AUTHOR:
Scott T. Vergano
Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA
CITATION: Vergano ST. 4 top papers you may have missed in September 2022. Consultant360. Published online October 20, 2022.
By the time you are reading this column, I will have returned from the American Academy of Pediatrics National Conference and Exhibition (AAP NCE) in Anaheim. It is truly exciting to be back in person with more than 10,000 pediatric providers. If you have never had the opportunity to attend, I would highly recommend it.
For this month, I have highlighted important publications related to screening for type 2 diabetes, vaccines and asthma, and the treatment of pancreatitis and lice. I hope you find the articles valuable and the commentary informative. I am interested in hearing your experiences and opinions. Please feel free to share them by writing to editors@consultant360.com.
Screening for Prediabetes and Type 2 Diabetes in Children and Adolescents1
The Americans with Disabilities Act (ADA) currently recommends screening for type 2 diabetes in all children and adolescents who are overweight or with obesity who have at least 1 risk factor. Screening should begin at 10 years of age and be performed at least every 3 years. The risk factors for type 2 diabetes include family history of type 2 diabetes, maternal diabetes or gestational diabetes during pregnancy, signs of insulin resistance on physical exam, and non-White race. The American Academy of Pediatrics (AAP) and ADA had previously recommended screening in children who are overweight or with obesity with at least 2 of the preceding risk factors.
This new United States Preventive Services Task Force (USPSTF) recommendation was formulated after examining the literature on screening, treatment, and prevention of type 2 diabetes and prediabetes in non-pregnant children and adolescents. Their systematic review found insufficient evidence of documented benefit of screening for type 2 diabetes or prediabetes and lack of proven benefit from treatment to delay the onset or complications of type 2 diabetes in the pediatric population. They conclude that evidence at present is insufficient to recommend for or against screening for type 2 diabetes in children and adolescent.
I have generally followed the AAP recommendation and have yet to diagnose a child with type 2 diabetes, despite fairly extensive screening. It is not clear to me exactly what the impact of the new USPTF task force recommendation will be, particularly as we seek to move away from race-based health care policies.
Association Between Aluminum Exposure From Vaccines Before Age 24 Months and Persistent Asthma at Age 24 to 59 Months2
Funded by the Centers for Disease Control and Prevention (CDC), the authors of this retrospective cohort study to be published in Academic Pediatrics use data from the Vaccine Safety Datalink to examine a possible link between aluminum in vaccines and the development of asthma in childhood. While controlling for a number of potential confounding variables, they find an association between cumulative aluminum exposure from adjuvants in vaccines and the diagnosis of persistent asthma between ages 2 to 4 years of age, as measured by at least 1 inpatient or 2 outpatient visits for asthma and the dispensing of at least 2 asthma controller medications.
I am concerned about methodologic flaws in this study. In particular, the conclusion that having more vaccines is associated with higher incidence of asthma seems unjustified by the data. The authors include in their definition of persistent asthma the requirement that at least 2 asthma controller medications were dispensed. It seems plausible that the same families who did not fully vaccinate their children might also not have filled prescriptions for their asthma controller medications. Although the authors attempt to control for health care utilization, the correlation in this study between fewer vaccines and less asthma treatment might be equally likely explained by less aggressive adherence to recommended medical interventions as to the conclusion that aluminum in vaccines causes persistent asthma.
This study represents a preliminary investigation with an intriguing association that deserves further research. Nonetheless, given the well-documented benefits of immunization, it should not be used to change vaccine policy or decrease the use of our currently available vaccinations.
Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis3,4
In this multicenter, randomized clinical trial spanning 4 countries and 18 centers published in the New England Journal of Medicine, adult patients with acute pancreatitis were randomized to receive aggressive or moderate intravenous (IV) fluid resuscitation with lactated Ringer’s solution. Patients in the aggressive resuscitation group were given an IV fluid bolus of 20mL per kg followed by infusion of 3mL per kg per hour for at least 48 hours. Patients in the moderate resuscitation group were given a bolus of 10mL per kg followed by an infusion of 1.5mL per kg per hour for at least 20 hours. Participants were monitored for the development of disease complications as well as fluid overload.
The investigators found no statistically significant difference in the development of moderate or severe pancreatitis, organ failure, intensive care unit admission, or duration of hospitalization between the 2 groups, although results of several of these measures trended in favor of the moderate resuscitation group. After enrolling only 249 of an anticipated sample size of 744 patients, the data and safety monitoring board stopped the trial. At this first interim analysis point, it was felt inappropriate to continue, as 20.5% of aggressively hydrated patients vs 6.3% of moderately hydrated patients developed fluid overload, without any suggestion of better clinical outcomes.
As stated in the accompanying editorial in the same issue, “These results are stunning and given the carefully crafted trial methods, irrefutable.” This well-designed study will likely lead to a change in the standard approach to IV fluid resuscitation in adult patients with acute pancreatitis and may signal the need for a similar change in pediatric patients.
Head Lice5
This AAP policy statement updates recommendations for the diagnosis and treatment of head lice since the previous statement was published in 2015. As increasing resistance has been documented to the popular over the counter (OTC) lice preparations, the committee produced an algorithm for the decision to treat with permethrin or pyrethrins or with newer prescription medications. The statement recommends the OTC preparations as first-line therapy when treatment is required. It is recommended to choose topical ivermectin lotion or spinosad (6 months of age or older) or malathion 0.5% (6 years of age or older) if a patient has failed therapy with a first-line OTC treatment or in an area in which resistance to these agents has been demonstrated. Finally, the statement reaffirms recommendations for non-pharmacologic treatment and for the elimination of no-nit exclusion policies from schools and daycares.
In a study published in 2016, which received significant attention, genes that confer high-level resistance to permethrin and pyrethrins were documented from sites in 46 of 48 states that were included. The policy statement points out that the relation between resistance genes and clinical failure is not well established. Although studies have documented significant decreases in the clinical effectiveness of the OTC agents, resistance patterns vary significantly by region and country. As local resistance patterns are not readily available, the present policy statement is difficult for practitioners to implement.
I will continue to use permethrin as my first-line agent. It is inexpensive, well tolerated, readily available, and has a residual effect against newly hatched lice if not rinsed immediately from the scalp. My plan is to take this policy statement literally, and as there has not been significant resistance documented in my area (to my knowledge), I will continue to recommend permethrin first and use the prescription agents if the initial appropriately applied treatment fails.
References:
Diabeets
21/10/2022