4 Top Papers You May Have Missed in July 2022

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 July 2022. Consultant360. Published online August 15, 2022.

In keeping with a theme from last month, I would like to add a few additional publications from July related to racial bias in medicine and pediatrics. In addition, I call attention to 2 preliminary studies that identify issues you may hear more about in the future regarding hypospadias and a potential adverse effect of macrolide antibiotics. I hope that you find these articles interesting and instructive. Please feel free to share with your colleagues, discuss in your offices, and write to editors@consultant360.com with your thoughts and opinions.

Assessment of Racial and Ethnic Differences in Oxygen Supplementation Among Patients in the Intensive Care Unit¹

In this retrospective cohort study of 3069 patients in the adult intensive care unit (ICU) at Beth Israel Deaconess Medical Center from 2008 to 2018, the authors compared differences in hidden hypoxemia and oxygen supplementation between patients of varying races and ethnicities. The authors described hidden hypoxemia as a hemoglobin oxygen saturation measured by blood gas of less than 88% with a simultaneous pulse oximetry reading of 92% or greater. Compared with the 2667 patients identified as White, the 207 identified as Black patients, 112 identified as Hispanic patients, and 59 identified as Asian patients all had greater degrees of hidden hypoxemia. In addition, for a given level of hemoglobin oxygen saturation, each of the cohorts identified as non-White received less supplemental oxygen when adjusted for other cofounding factors. 

The authors conclude that non-White patients in their ICU received less supplemental oxygen than their White counterparts, and that the discrepancy was associated with differences in pulse oximetry readings. Although done in adult patients, this study, when taken in conjunction with those mentioned and references in last month’s articles, should raise serious concern in those of us who rely on pulse oximeters as they currently function to determine the need for oxygen supplementation and other clinical interventions in our pediatric patients.

Are Black Girls Exhibiting Puberty Earlier? Examining Implications of Race-Based Guidelines²

Before the year 1997, the standard definition of precocious puberty was onset of pubertal development younger than age 9 years in boys or 8 years in girls. A large multisite study of the American Academy of Pediatrics Research in Office Settings network, which was published in that year and in which my office participated, suggested that puberty was occurring earlier than reported. In particular, the study identified that significantly more Black girls than White girls experienced breast development earlier than age 8 years. Although not without controversy, subsequent reports, guidelines, and teachings have labeled as precocious any breast development younger than age 6 years in Black girls and 7 years in White girls.

The authors of this commentary published in Pediatrics decry the race-based medicine implicit to the diagnosis of precocious puberty based upon race. While acknowledging the studies documenting earlier breast development in Black girls, they made the following points: (1) earlier breast development may not be genetic but might likely be a reflection of variable incidence of obesity, poverty, environmental exposures, and stress; (2) the idea that breast development in Black girls can be normal as early as age 6 years leads to the disparate adultification of Black girls; (3) the application of different ages for Black and White girls can lead to undertesting and underdiagnosis of true hormonal disorders in Black girls; and (4) using race-based definitions of precocious puberty is a form of racism that is not consistent with best practices and may perpetuate true racism. In relation to precocious puberty, they concluded, “it is important to move away from race-based medicine and adopt principles of race-conscious medicine. Race-conscious medicine decenters race and identifies racism as a primary driver of disparities.”

The issues surrounding race as a factor in medical conditions are complex. I support the move to eliminate race as an intrinsic determinant of disease. Nonetheless, it is a challenge to identify and recognize racial differences and address and repair disparities without eliminating race all together as a factor in evaluating and treating patients. 

What are your thoughts? How will these 2 publications affect the evaluation and management of your patients? I would love to hear your perspective!

Prevalence and Clustering of Congenital Heart Defects Among Boys With Hypospadias³

Based upon preliminary reports connecting hypospadias and congenital heart defects, the authors of this retrospective cohort study used birth-registry data from infants in 11 states born between 1995 and 2014 to examine the correlation between the 2 conditions. They queried data from active state-based surveillance programs in Texas and Arkansas and confirmed their findings through active and passive surveillance programs in 9 additional states through the National Birth Defects Prevention Network. The authors found that boys born with hypospadias were 6 times more likely to have a co-occurring congenital heart defect, with heart disease more likely in boys with third-degree hypospadias than with first-degree hypospadias.

More studies are needed to confirm the impressive degree of association reported here and to investigate potential underlying genetic causes. It will be interesting to see if this publication leads to official recommendations to screen all boys born with hypospadias with an echocardiogram to look for undiagnosed congenital heart defects.

Association of Outpatient Oral Macrolide Use With Sensorineural Hearing Loss in Children, Adolescents, and Young Adults⁴

The authors of this case-control study examined 875 patients who were neonates to 18 years of age with diagnosed sensorineural hearing loss (SNHL) and matched them with 875 control patients. They then examined for antibiotic exposure within the last year and compared the odds of having received a macrolide prescription with the odds of having received a penicillin prescription. Consistent with earlier reports of SNHL in adults, the authors found that the adjusted odds ratio that a child with SNHL had a macrolide prescription within the last year compared with a penicillin prescription was 1.31. They concluded that further study of the association between macrolide antibiotics and SNHL is needed.

The data here are not overwhelming. Nonetheless, when combined with the significant risks of allergic reactions, arrhythmias, gastrointestinal adverse effects, and drug interactions, the present study adds to my reluctance to use macrolide antibiotics in children unless no other antibiotic is appropriate.

References:

1. Gottlieb ER, Ziegler J, Morley K, Rush B, Celi LA. Assessment of racial and ethnic differences in oxygen supplementation among patients in the intensive care Unit. JAMA Intern Med. 2022;182(8):849-858. doi:10.1001/jamainternmed.2022.2587
2. Osinubi AA, Lewis-de Los Angeles CP, Poitevien P, Topor LS. Are black girls exhibiting puberty earlier? Examining implications of race-based guidelines. Pediatrics. 2022;150(2):e2021055595. doi:10.1542/peds.2021-055595
3. Richard MA, Patel J, Benjamin RH, et al. Prevalence and clustering of congenital heart defects among boys with hypospadias. JAMA Netw Open. 2022;5(7):e2224152. doi:10.1001/jamanetworkopen.2022.24152
4. Dabekaussen KFAA, Andriotti T, Ye J, Prince AA, et al. Association of outpatient oral macrolide use with sensorineural hearing loss in children, adolescents, and young adults. JAMA Otolaryngol Head Neck Surg. 2022:e221293. doi:10.1001/jamaoto.2022.1293