Machine Learning for Clinical Decision Support of Acute Streptococcal Pharyngitis: A Pilot Study

BACKGROUND

Group A Streptococcus (GAS) is the predominant bacterial pathogen of pharyngitis in children. However, distinguishing GAS from viral pharyngitis is sometimes difficult. Unnecessary antibiotic use contributes to unwanted side effects, such as allergic reactions and diarrhea. It also may increase antibiotic resistance.

OBJECTIVES

To evaluate the effect of a machine learning algorithm on the clinical evaluation of bacterial pharyngitis in children.

METHODS

We assessed 54 children aged 2-17 years who presented to a primary healthcare clinic with a sore throat and fever over 38°C from 1 November 2021 to 30 April 2022. All children were tested with a streptococcal rapid antigen detection test (RADT). If negative, a throat culture was performed. Children with a positive RADT or throat culture were considered GAS-positive and treated antibiotically for 10 days, as per guidelines. Children with negative RADT tests throat cultures were considered positive for viral pharyngitis. The children were allocated into two groups: Group A streptococcal pharyngitis (GAS-P) (n=36) and viral pharyngitis (n=18). All patients underwent a McIsaac score evaluation. A linear support vector machine algorithm was used for classification.

RESULTS

The machine learning algorithm resulted in a positive predictive value of 80.6 % (27 of 36) for GAS-P infection. The false discovery rates for GAS-P infection were 19.4 % (7 of 36).

CONCLUSIONS

Applying the machine-learning strategy resulted in a high positive predictive value for the detection of streptococcal pharyngitis and can contribute as a medical decision aid in the diagnosis and treatment of GAS-P.

Personal hygiene, environmental conditions, and toilet use of children in primary schools: A cohort study

BACKGROUND

Many primary school children withhold urine and stool whilst at school for various reasons. Limited toilet access and the failure to provide safe, sanitary toilets are putting children at risk for toilet avoidance behavior.

OBJECTIVE

We aimed to examine personal hygiene, environmental conditions, the perception of these on children, and their toilet use in primary schools.

STUDY DESIGN

Children aged 6-12 and their parents were asked to complete a self-report questionnaire regarding toilet behavior and the perception of school toilet standards.

RESULTS

The main findings are listed below using the data from the questionnaire.

DISCUSSION

We found that 9% and 63% of the children avoided urination and defecating at school, respectively. Similar results were reported previously. The participants' perceptions regarding the environmental conditions of school toilets and conditions revealed that 34% of the children felt that the toilets were dirty or very dirty. Around one-third of them reported a lack of toilet paper sometimes or most of the time. These unsatisfying hygienic conditions of school toilets can be easily solved. Unfortunately, 46% of the children in our study experienced bullying in school toilets. These worrisome data are seldom reported in other studies. The urination habits of the girls, who mostly preferred to partially squat or stand may lead to dysfunctional voiding and incomplete bladder emptying. Our study was limited by the relatively small population, the subjectiveness of the self-reporting questionnaire, and the voiding and defecation habits of the investigated children during school hours. These hours do not necessarily reflect the children's habits after school hours and during the weekends. Despite these limitations, the discussed issues regarding personal hygiene and the environmental conditions in the sampled primary schools are extremely important.

CONCLUSION

Nearly half of the school children had negative perceptions of school toilets. This should raise awareness and concern for school staff to consider and investigate potential facilities improvement in light of the impact observed here. Implementation of appropriate education and a better environment of toilet facilities and security is important for the children's well-being.

Antibiotic Stewardship for Community-Acquired Pediatric Pharyngitis: A Pre-Post Intervention Study

BACKGROUND

Group A Streptococcus (GAS), the predominant bacterial pathogen of pharyngitis, is sometimes difficult to distinguish clinically from viral pharyngitis. Despite the high prevalence of viral pharyngitis in children, antibiotic treatment is common.

OBJECTIVES

To investigate the effectiveness of an antibiotic stewardship program (ASP) on antibiotic prescription in children with GAS pharyngitis (GAS-P) at a large pediatric community clinic.

METHODS

Antibiotic prescription data were collected from October 2016 to March 2017 (pre-intervention period) and from October 2017 to March 2018 (post-intervention period). The intervention was a one-day seminar for primary care pediatricians on the diagnosis and treatment of GAS-P in children according to national guidelines.

RESULTS

The overall prevalence of testing differed between the two time periods. There was a decrease in children who did not undergo any testing (from 68% to 63%), an increase in streptococcal rapid antigen detection testing (28% to 32%), and a slight increase in throat cultures (3% to 4%) (P = 0.02). There was no change in the types of antibiotics prescribed before and after the intervention (P = 0.152).

CONCLUSIONS

The ASP resulted in a slight reduction in the percentage of children who did not undergo laboratory testing for GAS-P and a slight reduction in the percentage of children who received antibiotic treatment. The ASP did not reduce the use of broad-spectrum antibiotics and macrolides.

COVID-19 vaccine compliance in adolescents with attention-deficit/hyperactivity disorder

OBJECTIVE

To compare the rate of the administration of the Pfizer-BioNTech COVID-19 vaccinations between adolescents diagnosed with attention-deficit/hyperactivity disorder (ADHD) and non-ADHD subjects.

METHOD

A retrospective chart review was performed on all adolescents aged 12-17 years registered at a central district in Israel from January 1^st 2021 to October 31^st 2021.

RESULTS

Of the 46,544 subjects included in the study, 8241 (17.7%) were diagnosed with ADHD. Of them, 3% were PCR-COVID-19 positive. Among the patients with ADHD, the older adolescents were more likely to be vaccinated: 48.8% of those aged 12-15 years were vaccinated versus 59.6% of patients aged 16-17 years. The ultra-orthodox Jewish and Arab adolescents in the ADHD group were far less likely to be vaccinated (22.9% and 34.6%, respectively), compared to the adolescents with ADHD in the general population (60.5%). Girls were also somewhat more likely to be vaccinated.

CONCLUSIONS

Adolescents diagnosed with ADHD had a higher COVID-19 vaccination rate compared to their non-ADHD counterparts. The vaccine uptake was lower amongst Arab and ultra-orthodox Jewish populations.

Pediatric Antibiotic Stewardship for Community-Acquired Pneumonia: A Pre-Post Intervention Study

We aimed to investigate the effectiveness of an antibiotic stewardship program (ASP) on antibiotic prescription in children with community-acquired pneumonia (CAP). Antibiotic purchasing data were collected for children aged 3 months to 18 years diagnosed with CAP from November 2016 to April 2017 (pre-intervention period) and from November 2017 to April 2018 (post-intervention period). The intervention was a 1-day seminar for primary care pediatricians on the diagnosis and treatment of CAP in children according to national guidelines. There was a substantial decrease in the use of azithromycin after the intervention. In younger children, there was a 42% decrease, alongside an increased use of amoxicillin (P < .001). In older children, there was a smaller, non-statistically significant decrease in the use of azithromycin (P = .45). Our data demonstrate that the implementation of an ASP was associated with a reduction in the use of broad-spectrum antibiotics and macrolides and increased guideline adherence for the safe treatment of CAP.

Acceptance Rates of COVID-19 Vaccine Highlight the Need for Targeted Public Health Interventions

We aimed to examine rates of COVID-19 vaccination to elucidate the need for targeted public health interventions. We retrospectively reviewed the electronic medical files of all adults registered in a central district in Israel from 1 January 2021 to 31 March 2022. The population was characterized by vaccination status against COVID-19 and the number of doses received. Univariate and multivariable analyses were used to identify predictors of low vaccination rates that required targeted interventions. Of the 246,543 subjects included in the study, 207,911 (84.3%) were vaccinated. The minority groups of ultra-Orthodox Jews and Arabs had lower vaccination rates than the non-ultra-Orthodox Jews (68.7%, 80.5% and 87.7%, respectively, p < 0.001). Adults of low socioeconomic status (SES) had lower vaccination rates compared to those of high SES (74.4% vs. 90.8%, p < 0.001). Adults aged 20−59 years had a lower vaccination rate than those ≥60 years (80.0% vs. 92.1%, p < 0.0001). Multivariate analysis identified five independent variables that were significantly (p < 0.001) associated with low vaccination rates: minority groups of the ultra-Orthodox sector and Arab population, and underlying conditions of asthma, smoking and diabetes mellitus (odds ratios: 0.484, 0.453, 0.843, 0.901 and 0.929, respectively). Specific targeted public health interventions towards these subpopulations with significantly lower rates of vaccination are suggested.

Trends in Pediatric Ambulatory Practice during COVID-19 Lockdown

BACKGROUND

On 18 March 2020, the Israeli Health Ministry issued lockdown orders to mitigate the spread of coronavirus disease 2019 (COVID-19).

OBJECTIVES

To assess the association of lockdown orders on telemedicine practice and the effect of social distancing on infectious diseases in a primary care community pediatric clinic as well as the rate of referrals to emergency departments (ED) and trends of hospitalization.

METHODS

Investigators performed a retrospective secondary data analysis that screened for visits in a large pediatric center from 1 January to 31 May 2020. Total visits were compared from January to December 2020 during the same period in 2019. Visits were coded during the first lockdown as being via telemedicine or in-person, and whether they resulted in ED referral or hospitalization. Month-to-month comparisons were performed as well as percent change from the previous year.

RESULTS

There was a sharp decline of in-person visits (24%) and an increase in telemedicine consultations (76%) during the first lockdown (p < 0.001). When the lockdown restrictions were eased, there was a rebound of 50% in-person visits (p < 0.05). There was a profound decrease of visits for common infectious diseases during the lockdown period. Substantial decreases were noted for overall visits, ED referrals, and hospitalizations in 2020 compared to 2019.

CONCLUSIONS

COVID-19 had a major impact on primary care clinics, resulting in fewer patient-doctor encounters, fewer overall visits, fewer ED referrals, and fewer hospitalizations.

Attention-Deficit/Hyperactivity Disorder as a Risk Factor for COVID-19 Infection

OBJECTIVE

To postulate that ADHD is a potential risk factor for COVID-19 infection; to evaluate the COVID-19 risk factor on drug-treated ADHD subjects.

METHODS

A retrospective chart review was performed on ADHD subjects aged 6 to 18 years in Israel, who had undergone at least one COVID-19 test during the study period.

RESULTS

Of the 64,409 subjects included in the study, 6,207 (9.64%) had at least one positive COVID-19 test result, 13,300 (20.65%) were diagnosed with ADHD, and of whom 1,751 (13%) had purchased at least two ADHD medications 3 months prior to COVID-19 testing and were defined as being medically treated. Medically-treated ADHD subjects had a significantly lower likelihood to be infected with COVID-19 than untreated subjects.

CONCLUSION

Untreated ADHD patients seem to constitute a risk group for COVID-19 infection. Drug treatment ameliorates risk of spreading COVID-19 infection within the pediatric population and secondary spread in the general population.

How to increase COVID-19 vaccine uptake among children? determinants associated with vaccine compliance

OBJECTIVE

Three aims: to elucidate determinants associated with COVID-19 vaccine uptake in children and the association with parental vaccination; to compare rates of PCR-positive SARS-CoV-2 results between vaccinated and unvaccinated children; to estimate the rate of parental COVID-19 vaccination and its association with the vaccination rate of their children.

METHODS

We performed a retrospective chart review of all children aged 5-11 years registered at a central district in Israel from November 21st, 2021 to April 30th, 2022, and characterized COVID-19 vaccinated vs. unvaccinated individuals. Data retrieved from the electronic medical files included: demographics [age, gender, sector, socioeconomic status (SES)]; COVID-19 vaccination (first and second doses) and influenza vaccination status; co-morbidities; and parental vaccinations for COVID-19. We divided the population into three distinct demographic groups: non-ultra-orthodox Jews (43,889 children), ultra-orthodox Jews (13,858 children), and Arabs (4,029 children).

RESULTS

Of the 61,776 children included in the study, 20,355 (32.9%) received at least one dose of the COVID-19 vaccine. Vaccination rates were similar amongst males and females and were higher in children aged 9-11 years compared to children aged 5-6 years. Multivariate analysis identified five independent determinants that were significantly (p < 0.001) associated with low vaccination rates: Arab and ultra-orthodox sectors (odds ratios: 0.235 and 0.617, respectively); children aged 5-8 years; children of low SES; and children who had not received previous seasonal influenza vaccination. Relatively high vaccination rates were noted amongst children with the following medical co-morbidities: treatment with biological agents (42.9%); solid tumor transplantation (42.9%); type 1 diabetes mellitus (38.5%), asthma (38.2%), and attention deficit and hyperactivity disorder (ADHD) (37.6%). Regarding the uptake of two vaccine doses among children with co-morbidities, it was highest in those with type 1 diabetes mellitus, heart failure, treatment with biological agents, asthma and obesity.

CONCLUSION

This study highlights several pediatric sub-populations with low and high vaccine uptake. It is essential to focus on determinants associated with low vaccination rates.

High rates of serology testing for coeliac disease, and low rates of endoscopy in serologically positive children and adults in Israel: lessons from a large real-world database

BACKGROUND

Although coeliac disease is common worldwide, little is known regarding screening patterns in unselected populations, and on real-life adherence to professional guidelines for coeliac disease diagnosis and management.

OBJECTIVE

To explore current practices in the diagnosis and management of coeliac disease, using data from a large Health Maintenance Organization in Israel that covers 54% of the population.

METHODS

A population-based electronic database of about 4.5 million individuals was reviewed during the period of 1 January 2008 to 31 December 2015. Rates and results of coeliac disease serology testing and endoscopy procedures were examined. Subgroup analysis was performed by age, sex, ethnicity and socioeconomic status.

RESULTS

Coeliac disease serology cumulative testing rate was 17.1% and 8.9% in the paediatric and adult population, respectively. The cumulative incidence of positive coeliac disease serology was 0.45% in children and 0.17% in adults, and was associated with age, sex, ethnicity and socioeconomic status sub-groups (P-value < 0.01). Gastrointestinal endoscopies were not subsequently performed in 44.1% of children and 47.1% of adults with positive coeliac disease serology. Within the study period, 36% of children and 56% of adults never achieved coeliac disease serology normalization.

CONCLUSION

In a large real-life database, screening for coeliac disease was common. However, confirmatory intestinal biopsies were under-utilized, and coeliac disease serology often remained positive over a long period time in both children and adults.

Burnout and intentions to quit the practice among community pediatricians: associations with specific professional activities

BACKGROUND

Burnout is an occupational disease expressed by loss of mental and physical energy due to prolonged and unsuccessful coping with stressors at work. A prior survey among Israeli pediatricians published in 2006 found a correlation between burnout and job structure match, defined as the match between engagement with, and satisfaction from, specific professional activities. The aims of the present study were to characterize the current levels of burnout and its correlates among community pediatricians, to identify changes over time since the prior survey, and to identify professional activities that may reduce burnout.

METHODS

A questionnaire was distributed among pediatricians both at a medical conference and by a web-based survey.

RESULTS

Of the 518 pediatricians approached, 238 (46%) responded to the questionnaire. High burnout levels were identified in 33% (95% CI:27-39%) of the respondents. Higher burnout prevalence was found among pediatricians who were not board-certified, salaried, younger, and working long hours. The greater the discrepancy between the engagement of the pediatrician and the satisfaction felt in the measured professional activities, the greater was the burnout level (p < 0.01). The following activities were especially associated with burnout: administrative work (frequent engagement, disliked duty) and research and teaching (infrequent engagement, satisfying activities). A comparison of the engagement-satisfaction match between 2006 and 2017 showed that the discrepancy had increased significantly in research (p < 0.001), student tutoring (P < 0.001), continuing medical education and participation in professional conferences (P = 0.0074), management (p = 0.043) and community health promotion (P = 0.006). A significant correlation was found between burnout and thoughts of quitting pediatrics or medicine (p < 0.001).

CONCLUSIONS

Healthcare managers should encourage diversification of the pediatrician's job by enabling greater engagement in the identified "anti-burnout" professional activities, such as: participation in professional consultations, management, tutoring students and conducting research.

Efficacy and tolerability of a polysaccharide-resin-honey based cough syrup as compared to carbocysteine syrup for children with colds: a randomized, single-blinded, multicenter study

BACKGROUND

Available pediatric treatments for acute cough are limited by lack of demonstrated efficacy. The objective of this trial is to compare the effects of a polysaccharide-resin-honey based cough syrup, and carbocysteine syrups on nocturnal and daytime cough associated with childhood upper respiratory tract infections (URIs).

METHODS

Using a single-blind randomization design, the study recruited children from 4 general pediatric community clinics. Participants included 150 children aged 2 to 5 years with an URI, nocturnal and daytime cough and illness duration of ≤7 days. To be eligible, children had to be free of medication on the day before presentation. A survey was administered to parents on 4 consecutive days beginning from the day of presentation in clinic. Children received the study preparation on the first evening and then 3 times per day for 3 further days. Main outcome measures were cough frequency, cough severity, bothersome nature of cough, and quality of sleep for both child and parent.

RESULTS

Both preparations were well tolerated and cough improved over the study period. After one night and on all survey days, there was a significantly better result for polysaccharide-resin-honey (P<0.05) for all the main outcome measures. The trend of improvement over the 4 days was steeper for polysaccharide-resin-honey (P<0.05) with regards to all cough parameters.

CONCLUSIONS

Both polysaccharide-resin-honey and carbocysteine cough syrups were well tolerated in children over 2 years of age. The polysaccharide-resin-honey syrup was associated with a more rapid and greater improvement in all clinical cough symptoms measured, beginning from the first night of therapy. Both nocturnal and daytime cough improved, as did sleep quality for both children and parents.

A survey of energy drink and alcohol mixed with energy drink consumption

Background

Energy drink consumption among youth is increasing despite recommendations by the American Academy of Pediatrics to eliminate consumption by youth. This study provides information on consumption of energy drinks and alcohol mixed with energy drinks (AmED) in a sample of Israeli youth and how consumer knowledge about the risks affects consumption rates.

Methods

The study was conducted in three Tel Aviv public schools, with a total enrollment of 1,253 students in grades 8 through 12. Among them, 802 students completed a 49-item questionnaire about energy drink and AmED consumption, for a 64 % response rate Non-responders included 451 students who were absent or refused to participate. All students in the same school were administered the questionnaire on the same day.

Results

Energy drinks are popular among youth (84.2 % have ever drunk). More tenth through twelfth grade students consumed energy drinks than eighth and ninth grade students. Students who began drinking in elementary school (36.8 %) are at elevated risk for current energy drink (P < .001) and AmED (P = .002) use. Knowledge about amounts consumed and recommended allowances is associated with less consumption (OR 1.925; 95 %CI 1.18–3.14).

Discussion

The association between current AmED consumption and drinking ED at a young age is important. Boys and those who start drinking early have a greater risk of both ED and AmED consumption. The characteristics of early drinkers can help increase awareness of potential at-risk youth, such as junior and senior high school students with less educated or single parents.

Conclusions

Risks posed by early use on later energy drink and AmED consumption are concerning. We suggest that parents should limit accessibility. Increased knowledge about acceptable and actual amounts of caffeine in a single product might decrease consumption.

Seasonality of asthma: a retrospective population study

OBJECTIVES

Seasonal variations in asthma are widely recognized, with the highest incidence during September. This retrospective population study aimed to investigate whether this holds true in a large group of asthmatic children in primary care and to assess the impact of age, gender, urban/rural living, and population sector.

METHODS

The key study outcomes were the diagnosis of asthma exacerbations and asthma medication prescriptions, recorded by family physicians during 2005 to 2009. These were analyzed by "week of diagnosis" in Clalit Health Services' electronic medical record database. Regression models were built to assess relative strength of secular trends, seasonality, and age-group in explaining the incidence of asthma exacerbations.

RESULTS

A total of 919,873 children aged 2 to 15 years were identified. Of these, 82,234 (8.9%) were asthmatic, 61.6% boys and 38.4% girls; 49.1% aged 2 to 5 years, 24.1% 6 to 9 years, and 26.8% 10 to 15 years. We observed a 2.01-fold increase in pediatric asthma exacerbations and 2.28-fold increase in prescriptions of asthma bronchodilator medications during September (weeks 37-39 vs weeks 34-36) compared with August. The association between the opening of school and the incidence of asthma-related visits to the primary care physician was greatest in children aged 2 to 5 years (odds ratio, 2.15) and 6 to 11 years (1.90-fold). Adolescents (age 12-15 years) had a lesser peak (1.81-fold). In late fall there was a second rise, lasting with fluctuations throughout winter, with a trough in summer.

CONCLUSIONS

Returning to school after summer is strongly associated with an increased risk for asthma exacerbations and unscheduled visits to the primary care physician.

Effect of honey on nocturnal cough and sleep quality: a double-blind, randomized, placebo-controlled study

OBJECTIVES

To compare the effects of a single nocturnal dose of 3 honey products (eucalyptus honey, citrus honey, or labiatae honey) to placebo (silan date extract) on nocturnal cough and difficulty sleeping associated with childhood upper respiratory tract infections (URIs).

METHODS

A survey was administered to parents on 2 consecutive days, first on the day of presentation, when no medication had been given the previous evening, and the following day, when the study preparation was given before bedtime, based on a double-blind randomization plan. Participants included 300 children aged 1 to 5 years with URIs, nocturnal cough, and illness duration of ≤ 7 days from 6 general pediatric community clinics. Eligible children received a single dose of 10 g of eucalyptus honey, citrus honey, labiatae honey, or placebo administered 30 minutes before bedtime. Main outcome measures were cough frequency, cough severity, bothersome nature of cough, and child and parent sleep quality.

RESULTS

In all 3 honey products and the placebo group, there was a significant improvement from the night before treatment to the night of treatment. However, the improvement was greater in the honey groups for all the

CONCLUSIONS

Parents rated the honey products higher than the silan date extract for symptomatic relief of their children's nocturnal cough and sleep difficulty due to URI. Honey may be a preferable treatment for cough and sleep difficulty associated with childhood URI.

Inverse association between Helicobacter pylori and pediatric asthma in a high-prevalence population

BACKGROUND

Helicobacter pylori-associated disease has led to aggressive diagnostic and eradication protocols that are partially responsible for the decrease in prevalence of H. pylori carriage. Recent evidence indicates that in low-prevalence populations, H. pylori may have protective effects on allergic diseases. The aim of this study was to explore the relationship between pediatric asthma and H. pylori infection in a population with high prevalence of H. pylori infection.

MATERIALS AND METHODS

A national referral laboratory was screened for all (13) C urea breath tests performed in children aged 5-18 years between 2007 and 2008, for patient demographics and physician-diagnosed asthma. Data concerning asthma-associated medication usage were extracted from electronic medical records and databases. Data were analyzed using a stepwise logistic regression model.

RESULTS

During the study period, 6959 patients underwent urea breath testing (average age 12.4±3.5years). Of these, 3175/6959 (45.6%) were positive for H. pylori, and 578/6959 (8.3%) had asthma. Rates of asthma in H. pylori-positive and H. pylori-negative children were 7.3 and 9.1%, respectively (odds ratio 0.82; 95% confidence interval (CI) 0.69-0.98; p=.032). We also confirmed that male gender, urban residence, and age are associated with childhood asthma.

CONCLUSIONS

We demonstrate an inverse association between H. pylori and pediatric asthma in a population with a high prevalence of H. pylori.

Microbial contamination of nebulizers in the home treatment of cystic fibrosis

BACKGROUND

Home nebulizers are in widespread use in cystic fibrosis (CF) and other chronic pulmonary diseases. Bacterial contamination may be a source of respiratory tract colonization.

OBJECTIVES

To investigate microbial contamination of home nebulizers in CF patients, compare with sputum cultures and relate to cleaning practices.

METHODS

A total of 29 home nebulizers of CF patients were cultured. Families were interviewed regarding cleaning routines and patients had sputum cultures for bacteria and fungi.

RESULTS

In total, 19/29 (65%) nebulizers were contaminated: 18 reservoir cups, 14 mouthpieces and five filters. Pseudomonas spp. were isolated from 10 nebulizers (35%) and all 10 had Pseudomonas aeruginosa airway infection although without genetic typing we could not be sure this was the same bacteria as that from their nebulizer unit. An additional 7/29 had Pseudomonas aeruginosa airway infection without a contaminated nebulizer (P=0.001). No nebulizers were contaminated with Aspergillus. Only 4/19 contaminated nebulizers (22%) had been cleaned after every use, compared with seven of the 10 (70%) uncontaminated nebulizers (P=0.017). Only 7/19 patients with contaminated nebulizers (37%) and 5/10 with clean nebulizers (50%) recalled receiving cleaning instructions (not significant).

CONCLUSIONS

Home nebulizers are frequently contaminated, particularly when cleaning instructions are inadequate, and may be a source of airway infection or reinfection especially following contamination from a patient chronically colonized with P. aeruginosa. Simple oral and written cleaning instructions should be offered.

Antipyretic treatment in young children with fever: acetaminophen, ibuprofen, or both alternating in a randomized, double-blind study

OBJECTIVE

To compare the antipyretic benefit of acetaminophen or ibuprofen monotherapy with an alternating regimen of both drugs in young children aged 6 to 36 months.

DESIGN

Randomized, double-blind, parallel-group trial.

SETTING

Three primary pediatric community ambulatory centers in central Israel.

PARTICIPANTS

A total of 464 children aged 6 to 36 months with fever.

INTERVENTION

Infants were assigned to receive either acetaminophen (12.5 mg/kg per dose every 6 hours) (n = 154) or ibuprofen (5 mg/kg per dose every 8 hours) (n = 155) or to receive alternating acetaminophen and ibuprofen (every 4 hours) (n = 155) for 3 days after a loading dose.

MAIN OUTCOME MEASURES

Temperature, stress score, amount of antipyretic received, total days that the infant or caregiver was absent from day care or work, respectively, at the 3-day time point, recurrence of fever, and number of emergency department visits.

RESULTS

The group given the alternating regimen was characterized by a lower mean temperature, more rapid reduction of fever, receiving less antipyretic medication, less stress, and less absenteeism from day care as compared with the other groups; all of the differences were statistically significant (P< .001). None of the regimens were associated with a significantly higher number of emergency department visits (P = .65) or serious long-term complications (P = .66). The drug used for initial loading had no effect on outcome in any of the groups.

CONCLUSIONS

An alternating treatment regimen of acetaminophen (12.5 mg/kg per dose) and ibuprofen (5 mg/kg per dose) every 4 hours for 3 days, regardless of the initial loading medication, is more effective than monotherapy in lowering fever in infants and children.

Survey of parents, nurses, and school principals on their perceptions of the controversial role of schools in health promotion

BACKGROUND

The aim of this paper was to study the perceptions of parents, nurses, and school principals of the role of the health services in elementary schools.

METHODS

A questionnaire was distributed to the heads of parents' committees, school nurses, and school principals of 35 randomly selected elementary public schools in Israel. Respondents were asked to qualify the degree of importance of the traditional and contemporary roles of the school health-care team.

RESULTS

Response rates were 80.0% for parents, 100% for nurses, and 97.1% for principals. All respondents agreed that both the traditional and new roles are very important. Nurses rated three interconnected roles significantly lower than parents and school principals: 'Evaluation of students with behavioral problems', 'Evaluation of students with low academic performance', and 'Follow up and care of students with behavioral problems and low performance'.

CONCLUSIONS

Nurses, parents and school principals in Israel agree that the traditional roles of health teams in elementary schools, that is, providing first aid and ensuring school hygiene, are very important. Most are ready to accept a move from an illness-based to a social-based model, with less time spent on screening and surveillance and more on identifying and managing special needs of children and staff.

Pediatrician attitudes to exclusion of ill children from child-care centers in Israel: pressure on ambulatory practices

BACKGROUND

The exclusion of ill children from child-care centers may be associated with high social, economic and medical costs.

OBJECTIVE

To assess the opinions of pediatricians working in an outpatient setting in Israel on the exclusion/return of children in child-care centers.

METHODS

A questionnaire on practices of exclusion/return of children in child-care centers, in general and according to specific signs and symptoms, was administered to a random computer-selected cross-sectional sample of 192 primary care community pediatricians in Israel.

RESULTS

One hundred and seventy-three pediatricians completed the questionnaires, for a response rate of 90%; 147 were board-certified and 26 were not. About half the pediatricians felt pressured by parents requesting antibiotic therapy to accelerate the return of their sick child to the child-care center. The majority also believed their practice was overloaded by often unnecessary demands for medical notes by the child-care centers before children could return. More than half based their decision to exclude children on "common sense" and the remainder, on accepted guidelines. Except for scabies and lice, there were no significant correlations between the physicians' stipulation for a note on return of the child and the specific illness guidelines.

CONCLUSIONS

This study shows that a high proportion of pediatricians based their exclusion practices on "common sense" and personal understanding instead of established guidelines, and that the guidelines did not affect their opinion on the duration of illness that warrant a note. Furthermore, half were subjected to parental pressure to employ inappropriate practices. These findings, combined with our earlier survey of child-care centers staff, indicate that better education of parents and day-care staff about ill child-care-center-exclusion policy in Israel would increase their common understanding with pediatricians.

Parents' and medical personnel's beliefs about infant teething

Many symptoms are attributed to teething. Little evidence exists to support these beliefs, despite their implications on clinical management. This study attempted to investigate parental and medical personnel's beliefs about teething. The study was conducted by means of a questionnaire, submitted to 55 pediatricians and 130 nurses. A parent survey was conducted simultaneously. We evaluated 462 questionnaires. An association of teeth eruption with infant morbidity was believed to exist by 76% of the responders, mostly by parents and nurses, and less so by physicians. Irritability, fever, and loose stools/diarrhea were believed to be the most common symptoms associated to teeth eruption. We conclude that almost all parents, the majority of nurses, and many physicians believe that teething is associated with the appearance of symptoms, most of which are minor and relate to discomfort rather than physical illness, but a substantial minority still ascribes potentially serious symptoms to teething.

Exclusion of ill children from child-care centers in Israel

The aim of the study was to examine criteria for ill children in child-care centers. A questionnaire on practices of exclusion/return of children according to specific signs and symptoms was mailed to the directors of care centers in central Israel. Thirty-six of the 60 questionnaires (60%) were returned by mail and the reminded were completed in personal visits to the CCCs achieving a response rate of 100%. About half (51.7%) used "common sense" and "personal feelings" to exclude children and to allow their return, and 29 (48.3%) used the guidelines of the Ministries of Education and Health or other authorities. The percentage of centers excluding children by signs/symptoms was as follows: high fever (>38 degrees C), 100%; low-grade fever, 76.7%; asthma exacerbation, 80.0%; heavy cough, 75.0%; eye discharge or conjunctivitis, 83.3%; diarrhea and vomiting more than twice per day, 100%; rash, 72.3%; otalgia, 46.7%; and infected skin lesion, 66.7%. Only four centers excluded children with head lice. Most centers required a physician's note on return of a child after high fever (76.7%), eye discharge or conjunctivitis (48.3%), and from 75 to 80%, respectively, for frequent vomiting and bloody or mucinous diarrhea. The results show that exclusion practices among child-care centers (CCCs) vary widely, suggesting the need for the establishment of a uniform exclusion and return policy in Israel, with distribution of clear, up-to-date guidelines on the prevention and control of communicable diseases to all day-care centers. In a simple way, this study identified attitudes concerning the exclusion/return of sick children in CCCs and was useful for the discussion of the related policy with CCCs responsible and national health and educational authorities.

Naturopathic treatment for ear pain in children

OBJECTIVE

Otitis media is 1 of the most frequent diseases of early infancy and childhood and 1 of the most common reasons for children to visit a physician. In the past 2 decades, there has been a substantial increase in the diagnosis of otitis media worldwide. In the United States, 93% of all children have had at least 1 episode of acute otitis media (AOM) by 7 years of age. Otalgia is the hallmark of AOM. Most affected children either complain of earache or manifest behavior that the parents interpret as indicating ear pain. Treatment of the ear pain early in the course of AOM decreases both parental anxiety and the child's discomfort and accelerates the healing process. The objective of this study was to determine the efficacy and tolerability of naturopathic versus traditional treatment for the management of otalgia commonly associated with AOM in children.

METHODS

The study was designed as a double-blind trial in an outpatient community clinic. A total of 171 children who were aged 5 to 18 years and had otalgia and clinical findings associated with middle-ear infection were studied. The children were randomly assigned to receive treatment with Naturopathic Herbal Extract Ear Drops (NHED) or anesthetic ear drops, with or without amoxicillin. On enrollment, the children were assigned by computer-numbered randomization to receive NHED (contents: allium sativum, verbascum thapsus, calendula flores, hypericum perfoliatum, lavender, and vitamin E in olive oil) 5 drops 3 times daily, alone (group A) or together with a topical anesthetic (amethocaine and phenazone in glycerin) 5 drops 3 times daily (group B), or oral amoxicillin 80 mg/kg/d (maximum 500 mg/dose) divided into 3 doses with either NHED 5 drops 3 times daily (group C) or topical anesthetic 5 drops 3 times daily (group D). A double-blind design was used, and all ear drops were placed in identical bottles. Treatment was initiated by the nurse in all cases. A single physician (M.S.) evaluated and treated all of the patients included in the study and recorded all of the data. The presence or absence of ear pain was assessed over 3 days with a visual analog scale. Ear pain was assessed by a specially devised observational instrument based on previous reports. One side of the instrument consisted of a linear numbered scale, from 1 (no pain) to 10 (worst possible pain), and a corresponding color scale, ranging from blue to dark red. The reverse side contained a scale of 5 facial expressions, ranging from broad smile (no pain) to a sad and crying face (worst possible pain), and a corresponding color scale, ranging from blue to dark red.

RESULTS

There were no significant between-group differences in patient age or gender, degree of fever, main symptoms, associated symptoms, and severity or laterality of acute otitis media. Each group had a statistically significant improvement in ear pain over the course of the 3 days. Patients who were given ear drops alone had a better response than patients who were given ear drops together with amoxicillin. Results were better in the NHED group than in the controls. Nevertheless, the findings indicated that the pain was mostly (80%) self-limited and could be explained simply by the time elapsed. The American Academy of Otolaryngology-Head and Neck Surgery guidelines recommend topical medications as the first line of treatment for ear pain in the absence of systemic infection or serious underlying disease. Because no evidence was found that systemic antibiotics alone improved treatment outcome, if antibiotics do not change the natural course of otitis media, then the main goal of treatment, as in the present study, should be to alleviate the ear pain. The alternative, naturopathic herbal extract medications, may offer many new possibilities in the management of ear pain associated with AOM. Primary care physicians should be aware that at least 10% of their patients may have tried 1 or more forms of alternative/complementary medicine before presenting for consultation. As it was widely reported in the medical literature, these herb, these herbal extracts have the potential to meet all of the requirements of appropriate medication that could be routinely used in the pediatric patient, namely in vitro bacteriostatic and bacteriocidal activity against common pathogens, immunostimulation ability, antioxidant activity, and anti-inflammatory effects. They are also well-absorbed with good penetration into the tissue surrounding the tympanic membrane. They have been found to enhance local immunologic activity. Finally, herbal extracts are well-tolerated (owing to their long elimination time), easy to administer, and less expensive than the new antibiotics. There are no documented side effects. On the basis of our findings that the group with the most significant treatment effects (NHED with topical anesthetic) explained only 7.3% of the total pain reduction, we propose that sometimes the general practitioner or pediatrician needs to give the human body a chance to repair itself. Nevertheless, if the physician believes that there is an indication for some treatment, especially if the parents are anxious, then a local treatment such as one used in our study might be adequate.

CONCLUSIONS

This study suggests that in cases of ear pain caused by AOM in children in which active treatment, besides a simple 2- to 3-day waiting period, is needed, an herbal extract solution may be beneficial. Concomitant antibiotic treatment is apparently not contributory.