Top Papers Of The Month

3 Top Papers You May Have Missed in May 2021

AUTHOR:
Scott T. Vergano, MD
Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA

CITATION:
Vergano ST. 3 top papers you may have missed in May 2021. Consultant360. Published online June 8, 2021.


Some great general pediatric articles caught my attention in May, including publications about otitis media and tympanostomy tubes, preschool attention-deficit/hyperactivity disorder (ADHD), and the decrease in asthma exacerbations during COVID-19. Hope you enjoy! Please feel free to share your thoughts with us and with your colleagues: editor@consultant360.com.

Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media1

In this randomized trial of tympanostomy tube placement vs medical management, one of the pre-eminent otitis media research groups in the United States evaluated 250 children aged between 6 and 35 months who had had at least 3 episodes of otitis media in the prior 3 months or 4 episodes in the prior year. The patients were randomly assigned to 1 of 2 groups: one scheduled for tympanostomy tube placement and the other for management with antibiotics to treat recurrences of otitis media. The patients were followed for 2 years, comparing the incidence of new episodes of acute otitis media. The authors found that the mean number of episodes of otitis media over the next 2 years was 1.48 episodes in children in the tympanostomy group and 1.56 episodes in children in the antibiotics group. They concluded that in children aged between 6 and 35 months, the number of episodes of otitis media was not lower in a group of patients assigned to tympanostomy tube placement than in a group assigned to medical management alone.

In an accompanying editorial,4 Ellen Wald, a former colleague of the authors in Pittsburgh, points out the strengths of the study—the rigorous inclusion criteria for acute otitis media—and the weaknesses; most prominently, the researchers randomly assigned only 250 patients, and 45% of those randomly assigned to medical management ended up with tubes, either because of treatment failure of medical management or parental preference. She concluded that the study was underpowered to draw appropriate conclusions about the equivalence of medical management and tube placement and recommended a discussion of risks and benefits of both approaches with every family.

Although this study represents a significant contribution to the literature on tympanostomy tube placement, I agree with Ellen Wald. Due to the modest sample size and the reassignment of patients—children in the tympanostomy tube group who did not undergo surgery and children in the antibiotics group who did—I believe that further study is needed before a more definitive conclusion can be drawn regarding the indication for tube placement to decrease the incidence of recurrent acute otitis media. I plan to continue to offer referral to the parents and guardians of my patients who have more than 3 new episodes of acute otitis media in 6 months or 4 in a year, as well as for those in whom persistent serous fluid (otitis media with effusion) is present for longer than 3 months.

α2-Adrenergic Agonists or Stimulants for Preschool-Age Children With Attention-Deficit/Hyperactivity Disorder2

The authors of this retrospective study examined the records of 497 consecutive patients younger than age 6 years who were treated with medication for ADHD in 7 developmental pediatrics practices in the United States. Children who received stimulant or α-2 adrenergic medications were included, and the authors studied the rates of improvement and the incidence of adverse effects in each child. Overall, in the young children taking stimulants, 78% had experienced improvement in symptoms, although more common adverse effects included moodiness, irritability, appetite suppression, and difficulty sleeping. In the young children taking α-agonists, 66% had experienced improvement in symptoms, with daytime sleepiness noted as the most common adverse effect.

It is nice to read publications about medication use in preschoolers with ADHD. Because the American Academy of Pediatrics (AAP) recommends parent training in behavior management as the primary approach to the treatment of ADHD, not much evidence has been published on the effectiveness of medications in this age group. This publication significantly adds to my understanding of how to prescribe ADHD medications to those few preschool children in whom they are necessary.

What are your thoughts? Do you have experience prescribing medications to preschool children with ADHD when behavioral management is insufficient? Or have you referred all of these patients to a specialist for further management?

Effect of COVID-19 on Asthma Exacerbation3

The authors of this Clinical Communication report their observations of asthma incidence as part of an open-label inhaled corticosteroid study of 1178 adult Black/African American and Hispanic/Latinx individuals with moderate to severe persistent asthma. While collecting monthly self-reports of asthma exacerbations as a part of the study, the authors noted a 41% decrease in the rate of asthma exacerbation when comparing the first quarter of 2020 with the second quarter of 2020. Importantly, these data were obtained by remote self-reporting and were not impacted by avoidance of visits to health care providers. They conclude, “For Black/African-American and Hispanic/Latinx individuals with moderately severe asthma, there was nearly a halving of asthma exacerbations following the coronavirus disease 2019 (COVID-19) pandemic.”

Although this was an adult study within a particular population, it should serve as a reminder to us that patients with moderate asthma may have had significantly fewer asthma exacerbations during COVID-19 restrictions, presumably because of decreased exposure to triggers. When I see these patients for asthma reassessment this year, I plan to exercise caution before reducing their controller medication. While it is possible that their asthma severity has decreased in the past year, it is also possible that they still have equal potential for exacerbations as in the past but have had fewer exposures this year because of COVID-19 restrictions.  

In our local emergency department this spring, my colleagues report that they have seen several children presenting with status asthmaticus whose caretakers and/or providers felt that their child’s asthma severity had improved over the past year and had discontinued the use of their daily controller medication. What has your experience been?

Finally, just a quick note on the release of the anticipated 2021 AAP Committee on Infectious Diseases Red Book. Of everything I look at regularly, the Summary of Major Changes with the new edition every 3 years is perhaps the highest-yield reading I do. I strongly recommend it!

As always, would love to hear your thoughts, opinions, and experiences: editor@consultant360.com. Happy summer!

References:

  1.  Hoberman A, Preciado D, Paradise JL, et al. Tympanostomy tubes or medical management for recurrent acute otitis media. N Engl J Med. 2021;384(19):1789-1799. https://doi.org/10.1056/nejmoa2027278
  2. Harstad E, Shults J, Barbaresi W, et al. α2-adrenergic agonists or stimulants for preschool-age children with attention-deficit/hyperactivity disorder. JAMA. 2021;325(20):2067-2075. https://doi.org/10.1001/jama.2021.6118
  3. Salciccioli JD, She L, Tulchinsky A, Rockhold F, Cardet JC, Israel E. Effect of COVID-19 on asthma exacerbation. J Allergy Clin Immunol Pract. 2021;S2213-2198(21)00500-6. doi:10.1016/j.jaip.2021.04.038
  4. Wald ER. Management of recurrent acute otitis media. N Engl J Med. 2021;384(19):1859-1860. https://doi.org/10.1056/nejme2104952