Pediatrics

4 Top Papers You May Have Missed in June 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 June 2022. Consultant360. Published online July 18, 2022.

 

We are entering my favorite season in the general pediatric office. I have always enjoyed seeing healthy kids. The illnesses in the summer seem less acute: swimmer's ear, poison ivy, and minor trauma. The kids seem happier and the families more relaxed. Finally, it is a chance to catch up with some of the older children whose families I have seen through rough patches in infancy and childhood and have grown into their own in adolescence, even with all its inherent challenges. I hope you have such pleasurable periods in your work as well.

Here are my choices of articles for the month of June. Please feel free to share with your colleagues, discuss in your offices, and write to editors@consultant360.com with your thoughts and opinions.

Policy Statement: Breastfeeding and the Use of Human Milk1

An American Academy of Pediatrics (AAP) policy statement from the Section on Breastfeeding contains several new and updated recommendations. The AAP now recommends exclusive breastfeeding until the infant is approximately 6 months of age and continuing, if desired until the child is 2 years of age. The extended duration of nursing is consistent with recommendations from the World Health Organization (WHO) and is associated with numerous health benefits for both mother and child. In addition, the statement also discusses:

  1. Medical conditions, medications, and substances that are contraindications to breastfeeding
  2. Hospital support to promote the initiation of breastfeeding
  3. Breastmilk in preterm and very low birth weight infants
  4. Breastfeeding disparities and breastfeeding within diverse populations

Regarding the timing of the introduction of complementary foods, up until now, I have generally recommended the introduction of complementary foods at 4 to 6 months of age. I think that as the scientific evidence has accumulated, a recommendation of approximately 6 months of age seems more justified. The statement cites new evidence that the introduction of complementary foods at 4 months of age or earlier has been associated with increased risk for overweight and obesity without providing benefits for growth, development, or iron status.

I agree most with AAP policy as articulated in the AAP Pediatric Nutrition handbook,2 which states, “Several organizations, including the WHO, have recommended exclusive breastfeeding through 6 months. The AAP supports this recommendation, stipulating the introduction of complementary foods at approximately 6 months [...] Of note, however, is the distinction between recommendations for populations and those for individual infants, all of whom should be monitored for growth faltering or other adverse effects, and appropriate interventions should be undertaken when indicated. Similarly, health care providers should encourage responsive feeding and consider the wide variations in the attainment of oral motor and other critical developmental skills in infants when deciding when to initiate complementary feeding."2

What will you recommend to your families now?

Racial and Ethnic Discrepancy in Pulse Oximetry and Delayed Identification of Treatment Eligibility Among Patients With COVID-193

The authors of this article in JAMA Internal Medicine compared oxygen saturation measured by pulse oximetry and by arterial blood gas in 1216 adult patients with COVID-19 infection. They discovered that occult hypoxemia (defined as arterial saturation < 88%  with concurrent pulse oximetry reading of 92%-96%) occurred in 79 White patients (17.2%), 136 Black patients (28.5%), 64 non-Black Hispanic patients (29.8%), and 19 Asian patients (30.2%). In addition, as eligibility for COVID-19 treatments depended on a pulse oximetry reading of less than 95%, the researchers calculated a disproportionate percentage of non-White patients in a separate, larger cohort who were denied COVID-19 therapy and who experienced a delay in guideline-recommended therapy for COVID-19, because of inaccuracies in the pulse oximetry readings.

Racial disparities in oxygen saturation have been reported in less well-disseminated journals, as well as in a research letter to the New England Journal of Medicine in 2020.4 This is the first article I have read to document a racial and ethnic disparity in guideline-recommended therapy based on inaccurate pulse oximetry readings. I applaud the authors for their diligence in recognizing the systemic biases they uncovered in the use of pulse oximetry. I will now view with a bit more caution the readings I obtain in my office for my non-White patients with respiratory illnesses.

Effect of Point-of-Care Testing for Respiratory Pathogens on Antibiotic Use in Children5

This randomized clinical trial, conducted in a Finnish pediatric emergency department (ED) prior to the COVID-19 pandemic, examined the effect of point-of-care polymerase chain reaction (PCR) testing for respiratory viral pathogens on prescriptions for antibiotics in 1243 children discharged from the pediatric ED. Patients were randomly assigned to undergo rapidly available respiratory viral PCR testing vs usual ED care, which included PCR assays for influenza A and B and respiratory syncytial virus. The authors found no significant difference in the percentage of children discharged with a prescription for antibiotics, despite the availability of respiratory PCR testing in the intervention group.

Now that PCR-based testing for respiratory pathogens has become commonplace in the pediatric office, I am always looking for studies to help define the role of these tests in my evaluation of children with respiratory illnesses. Given the tests’ expense and the absence of utility in knowing which virus is responsible for most upper respiratory infections, I am always pleased to read studies that suggest not performing such testing. My worry is that parents will become accustomed to learning the name of the particular virus causing their child's symptoms and start to demand expensive testing that does not change treatments or outcomes. 

What are your thoughts and experiences?

Safety of Live-Attenuated Vaccines in Children Exposed to Biologic Response Modifiers in Utero6

Current guidelines from the AAP recommend avoiding live-attenuated vaccines in children who were exposed to maternal biologic response modifiers (BRM) in utero for 12 months after the last exposure.7 These children currently should not receive rotavirus vaccine or any early dose of measles vaccine prior to 12 months of age.

The authors of this research brief published in Pediatrics retrospectively examined outcomes for 954 children exposed to BRMs in utero who were vaccinated against measles by 2 years of age, and for 929 infants exposed to BRMs in utero who were vaccinated against rotavirus in infancy. They found no increase in serious or minor adverse reactions in either group, compared with children not exposed to BRMs.

These data are useful to help inform policymakers and may lead to an alteration in the current recommendations. However, until such changes are recommended, I will still avoid giving live-virus vaccines to most of the children exposed in utero to these agents.

Enjoy your summer!

References:

  1. Meek JY, Noble L. Policy statement: breastfeeding and the use of human milk. Pediatrics. 2022:150(1)e2022057988. doi.10.1542/peds.2022-057988
  2. Pediatric Nutrition. 8th ed. Academy of Pediatrics; 2020. Accessed July 12, 2022. https://publications.aap.org/aapbooks/book/684/Pediatric-Nutrition-Sponsored-Member-Benefit
  3. Fawzy A, Wu TD, Wang K, et al. Racial and ethnic discrepancy in pulse oximetry and delayed identification of treatment eligibility among patients with COVID-19. JAMA Intern Med. 2022;182(7):730-738. doi:10.1001/jamainternmed.2022.1906
  4. Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial bias in pulse oximetry measurement. N Engl J Med. 2020;383(25):2477-2478. doi: 10.1056/NEJMc2029240
  5. Mattila S, Paalanne N, Honkila M, Pokka T, Tapiainen T. Effect of point-of-care testing for respiratory pathogens on antibiotic use in children: a randomized clinical trial. JAMA Netw Open. 2022;5(6):e2216162. doi:10.1001/jamanetworkopen.2022.16162
  6. Zerbo O, Modaressi S, Goddard K, et al. Safety of live-attenuated vaccines in children exposed to biologic response modifiers in utero. Pediatrics. 2022;150(1):e2021056021. doi:10.1542/peds.2021-056021
  7. Immunization and other considerations in immunocompromised children. In: Kimberlin DW, Barnette ED, Lynfield R, Sawyer MH, eds. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021:82-83.