serum albumin level;
• Alkaline phosphatase level;
• Tissue transglutaminase level;
• Immunoglobulin A assessment;
• Growth factor profile;
• Thyroid tests;
• Karyotype (for girls); and
• Bone age.

The current study was conducted to identify how often the recommended screening procedure identifies a pathologic diagnosis. The researchers added a cost analysis to their investigation.

The study involved a cohort of children who were referred for short stature to a single pediatric endocrinology clinic during 2008-2011. Children were included if their height was < 3rd percentile; previous height velocity was < 5 cm/yr; and if no diagnosis could be made after history, review of systems, and physical examination.

Ultimately, the researchers identified 235 children for analysis. In addition to body measurement data, data on parental stature, and typical clinical data, they evaluated the yield of the screening tests recommended in the 2008 guidelines.

Study Findings

Of the 235 children, 72.8% were boys, and the mean age of referral was 10 years. Tanner stage I pubertal development was exhibited at the time of the first evaluation of 60.6% of the children, and 24.9% exhibited Tanner stage II. The average height SD was -2.5.

Three (1.3%) of the children in the study were identified as having short stature due to a pathologic diagnosis. One child had confirmed celiac disease, another child had a possible insulin-like growth factor-1 receptor defect, and the third had an abnormal tissue transglutaminase level that could not be confirmed.

Among the 232 children who did not have a pathologic diagnosis, 36% were diagnosed with idiopathic short stature. Another 41% were diagnosed with constitutional growth delay and 23% with familial short stature.

Among all of the children, the average percentage of recommended tests completed was 64.3%, with the average cost of testing amounting to $1341 for each patient. This resulted in a cost of $105,000 per pathologic diagnosis identified. If the patients had completed all of the recommended testing, the cost would have averaged $2385 per patient.

The investigators concluded that healthy children with short stature do not warrant broad screening, and they instead urge moving toward an approach that is patient-specific.

Viewpoint

The value of this report for general pediatric providers is to remind us of the short stature screening that can be completed in the primary care setting. In an accompanying editorial,^[2] Dr. Rogol argues that the primary care provider and his or her long-term knowledge of the patient may be the best test for identifying a cause of short stature. However, both the study authors and the editorialist suggest that the menu of screening laboratory tests should be shortened on the basis of the child's history.

I would bet that the data to help us accomplish that are available, although they are probably isolated in individual pediatric endocrine clinics across the country. If these data could be pooled, it would be a relatively simple (but admittedly time-consuming) analytic effort to identify which of these suggested screening laboratory tests have the highest overall yield, and even prioritize them according to the presenting scenario. For example, do the highest yield tests vary by the age of the patient? Or do tests have different yields if the parents are of normal vs short stature?

Antibiotics for Acute Otitis Media in Children

Principles for Judicious Antibiotic Prescribing

Lauri Hicks, DO

November 19, 2013

Hello. I'm Lauri Hicks, medical director of CDC's Get Smart: Know When Antibiotics Work program. Did you know that ear infection, specifically acute otitis media (AOM), leads to more antibiotic prescriptions than any other syndrome? Just this year, the American Academy of Pediatrics (AAP) released updated clinical practice guidelines for the diagnosis and management of AOM. Although many episodes are self-limited, more than 3 out of 4 visits for AOM result in an antibiotic prescription. I urge you to apply 3 principles of judicious antibiotic use in your practice to improve the quality of care for your patients with AOM and reduce unnecessary antibiotic use.

Principle 1. Determine the likelihood of a bacterial infection. The AAP guideline states that an AOM diagnosis requires either of the following 2 conditions: evidence of middle-ear effusion, as demonstrated by moderate to severe bulging of the tympanic membrane (TM), or new onset of otorrhea that is not caused by otitis externa. AOM may also be diagnosed when a child presents with only mild bulging of the TM but with additional symptoms of recent onset of ear pain or intense erythema of the TM. If your patient does not have these findings, antibiotics are not indicated.

Principle 2. For patients who meet diagnostic criteria for AOM but may not need antibiotic treatment, apply principle 2: Weigh the benefits vs the harms of antibiotics.It's important to consider the potential harms of antibiotics every time you prescribe them. Antibiotic-related adverse drug events are among the most frequent causes of drug-related emergency room visits among children in the United States. Although symptoms may improve more rapidly with antibiotic therapy, each time a patient receives an antibiotic, there is a risk for adverse events, including diarrhea, dermatitis, C difficile colitis, and subsequent development of antibiotic resistance.

At least half of patients with AOM will recover without antibiotic therapy. If your patient has findings consistent with AOM, always consider disease severity, laterality, and patient age when determining whether to prescribe an antibiotic. Children who benefit the most from antibiotics are less than 24 months of age, have severe disease, or have bilateral infection. Consider observation, also termed "wait and see," or "delayed prescribing" instead of immediate antibiotic therapy. Observation may be considered an alternative strategy for AOM management for children at least 6 months of age without severe symptoms. Studies among patients with AOM have shown that this approach reduces antibiotic use, is well accepted by families, and when supported by close follow-up and patient education, does not result in worse clinical outcomes. The use of this approach is an opportunity to engage in a discussion about the potential benefits and risks associated with antibiotic therapy.

Principle 3. If your patient has a diagnosis of AOM and the benefits of prescribing outweigh the harms, apply principle 3: Implement judicious prescribing strategies.Select the recommended antibiotic agent that treats the most likely pathogens: amoxicillin or amoxicillin-clavulanate. Prescribe the appropriate dose for the shortest duration required, commensurate with patient age and disease severity. For children 2 years or younger with severe symptoms, a 10-day course is recommended. For children 2-5 years old with mild or moderate disease, a 7-day course is recommended. For children 6 years or older with mild to moderate disease, the recommended treatment course is 5-7 days.

Remember that the principles of judicious antibiotic use include establishing the likelihood of a bacterial infection, weighing the benefits vs the harms of antibiotics, and employing judicious prescribing practices. If parents demand antibiotics when they are not indicated, we recommend sharing your treatment rules, highlighting the potential adverse effects of antibiotics, and creating a treatment plan directed at symptomatic relief.

When it comes to managing AOM, we recognize the challenges that you face with making an accurate diagnosis and communicating your findings and treatment plans to parents. To encourage appropriate antibiotic use, CDC has created resources for both patients and providers, such as symptomatic prescription pads. For more information about guidelines and other tools related to antibiotic use, refer to the links below and visit our Get Smart site. Thanks for tuning in to this CDC Expert Video Commentary on Medscape.

Joint BSPGHAN and Coeliac UK Guidelines for the Diagnosis and Management of Celiac Disease in Children

Joint BSPGHAN and Coeliac UK Guidelines for the Diagnosis and Management of Celiac Disease in Children

Για το άρθρα πατήστε ΕΔΩ.