Top Papers Of The Month

4 Top Papers You May Have Missed in September 2021

AUTHOR:
Scott T. Vergano, MD
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 2021. Consultant360. Published online October 15, 2021.

 

During the surge of delta variant COVID-19, and the respiratory viral illnesses flooding our offices, urgent care centers, and emergency departments​ out of concern for COVID-19 infection, I offer a respite. Here are several articles of importance from the past month, not related to the current pandemic. As always, please discuss them with your colleagues and share your thoughts with us: editor@consultant360.com.

High Congenital Syphilis Case Counts Among US Infants Born in 20201

Congenital Syphilis Diagnosed Beyond the Neonatal Period in the United States: 2014–20182

Correspondence published in the New England Journal of Medicine and an article published in Pediatrics call attention to the epidemic of congenital syphilis in the United States in recent years. The Centers for Disease Control and Prevention (CDC) report 2022 cases of congenital syphilis as of July 29, 2021, the highest number of annual cases since 1994 and already surpassing the total number of cases from the previous year. In a separate investigation, the CDC reports on 67 infants with symptomatic congenital syphilis diagnosed after 1 month of age, from 2014 to 2018. The researchers state that these infants represent “ultimate failures” of the public health system, as their diagnoses were not made during the neonatal period and led to symptomatic disease diagnosed late.

In this era of resurgence of syphilis and of congenital syphilis at epidemic levels, it is more important than ever to strictly follow CDC guidelines for screening for maternal syphilis and evaluation of the neonate exposed in utero. In addition to screening early in pregnancy, the current guidelines call for repeat maternal screening at 28 weeks' gestation and again at birth in individuals and communities at high risk. Any infant exposed to syphilis in utero needs a titer drawn after birth. If an infant was inadequately treated in utero or shows physical examination evidence of syphilis or has a titer that is 4-fold greater than the mother's titer, further evaluation in the nursery is mandatory. The authors identify multiple reasons for failure of identification of congenital syphilis in their 67 infants with symptomatic late diagnoses.

For the first time since pediatric residency 25 years ago, while rounding in the newborn nursery, I saw a newborn exposed to maternal syphilis in utero. I needed to read and process the relevant section of the Red Book once more to ensure adequate evaluation of my patient. It is clear to me that the epidemic of congenital syphilis can reach geographic areas that have not previously been affected. It is important for all pediatricians caring for neonates and infants to review the guidelines, advocate for appropriate maternal testing, and not discharge neonates without thorough investigation of their syphilis status.

Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial3

This intriguing single-center randomized controlled trial published in JAMA Pediatrics enrolled 125 adolescents and young adults presenting to the emergency department within 24 hours of a concussion. They were randomly assigned to 1 of 2 groups: one group was asked to abstain from use of screen time for the next 48 hours, and the other was allowed screen time. The authors report a highly significant difference in the time to recovery between the 2 groups. The median time to recovery in the screen time–abstinent group was 3.5 days, compared with 8.0 days in the screen time–permitted group. The authors recommend confirmation of their findings in a larger randomized clinical trial.

Over the past 2 decades, I have seen the pendulum swing dramatically on appropriate post-concussion recommendations. As the literature evolved, my initially lenient instructions changed to complete mental and physical rest and have now settled somewhere in between. It is not clear to me that abstinence from screen time should have such a profound effect on recovery, as demonstrated in this article. Nonetheless, it is an intervention that is reasonable, implementable, and consistent with my current approach to post-concussion activity restrictions. In the absence of a more definitive study, it is likely I will make this recommendation to my patients. What are your thoughts?

Screening for Anxiety in Pediatric Primary Care: A Systematic Review4

​In this systematic review published in Pediatrics, the authors reviewed 2653 published reports on anxiety screening in children and adolescents. They searched for screening and treatment studies that evaluated an unselected study population presenting for routine care at a primary care office. To their surprise, they were able to include in their analysis only 3 studies that met these inclusion criteria. The authors concluded that significant gaps exist regarding screening for anxiety during wellness examinations in a general pediatrics office or clinic.

Depression screening for adolescents and postpartum depression screening of mothers have both become routine in my office. Given the high prevalence of anxiety disorders among my patients, particularly among adolescents, it is tempting to implement the recommendation of the Women's Preventative Services Initiative, which last year endorsed​ anxiety screening for adolescent young women aged 13 years or older. Nonetheless, as this article points out, an appropriate screening instrument has yet to be validated for this population, and questions persist regarding the appropriate population to be screened. As of now, I am resigned to my typical close surveillance for anxiety, until an effective screening questionnaire can be validated.

As always, I am interested in hearing your thoughts, current practices, and responses to the articles I have highlighted.

References:

  1. Bowen VB, McDonald R, Grey JA, Kimball A, Torrone EA. High congenital syphilis case counts among U.S. infants born in 2020. N Engl J Med. 2021;385(12):1144-1145. https://doi.org/10.1056/nejmc2111103
  2. Kimball A, Bowen VB, Miele K, et al. Congenital syphilis diagnosed beyond the neonatal period in the United States: 2014-2018. Pediatrics. 2021;148(3):e2020049080. https://doi.org/10.1542/peds.2020-049080
  3. Macnow T, Curran T, Tolliday C, et al. Effect of screen time on recovery from concussion: a randomized clinical trial. JAMA Pediatr. Published online September 7, 2021. https://doi.org/10.1001/jamapediatrics.2021.2782
  4. Kemper AR, Letostak TB, Hostutler CA, Stephenson KG, Butter EM. Screening for anxiety in pediatric primary care: a systematic review. Pediatrics. 2021;148(4):e2021052633. https://doi.org/10.1542/peds.2021-052633