Game Changers in Pediatrics 2011
Medscape asked members of the Medscape Pediatrics Advisory Board and experts at Children's Hospital of Philadelphia (CHOP) to review the year in pediatric research. What were the "can't miss" studies and papers of 2011 that are changing clinical practice? We have summarized them and, based on interviews with these and other experts, noted why they are important and speculated about what this means to the world of primary care pediatrics. It should be noted -- this list is not all inclusive nor in order of importance because all are important and a truly comprehensive list would be impossible to construct.
What to Do for the Infant With Bronchiolitis?
Bronchiolitis is a frequent and often scary condition seen in primary care. Beginning as a common cold, it can quickly progress to wheezing, hypoxia, and significant respiratory distress. It is a major cause of illness and a significant financial burden worldwide. Historically there has been great variation in its management with many clinicians relying on bronchodilators even in the absence of clear evidence to support their use.
A Cochrane systematic review published earlier this year examined data from 19 studies of over 2000 infants.The review excluded studies in the intensive care unit (ICU) setting or involving children requiring intubation, which means findings should not be applied to children with more severe disease or complicating comorbidities. The authors concluded that, while there was variation in the included trials in delivery of interventions including the type of epinephrine, number of administrations and dose, epinephrine administered early in the course of the illness was effective for most clinically relevant outcomes. Most importantly, epinephrine reduced the chance of an infant requiring hospitalization.
Other key findings included:
No evidence of effectiveness for repeated dosing of epinephrine or epinephrine and dexamethasone combined;
Epinephrine significantly decreased length of stay when compared with salbutamol; however, there were also no demonstrated differences in length of stay found for epinephrine vs placebo;
There were insufficient data to allow for comparisons based on age, severity or stage of illness, comorbidities, viral etiology, and atopic status of the child or family; and
No differences in adverse effects with epinephrine over the short term.
Why Is This a Game Changer?
At least for now, this article re-establishes nebulized ephinephrine as an effective emergency treatment to decrease hospitalization for these infants. Epinephrine, both racemic and levo(1)-epinephrine, is superior to inhaled salbutamol. When these kids present wheezing and with scared parents, after suctioning and re-evaluation -- the clinician can be confident in the choice of first-line therapy. Amy Baxter, MD, a Clinical Associate Professor in the Department of Emergency Medicine and Director of Emergency Research at Scottish Rite Children's Healthcare in Atlanta notes that these conclusions change the more iffy results from the previous 2004 review. "When clinicians saw a benefit in the emergency department with nebulized epinephrine, they may still have been reluctant to discharge a patient who wouldn't have access to that treatment at home. This study not only supports a much more definitive 'epinephrine reduces hospitalizations' but also supports the safety of discharging an infant who is clinically improved after a single treatment in the ED."
Medscape Pediatrics © 2011 WebMD, LLC
Cite this: Laurie E. Scudder. Game Changers in Pediatrics 2011 - Medscape - Nov 23, 2011.