Pediatric Potpourri

1. Pediatric Potpourri John Hickner, MD, MS Editor-in-Chief, Journal of Family Practice

2. Objectives 1. Describe some effective and some ineffective uses of probiotics in children 2. Review recent studies regarding treating pediatric ENT problems and infections 3. Provide updates on effective screening strategies for children and adolescents

3. Probiotics to prevent eczema 1. Lactobacillus rhamnosusHN001 but not Bifidobacterium lactis NH019 reduced eczema in children at 11 year follow up • 11 year follow up of previously reported positive trial • HN001 caused a significant reduction in atopic sensitization (hazard ratio[HR] = 0.71), eczema (HR = 0.58) and wheeze (HR = 0.76) 2. Lactobacillus rhamnosus did not prevent infant eczema when give to pregnant women: RCT 2. Lactobacillus rhamnosus HN001 did not prevent infant eczema when give to pregnant women: RCT • Giving to infant and mom worked in prior trial, HR 0.61 • This study tested if giving probiotics to mom alone is effective; 433 women randomized starting 16 weeks pg. • Did NOT reduce eczema, allergies or wheezing at 12 months

4. Probiotics to prevent eczema 3. Lactobacillus rhamnosus GG did not reduce infant eczema or asthma at 2 years of age • RCT 184 infants vs. placebo for first 6 months of life • Median follow-up 4.6 years • Eczema at 2 years: 30.9% vs. 28.7% • Asthma at 5 years: 17.4% vs. 9.7%, nonsignificant diff. 4. Bath oils do not improve eczema in children • RCT: 483 children between the ages of 1 year and 11 years with atopic dermatitis; bath oil of choice or no bath oil • Improved 2.0 and 1.7 respectively, not clinically significant

5. Probiotics for infant colic 5. L reuteri DSM17938 reduces colic in breast-fed infants; uncertain in formula-fed infants • 2018 meta-analysis: 4 double-blind trials enrolling 345 infants with colic • day 21 adjusted mean difference in change from baseline [minutes] -25.4 minutes • Non-significant diff. in bottle fed infants 6. Two lactobacillus strain probiotic decreased mean crying time more than placebo in breast-fed infants with colic • RCT infants aged 4 to 12 weeks; used Baby’s Day Diary • On day 28, mean cry and fuss time 142 min vs. 199 • Mean change in cry and fuss time from day 0 to day 28: -163 min in the probiotic and -116 min in the control group

6. Probiotics and acute gastroenteritis 7. Two strain lactobacillus did not prevent moderate to severe diarrhea in children with gastroenteritis • 886 children 3 to 48 months of age • 5 days of combo lactobacillus • Mod to severe gastro. 26.1% vs. 24.7% in controls • No difference in diarrhea or vomiting duration or any other outcomes, such as missed school days

7. Pediatric ENT and Infections 8. Use narrow spectrum antibiotics to treat children with acute respiratory tract infections rather than broad spectrum antibiotics • Cohort study: 30,159 children age 6 mos. to 12 yrs. with otitis media, group A strep pharyngitis, and sinusitis • Broad: amox-clav, cephalosporins, and macrolides vs. Narrow: amoxicillin or penicillin • Treatment failure rate same: 3.4% vs 3.1% • more complications for broad: 35.6% vs 25.1%

8. Pediatric ENT and Infections 9. Surgical removal of tonsils and adenoids was associated with increased risk of respiratory, infectious and allergic diseases • Cohort of 1.2 million children in Denmark; followed up to 30 years of age • 2 to 3 fold increase in respiratory track diseases; 2% absolute increase in infectious diseases (NNH: 50) 10. Tubes ineffective in treating otitis media in children • Meta-analysis:16 studies • Temporary improvement in hearing; none at 12 to 24 months • No long term improvement in cognition, behavior

9. ENT and EYE 11. Oral prednisolone = placebo in children with otitis media with effusion (OSTRICH) • RCT 380 children age 2 to 8 with OME • 7 days prednisone vs placebo • 4 wk. 6 mo, 12 mo. No diff in hearing 12. Optimum time for probing lacrimal ducts • One in 9 infants have nasolacrimal duct obstruction • 84% resolve without treatment by 9 months age • Probing at age 12 months has best outcome with least intervention

10. Screening 13. Screening for child abuse gets an “I” rating from the USPSTF • Insufficient evidence to screen in otherwise healthy, children and teens if there is no suspicion of abuse 14. “I” recommendation for scoliosis screening from USPSTF • ages 10 to 18: prevalence 1% to 3% • No recent RCTs: one in MN. years ago was negative • Am Academy of Pediatrics does recommend screening

11. Screening 15. Most infants with hip clicks do not have hip dysplasia • case series of 362 infants referred for “clicky” hips • 14 weeks old average • 97% normal hips 16. Brief alcohol interventions for adolescents in primary care settings can result in clinically important changes in alcohol-related outcomes • Systematic review found 13 studies of brief office interventions • Decreased drinking behavior noted (see appendix)

12. Bottom Lines 1. Use lactobacillus rhamnosus HN001 to reduce the incidence of eczema in allergy prone infants. 2. Recommend lactobacillus for colicky infants. 3. Don’t recommend probiotics for children with acute gastroenteritis. 4. Don’t use prednisone for otitis media with effusion.

13. Bottom Lines 5. Exhaust non-surgical options before considering tonsillectomy/adenoidectomy and ear tubes. 6. Don’t routinely screen for child abuse, but have a high index of suspicion when appropriate. 7. Routinely screening for scoliosis may not be effective, but do refer those with significant scoliosis when you find it. 8. Do identify teens with alcohol problems and intervene. Brief office interventions help some patients.